Q. My husband, Billy, 72, was diagnosed with dementia a few years ago. He has become combative recently and has become verbally and physically abusive, which is so unlike him. I’m not accustomed to this behavior from my typically mild-mannered husband, and I’m afraid it could get worse. What are the best ways to handle aggression and agitation in dementia patients, before turning to antipsychotic medications? Thanks for your help!
A. Behavioral and psychological symptoms such as aggression are very common in dementia and affect up to 90% of people suffering from dementia. In addition to memory changes, people with dementia may experience agitation, psychosis, anxiety, depression, and apathy. These behavioral symptoms often lead to distress for everyone involved.
According to the Alzheimer’s Association, the chief cause of behavioral symptoms is “the progressive deterioration of brain cells.” Medication, environmental influences, and some medical conditions can also cause symptoms or make them worse. Depending on the type of dementia and the individual, behavior and personality changes such as irritability, anxiety, and/or depression can occur in the early or later stages of the disease.
When people with dementia become agitated or aggressive, doctors often prescribe medications to control their behaviors in spite of the known risks of serious side effects. The most frequently prescribed medication classes for agitation in dementia carry serious risks of falls, heart problems, stroke, and even death. There are also several non-drug approaches to managing behavior symptoms that promote physical and emotional comfort that can be considered first.
Research Shows That Non-Drug Therapies Are More Effective
According to a study in the Annals of Internal Medicine, non-drug interventions appeared to be more effective than medications in reducing agitation and aggression in people with dementia. Researchers found that:
- Non-pharmacologic interventions that were more effective than usual care included multidisciplinary care, massage and touch therapy, and music combined with massage and touch therapy.
- For physical aggression, outdoor activities were more effective than antipsychotic medications.
- For verbal aggression, massage and touch therapy were more effective than care as usual.
Medications are often prescribed as first-line interventions despite what we know about the effectiveness of non-drug options. As a result of this study, the authors recommend prioritization of non-drug interventions over medications, a treatment strategy also recommended by the practice guidelines of the American Psychiatric Association (APA).
Starting with Non-Drug Options
Consult with your physician to determine the best course of treatment for a loved one with dementia who is exhibiting aggression and/or agitation symptoms. If non-drug options are a starting point for your loved one, these are some things to consider doing:
- Notice the first signs of agitation (non-drug options work best the earlier they are used).
- Recognize that the person is not just “acting mean or ornery,” but is having further symptoms of the disease.
- Discover what works for your loved one by trying to stimulate, or de-stimulate, different senses.
- Modify the environment to resolve obstacles to comfort and calm, for example, by trying to reduce or eliminate excessive noise, strong smells, visual distractions such as glare, and background distractions such as a loud television.
- Monitor personal comfort by checking regularly for pain, hunger, thirst, constipation, full bladder, fatigue, infections, and skin irritation.
- Maintain a comfortable room temperature.
- Encourage positive behaviors.
- Allow adequate rest between stimulating events.
- Redirect the person’s attention and try to remain calm, flexible, patient, and supportive by responding to the behavior and not blaming the person.
- Go for a walk or on an outing for a change of scenery, as physical activity can benefit mood and memory, and lower anxiety.
- Try massage and touch therapy, which could be something as simple as a short shoulder massage or a light and calming hand massage or foot massage.
- Consider aromatherapy — first purchase a sampler of many different types of essential oils and then see which scent seems most appealing/calming to your loved one, then purchase an inexpensive diffuser that you can use to fill a specific area with that calming scent.
- For some, mundane activities such as folding (and refolding) laundry, or brushing/combing hair, may be calming.
- Listening to certain types of music or engaging in certain types of dancing can be calming for many.
- Educate all the people caring for your loved one on the interventions that work best, and check in with them about how these approaches are working.
- Involve the person in activities such as:
- talking about memories or looking at photos;
- meditating;
- coloring pictures;
- playing with or petting a trained animal
- Find a multidisciplinary team of specialists. This may include a geriatric psychiatrist to carefully consider the risks and benefits of medications for managing behavior, a regular geriatrician to optimize your loved one’s medical situations, and an occupational therapist to consider modifications of your loved one’s living environment and daily routine.
If medication is ultimately needed, work with the doctor to monitor response and side effects; and talk to the doctor regularly to see if symptoms have improved.
Caregivers can learn to understand symptoms better and improve communication skills with the person living with dementia. By learning how to care for and cope with the symptoms of agitation and psychosis, families can reduce their sense of burden and improve their own well-being.
Additional Resources About Aggression and Agitation in Dementia
The following are additional resources that may be helpful:
- The Alzheimer’s Association webpage: Features resources about behavioral and other challenges in dealing with dementia and also connects to local chapter resources and events.
- Alzheimer’s Foundation of America: Partners with 1,700 member organizations, focuses on increasing the quality of care for people with dementia, and features a tip sheet titled Behavioral Challenges: Coping with… Anger and Aggression.
- Alzheimer’s Society: Provides resources to individuals and families affected by dementia and has provided a Factsheet: Dementia and aggressive behavior, which is available in both print and audio versions.
- Dementia Today: Provides information and resources about caring for someone with dementia. Their post Dementia and Aggressive Behavior details tips to deal with the behavior and to promote self-care for caregivers.
If behavioral therapy has been unsuccessful, there are of course medications that can help, and there are also some ongoing clinical trials for drugs that are being tested to help people with Alzheimer’s who are suffering from behavioral disturbances:
https://clinicaltrials.gov/ct2/show/NCT03620981
https://www.otsuka.co.jp/en/company/newsreleases/2021/20210413_1.html
Medicaid Asset Protection for Loved Ones with Dementia
Do you have a loved one who is suffering from Alzheimer’s or another form of dementia? Persons with Alzheimer’s and their families face special legal and financial needs. At the Farr Law Firm, we are dedicated to easing the financial and emotional burden on those suffering from dementia and their loved ones. We help protect the family’s hard-earned assets while maintaining your loved one’s comfort, dignity, and quality of life by ensuring eligibility for critical government benefits such as Medicaid and Veterans Aid and Attendance. Please call us when you’re ready to make an appointment for an initial consultation:
Fairfax Medicaid Planning: 703-691-1888
Fredericksburg Medicaid Planning: 540-479-1435
Rockville Medicaid Planning: 301-519-8041
DC Medicaid Planning: 202-587-2797
About Evan H Farr, CELA, CAP
