Anger & Aggression

ANGER and AGGRESSION

The sudden flare of anger is common with dementia patients and somewhat unpredictable; and sometimes that anger results in an aggressive act.  These are common enough to provide many stories; happily most of the time violence is prevented by appropriate intervention.  Some examples: 

Beverly had completely drunk her preferred Dr. Pepper that I had brought her.  We were in a large room without drink dispensers and the only handy soft drink was Diet Coke in a pitcher; I poured that into her glass.  She drank a little, spit some of it out, said it was awful, and then was furious with me, stating loudly that that I had tried to poison her.  Shortly she settled down some, but remained agitated for 10 – 15 minutes.  She had drunk Diet Coke many times before without incident.

One easily angered man (call him Mr. Angry) was sleeping in his room early in the evening.  Another man (call him Mr. Confused) was roaming one evening; he was lost amd  started to enter Mr. Angry’s room.  I was right across the hall and I said to him. “Don’t go in there.”  That had no effect, so he continued, then began pounding on the wall, one of Mr. Confused’s interesting“habits.”  I kept telling him to come out, without yelling, for fear of waking up Mr. Angry.  Finally a young female caregiver heard me and entered the room; she took Mr. Confused out, just as Mr. Angry awoke and immediately said in the loudest voice imaginable, “What the F…is going on?”  Then he moved quickly to the door , though too late to catch the intruder.  Then he asked me very loudly “Where the F…did he go?”  The invasion and pounding would awaken and perturb any of us, though not likely to the point of the physical attack that nearly happened.  The level of anger was very intense and there would have been physical violence if Mr. Confused had not been removed as quickly as he was.

One morning the same Mr. Angry was ready to strike Beverly. She had reached over and picked up his coffee cup at breakfast; he got up to attack her and someone intervened to prevent an attack, which was likely according to reports. 

Early in our time at the facility I was in the front lobby and the staff person regulating the door went to the front of the lobby to let some people out under her direct control since one man (Mr. Escape) was hanging too close to the front, obviously looking for an opportunity to escape.  As she turned her back on him to open the door with a code, he suddenly decided to charge her from behind.  I was just close enough to step over and place myself directly between them (with very little room to spare) and facing him.  My hands were at my side, he quickly raised both hands and struck me in the lips, luckily not full force, so there was only minor bleeding.  The staff all told me, “Don’t do that again,” as family are supposed to stay out of any confrontation. But many of us would the same action to protect someone, though next time I would put my hands up defensively in front of my face.

I was walking with Beverly in the facility; she grabbed a passing man’s hand and started walking off from me.  I came to her and said, “Can you come with me?  It hurts my feeling when you just run off like that.”  She was mad and said a few very angry things to me.  So I left.

Or one day I was simply trying to get her to eat enough of her lunch and said, once too often, “just have one bite.”  She was quickly upset and said angrily, “I don’t want any of that.”  But her anger passed quickly.

            I have a particularly striking memory of having an argument that erupted into dangerous anger; this was from well before we went to the Memory facility.  In the Summer, I told Beverly we would go to this top of the line department/clothing store to get her a new watch since she lost her good watch and her birthday was approaching.  As we drove there, she noticed I was wearing shorts and told me that I could not wear shorts into this fancy store, and  insisted that I must go back to the house and put on pants.  I disagreed and the discussion went back and forth; I was not conceding. She became angry as I was not giving any ground.  Then, in her anger, she strongly grabbed the steering wheel and tried to pull it forcefully toward her.  Fortunately I had both hands on the steering wheel and resisted just enough.  We were on an access ramp to the interstate and almost up to freeway speed; a minimal turn to the right would have resulted in violently hitting a tall concrete wall less than 3 feet away.  Luckily that was averted.  Of course, when we arrived at the department store, many men were wearing shorts.  I didn’t even mention that to her.  I now know I should NOT have argued about whether I could wear shorts there; the right reaction was “OK, I’ll change” and then continued on to the store, as it was all quickly forgotten.  As Jolene Brackey wrote in her book Creating Moments of Joy, “…you are wrong and the person with dementia is right.”  That sounds terrible and even difficult to manage, but it the accepting reaction could save a disaster or at least avoid an angry reaction

More than normal folks, many of those with dementia have times when there anger is on a hair trigger.  Sometimes it is a drug that was not administered soon enough, sometimes fatigue, sometimes other incidents..  But often it is hard to predict.

What can we make of this and many, many more?  Some of it is unpredictable as the Diet Coke incident illustrated.  Also, there are enormous individual differences, as Mr. Angry shows.  Experienced people who work with dementia patients are amazingly skilled at cooling such people down.  The rest of us can learn from experience as well.  Certainly, do not challenge or even continue to disagree with them, even if the issue is very minor and anyone else would agree with you.  Don’t invade their space or food/drinks, even if they don’t mind invading yours.  Most of all, stay calm, assuring your loved one or others with dementia that everything is fine.  Nearly always calm will prevail.  And it is important to know that, as with children, many emotional reactions, including anger, often come and go very quickly. Strong anger, if embraced by calm assurance, can go away almost instantly.  Nonetheless there are individuals in particular situations who are beyond behavioral management for their aggression.  Mostly calm will be effective, but there are exceptions.

            So, what are the common trigger points?  What are the matters that set dementia people off?  These matters vary from important to virtually nothing, and of course vary with the individual.  Unhappily there is less predictability than one would like.

  A major issue is being told what to do, especially when coming from a close relative (spouse, son or daughter, sibling), especially the one who is the main caregiver.  And this includes more than being told, such as grabbing a hand to take them somewhere.  And, of course, the reaction is not entirely predictable.  As with normal folks, it depends upon “timing.”  If they are busy with something, such as Beverly’s “work” (meaning efforts to help someone), then telling her we are going to lunch may set something off.  Obviously repeating the request aggravates the matter, as does getting frustrated with them, as I have done too often.  It is best for someone else to make such requests (this is called the “Third Party Advantage”).  

Another major issue is disagreeing with them.  If they say something that is clearly wrong, a single effort at correction might be OK.  But don’t try a second time!  Simply accept their statement as true.  This may be difficult for those (such as me)who like for matters to be correct.  But ultimately it is not worth the emotionality for most issues.  As I once heard Dr. Fehlauer (the facility physician) say,  “Do not disagree with them unless the issue is about immediate physical danger.”

And don’t be in a hurry about anything, such as getting out on time to meet someone for dinner or a doctor’s appointment.  As soon as Beverly is told that we are in a hurry, there is a tendency to freeze up and, if pushed a bit more, get angry.  That is true of others with dementia.

And, obviously there are issues related to failure by them, namely not being able to do something they should be able to.  Obviously there are failures, increasingly as their capabilities decline.  There does come a point in the deterioration when they are no longer aware of their failing,  In Beverly’s case, the striking example was being tested, either by staff or the insurance person. The standard mental status questions and the more elaborate Mini-Mental State Exam were not at all happy for her; she knew she was failing at them.  The last time I can remember where she actually was tested to the end was well before her Alzheimer’s was advanced.  But she was angry after the test when she was given a block of wood and asked to describe it. She told me afterwards how mad that made her.  “That is so stupid.  Of course, I know what it is, etc.”  After that, she always refused to be tested. Failing at something is frustrating to us all, and more so for those with dementia.

And certainly being treated like a child is a trigger point.  This is mostly about tone of voice and other nonverbal cues, including physical stance.  But it can involve what is said too.  The best approach is to be very direct, calm, and clear, but not talk as if you were instructing a child or a dog.

Residents, as others, also are disturbed by which person is attached to whom, perhaps “romantically.” While not much generally happens beyond holding hands, it can be a trigger for one of the woman to feel that this guy is mine mostly because they walked around holding hands and sat together.  Then when she sees him walking off holding hands with other woman, there is anger.  And this is for all about participants who are residents of the facility.

And, guys, it is mostly us men who are violent.  In all the time I spent visiting the facility, virtually every violent act was from a man.  There was one physical confrontation between two women out of dozens of violent acts I knew of directly.  And many of the men (certainly a third or more) had difficulty over some violent outburst or fight.  And for those with a diagnosis of frontotemporal dementia (a diagnosis different and much less common than Alzheimer’s), the problem seemed especially high.

Another reason for violent events related to the necessity of giving drugs on a timely basis.  Indeed, a delay long enough for the drug to somewhat wear off often resulted in a battle over it being administered.  Of course, on that front, the physician’s (Dr. Fehlauer) serious task was figuring out which drug and how much needed to be administered to control the violence and still maximize the patient’s functioning otherwise.  Dr. Fehlauer strongly opposes sedating people unless absolutely necessary to prevent violent attacks.  The use of drugs is a delicate balance if done ethically.  We should all agree with Dr. Fehlauer’s attitude, but (based on reports I have heard) some other facilities do manage many of their residents with excessive drugging.  Staff members can head off most violence with careful appropriate interventions.

Then there are the truly lesser issues.   A common one is taking something that is someone else’s, often as simple as a piece of bread or a drink.  Residents do this with a high frequency as they seem to lose track of normal boundaries and of the reality of what belongs to someone else.  There was the coffee cup incident described earlier.  The failure to manage normal boundaries is common with many; the issue seems to be keeping track of whose plate of food, glass or cup, silverware is whose; usually this is not consequential.  

On another occasion, Beverly was in a physical confrontation with a male resident because she grabbed his walker.  When he grabbed it to keep it in his possession, a tussle ensued.  And he ended up on the floor.  Taking someone else’s walker or wheel chair is a common cause of outbursts and at least near fights.

            And, of course, issues of who is currently entitled the attention of someone else, such as the nurse or caregiver.  Once, when I finally found Beverly’s current caregiver and asked her about evening events, the resident she was walking with had an angry outburst, stating that “she is with me” and “we are going off to do…” something or other.  Usually waiting with Beverly for the nurse to give her the medications goes fine if others are waiting too, but not always.  Similarly the demands by multiple residents for the care of anyone who helps many different people eat, get up in the morning, get ready for bed, etc.  But sometimes they become angry about not getting the immediately demanded help now, of course.

And I have seen many angry outbursts over whose room this is.  I was in the building when a woman was screaming in her room.  A caregiver went in the room to find a large man hitting the woman in the face.  And, according to reports, he had gone in her room and told her (wrongly) that this was his room.  When she objected, his anger erupted.  These events of mistaken room are not uncommon, in part because many residents do not know where their room is.

Clearly anger and aggression are serious matters in any Memory (dementia) facility.  How the behavior is managed/mitigated by calm and effective staff is critical to the overall atmosphere of any facility.  And, in addition, it is critical how the physician and nurses manage selecting and administering the right drugs to minimize emotional reactions and dangerous behaviors.