Dealing with anger and aggression in dementia

What is dementia aggression?

One change seen in people with dementia is an increase in anger and aggressive behaviors. This occurs in around half of all people with dementia, although this may vary depending on the dementia subtype someone is diagnosed with ^[2]. Often, as a person’s cognitive decline worsens, the aggressive behaviors they demonstrate will increase.

Dementia anger and aggression can be physical or verbal and are often directed at the person’s caregiver. This can cause issues in the way the caregiver is able to provide care. As a result, aggression can increase the discomfort of both the caregiver and the person with dementia ^[2][3].

Causes of anger and aggression in people with dementia

Emotional changes

Dementia can cause several emotional changes, such as depression, mania, fear, and agitation, all of which may increase distress and the risk of aggressive behaviors occurring ^[4].

Physical changes

There could be several reasons for anger that are related to physical changes a person experiences. For example, sleep and appetite can be greatly affected by aging and by dementia, so someone may become angry or aggressive when they are tired or hungry. ^[5].

Similarly, if the person is in pain, this could cause them to lash out in anger, particularly if they struggle to articulate the cause of this pain ^[5][6]. For people who require assistance with movement or may need some level of restraint, their pain may be exacerbated by this physical interaction, potentially causing them to react with aggression.

Relationship with caregiver

There is a great deal of research that suggests that the relationship between the person with dementia and their caregiver can have significant impacts on the development of verbal or physical aggression. Research suggests that an increase in caregiver burden directly affects the chance of agitation, depression, and aggression in their patient ^[6][7][8].

For instance, caregivers who have been attacked by the person they are caring for may feel an increase in the level of burden or fear they encounter. Whether knowingly or not, this can change their perception of the patient or the way in which they communicate, which could be noticeable and impactful to the patient’s behavior.

Environment

People with dementia may easily experience over or under stimulation ^[5]. For example, if they sit in the same chair with the same view for the majority of the day, they could feel under stimulated and bored, potentially causing an expression of aggression.

Similarly, they may feel over stimulated if they are surrounded by many people throughout the day, or are unable to be in a quiet, calming environment.  This can also happen after a change in routine, for example a different feeding or sleeping time.

Psychotic symptoms

Dementia can cause psychotic symptoms, such as delusions and hallucinations. This can increase the chance of agitation and anger occurring, particularly if these delusions lead them to become suspicious of others around them ^[3].  

For example, a person with dementia may believe someone is stealing from them, that their loved one has been replaced by an imposter, or that their partner is cheating on them. These suspicions may cause them to lash out at their caregiver or loved one.

Gender

Some research suggests that gender plays a part in the development of aggression in dementia, indicating that it may be more common in males ^[3].

Brain changes

Dementia causes a variety of changes in the brain, including the way in which certain neurotransmitters function. Some of these changes can cause feelings of anger, agitation, or depression ^[3].

Changes in the brain can also result in difficulty speaking or understanding others, which may cause frustration and lead to anger ^[5].

How to manage anger and aggression in people with dementia

Early intervention

First, try and find out if there is a clear trigger for their agitation or anger, such as physical discomfort, hunger, or loud noises, and try to resolve this if possible.

If there is no clear reason for their change in behavior, try to intervene as soon as signs of discomfort or agitation occur. You can utilize techniques such as relaxation or distraction before an escalation in emotion or behavior occurs. 

Environmental changes

It may be that the person with dementia is becoming distressed because of something in the immediate vicinity, such as loud noises, too many people, or something on the television ^[5]. Reducing their anger may be as simple as changing the TV channel or helping them move to a different area of the house or outside. 

Consult a specialist

Caring for a person with dementia can be challenging, especially as their condition worsens and if they begin to exhibit aggressive behaviors. You may wish to consult a specialist for help in managing their condition.

Occupational therapists (OTs) can help with day-to-day routines and mental stimulation, and assess the physical and environmental needs of the person with dementia. Their input could include therapeutic or calming activities, or making changes in the home for ease of movement, understanding, or communication ^[9].

Psychiatrists and mental health professionals can help with diagnosis and prescribing and administering medications.

Music therapy

Various studies suggest that music is able to help alleviate feelings of agitation and aggression in patients with dementia, within a group or just with the individual ^[10][11]. These studies also suggest that music therapy can help reduce the need for medications and help alleviate distress in these patients.

Try to play music that you know they enjoy, either from their past or something they have shown interest in recently. Singing along to this music can have even more positive effects and may encourage the patient to sing along with you ^[11].

Aromatherapy and touch therapy

Various studies have found that touch therapy and massage with the use of essential oils  can help to reduce feelings of anger and agitation in patients with dementia ^[12][13][14]. However, it’s important to be very careful of skin sensitivities when using essential oils on the body. For this reason, it’s best to leave this to a licensed massage therapist or naturopathic doctor.

It is important to understand what the patient is comfortable with before beginning any kind of massage or touch therapy. You must gain their consent to use this intervention. Some may enjoy hair brushing, hand, arm, or neck massage, and the use of scented oils, such as lavender or eucalyptus. 

Going outside

There is a great deal of evidence to suggest that being outside and engaging in exercise can help lift mood, and this is also true of anger within dementia ^[3][4]. Going for a walk or an outing with this person can help them feel calmer and happier.

Medication

It is widely accepted that medication should not be the first line of treatment for aggression and anger within dementia patients ^[3][4][15]. There is evidence to suggest that nonpharmacological approaches (intervention without medication) can be just as, if not more, useful in reducing distress ^[4][16].

Typically, older adults are at an increased risk of side effects and drug interactions from taking various medications. As such, medications should only be used when entirely necessary and the benefit is deemed to outweigh any associated risks ^[3]. Their doctor or health care provider can help weigh the risks against the potential benefits.

If a doctor does deem it necessary, they may prescribe the person with dementia one or more medications to help manage their symptoms.

This may include antidepressants, which can help reduce feelings of depression, irritability, and agitation, or antipsychotics to reduce aggression, agitation, and psychosis. It is important to note that antipsychotics can cause serious side effects and should be used with caution. Doctors may instead recommend anticonvulsant mood stabilizers since these medications target similar symptoms. Individuals with dementia may also benefit from short-term use of benzodiazepines to minimize acute instances of agitation and aggression ^[3][15].