Last Updated: October 8, 2014
Charlie Powell feels like he lost his dad a long time ago.
His dad who has Alzheimer's
disease, doesn't just forget who Powell is-he sometimes becomes
"Once, me and mom disabled his car so that he couldn't drive it,
and he soon realized what we'd done," Powell, 50, says. "He rushed
across the living room and literally growled at me like a bear in
the most frightful way. Thirty seconds later, he didn't know he'd
done it, and everything was fine."
The "bear incident" is just one of many that eventually caused
Powell and his family to put their 86-year-old father into a nursing home. "Once, the doctors noticed
that mom's eardrums were both ruptured, and they realized dad
probably slapped her upside the head and cupped her ears."
Unfortunately, Alzheimer's aggression is fairly common among
Alzheimer's patients. There's cursing, hitting, grabbing, kicking,
pushing, throwing things, scratching, screaming, biting, and making
strange noises. More than 4.5 million Americans are diagnosed with
Alzheimer's disease every year, and up to half can show some of
these behaviors. The number of total Alzheimer's sufferers is
projected to balloon to 16 million by 2050.
Alzheimer's aggression is one of the main reasons most people
put their parents in nursing homes. Fortunately, new medications
and coping methods can help, though agitation and aggression are
still a misunderstood aspect of Alzheimer's.
"The public thinks Alzheimer's is a memory disease," says Dr.
Ramzi Hajjar, a geriatrician at St. Louis University in Missouri.
"But, in fact, there are lots of neuropsychiatric symptoms.
Alzheimer's patients often develop delusions. They think their
family is stealing things from them, for example. And they get very
aggressive and irritable towards their spouse."
He stresses that families need to always remember that
Alzheimer's aggression really has nothing to do with them. "The
child always wants to take it personally, which causes unnecessary
anxiety," Hajjar says.
What's Behind the Behavior
No one knows for sure why some Alzheimer's patients lash out and
others don't, but one University of Kansas study showed that
recognition was the strongest predictor. Forgetting what something
was, or what was inside something, was the most common cause of
Other studies have shown that Alzheimer's patients sometimes act
out because of side effects like headaches, constipation, and
nausea from some anti-anxiety medications such as Xanax®
(alprazolam), Ativan® (lorazepam), and BuSpar® (buspirone).
Patients who can't communicate often express their discomfort from
those symptoms by becoming even more agitated and combative.
The first step in managing difficult behavior in the care for
Alzheimer's patients is to find out where it's coming from and what
it means. Does the agitation or combativeness mean the patient is
hungry or thirsty or scared? Is it a reaction to something
threatening or uncomfortable in their environment?
"I've seen people strike out because of their distress," says
Dr. Ruth Tappen, director of the Louis and Anne Green Memory and
Wellness Center at Florida Atlantic University in Boca Raton,
Florida. "Once, a Holocaust victim would have his memories return
at night, and he'd get aggressive, yelling and carrying on at his
wife; twice he even brandished a knife. He was defending himself
from long-gone dangers."
Other times, agitation starts when patients get frustrated with
themselves, as simple memories start slipping away. They might
forget where they put the keys, or what time their dinner
appointment is that night. After asking a few times, everyone
around them becomes irritated, and they get agitated.
But it's sometimes hard to know exactly why some lash out.
That's what author Jacqueline Marcell learned, the hard way.
Marcell, who wrote the book "Elder Rage" after an entire year of
experiencing her father's Alzheimer's aggression, says she grew to
learn what situations would trigger her dad's outbursts. But first,
it took a year of doctor visits to even diagnose him correctly with
Managing and Treating the Aggression
Using medications to manage aggressive behaviors in dementia
patients is considered very controversial. Doctors have tried
using traditional (first-generation) antipsychotic drugs such as
Mellaril® (thioridazine) and Haldol® (haloperidol), but their
effectiveness was limited and carried some unpleasant side effects
such as vomiting and nausea. Atypical," or second generation,
antipsychotics (such as Seroquel® and Risperdal®) have been found
to be somewhat more effective in reducing behavioral problems, but
they havenot been approved for use in dementia patients by the FDA.
In fact, the FDA has issued a warning in April, 2005 regarding
"atypical" (second generation) antipsychotics in dementia patients.
The warning states"that older patients treated with atypical
antipsychotics for dementia had a higher chance for death than
patients who did not take the medicine." Because this warning does
not actually prevent doctors from legally prescribing these
medications for this type of "off-label" use, it is extremely
important that families understand the potential risks involved and
proceed with caution.
Fortunately, drugs aren't the only answer. There are other ways
that you can improve your situation. The following are some
techniques and strategies that have helped many people successfully
care for Alzheimer's patients and manage the Alzheimer's
- Label and use signs, suggests Beth Nolan, PhD,
author of the University of Kansas recognition study (see
above:What's Behind the Behaviors). Place signs on rooms to say
what they're for, put name tags on guests when they visit, and put
labels on common items, like clocks and telephones. Tape
explanatory phrases on doors or cupboards to tell them what's
- Know what the triggers are, and try to divert
them. Typical triggers include getting people undressed
for showers-they find the shower rooms cold and echoing. Or, being
in a crowd can trigger the fear of getting lost. "If what you're
doing is causing them to react, stop and step away," says Patricia
Drea, RN, a 20-year eldercare veteran who works with Visiting
Angels, a company that provides in-home care for the elderly.
"Then, redirect them to another activity. Say, 'Here, let me help
you stand up,' then move them to the next thing you'd like them to
do." Try to distract the person with a pleasurable topic or
activity. Arguing will make things worse. If necessary, leave the
room and give the person time to calm down.
- Use logic and reason. "When my mom-who also
had Alzheimer's-left her watch in the sugar bowl, I didn't accuse
her," Marcell says. "Instead, I said, 'Mom, why is there a watch in
the sugar bowl?' She'd say, 'I don't know,' and I'd say, 'How do
you think it got there?' Using logic helped her a lot."
- Validate their feelings.Tell them it's OK to
be frustrated, or sad, or lonely.
- Use a gentle tone and reassuring touches.
Studies consistently prove this works. "Always smile, and look kind
and gentle," Drea says. "Your face is an important signal that
everything is alright."
- Stick to a regular routine. This will help
minimize the number of unexpected and stressful events.
- Ignore the angry behavior-if distraction and
support do not work. If the situation is threatening, make sure he
is unlikely to harm himself and stay clear until he calms
- Maintain a sense of humor. "Anticipating that
there will be ups and downs, and maintaining patience, compassion,
and a sense of humor will help you cope more effectively with
difficult behavior," says Catherine Johnson, PhD, a psychologist
who specializes in dementia at St. Joseph's Hospital in St. Paul,
Minnesota. "It's important to remember that it's the disease, not
the person, causing the behavior."
music. Sometimes singing an old favorite song can get
someone to calm down instantly. The American Academy of Neurology
recommends using music to reduce many problem behaviors. They say
it's most effective during meal or bath time. If you don't sing,
play a song from their old collection.
- Learn how to debrief after an incident and
identify what caused it. Ask yourself, "'What can I do differently
the next time, to avoid the aggressive reaction?'" Johnson says.
"Learn to resolve the emotional reaction you as a caregiver had.
Then, you can move forward effectively. Take care of
- Seek support for yourself as a caregiver.
Finding support groups and counselors to help you cope is one of
the most important things you can do. Not only can you help
yourself deal with the difficult times, some of the people you meet
may have some useful advice on managing the aggression. Some good
places to begin include The Alzheimer's Association (www.alz.org) and the Alzheimer's
Disease Education and Referral Center (ADEAR) (www.alzheimers.org).
Perhaps the most comforting thing about Alzheimer's aggression
is that, for many patients, it's a phase that will pass. While the
dementia itself is irreversible and will continue to worsen, for
many patients the aggressive behaviors do seem to subside over
time. Because this is a phase that can last for years, however,
trying to wait it out without dealing with the behaviors is usually
not an effective strategy for coping with the problem.
For some, the challenges of handling Alzheimer's aggression can
become too great, and they may decide that they must place their
loved one in a skilled nursing facility. Although this is never an
easy decision, those like Charlie Powell know they have done the
best they can, and that relying on the professional care available
in a nursing home is the smartest choice.
"I know my dad is getting the best possible care now," Powell
says. "And that's all that matters."