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Anger and Agitation

People with dementia may become agitated, angry, and even verbally or physically aggressive as the disease progresses.

Problems and Solutions: Anger and Agitation

Communications and Understanding

Are they anticipating an event, such as a visit from a relative or to doctor?

You may not be able to tell someone with dementia about an event days before it takes place, because the anticipation may create stress and anxiety. Informing the person about the event closer to when it will occur may reduce or eliminate stress.

Are they frightened or uncomfortable when you touch them?

While touch can be calming and reassuring, some people can misinterpret it. People with dementias like Alzheimer’s can also experience hypersensitivity to touch. If so, it may indicate an inability to correctly identify sensory input. These issues can also cause resistance to bathing, as person has trouble properly identifying the sensation of hot and cold or even water hitting the skin during a shower. It can also cause anger or agitation.

There are things you can do to help manage issues with touch.  Always approach from the front and then get their attention by making eye contact before touching. Tell them in simple terms what you are going to do. For example, before combing or brushing their hair, show them the comb before using it and gently talk them through what’s happening. For bathing, you can try pouring a little water gently over the person’s hand to show that the water won’t hurt them.

Are they looking for reassurance?

Sometimes repetitive questions or actions may be a cry for reassurance. Try a gentle touch or hug if the individual is okay with being touched. Reassure them that everything is fine, and then try redirecting them with a conversation or activity.

Are they picking up on their caregiver‘s anger or impatience?

Caring for a person with dementia can be stressful. Be aware of your tone, facial expressions, finger pointing and head shaking. Your frustration is easy to sense and can lead to agitation, refusing help, and other negative behaviors. Caregiver burnout is very high when dementia is involved. Be aware of your stress level and get relief before the situation becomes overwhelming.

Are they reacting to being corrected, lectured, or told no?

Verbally correcting an inappropriate behavior can lead to agitation. Rather than scolding or yelling, speak in a calm voice. Often your tone alone can trigger unwanted behaviors. In some cases, distraction can work better than trying to correct the behavior. If it happens regularly, look for triggers. It is better to prevent the problem than to try to correct it.

For example, if someone with dementia always grabs toilet paper on the way into the shower, the normal tendency is to “correct” the person and take the toilet paper away. Instead, before the person attempts to grab the toilet paper, hand over a washcloth or a hand towel, something that can easily be used in the shower. Alternatively, move the toilet paper so it isn’t easily reached on the way to the shower.

Try to avoid saying “no” to unwanted behaviors. Remember they are still an adult and will not like being constantly told what to do. If you know this is an issue, try to be prepared with pre-planned responses that will help redirect them. Using redirection will help relieve this problem. Also, try to avoid situations that are known triggers for agitation, screaming, and other unwanted behavior.

Are you speaking too quickly or hard to understand?

If you speak too quickly or are hard to understand, wandering, repetitive behavior , or refusing assistance can be a coping mechanism. Make sure you speak in a calm, clear manner. Be aware that hearing loss is common in seniors. If you suspect that the individual may not hear well, contact a health care professional.

Could they be feeling rushed?

Due to changes in the brain, making decisions and performing tasks can take much longer. Waiting for them to complete a single step of a task may be frustrating to you, but it is important to allow them to do as much on their own as possible. For decisions, give them up to 90 seconds to think things through.

If you are impatient or feeling frustrated, they can easily sense it and become agitated. Be aware of your tone of voice and your body language Take a quiet, calm, matter-of-fact approach with your communication. It often takes much longer to eat or perform routine tasks, so allow plenty of time and stay as patient as you can.

Remember to give the person with dementia a chance to get involved. While it may take more time to assist someone rather than doing it yourself, the extra time is well worth it. Doing as much as they can themselves can make them feel less dependent and enhance feelings of pride and self-esteem.

Try to speak in a calm, friendly tone and avoid complicated phrases. Do not talk down to someone with dementia or treat them like children.

Environmental

Are they bored or lonely?

If the person is living an isolated life, they may need more activity and human interaction. Try gradually increasing walks, visits by family or friends, and introducing additional activities to see if it helps reduce the problem.

Find activities they enjoy and find stimulating and try changing them up daily to avoid boredom. Consider past skills and interests when choosing activities and adapt them as necessary. Even doing part of an enjoyable activity can be beneficial.

Are they disoriented by the darkness or shadows?

Darkness and shadows in their bedroom at night can cause confusion, disorientation, and hallucinations. On the other hand, too much light in their bedroom can cause problems getting to sleep. Night lights can cut down on confusion should the person wake at night, and help prevent falls if they get up to go the bathroom. You’ll need to adjust the lighting to see what works best.

Are they in a new home or environment?

Changes or disruptions to the home environment can cause confusion or agitation, even hallucinations or paranoia. If they are in a new or unfamiliar environment, place familiar objects, furniture, and pictures around to make it feel more like home. Keep rooms easy to get around and uncluttered. Label rooms using door decorations and name plaques. For example, post a picture of a toilet on the bathroom door. Conversely, you may want to disguise or cover exit doors.

Could the temperature be too hot or cold?

Remember that what is comfortable to you may be either too hot or too cold for someone with dementia. In general, you’ll need to keep the house warmer than usual, especially the bathroom and bedroom while they undress.

As the disease progresses, they may also lose the ability to distinguish between hot and cold. When combined with the inability to verbalize, this can make it difficult for a caregiver to pinpoint the issue. Try playing with the room temperature or adding/removing layers of clothing to see if that helps.

Could they be afraid of poorly lit rooms and shadows?

Poor lighting can create rooms that are unfamiliar and frightening. In addition, shadows can be misinterpreted or scary. Make sure the living area is well lit and remember that older people usually require more light than younger folks.

Is a friend or family member out of sight?

Not being able to see or find a certain family member or friend may make the person with dementia feel lost, forgotten or insecure. It can also lead to agitation or angry outbursts. Speak in a reassuring voice and tell him/her that the person he/she is looking for is okay. Try to redirect the conversation with food, drink or an activity.

Is every room, including the bathroom, well and consistently lit?

People with dementia sometimes see things differently than those without dementia. Make sure there is adequate lighting, especially in the evening. The home may require brighter lighting than you feel is necessary.

Sometimes a room that is not well lit will create problems for someone with dementia as they may be unable to recognize the food on their plate, recognize people they would otherwise know, see their clothes in a drawer, or locate their toothpaste. In the extreme, shadows can feed paranoia and hallucinations.

It is also helpful to have the same level of intensity from room to room. That way they don’t have to adjust to different lighting levels when they enter a closet or bathroom, which can cause agitation.

Is sensory overload an issue?

Too many people, excessive activities, and noisy environments can lead to agitation, wandering, and other unwanted behavior. While keeping the person socially active is beneficial, it can also cause stress. Try limiting the number of people they interact with, as well as avoiding noisy situations to see if that helps.

Is their clothing making them physically uncomfortable?

Being uncomfortable can cause wandering, agitation, or repetitive actions. If the person is pulling or tugging on her clothes, change the person’s clothing and see if that stops the behavior.

Health

Are they getting enough fluids?
Not drinking enough fluid is very common, even for people not suffering from dementia. However, people with dementia may forget the last time they had a drink and their brain may not be getting the message from their body that they are thirsty. Dehydration can cause confusion, agitation, dizziness, and irritated bladders, just to name a few of the associated problems. These associated issues can also lead to incontinence. Remind them to drink regularly and offer foods that contain fluid, such as popsicles, Jell-O, and fruit.
Are they getting enough physical activity and exercise?
Exercise is beneficial for physical and mental health and can improve the quality of life for people in all stages of the condition. Regular physical activity helps keep their muscles, joints, and heart in good shape. It also helps people stay at a healthy weight and have regular toilet and sleep habits. Adding more exercise may also help curb negative behaviors, including wandering.
 
Go for a daily walk at a park, around the neighborhood, or at the mall. As the disease progresses, you will need to adjust your routine. Later stage activities could include assisting with simple tasks around the house, riding a stationary bike, seated leg raises, anything that is safe and keeps them moving.
Are they hungry?
People with dementia are often unable to identify or express hunger. This inability often leads them to wander, become agitated, loose sleep, sundown, or engage in other problematic behaviors. Adhering to a schedule for meals and snacks can help eliminate this as a cause. It’s also helpful to track how much was consumed and to note the time of day, especially if it’s difficult to get them to eat on a regular schedule.
 
If they don’t eat a lot or refuse to finish their food, try preparing smaller meals and offering food more frequently throughout the day. You can also keep snacks accessible on counters, rather than in cabinets. If they see the food, it may serve as a nonverbal cue to them that they’re hungry and should eat.
Are they overtired?
Adults with dementia can become agitated, begin to sundown, or even simply scream when they are overtired. It’s similar to when we get cranky from fatigue. Focus on ensuring that they are well rested by addressing any nighttime sleep issues. Try postponing tasks and activities it until they’re better rested and more willing to participate. If they aren’t sundowning or having trouble sleeping at night, consider having them try napping after lunch.
Could depression be an issue?
Depression is very common in seniors, including those suffering from dementia. Even if someone has never been diagnosed with depression, you may want to speak to the person’s health care professional about your concerns and possibly have the individual evaluated. If the person has been prescribed medication, make sure it is being taken regularly and as prescribed.
Could one of their prescription medications be causing or exacerbating the issue?
Did wandering, agitation, or other problematic behavior begin after a medication change? Could one medication be interacting negatively with another medication? Drugs also have side effects, which can include behavioral problems such as agitation or physical ones like incontinence, motor skill impairment, tooth or gum irritation, or difficulty sleeping. Repetitive actions like sticking the tongue in and out can also be caused by certain medications. Keep in mind that some drugs affect people with dementia differently. Speak to a medical professional immediately if you have any concerns with the medications they are taking.
Could poor vision or hearing be part of the problem?
Poor vision and hearing can leave people with dementia frustrated, scared, or confused. It can make routine tasks like dressing, bathing, or meals more difficult. It can also lead to “hearing noises” which are normal daily sounds, or misinterpreting things like shadows. These misinterpretations can lead to further agitation or even hallucinations.
  • Make sure they wear their glasses and hearing aides to help them function better in their environment and when traveling outside the home
  • Explain any misinterpretations, such as, “That is just a shadow. See how it disappears when I turn the light on” or “that pounding noise is the men working outside.”
  •  Have vision and hearing checked regularly by a professional
Many people with dementia also develop monocular vision, meaning they see with just one eye. As a result, they have no peripheral vision or depth perception; they see only what is directly in front of them. Color contrast is also a problem, so try to avoid plates that are the same color as the table or placemats, all white in bathrooms, white toothpaste on a white brush, etc.
Could they be suffering from a physical illness or ailment such as the flu, an infection, or arthritis?
A physical illness or ailment can often be an underlying issue that they can’t or won’t communicate. For example, a physical problem could be making it uncomfortable or difficult to perform certain tasks, or put them at high risk of falling. Remember that an individual may be unable to express discomfort; therefore, you may need to look for clues and work with a healthcare professional to determine potential causes. Things to consider include an infection, constipation, illness, urinary tract infection, and bruises.
 
Schedule a medical work-up to see if a health issue may be a contributing factor. Make sure the person has been seen by a physician and is taking any medications prescribed, including over-the-counter medications.
Do they need to use the bathroom?
Make sure they aren’t wandering, agitated, or verbalizing because they need to use the bathroom. Look for signals such as fidgeting with clothes. At night be sure the bathroom or a commode is easily accessible.
Have they soiled themselves?
Check to see if they may be uncomfortable due to a soiling accident. Keep in mind they may be unable to verbalize the discomfort. If accidents occur regularly, consider instituting a regular toileting schedule to minimize accidents. Also check regularly to make sure the person is clean and dry.

Task Related

Are activities too childlike?
Activities are very important, and a well-structured activity program can make a huge difference in creating successful outcomes. While you do not want to overwhelm the individual with complex tasks, you also do not want to treat the person like a child. Find activities that are level appropriate.
 
If you cannot find adult activities, have the person perform activities with or for the grandchildren. Assure the individual that she is “so great to do this project for little Johnny. He is only four, and I know he is going to love it! You are such a great grandma!” This will help to build confidence in the person with dementia while not being demeaning.
Are they trying to avoid a difficult or unpleasant task?

As the disease progresses, tasks that were once simple may become more and more difficult. Don’t expect them to do everything they used to do. Simplify tasks by breaking them down into small, easy steps. Explain each step clearly using gestures and demonstrations. If they are unable to complete the entire task, have them do as much as they can.

Are they unable to complete tasks?

The inability to complete tasks that were once easily accomplished can lead to anger, frustration, and negative behavior. Try simplifying tasks by breaking them down into small, easy steps. Explain each step clearly using gestures and demonstrations. If they are unable to complete the entire task, have them do whatever they can. The goal may not be to complete the task, but rather to participate. For example, when doing a puzzle, the goal may be to talk about the picture on the puzzle, rather than completing the puzzle.

Does they feel useless, left out, or helpless while watching others work?

Have them perform tasks they are capable of doing. Involve them in household activities, such as folding towels and washing dishes. Thank them for their help and be reassuring.

Has there been a change in routine or schedule?

Consistency is extremely important with Alzheimer’s or a related dementia. Any changes to the schedule or routine can cause confusion and agitation. Families often think getting mom out or having a party for her will make her happy, when in fact, it may cause problems. When performing an activity that is not part of the normal routine, make sure the person is well rested and comfortable. Go to extremes to make sure the person is not agitated prior to the new activity.

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