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Aggressive behavior in Alzheimer’s residents: causes and interventions

Patient talking with caring clinician

Aggressive behavior is a common behavior among Alzheimer’s and dementia patients in nursing homes. Staff sometimes struggle with how to manage these behaviors. Here are some ideas that can help.

Aggression can be resident-to-resident aggression (RRA) or resident-to-staff aggression (RSA). RRA is defined as aggressive physical, sexual, or verbal interactions between long-term care residents.

Risk factors for RRA

Some common risk factors for RRA are:

  • Male gender
  • Behavioral disturbance (especially wandering)
  • Moderate functional dependence
  • Cognitive Impairment

We also find that patterns of aggressive behaviors can vary by dementia diagnosis. For example, those with vascular dementia have a high incidence of agitation and aggression. In addition, patients experiencing depressive or delusional symptoms, hallucinations, or physical symptoms such as constipation or pain are at higher risk of developing aggressive behaviors.

How to respond to aggressive behaviors

Behavioral challenges are as unique as each individual patient and are influenced not only by medical condition(s), but also by medications, the environment, interactions with others, and the psychosocial landscape of a person’s experience. It is important to understand the patient’s experience and to recognize the suffering that may accompany aggressive behaviors.

Strategies that can help:

Be proactive. Try to identify and address unmet needs before they escalate. Often, there are early warning signs.

Remove triggers. A trigger for an individual could be environmental, such as uncomfortable ambient temperature, excess noise, overstimulation, or too many people nearby. It could be lack of privacy or the annoying behavior of another resident. Boredom, frustration, or fatigue can also be triggers for some individuals. Get to know your patients and learn what triggers can lead to aggression.

Manage physical symptoms. Remember that a patient with dementia may not always accurately express pain, physical discomfort, or even hunger. Recognize and address these symptoms as much as possible.

Be vigilant. Walk around the unit and observe residents. Avoid letting a group of staff become too involved in its own conversation.

Use eye contact and a pleasant tone. Staying positive and connected helps others do the same.

Practice self-awareness. This is critical. While it’s easy to feel stressed by aggressive behaviors, remaining calm is key. Avoid raising your voice. Instead, speak quietly. Use relaxed, open body language.

Approach in view. Face a patient when approaching him or her. Do not approach from behind, which can be startling.

Avoid reasoning or arguing. It works better to “go with the flow” when a patient expresses strong feelings. You are unlikely to change a person’s thinking, but you can influence a person’s feeling. Use reflective listening. Accept the patient’s feelings. Then you may be able to redirect the behavior.

Ensure safety. Follow your organization’s procedures around safety, which may include separating people, maintaining a safe distance, and getting help.

Focus on ADLs. RSA occurs most commonly when turning or moving a patient or assisting with ADLs. Stay focused. Be aware of privacy rights when you want to enter a patient’s room. It helps to use simple commands and let a resident respond to a statement before offering physical assistance. Remember to give residents space to engage in tasks independently when appropriate.

Learn from the patient. Aggressive behaviors can repeat. What have you learned that identifies patterns or triggers? Is there anything you can change in the patient’s environment? Are there situations you can watch for in the future? Team collaboration is very useful in this analysis.

Training in de-escalation

De-escalation is an important strategy in caregiving. The Joint Commission explains this concept as “a combination of strategies, techniques, and methods intended to reduce a patient’s agitation and aggression. These can include communication, self-regulation, assessment, actions, and safety maintenance in order to reduce the risk of harm to patients and caregivers as well as the use of restraints or seclusion.”

Staff training in de-escalation techniques can empower staff and help keep both patients and staff safe. Clinical psychologists from GuideStar Eldercare can provide in-service training for staff. (Read more about Behavioral Training for Dementia Care Staff.)

After an aggressive incident, it’s important to keep the physician and the clinical psychologist informed. If you are using the services of GuideStar Eldercare, you can take advantage of 24/7 on-call support in difficult situations. Get in touch!

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