Whether you are a PT, OT, SLP, Nurse or nursing tech- you will invariably be working with dementia patients over the course of your career. Feeling comfortable and capable caring for dementia patients is crucial no matter whether you’re working in acute, sub acute or a long term setting. A huge fear for caregivers is not knowing how to deal with a dementia patient who is becoming aggressive, or even worsening the situation.
Dementia can be an extremely intimidating and challenging condition to treat.
It can be unpredictable, heartbreaking, and the breakdowns in communication are intensely frustrating both to the person with dementia and to the person caring for them. Check out our (free!) Tips for Effective Interactions here for some guidelines on managing interactions with patients with any altered cognitive status.
Effective communication is becoming all the more relevant with each passing year- we all know the population is rapidly expanding and aging, and with that has come a massive increase in those with dementia. Right now, 1 in 3 people over 65 are affected by dementia- totaling about 5.3 million Americans. By 2050, that number is expected to increase to 14-16 MILLION! (and just to help wrap your head around that- 2050 is closer to us right now than 1989!)
There are many behaviors that a patient with dementia can have that can be ‘challenging’ to us as caregivers. How do we deal with a dementia patient who is aggressive? Agitated? Constantly repeating questions, wandering, or any number of other behaviors that we cannot figure out?
First, we should understand that behavior is just a way of trying to communicate, when other channels (like language, memory, problem-solving, orientation) have failed.
By being able to communicate better with these patients, we are going to exponentially increase their happiness and satisfaction, as well as our own. Bridging the chasm of broken communication will be one of the most effective ways we can reach our patients and help manage these disruptive behaviors.
How can we boost our communication with this vulnerable population?
1. Don’t ask Questions
Remember those cartoons where the hero got stuck in quicksand? A person with dementia is constantly trying to find their footing on a ground that is always shifting beneath them. Their fundament of understanding of themselves and the world around them is moving or slipping away- and when they try to figure out what they are “missing”, it causes, understandably, great upset. Any question we ask them, no matter how casual, will trigger this sense of worry and discombobulation. Think about it- If I ask you: “How was lunch?”, it requires of you to know: that you had lunch in the first place; what it was; if you ate it; if you enjoyed it; why you can’t remember it; whether you have even eaten today; in fact, whether you have eaten at all in weeks? These fleeting thoughts are impossible to hold onto and the fact that the answers may not come readily is extremely upsetting to someone with dementia. Essentially, it forces them to face the fact that they CANNOT REMEMBER LUNCH. This can cause a cascade of anxiety and emotion that can trigger behaviors like agitation, or eventually aggression. When you are working with someone with dementia, never, ever ask questions!
2. Never Contradict
Contradiction also challenges the dementia patient’s world view, and can throw them into unpleasant anxiety or confusion. Re-orienting the patient forcefully can also be extremely uncomfortable. At times, we want to be contradictory if we feel our patient is upset, for example “I want to go home” “But Mary, you can’t go home, remember, your daughter can’t take care of you anymore”, or “I need to get the train now” “What do you mean, there isn’t any train here!”. However, we can see that by explaining these realities to our patient, they are again forced to try to examine why their version of reality is not matching up to what they are being told. This can again lead to disruptive behaviors and a very unsettled person. Instead, we should nod and agree, smile and be comforting, and if necessary, try to redirect the person.
3. Redirect
Redirection is going to be one of the most effective tools in your chest, as you will be able to meet your own care goals, while keeping your patient from getting upset or agitated. Key to being able to redirect your person is being able to meet them where they are at. If your patient is convinced that they are “late”, then you should be focused on ‘helping them’ where you may begin by ‘taking them’ somewhere, and as you are walking with them, that you can start to discuss something you know to be a topic that they love to engage in. Similarly, if your patient is asking you where their husband/wife/son/daughter is, you can engage at that level, “hmm, I think he is still at work, but he should be home soon”, and then begin to redirect into a favorite topic or an experience you know they find enjoyable.
4. Learn from the Expert
Knowing information about your patient with dementia is going to be crucial to being able to skillfully redirect them or engage in their favorite activities. Think about what you know about them- at the very least you will know that they are an adult with a lifetime of experiences, who will expect a certain level of social respect (and believe me, will know if they are not receiving it!). You may also know if they are a parent, grandparent, perhaps their kids names, or their profession. You may know some hobbies or activities they love to do/talk about, places they have lived or communities they are a part of. Communication between all the people who are caring for this person is going to be really helpful to build a more comprehensive picture, and be able to summon up some of these topics of conversation for redirection or in order to be able to meet other care goals.
5. Recycle Acceptable Experiences
If your person enjoys flipping through their photo album, watching their favorite performer on TV, or talking about their garden, we should never stop doing it! A person with dementia will continue to derive a lot of satisfaction out of the exact same tasks again and again, without any need for novelty or newness. This can’t be undervalued! If we have a deck of acceptable experiences that we know our person is going to love, we should be willing to dip into them frequently and understand that every time is going to be comforting and enjoyable each time. Keep ‘acceptable’ activities, which you know makes your person happy, near to you. Use these acceptable experiences to help meet your therapeutic goals in other ways- such as, if you are leafing through the wedding album with your dementia patient, you can layer in breaks for drinking water and having a snack; or cutting their nails; etc.
Many of the ‘challenging’ behaviors that are associated with dementia are related to poor communication. Improving our communication with dementia patients is going to help them feel much safer and more comfortable, and help us to feel more effective and less intimidated.
We talk much more about communication techniques, how to deal with dementia patients who display aggressive behavior, and how your language and perspective may be holding you back in our fantastic one-hour webinar, ‘Settled and Secure: addressing ‘challenging’ behaviors associated with dementia’. Check it out, or get our free Care Approaches cheat sheet right here!
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More great resources for further reading about how to deal with aggressive or challenging behavior with your patients with dementia:
- Contented Dementia: by Oliver James.
- Spencer, S; Johnson, P. (2016) De-escalation techniques for managing aggression. Cochrane Database of Systematic Reviews 2016, Issue 1
- Jablonski, R et al (2011) An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist 31(3):77-87
- Kaufmann, E; Engel, S. (2016) Dementia and well-being: A conceptual framework based on Tom Kitwood’s model of needs. Dementia, 15(4):774-788
- McCrae et al (2019) The Specialized Early Care for Alzheimer’s method of caring for people with dementia: an investigation of what works and how. Scandinavian Journal of Caring Sciences, 2019 (12)
- Wong et al (2018) Applying the Person-Environment-Occupation Model to Improve Dementia Care. AOTA Continuing Education Article, May 2018