Introduction

Once the person has our attention by agitated or aggressive behavior, it’s our job to sort out what’s wrong. You know what the common triggers are, but often, once we’ve addressed the common triggers there is a tendency to get frustrated and say, "We have addressed all that and he still screams at night. He needs medication.”

Instead, let's look are more options you have available.

1. Ask yourself, "What are the things I do to reduce fear in myself?"
2. Take a moment to pause and think about your answers.
3. Now ask, "How do I help reduce fear in others?"
4. Take a few minutes to pause and think about your answers.
5. Now ask, "What else can I do?"

Responding to Agitation and Aggression

Observe closely for just two or three minutes over several days. Listen to what the person says or sounds he or she makes. This can be very informative. Pay special attention to what was going on before the behavior began (often referred to as antecedents). This includes the person’s mood, the environmental conditions and who was present. Then huddle with the team and share observations.

Possible Interventions for Calling Out When Alone (verbal agitation)

If a person calls out constantly when he/she is alone (verbal agitation), and you have eliminated the usual suspects, try a social intervention and see if the behavior changes. This will help if the trigger is loneliness. If social intervention can’t be tried or doesn’t help, use an individualized approach to activity based care (Module 3) and see if the behavior changes. Maybe the trigger was boredom.

Possible Interventions For Aggressive Behaviors

Examples of aggressive behavior include kicking, hitting, biting, and punching that is clearly directed towards someone else. The most common example of this behavior has been labeled 'combativeness of care'. There are whole books written about it!

From the outside, we say things like “she’s being resistive”, “difficult”, and “uncooperative”. From the inside, she may just be afraid. But basically, whatever the reason is, the individual who has kicked, hit, bit or punched is telling you one thing—“STOP!” She wants you to leave her alone.

So you stop.

You don’t call in reinforcements. Instead, you stop, step back, take a deep breath, and consider what to do next. You may need to consult with a peer. You remind yourself not to take it personally even though she kicked you and it hurts.

You remind yourself that most aggression is a fear-based behavior. It’s driven by our old friend the amygdala, unchecked by a well-functioning cortex. The amygdala is supposed to raise the alarm bells when there’s a threat. It’s supposed to make us alert, wary, prepared to strike. The problem for the person with dementia is when both the amygdala and the higher brain centers are out of whack, they can’t sort friend from foe. So what can you do?

Ask yourself the following questions:

• "Is pain also involved?" Some research suggests better pain management is a particularly good way to deal with both agitated and aggressive behaviors.
• "Does the behavior happen more at one time of day than another?" If so, change the schedule.
• "Can the family caregiver shed any light?" Did this happen at home? What helped?
• "Does it happen more with some caregivers than others?" Watch their approach. What’s different about it?

The importance of body language cannot be overstated when thinking about how to reduce fear in persons with dementia. One’s body language can signal that you want to fight with the individual, or that you come in peace. Calm yourself before you calm others.

The signal breath is one technique you should try to master.

Pay attention to how you reduce fear in yourself and in others. Here are a few ideas to help you get started:

• Make sure the person is fully awake and aware of her surroundings before you try to do personal care.
• Knock before you enter a room and wait for the person to invite you in.
• Use your best nonverbal and verbal communication skills.

Avoiding Unnecessary Drugs

There are two basic questions you can ask to avoid unnecessary medication when dealing with challenging behaviors:

• "What are some common triggers for this behavior?" How might you anticipate these triggers and meet their needs before it becomes a problem?
• "What is this person trying to tell me?" What needs to change? What information is needed? Who do I need to share this information with?

It’s okay to not know what to do right away. If we don’t quite understand the need, we might be able to use watchful waiting. Watchful waiting is an active process, and it involves closely observing the person for two or three minutes at a time over several days. What makes them smile? What’s going on around them when they are distressed? Who is around? Who is not around? It’s also a time to gather more information from the family.

Be sure to document clearly in the service, support and care plan that this is what you are doing. This is not 'doing anything'. You want other caregivers and surveyors to see that you are not ignoring the recipient but providing the best person-directed care.