Aggression

4. Preventing and managing aggressive behaviour

Finding ways to prevent and manage the behaviour in the future will help both you and the person with dementia. It will also make your caring role easier. Working out what is causing the aggressive behaviour will make it easier to find a solution.

To reduce or prevent aggressive behaviour, treat the person as an individual and work out why they are behaving in that way. Try to see what is happening from their point of view and identify the reason for the behaviour. They are probably reacting to or trying to communicate something so try to find out what it is and why. Use all the information you know about the person, including their personality, likes and dislikes, to find the right way to manage the situation you’re in.

Steps for managing aggressive behaviour

It may help to manage aggressive behaviour in steps. The following steps and questions can help.

1 Identify the problem

  • Is it the behaviour of the person with dementia that is causing the problem?
  • Is it the reaction or attitudes of other people?
  • Is it the person’s living situation?
  • What are the other factors? For example:
  • Is the person in pain?
  • Are they getting enough stimulation?
  • Is their environment suitable?

2 Look at the situation

  • When and where does the problem happen?
  • Does the person always act in the same way in the same place?
  • Does it always happen with the same person or in similar circumstances?
  • Who are the other people involved? For example they may be visitors, a family member, or a friend.
  • Look for patterns in the behaviour. It may be helpful to make a diary of when aggressive behaviour occurs, noting down everything that was going on at that time that could have triggered the behaviour.

3 Look at how the person is feeling when they behave aggressively

Is the person:

  • unwell, in pain, uncomfortable?
  • over-tired, over-stimulated, scared, anxious or frustrated?
  • embarrassed, ignored, misunderstood, feeling patronised?
  • delusional, having hallucinations, depressed?
  • bored, under-stimulated, lacking in social contact?
  • in a suitable environment?

4 Identify anything the person could be reacting to

Use what you know about the person to think about whether they could be reacting to:

  • an unpleasant incident or association
  • personal dislikes or fears
  • change
  • a memory
  • being provoked, or a conflict with someone’s personality.

5 Develop a strategy to manage the behaviour

Talk to the person with dementia and other people who they spend time with to come up with a plan. Start to make some changes and see whether or not they have made a difference to the person’s behaviour. You may need to try different things and find what works. Look at making a range of changes, for example changing the way that you talk to the person during care, as well as altering the environment. Focus on what is in their best interests and supports them best.

Go with the person to see their GP so that they can be checked for any physical problems that might be causing them to behave aggressively. Pain is often linked to aggressive behaviour in people with dementia. However, it is often not recognised, even in formal care settings like care homes. Look for signs from the person of pain or discomfort, such as:

  • rubbing or pulling at a particular body part
  • facial expressions – looking scared or clenching their teeth
  • body language – are they huddled or rocking, for example?
  • a change in appetite
  • being more restless
  • new swellings or inflammations
  • a high temperature.

Also look for or think about things that may cause the person pain, including:

  • infections (such as chest infections and urinary tract infections (UTIs))
  • existing injuries such as cuts or bruises
  • constipation
  • existing conditions such as arthritis
  • being in an uncomfortable position or being moved in an uncomfortable way
  • toenails or fingernails that need cutting
  • toothache, earache or problems with dentures.

The person should also have their hearing and eyesight tested, and get glasses or hearing aids if needed.

Other ways to manage aggressive behaviour

Treating aggressive behaviour without drugs

Communication – When you’re communicating with the person, keep in mind anything you learnt from following the steps above. Think about what you’re saying, how fast you’re speaking and what tone you’re using. Good body language can also help the person feel they are being respected and listened to. For more information see factsheet 500, Communicating.

Music – Music may help to reduce aggressive behaviour. It may be listening to a favourite piece of music, enjoying music in groups (singing, playing instruments) or music therapy (with a trained professional). For example, if there is a certain time of day when the person tends to become aggressive, it may help to put on some music that you know they enjoy at that time. If a particular activity, such as bathing, can lead to them behaving aggressively, put on some music before you begin.

Social interaction and stimulation – Most people have a need to spend time with other people. Lack of social interaction can make someone feel bored, isolated and unhappy. Make sure that the person with dementia regularly receives some good one-to-one interaction. It could just be a chat or reading together, but it is important to have proper time for this, when they can have your or someone else’s full attention. Planning new activities that you both enjoy, or adapting daily tasks so that the person can still take part in them, will help. If you find something that works well, keep doing it.

Reminiscence – Reminiscence or life story activities involve recalling and talking about past experiences, such as sharing photos of the person’s family or events from the past. These should be positive and personally significant, such as a family event, favourite football match or places they’ve visited. Activities like these have been found to improve the mood of many people with dementia, reducing the risk of aggressive behaviour.

You could try making a memory box of photos and familiar items, which the person can go through with a friend or relative. Developing a life story book may also be an option. These help to keep the person with dementia at the centre of their care, as well as helping people see beyond the dementia.

People may have negative experiences as well as positive ones, and you should be prepared to support the person with both types of memories. However there may also be reasons why reminiscing is not enjoyable for them so bear in mind whether this is something that they are likely to enjoy.

Changes to the environment – Think about the person’s surroundings, as these will have an effect on their behaviour. It may be that you can make small changes to the person’s home that will make it a better environment for them. For example:

  • Is there enough light?
  • Is it too hot or too cold?
  • Can the person with dementia find the toilet?

If finding the toilet is a problem for the person, make sure that the path to the toilet or bathroom is free from obstacles and put a sign on the door with both pictures and words. It should also be clearly visible and in the person’s line of sight.

Using signs on kitchen cupboards and drawers can also help, to show the person what’s inside them. For example, you could put a picture of knives and forks on the cutlery drawer.

Exercise – Physical activity and exercise can help to reduce agitation and aggression, as well as improving sleep. It can help to use up spare energy and act as a distraction. It also provides opportunities for social interaction with others and can provide you with a break. For more information see Exercise and physical activity.

Other methods that may help include:

  • hand massage
  • aromatherapy
  • stimulating the senses, for example with nature sounds or familiar, repetitive actions such as folding clothes or sorting buttons
  • cognitive stimulation – this involves activities and exercises that are designed to improve memory and communication skills. Activities are based on day-to-day interests, reminiscence and information relating to the current time and place
  • light therapy or bright light therapy – this involves a person sitting in front of a light box for a set amount of time each day
  • animal-assisted therapy
  • doll or toy therapy
  • arts therapy (including dance, drama, drawing or painting).

Drug treatments

In the past, antipsychotic drugs were often prescribed for behaviours that challenge, including aggression. However, these drugs can stop the person behaving in a certain way without addressing the cause of their behaviour, and may add to the person’s confusion.

Antipsychotic drugs should not be the first treatment that a professional prescribes when a person with dementia behaves aggressively, unless the behaviour puts them or the people around them at an immediate risk of harm.

In some people antipsychotics can help reduce the symptoms. Some of these drugs have been shown to help with aggressive behaviour in people with Alzheimer’s disease when taken for 6–12 weeks. However, antipsychotic drugs can also have serious side effects. For more information see Drugs for behavioural and psychological symptoms of dementia.