Dementia Care: Managing Combativeness

Combativeness is common in dementia, impacting 90 percent of people who live with the condition at some point during the disease progression. Successfully managing combativeness relies on our response to the expression.

For caregivers, understanding why verbal and physical aggression occurs can improve empathy and provide clues to help avoid triggering combative expressions.

The caregiver or the environment are common triggers of combative behaviors. Most often physical and verbal aggression occurs during activities of daily living when a caregiver is trying to assist the person with dementia in doing things they have been doing for themselves for decades – bathing, dressing, eating, toileting and grooming.

“As caregivers, we find these behavioral expressions challenging because all we’re trying to do is help. But for a person with dementia, they know how to do these things. They’ve been doing them for years, and now we’re telling them they’re doing it wrong or doing it for them,” said Hollie Glover, director of education and family support services at the James L. West Center for Dementia Care. 

Glover leads free education sessions for family caregivers on coping with challenging expressions.

“It’s important for caregivers to understand why behavioral expressions happen because that helps develop empathy for dealing with them, and provides clues for caregivers to avoid situations that trigger the behaviors,” Glover said.

What is combativeness

Both physical aggression and verbal aggression are considered combative behavioral expressions.

Physical aggression includes hitting, pushing, kicking, spitting, grabbing, pinching and throwing things.

Verbal aggression includes repeating words or questions, demanding constant attention, shouting, name-calling, cursing, and vocal agitation.

People who have never cursed or been aggressive can exhibit these behavioral expressions as part of the disease process.

“All behavioral expressions are forms of communication,” Glover said. “They are expressing fear, frustration or an unmet need. And often, the trigger is something we’re doing, even though we don’t mean to.” 

The most common trigger for difficult expressions is someone helping with their self-care activities. Due to the confusion that comes with dementia, they do not understand why they need help. Maybe they’re putting their pants on before their underwear or they’re forgetting to comb their hair. In their mind, they know what they’re doing and they don’t need help.

“Anger is the easiest emotion for most people to have,” Glover said.

What’s happening in the brain

As dementia progresses, the brain physically changes. A normal, healthy brain weighs three pounds, but as dementia affects it, the brain shrinks and develops holes. In advanced Alzheimer’s disease, the brain weighs one pound or less.

As the different areas of the brain shrink, the ability to process information, complete tasks in ordered steps, and control behavior is impacted. 

People experiencing delusions or hallucinations tend to be more aggressive than others living with dementia. When a person experiences delusions, they can’t tell the difference between what’s real and what’s imagined. With hallucinations, the person sees or hears something that’s not there.

Risk factors and signs of combative behavior

Many causes for combativeness result from confusion and difficulty communicating or misinterpreting what’s said. However physical problems such as undiagnosed pain can also trigger combative behaviors. 

Overstimulation from too much noise or activity is another common trigger. During the holidays, a person with dementia may exhibit combative expressions because there are many more people around and their routines are interrupted. There’s more noise and bright or flashing lights.

Often, the person with dementia will use the word “no” to answer every question, even when the answer is yes. Because it’s one of the first words we learn, it is one of the last words that people with dementia lose.

A negative approach from a caregiver triggers combative expressions as the person with dementia continues to process body language and tone late into the disease.

New or unfamiliar environments, including hospitals and medical offices, can be a trigger for combative expression.

Signs of an impending combative behavioral expression

A person with dementia may demonstrate signs that they are experiencing a trigger for a combative expression. 

Signs include:

Glover recommends avoiding necklaces or hoop earrings that can be easily grabbed and pulled or open-toe shoes. Avoiding these items protects the caregiver from injury during a physically aggressive incident. It’s also best to back away from the individual and give them some space.

As the disease progresses, and the brain changes, so will expressions and what triggers them. 

“Something that never bothered them could bother them now,” Glover said. “The person with dementia isn’t giving you a hard time, they are having a hard time.”

Managing combativeness

In the early stages of dementia, combative behavioral expressions are less common. Maintain structure and routine, simplify the environment, provide written reminders for daily tasks, and give positive reinforcement throughout the day. Watch for signs of frustration and provide reassurance and treat depression if present.

In moderate stages of dementia, break tasks into small steps and provide verbal reminders. Be reassuring and offer simple answers. Let go of little things that aren’t important. Expand the care network and seek home and community-based services like respite, adult day programs, home health, therapy or other support services. 

Managing expressions in the later stages requires caregivers to become detectives as the person with dementia’s ability to communicate verbally is dramatically reduced. Interventions focus on prevention and responding to a person’s expressions. 

Prevention includes paying attention to non-verbal signs that indicate the person with dementia is becoming frustrated. Distract the person from what they are upset about long enough for them to forget what upset them.

Responding focuses on identifying the emotion behind the expression, refocusing and making a connection with them. 

“The important thing is to be consistent and let some things go that aren’t deal-breakers,” Glover said. “If it is a deal-breaker, you may have to back off and try again later. Don’t force them to participate because that sets up combative expression.”

The caregiver’s response will determine whether the situation escalates or de-escalates. Keep your hands by your sides. Do not have an aggressive stance. Have only one person talk at a time. 

Validation therapy is a technique that emphasizes the emotional aspects of what is being said or done rather than the actual words or expressions. Use this approach to connect and impart respect and dignity. Listen actively with empathy and respect so they feel valued. Reminisce, but avoid using the word “remember.”

Physical and verbal aggression are among the expressions that respond well to medication. If attempts to manage the behavioral expressions are unsuccessful, talk with your loved one’s physician to see if medication is an appropriate intervention.

We can’t change the person, but we can determine and accommodate an unmet need. Changing how we respond to challenging expressions can make it easier to manage when they occur.

The James L. West Center for Dementia Care offers free education for family caregivers, including several sessions on managing challenging expressions. Explore the available sessions or find upcoming live sessions on the Education Calendar.