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How to Deal with Combativeness

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Elderly Woman
When an elderly patient lashes out it is more often than not a manifestation of an underlying condition. Just as fever can be a symptom of infection, aggression suggests the presence of a medical, psychological, or social problem. Each person with dementia experiences unique changes in behavior. While the changes can be upsetting to others, the person is not acting this way on purpose. When people with dementia become anxious or agitated, they may even scream, hit, or push. Frustrations from difficulty with communications, pain or illness, noisy environment or overstimulation or simply an unfamiliar environment can trigger a behavioral problem in a dementia patient.

Caregivers need to keep expectations realistic. The people in their care will not get better, but with good caregiving dementia patients can maintain their independence and dignity for a long time. Caregivers need to be prepared for problem behaviors and to be tolerant when such behaviors arise.

Flexibility is also important. The situation will change from day to day. What worked yesterday may not work today. There will be days when caregiving seems impossible. Understanding what triggers such reactions and steps you can take to minimize the reaction will allow the patient to use whatever cognitive skills they retain.

Understanding combativeness in dementia patients

Babies do cry or exhibit some abnormal behavior that we learn to recognize in our young ones. In the same way, an outburst from a dementia patient can be for example a result of a urinary tract infection or pneumonia. Aggression is often the result of a medical condition. If we are able to identify the cause of the aggression and intervene, we can manage the aggression.

People with dementia have impaired cognitive abilities and that makes it very difficult for them to communicate their situation. It is then up to the caregiver to rely on observation technique to determine situations that make the patient behave aggressively and intervene. Endocrine problems, medication reactions and interactions, alcohol and drug abuse must be considered as possible causes for such behavior.

A number of psychological problems can translate into aggressive behaviors. These include depression and a host of serious and persistent mental disorders. Depression is marked by a pervasive feeling of sadness, guilt, thoughts of death, dread, and despair, as well as physical symptoms such as a diminished appetite and difficulty with sleep.
Recognizing the pattern for aggressive behavior display can also help in a successful intervention. Are the combative outbursts tied to particular activities? Do they occur at specific times, such as late afternoons or evenings? For example, outbursts that occur late in the day could signal that the care recipient is prone to being combative when he or she is tired. In dementia patients, it could be a sign of Sundowner's Syndrome.

If no medical condition can be linked to the behavior, it could very well be related to unhappiness about the environment. Frustrations resulting from communication difficulties, new surroundings, problems achieving a goal such as finding the bathroom or conflict with another person, can lead to combativeness.

Managing Combativeness

The key to managing combativeness is the removal of the agent that is triggering the combativeness. What works for one situation or individual may not work for another. There are a number of techniques that can help in dealing with different triggers.

Listening and Patience

It is not easy to solve a problem if you do not know what the problem is. If you listen to the patient carefully, you may be able to understand the reason for the agitation and manage it. This is particularly important if the cause of the agitation is difficulty with communicating his need.
An effective technique involves looking directly at the patient. You can get his attention with a gentle touch and slowly address the patient. You have to be patient and gently wait for his response. When you speak to him, you have to do so slowly and deliberately. You however do not have to shout. Shouting may make him feel that you are scolding him or treating him like a child.

Avoid quizzing him although asking a few questions may be necessary. The goal is for him to talk to you so that you can better understand his plight.

Take your time. Each gesture and action from you can help in calming the patient down. A kind word or touch can do wonders.

Letting the patient have his space may also allow the episode to wear itself out. You have to understand that elderly patients have spent most of their life being independent. The limiting effects of the disease can have its toll. It can feel very violating to have another person bathe you when you have done so privately for years. By gently reminding the patient how clean and comfortable he or she will be afterward could be all it takes to calm him down.

Keep a good posture and stance

When you are talking to a patient who is agitated, you have to make sure that your posture is not threatening; you are out of harm’s way and maintain a good balance. A good stance for example is to stand to the side of the patient rather than in front, feet about shoulder length apart and about six feet from the patient. This positioning will help you keep a good balance and you would be less likely to be hit if the patient should lash out.

Redirection

The goal in redirection is to draw the patient’s attention away on the trigger and refocus him on something else. There are situations when you may have to use a “white lie” or “fiblets” to redirect the patient. Fiblets the subject the patient is dwelling on, provide some comfort, and allow the patient to mentally move on to another subject. I heard a very good example at a workshop on aging the other day. A worker from one of the facilities gave an example of one of their residents who was always agitated around 4.00pm everyday because "his factory shift was up and he had to catch the bus home." He would pace the floor and wanted to get on the bus. Staff recognized his daily distress, and each afternoon at 3:55 p.m. would give him a ticket for his bus and tell him to wait for it. The "ticket" was a “fiblet” that redirected him. After a few minutes he became interested in supper and forgot about the bus.
There are a number of other techniques that can be used for redirecting the patient.

Take care of the environment

Noise and distractions in the environment can lead to overstimulation of the patient. If reducing the noise and distractions in the environment, you can reduce combativeness in some patients. Make sure to remove objects that the patient can use to hurt himself from the environment.

Use Therapies

Sometimes a good warm soapy bath can calm the patient down. The use of his or her favorite aroma in the bath has also been used effectively.

Music is very effective in easing the stresses of dementia. The rhythm, pitch and melody can stimulate different parts of the brain. It can soothe an agitated person, relieve anxiety and decrease pain. Furthermore, it provides a means of reminiscence and can bring a sense of belonging and spirituality. If bathing provokes combativeness for example, playing soothing music in the background may be helpful.

Music helps a person with dementia express himself. By singing or playing a familiar song, you may notice changes in facial expression, increased eye contact, vocal activity and movement. You may have to try different types of music to find one that is soothing to the patient. Some music could trigger negative feeling while others could be positive.

If your loved one likes animals, consider animal therapy. Visits from calm animals are a great way to introduce something new and interesting to his or her environment, and research has shown that the interaction between humans and animals have therapeutic healing qualities. Make sure the animal you bring is not aggressive or excitable, and stay close during initial visits.

Exercise

Speak to your loved one's physician so you know what kinds of exercise are physically possible. If your patient is particularly agitated at night, if you get him to expend excess energy during the day through exercises, he is more likely to be too tired to be agitated at night.
Daily walks are beneficial for both of you, but if that's not appropriate, you may want to consider chair exercises. Remember, there is an additional benefit from exercising – it keeps the patient healthier.

Pharmaceutical drugs and Diet Modification

If the combativeness can be traced to difficulty sleeping at night for example, reducing caffeine intake in the evening can help make the patient sleep easily. There are a number of medical conditions that can be alleviated by nutrition modification. Working with his physician and nutritionist, diet modification could be used for managing some underlying cause and combativeness in dementia patients.

Sometimes the underlying medical conditions can be managed by the use of pharmaceutical drugs. Working with his physician, an effective medical intervention can be added to some of the techniques described here in managing combativeness in dementia patients.

It is tough taking care of a patient with dementia even without combativeness. You have to remember that he is not just acting out; there are underlying causes that you probably can manage. You want to make sure that you can help the patient maintain his sense of dignity and have a higher quality of life.



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