Dementia aggression toward caregiver: what to do when he lashes out

When a parent with dementia turns on you, your first job is to get safe and bring the temperature down, not to win. Step back out of arm's reach, drop your voice, stop explaining and give him one easy thing to do. If that doesn't work within a minute or two, leave the room. If you searched "dementia aggression toward caregiver" after a bad night, know that it almost always has a trigger, such as pain, fear, noise or being pushed to do something hard, and finding it is how you get fewer bad days.

None of that makes it hurt less. He may shove you while you're helping him dress, or call you names he'd never have said out loud before. You're allowed to be shaken by it. You're also allowed to protect yourself.

Dementia aggression toward caregiver: why it's aimed at you

The disease damages the parts of the brain that handle judgment and self-control. Fear that once would have come out as worry now comes out as shouting or a raised fist. The National Institute on Aging puts it simply: most of the time, agitation and aggression happen for a reason.

Its list of common causes is worth reading slowly, because several are things you can change:

• Pain, depression or stress.
• Too little rest or sleep.
• Constipation.
• A sudden change in a familiar place, routine or person.
• Feeling a loss, like missing the freedom to drive.
• Too much noise, too much going on, or too many people in the room.
• Being pushed to do something that's now too hard, like bathing or remembering people and events.
• Loneliness.
• Certain medicines, or two medicines interacting.

The Alzheimer's Association adds poor communication: instructions that are too complicated, or too many questions at once. It also notes that he may pick up on your stress.

You get the worst of it because you're the one there, and you're the one asking him to shower, take pills and get in the car. The daughter who visits at Christmas doesn't ask him for anything. Caregivers have a phrase for this: it's the disease talking. You won't always be able to believe that in the moment, and that's normal.

How to deal with an aggressive dementia patient in the moment

Work through these in order. The first two matter most.

1. Get out of reach. Take two steps back and stand a little to the side, not square in front of him. The National Institute on Aging says to stay at a safe distance until the behavior stops.
2. Stop arguing. Drop the facts, the proof and the "but you said." The Alzheimer's Association advises focusing on the feeling, not the details.
3. Lower everything. Speak slowly and softly. Turn off the TV. Ask any extra people to leave the room.
4. Check his body. Is he hurting, hungry, thirsty, cold or in need of the bathroom? The Alzheimer's Association says to rule out pain first. A man who can't say "my hip hurts" may show it by swinging at whoever moves his leg.
5. Drop the task. If it started over the shower or getting dressed, stop. You can try again in an hour, or tomorrow, or with someone else.
6. Offer one thing. A drink, a snack, a song he loves, a walk to the mailbox. One offer, not a list of choices.
7. Leave if it isn't working. Make sure he can't easily hurt himself, then go to another room or sit in your car for ten minutes. Many people with dementia forget the outburst before you're back. Don't bring it up.

What to say during dementia anger outbursts

Keep it to one short line, said slowly, then wait. If it works, say the same line next time.

The second line is often the one that lands, because so many outbursts start with him feeling forced. The last line is permission to leave without making it a punishment. For more lines for everyday confusion, see the guide on what to say to someone with dementia.

Take Linda, whose father hit the bathroom counter and yelled at her nearly every evening when she started his bath. She moved bath time to 10 a.m., warmed the room first and stopped asking him whether he wanted one. Some mornings he still refused. On those days she said, "No problem, we'll do it later," and he usually let her help him wash at the sink after lunch.

Sudden aggression can be pain, infection or delirium

Aggression that creeps in over months is often the disease moving on. Aggression that appears over a few days is a medical question first. MedlinePlus says delirium usually starts suddenly, over a few hours or days, and that anger and agitation can be signs of it. Dementia raises the risk. Infections such as UTIs and pneumonia, and side effects of medicines, are common causes. The Alzheimer's Association names unnoticed pain and infections, especially urinary tract infections, as possible causes of aggression.

Before the appointment, write down a week of outbursts: the time, what happened just before, what he did and what calmed him. Patterns show up fast, like every outburst coming in the late afternoon, which can be part of sundowning. The doctor may bring up medicine. That decision belongs with the doctor, so ask about the risks and what to watch for, and don't add or stop anything on your own.

Make the house safer before the next outburst

Do these on a calm day. The National Institute on Aging recommends hiding or locking up car keys and anything that could be used to hurt someone, such as guns and kitchen knives.

• Guns go out of the house, not into a safe whose code he knows. A relative can hold them. Ask your local police how to transfer them legally in your state.
• Knives, power tools and heavy objects near his chair go into a locked cabinet.
• Car keys go somewhere he won't find them.
• Keep your phone in your pocket, not across the room.
• Know which room you can go into and close the door behind you.

When to call 911 or Adult Protective Services

Call 911 if he's hitting, choking or threatening anyone, if there's a weapon involved, or if you can't get away safely. Both the Alzheimer's Association and the National Institute on Aging say to tell the dispatcher he has dementia. Go somewhere safe while you wait.

Adult Protective Services is for a different problem: an older adult who is being abused or neglected. If you think an aide, a relative or anyone else caring for him is hurting him, report it. The Alzheimer's Association says you don't need proof, because it's up to the professionals to investigate. Its 24/7 Helpline at 1-800-272-3900 or the Eldercare Locator at 1-800-677-1116 can connect you with your local office.

Be honest with yourself here too. The Alzheimer's Association lists strained relationships and frequent arguments between caregiver and patient as a possible warning sign. If you're grabbing him back, yelling every day or scared of what you'll do, that's a sign you need more help, not more willpower. Call the helpline and say exactly that. If you're having thoughts of hurting yourself, call or text 988.

If he's hurting you again and again, home may no longer be safe for one of you. The guide on when it's time for memory care lays out the signs.

Questions caregivers ask

Why is my dad with dementia only angry at me?

Because you're the one who's there, and you're the one who asks him to do hard things. He may also feel safest with you, so the fear comes out where it's safe to let it out. It isn't a verdict on you as a daughter. If you're carrying guilt about the times you've snapped back, the guide on caregiver guilt is for you.

What stage of dementia is aggression?

There's no fixed stage. The National Institute on Aging says people may become agitated or aggressive as the disease gets worse, and the NHS lists shouting, verbal abuse and sometimes hitting among the behaviour changes that can come in the later stages. A sudden change at any stage is a reason to call the doctor.

How do you deal with a verbally abusive dementia patient?

Don't answer the insult. Say one calm line, such as "I'm going to give you some space," and leave the room. The Family Caregiver Alliance suggests staying calm, accepting his feelings and then turning his attention to something else. Afterward, tell someone what was said. Carrying it alone makes it heavier.

Is dementia aggression worse at night?

For many people it is. Late-day agitation is called sundowning, and tiredness, low light and hunger all feed it. Moving hard tasks like bathing to the morning often helps.