With people all over the world living longer, more and more of them develop problems with brain functions. Some of these problems are mild, e.g. slight forgetfulness, but some may interfere with their daily activities, such as driving and using appliances. Serious problems could be due to several reasons, e.g. diet, brain injury, hormonal imbalance, but the most common reasons are one of the progressive neurological diseases causing dementia. The most common of them is Alzheimer’s disease and the others are dementia with Lewy bodies, frontotemporal dementia and vascular dementia.

These diseases cause not only problems with memory, judgment and language but may also cause changes in person’s behaviors. They may become less interested in their environment and may also develop new behaviors. Some of these behaviors occur when the person is alone or feels to be alone, and some of them when they are involved in an activity with others. When they feel alone, they may wander, become restless, ask repetitive questions, keep complaining and may cry out repeatedly. These behaviors indicate that the person is in distress and is agitated (Fig. 1).

Fig. 1. Causes and symptoms distinguishing two separate behavioral syndromes in dementia.

Another change in person’s behavior caused by development of dementia occurs when the person interacts with others. Many of these interactions are needed because dementia makes persons unable to perform usual daily activities, including personal hygiene. When a care provider tries to help with dressing, washing and other tasks, the person with dementia may not help but may oppose this help. Explanation by the care provider about the need for this activity is not effective because dementia impairs judgement and understanding of language, and the person may not understand the need for help. The persons with dementia may defend themselves verbally or physically from this unwanted interaction and this defense is called reactive aggression.

Agitation and aggression are two separate behavioral consequences of dementia. Agitation may develop early in the course of dementia while incidence of aggressive episodes increases with dementia progression, which causes more severe problems with judgement and understanding of language. A person with dementia may exhibit both agitation and aggression but not at the same time. The distinction between agitation and aggression is very important, because different strategies should be used for treatments of these conditions.

The most effective treatment for agitation is making available meaningful activities. Persons with dementia are unable to initiate activities and, therefore, activities need to be provided. The most effective activity is human interaction, but in care homes the providers do not have enough time. What can be provided are group activities, which should be tailored to abilities of persons with dementia. Therefore, there may be need for three levels of group activities, for persons with mild, moderate and severe dementia. Activities should be provided for most of the waking hours, seven days a week, if prevention of agitation wants to be accomplished.

Reactive aggression can be prevented by improving communication between care providers and persons with dementia, and by changing care strategies. For instance, the communication can be improved during bathing by speaking in simple sentences and providing non-verbal clues for the activity by showing towels and soap. The bathing strategy could also be modified, because persons with dementia may resist tub or shower bathing but may be comfortable with a bed bath. Reactive aggression is also decreased if persons with dementia receive regular pleasant touch by hand and/or face massage. They become used to touch and do not resist it during daily hygiene activities. Reactive aggression could be limited if all activities of daily living are performed in unhurried manner with both verbal and non-verbal cues.

Ladislav Volicer
School of Aging Studies, University of South Florida, Tampa, FL, USA
3rd Medical Faculty, Charles University, Prague, Czech Republic

Publication

Agitation and Aggression Are 2 Different Syndromes in Persons With Dementia.
Volicer L, Galik E
J Am Med Dir Assoc. 2018 Dec

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