How to handle physical aggression

bookwormRN

My mom was diagnosed by her primary care provider with dementia in January. We were referred to a neurologist but my mom refused to go until June. We are now in the process of a full neurological work up. Mom has had an EEG and an MRI and will have the extensive cognitive testing in about a week. She has started Aricept and Celexa. Her symptoms have progressed rapidly since January. But the hardest thing is that she is extremely angry with me about the doctor’s appointments and testing. She says that there is nothing wrong with her and I’m making a big deal out of nothing. That anger has progressed to include paranoia that I am “in cahoots” with the doctors, I’m trying to trick her, I’m trying to take her car away, etc. She has been extremely hurtful and verbally aggressive with me but I have tried to persevere because I know she needs help. Today we moved into a new phase because she was physically aggressive with me. In her anger, she grabbed me by the arms and shook me. I tried to walk away but she followed me and grabbed me again. She was yelling and frankly out of control. I am posting here to ask for advice. I know this is part of the disease but how do I handle physical aggression in a compassionate way but still protect myself moving forward? Thank you in advance for any suggestions.

star26

Sorry to state the obvious, but avoid things that agitate her. This will likely include discussing her memory or other cognitive problems. Many people with dementia have anosognosia: they can’t recognize their deficits and don’t believe anything is wrong with them. You can read about this. There’s no need to use the word dementia with her or discuss her problems with her. 

If the agitation/aggression is coming out of nowhere or about something else, you can validate what she’s saying (even if it’s not true), offer reassurance, and redirect her to a new subject. 

If the physical aggression continues and deescalation techniques and avoiding hot topics aren’t working, you may need to talk to her doctor about treating this with medication. 

Suggested reading: “Understanding the Dementia Experience” by Ghent-Fuller. You can find it online for free. It offers tips for interacting with people with dementia and also understanding the various behaviors. 

John2.0.1

If the physical aggression continues you should be emotionally prepared to call 911, have her taken to the ER, have her evaluated and possibly admitted to a Geriatric Psych unit for treatment.

Are you Health Care Proxy?

Only you can judge if/when she reaches this point. But you should be prepared if necessary.

abc123

Dear bookworm, the first thing I want to tell you is I’m so sorry this is happening to you and her. I would be devastated if I had to experience this with my own mom. My mom is very strong and if she grabbed hold of me, she could seriously hurt me. Please be careful. Is it possible to record some of these episodes on your phone? Try to record a verbal assault too. You could then share them with her doctor/Doctors. I think it’s really important to document this behavior. I’m sorry for you both. Please let us know how you are doing. We all care about you and your safety.

harshedbuzz

Bookworm-

This isn't uncommon, but none the less distressing.

We had similar behavior from my dad before his disease progressed to the point of anosognosia (the inability to recognize one has had a cognitive shift and is less capable than before). Dad was paranoid and accusing- I was trying to get his stuff and "take away his freedom". He was enough on the ball to recognize that a diagnosis would cascade into changes he didn't want to make. In a sense he was spot on- for years he had my mother convinced his memory issues were a normal part of the aging process- but once I push for and got a diagnosis, he had to stop driving, managing his investments and even lost the right to live where he wanted. I was to blame and on the receiving end of his wrath.

That said, if this behavior is completely out of the blue for your mom, it could be triggered by a medication or infection. Symptomless UTIs can result in challenging new behaviors, so I quick test and culture would be worth doing. New psychoactive medications can sometimes cause behaviors if they're a poor fit. You mentioned Celexa which can be activating for some people worsening or causing new concerning behaviors. Celexa takes about 4-6 weeks to kick in, but some people will start to have negative behaviors sooner than that. If she's been on Celexa less than 6 weeks, I would reach out to her prescriber and ask what they think. Do not discontinue it cold turkey.

You might want to consider adding a geriatric psychiatrist to her team. Ideally, this is the specialist for managing psychoactive medications. If she has challenging behaviors, this could end up being the most important member of her care team. In the meantime, have some record her if she acts out again to share privately with her doctor; I used email and the electronic patient portal to do this rather than whip out my phone during an appointment.

Until then, find out which hospital in your area has the nearest geriatric psych unit; your local Agency for Aging will know which these are. If she ramps up, have her transported by ambulance to that hospital's ER.

Good luck. I personally found this stage of the disease more difficult than what came after.

HB

SRCB

I'm sorry you're dealing with this. It is part of the disease and it will be OK. 

Rule out anything physical like a UTI and have her seen by a dementia specialist or a geriatric psychiatrist. There are medications that can help with this behavior. 

Your mother is scared and she's experiencing fight or flight response. Her life is changing, her environment is changing, and she can't control it. Try to redirect if you can to things she can control. Does she have a hobby she loves and can continue to do. 

The work you're doing is exhausting. Stay positive, take care of yourself, and if you are the only caregiver try to get someone to give you a break even if just a friend or family to watch a movie with her and give you a few hours. 

jfkoc

Hi Bookworm....

I see that you are an RN which likely makes you really want a diagnosis but at this point I think I would let it go...for now. Why? The diagnosis of AD is mostly ruling out what is causing the symptoms you are seeing.

The first part of this is the use of lab work to rule out things like a vitamin deficiency or a thyroid problem. Your mother has had an EEG and an MRI for further elimination.

While an appointment with a neurologist is a good thing I think it would be time to take a look at the need for it and I do not understand the multiple appointments.

 You already know about where on the scale your mothers place is. Do you really need test results to back up what you already know?

I suggest you spend the energy on learning about non-medical treatment which some research has shown to be as effective as drugs and even better in some cases.

In other words, how is the testing going to help and at what price to your mother are you willing to get it done?  I think "moving forward" at this time may not be helpful at all

I would move forward with  caregiver 101 and getting legal, financial and medical matters in place.

Jo C.

Hello bookwormRN, I am sorry for what is happening; it is a very difficult and frustrating place to find oneself.   I also experienced much of the same with my mother, and it took a bit of time to get it all sorted out while facing significant challenges which included near constant irritability, acting out, and aggressive anger- most of it focused upon me. Not unusual; a person with dementia if blaming someone, will most often do so against the person doing the most for them. You are doing a very good job of being your mother's advocate and caring for her under difficult circumstances; she is blessed to have you by her side. 

By the way; I too am an RN and I too am also a book worm - glad to see I am not alone in that category. I also unnderstand your approach to working at finding out specifically what and why things are happening.  That can be important for multiple reasons. Our professions also play a part in our assessments and our internal instinctive feelings even if we cannot put a name to what is happening as of yet.   I have also lived that and I get it.

Back to what is happening.  My mother was also diagnosed by her primary care MD, a Board Certified Geriatrician, as having Alzheiemer's.  She was started on Aricept,.  Her behavioral symptoms became far more florid; she was much worse over the weeks and initially I thought it was the dementia . . . . yet; something was not feeling quite right; I thought there really was something being missed. It needed attention and I am SO glad that I followed that instinct.

One of the most important things we need to do for our LOs best interests in care is to have a dementia specialiist as part of the healthcare team.    An accurate diagnosis for type of dementia is crucial as meds for one type can be contraindicated in another and make things even worse.  I learned that the hard way.  The spccialty that is best at making that accurate diagnosis is a good Neurologist who sees dementia patients as a routine part of his/her practice.  Our primary care MDs are wonderful at so much, but they are not on the cutting edge of dementia dynamics or treatment.  A dementia specialist is really necessary.

Due to the increased issues with my mother, I finally by using "therapeutic fibs," got her to an excellent  Neurologist.  Those fiblets were key in getting my mother settled and to get her to appts. or whatever without having her adamantly refuse or having meltdowns.  Her primary MD mentioned her needing to see a "specialist" for her back pain and blood pressure - we clued the Neurologist to these fiblets and he was wonderful in his accommodation - he had experienced that many times before.

Never, ever, ever could I use or even hint at  the word "dementia," or "Alzheimer's," with my mother - it completely undid her to major upset anger and caused resistance that could last for days and longer.  Fiblets became a kindly tool in my Caregiver's Toolbox.  Hard to use a fiblet as I honor honesty; but this really is not a moral lapse but is a kindness to our LOs.

Anyway; MRIs, one from her primary MD and one ordered by Neuro showed not much of anything.   However; Neuro too felt things were not fitting the categorization for Alz's, so a SPECT Scan was done - there it was as big as could be; Frontotemporal Dementia.  Huge difference.  Her type of disease was a behavioral variant of FTD which fully explained her agitation and behaviors. 

It so happens that Aricept is contraindicated in FTD; it was disontinued and that made a difference almost right away.  Also,"silent" urinary tract infections can also cause quite a change in behavior to the very negative side of the ledger.  These UTIs are called "silent" because they most often have no physical symptoms but will lndeed cause behavioral issues that can be quite dramatic.until the UTI is treated. Many of us have had that happen with our Loved Ones (LOs) more than once.

You are on the right track in finding a good dementia specialist and confirming the diagnosis for type of dementia.

It is best never to argue with our very compromised LOs; nor to point out facts, try to explain, etc. That simply ramps things up.  I also learned the hard way NOT to explain there was a doctor's appt. ahead of time. I simply waited until the night before so there was no time to build and build fury over days.  I also tried the bit of fiblets as necessary and also going out to lunch or getting a dessert at a restaurant after the appt.; sometimes that helped.

Another issue is; the physician absolutely needs full information regarding changes in cognition, fiinction AND behaviors for the appt. to have releveance and building an adequate care plan. However, no way could I talk about my mother in front of her. What I did was to write a succinct but detailed memo outlining all the changes in said behavior, cognition and function.  I sent this to Neuro several working days prior to the appt.  I called statt and let them know it was being faxed over, that it was time sensitive to an appt on such and such a day and asked that it be placed on the doctor's desk asap.  I followed up later in the day to ensure that had been done. Just in case - I carried a copy in my handbag to the appt. and excused myself to "use the bathroom" then found out if the doctor had read the memo or not. If he did; okay, if it had been missed I gave the copy I carried in.

I also learned that if our LOs are driving us to absolute distraction, imagine what it is like to live inside their heads not only believing all those false delusional thoughts, but FEELING them.  Horrible, and affects their very quality of life.  Our Neurologist was most excellent at treatment and as necessary was able to prescribe assisting medications that made a difference.  It was always, start low and go slow, so that an assessement could be done for effectiveness at the lower level and also for tolerance and was adjusted as needed.

Also, another lesson learned the hard way:  Do not react to the words they are saying; instead, respond to the feelings behind the words and validate those feelings including taking blame for things even if you do not have blame.  "I am so sorry you are  feeling angry and are upset, I did not mean to upset you and will do better; I would be pretty angry too." OR: she may have misplaced an obect and blames you:   "Oh, your purse is missing; you feel I have stolen it - it has made you very upset and angry - you know, I was cleaning up in here and may have moved it, I will go and find it; I am so, so sorry and I will not do that again."  Rinse, repeat.      Then it is important to right away refocus her onto something else; a different topic, looking out the window at a bird or whatever; or deciding to get some coffee and a sweet in the kitchen, or a small chore like folding towels, etc. That will usually break the cycle our LO is in.  Validating feeling will sometimes stop a rant in midstream.

There is no perfection in all of this; there is only the best you can do under the circumstances with the challenges at hand and you are doing a very good job of it.   Hang in there, the behaviors do evolve and as said, as necessary, there are medications that can help.

Please do let us know how you are doing; we will be thinking of you and we truly do care.

With warm thoughts from one daughter to another,

J.

Stuck in the middle

All I can add to the good advice above is to suggest your mother is right about one thing.  If you aren't taking her car away from her, you should be.  She is emotionally unstable and has no business operating cars, guns, or any other power tools.  Further, she has been diagnosed with dementia and will be blamed for any collision in which she is involved, regardless of the other circumstances.

bookwormRN

Thank you for all of your suggestions and advice. I really appreciate your perspective. Yes, I am an RN but in this situation I am very much an overwhelmed daughter trying to accept the unimaginable changes in my mom over the last 6 months.

ArtsyCraftsy

Thank you all so much also.  Your comments helped me a lot.  I'm new here today because I finally decided I needed to find some AD support. I live with my 87 year old mom and 89 year old dad after I sold my house nearly 10 years ago and after my husband died suddenly in 2008 at 54.  I've had my own med issues and have been on disability since 2019. I'm all better now but spent most of covid lockdown getting treatment and a couple surgeries that couldn't wait. My dad is doing good physically and mentally so it's my mom with an AD diagnosis.  She indeed does forget that she has an AD diagnosis and will periodically see that information on her appointment documentation and think we're lying to her.  She gets very mad at me sometimes, certainly coming from out of the blue, when she feels like I'm taking over as "Queen Bee" or that I prioritize my dad over her, which I don't.  That one idea came to her because many years ago I did some artwork for their anniversary - I drew their illuminated initials together, their names and the year.  My dad's initial appeared bigger because that was the best fit on the paper.  Decades later, she's mad at me for that.  I think she trashed the whole thing.  Anyway, I know that she can't help any of it and, thank God, she's still sweet sometimes too.  I wanted to thank all of you for the great insight.  Truly helpful!  More to come.  

AC