AGGRESSION IN DEMENTIA AND THE ROLE
OF NON-PHARMACOLOGICAL
INTERVENTIONS
Kim Schlegel, MSW, RSW
Lisa Joworski, TRS, R/TRO
Brynn Roberts, MSc. OT, OT Reg. (Ont.)
Case Study – Ms. Josephine Allegro

91 year-old widow currently living in long-term care.

Diagnosis of Alzheimer Dementia in moderate stage.

Josephine came from home where she was previously living independently.

Recently reverted back to native Italian language.




Josephine has shown increasing physical aggression and verbal aggression during
bathing care. At times she requires 3 or 4 staff members to complete the task.
Josephine paces continuously during the afternoon until dinner and is verbally nonaggressive as she calls out in Italian. Staff worry about her risk for exhaustion or
falls.
When staff approach her she becomes verbally aggressive and on two events she
has struck out when staff try to redirect her.
Josephine worked as a seamstress and was a homemaker. She raised 6 children with
her husband.
Why is studying this important?

Dementia is on the rise- at home and
internationally
Behavioural and Psychological
Symptoms of Dementia
Agitation and Aggression
Defining Aggression
Physical/Aggressive
 Physical/Non-Aggressive

Verbal Aggressive
 Verbal Non-Aggressive

The Four Models of Behavioural
Assessment
Behavioural/Learning
Model
Reduced Stress Threshold
Model
- Behaviours are: Used
because they have been
reinforced over time.
- Behaviours are:
Responses to heightened
vulnerability to the
environment
Biological Model
Unmet Needs Model
- Behaviours are:
Symptoms of the
underlying brain
damage
- Behaviours are:
Communication to staff
that there is an unmet
need
Hierarchy of Needs In Dementia
Scholzel-Dorenbos, Meeuwsen & Olde Rikkert (2010) Integrating unmet needs into dementia health-related quality of
life research and care: Introduction of the Hierarchy Model of Needs in Dementia. Retrieved from Aging & Mental
Health, 14.1, p.117
Case Study: Josephine
How would each of these four models explain Josephine’s responsive behaviours?
Behavioural/Learning
Model
Reduced Stress Threshold
Model
- Behaviours are: Used
because they have been
reinforced over time.
- Behaviours are:
Responses to heightened
vulnerability to the
environment
Biological Model
Unmet Needs Model
- Behaviours are:
Symptoms of the
underlying brain
damage
- Behaviours are:
Communication to staff
that there is an unmet
need
Alzheimer’s Disease
Stage
Mild
MMSE
21-26
Functional Deficits
 Forget names and current events
 Complex tasks are difficult
 Items of value go misplaced
 Complicated interests abandoned
 Prompting for self-care required
 Denial of having a problem exists
 Withdraws and develop
behaviour problems
Moderate 
MMSE

10-20





Greater assistance required
Sleep disturbed
Difficulty remembering important
things
Orientation affected
Greater independence early. Then
greater dependence later in this
stage
Become agitated, isolated and
anxious
May become delirious with
infection
Things to Consider
 Help to feel competent and valued
 Can do old habits and routines and
likes familiar
 May want full attention or less
contact
 Change is difficult
 Tells the same stories and asks the
same questions





Want to feel like they have a
purpose
Gets lost in past life, places and
roles, so go with the flow
Memory leads to thoughts of others
taking their memorable items
Needs help, but does not know it or
like it
Can become emotional quickly
Alzheimer’s Disease
Stage
Severe
MMSE 0-10
End Stage
MMSE 0
Functional Deficits
Remembers own name, but can forget
partners
Unable to solve problems
Full assistance with bathing and
toileting.
Difficulty with walking and falls risk
starts
Delusions and hallucinations may
continue
Anxiety, aggression and agitation
occurs
Sleep disturbance continues
 Unable to talk
 Only recognize spouse
 May scream out at times
 Full assistance with eating and
drinking
 Resistant to care
 Unable to walk
 Increased risk and incidence of
infection.
Things to Consider
Likes rhythmic movements and actions
Fascinated by watching others
Like to pick-up, hold, carry, rub or grip
things
Fine motor movements are lost
Big movements are kept
Limited visual awareness
One direction – forward, cannot back
up





Likes pleasant sounds and familiar
voices
Like warmth and comfort feelings
Aware of the world around them for
short periods
Limited movement
Hard to connect with them
Frontotemporal Disease (FTD)
Stage
Functional Deficits
Consider:
Mild
•
•
Disinhibition, apathy and overeating
Problems with planning, organization and
memory
Impaired judgement with financial decisions
Social Withdrawal: less interest in family,
friends, babies. May be inappropriate with
strangers and lose social manners.
Impulsive actions
• Behaviours can be managed
with changes in lifestyle &
environment
• May still be capable of
managing household tasks
• Independent with self care
with little help
Symptoms more pronounced
Compulsive behaviours
Cognitive: Mental rigidity, forgetfulness,
Severe deficits in planning and attention.
Further deterioration with motor co-ordination,
cognition, emotions and learning depending of
side of brain affected.
• Utilize compulsive behaviours
as a strength (ie. hole punching,
cleaning, painting,
wordsearches, math sheets)
• Modify/decrease steps in
activities to ensure the task is
failure free
•
•
•
Moderate
•
•
•
•
•
Severe
• Apathy, loss of empathy, disinhibition with
language difficulties and memory loss.
• Focus on remaining strengths
, interests (music, counting)
Semantic Dementia:
Stage:
Functional Deficits
Consider:
Mild:
• Left side of brain: Difficulty finding
words or name for something.
• Right side of brain: Decline in
empathy or awareness of other’s
emotions
•
Moderate:
• Left and right begin to appear
similar.
• Some behaviours similar to FTD.
• Difficulty understanding expressive
communication, recognizing
names/faces.
• Reading/ writing declines.
• Some remaining strengths with numbers,
colours and shapes.
•Try simple wordsearch games, large piece
jigsaw puzzles (25-100pc)
•Sorting: artificial money, dice, coloured
stickers poker chips
Severe:
• Language significantly impacted.
• Behaviours similar to FTD.
Left side: more interest in non -verbal
activities (ie. expressive arts, music)
Right side: may prefer games with words and
symbols.
•
•
Offer communication techniques (ie.
pictures, model actions, note pad,
whiteboard)
Use humour for + redirection
Ask for help with tasks that require
modified, repetitive steps
Progressive Non Fluent Aphasia:
Stage:
Functional Deficits:
Consider:
Mild:
• Increased difficulty speaking and
producing languages
• Symptoms incl. slowed speech,
trouble getting words out
•
can understand expressive communication
and knows what he or she wants to say
Moderate:
•
•
•
•
Try board or number of pictures to help
express their meaning.
Skills remain intact with numbers, colours,
shapes
Able to read emotion – empathize and
validate
Reading/writing still good
Significant problems with speech
Increased use of short sentences
May use extra articles and/or
adjectives (ie. “that thingy over
there”)
•
•
•
Severe:
End stages
• Essentially mute
• BPSD similar to FTD
• Some develop Parkinson’s like motor
problems like muscular rigidity and
stiffness.
•
•
•
•
Non Verbal Communication is key.
Use a pro-attention plan
Know psychosocial history: interests in
music, animals, spirituality
Sensory Stimulation
• involves difficulty with swallowing,
chewing, moving, bladder.
•
•
+Time needed to process task at hand,
Comfort measures
Lewy Body Dementia
Common
Change:
Description:
Consider:
* Distorted
Perceptions
•
Very common, up to 80% of people experience
hallucinations. Often of children and animals.
•
Do not argue or rationalize. Use
validation.
Visual/Spatial
difficulties
•
Difficulty judging depth/recognizing distance between
self and objects
•
Monitor for falls; utilize high
contrast colours (colourful tape)
Parkisonian
symptoms
•
Slowed movements, difficulty walking, balance
impairment, rigidity, stooped posture, shuffling walk,
tremor at times, reduced facial expression, difficulty
swallowing, weak voice, small handwriting
•
Monitor for risk of falls; refer to
PT/OT for assessment
Sleep
•
•
•
REM sleep disturbance, active dreams, sleep walk, talk in
sleep.
Increases in frequency as dementia progresses
Have a plan for nighttime; provide
low stimulation and appropriate
activities to engage in at night;
music, tea.
* Rapid mood
changes
•
•
Can shift rapidly through anger, depression, tearfulness.
Heightened sensitivity to stimuli (noise, quick movements)
•
Keep stimulation low, be mindful of
movements (move slowly!); Keep
predictable, consistent schedule.
* Rigidity
•
Unable to move past a topic of conversation or to
physically move
•
Validate, allow time for processing,
provide time and space, do not try
to re-direct, answer questions/
comment each time as thought it is
new
Types of non-pharmacological
interventions reviewed:
1.
2.
3.
4.
5.
Sensory intervention
Music, Massage/touch, White
noise, Sensory stimulation
Social contact
One to one, Pet visits, Simulated
presence therapy and videos
6.
7.
Behavioural therapy
Differential reinforcement,
Cognitive, Stimulus control
Staff training
Activities
Structure
Walks
Physical activities
Environmental interventions
Wandering areas, Natural and
enhanced environments, Reduced
stimulation environments
Medical/nursing care
interventions
Light therapy, Sleep therapy, Pain
management, Hearing aids,
Removal of restraints
8.
Combination therapies
9.
Individualized Interventions
Social Contact
Successful Interventions
 Pet Therapy / Animal Assisted
 One to one interaction
 Simulated Interactions / Presence
 Reminiscence
Take Home Thought:
• Any contact was found to be
effective in reducing verbally
non-aggressive behaviours
• Reminiscence was found to be
effective in reducing resistance to
care
• Real human contact was found to
be the most effective
Exercise and Activity Therapy
Successful Interventions:
Interventions to consider:
 Low intensity work-outs
Walking programs
 Free access to outdoor area
 Activity programs
ADL’s
 Stage of dementia
Take Home Thought:
• Low intensity programs can be
successful in reducing physical
aggression and agitation- but
know the person’s stage & needs
• Activity is Prevention: Activity is
important in maintaining
capabilities!
Caregiver Training
Successful Interventions
 Formal and informal caregiver education:
 Focused on education on recognizing, preventing, and planning for
aggressive behaviours
Focused on dementia, and using the ABC model or behavioural mapping
“Culture shift”
 Caregiver modelling
 Bathing without Battle
Take Home Thought:
• This is our “time saving”
intervention!
• Even 3 sessions with nursing home
staff could lead to less
aggressive acts!
Nursing and Medical Care
Correlations:
• Pain: Verbalizing, Physical
aggression
• Sensory impairment: Agitation
• Discomfort: Verbal aggression and
non-aggressive behaviours; Physical
aggression
Interventions to try:
1) Pain Management:
http://pda.rnao.ca/content/managem
ent-pain-non-pharmacologicalmanagement
2) Deep breathing
3) Modified daily activity
4) Changing the pace
5) Allowing breaks
6) Scheduling to allow for downtime
7) Changing body position during
care and rest
8) Increasing pleasant activity
9) Offering sensory aids (hearing
aids)
Environmental Changes
Successful Interventions
Interventions with Limited EVB effect
 Covering doorknobs and doorways with
 Covering doorways has some
curtains/blinds*
contradictory results*
 Having free access to outdoor
 Covering doorways with mirrors can lead
environments & gardens (greater freedom
to increased agitation.
of movement).
 Evidence on special care environments is
 Normal natural light versus bright light.
mixed.
 Smaller tables and group sizes
Take Home Messages:
 Neutral wall colours
1) Create choice & freedom
 Moderate noise level; Low volume
2) Home-like environment: Use
television, radio, and telephones
natural light and sounds
 Structured daily routine
3) Maintain low stimulation
 Nature songs with large matching photos
4) Coverings are
 Engagement more successful in afternoon
contradictory- but try them!
(between 2:00-5:00 p.m.) versus the
Depends on the person.
morning
Sensory Interventions
• Successful Interventions
Interventions with Limited EVB effect
 Glider-swing/Rocking chair
 Music
 Music vs. music therapy
 Recreation Therapy
 Spa baths
 Massage and touch
 Bright Light Therapy
 Aromatherapy
 Snoezlen/multi-sensory room
 Natural Elements
 Music
 Length of effect
Person-Centered Care
Successful Interventions
 Getting to know the person: Who is this person? What is their personality?
What do they like?
 Dependent variable in care- we cannot change the person! We must
accept them for who they are
 Utilize this information in their care plan: Shows significant reductions in
behaviours!
Take Home Message:
 Person-centered bathing
- The first step is accepting this
 Use of music
person for who they are
 Person-Centered vs. Person-Driven Care
- Know the client: Formal and
informal caregivers working
closely together is our best
tool for success!
- Use the All About Me to help
gather information
Stimuli
Table 2. Predetermine Stimuli: The order of stimuli was randomized.
Stimulus Category
Stimuli Used
Live social
A real baby, a real dog, and one-on-one socializing
Reading
Reading a large print magazine.
Self-Identity
Individualized stimuli matched to each participants past
identity with respect to occupation, hobbies or interests.
Music
Listening to music.
Work
Stamping envelopes, folding towels and sorting envelopes.
Simulated Social
A life-like baby doll, a childish-looking doll, a plush animal, a
robotic animal and a respite video.
Manipulative
A squeeze ball, a tether ball, an expanding sphere, an activity
pillow, building blocks, a fabric book, a wallet for men, a purse
for women, and a puzzle.
Baseline
No stimulation provided / usual care
Cohen-Mansfield, J.S., Marx, MM.S., Dakheel-Ali, M., Tegier, N.G., Thein, K. & Freedman, L. (2010). Can agitated behaviour in nursing home residents
with dementia be prevented with the use of standardized stimuli. Retrieved and adapted from Journal of American Geriatric Society, 58, p. 1461
The Ten Absolutes of Caregiving









Never Argue – Instead Agree
Never Reason – Instead Divert
Never Shame – Instead Detract
Never Say “Remember” - Instead Reminisce
Never Say “I told you” – Instead Repeat & Regroup
Never Say “You can’t” – Find out what they CAN DO!
Never Command or Demand – Instead Ask or Model
Never Condescend – Instead Encourage and Praise
Never force – Instead, Reinforce
Take Home Messages
Physical Aggression
Physical NonAggression
Verbal Aggression
Verbal NonAggression
 Pain
 Discomfort
 Low-intensity
programming
(walking)
 Caregiver
training/education
 Any type of social
contact
 Task-specific
activities
 Person-centered
care plan
 Music (Bathing)
 Reminiscence social
contact
 Low-intensity
programming
(walking)
 Unrestricted
outdoor space
 Door/window
coverings
 Sensory aids
 Social interventions
(recreation)
 Person-centered
care plan
 Music (agitation)




 Any type of
contact
 Home-like
environment
 Low stimulating
environment
 Discomfort
 Music
 Social
opportunities
(recreation)
 Task-specific tasks
 Touch/Massage
Pain
Discomfort
Live social contact
Task-specific
activities
 Music
 Social interventions
(recreation)
 Touch/Massage
Resources & Links
Dementia Care Leaders for long term care homes:
Eden Alternative: www.edenalt.org
Sherbrook Community Centre: www.sherbrookecommunitycentre.ca
Dementia Village: www.cnn.com/2013/07/11/world/europe/wusholland-dementia-village/index.html
Positive Video Links:
Eden Alternative: http://www.youtube.com/watch?v=ZKRMd-r2dN8
Wattle’s Innovative Program for People Living with Dementia:
www.youtube.com/watch?v=1LCRrcxlrXE.
Resources & Links
Montessori :
https://globalnews.ca/video/1360548/a-new-way-of-caringfor-those-with-dementia
Dementiability Free Resources: www.dementiability.com
Teepa Snow (Dementia Care Educational Resources):
www.dementiacareacademy.com
Music Resources:
Java Music Club: www.javamusicclub.com
Room 217: www.room217.ca
Ipod Project: www.imnf.org
Resources & Links
Animal Assisted Therapy/Visits:
Canada’s Guide to Dogs: www.canadasguidetodogs.com
St. John Ambulance: http://www.sja.ca
Hand Massage:
https://www.youtube.com/watch?v=tAJ6JsITQo0&feature=youtu.be
Multi Sensory:
http://www.youtube.com/watch?v=IpuYfZQGN8&list=PLeepEjmy_AglymCxHgUivtcwyziSyVZvL&index=4
Activity Resource Catalogues/Websites:
Concepts du Sablier: www.sablier.com
Nasco Seniors Spectrum: www.enasco.com
Thank You!
Questions?
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