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Combativeness | Just the Facts

When an Alzheimer's patient becomes combative, angry or agitated, it may be because of frustration. The individual may feel that he's being pushed to do something that simply can't be done.

Consider the following factors as possible sources of frustration:

Dressing
The person who can't get his arm through a sweater may grow increasingly upset and start to thrash around.

Bathing
The person who's frightened by running water in the bathtub may push away a caregiver who's trying to give him a bath.

Eating
The person who doesn't like a certain type of food may refuse to eat it.

Keep in mind that combativeness takes many forms. Sometimes the person may simply try to push your hand away, while at other times the person may resist or strike you.

Deal with combativeness by trying to examine the underlying causes. Consider the following issues:

Physical Causes
Is the person tired because of inadequate rest or sleep? Are medications such as sedatives and tranquilizers creating side effects? Is the person unable to express the fact that he's in pain?

Environmental Causes
Is the person overstimulated by loud noises, people or physical clutter? Is the environment unfamiliar? Does the person feel lost or abandoned by the caregiver?

Poor Communication
Are you asking too many questions or making too many statements at once? Are your instructions simple and easy to understand? Is the person picking up on your own stress and irritability? Are you making the person more frustrated by being overly negative or critical?

Action Steps

Be on the lookout for frustration. Look for early signs of frustration in such activities as bathing, dressing or eating, and respond in a calm and reassuring tone.

Don't take aggression and combativeness personally. Keep in mind that the person isn't necessarily angry at you. Instead, he may misunderstand the situation or be frustrated with his own disabilities.

Avoid teaching. Offer encouragement, but keep in mind the person's capabilities and don't expect more than he can do. Avoid elaborate explanations or arguments.

Use distraction. Don't persist in making the person perform a particular task, especially if she has been repeatedly unsuccessful. If you see the person getting frustrated with buttoning a shirt, try to distract her with another activity such as putting on a pair of pants. After a time, you can return to the shirt. Or take the person to a quiet room, have a cup of tea, or go for a walk.

Communicate directly with the person. Avoid expressing anger or impatience in your voice or physical actions. Instead use positive accepting expressions such as "please," "thank you," and "Don't worry, everything's going to be find." In addition, use touch to reassure and comfort the person. For example, you might want to put your arm around the person or give him a kiss. In addition, follow these tips:

  • Speak slowly and clearly.
  • Use short, simple sentences.
  • Approach the patient slowly and from the front.
  • Use repetition and frequent reminders.

Decrease your level of danger. Assess the level of danger-both for yourself and for the person. In other words, if the person becomes combative, ask this question: "How much trouble am I in-and what can I realistically do about it? Often you can avoid harm by simply taking five steps back and standing away from the person for a short period of time. On the other hand, if the person is headed out of the house and onto a busy street, you need to be more aggressive.

Be conservative in using restraint or force. Unless the situation is serious, try to avoid physically holding or restraining the person. By fighting with the individual, you'll probably make him even more frustrated and anxious.

Experiment with objects that have a soothing effect. Some caregivers believe that stuffed animals have a soothing effect on the person, while others find that pets-from cats and dogs, to birds or goldfish-have a calming effect.

Learn from previous experiences. Try to avoid situations or experiences that make the person combative. For example, if the individual tires easily when she visits with family members, you might want to limit the length of the visits. Try to identify early signs of agitation. For example, outbursts are sometimes preceded by restlessness, frustration, fidgeting, or blushing.

Restructure tasks and the person's environment.

  • Simplify tasks or plan more difficult tasks for the time of the day when the person is at his best.
  • Give the person adequate time to respond to your directions or requests.
  • Allow the person to make some choices, but limit the total number of choices. Having too many decision to make about what to eat or wear might be confusing or overwhelming.
  • Break down each task into small steps and allow the person to complete one step at a time.
  • Keep the environment calm, quiet and clutter free.
Resources

One of the best places to turn for additional help is the Alzheimer's Association. The Alzheimer's Association has more than 200 Chapters and 1,600 support groups nationwide, where family members of patients with Alzheimer's disease or a related disorder share their experiences, provide each other with emotional support, hear practical suggestions and learn to rebuild their lives.

The primary resource for this fact sheet was Peter V. Rabins, M.D., a geriatric psychiatrist and director of the Price Teaching Services and associate professor of psychiatry at the John Hopkins University School of Medicine, Baltimore, M.D.

Special thanks goes to the following Alzheimer's Association's:

Indianapolis Area Chapter
Cincinnati Chapter
Eastern Massachusetts Chapter
Cleveland Chapter
South Central Michigan Chapter
Dallas Chapter

Miriam K. Aronson, Ed.D. Understanding Alzheimer's Disease. New York: Scribner's, 1988.

David L. Carroll. When Your Loved One Has Alzheimer's. New York: Harper and Row, 1989.

Donna Cohen, Ph.D. and Carl Eisdorfer, Ph.D., M.D. The Loss of Self: A Family Resource for the Care of Alzheimer's Disease And Related Disorders. New York: Norton and Co., 1986.

Lisa P. Gwyther. Care of Alzheimer's Patients: A Manual for Nursing Staff. Washington, D.C.: American Health Care Association, and Alzheimer's Disease and Related Disorders Association, 1985.

Nancy L. Mace and Peter V. Rabins, M.D. The 36-Hour Day. Baltimore: John Hopkins University Press, 1981.

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