If you are caring for someone with dementia, you may find that they sometimes over-react to a trivial setback or a minor criticism. They might scream, shout, make unreasonable accusations, become very agitated or stubborn, or cry or laugh uncontrollably and inappropriately. This tendency to over-react is part of the disease and is called a "catastrophic reaction". Sometimes a catastrophic reaction is the first indication to make relatives aware of the dementia. It may be a passing phase, disappearing as the disease progresses, or it may go on for some time.

Coping with such behaviour can be very difficult and is often a matter of trial and error. Remember that the behaviour is not deliberate: it is out of the person's control and they are probably quite frightened by it. They need your reassurance, even though it may often not appear that way. Trying to make sense of the environment becomes a difficult task confronting the person with dementia. Simple tasks such as bathing, dressing and eating are all major hurdles to overcome. People with dementia are frequently confronted by failure, so maintaining their dignity is most important.

Three Common Worries Which Caregivers Express:

• Is the person for whom I am caring brooding about past tensions and misunderstandings which have occurred between us?
• Does he hate me now?
• Have I done something unintentionally to upset him?

These are all normal reactions - it is important to realise that most of the anger and aggression is directed against the cargiver because you are the closest person, however, it is not a calculated personal attack.

Causes of Catastrophic Behaviors:

• stress caused by the excessive demands of a situation;
• frustration caused by misinterpreted messages;
• another underlying illness.

Aggressive behaviour may come on without warning and make you feel very apprehensive. However, if you can figure out what situations trigger catastrophic behaviour (perhaps by keeping a diary), you may be able to work out ways of avoiding them. If not, you may still be able to find methods of dealing with the behaviour quickly and effectively when it occurs. Remember, each person with dementia is an individual and will react to circumstances in their own particular manner.

Try To Minimize Stress:

A calm, unstressed environment in which the person with dementia follows a familiar routine can help to avoid such reactions.

• approch the person slowly and calmly: try to avoid conveying your own stress, fear or alarm;
• be aware that the person may not recognise you: try to give some information which may help, such as your name and your relationship to them;
• try to make eye contact and address them by name; touch may be helpful and reassuring, but be aware that some people may not like it;
• speak clearly and use simple sentences, allowing time for response;
• try to ask questions that require only a 'yes' or 'no' response;
• try to talk in a place that is free from distractions;
• try to focus on familiar skills which are within their capabilities;
• give limited choices only, to avoid confusion;
• break a task down into simple steps which are not overwhelming;
• modify these steps as the person becomes less able;
• demonstrate visually what you are trying to say;
• if it has become difficult to understand what the person is saying, try to focus on a word or phrase that makes sense, or respond to the feeling they are trying to express;
• it may be necessary to remove yourself from the situation until the person calms down.

Modifying The Environment:

People with dementia often become extremely upset if they find themselves in a strange situation or among a group of unfamiliar people where they feel confused and unable to cope. The situation may seem to be very simple, but the frustration caused by being unable to meet other people's expectations may be enough to trigger an outburst.

• be aware of what situations lead to difficult behaviour such as aggression and try to avoid them;
• try to do difficult and frustrating tasks when the person is at their best and not tired;
• use a diary to help you monitor when good and bad times are likely to occur;
• pictures or labels on objects may help identify or locate them;
• try to avoid frustration by adapting the environment to cope with the problem behaviour: e.g. allow the person to go for a walk if they want to wander;
• close off certain areas of the house where problems are occurring;
• simplifying the environment: e.g. place only essential cutlery on the dining table;
• try to use the person's other senses such as smell and touch;
• try to remember that problem behaviour may intensify when there is a major change in lifestyle such as moving house or moving into residential care.

Distraction:

• if there are a few moments before an outburst when the person becomes increasingly agitated, you may be able to prevent the over-reaction by calming the person down early;
• first try to respond to the feelings of anger by soothing, comforting and reassuring the person gently. Then try to defuse the situation by distracting them and, finally, praise success;
• alternatively, you could try calmly ignoring the outburst and busying yourself with something else;
• try to distract a person who is sobbing excessively or laughing uncontrollably because this is not a sign of true emotion and may be very exhausting.

Things To Avoid:

• try not to argue with the person when they become upset because they no longer have the ability to be rational or logical and there is no point in trying to reason: save your energy and concentrate on trying to remain calm.
• try not to get upset or excited as well or the situation will simply escalate further;
• try not to order the person around;
• never reprimand or punish, even if the behaviour appears like an unreasonable tantrum: they are not responsible for it, cannot learn from it, and may forget the whole incident quite quickly;
• try not to focus on what the person cannot do: focus on the positive;
• try not to be condescending or sarcastic;
• try not to ask questions which rely on memory;
• try not to talk about the person in their presence;
• try not to take things personally;
• try not to hurry the person;
• never try to restrain a person because this just increases their anxiety and distress;
• never put your own safety at risk: if the behaviour escalates out of control, remove yourself from the situation, call your doctor or the police.

Violence And Aggression:

Sometimes the person with dementia may become very violent for a short time. They may become verbally abusive, cause damage to property or become physically violent. (Physical violence almost always occurs when someone else initiates physical contact.) Try to stay calm and not show fear or alarm. Try to understand that even if the aggression is directed at you, it is not a personal attack.

Violence could be caused by:

• defensive behaviour - people with dementia may feel humiliated and frustrated when they are placed in a situation where they have to accept assistance, especially with intimate tasks such as bathing and toileting: when their independence and privacy are disrupted, they may react angrily; failure of competence - the person is not able to cope with certain tasks and may feel a failure;
• misunderstanding and bewilderment about what is going on - as the illness progresses, the person may be bewildered by events, for example, accusations of stealing may be an attempt to make sense of their inability to locate something and an unwillingness to accept that they have forgotten where they put it;
• fear - if the person is unable to recognise people or places, this may be very frightening. The person may be convinced they should be somewhere else (e.g. childhood home) or may believe the person with them is a stranger. Sudden noise or people approaching from behind may cause a hostile reaction;
• changes in routine such as the presence of a lot of people, a special event, distracting noise or activity may cause the person to feel unable to cope;
• attention-seeking;
• boredom, distress, restlessness, illness or pain may be expressed in terms of anger, aggression or agitation, especially if the person is unable to communicate such difficulties verbally;
• attempts to control other behaviours such as wandering.

Coping With Aggressive Behaviors:

Preventive measures

• attempt tasks which cause outbursts at the time of day when the person is at his best;
• try not to rush the person - reduce stress by minimising distractions such as loud noise or lots of activity;
• be aware of the person's limitations and don't expect too much;
• encourage independence by allowing the person to do as much for himself as possible even if it takes longer and is not as efficient;
• avoid confrontation wherever possible - try distraction or suggesting alternatives;
• praise things which are done well and try not to criticise;
• think about how to offer help tactfully without taking over;
• a simple suggestion such as having a cup of tea may defuse the situation - or you may need to withdraw until things have calmed down;
• it may be helpful to explain the situation to other people;
• be aware of warning signs such as anxiety or agitation (flushing or restlessness, or refusal to comply with requests);
• exercise may be a helpful preventive measure;
• if you suspect the person is ill or in pain, particularly if the aggression is uncharacteristic, it would be wise to consult your GP. The outburst may have been caused by an infection or discomfort which can be remedied;
• remember that preventive measures may not always work: don't blame yourself if aggression does occur, but concentrate on handling it as calmly as possible.

Coping Strategies

• do not attempt to restrain the person, lead them away, corner them, approach them from behind or initiate any form of physical contact: it may be better to leave them alone until they have recovered or you may wish to call in a friend or neighbour for support;
• try not to take it personally;
• try not to raise your voice;
• do not provoke by teasing or laughing;
• avoid punishment - the person will probably not remember the event and is therefore not able to learn from it;
• try not to show fear or alarm;
• try to provide alternatives to the behaviour;
• speak in a calm, reassuring voice and attempt to distract;
• try to remain detached and do not allow yourself to be provoked or drawn into an argument; try taking a deep breath and counting to ten;
• try to tell yourself that you are dealing with the illness rather than the person;
• if you do lose your temper, don't feel guilty - but do try to talk it over with a friend or professional worker who can offer you support;
• if aggressive incidents are very frequent, consult your GP and, if necessary, a geriatrician or psychiatrist - it may be necessary to consider using some form of medication and this will need to be done with careful monitoring. Some tranquillising medication can increase confusion.

Looking After Yourself:

Sudden over-reactions may leave you upset and a little shaky. It is essential that you seek support for yourself from a supportive family member, a friend, an understanding professional or a support group, and that you get a break from the constancy of the task. Identify the areas of support that you need and learn about the services in your area ( respite care, in-home care, day care etc.) which are available to help you.

Allow yourself to get help with other tasks such as cleaning so that you can conserve your energy.

Remember that your own feeling of distress, frustration, guilt, exhaustion and exasperation are quire normal: However, if you feel you are losing control, talk to someone, a support group, a neighbor, a friend, family member or clergy anyone who will listen and understand.

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