Alzheimer's clients can demonstrate agitation and combative behavior. There are several reasons believed to be factors in manifesting agitation.

• The disease destroys brain cells that control inhibitions and social functions learned in childhood.
• Patients may be responding to delusions and hallucinations.
• They may be cold, constipated, hungry or in pain and may be frustrated by their inability to communicate these feelings.
• Improper medications can trigger outbursts.
• Frustration and depression over feeling helpless.
• Paranoid feelings.
• Major environmental changes, such as a move to a new home or a change in a comforting routine. Types of behavior a care provider may encounter with a client.
• Resisting care - for instance, aggressively hampering efforts at bathing or dressing.
• Verbal aggression - such as arguing, cursing, accusing or threatening.
• Fighting - endangering residents or care providers with punches, kicks and other hurtful acts.
• Catastrophic reaction- sudden mood changes with outbursts that indicate a client is overwhelmed and unable to control feelings.
• Physiological Responses - heart rate increases, central blood flow decreases by constriction of blood vessels, peripheral blood flow increases by dilation, respiration increases and digestion ceases.

Definition of Combative Behavior: physically aggressive act that causes or intends to cause hurt or damage to person or object. Causes can range from brain disorder to environmental situations. For example:

Dementia is a brain disorder in which both personality and thinking abilities deteriorate. Alzheimer's residents lose touch with reality, combative behavior may result from an inability to understand what is going on in the care setting.

Other health-related causes may include hearing or visual impairment, acute illness, multiple illnesses and disabilities, hormonal changes, loss of control over bodily functions.

Psycho-social causes of combative behavior may stem from a client's feeling threatened by life changes and frustrated by a perceived loss of control.

Environmental causes of combative behavior can be varied. Bright or dim lights, loud radios and TV's, intrusive loud speaker messages, cluttered rooms, or the constant traffic of people coming and going can upset clients.

Unskilled care-giving acts that can contribute to combative behavior include being overly authoritarian, rough or hurried handling during care-giving , and impatient, loud or demeaning conversations.

Managing Combative Behavior

Assessing the Client. Focus on efforts to determine what the client is trying to communicate.

• Increase Awareness of behavior that may give clues to the onset of an aggressive act.
• Strive for Containment with efforts to decrease the frequency, intensity, duration, and disruptiveness of combative behavior.

Prevention

• Validate the reality of the confused client.
• Watch for clues that combative behavior may erupt, such as agitation, nervousness, frustration, fear, panic, despair, guilt, suspiciousness, hostility, confusion, annoyance, and resentment.

Review the following ways to work effectively with Alzheimer's clients especially those with agitative and combative tendencies.

• With your words and actions, "mirror" such qualities as kindness, patience, good humor, respect, and friendship. Often, a resident may draw reassurance from you, and "mirror" your good will in their responses.
• Approach slowly from the front to avoid startling the resident. Don't appear afraid or unsure of yourself even though you may be shaking on the inside.
• Allow the client more space when they are angry. Be aware or your position. Watch so that you don't do something intentionally or unintentionally to intimidate the individual.
• Keep at arms length and one small step away from the individual whether standing or sitting.
• Get yourself at eye level.
• Move with the individual, not ahead or after the individual.
• Speak deliberately and respectfully, with short words and sentences.
• Identify yourself and the care you're planning to provide.
• Don't argue.
• Don't Demand.
• Don't promise anything that you can't deliver.
• Listen carefully and respond to the problem and not the words(or observe carefully in the case of a nonverbal individual).
• Accept and acknowledge the individual's statements as expressions of their feeling.
• Often, a client won't be able to remember or carry out a series of tasks, so break the tasks into single acts:
  • Out of bed
  • Into the bathroom
  • Use the toilet
  • Brush teeth
• When beginning a conversation, identify yourself and address the person by name
• Speak slowly and clearly.
• Use short, simple, familiar words
• Break tasks and instructions into clear simple steps
• Ask one question at a time and allow enough time for a response
• Avoid using pronouns ("he" or "she"); instead, identify people by name
• Avoid negative statements and questions ("You know who that is, don't you?")
• Use nonverbal communications such as pointing and touching
• Don't talk about the resident as if they weren't there
• Be patient, flexible, and understanding
  

Documenting and Communicating with Care Director and Family

• Document in detail any aggressive or combative behavior
• Call FTHC Care Director immediately with combative behavior
• Notify family of any incident
• Maintain safety of client and care provider to the best of your ability
• Call 911 when client or care provider has become unsafe.

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