I walked into the patient’s room during my morning rounds, and to my surprise, she was in physical restraints and she was crying. I asked her what happened, but she couldn’t tell me. She was in her 70s, had late-stage dementia, and was hospitalized for a stubborn urinary tract infection.
I immediately took off the restraints and continued my exam. I asked her nurse why she was in restraints, and she told me that the patient had an aggressive episode overnight and the night staff had to restrain her.
The patient deserved better
"I was quite disturbed—there was no note in her chart about the occurrence, and I was unhappy she had been restrained the whole night."
— Kristen Fuller, MD
I thought that surely something else could have been done for a late-stage dementia patient.
I understand that we can become overwhelmed with a high patient census, and when a patient becomes aggressive, we must look out for our own well-being as well as the patient’s. However, there is a specific place and time for physical restraints, and a patient with dementia should never be restrained.
Unfortunately, many physicians and nurses are not trained in how to deal with dementia patients, with or without aggressive tendencies, and as a result, we may end up doing more harm than good.
Looking for the triggers of aggression
Behavioral symptoms in patients with dementia generally mean their disease is worsening as their brain cells are deteriorating. As a result, these patients can act out in ways that seem violent, inappropriate, or odd. Examples may include screaming, hitting, pacing, agitation, and general emotional distress, leaving healthcare workers feeling helpless and stressed. These symptoms affect the majority of patients with dementia, and doctors often prescribe medications to control these behaviors despite the known serious side effects.
Understanding the events or changes in the environment that trigger these behavioral outbursts is essential. New environments, such as hospitals, nursing homes, and doctor’s offices, as well as being introduced to new people, can cause these emotional outbursts. Often, these patients cannot verbally express they are scared or anxious, so they act out through aggression.
"Our job as physicians is to understand why our patients act out in this way so we can work compassionately to alleviate their distress."
— Kristen Fuller, MD
Other triggers for aggression include treatable medical illnesses such as urinary tract infections, pressure sores, constipation, or having a full bladder. Physicians can complete an assessment to try to understand the root of this aggression.
This assessment includes talking to the patient’s loved ones, reviewing their medication list, and examining them for any underlying infections. Press on their bladder or do a bedside bladder scan to see if their bladder is full—often, late-stage dementia patients cannot express this verbally. Look for pressure sores, aching joints, or any other signs of pain or discomfort that may be causing their aggression.
Non-pharmacological approaches for compassionate care
One of the reasons we go into bedside medicine is because we are caring, compassionate individuals who want to do good in the world. We must use this mindset as a guiding principle for handling patients with dementia who are aggressive.
We want our patients to feel safe and comfortable and have a sense of control. It is essential to understand that our patients are experiencing symptoms of their disease, they are not just being arbitrarily malicious. We can provide compassionate care by smiling and making eye contact; creating a calm environment; providing a security object, such as a picture, blanket, or stuffed animal; redirecting the patient’s attention; and acknowledging and responding to their requests.
We can also play calming music or a recording of their loved one discussing happy memories. Human touch and communicating with family members about how they approach their loved one are also examples of compassionate care.
You can ask loved ones about what can help the patient feel more comfortable during a physical exam, while we administer vaccines, or while drawing blood. More often than not, they may be able to tell you some tips and tricks that have worked for the patient in the past.
Another technique to help calm your patient that includes physical touch is “hand under hand.”
“This refers to the caregiver's placing his or her hand underneath the patient's hand while guiding the patient through an activity,” writes the author of an article in the AMA Journal of Ethics. “This hand-under-hand position reduces the patient's resistance to direction and provides adequate support. When a patient does show resistance, caregivers should remember that arguing or reasoning will not change the unwanted behavior.”
Medication: The last resort
If there are no underlying triggers or if you have treated these triggers and have tried the aforementioned non-pharmacological approaches consistently, introducing medications to help manage aggressive behaviors may be appropriate. This especially holds true if the patient is at risk of causing harm to themselves, you, or other medical staff.
While prescription medications can be effective in certain circumstances, they do not come without known risks. Antipsychotics and benzodiazepines are the most widely used classes of medications for treating agitation in patients with dementia.
Antipsychotic drugs such as haloperidol, aripiprazole, quetiapine, risperidone, and ziprasidone have an increased risk of stroke and death in older patients with dementia, and have a “black box” warning. Benzodiazepines are known to worsen cognitive functions in individuals with dementia.
It is important to note that atypical antipsychotics are typically used “off-label” to treat behavioral and psychotic symptoms in patients with dementia. Brexpiprazole was granted supplemental approval on May 11, 2023, by the FDA for treating agitation linked with Alzheimer's disease; however, it carries the risk of stroke and death in this patient population.
Each week in our "Real Talk" series, mental health advocate Kristen Fuller, MD, shares straight talk about situations that affect the mental and emotional health of today's healthcare providers. Each column offers key insights to help you navigate these challenging experiences. We invite you to submit a topic you'd like to see covered.