Violence in Caregiving

What do you do when your loved one turns violent or aggressive?

The mother with memory loss who once loved casinos but grew so agitated during a visit that casino security intervened. 

The veteran whose post-traumatic stress disorder activated as he watched the war movies he once enjoyed. 

The wife with dementia who battered her husband when he attempted to give her a shower.

These real stories happen frequently, says Jeannine Forrest, who shared them. Forrest is a Chicago-based advisor for the Dementia Society of America and dementia educator and care consultant with Through the Forrest. 

Yet, Forrest also notes that caregivers shouldn’t expect their loved ones with dementia to become violent. This is not a normal expectation of dementia, but it can be common if caregivers don’t pay attention to the triggers that underlie aggressive reactions. People who become extremely distressed are trying to communicate an unmet need. 

A 2022 study published in the journal BMC Geriatrics showed that of 123 people who care for older adults, 28% had experienced violence from their care recipient. 

Aggressive behavior, especially if out of character, can be confusing for caregivers. The first step is understanding why the person is acting out, says Ellen Carbonell, an assistant professor of social work at Rush University and a social work consultant for caregiver programs. “Begin by looking for something that might be creating pain. It could be an injury, an illness, or an infection. One common cause of an abrupt change in behavior is a urinary tract infection. And if the person is living with a disease that causes cognitive changes, aggression should be seen as the disease talking rather than a reflection of the relationship.”

“To her, it felt like violence, but immediately we triaged it and realized that it was a dignity issue.”

The next step is understanding how to respond. People with memory loss, for example, have multiple potential triggers for violent behavior, including: physical ailments, an inability to express themselves, and overstimulation, Forrest says. An angry reaction may be their only way to communicate. 

Social worker Tessa Garcia McEwen, a certified dementia practitioner at The University of Chicago Medicine’s Memory Center, remembers one man who unintentionally tore his favorite caregiver’s shirt while trying to communicate after she refused his help with the groceries. “To her, it felt like violence, but immediately we triaged it and realized that it was a dignity issue,” she says. “He wanted to be a gentleman, but was over and over and over again not being heard. Instead, she could have acknowledged his offer, given him a light load to assist, and then brought in the rest herself. Individuals with cognitive impairment genuinely have less verbal capacity and abilities, so when their needs and wants go unmet, behavior is their only possible form of communication. It’s then often misinterpreted as harm, when it can be prevented through informed, compassionate dementia care.” 

If your loved one is lashing out, here’s what to do.

Consider physical distress

Illnesses such as urinary tract infections or pneumonia can prompt delirium, sparking violent behavior especially in those with dementia, Forrest says. Worsening arthritis or an injury such as a sprained ankle can prompt an extreme reaction, too. “Over time, people lose the ability to articulate [their pain levels],” she says. “And now someone is trying to get [them] dressed, and [they] can’t tell you that [they] hurt.” 

What appears to be a violent reaction may actually be the person’s attempt to protect themselves. Especially in cases of a sudden, out-of-character violent episode, get your loved one to the doctor to understand if physical pain might be the cause.

Watch your reaction

Try not to match your loved one’s anger. “Speak in a calm tone. Try to keep your anger at bay,” Carbonell says. 

And never argue with them, even when their claims are unfounded. Doing so could easily escalate the episode. Instead, go along with what they’re saying, and use that energy to redirect them toward another activity.

Create a safe space

Loud, cluttered spaces can be overwhelming, especially for someone with cognitive impairment. “That can literally set someone off,” Forrest says. Steer clear of overstimulating public spaces, declutter the home, and add calming scents or music that your loved one has always enjoyed.

Also, get rid of any guns and ammunition. This can be a hard ask, Carbonell acknowledges. However, she adds, “Ultimately, if police need to be called, and they see a gun, they’re going to assume it’s loaded.” And that has a likelihood of escalating any already unstable situation.

Make a plan

Even before violence occurs, map out a strategy to keep yourself safe. Let police know at the neighborhood precinct that you’re caring for somebody who may be unable to cooperate with them, Carbonell says.

Remember that bystanders and first responders may not know your loved one’s backstory. People with cognitive impairment are highly attuned to body language and tone, so a subtle facial expression or comment that makes them feel embarrassed or rejected may escalate behavior unnecessarily. 

McEwen recommends printing out awareness cards with sentiments such as ‘My loved one has a brain condition. Thank you for your patience.’ to show strangers who witness a tense moment. Proper signage and communication is key to unlocking others’ understanding, patience, and compassion. It immediately transforms the interaction, helping them feel safe, heard, and calm. To alert law enforcement, if 911 is ever called to the person’s home, hang a sign or post a sticker in a visible spot, such as the front door. 

And for the caregiver, always have a cell phone charged and in hand. Make sure you have a space with a locked door if you need somewhere safe during an episode.

Get help

Don’t wait for violence to seek support. The U.S. Administration on Aging’s Eldercare Locator (eldercare.acl.gov) connects families to local resources, such as caregiving groups and respite care.

These resources can educate and provide breaks for stressed-out caregivers. They also can help build an understanding community, says Sandy Pastore, division manager of home and community services for the Illinois Department on Aging. “There are lots of other people who are going through this, and you wouldn’t even know it unless you find these resources and participate.”