This blog is the second in a series by the same authors on "How to Respond to a Person With Dementia Who Is..."
Co-written by Nettie Harper, MSRS and Michael Friedman, L.M.S.W.
"Go away, you thief," Margaret screamed when her son knocked on the door of her room. "You stole my money." He opened the door and entered. "Get away!" she screamed again. She was sitting in her easy chair. A cup of coffee was on the table next to her. She grabbed it and threw it at him.
"Mother, it's me, David," he says. "I didn't steal your money. You don't keep money in the room."
"You're lying, you thief. Get away from me." She was looking for something else to throw.
Stung by her words, he felt anger well up in him. He wanted to scream back, but he turned and left the room, closing the door behind him.
His mother has been living with Alzheimer's for almost a decade. Her memory for names and recent events has diminished more and more over time, as has her ability to deal with situations that diverge from her routines. She can no longer manage her finances, shop, cook or keep herself clean.
David is the child who has stepped in to make sure she has everything she needs and spend time with her. Today's outburst stunned and hurt him. He was uncertain what to do.
He is far from alone. Nearly 6 million people in the U.S. have Alzheimer's, many of whom are in the early stages and can manage without much help. But caregivers of those with more limited functional capacity face difficult challenges virtually every day. Dealing with distrust and anger is one that emerges from time-to-time. What should they do?
David's instinctive reaction to walk away was a good one. Screaming back would have frightened his mother and accomplished nothing. It's even possible that this was a passing moment and that she will forget her suspicions and be herself when he returns to the room.
But if it is not a fleeting experience, what could be happening and what can be done?
It is tempting to think that Margaret's feelings and behavior are the result of Alzheimer's because the condition involves changes in brain function that often make it difficult to contain emotions. But most people with dementia do not behave abusively toward people caring for them, and Margaret and David have had a warm relationship until today. Something must be troubling Margaret today!
It could be that something in the situation itself set her off. Perhaps David's knock on the door startled his mother awake from a nap. Perhaps his voice through the closed door was muffled and merged with something ominous that she was dreaming.
There may be a physical cause. Is she constipated or does she have an impacted bowel? Does she have a urinary tract infection or a toothache? Has she been sleeping enough or possibly too much? Is she having trouble hearing? Has her vision blurred or darkened? Is she taking a new medication? Physical conditions such as these can have a terrible impact on mood and behavior.
It is also possible that her "paranoia" and "irritability," her suspicions and anger, are psychologically rooted. A psychiatric evaluation and non-pharmacological interventions, such as structured activities or psychotherapy, can be helpful for people with co-occurring dementia and psychiatric disorders. Psychiatric medications are sometimes indicated but must be used with extreme caution because of their risks to the physical health of people with dementia.
David's mother's distrustfulness could reflect distress about a change in her physical or social environment. Has she moved? Has the place where she lives been renovated or rearranged? Is someone she cares about sick? Has someone died? Has there been a change in caregivers? Have eating or other routines changed? Changes in environment or routine can both cause confusion and distress in a person with dementia.
David's mother's anger might be justifiable but aimed at the wrong person. Has something been stolen? Has someone been harsh with her? Has someone hit her? Has she been molested? It may seem a long way from being insulted to becoming convinced that your son has stolen your money, but the mind follows its own path.
Sometimes it is fairly easy to figure out what is going on. Sometimes it may seem impossible. But there is always a reason -- a reason other than, "It's the dementia."
Here are some rules of thumb that may help you when faced with anger.
• Never yell back. A shouting match may succeed in winning a frightened silence, but you will not achieve a change of inner feeling.
• Deal with your own emotions about being distrusted by someone you care for and for whom you are doing your best. It can be very hard to take, but it's probably not something that the person with Alzheimer's can control voluntarily.
• Don't try reasoning ("Mother, you don't keep money in your room.") People with or without dementia who are angry and suspicious are almost never moved by reason and logic.
• If conversation is possible, ask questions about the situation and listen attentively to whatever explanation is given -- sensible or not. You may get a clue to what's going on.
• Avoid disrupting the routines of the person and, if there are changes, get back into the routines as soon as possible.
• If there were only one rule of thumb it would be: Be kind.
Nettie Harper, MSRS, is Director of Operations at Hearthstone Alzheimer Care. Michael Friedman, L.M.S.W. founded the Geriatric Mental Health Alliance and currently teaches at Columbia University's schools of social work and public health.