Ask the Expert: How are people with dementia who have aggressive behaviours treated? Should they be restricted in confined hospital units?

Aggression in patients with Alzheimer's Disease and other dementia occurs in about 10-20% of individuals, but can be more common in the later stages of the disease and can be particularly common in patients who have required placement in a nursing home. There are many "causes" of the aggressive behaviors, including biological, psychological, and environmental causes. Some researchers have focused on "unmet needs" as a cause, while others have taken a more biological approach examining the brain changes (structural and functional, chemical, etc.) that distinguish Alzheimer's patients with aggression from those who are not aggressive.

Treatment of aggression always begins with investigations to determine if there is an obvious cause: a change in their medications, a new medical illness (e.g. infection), pain, a change in the way their caregiver is providing assistance, or a change in the environment (e.g. moving to new home, change in primary caregiver, etc.). Treatment would then start with environmental and behavioral approaches which are often helpful at reducing the behaviors. Medications used to treat aggression should only be used if these non-drug approaches are not good enough, and/or if serious aggression puts the patient, or those in the environment, at risk of imminent and serious physical harm. The reason for this is that many of the drug treatments of aggression are associated with significant side effects, including sedation, falls, stroke, and even death.

To answer the specific question - the hospital is the last place an agitated, aggressive dementia patient should be placed in. Hospitals are noisy, frenetic environments that are not designed to care for patients with dementia, can be terrifying for them, and may make their behavior worse. Avoiding a hospitalization should be a key goal of treatment, which means getting professional help with this behavior earlier, rather than later, is essential.

Professor Nathan Herrmann

Nathan Herrmann MD FRCPC

Professor, Faculty of Medicine, University of Toronto

Lewar Chair in Geriatric Psychiatry
Head, Division of Geriatric Psychiatry

Sunnybrook Health Sciences Centre