De-escalating violent outbursts in dementia caregiving

When a person living with dementia hits, kicks, spits, shoves, or shows other aggression towards a caregiver it may be motivated by pain, strong dislike, or fear. I recently coached a professional caregiver, Lila, who had a troubling encounter with a resident at the assisted living community where she worked.

Lila had entered his room and was preparing to take his blood pressure on her morning rounds. But the resident, Richard, was having none of it. Grabbing her by the wrist, he barked out, “Get away from me with that tourniquet!” before shoving her arm away. Lila had been holding the blood pressure cuff out in front of her as she approached him.

This violent outburst was likely triggered by a sense of threat. Lila was going about her business in a routine, efficient manner, wasting as little time as possible. However Richard likely wasn’t mentally prepared for her visit, since his dementia made it difficult for him to remember who Lila was and that she always took his blood pressure in the mornings. And her swift movements may have been misinterpreted, since his dementia also made it hard for him to process motion. In his startled state, it was clear that he didn’t comprehend what the blood pressure cuff was, even though he could associate the tight sensation it caused, in the past, with the object he was looking at in the present.

Lila has to take his blood pressure as part of her job responsibility associated with every resident’s care. How can she change her process so that her task is not upsetting to residents and doesn’t put her at risk of injury or of resident distrust? In coaching Lila, we devised a new plan for taking blood pressure – one she could adopt in caring for all residents in her care, not just those living with dementia.

Avoiding the triggers to violent outbursts

Instead of breezing in each room and moving directly to each resident’s side, she will stop just inside the resident’s entryway – close enough that Richard and others can see her, but still far enough away that her presence will not cause any resident to feel threatened. She will introduce herself to each resident, each time she enters a room, and state her purpose. “Good morning, Richard. It’s Lila here, coming to take your blood pressure.”

Mindful of her body language, she does not raise the blood pressure cuff up when she is explaining her intention. Instead, she uses her other hand to point to the equipment, which is still at waist level. If a person feels threatened, lifting any object upward, especially when done so quickly, can be perceived as a threat.

Lila will only come closer once she has established eye contact with Richard. “Is it alright for me to get started?” she will ask. Or, “Are you ready for me to take your blood pressure?” The point is to convey that she will be coming closer, and to get acknowledgement of this fact before she approaches Richard’s personal space and actually touches him. Unwanted touch can trigger violent outbursts.

Lila will position her body on par with Richard’s, rather than standing above him. This way, she can reinforce that they are in equal stance as opposed to her being in a dominant position. As often as possible, caregivers should try to position themselves at eye level or below eye level to reinforce that they are not a physical threat to a person with dementia. In the case of performing a blood pressure test, positioning oneself below the person with dementia would be impractical. Mindfulness about body stance and body language is critically important to maintaining trust.

Taking cues from the person with dementia

That Richard equated the blood pressure cuff with pain (“…that tourniquet…”) is important information to consider as Lila seeks to create more joy in these encounters with the residents in her care.

Lila may choose to narrate as she goes. “After I place this on you and start to inflate it, you will feel pressure. It’s normal, and some people find it painful. But as soon as I can I will stop inflating the cuff, and you will start to feel relief. After it’s over, any pressure you feel will disappear.”

Everything Lila does is for the purpose of building and maintaining trust, and eliminating any possible sense of threat she may be causing in these encounters. As she inflates the cuff, she might ask, “How is this pressure, is it what you might expect?” And as she goes, “You’re doing great, it’s just a few seconds more and then I can release the pressure for you.” Comments like these help a person with dementia feel that caregivers are on their side, understand their feelings, and have concern for the person’s well-being.

It’s all in your point of view

All dementia caregivers, professional and family members alike, can benefit from taking a moment to see any situation from the point of view of the person living with dementia. Couple that with demonstrating with words and actions that you have that viewpoint in mind will go miles toward establishing the trust necessary to build the bonds that ensure positive caregiving.