Importance of Distinguishing Reactive and Proactive Aggression in Dementia Care

Abstract

Aggressive behavior is one of the most disturbing symptoms of Alzheimer disease and other progressive neurodegenerative dementias. Development of strategies for management of aggressive behaviors in people with dementia is hindered by a lack of recognition that aggression is not a uniform behavioral construct. It is possible to distinguish 2 types of aggression: reactive or impulsive aggression and proactive or premeditated aggression. Research concerning aggressive behaviors in people with dementia is hindered by scales describing behavioral symptoms of dementia which do not distinguish between reactive and proactive aggressions because they do not consider the factors leading to these behaviors. Reactive aggression is caused by lack of understanding, leading to rejection of care, while proactive aggression could be caused by a psychopathic personality, hallucinations or delusions, and other determinants. It is difficult to underestimate the importance of distinguishing reactive and proactive aggressions in people with dementia because there are different strategies that can be used for management of these behaviors. For reactive aggression, delayed treatment, distraction, improved communication, and change in treatment strategy is useful, while antipsychotic medication may be needed for treatment of proactive aggression. Dementia is increasing the risk of both types of aggressions and antidepressant treatment can be helpful. Most importantly, persons exhibiting reactive aggression should not be labeled “aggressors” because this behavior could be caused by unmet persons’ needs, pain and poor communication with care providers.

What are the factors associated with people with advanced dementia refusing assistance with personal care?

“… 43 However, work examining refusals and other behavioural expressions in dementia has shown that refusals are separate entities to agitation or aggression, caused by different contributory factors and thus require differently focussed interventions. 44 , 45 , 46 Refusals of care occur within the context of care interactions, 47 therefore it is not surprising that more dependence in ADLs is associated with refusals, since more care interactions would be required to assist the person with these activities as they become more dependent. ADL dependence would also be a clear sign of greater cognitive deficits, that is, reflecting a person's difficulties in processing what is occurring around them.…”

“…Often, refusals of care have been conflated with other behavioural expressions such as agitation or aggression in dementia, for example, in assessment scales of behavioural change [43]. However, work examining refusals and other behavioural expressions in dementia has shown that refusals are separate entities to agitation or aggression, caused by different contributory factors and thus require differently focussed interventions [44][45][46]. Refusals of care occur within the context of care interactions [47], therefore it is not surprising that more dependence in ADLs is associated with refusals, since more care interactions would be required to assist the person with these activities as they become more dependent.…”

“…However, work examining refusals and other behavioural expressions in dementia has shown that refusals are separate entities to agitation or aggression, caused by different contributory factors and thus require differently focussed interventions [44][45][46]. Refusals of care occur within the context of care interactions,47 therefore it is not surprising that more dependence…”

Probing the relevance of the accelerated aging mouse line SAMP8 as a model for certain types of neuropsychiatric symptoms in dementia

“…NPS pose a major burden for the caregivers and are associated with a worse course of the disease ( 1 ). One of the most frequent and pervasive NPS in PwD is agitation; it is characterized by excessive motor activity and reactive verbal/physical aggression, and it is associated with signs of emotional distress ( 2 ). From a neuropsychological perspective, agitation has been proposed to arise from an exaggerated response to emotionally salient stimuli (e.g., interaction with caregivers) ( 3 ).…”

How do family carers and care-home staff manage refusals when assisting a person with advanced dementia with their personal care?

“…There may be similar discrepancies around the term ‘refusal of care’, which implies a deliberate act from the person with dementia. In alternative framings, refusals of care, also termed resistiveness-to care/rejection of care ( Galik et al, 2017 ; Ishii et al, 2012 ), have been defined as meaningful communicative actions by the care recipient invoked from the care interaction ( Spigelmyer et al, 2018a ; Volicer, 2020 ).…”