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The following story was told to me thirty years ago by my friend Lisa, who had just returned from a trip to Israel, my homeland.

"One evening, my friend and I decided to go to the movies. We bought tickets and chose a seat that was in a perfect location in the theater. Suddenly, out of nowhere, a young guy approached us and started yelling in Hebrew. We didn't understand a word, and although we tried explaining to him that we had no idea what he wanted, he kept yelling at us. So, we did what any two nineteen-year-old girls would do when they feel threatened; we started yelling back at him in English. Eventually, another woman intervened. In a calm, quiet voice in English, she explained that in Israel, the seats in the movie theatre are assigned by your ticket, and we were sitting in this young guy's seat. Once we understood the situation, we got up, smiled at him, apologized (the woman translated what we said), and found the seats written on our tickets."

Why am I telling you this story? Although it seemingly has nothing to do with dementia, it’s actually a great analogy to what often happens when a person with dementia behaves in an inappropriate manner. 

Shift Your Thinking About Behavior 

The brain is an amazing machine. One of its many jobs is to interpret everything that we see, hear, touch, smell, taste. In short, the brain takes the input we get through our senses from the world around us, analyzes it, and makes the right decisions regarding how to react. When brain cells die, for instance as they do in dementia, the input-interpretation-output operations stop functioning correctly. Think of a car with all its parts intact, but the battery’s dead. Only one part of the car is faulty. But even so, the engine won't ignite, and the vehicle won’t properly move. 

Before we label the actions of a person with dementia as aggressive, let's shift our thinking: it’s not their fault that their brain cells responsible for appropriate behavior are dead or misfiring. Once we truly understand that, we can accept that the person is not intentionally doing anything wrong. Unlike replacing a dead battery we, unfortunately, can't fix the damaged brain.

And just like we saw in my friend Lisa's story, when a person doesn’t understand the situation, and they don’t understand the person explaining the situation, they felt threatened and reacted by yelling.

Think like a detective

As a family member's caregiver, have you witnessed your loved one behaving in any of the following ways?
•    Told you that you are a lousy caregiver
•    Insulted or called you names
•    Pushed or tried hitting you
•    Yelled or spat at you
•    Accused you of stealing valuables
•    Lied to you
•    Purposefully upset you

Or any other number of aggressive behaviors.

Unless your family member has a history of mental health, in most cases the reason for their behavior is rooted in dementia. Sometimes the cause of their outburst is apparent and you can easily connect the dots. But in most cases, you'll have to be a detective and look for the underlying cause. This requires patience and creative thinking. But once you discover it, you can come up with a solution that can defuse the behavior. Further, it can help you prevent, quickly address, and be more patient in the future.

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Your Clues

The following is a long, but certainly not complete, list of potential clues as to why your loved one may be acting out.
When you understand the brain's changes and how they affect the input-interpretation-output cycle, you become a better detective.

So, let's go to work!

Our speech is composed of two parts: understanding and speaking. Lacking either element will result in aphasia, also known as non-fluent speech.

Receptive aphasia
Receptive aphasia is when a person doesn't comprehend what’s being said to them. In this type of aphasia, the person speaks nonsensically, but in a normal cadence and pace.
Imagine you are driving in Macedonia and a policeman pulls you over. You have no idea what rule you violated, and you don't understand a word that the policeman is saying (remember my friend Lisa?). Wouldn't you get frustrated? Angry? Wouldn’t you gesture wildly in an attempt to be understood? 

Expressive aphasia
Expressive aphasia is when a person has difficulty expressing their thoughts. They know what they want to say, but their sentences just won’t come out as they want them to. 
Now imagine trying to explain to the policeman that you don't know what you did wrong and know only a few disparate words in Macedonian. Wouldn’t you get frustrated that you can't explain that you’re innocent?

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The inability to understand what is being said or what you are being asked to do causes immense frustration. And that frustration only increases when the situation is urgent, such as when you’re tired, hungry, in pain, or need to go to the bathroom?

* Click HERE for more tips on how to communicate with people living with dementia. 

In Alzheimer's, vision changes. While a person starts out with an excellent vision, their peripheral vision deteriorates until they can see only straight ahead (binocular vision), and eventually through only one eye (monocular vision). Other associated conditions like poor posture and cataracts can exacerbate limited vision.

Binocular vision
*Make an oval with your thumbs and index fingers and put it around both eyes; you can see how the peripheral vision of the person living with dementia is now limited.

Monocular vision
Make an oval with your thumb and index finger of one hand and put it between your eyes. You can see how your peripheral vision and depth perception is farther limited. In order to fully take in your surroundings, you need to move your head from side to side and up and down. 

Add to the loss of peripheral vision a slouch sitting with limited mobility in the neck. Now you have also lost sight in the upper field. 

Vision degeneration
Normal aging of the eyes can even limit the vision of the person living with dementia even further. Cataracts cause blurry vision, macular degeneration causes a spot in the middle of the visual field, glaucoma causes a loss of peripheral vision and blurriness, and floaters get in the way of viewed objects.

Put yourself in their shoes: how would you react if you can't properly see what’s around you? It’s frightening to hear a noise and be unable to discover what it is, or to suddenly encounter a person appearing in your visual field without warning?
What if you want to drink but can't see the glass of water on the table next to you? 
How do you react when you are scared, frustrated, or startled? 
Most people’s reaction is to wave a hand for protection or get angry as an expression of frustration or fear.

The takeaway:
When you approach a person with dementia, don’t come from the side. Instead, always approach them from the front, you may even need to band down to their eye level. And don’t forget to announce your coming by calling to them by name!

Poor vision can lead to extreme light sensitivity. How would you feel if you wake up from sleep to a bright light shining into your eyes? Or exiting a dark house into the blinding sun?
Or entering a dark room and not being able to see what you’re looking for?
Would you get irritated?

The takeaway:
*If your loved one takes naps in the recliner, consider dimming the light while they sleep.
*When you wake them up in the morning, don’t turn the light on too strong or open the curtains too wide. Allow your loved one time to adjust to the bright light.
*Make sure the room they sit in during the day has good enough lighting. 
*If they have any eye condition, consult with their eye doctor about the best way to ensure optimal vision.

Declined hearing is normal at old age. Let’s say someone is talking to you and you don't hear them; they will probably repeat their question. But after a few times of missed questions and responses, irritation may set in. They may get irritated with you, you may get annoyed back, and when they raise their voice at you, you may well yell back at them in anger.

In dementia, the brain loses its ability to differentiate between certain noises. A healthy brain can watch the tv and tune out the ambient noise coming in from the street. But for the brain with dementia, these noises get mixed up. Often, they may interfere with a person’s ability to focus and understand what someone is saying to them.
It’s understandable that this cacophony of sound can create irritation that leads to anger, yelling, or even hitting.

The takeaway:
*Make sure there’s not too much noise from different sources in your loved one’s surroundings. 
*Give them headphones to use when they watch TV or listen to music.

The loss of extremity agility affects a person with dementia’s ability to perform simple tasks. When dealing with poor dexterity, putting a bra on, pulling up pants, holding a toothbrush, and opening a door can become a monumental task.

To understand what it may feel like to your loved one with dementia, put on heavy gloves and try performing any of the above-mentioned tasks. If you struggled, you could imagine how frustrating it could be for a person with dementia to constantly face these daily, difficult tasks.

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The takeaway:
*Allow your loved one to do as much as they can, and offer your help with the fine motor tasks.

Smell and Taste
It’s not uncommon to lose your sense of smell in old age. A loss of smell leads to a decreased ability to taste food. Thus, the loss of taste is not uncommon in old age. However, the ability to taste salt and sweet always remains.

Before you get upset that your loved one doesn't want to eat their favorite dish, or picked up the habit of munching on sweets and drinking soda, you may want to consider why they’ve begun to eat differently.  This isn’t a childish behavior. Rather, it’s the behavior of someone who enjoys flavorful food.

The takeaway:
Consider adding salt or sugar to your loved one’s food.
Make healthy shakes with fruits, greens and protein powder, and add ice cream or honey for extra sweetness.

We already talked about the loss of language and the ability to express one's needs clearly. 
Have you ever been in pain but couldn't get relief fast enough? Were you a pleasant person to be around at that time? And if you couldn't explain that something hurtl, or where the pain was, would you be a happy camper? Probably not!

The takeaways:
*Watch as your loved one moves around; if they avoid putting weight on one leg, make sounds that indicate pain when they sit or stand, or avoid lifting their arm, they may be in pain
*Watch for any facial expression that may indicate pain.

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The Frontal Lobe
The frontal lobe is the part of the brain that is responsible for executive function. Executive function is in charge of working memory, problem-solving, and self-control. We use these skills every day to learn, work, and manage daily life. Trouble with executive function can make it hard to focus, follow directions, and control emotions.

In addition, the frontal lobe is our thought filter. It makes sure that we don’t blurt out every thought that comes to our mind so we behave appropriately in social situations.
If you’re sitting next to an overweight person on the bus, you’re not going to tell them to their face, “You’re fat!” 
But if your mom has damage to her frontal lobe, she may say some hurtful things to you and others. And she won’t even be aware there was anything wrong with what she said.

One of the most overlooked reasons for aggressive behavior is as simple as constipation.
When a person is constipated, they feel very uncomfortable, bloated, and even pained. The effort to "push" can cause hemorrhoids, which is another cause for pain and may make sitting uncomfortable for a length of time.
What’s constipation? It’s generally considered to be a lack of a bowel movement for three days, or having very hard, small stool for several days in a row.

The takeaway:
*To keep your loved one regular, encourage them to drink water.
*Before doling out medications, try prunes, prune juice or smooth tea. 
*Encourage them to be active throughout the day by exercising or walking.

 Hunger, Thirst, Tiredness, Bathroom
These four annoyances are common sources of disorientation, especially when a person with dementia can’t identify their particular urge. If they can't tell you that they are hungry, thirsty, tired, or need to pee, then these unidentifiable feelings can cause immense discomfort.

The takeaway:
*Offer snacks or drinks.
*Take them to the bathroom on a schedule

As weird as it may sound, if your loved one used to be a busybody, they may get irritable sitting idly during the day.

The takeaway:
Keep them engaged and active through fun activities and brain games.

Remember To Be a Patient Detective

Now that you understand many of the reasons that can cause your loved one to “misbehave," you can put your detective hat on and get to work.

Whenever your loved one exhibits one of those behaviors, stop for a moment to think: is there loud music playing? When was the last time they had a bowel movement? Did I move too fast in front of his face? Is he trying, unsuccessfully, to feed himself? Is he bored?

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There will be times where the answer will be right in front of you. There will be times when you will scratch your head, and nothing you try would work. But the most important thing to remember is that whenever your loved one exhibits any vocal or physical aggression, it is not because they WANT to behave this way. It is not because they WANT to hurt you. It is a behavior that is a result of their dementia brain. It is not the person that is your mom, dad, grandma, a spouse that behaves this way. 
It is the dementia behaving this way.

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