Dementia and anger: What’s the connection and how to cope

When you think of common dementia symptoms, you might think of someone struggling to remember words, frequently misplacing items or getting disoriented and lost. But dementia and anger often go hand in hand, and seeing signs of anger or aggression in a loved one can be jarring.

When someone with dementia shows signs of anger or aggression, “it can be frustrating, irritating and even scary,” says Dr. Aaron R. Ritter, psychiatrist and director of the Memory & Cognitive Disorders Program at Hoag Medical Group. “It’s one of the most common reasons for caregiver burnout, and probably the most common reason a person with dementia will be treated with medications or need placement in a nursing home.”  

But there’s hope. While anger in dementia might not always be preventable, it can be managed. Learning about what causes and triggers anger in dementia allows you to understand your loved one or client better, and help them get the support they need. 

Dementia and anger: What’s the connection? 

First of all, it’s important to understand that while aggression in dementia is common, it’s not universal. “There is a misconception that aggression always occurs in dementia,” says Ritter. In reality, research suggests that about 50% of people with dementia experience agitation or aggression.

There are typically multiple causes of anger, aggression and agitation in dementia, including:

Dementia pathology

The brain changes that occur when you have dementia often make you susceptible to anger. “As brain cells die, the areas responsible for judgment and impulse control weaken,” says Shebna N. Osanmoh, a board‑certified psychiatric nurse practitioner at SavantCare, “so those with dementia may react more strongly to what feels like threats.” 

Medical issues

Having concurrent medical issues along with dementia can make someone more likely to experience feelings of anger or aggression. “Anger and aggression may be the first sign of an additional medical issue, such as undiagnosed or undertreated pain, an infection — urinary tract infections are notorious for triggering agitation,” Ritter shares. Having a mood disorder (like anxiety or depression) along with dementia may also play a role, he adds. 

“In dementia, one of the first things that is lost is executive control. Without that internal voice, it might be easy to get agitated or frustrated.”

— Dr. Aaron R. Ritter, psychiatrist

Frustration and confusion

All of us experience frustration in life, but these feelings can be more difficult to process when you have dementia. For example, if you have dementia and you are told you can no longer work, drive or handle your own finances, you may not fully understand what is happening or why. This can trigger feelings of anger or aggression, Ritter says. 

Loss of executive control

People with dementia lose executive control, which is the voice in our heads that helps calm us down when we experience challenges in life, says Ritter. For instance, executive control tells us that pain is temporary, that another person may be having a bad day or that certain things are beyond our control.

“In dementia, one of the first things that is lost is executive control,” Ritter explains. “Without that internal voice, it might be easy to get agitated or frustrated.”

Recognizing the signs of dementia-related aggression

Ritter says there are three main ways ways that anger and aggression can manifest:

• Verbally aggressive behaviors: Yelling, swearing, moaning.
• Physically non-aggressive behaviors: Pacing, wandering, ruminating.
• Physically aggressive behaviors: Kicking, punching, slapping.

Some signs of anger and aggression in dementia are more obvious, like raised voices, threats, pacing, hitting or even throwing objects, says Osanmoh. But others are less obvious. “You might notice clenched fists, glaring looks or refusal to cooperate with bathing or eating,” he explains.

Anger and aggression triggers 

There are many possible triggers for anger and aggression in dementia. “Everyday frustrations — like not knowing where the bathroom is or forgetting words — can lead to outbursts,” Osanmoh describes. Additional triggers might include:

• Pain.
• Feeling unwell.
• Side effects from medication.
• Hunger.
• Too much sensory stimulation.

“Even something as simple as a room that’s too noisy or bright can feel overwhelming,” says Osanmoh.

One other trigger to keep in mind is time of day. Many people with dementia exhibit anger and aggression as the day progresses and they become fatigued. “This is because stress builds up in the body and the brain cannot control its responses,” Ritter explains. Troubling nighttime behaviors in dementia are called sundowning, or sometimes sundown syndrome or sundowners.

Do different types of dementia influence aggressive behavior? 

There are several different types of dementia. Alzheimer’s disease, Lewy body dementia, vascular, and frontotemporal are the most common. While all types of dementia can cause symptoms of anger and aggression, how and when these symptoms present may be different depending on the type of dementia someone has.

Here’s what to know, according to Osanmoh:

• Alzheimer’s disease: In Alzheimer’s disease, aggression often comes later in the disease and is usually associated with confusion and misinterpreting situations.
• Lewy body dementia: This type of dementia can cause vivid hallucinations or paranoia, which may lead to fear-driven aggression.
• Vascular dementia: With vascular dementia, symptoms can be “step-like”, where a mini‐stroke triggers new types of aggression or depression suddenly.
• Frontotemporal dementia: This type of dementia may cause personality changes early. For example, the person might say inappropriate things or lose empathy, which may result in sudden anger.

“Seek help when outbursts become frequent, severe or unsafe — for you or your [client or] loved one.”

— Shebna N. Osanmoh, psychiatric nurse practitioner

How to respond to dementia-related aggression 

As a caregiver, it can be difficult to know how to respond when your client or loved one acts out aggressively. It’s hard not to take it personally if the anger is directed to you. But responding in the right way is important and can help de-escalate the situation.

Here are some tips for responding to dementia-related agitation from Osanmoh:

• Give yourself space. Step back, take a drink of water or count to ten.
• Speak a calm, soft voice. Responding by shouting only raises stress for everyone involved.
• Use simple sentences. Try to offer limited choices (“Would you like the red towel or the blue towel?”) to give your loved one a sense of control.
• Redirect their attention. For instance, if they resist putting on shoes, ask them to help you find the keys instead.
• Validate their feelings. Say “I see you’re upset” or “I’m here with you,” rather than arguing.
• Plan for in advance triggers. For example, if mornings are busy, lay out clothes the night before. 
• Practice self‑care. This might look like joining a support group, taking breaks and trying not to feel guilty when you need respite.

When and how to seek support for dementia and anger

Dealing with anger and aggression in dementia can be manageable at times, but there may come a point when you can’t handle these behaviors on your own. When is it time to seek more support? “Seek help when outbursts become frequent, severe or unsafe — for you or your [client or] loved one,” Osanmoh recommends.

There are various options for seeking support in this situation. First, Osanmoh suggests talking with the person’s doctor. Together, you can explore possible medical causes (like a urinary tract infection) that could be contributing. Additionally, ask about medications, such as low‑dose antipsychotics or mood stabilizers. Keep in mind that while these drugs may be helpful, they do carry risks, so they’re usually a last resort and carefully monitored.

If a loved one with dementia is living at home and/or not already getting professional care, now is a good time to consider care options. Some of the best care options for dementia include:

• Home health aides. Make sure the aides have experience handling dementia symptoms like anger and aggression.
• Long-term care facilities. This includes memory care, assisted living and nursing homes. “Many long‑term care facilities accept residents with aggression, but it’s important to discuss their experience, staffing levels and behavior‑management policies,” Osanmoh says. “A good facility will have staff trained in de‑escalation techniques and personalized care plans so your loved one can live as safely and comfortably as possible.”
• Respite care. This is temporary care that can provide needed breaks and support for caregivers to help prevent burnout.

Being a caregiver to someone with dementia is one of the most challenging situations a person can find themselves in, Ritter says. If aggression and agitation is complicating the situation, it can make it nearly impossible to continue providing care on your own.

“My number one recommendation is to get help,” Ritter says. That can come in the form of speaking to doctors, seeking higher levels of care or reaching out to family and friends for additional resources and support. The idea is not to wait — seek support as soon as the behaviors become too much for you to manage.