People with Alzheimer's may, without warning or apparent provocation, become irate and abusive, verbally and physically. They may throw objects, scream, kick, bite or strike out at their caregiver or others. Because people with Alzheimer's cannot explain these outbursts, researchers are uncertain about what causes them. They may reflect the person's unconscious fears or anger, or they may be caused by brain damage.

These violent episodes can be justifiably frightening and upsetting to caregivers and other family members and friends. The first step in attempting to reduce the frequency or severity of such behavior is to identify potential triggers. One such trigger for many people with Alzheimer's is fear. Other triggers of combative behavior may include:

* A task with complicated or to many steps. This can promote confusion and frustration.

* Trying to rush the person or acting upset.

* Not being able to make themselves understood. Loss of exact words can lead to overwhelming frustration.

* Noisy, overcrowded, or unfamiliar surroundings, such as a restaurant or family gathering.

* Illness or fatigue. Frustration increases in most people when they are in pain or have not had adequate sleep.

In addition to identifying triggers, there are other steps you can take to limit combativeness. These may include the following:

* At the first sign of frustration, remain calm.

* Keep your explanations and instructions simple. Use short, simple, sentences. Also use encouraging or reassuring phrases. " You did a good job" or " That's okay...take your time, I'm in no hurry."

* Try to maintain non-threatening eye contact with the person as much as possible. This can give you a feeling of being in charge and in control, which is then conveyed to the person you're caring for.

* Distract the person from a task that is causing anxiety.

* Determine which activities are soothing to the person. A ride in the car, a walk down a quiet street, soft music, watching fish in an aquarium.

* If the person seems receptive, pat her hand, hug her, or slowly rock her. Some people may not want to be touched, however, or they may experience rocking as a form of restraint. Use your own judgment.

* Keep a record of outbursts and look for a pattern. Note when and what happens. Who was there? When did it happen and where? And what happened just before the person became aggressive? Did the individual seem restless in the moments preceding the incident? Overly tired? Was there a lot of confusion or noise in the room? Was he or she upset when a particular individual came into the room?

Sometimes despite your best efforts the person with Alzheimer's may become so violent that he or she is a danger to himself or others. If you find yourself in a potentially dangerous situation, take the following steps to protect yourself and the person in your care:

* Do not attempt to restrain or hold the individual. You may end up hurting yourself and or the person unnecessarily.

* Step back five or six steps from the person and remain quiet. Wait to see if they calm down alone. Many people with Alzheimer's who are hostile become manageable after a few minutes.

* Protect yourself with an object you can use as a shield--a pillow, chair, box, wasterbasket.

* Do not shout or scream. Either remain silent or talk in a low monotone. People with Alzheimer's tend to imitate what they see and sense. If you remain calm, they may become calm as well.

* If the person grabs you, go limp. Do not fight back.

* Call friends, relatives, or neighbors for help as soon as possible. If you believe your safety or that of the individual is in jeopardy, call 911 or the other local medical emergency number. Medical personnel are more likely to be trained to handle a person who has Alzheimer's disease than the police.

If aggression and combativeness becomes a problem, as they frequently do as the disease progresses, your physician may prescribe tranquilizers, such as diphenhydramine, thioridazine, haloperidol, or oxazepam.

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