When Nothing Stops the Violence

February 3, 2011

My father-in-law was an upstanding citizen in his small town — chairman of the Administrative Board at the Methodist church, city councilman, Scout troop leader, etc.  He led the kind of life we would all hope any son of ours would lead.  He was a wonderful husband, great dad and a loving grandfather.  He NEVER abused anyone — wife, child, employee, ANYONE.  That is, until he got Alzheimer’s disease.

I have touched on the subject of violence before, but it bears revisiting.  My father-in-law had an interesting variation of the Alzheimer’s disease theme, which closely resembled “fronto-temporal dementia.”  This form of dementia causes incredible behavioral problems in the patient, because the frontal lobe of the brain (located behind the forehead) is the center of judgment and self-control, among other things.  It also seems to progress more rapidly than regular Alzheimer’s, so behavioral problems often arise very rapidly.

With clarity of hindsight, we can see subtle personality changes and uncharacteristic behavior before his diagnosis.  The main occurrence that comes to mind was when he grew very angry with the church trustees when they ordered a diseased tree in the church yard to be cut down.  He visited the trustees in their homes one Sunday afternoon and told them very emphatically what he thought about their tree-cutting —  completely uncharacteristic behavior for my father-in-law.

As his disease progressed, this gentle man grew physically violent, pushing down my mother-in-law on his way to the bathroom.  He was very strong and physically, very healthy.  As he lost his language function (another characteristic of when the frontal lobe of the brain is affected), he could only say a few phrases over and over.  He loved to remind us, “I can put 200 pounds over my head!”  And he really could.  When that strength turned against a loved one or a caregiver, injury sometimes resulted.

I addressed how to deal with physically violent dementia patients in an earlier blog, so I will attempt not to be repetitive.  Suffice it to say that sometimes he was impossible to deal with.  Whatever the cause, he had agitation, obsessive / compulsive tendencies, and anger management issues.  Yes, most of the time, if you approached him correctly, he would not become violent.  However, he had multiple caregivers in the 7 facilities he went through in 2 years.  There is no way perfect behavior on their part and his could be assured.

First of all, doctors tried medications.  The difficulty is that all medications, no matter how seemingly benign, have side effects.  The choice before the physicians and family is, are the benefits worth the side effects?  The answer is, sometime yes and sometimes no.  In cases my father-in-law’s case, I can tell you that medications were essential to controlling his behavior, even with their myriad negative side effects.

As the disease progressed, he was increasingly difficult to deal with, even with multiple medications.  Unlike many patients, his physical condition did not deteriorate like his mental condition.  The crisis came in the spring of 2006, when he was sending nursing home workers to the emergency room with regularity and we lived in real fear that he would seriously harm or kill someone.

At that point, we knew he required more serious psychiatric care than he could get in any outpatient setting.  He needed to be admitted to the geriatric dementia psychiatry facility in the state mental hospital, but the only way this could happen was to have him committed through the probate court system.

Every state is different, but in Alabama, the probate judge appoints an attorney to represent the patient and the family hires its own attorney.   Two healthcare professionals (doctors and / or nurse practitioners) are required to testify to the patient’s condition.  A family member also testifies.  Prior to the hearing, the attorney for the patient investigates the situation and then, makes her recommendations under oath to the court at the hearing.  In our case, my father-in-law, who would have been unable to answer questions for himself, was not required to be present.  After the hearing my father-in-law was transferred to the Mary Stark Harper Center at Bryce Hospital.  This place was an incredible blessing to my father-in-law and our family.  At this in-patient facility, he was placed on a cocktail of medications which calmed his violent tendencies and for the 16 remaining months of his life, he was peaceful.

One of the hardest things my husband has ever done was to testify that his father was a danger to himself and others.  However, he knew if his father had 5 minutes of sanity, he would choose to be committed a million times rather than harm anyone once.  If you are in this situation, you can console yourself with that.

6 Comments

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6 Responses to “When Nothing Stops the Violence”

  1. DLM says:

    We are having similair problems with my husbands mother. She has had mental problems since a cardiac arrest during surgery. That was 18 years ago, she has been intermittently violent for a year now. One nursing home has kicked her out, another will not take her back. At the moment she is on Ativan and resperidol, but it does not seem like enough. Fortunately she is 92, and small, so no serious injuries so far. But she is mean! It is really unbelievable how much trouble one little old lady can cause. She has been accusing us of killing her for years! She has escaped from assisted living, and is currently trying to escape from a locked ward. How long can this go on?

    • Ellen Potts says:

      That is such a difficult situation! There are two strategies I would try. First, if she has not seen a geriatric psychiatrist or a neurologist who is familiar with treating dementia, she needs to see one to get her behavior under control. Medication management is key. Some people say you can manage without medication, but I don’t think they’ve ever dealt with someone who has had real issues with violence! Second, and this is FAR more difficult, you need to deal with the way you and the staff interact with her. Do your best NOT to correct her, argue with her, etc. No matter what she says, agree with her if you can, say something neutral if you can’t, and leave the room if you must. If you can find a facility that espouses these techniques, that will go a long way toward controlling behavior.

      At 92 years old, with cardiac issues, I would not think this could go on for that much longer. With her doctor, you need to consider some difficult choices about non-behavioral medications, if you have not done so already. With every family member who was on such medications, we made the decision to take our loved one off anything that did not keep that person comfortable or control his or her behavior. In other words, any drug that would prolong life — blood thinners, cardiac meds, cholesterol lowering meds, etc. — was discontinued. It was a difficult decision and every family must consider this for themselves. For us, it was a decision based on faith. If we believe what we say we believe as Christians, then why would be try to hinder the merciful process God has put in place to take our loved one to heaven? As I said, it’s a difficult decision and every family must make it based on their own beliefs and what their own loved one would wish.

      You remain in my prayers as you deal with this awful time. I know it seems like it will go one forever, but it really is a finite period of time.

    • david says:

      may the good lord take her into his arms when he is ready, amen

  2. david says:

    i have it. im 53 with dementia. it sucks and now my finger bones, both pinky fingers have cracked. i love life i dont want it to end like this. i get lost in circles when i drive during the day time.

  3. Theresa collins says:

    My mom has Alzheimer’s undiagnosed. She refuses to go to doctor
    She kicked me out of her house. She screamed and cursed at me
    Every day for the last 3 months. She got a puppy, big mistake. The
    Puppy would go to the bathroom in her bed. I put her on a cage to train
    The puppy. She would scream and holler about it. She became obsessed
    With the puppy. I was just trying to help her train puppy. Was it wrong
    To not let the puppy in her bed at night. She goaded me every day. Most
    Of the time I could walk away but she would follow after me cursing and she hit
    Me a couple of times. She told me she hated my guts and to get out of her
    House so I left. I feel terrible I know it wasn’t her but she was so mean and
    Hateful I don’t even want to talk to her. She doesn’t want to see me anymore
    Any advice.

    • Ellen Potts says:

      I’m so sorry your mother is treating you this way, but you are correct: It’s Alzheimer’s disease speaking, not your mother. You can’t take her words personally, although that is incredibly hard.

      First, you should do whatever necessary to keep yourself safe, and secondarily, to keep the puppy safe. If that means removing the dog and yourself permanently from the house, then so be it. If she physically assaults you again, you need to call 911 and explain the situation to the police. We had to commit a family member with Alzheimer’s disease to a geriatric psychiatry hospital through the state probate court, because he was a danger to himself and others. It was a horrible thing to have to do, but it got him the help he needed. He was in the hospital for about a month, and Medicare and private insurance covered the cost. Before Alzheimer’s disease his personality was that of a gentle giant, but at the time he went to the hospital, we were afraid he would seriously harm someone.

      I would find an elder law attorney as quickly as possible to help you navigate the legal aspects of what you need to do, whether or not you end up committing your mother. There are federally funded elder law clinics around the country in major cities and in law schools which offer services for free, regardless of income level. If you hire someone, make certain the person is a certified elder law attorney, not just an estate attorney or a person who calls him/herself an elder law attorney.

      The sooner you meet with an elder law attorney and formulate a plan, the better you will feel about the whole situation. The future will hold many challenges, and some will be unexpected, but if you have a general plan as to how you should proceed and a good elder law attorney on board to help when you don’t know how to proceed, you will be light years ahead of where you are now.

      Do you have siblings or relatives who could help? If so, the more you can get them in agreement with the plan, the better.

      I recommend you read our blogs and book, both of which give strategies for dealing with behavioral difficulties commonly seen in Alzheimer’s disease. Also, if you can solicit your mother’s primary care physician’s help, that would be another strategy. Explain the situation to the doctor, and tell your mother you are taking her to see the doctor for some other reason (arthritis, high blood pressure, etc.). While there, the physician can perhaps prescribe meds for the memory and behavioral issues. Often, depression accompanies Alzheimer’s disease and causes many of the behavioral problems. If this is the case, you can treat the depression and often help the challenging behaviors.

      Lastly, remember that this is a season, and that seasons have beginnings and endings. Right now, it seems this season will have no end, but it really will. Make sure you take care of yourself, seeking help through friends, a professional counselor, clergy, etc. This is a marathon, not a sprint. To make it to the end of the race, you have to pace yourself and take care of yourself. Online or in person support groups can be a wonderful resource. For online help, Memory People is of great assistance to many caregivers. For support groups held in your area, call your local senior citizens agency or agency on aging. If you can’t find them in the phone book, your local United Way may have a list of resources, or your physician’s office.

      Please let us know how things go!

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