Physical aggression in elderly people with cognitive disorders represents one of the most feared and delicate situations to manage in institutions. Hits, bites, scratches, shoves: these behaviors endanger the safety of caregivers, other residents, and sometimes the person themselves. In the face of these situations, the temptation may be great to resort to restraint to "protect everyone." However, restraint, far from being a solution, poses serious ethical, legal, and therapeutic problems.

Understanding Physical Aggression in Geriatric Context

Before intervening, it is crucial to understand that physical aggression in a person with cognitive disorders is never a deliberate choice to harm. It is a defensive reaction to a perceived threat, an expression of deep distress, or a manifestation of brain injuries that alter impulse control.

The Neurological Causes of Aggression

In neurodegenerative diseases like Alzheimer's or frontotemporal dementias, certain areas of the brain responsible for emotional regulation and behavioral control are affected. This manifests as:

Common Triggering Factors

Physical aggression rarely occurs without reason. Identifying triggers allows for better prevention and management of these situations:

• Intimate Hygiene Care: Bathing, dressing, changing are experienced as intrusions into intimacy, triggering an instinctive defensive reaction to protect one's body.
• Unidentified Pain: Intense pain that the person cannot verbalize manifests as an aggressive reaction towards anyone approaching - it's a non-verbal "Don't touch me, it hurts!"
• Fear and Confusion: Not recognizing the place or people, being disoriented in time and space generates a panic that can turn into defensive aggression.
• Extreme Frustration: The inability to communicate needs or achieve desired actions accumulates emotional tension that eventually explodes physically.
• Hallucinations and Delusional Ideas: Seeing intruders, believing one is being poisoned, thinking one is being stolen from can generate violent defensive behaviors against these perceived threats.

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Why Restraint Is Not the Solution

Before addressing alternatives, it is essential to understand why restraint - whether physical (straps, vests, bed rails) or chemical (excessive medication sedation) - should be avoided as much as possible.

The Serious Medical Risks of Physical Restraint

Chemical restraint (excessive sedation by neuroleptics or benzodiazepines) also presents specific dangers:

• Falls related to excessive sedation and loss of balance
• Worsening confusion (frequent paradoxical effect in elderly people)
• Iatrogenic Parkinsonian syndrome (rigidity, tremors)
• Risk of strokes with certain antipsychotics
• Dangerous drug interactions

The Unavoidable Ethical and Legal Implications

From an ethical standpoint, restraint represents a serious violation of the fundamental rights of the human person:

"Restraint is never trivial. It is a deprivation of liberty that can only be justified by immediate and serious danger. Our professional and ethical responsibility is to first seek all possible alternatives."

Preventive strategies: acting before the crisis

The best management of physical aggression is to prevent it from occurring. A well-thought-out preventive approach can reduce violent incidents by up to 70%.

In-depth knowledge of the person: your best tool

The more you know the person - their history, habits, triggers, calming strategies - the more you can anticipate and prevent risky situations. This knowledge must be formalized and shared with the entire team.

Adapting the physical environment

An environment designed to reduce stress factors significantly decreases the risks of aggression. Principles of therapeutic layout:

• Reduction of stressful stimuli: Soft and adjustable lighting (avoid harsh neon lights), quiet spaces available, limiting ambient noise (television at a reasonable volume, calm discussions), comfortable temperature (neither too hot nor too cold)
• Accessible decompression spaces: Secure therapeutic garden where the person can walk, Snoezelen room with soothing sensory stimulation, reading/rest area with comfortable armchair, calm manual activity zone
• Appropriate signage and visual cues: Clear pictograms for toilets, dining room, facilitating orientation reduces confusion and anxiety, color codes by floor or area, photos on bedroom doors
• Familiar reassuring objects in the room: Well-visible family photos, personal furniture if possible, bedspread from home, significant objects (old book, radio, precious trinket), anything that creates a feeling of "home"

Proactive management of physiological needs and pain

Anticipating needs and addressing pain before it becomes unbearable is a major preventive strategy often overlooked:

• Regular hydration and nutrition: Do not wait for the person to express hunger or thirst (they may no longer be able to). Offer drinks every 2 hours, snacks between meals
• Assistance to the toilet at fixed times: Prevent discomfort related to the need to urinate or defecate by systematically offering every 3-4 hours, even if the person does not ask
• Systematic pain assessment: Use behavioral scales for non-verbal individuals (Algoplus, Doloplus, ECPA). Observe: grimaces, moans, protection of an area, refusal to be touched, change in behavior
• Preventive pain treatment: Before potentially painful care (hygiene, mobilization, dressing), administer preventive pain relief 30 minutes prior if prescribed
• Monitoring of intercurrent pathologies: Urinary infection, constipation, dental problems can generate significant pain expressed through aggression

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Boredom and frustration are major factors of aggression. Offering suitable and rewarding activities can significantly reduce these behaviors.

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Management techniques during a physical aggression episode

Despite all preventive measures, situations of physical aggression can occur. Here’s how to manage them professionally with safety AND respect.

Phase 1: Early recognition and immediate intervention

As soon as you detect precursor signals (increasing verbal agitation, abrupt gestures, evasive or fixed gaze, visible muscle tension, agitated wandering), intervene immediately before physical escalation:

Phase 2: Verbal and non-verbal de-escalation

Your communication will be crucial. Key principles:

• Soothing tone: Calm voice, moderate volume, slow pace. NEVER raise your voice, even if the person is shouting. Your vocal calm has a regulating effect.
• Emotional validation: "I see that you are very angry. This is difficult for you right now." Acknowledge the emotion without judging it.
• Positive formulations: No "Don't hit me", "Don't be afraid". Prefer: "I am here to help you", "You are safe here", "We will find a solution together".
• Proposing simple alternatives: "Would you like me to call [familiar person]?" or "Would you like to go to your room?" or "Would you prefer to sit for a moment?" Give a sense of control.
• Breathing synchronization: Breathe slowly and deeply in a visible manner. The person may unconsciously synchronize with your calm breathing rhythm.

Phase 3: Physical protection techniques without restraint

If physical aggression is imminent or ongoing, you must protect yourself while respecting the person. Protection techniques taught in specialized training:

Phase 4: Request for help and coordinated team management

NEVER stay alone in the face of a situation of physical aggression. Team management is more effective and safer:

• Immediate alert: Use the establishment's alert system (emergency button, mobile phone, vocal call "Help room 12!"). Each establishment must have a clear alert protocol known to all.
• Coordinated arrival of reinforcements: The arrival of several caregivers must be calm and coordinated. Avoid the "commando" effect with several people arriving running and talking loudly (increases fear and aggression).
• A designated leader: Only one person (usually the referent caregiver or manager) speaks and gives instructions. Others observe, are ready to intervene if necessary, but do not multiply contradictory voices.
• Cautious surrounding strategy: If several caregivers are present, never completely encircle the person (feeling of deadly trap). Stay all on the same side with a visible and clear exit for the person.
• Discreet team communication: If you need to consult, do it quietly or by gestures, not in front of the person who might interpret this as a conspiracy against them.

Essential institutional protocols

Each medico-social establishment must have clear, formalized, and regularly updated protocols for managing physical aggression. This is not optional, it is a legal and ethical obligation.

The alert and graduated intervention protocol

The individualized crisis management protocol for each resident

For each resident at risk of aggression, a specific protocol must be developed and regularly updated:

• Resident profile: Documented precursor signals, identified and validated triggers, detailed history of crises (frequency, intensity, context)
• Validated personalized strategies: What specifically works with this person (verbal approach, distraction, change of environment), what does not work or worsens (to be absolutely avoided)
• Clear safety instructions: Should there always be a minimum of two interveners? Avoid certain care at certain times? Favor certain caregivers with whom the person is more cooperative?
• SOS medication treatment if prescribed: Crisis medication prescribed by the doctor (with exact dosage, route of administration, maximum frequency, contraindications), only after failure of non-drug techniques

The mandatory ongoing training protocol

The team must be trained regularly and continuously. This is not a "plus," it is a legal obligation of the employer:

• Initial training for all newcomers: In the first month of arrival, training in managing aggressive behaviors, visiting the establishment's protocols, identifying resource persons
• Annual refresher training for all: Updating knowledge, practical training in protection techniques (with mannequin or role-playing), analysis of real cases experienced in the year
• Specialized training for referents: For referring caregivers of difficult residents: in-depth training such as "Prevention and management of violence" (3-5 days), "Humanitude," "Therapeutic validation," "Management of behavioral disorders"
• Regular practice analysis: Monthly or bi-monthly sessions for collective analysis of difficult situations encountered, led by a psychologist or external trainer

💝 For caregivers facing aggression

If you are a caregiver and your loved one sometimes becomes physically aggressive, you are experiencing an extremely difficult and painful situation. The aggression of a loved one can be traumatizing and call into question your ability to continue.

Our training "Behavioral Changes Related to Illness: Practical Guide for Caregivers" helps you understand aggression, protect yourself without losing the emotional bond, and especially recognize your limits and ask for help before being in danger.

Important: If you are regularly a victim of physical aggression, this is no longer sustainable. Talk to their treating physician, contact France Alzheimer, consider professional home help or temporary placement in a facility. Your safety matters too.

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Conclusion: Safety AND dignity, a non-negotiable balance

Managing physical aggression in a facility without resorting to restraint is a daily challenge that requires professionalism, ongoing training, teamwork, and strong institutional support. But it is a challenge that is not only possible but necessary and ethically mandatory to meet in order to honor the fundamental rights of the people we support.

The key lies in a comprehensive and systemic approach combining:

• Intensive prevention: In-depth knowledge of the person, adapted environment, proactive management of pain and needs, rewarding activities
• Solid and ongoing training: Competent teams in de-escalation techniques, restraint-free protection, therapeutic communication
• Clear and applied protocols: Institutional procedures known to all, regularly reviewed and improved
• Optimal team coordination: Multidisciplinary work, fluid communication, mutual support, regular supervision
• Support for caregivers: Systematic debriefing, recognition of the difficulty of the work, access to psychological support, rights respected
• Continuous re-evaluation: Analysis of each incident, adjustment of strategies based on results, culture of continuous improvement

No one should have to choose between their safety and their freedom. No caregiver should have to work in daily fear. And no institution should accept restraint as an easy solution when alternatives exist and are effective.

With the right practices, the right tools, the right training, and the right mindset, it is possible to secure without hindering, to protect without humiliating, to intervene without violating fundamental human dignity.

Because every person, regardless of their cognitive or behavioral state, deserves respect, safety, and dignity. Without compromise. 💙