Aggressive Behavior In Stroke Patients: Understanding The Why

A stroke can lead to changes in a person's behaviour, which can be due to damage to the brain or linked to emotional problems. A stroke can impact one's mood and outlook, and the area of the brain injury and chemical changes may have significant effects on the brain. Aggressive behaviour is common after a stroke, and can include physical behaviours such as hitting, kicking, biting, and throwing objects, as well as verbal behaviours such as screaming, refusal of treatment, and muttering of unkind or hostile words. Aggressive behaviour puts both the patient and those around them at risk, so it is essential that the patient learns how to manage it. Aggression is particularly noticeable in stroke survivors who have had a large stroke or who have a stroke pattern that produces vascular dementia. Antidepressant medications such as Prozac (fluoxetine) and Celexa (citalopram) may help people with aggression who have dementia.

What causes aggression in stroke patients?

Aggression in stroke patients can be caused by a combination of factors, including brain injury, emotional problems, and environmental factors.

Brain Injury

Research suggests that aggressive behaviour after a stroke is more likely to be a symptom of brain injury rather than reactive behaviour. When a stroke affects the frontal lobe, lenticulocapsular, or pontine base areas, it can lead to emotional incontinence, or the inability to control emotions. The frontal lobe plays a crucial role in reasoning, problem-solving, and controlling basic impulses like anger. Damage to this area can affect emotional regulation and lead to aggressive behaviour.

Emotional Problems

The emotional impact of a stroke can also contribute to aggression. The sudden and shocking nature of a stroke can bring about various emotions, such as fear, frustration, anger, grief, and sadness. Additionally, the physical limitations caused by a stroke, such as weakness, vision loss, and coordination problems, can lead to feelings of disempowerment and helplessness, further contributing to aggressive behaviour.

Environmental Factors

Environmental factors can also trigger aggressive behaviour in stroke patients. Overstimulation, such as excess lights or sounds, confusion, disruption of routine, and a lack of control over the environment or physical functions, can all contribute to aggression.

How can stroke patients manage their aggression?

Aggressive behaviour can put stroke patients and those around them at risk, so it is important to learn how to manage it. Here are some ways stroke patients can manage their aggression:

• Learn your triggers: Talk to your friends and family to identify what makes you angry and how to avoid it. If you have fatigue and your behaviour changes when you are tired, try telling loved ones so they can understand how you feel. Try to get more rest or do things earlier in the day when you have more energy.
• Develop a strategy: Agree on a word, phrase, or sign that your family and friends can use to let you know that you are acting aggressively. Alternatively, agree that they will walk away and leave you alone for 15 minutes.
• Seek medical help: Contact your GP, who may refer you for expert help. Antidepressants such as Prozac (fluoxetine) and Celexa (citalopram) may help people with aggression who have dementia.
• Therapy: Cognitive behavioural therapy (CBT) can help you learn how to think through your actions and understand their effect on other people. A therapist could also work with your family members to help them adjust to your changed behaviour.
• Try applied relaxation: This is a specific way of relaxing the muscles to help let go of tension and anxiety.
• Take slow, deep breaths: Relax your face muscles and try to focus your attention on something different.
• Let people know: If possible, inform people about your condition so that they understand and know what to expect.

What are the effects of stroke on a patient's emotional state?

A stroke can lead to changes in a patient's emotional state, which can be due to damage to the brain or linked to emotional problems. These emotional changes can be distressing for both the patient and their caregivers and negatively impact the patient's quality of life.

Anger and Aggression

Aggressive behaviour is a common secondary effect observed in stroke survivors, especially in the acute stage of recovery. This can be temporary or long-lasting and is a sign of damage to specific areas of the brain. Aggressive behaviour can be physical, such as hitting, kicking, biting, and throwing objects, or verbal, such as screaming, refusal of treatment, and muttering of hostile words.

Aggressive behaviour is more likely to be a symptom of brain injury rather than reactive behaviour. When a stroke affects the frontal lobe, lenticulocapsular, or pontine base areas, emotional incontinence (the inability to control emotion) is more likely to occur. The frontal lobe plays a role in reasoning, problem-solving, and controlling basic impulses like anger. Damage to the frontal lobe can affect emotional regulation and lead to aggressive behaviour.

Other Emotional Changes

In addition to anger and aggression, stroke patients may experience a range of other emotional changes, including irritability, forgetfulness, carelessness, inattention, confusion, fear, frustration, grief, sadness, anxiety, and depression. These emotional changes can be caused by physical limitations, health worries, and changes in brain function.

Stroke survivors may also experience a loss of cognitive skills, such as trouble with language, problem-solving, reading, and simple mathematical calculations. They may also become emotionally unstable, with mood changes and uncontrollable expressions of emotion. This can be caused by damage to parts of the brain that control emotional responses, particularly the cerebellum, which helps monitor the expression of emotions.

Stroke patients may also experience a lack of motivation, described as apathy, and a loss of empathy, which can result in self-centred behaviour and damaged relationships. These changes are typically caused by damage to regions of the right side of the brain, which can affect the perception of other people's emotions and facial expressions.

How can caregivers help stroke patients with their aggression?

Aggression in stroke patients can be distressing for both the patient and their caregiver. It is important to understand the causes of aggression in stroke patients to help manage it effectively. Aggression can be caused by damage to specific areas of the brain, particularly the frontal lobe, which plays a role in impulse control. It can also be triggered by neurochemical dysfunction, unfavourable environments, and frustration due to physical limitations.

• Understand the triggers: Aggression in stroke patients can be triggered by overstimulation, confusion, disruption of routine, and lack of control over their environment or physical functions. Understanding these triggers can help caregivers anticipate and manage aggressive episodes.
• Provide a calm and supportive environment: Create a calm and familiar environment for the patient to reduce overstimulation and confusion. Minimise loud noises, bright lights, and sudden changes in routine.
• Encourage rest and relaxation: Fatigue and tiredness can increase irritability and aggression. Encourage the patient to rest and conserve their energy for important tasks and social interactions.
• Establish a routine and structure: A consistent daily routine can help reduce confusion and provide a sense of control for the patient. Structure can also help with apathy, a common issue after a stroke where patients lack the motivation to engage in activities.
• Involve the patient in decision-making: Feelings of anger and aggression can arise from feeling ignored or a lack of control. Involve the patient in decisions, even if it is as simple as choosing what to eat for lunch.
• Seek professional help: If the patient's aggression is severe, persistent, or puts themselves or others at risk, seek professional help. A therapist or counsellor can help the patient identify and manage their aggressive behaviours. Medication, such as selective serotonin reuptake inhibitors (SSRIs), may also be prescribed to treat aggression and improve emotional regulation.
• Join a support group: Support groups and stroke clubs can provide an opportunity for stroke survivors and their caregivers to connect with others going through similar experiences. It can help caregivers gain a better understanding of the patient's condition and provide a sense of community.
• Prioritise the caregiver's well-being: Caring for a stroke patient can be physically and emotionally demanding. It is important for caregivers to prioritise their own well-being and seek support when needed. This can include joining a support group, practising self-care, or seeking counselling to cope with the challenges of caring for a stroke patient.

Remember, each stroke patient is unique, and the causes and manifestations of aggression can vary. It is important to work closely with the patient's medical team to understand the specific causes and develop an individualised management plan.

What are the long-term effects of stroke on a patient's behaviour?

Long-term effects of stroke on a patient's behaviour

The long-term effects of a stroke on a patient's behaviour depend on which part of the brain was damaged and how extensively. The most common types of disability after a stroke are changes to speech, learning and understanding, and weakness or paralysis on one side of the body.

Emotional and personality changes

It is common for stroke survivors to experience changes in their mood and personality. These changes may be caused by damage to the brain, or they may be linked to emotional problems. Depression is common in the first year after a stroke, particularly in people who have trouble understanding, finding words and communicating (aphasia). Anxiety is also common, with one-fifth of stroke patients in a 2018 study experiencing an anxiety disorder, mostly involving avoiding certain situations, including social gatherings.

Personality and behavioural changes can include:

• Irritability
• Aggressiveness
• Apathy or lack of motivation
• Repetitive behaviour
• Disinhibition
• Impulsiveness

Changes to thinking, memory and perception

A stroke can change a person's thinking and memory, and also how they see, hear and feel. This can affect how they feel about themselves and their relationships with family and friends. Cognitive skills that can be affected include:

• The ability to learn new skills
• The ability to problem-solve
• Attention and concentration
• Orientation, or knowing the day and time
• Short-term memory

Communication

For some people, a stroke affects the part of their brain that helps with speaking, reading and communication. Symptoms can include:

• Difficulty in finding the right words or understanding what others are saying (aphasia or dysphasia)
• Weakness in the muscles that help with speech (dysarthria)
• Dysfunction of the nerve connection between the brain and mouth, making speaking difficult (dyspraxia)
• Reading and writing problems

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