American Journal of Alzheimer's Disease and

Other Dementias
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A Case of Undue Violent Behavior Associated With Alzheimer's Disease

Kuljeet Singh Anand and Rohit Verma
AM J ALZHEIMERS DIS OTHER DEMEN 2012 27: 10
DOI: 10.1177/1533317511436208

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Thoughts, Opinions and Controversies
American Journal of Alzheimer’s
Disease & Other Dementias®
A Case of Undue Violent Behavior 27(1) 10-12
ª The Author(s) 2012
Reprints and permission:
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DOI: 10.1177/1533317511436208
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Kuljeet Singh Anand, MD, DM, MNAMS1 and Rohit Verma, MD2

Abstract
Although dementia is diagnosed by observing cognitive symptoms, noncognitive abnormalities are also highly prevalent. Although
aggression is a common symptom, its presence is usually justifiable by a multitude of externally provoking factors. We present a
case of Alzheimer’s disease with marked unwarranted violent behavior.

Keywords
Alzheimer’s disease, dementia, BPSD, aggression, Risperidone

Introduction violent behavior had become significantly worse in the past

Alzheimer’s dementia (AD) is one of the most compelling
problems of social and public health. It usually leads to a
marked decrease in the cognitive, mental, and also in the phys-
ical skills of the affected person who over time requires an
increased amount of care, aid, and support. In course of time,
the elderly patients with dementia manifest increasing diffi-
culty in carrying out activities of daily living along with beha-
vioral and psychological symptoms of dementia (BPSD)
including signs of disturbed perception, thought content, mood,
or behavior like hoarding, wandering, aggression, and disinhi-
bition.1 The BPSD tend to occur in clusters, which have been
grouped into the categories of aggression, psychomotor agita-
tion, psychosis, apathy, and depression.2
Violent behavior is commonly seen in individuals with demen-
tia, and although neuroleptics often alleviate these problems,3 the
mechanisms underlying aggressive behavior are still unknown in
this disease. Literature suggests violent behavior to be usually
in response to a psychopathology, interaction/communication
difficulty, or impaired self-esteem among other causes via pre-
sumably a neurobiological dysregulation.4 Here, we present a
case with strikingly unwarranted violent behavior with no
externally provoking factor or psychopathology in an individ-
ual with dementia.
Case Report
Mr A, a 78-year-old male, a case of AD was diagnosed 1 year
previously and has since been managed on donepezil 10 mg/d
for the same duration with slight improvement in memory. He
presented with a history of exhibiting aggressive behavior for
the last 1½ year, but the symptoms of undue aggression and
2 months. Consequently, the patient became problematic to
manage. He was highly aggressive and frequently resorted to
hitting and head butting anyone at arm’s length of him regard-
less of whom it was without any externally provoking stimuli.
He face was noticed to flush during the rage. His elder son, in
an attempt to control his violent behavior replied with similar
physical attacks which he regrets. The patient never reported
of any delusional psychopathology or hallucinations, nor was
there any hallucinatory behavior. He reported of remorse at
times after the violent episode.
The general physical and systemic examination was normal.
Although cooperative, Mr A displayed apathetic indifference
and psychomotor retardation. He was unresponsive to verbal
communication initially but later responded to questions. How-
ever, there were many inconsistencies in his story with vague
content with slight latency of responses. Mood was irritable
with restricted range and at times appeared dazed and childlike.
No perceptual phenomena, delusions, obsessions, compulsions,
or any anxiety symptom was elicited on serial mental state
examinations. He was disoriented to the time and unable to
1
Department of Neurology, Post Graduate Institute of Medical Education and
Research, Dr Ram Manohar Lohia Hospital, New Delhi, India
2
Department of Psychiatry and Drug De-addiction, Post Graduate Institute of
Medical Education and Research, Dr Ram Manohar Lohia Hospital, New Delhi,
India
Corresponding Author:
Rohit Verma, Department of Psychiatry and Drug De-addiction, Post Graduate
Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital,
New Delhi, India
Email: rohit.aiims@gmail.com

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Anand and Verma
do serial 7. He did not show aphasia or apraxia with intact cra-
nial nerves. There was no weakness or muscle atrophy and gait
was normal for age. Deep tendon reflexes were exaggerated;
however, no Babinski sign was noted. Sensory examination
was intact. His Mini-Mental State Examination score was 5,
consistent with stage 3 of disease severity.5
Laboratory workup, including hemogram, electrolytes, B12
assay, blood sugar, serum testosterone, Venereal Disease
Research Laboratory (VDRL)/human immunodeficiency virus,
liver/kidney function tests, chest X-ray, urine/stool examina-
tion, electrocardiography, electroencephalography, computed
tomography scan head, and cerebrospinal fluid analysis yielded
normal results. Examination of fundus did not show any sign of
raised intracranial tension or abnormal deposits. Magnetic
resonance imaging brain scan only reported generalized corti-
cal atrophic age-related changes.
The assessment was made on the Agitated Behavior Scale,6
and he was prescribed risperidone 1.5 mg/d. Family members
were psychoeducated on various aspects of avoiding confronta-
tion and dealing effectively with the patient during violent
behavior. A week later, trihexyphenidyl 2 mg/d was added due
to onset of extrapyramidal symptoms. Subsequently within
3 weeks, there was a significant improvement in his behavior
with a reduction of 28 points compared with baseline on
Agitated Behavior Scale.
Discussion
Violence is a common phenomenon in AD and about half of the
sample of outpatients with AD is suggested to present with
agitation, one third with violent behavior, and one fourth with
verbal outbursts.7 In a study of 262 patients of AD living in
noninstitutional setting, 52% exhibited some aggressive beha-
vior.8 Of these, 91 (35%) patients were reported to be verbally
aggressive and a further 46 (18%) assaulted their carers. Male
gender and presence of dyspraxia were reported to increase the
likelihood of violent behavior.8
Higher behavioral dysfunction, agitation, and mood compo-
nent scores have been associated with earlier age of AD onset and
severity of cognitive impairment but not with age at assessment or
number of apolipoprotein E epsilon4 alleles.9 In a study of 75
patients with AD, 33% had verbal outbursts and 17% engaged
in physical aggression.10 Aggressive patients and nonaggressive
patients did not differ regarding age, education, gender, level of
depression, or severity of dementia. Physical aggression was
associated with activity disturbance and hallucinations, and
verbal aggression was associated with delusional ideation. No
other clinical correlates of aggression were identified.
The exact cause of such behaviors in these patients remains
unknown, although preservation of pigmented substantia nigra
neurons has been suggested a risk factor for physical aggres-
sion in AD.11 But the study did not compare violence in
perspectives of provoked and unprovoked.
The dopaminergic system is involved in behavioral activa-
tion, motivated behavior, and reward processing.12 It also plays
an active role in the modulation of aggressive behaviors. In
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11
animal studies, hyperactivity in the dopamine system is associ-
ated with increases in impulsive aggression.13
Muneoka et al reported a case of AD wherein the aggres-
siveness disappeared after an infarct in the anterior thalamic
nucleus.14 The authors suggested that the temporal lobe degen-
eration might have disturbed the frontal cortical function lead-
ing to aggression and the thalamic infarct may have reduced
this disturbance, thus normalizing the frontal cortical function
rather than causing impairment.
Several drugs have been implicated for treating aggression
in patients with dementia including antipsychotics, cholinester-
ase inhibitors, anticonvulsants (eg, carbamazepine and valpro-
ate), antidepressants (eg, fluoxetine), and memantine, as well
as the benzodiazepine lorazepam.15 Neuroleptics are the first-
line choice of psychotherapeutics for controlling severe aggres-
sion, especially the violent outbursts often seen in severely
demented patients. But their efficacy for this problem is limited
and their use is frequently complicated by side effects.16 They
are more effective for particular symptoms, such as anger,
aggression, and paranoid ideas in patients with AD. However,
they do not appear to improve cognition, functioning, care
needs, or quality of life.17
Aggressive behavior complicates management in a patient
with AD and severely violent behavior among patients with
AD has previously been described but having delusional psy-
chopathology.18 To our knowledge, a case as ours with an
undue severe violent behavior in the absence of a delusional
pathology or external provoking factor has never been reported
before. Our case had no external provoking factor, strongly
implicating an underlying neurobehavioral dysfunctioning
leading to aggression which may be denoting an endopheno-
type in AD population. Hyperactivity in the dopamine system
may have been responsible for these explosive impulsive beha-
viors as there was good response to the antipsychotic even
though there was no prominent psychotic psychopathology.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
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