Preventing and managing catastrophic reactions

The following scenario describes the recommended approach and responses to catastrophic reactions. Below the flow chart you will find specific strategies for ongoing management of catastrophic reactions.

Catastrophic Reaction ABC Flowchart

C = Consequence B = Behaviour A = Activating Event

What is a catastrophic reaction?

Catastrophic reactions are emotional outbursts, sometimes accompanied by physical acting-out behaviour, that seem inappropriate or out of proportion to the situation. The reaction may be triggered by a present event or by one from the distant past” (Santo Pietro M J. & Ostuni E. 1997, p.272)

Why does a catastrophic reaction occur?

  • Excessive response - People with brain damage are easily overwhelmed and may respond with excessive emotions and behaviours (e.g.: panic or aggression) as a result of frustration, cognitive overload or the inability to communicate needs or perform tasks.
  • Carers unwittingly precipitate this reaction in people with dementia due to:
    • a lack of understanding of the causes of catastrophic reactions
    • a lack of communication
    • the result of a power struggle that leaves the resident and carer feeling frustrated or stressed.
  • Physical violence nearly always occurs if someone initiates physical contact whilst the resident is suffering from a catastrophic reaction.

What can we do to avoid catastrophic reactions?

Prevention is always better than the cure! Avoid:

  • Presenting a task that is too difficult
  • Overwhelming them with decisions (e.g. “would you like to wear this dress, or would you rather have a tracksuit or stay in your pyjamas” = Brain overload)
  • Recalling distressing memories
  • Making sudden or unnecessary changes
  • Applying physical restraint
  • Arguing or trying to make them see it from your view
  • Communicating in a way that asserts authority or lack of respect
  • Creating unnecessary changes to the environment or staffing arrangement

Specific management strategies for catastrophic reactions

  1. Identify what, where and when catastrophic reactions occur for the individual.
  2. Assess for and treat any physical causes - eg delirium; history of recent falls may indicate an undiagnosed fracture.
  3. Assess for psychological causes - eg anxiety may escalate to terror in the absence of appropriate communication.
  4. Plan a management strategy to prevent the catastrophic reaction - We cannot alter the cognitive ability of the person with dementia but we can manage the environment and change our own attitudes. (Please refer to the Ten top tips for dealing with people who have dementia and Communication tips).
  5. Eliminate distractions - eg background noise, intrusions by other staff & residents.
  6. Prevent escalation by backing off - If the resident does not present a danger to themself or to others, observe them from a distance and allow them to settle without intrusion before proceeding any further.
  7. Maintain personal space - to ensure both their safety and your own. Do not invade personal space or touch unless appropriate and safe to do so unless there is immediate physical danger (please review the aggression scenario.)
  8. Observe resident’s body language and validate the emotions they are feeling - e.g.: “Tom, I can see that you are very angry, can I help?” Angry & agitated behaviour may be caused through feelings such as fear, frustration, anger, or confusion.
  9. Set signals - that all staff are aware of which are to be used if other strategies fail and you need help. For example, develop hand signals that indicate to colleagues when to remove other residents, shut doors into hallway; or in an emergency, to restrain or remove from danger etc.

Specific communication strategies:

  1. Adopt a calm approach. Keep body language relaxed & non-threatening, arms down palms open.
  2. Use positive non-verbal communication. Establish eye contact and keep your facial expression warm, open and friendly. Remember that a neutral expression does not convey understanding or empathy.
  3. Call the person respectfully by name to help establish eye contact. Introduce yourself even if they know you “Mrs Robinson…..It’s me Clare”.
  4. Speak slowly and clearly in an adult tone of voice. Do not confront and avoid asking the person to explain themselves.
  5. Provide frequent reassurance, “I’m here to help you”, “Everything will be OK”.
  6. Use short uncomplicated sentences.
  7. Only use touch to guide and reassure and only if it has a positive effect.

References and recommended reading

Alzheimer's Association Australia (2000). Help Sheets for people with dementia and their families and carers. Alzheimer's Association Australia. [available online]

Santo Pietro, M.J. & Ostuni, E. (1997). Successful communication with Alzheimer's Disease Patients - An In-service Manual. Boston:MA, Butterworth-Heinemann.

Smith, P.A. (1993). Professional Assault Training (PART) Manual - Revised, Australian version. Australian revisions by Reid, G.V. Sheahan, C. & Sheahan, P. The Australian Centre for Posttraumatic Mental Health (2001) Posttraumatic Stress Disorder (PTSD) and War-related Stress: Information for veterans and their families. [available online September 2002].