Combative Behaviors in Dementia: The Role of Food in Changed Behavior

This year marks my tenth year as a caregiver. I do not know how I feel about that. I do not feel great knowing that my family members needed me to take care of them at the end of their lives because I know they would have preferred to not have terminal illnesses (as would I, honestly).

At the same time, I am honored to have given them the dignity, respect, and everything they asked for during our journey through Alzheimer's and dementia. I still have more to do with my current family member, so I do look for things to do together in the evenings, such as working on puzzles.

I am also honored to have been assisting others for the last ten years with their own journeys with their own loved ones. It does feel good to continue to use my health sciences background and make a positive difference. Keep going. You are doing good work for your own family members.

Now to the actual topic of behavioral changes.

At the end of 2025, I experienced new behaviors from my loved one.

Not all new experiences or milestones are worth celebrating, though.

Some feel like dread and that you need to mentally prepare NOW.

A New Stage

It is not easy when your loved one enters a new stage. That is exactly what I had the unfortunate experience of being in the middle of. The declines are difficult; however, when they come with new negative behaviors, it makes them more difficult.

Unfortunately, I have to remind myself that each new stage of dementia comes with new negatives and fewer positives, and you really do not know which new thing is going to happen.

One of these new behaviors is that of combativeness. This transcends agitation and aggressiveness. I would even take hallucinations over combativeness. Luckily, I did not have to experience much of this with my dad or any other family member that I assisted with through the years. Most of the time, they were wonderful and remained cheery, positive, and easily redirected. The one exception with my dad was the one day that I had to drive him to one last court hearing an hour and a half away when he was convinced and fixated on the idea that I was taking him "home."

I do not miss those days; I had to be up and on the road by 5 am to be at his side by 6 am to help him dress, get ready, and be at the courthouse by 9 am. Instead of his usual self, he was adamant that I was "taking him home." When he hit his limit and was beyond consolation, which occurred when we were closer to the destination, he went to punch my face.

He stopped himself, fortunately, but he held his fist close to my face too long for my comfort. Then, without warning, he opened the car door and was going to get out of the car. Mind you, this all occurred very suddenly on a highway while we were traveling at 70 mph, and I was very pregnant with my second child. He did not know how to close the car door, so I pulled over and had to do that for him. That was the one and only time I had to deal with physical aggression and combativeness. I de-escalated the situation quickly, and we went on with the day.

Jumping to now...

This is different simply because every person is different.

My loved one is not as positive or genuinely happy as my other family members were at their core selves. This loved one had been able to fake it for those outside of our relationship and family dynamic, but I am unsure how much longer they will be able to hold up the facade with strangers. They have already started screaming at the people paid to assist me with their care and saying they are being screamed at.

For the first time with this person, I saw them step into the 6th Stage of Dementia. I could not redirect them during a situation; instead, they escalated to screaming in my face. A gentle touch on their arm to physically redirect caused an escalation and increased their screaming, rather than the actual intended redirection. In that moment, I could tell that they did not recognize me by their behavior, the words they chose, the escalation, but mostly from their eyes.

I have a knack for reading people through their facial expressions, body language, and eyes. The eyes tell a lot about someone. The strange part of dementia is seeing when someone "is there" versus "not there." Confusion has more to do with that in most cases involving dementia, though.

It was startling to see that they did not know who I was for those minutes. Then, with that realization, comes the weight of what I know is coming.

At the core, it is strange for someone to forget the immediate family in their life. Scary, for sure in the beginning. Eventually, they do not remember anymore, and you become a vague familiarity. They seem to expect you to be present, yet they can no longer quite pin down why.

To be on the receiving end of this -again- is strange. And it makes my stomach hurt.

So What Is There To Do?

First off, take them to the Emergency Department.

Why?

Non-dementia related issues need to be ruled out, especially if de-escalation is not working and the behavior is new and sudden.

This includes Urinary Tract Infections (UTIs), other infections, stroke, falls, and other issues that may be related to other health issues.

If you have not dealt with a UTI with a dementia patient, buckle up because that is coming. And it will hit viciously and suddenly. The situation is not fun. They are not fun. The person seems to change instantly. So if you are caring for someone, and they suddenly are more confused, easily angered, unable to redirect, and seem completely unlike themselves and in a fog.... In most cases, that is a UTI.

Signs that one could be on the horizon include, but are not limited to:

• dehydration - an unwillingness to drink enough water, claiming they drank water but really did not

• unhealthy hygiene practices - not bathing, not changing their clothes, refusing to wear clean clothes, etc.

• forgetting to do basic necessary hygiene, such as proper wiping and/or wiping at all after bowel movements

Why Food Matters

With other issues related to other health issues, a major contributor to behavioral changes and confusion could be food related.

Certain diseases are managed by diet.

Having a "cheat day" could wreck havoc on the person... and YOU, the person who has to manage the person, the behaviors, any messes, and assess the aftermath.

This is especially true with those who have Kidney Disease, Liver Disease, Diabetes, dietary intolerances, and have had appendectomies and cholecystectomies. To put it as simply as possible, the body can no longer digest - or digest well- or tolerate specific foods.

So, at all costs, those specific foods need to be avoided all the time.

The body does not understand the mind's logic of a "cheat day;" it is going to do what it does or does not do everyday, regardless of what your thought process and reasoning behind the idea is.

The digestion system runs on automatic, so adjust accordingly.

For Kidney Disease, the body can no longer filter potassium out of the blood. Add in the complication of dementia and declined cognitive reasoning, thinking, and memory, and dialysis is taken off the table as a treatment option. When caught early, Kidney Disease can be managed through diet. This means removing potassium rich foods from the meal plan completely.

This is not a "one size fits all" scenario, so understanding where someone is in their kidney function and dementia states are important to consider. If the person is able to have dialysis, then those potassium-rich foods and proteins will be added back to the diet, but that is because a machine is physically cleaning the blood, not the body. Those with dementia who are unable to tolerate dialysis, if caught early enough (like this case, specifically), will have to manage with diet alone by cutting potassium as much as possible to prevent kidney failure, other organ failure, and other adverse secondary reactions..

And you can tell when those foods have been eaten. The person becomes more confused, reasoning is foggy, they are more easily angered, more reactive, and more fatigued. This can last up to two weeks as well, just from one "cheat moment" in one day.

Not all diseases and conditions are that bad, though. Most food intolerances can be recovered from within hours. However, it is important to note that "cheating" with food that your body has an intolerance to digesting does cause damage to the intestines. So while you may miss eating specific foods, it is important to find replacements that will not cause discomfort, pain, or damage to the digestive system to prevent additional complications and possible diseases later.

As a caregiver, it is our job to be on the watch for our loved one's care to see if they are eating properly, even when the food is bland.

I do have to ask myself - more often these days- if I am doing them a disservice by withholding the more indulgent foods from them that they want and ask for. Those foods that assisted with the progression of dementia, in addition to the diseases, that impacts their lives that they still want and ask for.

Some questions that go through my mind include:

How many days or weeks are being shaved off of their life with each meal?

Is it worth it to make them happy?

Are they really enjoying their life by eating healthier food that they do not want?

Does prolonging their life in this way really benefit them?

Or is it only their suffering that is being extended?

You may find yourself at this crossroad as well at some point.

Do you just give them what they want to make them happy vs. keeping their body as healthy as possible while they are unhappy about the food, which may or may not be the only thing they look forward to each day.

Final Thoughts

As you go through your own caregiving journey, you will ask yourself so many questions. Food will be at the center of some of them at some point. Some of the negative behaviors and adverse side-effects will have the possibility of being food-related. After all, we are what we eat.

While we have many daily choices as we care for our loved ones, we do need to watch closely for those sudden behavioral changes that necessitate immediate action. While I was hoping my loved one's sudden change was due to eating food too rich in potassium or something treatable, like a UTI, we are stepping into the next stages of the progression of their dementia.

For those who have not experienced their loved one not recognizing who you are, please be aware that it is coming. There is not anything that can predict when, but it is a "when," not an "if."

Eat well. Moderation is key. Enjoy life as much as you can. And remember that your digestive system runs on automatic and does a lot.