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Understanding and Dealing With Resident Aggression

March 1, 2004
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Techniques for managing a delicate situation by Stephen Soreff, MD, and David Siddle, PhD
Understanding and dealing with resident aggression

Exploring the extent, causes, and impact of aggressive outbursts and how to handle them

BY STEPHEN SOREFF, MD, AND DAVID SIDDLE, PHD From time to time, residents can become aggressive and, yes, violence does happen. However, these aggressive outbursts can be understood and, in many cases, prevented. In all situations the combative behavior can be managed. Staff can anticipate and in many instances de-escalate a potentially violent episode. Furthermore, once the aggressive episode is under way, there are ways in which staff can effectively intervene.

Extent of Aggressive Behavior
Although there is the cherished image of Grandma baking and handing out cookies and Grandpa fishing with the grandchildren, there is another picture of a senior citizen who is angry, shouting, kicking, and occasionally striking out at others. In fact, OSHA has found long-term care facilities to be dangerous workplaces because of resident combativeness.1 At these facilities CNAs constitute 90% of the victims.2 In one nursing facility, 18% of the staff noted aggression as a daily occurrence.3 Five percent of nursing home residents will be involved with aggressive behavior each week, and 40% of nursing home aggression is recurrent.4 Elder aggression in the community is also significant: Elderly people with dementia residing in the community have a 65% incidence of aggressive behavior.5

Causes of Aggressive Behavior
As extensive as elder aggression can be in long-term care facilities, so too can be the causes for combative behavior. When a resident lashes out it is more often than not a manifestation of an underlying condition. Just as fever can be a symptom of infection, aggression suggests the presence of a medical, psychological, or social problem.

Aggression is often the result of a medical condition. For example, a resident's outburst may reflect a urinary tract infection or pneumonia. One 76-year-old female resident would become disruptive every time she had a respiratory infection. Hence, the treatment of her aggressiveness involved the use of antibiotics. One especially important reason to look at physical causes for the aggressive behavior first is that the underlying illness may be readily treatable. Similarly, endocrine problems, medication reactions and interactions, and alcohol and drug abuse must be considered as possible causes for such behavior.

Another major contributor to aggression is dementia,6 defined by memory loss, disorientation, and difficulty in communication-symptoms that can lead to fear, depression, anxiety, and panic. In one study, among residents with dementia, 45% exhibited aggressive behavior within a two-week study period.7 Although Alzheimer's disease represents the majority of dementia cases, there are many other causes, such as head trauma, atherosclerosis, and multiple cerebral infarcts. One 66-year-old male resident with Alzheimer's would forget where he placed his glasses. When he could not find them, he would accuse staff of stealing them. Later, he would become agitated and threatening toward those around him. Things would gradually quiet down when the staff found his spectacles.

There is often a relationship between dementia and infections. When a resident with dementia contracts an infection, he may have difficulty telling others of his discomfort, and an aggressive outburst may be his way of communicating it. Based on our work in many long-term care facilities, we have found that unexpressed and unrecognized pain can lead to aggressive events.

A number of psychological problems can translate into aggressive behaviors. These include depression and a host of serious and persistent mental disorders. Depression is marked by a pervasive feeling of sadness, guilt, thoughts of death, dread, and despair, as well as physical symptoms such as a diminished appetite and difficulty with sleep. Depression is common within long-term care facilities.6 Many people with depression also experience a sense of loss. Residents entering a long-term care facility, no matter how wonderful it may be, can experience a number of losses, including their homes and their independence. Residents also might have other losses in their lives, such as jobs, health, and loved ones. For some the contemplation of their own deaths can be depressing.8 That depression can evolve into anger and, in turn, lead these residents to strike out at others.

For some, mental illnesses have been a persistent and lifelong struggle. These illnesses include schizophrenia, bipolar disorder (manic-depressive illness), some anxiety disorders, and post-traumatic stress disorder (PTSD). Although most of these disorders can be effectively treated with medications, sometimes a resident's symptoms emerge and can trigger an aggressive episode. For example, an 81-year-old female resident with bipolar disorder periodically would develop symptoms of mania manifested by loud singing and yelling at staff. For many residents suffering from PTSD, memories of war, the Holocaust, other incidents of genocide, or early child abuse still live in their minds and occasionally erupt into violent events.

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