Caring for angry elders: what makes them that way, and what you can do about it.

For all human beings, anger can be an ordinary reaction to life situations or indicative of emotional illness. It is particularly important for those working with older individuals to understand and competently manage their patients'/residents' anger. If not, resident care and the facility's reputation for quality service can be diminished.

Anger can be healthy, and this should be recognized. For some elders, anger correlates with good mental health. The "anger juices" keep the older person alive. Validation of such anger by the caregiver is a must. To do this, the caregiver can make comments such as "You seem frustrated" or "You're feeling angry today, aren't you?"

Comments such as "She's just looking for attention" are generally unfounded. Maybe the elder is justified in her or his behavior. The caregiver must always ask him- or herself why this behavior is occurring. Then that caregiver can move on to discovering how the anger can be managed in a constructive fashion. The rechanneling of anger can be promoted through the use of physical activity, resident councils, recreation activities and other socially acceptable means.

Elders should not be made to sit and absorb pain. They cannot run away like younger people, nor can they engage in strenuous physical activity; thus the tension builds. Sometimes the caregiver must work with the system to make the environment more adaptable to the elder's anger, rather than trying to force the elder to adapt to the environment. If the elder's anger is not dealt with effectively, the anger may turn inward, transforming into depression and, in the worst cases, suicide.

Depression is regarded as an alternative to anger - anger turned inward. Depression presents particularly difficult problems in the elderly population. When people were clinically depressed during the 1930s, there were no mental health centers available, only mental hospitals. This meant that people "went to bed" or were nurtured by their family when they were mentally ill. Consequently, elders will often say they have never been depressed because they have never been clinically treated. It is suggested that if you are trying to discover a history of depression in the elderly, they be asked if they have ever felt depressed or, put another way, had to "take time out from life."

Another significant consideration in dealing with geriatric depression results from the stereotyping that has traditionally surrounded the mentally ill. Even in today's society, the image of the mentally ill is subject to considerable skepticism by many elderly (and others).

Nevertheless, in dealing with angry elders, it can help to evaluate, to the extent possible, the quality of the older person's past relationships with parents, siblings, children and friends. If the elder is in a long-term care facility, are family pictures on the wall? Does the elder prize them? Relevant questions include the following: What was the elder's birth order? Did the elder lose a parent or a sibling? Was he or she victimized or abused by siblings? What was the quality of her or his parenting? How did the elder handle conflict and life stressors?

It is also important to consider the elder's work history. How important was work to him or her? Did the elder's work revolve around a family that has now dissolved? Was there an "empty-nest syndrome," and what impact did this have on the marriage partners?

Complete assessment of an emotional disorder also includes a sexual history. Very often, reluctance to discuss sexual history is generally the caregiver's problem rather than the elder's. After establishing rapport with the elder, try asking him or her about the closeness of the relationship with his or her spouse, and whether or not this might be figuring into a sense of loss and depression.

The last aspect of the resident history to be addressed involves how the elder views her or his life. Does the elder perceive herself or himself to have been the family scapegoat? The hero? Does the elder feel guilty about anything she or he did or did not do when younger? It may be that the elder's anger is characteristic - a part of the suit of clothing the person has worn since childhood. Another possibility is that the elder's anger response has become conditioned over time. The elder could be trying to gain attention or to distance himself or herself from others through the use of anger. If the elder's personal boundaries were repeatedly violated during childhood, the elder might have created increased personal space through the use of anger, and is creating the same situation now at the age of ninety in a nursing home.

We must also remember that life was not easy for many, or perhaps most, children when these elders were growing up. Children were often forced to spend time apart from their families because of poor economic conditions. Contrary to the depiction of family life in shows like The Waltons or Little House on the Prairie, the elder might have been deprived and abused. There might not have been enough food to eat or sufficient clothing to wear. Helping an older person to reminisce might bring losses, rather than heartwarming memories, to the surface.

In the post-Victorian era in which the elder was raised, it was unacceptable to express anger against misfortune or against God; anger became generalized, diffused and displaced on others. For example, if an elder's loved one has died, the grief might translate into dissatisfaction with current living conditions. Allow ventilation - indeed, encourage it. The caregiver must help the elder deal with the reality of a loved one's death while "tip-toeing" through his or her anger until it can be resolved healthily.

Perhaps the most significant loss to an elderly person involves the loss of a function, or of control of the body or mind. This can produce fear, and fear triggers the "fight or flight" response, i.e.; since the elder cannot run away from the situation, he or she must stay and fight, and this in turn triggers anger. Much of the paranoid behavior associated with geriatric dementia stems from fear. Cues start slipping away progressively until fear translates into aggression. Healthcare providers, as educated, caring people, should appreciate that most aggression by these residents stems comes from apprehension and be able to respond gently and sympathetically.

Of course, it can be a major problem for caregivers to avoid taking elders' anger personally. There can be hurt feelings and defensive reactions. We might respond by avoiding the angry person or by adopting a too-nice persona. We begin to use the term "we" when interacting with an older resident: "We need to take our bath now" or "We have to eat all our dinner if we want to get better." Another reaction is to address all older people as "dear" or "hon." As a defense against anger, this is terribly condescending, not to mention ineffective.

Denial is another inappropriate technique. For example, the nurse might tell an angry elder that he or she is "not really angry." This does the elder a disturbing injustice - many are really angry, and for good reason.

Setting limits

When dealing with an angry elder, it is important to set limits - not as a parent would, but for the purpose of containing the anger while allowing its expression. An angry elder may feel unsafe and actually desire to be restrained. Limits can be set verbally, chemically and physically. But no matter which system is used, all ongoing evaluation process should be in place from the outset.

Verbal restraint is the simplest and least intrusive. The caregiver might consider establishing a program of positive and negative reinforcement for the angry elder, i.e., behavior modification. Behavior modification can be effective in that it allows older people to channel their angry energy into constructive behavior. One behavior modification strategy for an angry resident of a long-term care facility might be to appoint him or her to serve on the resident council.

Although chemical restraint is a second option, polypharmacy is a major problem in the long-term care setting, so chemical constraint should be used sparingly, and only after other methods have repeatedly failed. If chemical intervention is used, it is preferable that a psychiatrically trained clinician follow the resident's case.

Physical restraint is generally not recommended for these individuals, although restraints can be a valuable tool for the hostile, combative elder who is temporarily out of control and needs to regain it.

Conclusion

Our current system of caring for the elderly population is sorely in need of modification, especially in terms of the attitudes about the aged commonly held by healthcare providers and society in general. Care providers must attend to the morale of the institutionalized elderly and find ways to empower them and help them deal with their anger. Residents must be given more control, and barriers to that control must be eliminated. This typically includes modifying residents' physical environment and psychological environment, including directly recognizing, acknowledging and helping residents deal with their anger.

Norma McKinnon, EdD, is a former director of nursing and nursing home owner/operator now concentrating on writing for the long-term care field. For further information, [phone].