Managing the combative demented resident.

Managing combativeness is a major problem in nursing home resident care. It is extremely common for demented patients, for example, to hit, kick, spit at and bite others in their immediate environment. Caregivers of the demented are the main victims, with assaults occurring during such caregiving tasks as bathing, shaving and feeding.

Ambulatory demented patients who are combative may victimize other non-ambulatory patients, as well, and may elicit combative responses in return by behaving in an intrusive, bothersome manner - for example, by pulling at blankets, singing or yelling loudly, or simply entering another patient's room.

The factors that contribute to combative and aggressive responses are quite varied, and have inspired considerable literature on the subject. Many authors have written on aggression, describing and documenting assaultiveness in a variety of populations and settings, especially hospital settings, inpatient psychiatric wards and nursing homes.[1-14] Other papers address such issues as management techniques,[15-19] documentation of aggression by staff,[20] and educational programs for nurses.[21,22]

Of interest is a finding by Cooper and Mendonca[23] indicating that demented patients were more likely to become assaultive when they were being physically guided or led and during the administration of medication, although this was not true of schizophrenic patients.

As dementia progresses, some of those individuals who displayed tendencies to be very aggressive in normal life remain aggressive. And there are others individuals who were never combative in the non-demented state and who gain these aggressive behaviors only as their cognitive abilities decline due to dementia.

Decreased impulse control, inability to express hostility through verbalization, intense frustration with one's inability to perform over-stimulation by the environment, or a sense of perplexity often lead to combativeness in these residents. Consider the following examples:

1. Mr. Thomas, a 71-year-old patient diagnosed with Alzheimer's disease, routinely hits out when anyone tries to brush his teeth, wash his face, or shave him. He is incontinent of bowel and bladder. Changing his protective garment, bathing him and even combing his hair will generally elicit a combative response.

Mr. Thomas perceives caretaking behaviors as humiliating and uncomfortable. He cannot effectively verbalize his feelings, would prefer to be left alone, and has no insight or understanding as to the need to complete these tasks. He may not want to have his clothing removed, probably does not want to enter a tub of water, and does not mind the food caked on his clothing from breakfast. His olfactory sensitivity has diminished as a result of his Alzheimer's disease. Mr. Thomas' combativeness communicates the attitude: "Don't touch me! Don't bother me! I will hit you if you don't leave me alone!" 2. Mr. Henderson, diagnosed with dementia, is an 89-year-old man who will often behave in a combative manner when caregivers of African-American heritage try to complete his nursing care tasks. What he communicates through his combativeness is: "Don't touch me. I don't trust you. You look unfamiliar to me and I have never been around people of color. I think that you might want to hurt me. I want someone of my own color to take care of me. I will hit you because you look unfamiliar to me." 3. Mrs. Parker, age 6l, diagnosed with multi-infarct dementia, displays an exaggerated startle response. When someone approaches from the side or abruptly taps her on the shoulder, she startles and will often hit out. She is hard of hearing and her peripheral vision is poor. 4. Mr. Ward, a 68-year-old demented man, hits out when someone intrudes into his space. When another person grabs at his shirt and tries to take an afghan placed over his lap, he will hit out at her. Hitting is his response to someone coming too close, someone intruding, touching him or taking an item that he considers his own possession. 5. Mr. Davis, a 58-year-old man diagnosed with Alzheimer's disease, becomes upset and will hit out when staff try to change his clothing. He is a man who is extremely modest and private. He is unwilling to let them remove his pants without a fight. He wants to maintain his modesty.

Management Strategies

When a nursing home resident behaves in an assaultive manner and poses a risk to others, it is not uncommon for that resident to be transferred from the nursing home to a state hospital setting. This seems at times to be the only alternative, accomplished usually through the process of civil commitment. it may be avoidable, however.

As we have seen, the situations that elicit a combative response in demented individuals include exaggerated startle responses, attempts to maintain modesty and privacy, reactions to perceived intrusion into personal space, attempts to take a possession away, the desire to be left alone, and intense frustration with one's situation.

If the resident is hitting because of an exaggerated startle response, the caregiver should approach from the front with a smile, being sure to gain the resident's attention and to precede the physical contact with eye contact. Offering an introduction, explaining the task, and obtaining the patient's agreement before touching the resident or initiating the risk can be helpful.

If possessiveness of objects is a major cause of assaults, it is important to offer distracting but desirable objects and activities as alternatives. Thus, if the resident escalates to assaultiveness, a duplicate item (e.g., a spare afghan), a food snack or beverage, or the offer of an appealing activity such as a walk out of the area may elicit the resident's attention and serve as a distraction from the object provoking the assault.

Sometimes a resident may be observed isolating himself/ herself from others by wearing a blanket placed over the head. This is a clear message that the level of stimulation has been excessive for that resident and he/she needs to be left alone in a quiet area to regain a sense of peacefulness. In situations like this, a caregiver intruding upon the patient and uncovering the patient may become the object of the patient's anger and assault.

If the resident dislikes being cleaned or bathed, it is important to slowly and patiently explain what you are about to do and to gain the patient's agreement. Other important measures include talking calmly in a pleasant, low-pitched tone; using another staff member to hold the patient's hands; providing as many caregivers as necessary; avoiding abrupt, rough movements; developing a friendly relationship with the resident which incorporates warmth and humor; smiling frequently; and avoiding a hurried approach.

If humiliation and shame are issues, it may be helpful, if possible, to have the same staff member perform the resident's hygiene tasks in a private setting. Engaging the patient in a relationship, using a calm, matter-of-fact attitude, explaining the task in a warm, friendly manner before initiating it, reminding the patient that he/she knows you and that you are his/her friend and caregiver, and maintaining a warm, affectionate manner may prove to be calming. Using "folksy" language that does not demean the resident may also help (e.g., "It's time to change your britches," rather than, "I need to change your wet diaper.").

Taking note of postural cues, muscular tension and level of frustration will also help to decrease the probability and intensity of violent behavior causing injuries. Finally, allowing the patient to maintain as much control and decision-making capability as possible is also helpful.

As noted above, sufficient numbers of staff must be provided to perform care tasks with potentially combative patients. New staff who lack skill and experience and those who are unfamiliar with the patient's tendency to hit out are at greatest risk.

Conclusion

Efforts to anticipate assaults and minimize injuries to patients and staff are critically important in the nursing home population, particularly with the growing prevalence of dementia-related admissions. Working to identify the specific sources of the combativeness through close observation of the resident, consultation with family members, and review of the resident's history can offer insight into the reasons for the combativeness. Nursing staff may gain a more sympathetic view of the resident, and the cost of care and level of restrictiveness deemed necessary in the environment may be minimized.

Kathleen S. Mayers, PhD, is a counselor in the Geropsychiatric Medical Unit, Western State Hospital, Tacoma, WA.

References

[1.] Beck CM, Baldwin B. Modlin T, et al. Caregivers' perception of aggressive behavior in cognitively impaired nursing home residents. Journal of Neuroscielice Nursing 1990; 22(3):169-72. [2.] Burrows R. Nurses and violence ... psychiatric ward. Nursing Times 1984; 80(4):56-8. [3.] Caseem M. Violence on the wards ... psychiatric hospitals. Nursing Mirror 1984: 158(21):14-16. [4.] Convit A, Jaeger J. Lin SP, et al. Predicting assaultiveness in psychiatric inpatients: A pilot study. Hospital and Community Psychiatry 1988, 39(4):429-34. [5.] Haller RM, Deluty RH. Assaults on staff by psychiatric inpatients. A critical review. British Journal of Psychiatry 1988; 152:174-9. [6.] Hodginson P, Hillis, Russell D. Aggression management: Assaults on staff in a psychiatric hospital. Part 3. Nursing Times 1984; 80(16):44-6. [7.] Marx MS, Werner P, Cohen-Mansfield J. Agitation and touch in the nursing home. Psychological Reports 1989; 64(3):Part 2; 1019-26. [8.] Meddaugh DI. Reactance: Understanding aggressive behavior in longterm care. Journal of Psychosocial Nursing and Mental Health Services 1990; 28(4):28-33, 40-41. [9.] Meddaugh DI. Lack of privacy, control may trigger aggressive behaviors. Provider 1992; 18(7):39. [10.] Morrison EF. Violen Psychiatric inpatient in a public hospital. Scholarly Inquiry for Nursing Practice 1990: 4(1):65-82. [11.] Ruscitti C. Caring for a combative patient. Nursing 1992; 22(9):50-91. [12.] Sheridan M, Henrion R. Robinson L, et al. Precipitants of violence in a psychiatric inpatient setting. Hospital and Community Psychiatry 1990: 41(7):776-80. [13.] Thomas MD. Ekland ES, Griffin M. et al. Intrahospital relocation of psychiatric patients and effects on aggression. Archives of Psychiatric Nursing 1990: 4(3):154-60. [14.] Warner C. Responding to aggression. Nursing Times 1992: 88(30):46-7. [15.] Berky PS. Combativeness: A treatable problem in the elderly patient. Today's OR Nurse 1987; 9(12):20-3, 34-6. [16.] Mayers KS. Methods dealing with agitation, resistiveness and combativeness: Results of a survey of Washington state nursing homes. American Journal of Alzheimer's Care and Related Disorders and Research 1990: 5:19-21. [17.] Meddaugh DI. Before aggression erupts. Geriatric Nursing 1991: 12(3):114-16. [18.] Skews G. Try TLC for aggression... nursing the elderly. Lamp 1988; 45(7):13-14. [19.] Winter J, Schirm V. Managing aggressive elderly in elderly in long term care. Journal of Gerontological Nursing 1989: 15(2):22-7. [20]. Beck CM, Robinson C, Baldwin B. Improving documentation of aggressive behavior in nursing home residents. Journal of Gerontological Nursing 1992: 18(2):21-4. [21.] Feldt KS, Ryden MB. Aggressive behavior: Educating nursing assistants. Journal of Gerontological Nursing 1992: 18(5):3-12. [22.] Page S. Aggression in Alzheimer's Disease. Nursing Standard 1992: 6(24):37-9. [23.] Cooper AJ. Mendonca JD. A prospective study of patient assaults on nursing staff in a psychogeriatric unit. Canadian Journal of Psychiatry, 1989; 34(50:399-404.