Understanding and dealing with resident aggression: exploring the extent, causes, and impact of aggressive outbursts and how to handle them.

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.

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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.

Finally, the interpersonal social context of residents' lives can be responsible for aggressive episodes. The dynamics here can take many forms. Residents may have disagreements with their roommates or other residents. They may have conflicts with their spouses, children, or siblings. They may experience difficulties with staff. Although 85% of residents in long-term care facilities are white, (9) in many facilities staff members include people of different ethnic/racial origins. Some residents carry their lifelong prejudices into old age, and these biases may make them uncomfortable with some direct care workers.

Whatever the cause of resident aggression, each cause requires its own approach--for example, the treatment of an underlying urinary tract infection. More vexing is when several factors combine to trigger an outburst. For example, the phenomenon of "sundowning," in which residents become agitated as the sun sets, (10) can be the result of any combination of the resident's diminished eyesight and hearing, early dementia, feelings of hunger, and disorientation caused by staff shift changes.

Prevention/De-escalation

There are 10 basic techniques for effective de-escalation. Use of these procedures can not only diminish or halt the agitation, but can improve the quality of care. These are:

* active listening 

* effective verbal responding

* redirection

* "fiblets"

* stance

* positioning

* "tincture" of time

* not jumping to conclusions

* controlling the environment

* teamwork

Active listening and effective verbal responding represent the key aspects of good communication with all residents. This means taking the time to really hear what a person is saying and then thinking about the response. For example, an elderly gentleman was very upset and began angrily pacing the floor. As a CNA started to walk with him and listen to his concerns, he confided in her that his wife was late in coming to see him that day. When the CNA checked the day's schedule, she was able to reassure him in a calm, caring voice that his wife would arrive in two hours. He was relieved by this and his pacing ceased.

Residents with memory impairments benefit from the use of redirection and "fiblets." In redirection, staff simply draw the resident's attention to another subject and take her mind off of whatever she is focusing on. Fiblets are often called "little white lies." They address the subject the resident is dwelling on, provide some comfort, and allow the resident to mentally move on to another subject. In one facility, at 4 p.m. a resident became agitated because "her factory shift was up and she had to catch the bus home." She paced the floor and wanted to get on the bus. Staff recognized her daily distress, and each afternoon at 3:55 p.m. would give her a ticket for her bus and tell her to wait for it. The "ticket" was a fiblet that redirected her. After a few minutes she became interested in supper and forgot about her bus.

Attention to staff's stance and positioning in relation to an agitated resident is very important. By standing with feet about 18 inches apart, staff are able to work and move with a resident without losing their balance. Also, if they position themselves to the side rather than directly in front of a resident behaving aggressively, and maintain a distance of approximately six feet, staff are less likely to be struck by the resident--and he will feel less threatened by them, as well.

One technique of particular value is applying the "tincture" of time. This simply means allowing the resident to have time and space to let his/her outburst dissipate.

Not jumping to conclusions means listening to what the resident is really concerned about and then responding to it rather than assuming the obvious. For example, one day a resident began yelling. Staff assumed she was annoyed that her son had not visited that day. When her CNA asked what she was shouting about, the resident told the aide about pain she was experiencing in her right shoulder.

When a resident is becoming aggressive, there are a number of steps staff must take in controlling the environment. These include moving other residents and staff out of harm's way, removing objects that could be used by the resident to hurt herself or others, and blocking routes by which she could leave the facility. Staff must also make sure the agitated resident is not alone and is always kept in view.

Finally, dealing with an aggressive resident requires staff teamwork. The team must cooperate on many levels. When a resident is becoming agitated, several staff members working together can be very effective. It is important for each staff member to communicate with all members of the team about the resident's status. For example, if a resident has had a difficult visit from his brother in the morning, it is critical that the teams on all shifts know about the event. It is also important that direct care staff be present at treatment team meetings. They can provide firsthand observations about the resident, and they can receive medical, social, and rehabilitative information from other members of the treatment team.

There are other medical interventions that can be employed, but specifics of their use are beyond the scope of this article. (11)

Post-Episode Concerns

When aggression occurs, its aftermath has an impact on the resident who struck out, on other residents, on the resident's family, and on staff. The responses of all of them must be addressed.

Residents often react to their own outbursts, although in some cases a resident may not recall the event. In other incidents, the resident expresses mortification over his behavior. In one instance, a female resident yelled at her CNA. The resident had been experiencing severe arthritis pain and had become very frustrated by it. When she realized that she had actually shouted at the CNA, though, she became very upset and spent the rest of the day apologizing.

Other residents who might have witnessed the episode could have been terrified and concerned for their own safety. It is important to hear their concerns and reassure them that staff can not only handle aggressive outbursts, but also protect them from harm.

Families' responses to a loved one's aggressive behavior can vary. Many are horrified that their relative would act in such a way. Others may see staff as being at fault and blame them for causing the incident. In any case, it is important that staff inform families of aggressive episodes and listen to their concerns.

Finally, staff must pay attention to the staff member who has been on the receiving end of the aggression. That person may struggle with a series of emotional reactions that range from guilt and shame to depression and anger. In extreme cases, some staff even may develop PTSD. For example, one elderly male resident struck a nursing staff member in the face. The CNA not only sustained facial damage but also experienced PTSD and did not return to work for nearly a year. When a staff member is injured by a resident, it is critical that others show concern for that individual and listen to his or her concerns.

To summarize, resident aggression not only represents a growing long-term care concern but also is an important, complex subject. Many causes account for violent outbursts; hence, a comprehensive evaluation of each instance is needed. Such an assessment can both identify the aggression's etiology and lead to preventive measures. Furthermore, direct care staff can take many steps to de-escalate a resident's aggressive episode. It is important to recognize and address the impact of a violent incident on the initiating resident, other residents, the resident's family, and the staff who have been the target of the aggression.

References

1. Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. OSHA. 1996.

2. Brunk D. Random acts of violence. Contemporary Long Term Care 1997;20(7):38-42.

3. Astroem S. Umea U. Incidence of violence towards staff caring for the elderly. Scandinavian Journal of Caring Sciences 2002;16:66-72.

4. Cohen-Mansfield J. Billig N, Lipson S, et al. Medical correlates of agitation in nursing home residents. Gerontology 1990;36:150-8.

5. Ryden MB. Aggressive behavior in persons with dementia who live in the community. Alzheimer Disease & Associated Disorders 1988;2:342-55.

6. Lyketsos CG. Steele C, Galik E, et al. Physical aggression in dementia patients and its relationship to depression. Am J Psychiatry 1999;156:66-71.

7. Scheiner AS. Aggressive behavior among demented nursing home residents in Japan. Int J Geriatr Psychiatry 2001;16:209-15.

8. Kubler-Ross E. Death: The Final Stage of Growth. New York: Simon & Schuster. 1997.

9. Moody HR. Aging: Concepts & Controversies, Fourth Edition, Thousand Oaks, Calif: Pine Forge Press, 2002.

10. Bliwise DL. What is sundowning? J Am Geriatr Soc 1994;42:1009-11.

11. Soreff S. Siddle D. A Caregiver's Guide to Working With Combative Residents (e-book). Lakeville, Mass: Lighthouse CCUNIV Publications, Ltd., 2003.

Stephen Soreff, MD, is President of Educational Initiatives and is on the faculty of Metropolitan College, Boston University. Educational Initiatives offers a wide variety of highly interactive, experimental, innovative programs in psychiatry, sociology, fitness, and quality improvement. David Siddle, PhD, is Professor of Social and Rehabilitation Services at the Institute for Social and Rehabilitation Services, Assumption College, Worcester, Massachusetts.

Drs. Soreff and Siddle have been studying and teaching about aggression in the elderly for the last 10 years. They have put their findings into an e-book, A Caregiver's Guide to Working With Combative Residents, which offers explanations for elder aggression and provides caregivers with ways to deal with it. For more information on this e-book, visit www.ccuniv.org/ccunivceu/ebookindex.asp. For more information from the authors or to obtain a paperback edition of this book, please phone [phone], e-mail [e-mail], or write to Stephen Soreff, MD, 13 Uxbridge Street, Worcester, MA 01605-2512. To comment on this article. e-mail [e-mail]. For reprints, call [phone].

BY STEPHEN SOREFF, MD, AND DAVID SIDDLE, PHD