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Senior Aggression
WHAT SHOULD WE DO?
Through the years the Arcadia community has occasionally been confronted with a resident who becomes aggressive and, at times, violent. In this regard, I recently reviewed an article by Stephen Soreff, M.D., and David Siddle, Ph.D. entitled “Understanding and dealing with resident aggression”. The article appeared in the March, 2004 issue of “Nursing Homes”. Allow me to share some of the information I garnered from this article.
Aggressive outbursts of anger, shouting, kicking occasionally striking out at others can be understood and, on occasion, prevented. Combative behavior also can be managed. There are effective interventions when an aggressive or combative episode occurs.
We know that seniors with dementia (including Alzheimer’s) residing in a community have a 65% incidence of aggressive behavior.
Aggression suggests the presence of a medical, psychological, or social problem. For example, a resident’s outburst may be caused by a urinary tract infection or pneumonia, the treatment for which is antibiotics. Similarly, endocrine problems (caused, for example, by the thyroid or adrenal gland), or medication reactions and interactions, or alcohol and drug abuse are possible causes for aggressive behavior.
Dementia can lead to fear, depression, anxiety and panic. One senior with Alzheimer’s would forget where he placed his glasses. When he could not find them, he accused the staff of stealing and would threaten them. Things would quiet down, however, when staff found the glasses.
Unexpressed and unrecognized pain can lead to aggressive behavior.
Depression and mental disorder can also translate into aggressive behavior. Depression is marked by pervasive feelings of sadness, guilt, thoughts of death, dread and despair, as well as physical symptoms such as diminished appetite and difficulty with sleep. This Depression can evolve into anger and, in turn, lead depressed residents to strike out at others.
Personal relationships in a resident’s life can lead to aggressive episodes. For example, a resident may have a disagreement with a roommate, another resident, a spouse, child or sibling, and react aggressively. Carrying lifelong prejudices and biases into old age may also result in aggressive episodes with direct care workers.
“Sundowning” occurs when a resident becomes agitated as the sun sets. The agitation can result from a resident’s diminished eyesight and hearing, early dementia, feelings of hunger, and disorientation caused by staff shift changes. (At Arcadia, we have an activities program at and after sundown which calms our residents in Health Care who show signs of “Sundowning”.)
What are some of the basic techniques for effective de-escalation of aggressive behavior?
• Active listening and effective verbal response mean taking the time to hear what a person is saying and then thinking about an appropriate response. For example, a senior was angrily pacing because his wife was late in coming to see him. Once reassured that she would arrive in a couple of hours, the anger and pacing ceased.
• Residents with memory impairments benefit from the use of redirection and “fiblets”. Redirection is where a resident’s attention is drawn to another subject. A “fiblet” is a little white lie! For example, a resident became agitated at 4 p.m. each day “because her shift was up and she had to catch the bus home”. So, at 3:55 p.m. each day the staff gave her a ticket for the bus and told her to wait for it. After a few minutes she became interested in supper and forgot about the bus.
• Staff stance and positioning in relation to an agitated resident is important. If a staff member stands with his/her feet about 18 inches a part, the staff member is able to work and move with a resident without the staff member losing balance. In other situations, a staff member standing within six feet to the side of a resident, rather then directly in front of an agitated resident lessens the likelihood that a staff member will be struck by the resident, and, the resident feels less threatened.
• The “tincture” of time technique allows a resident to have time and space to allow his/her outburst to dissipate.
• Do not jump to conclusions. Try to find out the real reason for an outburst. For example, thinking that an outburst by a resident was because her son did not visit, upon inquiring and after a brief discussion the staff found that the resident’s outburst was really caused by pain in her right shoulder.
• Controlling the environment when a resident becomes aggressive means that staff should move other residents out of harm’s way, remove objects that could be used by the resident to harm oneself or others, block routes whereby the resident could leave the facility. When a resident is agitated, staff should not leave a resident alone and should always keep that resident in view during the aggressive episode.
• Finally, teamwork is critical. All shifts should know about any aggressive resident event. Sharing medical, social and rehabilitative information is a must.
Aggressive behavior must not be hidden or ignored. Of course, families’ are sometimes horrified that a father, mother or relative would act in an aggressive manner. But through it all, everyone must stay informed. The subject of resident aggression is complex, perplexing and disturbing. At Arcadia, not everyone will experience episodes of aggressive behavior, but it is important that we be aware of the possibility for any such behavior so that we can identify the etiology of the aggression and the reasonable preventive measures which can be taken.