Aggressive behavior in hospitalized psychogeriatric patients

Confined to barracks: The effects of indoor confinement on aggressive behavior among inpatients of an acute psychogeriatric unit

While there is evidence to suggest that in long term residential care settings the provision of more choices and better designed environments have a positive effect on agitation and disturbed behaviors, there are no controlled studies on the effect of imposed confinement in these settings or in acute units.

The effect of mandatory confinement indoors on the incidence of verbal and physical aggression and psychotropic medication use among patients with dementia and associated psychiatric and behavioral disturbance was studied. The setting was an acute psychogeriatric admission unit accommodated in a colonial building originally built as a military barracks. A convenience sample was studied to assess changes in levels of aggression and nurse-initiated psychotropic medication use during and after a 32-day period of indoor confinement. Correlations with gender, diagnosis, pre-admission disturbed behavior and ultimate discharge outcome were examined.

Release from mandatory confinement indoors was correlated with decreases in both verbal and physical aggression as well as medication use. Correlations could be identified between decreases in aggression and male gender, pre-admission aggressive behavior and discharge outcome. Decreased medication use was correlated with discharge outcome. The freedom to go outdoors or have access to extra space should be an important component of the environmental design and care philosophy for the acute admission of people who experience dementia and associated psychiatric and behavioral disturbance.

Aggressive behavior in institutionalized elders: A theoretical framework

This review article explores current research on aggression in institutionc ized elders and proposes a theoretical framework for use by caregivers. The relationships of brain dysfunction, past behaviors, social networks and environmental triggers to the expression of aggression a te discussed. The framework can be used to generate research hypothesis, or as a guide for assessing rise factors associated with these behaviors.

Determinants of Neuroleptic Drug Use in Long-Term Facilities for Elderly Persons

Neuroleptics, also called antipsychotic drugs (e.g., haloperidol, risperidone) are the cornerstone drug therapy for psychiatric disorders. Despite the fact that they are widely used in nursing homes, little is known about their clinical determinants. The goal of this cross-sectional study was to determine the prevalence rate of neuroleptic administration and to identify their determinants among 2,332 elderly residents in nursing homes. Among the residents, 649 (27.8%) had taken at least one neuroleptic drug. According to the logistic regression, the factors associated with neuroleptic drug consumption were younger age, few hours of family visits, severe cognitive impairment, insomnia, physical restraint, and disruptive behavior. In conclusion, neuroleptic drugs are administered to more than a quarter of residents in nursing homes. Alternative solutions to sleep problems and disruptive behaviors of the elderly living in long-term-care facilities should be implemented in order to reduce unnecessary use of neuroleptics.

Pharmacologic management of neuropsychiatric symptoms of Alzheimer disease

OBJECTIVE

To systematically review published clinical trials of the pharmacotherapy of neuropsychiatric symptoms of Alzheimer disease (AD).

METHOD

We searched MEDLINE and EMBASE for published English-language medical literature. Our review focused on randomized controlled trials (RCTs) and corresponding metaanalyses.

RESULTS

The pharmacotherapy of neuropsychiatric symptoms of AD has been studied with numerous RCTs. The largest number of studies has focused on antipsychotics. Data are of reasonably high quality and indicate that risperidone and olanzapine are more effective than placebo for institutionalized patients with severe agitation, aggression, and psychosis. The efficacy of antipsychotics is counterbalanced by safety concerns that include cerebrovascular adverse events and mortality. Cholinesterase inhibitors and memantine appear to have modest benefits for patients with mildly to moderately severe symptoms. Antidepressants are effective for treating depression in AD, but more data are required to determine the efficacy of trazodone and citalopram for agitation and aggression. Carbamazepine appears to be efficacious, although side effects and concerns about drug-drug interactions limit its use. The data do not support the use of valproate. Benzodiazepines should only be used for short-term, as-needed use. There are insufficient data on other pharmacologic interventions, such as beta blockers, buspirone, and estrogen preparations.

CONCLUSIONS

Although there have been numerous well-designed studies of the pharmacotherapy of neuropsychiatric symptoms in AD, safer and more effective treatments are urgently needed.

Bathing: A framework for intervention focusing on psychosocial, architectural and human factors considerations

The process of bathing is usually pleasurable and relaxing for most persons and, although it serves hygienic needs, it is often individualized to a person's preferences in order to enhance the pleasurable experience. In contrast, the bathing process for elderly people suffering from dementia is often a traumatic experience for both the persons with dementia and their caregivers. Agitated behaviors are manifested more often during bathing than at other times. Factors influencing the experience of the bathing process and resulting in agitated behaviors can be categorized into four broad groups: the needs of the person with dementia, the needs of the caregiver, the physical environment in which bathing takes place and institutional factors. A number of approaches have been employed to treat agitated behaviors during bathing; however, a comprehensive approach addressing all of the above factors has not been developed. This paper presents preliminary findings on the effectiveness of the Treatment Routes for Exploring Agitation (TREA) approach for non-pharmacological interventions within a larger framework of human factors, addressing the needs of residents and staff members, environmental factors as well as human factors analysis to improve the process of bathing. A case study demonstrates the efficacy of this approach in reducing agitated behaviors during bathing.

Assessing risk for imminent violence in the elderly: the Brøset Violence Checklist

OBJECTIVE

The Brøset Violence Checklist (BVC) assesses confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects as either present or absent. It is hypothesised that an individual displaying two or more of these behaviours is more likely to be violent in the next twenty-four hour period. This study aims to test the validity of the instrument in geriatric settings and to report on the predictive value of an easy-to-use risk assessment instrument.

METHOD

Eight thousand eight hundred and thirty-five BVC observations were completed in two psychogeriatric wards (n = 42 patients) and two special care units for patients with dementia (n = 40 residents). To measure violent incidents the study group was monitored using the Staff Observation Aggression Scale-Revised (SOAS-R).

RESULTS

This study disclosed that patients in geriatric wards and residents in nursing homes who are aggressive have higher BVC scores than the non-violent subjects indicating that the BVC does predict violent episodes in these settings.

CONCLUSION

From a clinical perspective, it is most important that a prediction aid has good sensitivity, so that most cases are detected and have a high negative predictive value so that most non-cases on the measure are indeed non-cases. Our results indicate that the BVC was able to achieve this goal.

Relationship between assault frequency and length of hospitalization in older patients with dementia--determining the maximum benefit of inpatient treatment

In this quantitative study, the author examined the relationship between duration of hospitalization and frequency of assaultive behavior in 42 older long-term patients with dementia in a Canadian psychiatric hospital. The study instrument used for data collection was existing incident reporting forms routinely completed in Canadian regional psychiatric hospitals. A secondary analysis was conducted using data previously collected on a regular basis by the psychiatric hospital serving as the study site. A significant negative correlation was found between the number of assaults committed and the number of months spent in the hospital, with significantly fewer assaults occurring in the second year of hospitalization compared with the first year. Male patients were observed to be significantly more assaultive than female patients. Findings suggest that the maximum benefit for patients hospitalized for assaultive behavior is obtained during the first 2 years of inpatient treatment and that patients within this population who are no longer assaultive may be more appropriately cared for in nursing homes. Based on these findings, resources should be allocated to assist with the transition of formerly assaultive patients with dementia from a psychiatric hospital to a nursing home. This scenario forecasts the development of a challenging new role for nurses.

Aggressive behaviour on acute psychiatric wards: prevalence, severity and management

AIM

This paper reports a study to investigate the nature and prevalence of inpatient aggressive behaviour directed at staff and other patients and, in the case of patient self-harm, the methods used by nursing staff to manage this.

BACKGROUND

Aggressive behaviour poses a threat to the physical and psychological health of psychiatric nursing staff. The fear that results from working in a climate of potential danger can also have a damaging impact on patient care.

METHODS

Nursing staff on five acute inpatient wards in one hospital in the United Kingdom collected data on aggressive incidents using the Staff Observation Aggression Scale - Revised during a 10 month period from June 2001 to April 2002.

RESULTS

There were 254 incidents of aggression recorded. Staff were most commonly targeted and were involved in 57 x 1% of incidents. The most frequent provocation of the aggression was the patient being denied something such as leave from the ward (29 x 5% of incidents). The most frequent means used by patients was verbal aggression (60% of incidents), the most frequent outcome for the victim was feeling threatened (59% of incidents), and verbal interventions were used most frequently to manage the aggressive behaviour (43 x 7%). Despite many incidents involving verbal aggression in both staff- and patient-targeted aggression, 35 x 9% of incidents involving staff and 25% of incidents involving other patients resulted in seclusion.

CONCLUSION

It is estimated that in a 12 month period at the hospital in this study a nurse would have a one in 10 chance per year of receiving any kind of injury as a result of patient aggression. Despite the predominance of verbal over physical aggression, the fear generated from working in such an environment and a difficulty in understanding the causes of patient aggression may motivate staff to manage aggressive incidents with physical methods such as seclusion and restraint on a frequent basis.

Characteristics of aggression in a German psychiatric hospital and predictors of patients at risk

This study investigated the aggressive behaviour of all mentally ill patients within a whole psychiatric hospital with a catchment area of 325 000 inhabitants over a 1-year period (i) to assess the 1-year prevalence and characteristics of aggressive episodes and index inpatients, and (ii) to identify predictors of patients at risk by a multivariate approach. Staff Observation of Aggression Scale was used to assess aggressive behaviour. Characteristics of index inpatients were compared with those of non-index inpatients. Logistic regression analysis was applied to identify risk factors. A total of 171 out of 2210 admitted patients (7.7%) exhibited 441 aggressive incidents (1.7 incidents per bed per year). Logistic regression analyses revealed as major risk factors of aggression: diagnoses (organic brain syndromes OR = 3.6, schizophrenia OR = 2.9), poor psychosocial living conditions (OR = 2.2), and critical behaviour leading to involuntary admission (OR = 3.3). Predictors of aggressive behaviour can be useful to identify inpatients at risk. Nevertheless, additional situational determinants have to be recognized. Training for professionals should include preventive and de-escalating strategies to reduce the incidence of aggressive behaviour in psychiatric hospitals. The application of de-escalating interventions prior to admission might be effective in preventing aggressive behaviour during inpatient treatment especially for patients with severe mental disorders.

Violence from young women involuntarily admitted for severe drug abuse

OBJECTIVE

To simultaneously evaluate actuarial and dynamic predictors of severe in-patient violence among women involuntarily admitted for severe drug abuse.

METHOD

All patients admitted to special facilities for involuntary treatment of absconding-prone, previously violent, drug abusing women in Sweden were assessed with the Staff Observation Aggression Scale, revised. Actuarial data on risk factors for violence were collected and considered in an extended Cox proportional hazards model with multiple events and daily assessments of the Broset Violence Checklist as time-dependent covariates.

RESULTS

Low-grade violence and being influenced by illicit drugs were the best predictors of severe violence within 24 h. Significant differences in risk for violence between different institutions were also found.

CONCLUSION

In-patient violence risk is rapidly varying over time with being influenced by illicit drugs and exhibiting low-grade violence being significant dynamic predictors. Differences in violence between patients could not be explained by patient characteristics.

Challenging behaviour in the elderly-monitoring violent incidents

OBJECTIVE

To explore the frequency and nature of violent incidents in psychogeriatric wards and nursing homes in terms of type and severity of incidents, what provoked the incidents, and what kind of measure was needed to stop the aggression.

MATERIAL AND METHODS

Aggressive behaviour of the study group was monitored using the Staff Observation Aggression Scale-Revised (SOAS-R( in two Norwegian nursing homes and two geriatric psychiatric wards for a period of three months. Severity of incidents were monitored with the built-in severity scoring system in SOAS-R.

RESULTS

During the study period 32 out of the 82 patients were reported to be violent. The majority of the incidents were generated by a minority of the patients. Physical injury to the staff as a consequence of the aggression was extremely rare. Situations where the client was denied something were the most provocative ones and a substantial number of incidents occurred at bath/shower times. Talking to the patient was the most frequent measure used to stop the aggression, but more intrusive measures were also used.

CONCLUSIONS

A substantial proportion of the incidents were associated with personal care tasks, suggesting a crucial role for communication difficulties and a focus for staff training. We suggest that personal care situations should be added to the variable list in future research.

Managing disruptive behaviors with neuroleptics: treatment options for older adults in nursing homes

Disruptive behaviors are frequent among elderly individuals in long-term care centers. Neuroleptics remain the most common pharmacological treatment for controlling these challenging behavioral manifestations. However, their effectiveness is a subject of controversy and it is unclear what specific behaviors are more likely to be managed with neuroleptic medications. The objective of this study was to identify the types of disruptive behaviors for which neuroleptics are given to elderly individuals in long-term care facilities and determine if the frequency of these behaviors increases the risk of being prescribed neuroleptics. A cross-sectional study was conducted with 2,332 participants ages 65 or older living in 28 long-term care facilities. Among them, 27.8% had taken at least one neuroleptic drug in the prior week. The administration of neuroleptics was not linked to the presence of any one specific disruptive behavior. However, a significant finding was that the greater the frequency of disruptive behavior exhibited by an elderly individual, the greater the risk of them being administered a neuroleptic medication. A multi-dimensional approach to the assessment of disruptive behaviors is recommended to facilitate the identification of the underlying causes of those behaviors. Accordingly, it is suggested that non-pharmacological treatment plans be adapted to each situation and then implemented to potentially reduce the use of neuroleptics.

Is the reducing effect of the Staff Observation Aggression Scale owing to a learning effect? An explorative study

Is the reducing effect of the Staff Observation Aggression Scale owing to a learning effect? An explorative study Abstract This study explores the decline in the amount of reported aggression incidents when using the Staff Observation Aggression Scale (SOAS). Because this decline could hold significant implications for practice or research, the objective of this study was to explore the plausible explanations for this phenomenon. The influence of systematic feedback of the gained data was also studied. The SOAS was introduced on a closed ward in a psychiatric institution in the Netherlands as a measuring instrument to assess the amount of aggression incidents during a 16-week period. The standard procedure for reporting general incidents was continued. After 10 weeks of registration, systematic feedback of the gathered data took place. Statistic analysis was used to determine significant changes in the total amount as well as on the various forms of aggression. During this observation period, qualitative data were collected to support the analysis of the quantitative data. A significant decrease in the total amount of reported aggression incidents as well as in the categories of 'verbal aggression' and 'remaining aggression' was found. However, the category 'physical aggression' was stable during the entire observation period. The number of standard procedure reports did not decrease when compared with the pre-test period. Nursing staff did not recognize a reduction in the amount of aggression incidents. The role of a learning effect in the reduction of reports on aggression incidents is not excluded but there are indications that the reduction is also the result of 'reporting fatigue' and 'shifting attention'.

Fifteen years of research with the Staff Observation Aggression Scale: a review

OBJECTIVE

Research on the prevalence and causes of in-patient aggression has been hindered by the use of different methods for measuring aggression. Since Palmstierna and Wistedt presented the Staff Observation Aggression Scale (SOAS) in 1987, this data collection method has been used in various studies, which may make comparisons more useful.

METHOD

Studies with SOAS aggression data were compiled using MEDLINE, the Internet, and references from SOAS papers.

RESULTS

Reviews of studies on psychometric properties suggest fair to good inter-rater reliability and validity for SOAS assessments. The number of aggressive incidents per patient per year found on acute admissions wards (n = 38) considerably varied, with a range of 0.4-33.2 incidents (mean = 9.3).

CONCLUSION

Although the aggression data included in the present review were obtained in highly comparable ways, substantial differences in aggression rates between wards were still found. Some countries (e.g. the Netherlands) appear to have a relatively high incidence of aggression on acute wards.

Improvement in behavioral symptoms and advance of activity acrophase after short-term bright light treatment in severe dementia

Ten elderly subjects with severe dementia were given bright light (5000-8000 lux) for 45 min each morning for 4 weeks. Two rating scales of behavioral symptoms in dementia were used as outcome measures: Cohen-Mansfield Agitation Inventory (CMAI) and Behavior Pathology In Alzheimer's Disease Rating Scale (BEHAVE-AD), a scale for sleep-wake disturbances, and actigraphy to monitor activity rhythm. Behavioral symptoms improved with treatment. No changes in sleep-wake measures were found. There was an advance of the activity rhythm acrophase during treatment. These results suggest that short-time bright light improves behavioral symptoms and aspects of activity rhythm disturbances even in severely demented subjects.

Sodium valproate in the treatment of aggressive behavior in patients with dementia--a randomized placebo controlled clinical trial

OBJECTIVES

The efficacy and tolerability of sodium valproate 2 x 240 mg compared to placebo were investigated in aggressive behavior in dementia.

DESIGN

A randomized, placebo controlled, double-blind cross-over design. The trial included a baseline period (one week); a placebo period (three weeks); a wash-out period with placebo (one week); and a treatment period with sodium valproate (three weeks).

SETTING

A psychogeriatric short-stay ward at a psychiatric teaching hospital.

PARTICIPANTS

Demented patients who met Patel's criteria for aggressive behavior and had a score of > or =3 on at least one of the items of the Social Dysfunction and Aggression scale-9 (SDAS-9).

INTERVENTION

A fixed dose of sodium valproate 2 x 6 ml of a 40 mg/ml suspension (daily defined dose of 480 mg) was compared to placebo.

MEASUREMENTS

Primary outcome variables were changes of the score of SDAS-9 and Clinical Global Impression scale (CGI) performed at the last week of each treatment period.

RESULTS

Data of 42 patients (F=25 and M=17; age 80.4+/-6.8 years) were analyzed. Treatment with sodium valproate showed no differences compared to placebo on aggressive behavior. The mean plasma level of sodium valproate was 40.9+/-10.8 microg/ml. Regression analysis showed a trend for improvement between the plasma levels of sodium valproate and the SDAS-9 and the CGI scores. Adverse events were not related to the plasma levels of sodium valproate. Secondary outcome measurements showed significant improvement on restless, melancholic and anxious behavior; a trend for improvement was found on suspicious and dependent behavior. Possible limitations of this study are the low dose of sodium valproate, the relatively short treatment period (three weeks), and the absence of statistical corrections for multiple comparisons.

CONCLUSION

This study showed no effect of sodium valproate 2 x 240 mg over placebo on aggressive behavior in dementia.

Violence and its prediction at a psychiatric hospital

Aggressive behaviour in psychiatric inpatients was assessed before and after a training course for staff members. The Social Dysfunction Aggression Scale (SDAS) was used to report and assess aggressive behaviour over time, and the Staff Observation Aggression Scale (SOAS) to report and assess single aggressive incidents. In addition, the numbers of nursing staff members who were on sick leave because of injuries in the periods before and after the course were recorded and compared. No statistically significant reduction was found in the number of aggressive patients or in the number of staff members on sick leave. One interesting finding was a lower reporting on the SOAS of perceived aggressive incidents after the training course in comparison with the SDAS reports. Directed verbal aggressiveness and violence towards things were found to be predictors of violence.

Treatment of agitation and aggression in four demented patients using ECT

Electroconvulsive therapy (ECT) has been shown to be effective in treating the behavioral symptoms associated with psychiatric disorders in demented patients. Four case studies are presented that show its efficacy in treating behavioral symptoms in demented patients. We suggest that ECT is beneficial in these potentially life-threatening behavioral disturbances.

Recommendations for the management of behavioral and psychological symptoms of dementia

BACKGROUND

The behavioral and psychological symptoms of dementia (BPSD) are common, serious problems that impair the quality of life for both patient and caregiver. In order to provide recommendations based upon the best available evidence, a qualitative literature review was performed.

METHODS

A search of the English language medical literature published between 1966 and 2000 was performed. The quality of the studies was assessed by considering the subjects, trial design, analysis and results. Final recommendations were based upon the quality of available evidence.

RESULTS

The management of BPSD begins with a thorough assessment to search for underlying causes of behaviour change. Concomitant medical illness should be treated and sensory impairment ameliorated. Nonpharmacological approaches should be instituted prior to medication use. These interventions include music, light, changes in level of stimulation and specific behavioral techniques. Antipsychotics are the best studied pharmacological intervention for agitation and aggression and have demonstrated modest but consistent efficacy. Antidepressants such as trazodone and selective serotonin re-uptake inhibitors, as well as anticonvulsants such as carbamazepine and valproic acid have also demonstrated efficacy. Benzodiazepines can be used for short-term treatment as p.r.n. agents when necessary. Pharmacotherapy must be monitored closely for both effectiveness and side effects, with consideration of medication withdrawal when appropriate.

CONCLUSION

The management of BPSD can significantly improve the quality of life for the patient and caregiver. Their assessment and management are essential components of the treatment of dementia.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia

OBJECTIVE

i) To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians towards the recognition, assessment and management of dementing disorders; ii) to disseminate and evaluate the impact of these statements and guidelines built on these statements.

OPTIONS

Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral; management of complications (especially behaviour problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations, neuroimaging and referrals; appropriate use of cognitive enhancing agents.

EVIDENCE

Authors of each background paper were entrusted to: perform a literature search, discover additional relevant material including references cited in retrieved articles; consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based upon this evidence, consensus statements were developed by a group of experts, guided by a steering committee of eight individuals from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems.

VALUES

Recommendations have been developed with particular attention to the context of primary care and are intended to support family physicians in their ongoing assessment and care of patients with dementia.

BENEFITS, HARMS AND COSTS

Potential for improved clinical care of individuals with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations.

RECOMMENDATIONS

See text.

VALIDATION

Four other sets of consensus statements and/or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

Analysis of behavioral disturbances among community-dwelling elderly with Alzheimer disease

One hundred seven community-dwelling elderly patients with Alzheimer disease were enrolled in a study to evaluate the characteristics specific to the patients' and caregivers' situations that are associated with behavioral disturbances and to examine how these disturbances are related to caregiving stress. The frequencies of the disturbance were assessed by using the Troublesome Behavior Scale according to its three categories, agitation, hyperactivity, and miscellaneous. The patients' characteristics found to contribute most to their own behavioral disturbances were visual and speech function, activities of daily living, years of education, cognitive function, and sex, whereas the caregivers' characteristics contributing to these disturbances were duration of caregiving, age of caregiver, and relationship to the patient. In addition, a mutual relation among the three categories was found. Among the three categories, agitation was most strongly related to the caregivers' psychologic health status rated by use of the General Health Questionnaire. Behavioral disturbance as a whole was the only predictor of the patient's institutionalization within 2 years after baseline examination. Thus, behavioral disturbances were found to be influenced by the personal characteristics and situational circumstances of both the patient and caregiver, influencing, in turn, the caregivers' psychologic health status.

Is aggressive behaviour influenced by the use of a behaviour rating scale in patients in a psychogeriatric nursing home?

OBJECTIVE

To study the influence of the introduction of a behaviour rating scale on reported incidence and management of aggressive behaviours in patients in a psychogeriatric nursing home.

DESIGN

An 8-month prospective cohort intervention study.

SETTING

Two wards of a Dutch psychogeriatric nursing home with residents of 65 years and older.

PATIENTS

All residents of the two wards were included (N=75).

INTERVENTION

Social Dysfunction and Aggression Scale (SDAS) assessed at weekly intervals during 4 months after a 4 months' baseline period.

ASSESSMENTS

During 8 months at 2 months' interval the BOP (ie the validated Dutch version of the Stockton Geriatric Rating Scale); frequency of aggressive behaviour reported at daily nursing staff report; mean prescriptions of psychotropic and somatic drugs; number of days a patient was submitted to physically restrictive measures.

RESULTS

Eleven patients (N=11) did not complete the study; information on 64 patients was analysed. The frequency of aggressive behaviour reported by the nursing staff increased, while prescriptions of psychotropic drugs decreased. No alteration was found for BOP scores, mean prescriptions of somatic drugs and the use of physically restrictive measures.

CONCLUSIONS

The introduction of a behaviour rating scale does influence the reported incidence and management of aggressive behaviour. Prospective intervention studies should include a stabilization phase for measurements prior to any planned trial.

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.

The Extended Staff Observation Aggression Scale (SOAS-E): development, presentation and evaluation

The Staff Observation Aggression Scale (SOAS) was developed as a scale for reporting aggressive incidents involving psychiatric in-patients. The SOAS -- Extended Version (SOAS-E) has the same aim, but has additional categories and subcategories. The SOAS-E clearly distinguishes between violent and non-violent aggressive behaviour and characterizes in more detail the associated situation. However, the main contribution of the SOAS-E is the introduction of a category of 'warning signals' that precede the releasing 'provocation factor' as a separate and primary aspect of the cyclus of aggressive incidents. The development of the SOAS-E is described, and the testing and inter-rater reliability of the warning signals category are examined. Compared to the SOAS, the additional categories of the SOAS-E are found to increase the scope for a detailed characterization of aggressive behaviour in psychiatric wards.

Treatment of agitation in dementia

Agitation occurs commonly in patients with dementia. Before symptomatic pharmacotherapy is undertaken, it is imperative to perform a sequence of evaluations and interventions to establish whether simpler and safer, nonpharmacologic approaches will be beneficial. When psychotropic medications are used they should be used judiciously, in the lowest effective doses and for the shortest period of time necessary. Ineffective medications should be stopped, and even effective medications should be empirically tapered in most patients to learn whether treatment is still necessary. Antipsychotics probably show the greatest benefit for agitation associated with psychotic features; they have less demonstrated efficacy for agitation not associated with psychotic features. The side effects of typical agents are legion; data are pending regarding atypical agents. The available evidence regarding nonneuroleptic medications ranges from case reports to well-designed, double-blind, placebo-controlled, randomized, parallel group studies. Literature exists describing the use of anticonvulsants, anxiolytics, serotonergic antidepressants, and other agents to manage agitation. Carbamazepine and divalproex sodium (valproate) have demonstrated efficacy in uncontrolled studies, whereas the use of carbamazepine has produced negative results in one small controlled study and positive results in two larger controlled studies. Buspirone has shown benefit in some open trials. Encouraging early findings have been reported for trazodone, including from one controlled trial. Varying results have been obtained using selective serotonin reuptake inhibitors, but with consistently encouraging anecdotes. In the aggregate, the evidence suggests but does not prove that alternatives to traditional antipsychotics exist. Again, none of these agents has yet been approved for this purpose by the FDA. As more studies become available we will have a better idea about which classes of agents are most efficacious. It is likely that there may be a role for "rational" polypharmacy in the management of this distressing complication of dementia. However, no studies that we know of address combination therapy, so the clinician must contemplate this option on a case-by-case basis. Clinical trials data are pending from studies with divalproex sodium, carbamazepine, haloperidol versus trazodone versus placebo, risperidone, olanzapine, quetiapine, donepezil, xanomeline, tacrine, buspirone, and sertraline, at the very least. These data will undoubtedly have a major impact on how we care for our patients and lead to revisions of current practice guidelines.

Physical aggressive resident behavior during hygienic care

Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Act (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was identified as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.

Pharmacotherapy of aggressive behavior

OBJECTIVE

To review the definition, clinical characteristics, prevalence, etiology, neurochemistry, and pharmacologic treatment of aggressive behavior, and provide recommendations regarding the use of specific pharmacologic agents for treating aggressive behavior.

DATA SOURCES

Data from the scientific literature were analyzed, interpreted, and summarized. An English-language MEDLINE search yielded clinical trials, case reports, letters, and review articles addressing the etiology and pharmacotherapy of aggression.

STUDY SELECTION

Because few well-controlled studies are available in aggression research, all literature addressing the pharmacologic treatment of aggressive behavior, as well as the neurochemistry and psychobiology of aggressive behavior, was reviewed.

DATA EXTRACTION

The literature was reviewed on the basis of the particular pharmacotherapy and the specific population used. A separate review of the treatment of aggressive behavior in the elderly was included.

DATA SYNTHESIS

The literature was assessed for applicability to clinical practice and usefulness to the general clinician. Recommendations were made from the primary literature in conjunction with trends in clinical practice. Pharmacotherapy is a primary mainstay of treatment for aggressive patients. In individuals for whom behavioral intervention alone is unsuccessful, drug therapy should be initiated along with continued nonpharmacologic intervention. Short-acting benzodiazepines and high-potency antipsychotic agents are effective in treating acute aggression on a short-term or as needed basis. Agents such as lithium, beta adrenergic blockers, carbamazepine, valproic acid, buspirone, trazodone, serotonin reuptake inhibitors, and clozapine may be useful in the chronic management of aggressive behavior. Every attempt should be made to streamline drug therapy in patients with chronic aggression and comorbid psychiatric disorders.

CONCLUSIONS

On the basis of available research and extensive clinical experience, lithium or propranolol should be considered as first-line antiaggressive agents in patients without comorbid psychiatric disorders. A minimum trial period for assessing drug efficacy should last at least 6-8 weeks at maximum tolerated dosages. Patients responding to pharmacotherapy should be reevaluated every 3-6 months, and periodic medication tapers and/or drug-free periods should be attempted.

Clinical research in aggressive patients, pitfalls in study design and measurement of aggression

1. Experience from scale validation studies and from controlled drug trials provided clues for optimalisation of studies in aggressive patients. 2. Definitions of target behaviour, selection of patients and measurement of aggression are reviewed and recommendations are presented.

Neuroleptic treatment of agitation and psychosis in dementia

Neuroleptics remain the mainstay for the treatment of behavioral disturbance and psychotic symptoms in demented patients. The limited available data suggest that low-dose neuroleptics are significantly more efficacious than placebo, though the magnitude of the effect is moderate in most published studies. Demented patients are particularly prone to neuroleptic side effects, and individualized dose titration may be necessary to achieve the optimal trade-off between efficacy and side effects. Target behavioral symptoms and side effects, including effects on cognition and activities of daily life, should be identified and assessed serially during neuroleptic treatment. The choice of neuroleptic depends more on likely side effects than differential efficacy, and non-response or intolerable side effects should lead to dose adjustment or a switch to an alternative class of neuroleptic (or an alternative type of medication). Further studies of optimal neuroleptic dosage, the optimal duration of continuation neuroleptic treatment, and placebo-controlled studies comparing neuroleptics to other classes of medications are needed.

Behavioral symptoms in dementia: an update

A descriptive literature review was done to identify research conducted in both community and institutional settings and published from 1986 to 1993 on the correlates of behavioral symptoms associated with dementia. Critical appraisal and synthesis of the 40 studies revealed theoretical and methodological problems that tempered conclusions about the relationships between behavioral symptoms and the correlates under study. While direct relationships were found in studies in which relationships between behavioral symptoms and cognitive impairment and contextual factors were examined, contradictory results were found in studies of demographic and functional variables. Recommendations for research-based practice are advanced, including the development and testing of alternatives to physical and chemical restraints in the care of persons with dementia.

Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment

Relaxing music was hypothesized to buffer the general noise level typically found in dining rooms of nursing homes, exert a calming effect, and thus reduce agitated behaviors among residents with severe cognitive impairment. Twenty-nine nursing home residents with severe cognitive deficits participated in a 4-week protocol in which, following baseline observations (week 1), relaxing music was introduced (week 2), removed (week 3), and reintroduced (week 4). Subjects were observed in terms of total number of behaviors of the Cohen-Mansfield Agitation Inventory present during a given week, and the number of behaviors present on the subscales of aggressive, physically nonaggressive, verbally agitated, and hiding/hoarding behaviors. Significant reductions were observed on the cumulative incidence of total agitated behaviors (63.4%); as well as the cumulative incidence of physically nonaggressive behaviors (56.3%) and verbally agitated behaviors (74.5%). No significant reductions were noted in terms of aggressive behaviors and hiding/hoarding behaviors. Where significant reductions were achieved, a distinct pattern was observed. Agitation decreased during week 2, increased again during week 3, only to decrease again in week 4. In addition, variance effects were noted as well, as ranges and standard deviations of agitated behaviors narrowed over time. These findings are interpreted within Hall and Buckwalter's (1988) model of a progressively lowered stress threshold among dementia patients.

Homicide and attempted homicide by patients suffering from dementia: two case reports

Two elderly patients suffering from a dementing illness are described. The patients manifested homicidal behaviour in association with dementia. Possible risk factors for such behaviour are explored. Implications arising from the cases are discussed.

A descriptive study of physically aggressive behavior in dementia by direct observation

OBJECTIVE

To study, by direct observation, physically aggressive behavior (PAB) in a cohort of older persons with dementia.

DESIGN

Cross-sectional survey.

SETTING

A locked special care unit for Alzheimer's Disease and an ordinary skilled unit of two suburban nursing homes.

PARTICIPANTS

Twenty men and women with a history of PAB.

MEASUREMENTS AND MAIN RESULTS

Portable bar-code-readers and daily diaries were used to determine the frequency of PAB as well as to elucidate the antecedents and consequences of it. PAB was most often directed toward staff (23/28 episodes), usually in the context of personal care (15/23 episodes). In the majority of cases, verbal aggression or non-compliance preceded the PAB. Most often PAB was followed by a rapid return to non-aggressive behavior.

CONCLUSIONS

Very little PAB was truly spontaneous, nor was it usually the participant's normal behavior. Most PAB occurred in response to intrusion into the participant's personal space by staff or other residents. The PAB is better understood as a defensive response than an expression of anger.

Aggressive behaviour among patients referred to a psychogeriatric service

The characteristics of a series of patients referred to a psychogeriatric service over a one-year period were examined. Patients exhibiting aggressive behaviour as a feature of the presentation were compared to those without. Aggressive patients were less likely to be living in their own homes, less likely to receive services, more likely to be referred from social services institutions, and be on multiple psychotropic drugs, particularly neuroleptics. The implication of this for adequate provision of psychiatric and social service is discussed. Only a small number of patients exhibited aggressive behaviour as a feature of their presentation.

Influences of prolonged bed rest and cognitive impairment on nursing home residents

Seventy nursing home residents with and 87 without cerebrovascular diseases (CVD) were examined by the modified Stockton Geriatric Rating Scale (modified SGRS) which measures four aspects of impairments; physical disability, socially irritating behavior, communication failure and apathy. They were divided into 3 subgroups according to walking ability; prolonged bed rest, walking with aids and walking by themselves in both groups. Physical disability of mental decline was significantly aggravated more than that of normal intelligence in all the subgroups. Although communication failure and apathy of mental decline had deteriorated more than those of normal intelligence in prolonged bed rest in residents without CVD, apathy of the former had deteriorated more than that of the latter in walking by themselves in residents with CVD.

Disruptive behaviors of a cognitively impaired nursing home resident

The descriptive case study of a 71-year-old man with Primary Degenerative Alzheimer's Dementia identifies and describes specific disruptive behaviors exhibited by a demented, disruptive nursing home resident and the biopsychosocial characteristics of these behaviors. The Disruptive Behavior Scale (Beck, Baldwin, Heithoff, & Cuffel, 1990) measured disruptive behaviors. Data collected included chart review, interviews, testing, and observation. The majority of observed disruptive behaviors fell under four categories: (1) walks aimlessly, (2) makes repetitive noises, (3) uses obscene/profane language, and (4) makes repetitive movements. Staff members and chart notes reported the same categories, except for "makes repetitive noises." All aggressive behavior toward the staff occurred during assistance with activities of daily living (ADLs).

The Present Behavioural Examination (PBE): the development of an interview to measure current behavioural abnormalities

Behavioural problems are an important feature of dementia and other neuropsychiatric conditions. This paper describes the development and performance of an investigator-based interview (the PBE) for the detailed assessment of the behaviour of subjects over the preceding four weeks. The interview is designed to be administered to carers. A test-retest reliability study was carried out on the penultimate edition of this interview; and the inter-rater reliability of the final edition was measured. These studies show that the reliability of the PBE is comparable with that of other investigator-based interviews.

Aggressive behaviour in elderly psychiatric inpatients

We describe the types of aggressive behaviour and determine their prevalence in a sample of hospitalized elderly psychiatric patients. Data were obtained by nurse ratings of aggressive behaviour using the recently developed Rating Scale for Aggressive Behaviour in the Elderly; 90 patients were rated over a 3-d period. Nearly half the sample were at least mildly aggressive; the frequencies of some specific types of aggressive behaviour were high. In contrast, the frequency of injuries and the use of restraints and medication for aggressive behaviour were low. Some correlates of the aggressive behaviour were also analysed.

A rating scale for aggressive behaviour in the elderly--the RAGE

A 21-item rating scale for measuring aggressive behaviour in psychogeriatric in-patients is described. This scale is designed to be completed by ward staff. It should prove valuable in treatment studies and in studies which aim to investigate the correlates of aggressive behaviour. Studies using the scale demonstrate that when used in conjunction with a ward check list the scale has high reliability and validity.

Correlates of disruptive behavior in cognitively impaired elderly nursing home residents

Disruptive behavior, resulting in negative consequences for both residents and caregivers, occurs in a large proportion of the nursing home population. This review of literature surveys studies that describe disruptive behavior and the correlates of this behavior in the cognitively impaired elderly. In the studies reviewed, the average prevalence of reported disruptive behavior among a total of 5,650 subjects was 42.8%. Correlates most frequently linked with disruptive behavior include cognitive status, functional ability, age, and premorbid personality. Suggestions for future research are discussed.

Violence among psychiatric inpatients

A considerable body of evidence suggests increasing levels of violence among psychiatric inpatients. The literature on the subject is reviewed, highlighting correlates of violence among psychiatric patients and methodological flaws in the published literature. Improvement in the definition of violence and the methodology as well as future areas of research are discussed.

Psychiatric symptoms and age dependency

The growing populations of the elderly is frequently regarded as a homogeneous entity. In this retrospective study 140 patients above 60 years, first admitted to a psychiatric hospital, were screened for individual psychiatric symptoms. This was done according to the D.S.M.-III-R criteria and with the european ADMP-IV scoring system. As expected dementia and related disorders are characteristic of the "older" categories, depressieve disorders were seen more frequently in the "younger" categories. Screening the elderly for psychiatric symptoms also shows differentiation within the group of the older patients. Symptoms related to dementia increase in frequency, also increasing are e.g. visual hallucinations. A decrease was found for hypochondriasis and phobia. So, the group patients above 60 years is clearly heterogeneous.

Mental and physical capacity and consumption of neuroleptic drugs in residents of homes for aged people

The mental and physical capacity of all residents in homes for aged people were estimated, and their neuroleptic drug consumption and duration of stay were registered. One third was moderately to severely mentally impaired and 38% demanded more extensive nursing care. Physical dependence was significantly associated with mental decline, and less with age. One quarter of severely mentally impaired people had stayed for less than one year; 23% of the residents received neuroleptic drugs. Treatment was more common in physically incapacitated people together with wandering and aggressive ones. Lack of psychogeriatric services may enhance the use of neuroleptic drugs in homes for aged people.