It’s been estimated that between 50% to 80% of residents living in skilled nursing homes around the country have some form of dementia, mainly Alzheimer’s disease. It is also well known that these disorders are associated with gradual loss of control and a tendency towards aggressive and combative behaviors. While it is not the fault of any older adult and is truly the disease process, staff must know their residents, be aware of triggers, and know how to patiently and lovingly respond.
What Causes Aggression? 5 Possible Causes
Inability to Verbally Communicate
Beginning with a person-centered framework, we see aggressive behaviors as a mechanism of communication in an attempt to share one’s needs, wants, or desires when this cannot be verbally articulated to the caregiver. It must be very frustrating to be unable to speak words directly to the other party when something is needed, like water, food, the bathroom, or safety.
Underlying Medical Conditions
Underlying physical or medical conditions may also be the root cause of aggressive behaviors. This is where good nursing assistants, who spend the majority of their day with residents, can be on the lookout for any physical, mental or cognitive changes that may be indicative of a new medical problem. A simple urinary tract infection or UTI, for example, can cause an already cognitively-impaired senior to strike out or yell at their caregiver.
Emotional and Psychological Issues
As one ages with most forms of dementia, the risk of paranoid ideation, confusion, hallucinations and delusions increase and are likely to occur at some point. Some older adults may be afraid of their caregiver for no good reason and resist care or become combative. It’s well known that depression is highly associated with dementia and the combination of the two can lead to lots of aggressive reactions.
Social and Relationship Problems
Sometimes, no matter how good the nursing assistant is, the resident simply does not like him or her, and resists care or treatment. The resident may also have personal problems with their own family members and become aggressive during visits. One very common problem in many nursing homes is when two residents who share a room do not get along. This can be fertile ground for aggression.
Physical Environment and Organizational Issues
Some nursing homes are warm and positive places where residents feel safe, comfortable and loved. Others may be more sterile, institutional and cold. Older adults with dementia may be particularly vulnerable to the effects of their immediate environment and respond in kind. In terms of the organization, staffing levels, policies and procedures, and staff training can all be associated with how residents react and behave.
Effectively Responding to Aggressive Behaviors
Behavioral Assessment
First and foremost, a behavioral assessment should be performed to identify any medical, psychological and cognitive conditions that may have been missed with the initial assessment at admission. The assessment may also identify specific behaviors as well as any known triggers.
Care Plan & Interventions
The behavioral assessment then guides the resident care plan and specific interventions that may reduce or eliminate the behaviors. It’s important to continually document behaviors, interventions and outcomes based on this plan. Make sure the staff know the plan and interventions and share this information with family members.
Continuing Education and Training
Information from assessments and resident care plans identifying potentially effective interventions are useless unless the direct care staff know the information contained within them. Staff should be well-trained on dementia and related behaviors, person-centered approaches, medical conditions that may underlie aggression, how to respond to and document each episode of aggression.
Compassion & Empathy
Having a plan and training are necessities in effectively intervening aggressive behaviors and a caregiver who understands the disease process but values the person is important, too. It takes a special person to work effectively with cognitively-impaired seniors with aggressive tendencies. Getting to know the resident, awareness of triggers and a kind approach can go a long way in reducing or eliminating aggressive behaviors.
Prevention is the Best Medicine
It’s been said thousands of times, but this is so true when working with seniors with aggressive behaviors. Prevention means to minimize or stop behaviors from occurring in the first place. This makes the lives of both residents and staff much better. Prevention involves being keenly aware of the environment, the resident’s mood and any potential triggers that can be avoided.
De-Escalation May be Necessary
In a perfect world, assessment, the care plan, and well-trained and loving employees would reduce or eliminate aggression, but it’s far from a perfect world. Therefore, de-escalation techniques will be necessary at times. De-escalation doesn’t need to be dramatic or scary. It can be successfully accomplished in a few steps, like the following:
- Keep your cool and manage your emotions, body language and responses.
- Stay around an arm length away from the resident if he or she is ready to strike out.
- Stay in front of the resident so he or she can clearly see you.
- Speak calmly, clearly, and purposely.
- Stay relaxed and try to redirect the resident’s attention to something more positive or light-hearted, like offering them something to drink.
- If aggression continues, make sure other residents in the area are safe from harm. Remove any objects that could easily be used as weapons.
- Get help from a team member but be sure not to seem forceful to the resident.
Evaluation and Debriefing
The final steps involve evaluating if your interventions and approaches were effective or not and to document everything about the episode. Staff may want to share their feelings with a supervisor if the episode was distressing or traumatic.
Final Thoughts on Aggressive Behaviors
Aggressive behaviors and many other types are a normal part of the nursing home experience at one point or another. Considering that a majority of residents have some type of dementia, it’s almost a guarantee. That’s why it’s necessary for staff know about these behaviors, understand dementia and know how to respond in therapeutically appropriate ways. Prevention is wonderful but not always possible, so staff should also be well-trained in de-escalation techniques. This knowledge will better ensure quality of life for the resident and less stress for the staff.