Defusing Violent and Aggressive Behavior in the Long-Term Care Setting

As the century draws to a close, society's awareness of the potential for violence has been heightened by what seem like almost daily reports of senseless murder and unprovoked damage or destruction of persons or property. Terms like homicide, battery, assault, and physical abuse, which formerly cropped up primarily in the vocabularies of law enforcement officers and in court transcripts, have become elements of our everyday speech. A growing number of lectures, seminars, and articles for the lay person address violence in our inner cities and in the work place.

The long-term care setting provides no exception to this trend; violence and aggression pose increasingly serious threats to residents, staff, property, and the overall caliber of care in nursing facilities. A deeper understanding of the possible causes and potential effects of patient-to-staff or patient-to-patient aggression and violence is a crucial first step in designing prevention and appropriate treatment plans to protect staff and property and improve levels of care for residents.

A Problem for All Settings

Traditionally, descriptions of violent or aggressive patients have been associated with the psychiatric milieu. However, management of patients who have dyscontrol and impulse control problems is a growing concern in the extended and acute medical care environments as well. In addition to the changing demographics in many nursing facilities-which now provide care for a variety of populations, including younger patients who need subacute care and patients in the later stages of AIDS-facility staff face problems with older residents, who tend to be sicker and to have more complicating factors.¹ Unfortunately, whenever factors are added that complicate either the environment or an individual patient's condition, the potential for aggression increases.

Tangible definitions of violence and aggression are difficult to provide due to interpretive and descriptive differences among clinicians. Generally, clinicians tend to define aggression as any behavior that may lead to destruction of a target entity.² Others indicate that it is a maladaptive, defensive behavioral response to real or perceived provocation that becomes troublesome when its intensity, duration, or frequency outweigh its legitimate adaptive role.³

Violence is usually defined as destructive aggression inflicting physical damage on persons or property; escalating aggression frequently leads to violence.² While aggression and violence are usually easy to spot in the clinical setting, instinct often prompts caretakers to turn away, flee, or ignore the problem rather than confront, address, and treat it. It is important to realize that violence and aggression, when viewed as symptoms rather than diseases, can be dealt with effectively, and must be confronted.

Environmental and Biological Factors

As with any symptom, identification of possible underlying causes is the first step in a good assessment program.^2,4,5 This requires caregivers to record the patient's pattern of dyscontrol or aggressive behavior and to explore possible relationships with environmental (sometimes called event-related) or biological (non-event-related) factors.^4,5

Environmentally precipitated episodes of dyscontrol are different from those that are biological in five ways:

• They usually occur in individuals with no history of central nervous system damage or dysfunction.
• They are somewhat predictable if the trigger event is considered.
• They are characterized by an element of control and understanding on the part of the patient.
• They escalate and diffuse in a relatively constant fashion.
• They are not usually associated with extreme remorse.

This type of aggression often responds to behavioral interventions alone, and while short-term or p.r.n. medication can help, prolonged drug treatment is rarely required.⁵

Biologically-based violence and aggression may be associated with neurological impairment; can be provoked by unusual, unreasonable, or no stimuli; are usually precipitous in nature, escalating and de-escalating with remarkable speed; are explosive and lack any element of control; and typically are followed by periods of genuine, profound remorse, since the patient rarely understands the cause.

A number of rating instruments are available to assess violent and aggressive behavior.⁵ Table 1 lists several conditions which may cause aggression and violence.^1,4-6

Table 1. Condition That May Cause or Contribute to Aggression or Violence

Medical Conditions (Non-CNS)	Possible Effect	CNS Condition
Chronic Obstructive Pulmonary Disease	May increase anxiety and agitation	Brain tumor or disease
Stroke	If demand exceed abilities, catastrophic reaction may occur	Seizure disorder or EEG abnormality
Dementia	Verbal or environmental cue may be misunderstood	CNS Infection
Polypharmacy	Synergistic side effects, drug interactions, or idiosyncratic reactions my occur	Substance abuse or alcoholism (current or previous)
Urinary Tract Infection	Confusion, disorientation, or increased agitation may occur	Traumatic brain injury psychoses
Pain	Impaired reasoning or lower frustration threshold common	Depression

An Integrated Approach to a Complex Problem

Though the previous discussion may lead the reader to an oversimplified view of aggression and violence, patients rarely fall clearly into one category or the other. In fact, individuals will usually be affected by both environmental and biological factors if dyscontrol is an issue.

For this reason, use of behavioral interventions or medication alone is rarely effective; an integrated approach is essential.

Traditionally, seclusion, restraint, and ongoing use of p.r.n. psychotropic medication were considered appropriate actions to take when dealing with an agitated patient or one whose aggression or violence was escalating. As our understanding has improved, however, we have learned that these approaches are not necessarily the best way to begin.^1,8

Certifying and accrediting bodies, for instance, have been quick to include criteria in their review processes that discourage unnecessary physical or chemical restraints. And research has revealed that patients-especially older patients-who perceive their needs are being taken seriously and are being appropriately addressed display an increased ability to function.⁴ For these and many other reasons, it is essential to assess and treat any underlying medical problem that may be contributing to aggressive or violent behavior (Table 1), especially if there is an element of pain involved.

Prevention is the First Step

In the psychiatric setting, prevention is emphasized as the first step; this principle should also be applied in the long-term care setting. Staff should be trained to recognize warning signs in those patients who are prone to aggression; anticipation and training improve caretaker ability to intervene successfully, decrease patient agitation, and keep the patient in the least restrictive environment.^1,8

When violence and aggression initially become a problem, judicious use of p.r.n. medication is a wise choice. In most instances, an oral or injectable benzodiazepine (usually lorazepam) will work quickly to calm the patient or resident and protect patient, staff, and visitors from harm.^2,5 The adage, "A stitch in time saves nine," applies here: benzodiazepines work best if employed early.^1,2

Used in this manner, benzodiazepines are safe and effective; however, long-term use of benzodiazepines may lead to disinhibition and an increase in the very symptoms being treated.^5,7,9

Failure to act quickly and contain an incident can contribute to group contagion; increasing noise and eroded therapeutic structure almost invariably lead to general agitation and resulting unrest.⁸ Anyone who has ever observed a group of children at play transform itself into a quarreling, angry mob will understand the theory of group contagion. For example, studies have shown that incidents of aggression and violence increase at mealtimes when patients come together.¹

Other factors that may contribute to aggressive or violent behavior include new or inappropriate admissions, high patient acuity, poor patient mix, unresolved familial issues, long-standing patterns of poor interaction with family or peers, or fatigued or overwhelmed staff members.^1,8 Concurrent use of simple but effective behavioral interventions can calm a milieu that appears to be escalating toward violence.

Nursing facility staff should be trained to recognize increasing tension and signs of imminent trouble; behavioral interventions should be quick, decisive, and executed with confidence. Calm, calculated verbal intervention is often the key to prompt resolution.⁸ Table 2 lists initial behavioral modification techniques to increase structure and maintain control when a patient or group begins to exhibit signs of escalation.^1-3,7,8

TABLE 2. Behavior Modification Techniques to Help Maintain Control

• Remain calm and quiet
• Increase staff presence
• Regulate interaction patterns
• Separate hostile parties
• Divide large groups into smaller, more manageable groups
• Minimize environmental stimuli
• Reduce noise
• Dim bright lights
• Modify daily life situations
• Redirect all efforts toward controlling the situation; ignore non-essential tasks
• Isolate offenders with time-out prior to seclusion
• Limit choices and create environmental cues
• Allow the most effective staff members to take the lead

If underlying biological causes are identified, treatment is essential and medication will probably be involved. However, a single etiology may not be responsible for the patient's symptoms of aggression.^5,7 Table 3 describes drugs that have been used with varying degrees of success. In some cases, treatment of the underlying condition will completely resolve the patient's control problems. For example, if the aggression is related to a seizure disorder or organic brain disorder, appropriate use of anticonvulsants can provide a measure of control.

TABLE 3. Agents Used to Treat Aggression

Agent	Indications	Dosing	Special Considerations
Anticonvulsants Carbamazepine Divalproic acid Valproic acid	Aggression related to seizure or organic brain disorders	Standard doses to maintain appropriate serum levels	Incidence of rash may be higher in the elderly Blood dysckasias are possible; monitor
Antidepressants	Aggression related to depression	Dose to maintain appropriate serum levels or standard dose	TCAs can be cardiotoxic; therapeutic serum levels have been established. Lower doses may be needed in elderly.
Atypical Neuroleptics	Aggression refractory to other agents	Standard doses	Orthostatic hypotension is possible. Weight gain and sedation sometimes a problem.
Benzodiazepines or sedatives	Acute episodes of aggression or violence	Standard doses	Paradoxical rage has been reported with long term use; may cause aggression over time.
Beta blockers	Chronic aggression related to organic brain disease or traumatic brain injury	Up to 800 mg per day in divided doses	Response may not be evident for up to six weeks. Risk of tardive dyskinesia exists with chronic use.
Buspirone or trazadone	Agitation associated with dementia	Standard doses	Orthostatic hypotension may increase falls in the elderly. Therapeutic effect may take weeks.
Lithium	Aggression related to mania or mood stabilization problems Aggression associated with mental retardation	Standard doses	Fluid balance and periodic serum level monitoring essential. May cause confusion or ataxia in the elderly. Elderly may be intolerant of side effects.
Neuroleptics	Aggression related to psychoses or requiring sedation	According to manufacturers' labeling	Risk of tardive dyskinesia with prolonged use Orthostatic hypotension is possible.
Serotonin Reuptake Inhibitors	Agitation related to dementia	According to labeling; lower doses may be needed in elderly	May increase agitation in some patients; administer early in the day to avoid insomnia.

In cases where no causal factor can be identified and the behavior continues, the agents identified in Table 3 can be tried sequentially, provided that an adequate trial period is employed before switching to another agent. Beta-blockers and antidepressants in particular require fairly lengthy trials of six weeks or more.^5-7,9

The basic tenets of prescribing must be followed:

• If a medication is effective, it should be used in the lowest dose possible.
• After a reasonable period of maintenance, tapering should be tried.
• Any medication that is either ineffective or loses its efficacy should be discontinued. Efficacy should be measured against quantifiable, predetermined improvements in target symptoms.
• Trials should be conducted systematically.
• Whenever possible, maximum doses of single agents are preferable to lower doses of multiple agents.^2,10

Additional Techniques

Once long-term therapy is deemed necessary, other behavioral modification techniques should be implemented to help the patient cope and retain control. The most common of these are token economies, aggression replacement, and decelerative techniques.

Token economies establish rules that clearly explain how tokens can be earned, and how they can be spent. Patients earn tokens when identified behaviors improve, and can exchange them for an item or privilege. Some programs fine patients if they engage in undesired conduct by taking a predetermined number of tokens away.⁵

Aggression replacement encourages patients to develop other mechanisms to cope with frustration, anger, or impulse. Positive reinforcement is an essential element in this type of program. Assertiveness training can help those patients who have difficulty expressing their needs in a positive way. They learn more effective communication techniques, and in successful cases, polite and concise requests replace demanding, inappropriate communication. When patients' behaviors are mapped, warning signs indicating escalating lack of control become familiar. Increased environmental structure, including participation in sports, reading, music, or other activities, can replace negative behaviors.^5,8

Decelerative techniques augment other interventions, but are the last used because of their punitive nature. Social extinction in its mildest form involves withdrawal of attention. In children, caregivers generally call this type of intervention a "time-out." It works well in older patients as well. If a brief time-out doesn't help, isolation or seclusion may be necessary. Some programs include the patient in this type of intervention by asking the individual to enter time out voluntarily and determine when he or she is ready to return to the group or activity. Making the patient a part of the process decreases the punitive sting and helps the patient understand the problem better. Physical restraints should only be used as a last resort. Decelerative techniques must be used if the patient is assaultive or dangerous to self or others.^1,5,8

Facilities can benefit by creating decision trees that are tailored to their resident characteristics. The best decision trees address medical, behavioral, and psychopharmacological considerations and should be used as a multidisciplinary training device to encourage prevention and safety. Figure 1 is a proposed decision tree for a long-term care facility. It is based on several decision trees that appear in our references, and assumes that an integrated approach is both desired and possible.^4,5

When long-term care facility staff maintain a calm, therapeutic unit environment, coupled with appropriate behavioral interventions and judicious use of medications, incidents of aggression and violence can be substantially decreased. This is surely a positive outcome, not only for the residents of the facility, but for staff and family members as well.

10. Brizer, D. Psychopharmacology and the management of violent patients. Psychiatr Clin North Am 988;11(4):551-69.

Jeannette Wick, RPh, MBA, is the Chief, Pharmacy Services, at the District of Columbia's Commission on Mental Health Services. Cecilia Reid, MS.Ed, RN, CNA, is Chief, Quality Assessment Branch at the District of Columbia's Commission on Mental Health Services.

Copyright © 1997, American Society of Consultant Pharmacists, Inc. All rights reserved.