Loxapine

I'm an RN in a long term care facility. I would like advice on how to manage aggressive behavior in one of our male residents who has vascular dementia. Specifically, he hits and grabs during morning and evening care. Staff members are fearful, as a few have been injured. Although this resident receives Ativan and Loxapine routinely to control his behavior, he continues to be aggressive and he can be unpredictable.

Aggressive behavior is often associated with some form of moderate dementia. Due to cognitive impairment, the resident tends to misinterpret, misidentify and be confused, especially by intimate caregiving. Usually, the aggression is a method of gaining control and a "fight or flight" stress response leading to resistance (Potts, Richie, & Kaas, 1996) and reactance (Meddaugh, 1990). Understanding the underlying meaning of the behavior and its causes is critical, but we also need to be creative and skillful in the way we provide care (Feldt & Ryden, 1992).

Pull your care team together and take on a detective method of problem solving. Look closely at resident, staff and environmental factors contributing to the behavior (Banazak, 1996).

Resident Factors

What is the specific behavior of the resident? When does it occur? What may be some reversible causes for the aggression? (Beck, Baldwin, Modlin, & Lewis, 1990)

Initially, meet with staff to hear their reports of the aggressive incidents, giving time for ventilation and sharing of best approaches.

During these meetings, introduce the ABC Behavior Observation sheet (Teri, 1990). Collect data for three to seven days. To encourage staff to use these flow sheets, be sure they understand how you will use the information.

Review the chart for medical diagnoses, including the type of dementia, social history, medications and incident reports. A screen for delirium should be included since acute confusion can lead to aggressive behavior. Some possible physical and psychiatric causes of delirium are infection, pain, dehydration, and sedation as a result of medication side-effects or depression.

Consider whether involving the family would be helpful. Sometimes families are very concerned if they realize their family member has become aggressive toward staff, especially if there is no past history. Family members may offer useful approaches for dealing with the behavior or have personal information that helps explain the behavior (e.g., dad was always very private and independent).

Staff Factors

Because the RN does not usually provide the morning or evening care, it is important to go to the bedside and experience the situation first-hand (Chou, Kaas, & Richie, 1996). Care attendants might be suspicious of the RN coming to the bedside with them, thinking they are going to find fault with the caregiving. Explain that you are there to understand what happens and pick up their best tips. You can assist with care, but your main objective is to observe for triggers and responses. Following the observation, review the best approaches and point out any safety issues the care attendant may have missed (e.g., if the resident has a very strong neurological grab, staff must avoid letting the resident grab hold of a wrist, hand or forearm as this may cause injury). Environmental Factors

Aggressive behaviors in people with dementia can be triggered by environmental stimuli, such as noise, rushing care or too many care attendants giving direction (Ryden, Bossenmaier, & McLauchlan, 1991). Physiotherapists can be very helpful in assessing environmental triggers. For example, a person with left hemiplegia and left visual field problems is best cared for from the right side. Is the resident's bed located for right side access? A particular transfer method may trigger pain, causing an aggressive response.

Care Plan

Once all information is collected, organize the data and write down the known triggers (see Tips for Comfort Care) and best approaches identified. Call your staff together again and begin to draft a specific care plan for this specific problem.

Summary

Staff often have excellent approaches to reduce, defuse or even eliminate aggressive responses to caregiving. However, unless these ideas are pulled together in an organized way to produce consistent care, the problem of aggression will continue (Banazak, 1996). Once the care plan is in place, it is important to evaluate and fine tune it regularly through team meetings. All members of the team should be considered as resources in managing this most difficult care dilemma.

REFERENCES

Banazak, D.A. (1996). Difficult dementia: Six steps to control problem behaviours. Geriatrics, 51(2J, 36.

Beck, C., Baldwin, B., Modlin, T., & Lewis, S. (1990). Caregivers' perceptions of aggressive behaviour in cognitively impaired nursing home residents. Journal of Neuroscience Nursing, 22(3),169-172.

Chou, K.R., Kaas, M.J., & Richie, M.F. (1996). Assaultive behaviour in geriatric patients. Journal of Gerontological Nursing, 22(11), 30-38.

Feldt, K., & Ryden, M. 1992). Aggressive behaviour: Educating nursing assistants. Journal of Gerontological Nursing, 18(5), 3-12.

Juan de Fuca Hospital. (1994). Care risk program. Victoria: Author. Meddaugh, D. (1990). Reactance: Understanding aggressive behaviour in

long-term care. Journal of Psychosocial Nursing, 28(4), 28-33. Potts, H.W., Richie, M.F., & Kaas, M.J. (1996). Resistance to care. Journal of Gerontological Nursing, 22(11), 11-16.

Ryden, M., Bossenmaier, M., & McLauchlan, C. (1991). Aggressive behaviour in cognitively impaired nursing home residents. Research in Nursing and Health, 14, 87-95

Teri, L. (1990). Management of behavioural disturbance in dementia: A behavioural approach. Video series. University of Washington.

Ann Marie Monahan, RN, MSN, is a clinical nurse specialist providing psychogeriatric education and consultation to staff of nursing homes, continuing care and home support in the Central Vancouver Island Health Region. She will present two RNABC teleconferences on managing difficult behavior, June 10 and June 17, 1999. The fee is $100 plus GST per teleconference. To register your agency or for information, contact Trudy Meyer, RNABC Professional Services, at (604) 736-7331 (ext. 331) or toll-free 1800-565-6505. Fax (604) 738-2272. E-mail MEYER@rnabc.bc.ca.

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