Cynthia D. Steele, RN, MPHThe Copper Ridge Institute

The Johns Hopkins University

Prevention and Management of AggressionComplex and difficultSupport confidence and vigilance, not fearProvide skills and coach routinelyCoaching means demonstration with the

aggressive patientIF you are not willing to “get wet”, why

should they?

Loyalty and SupportIt is unacceptable to abuse residents and it is

also inappropriate for you to be abused. We can solve the problems, but you must

report it promptly after one incident

ChallengesDementia units are the answerVictim blamingTurnoverTransferring the patientPoor discharge instructions to the receiving

staffTaking time to observe and be social firstLack of communication

Create a common language and a Routine and safe place for reporting and discussing behaviors.

The nurses “don’t ever listen”

Be a coach and “get wet” If you are asking them to change their behavior, you must be willing to try it first. They will not believe you. The aides must not be routinely blamed.

The Cynthia D. Steele, RN, MPH Caring Hands Award for Excellence in Care by Nursing Assistants, $1,000 award, recognition, status

Recognize success, usually one person who “never has a problem”

Categories of MisbehaviorsPhysicalVerbalSexualExit seekingOthers?

Significance

CommonAlienationRisk of institutionalizationRisk of dischargeIncrease in cost of care

Caregivers Perspective

Most common recipientDeliberate acts by a “bad patient”Random, unprovokedTolerance varies greatlyDemoralizationMany belief systems

A Dementia Sensitive CultureEducate everyoneUse the same languageConsistency of approachConfidence in ability to maintain safetyMinimize impact of behavior problems

Behavior Problems: Origins and Risk Factors

Cognitive impairmentPsychiatric disordersPhysical illness, DeliriumEnvironmental pressCaregiver approach

*often multi-factorial

The 5 D ProcessDescribe the behaviorDecode itDesign a planDetermine if it works

Document, document, document

Cognitive Risk Factors: The 4 A’sAmnesia: short term memory and learningAphasia: communicationApraxia: coordination Agnosia: recognition

Environmental risk factorsUnder/over stimulationNoiseActivity of peersCues and mis-cuesTemperature

Environmental AdaptationShelter from chaosStructure, routine, familiarityActivity program

Caregiver approachMiscommunicationRushingThreateningInflexibility Too many persons talking and touching

General Approaches

Adjust expectations to abilitiesIdentify and treat psychiatric conditionsGive vigilant medical careAdjust environmental pressFine-tune caregiver approachTrial and error important

Aggression

Any behavior, physical or verbal that causes or has the potential to cause harm to self, others or objects

“Handle with Care”Keenan and Steele, 1995

Cycle of escalationResponse at each levelMake a planOne person talkingSafe AttireBody positionSafe holds and releases

Cycle of Escalation

CalmAnxiousAngryHostile, threateningAggression

Micro-CuesFacial flushingPacingTension in musclesGestures

Response to Escalation

Anxious listen, comfortAngry give space,

monitorHostile make a planAggression allow to defuse if safe, if not,

use non-offensive physical control

Make a PlanCommunication essentialWorking together often more efficientWho will talk?Who will do care?

1) Relaxed posture

2) Eye level with the patient

3) “How-can-I-help” rather than “You-must-do”

4) Body language should convey choices not control

1) Far enough away so you won’t get hurt… but

2) During care, you’re never in the safety zone!

3) Constant vigilance is required.

Attire How you dress…1) Avoid dangling

hair, id tags, jewelry…

2) Wear footwear that favors movement.

3) Approaching patient? Remove glasses and watch

The Geri-Hold

Common ExamplesShowering: Mrs. X due for showerHas hx of biting and kickingYou reach across her to get the shampoo, she

bites

Exit seekingMrs. R. sees you go out the door and

attempts to follow youShe says “I have to go to the bus stop for my

kids”

DressingYou tell Mr. G. to hold up his arms so you can

pull over a sweatshirt He shoves you when you try to put the shirt

on

TransfersMrs. X has just returned from her dental

appt,She is sitting in a wheelchair and needs to be

transferred to a geri chair or reclinerShe hits and kicks

Approach to the Psychotic PatientNot usefulReality orientation

ArguingReasoningThreatening

Often usefulEmpathyReassurance

Offering to helpDistraction

“Don’t sit on my Mother!”Not useful

“There is no one here”

“Just calm down”

Often useful“What is

upsetting you?”

“May I sit down?” Remove the

chair

“I always wait for my husband to come home to eat!”Not helpful:

“You know he is dead” “I told you he isn’t coming”

“You’d better eat or I’ll have to take the food away”

Helpful:“Let’s get

started and I’ll watch for him”

“I’ll keep a plate of food warm for him”

“I am sure he is alright”

ConclusionsCaring for dementia clients is challengingAdjust expectations to abilitiesUse success of othersTrial and error is importantJoining “their world” can be fun