Resident Aggression Research Articles

Interpretive Guidelines Lead Facilities To Refocus on Their Efforts to Reduce Falls

Interpretive Guidelines Lead Facilities To Refocus on Their Efforts to Reduce Falls

Avoid Legal Difficulties While Ensuring Care Of Residents With Severe Mental Illness

Avoid Legal Difficulties While Ensuring Care Of Residents With Severe Mental Illness

Residential care for older people: job satisfaction and psychological health in care staff

Staff in local authority residential homes for older people care for dependent and demanding residents. Recent research has linked resident aggression to psychological disturbance in these staff. Despite this, little is known about the experiences of staff, many of whom are facing significant changes in the residents they care for. This paper examines psychological well-being, perceptions of the work environment and job satisfaction in 48 members of staff from two local authority homes. Results indicate that these staff experience equivalent stress to professional nurses in an NHS setting. Moderate levels of emotional exhaustion are associated with poor clarity about the job they are now required to perform. There is also a poor sense of personal accomplishment. Differences in the needs of staff, and the implications for staff development programs within individual homes are discussed. Given reports of high illness figures for care staff in public sector homes for older people, we argue that carefully targeted staff development programs have the potential for reducing burnout and days lost through illness. Such programs can also improve ‘therapeutic reciprocity’ which in turn might enhance psychological well-being in care staff, and the quality of life for residents.

Non-pharmacological interventions for aggression in persons with dementia: A review of the literature.

The Problem of Aggression Studies examining aggression in persons with dementia typically define aggression in terms of a variety of physical (e.g., hitting, pinching, biting) and/or verbal (e.g., cursing, threatening) behaviors. Estimates of the prevalence of aggression in cognitively impaired individuals vary widely from study to study, likely due to variations in definition of aggression and how aggression was measured. These estimates range from 13-86% (Deutsch, Bylsma, Rovner, Steelt, & Folstein, 1991; Hamel, et al, 1990; Lyketosos, et al., 2000; Pavesa, et al., 1992; Ryden, Bossenmaier, & McLachlan, 1991; Swearer, Drachman, O'Donnell, & Mitchell, 1988; Zimmerman, Watson & Treat, 1984). Aggressive is also strongly correlated with greater dependence during self-care (Schreiner, 2001). These numbers suggest that aggression in persons with dementia is a significant problem and becomes more likely as the disease progresses. Aggressive can have serious consequences for persons with dementia as well as their caregivers. Aggressive increases distress and burden for caregivers, which can result in nursing home placement (Hamel, et al., 1990; Ryden & Feldt, 1992). In addition, approximately 50% of nursing assistants have been injured during resident assaults (Gates, Fitzwater, Telintelo, Succop, & Sommers, 2004). Residents may also be at risk of being injured when engaging in aggressive behaviors (Ryden & Feldt, 1992). Aggressive residents in long-term care facilities may be labeled as difficult or combative, which can result in social isolation and modifications in caregiving that can exacerbate problems (e.g., having 2 or 3 caregivers dress a resident instead of just one). Furthermore, due to the aversive nature of working with patients that are aggressive, the relationship between caregivers and patients is compromised, thereby decreasing quality of life for both parties (Ryden & Feldt, 1992). In fact, aggression is a significant source of job-related stress and frustration for professional caregivers (Everitt, Fields, Soumerai, & Avorn, 1991; Hagen & Sayers, 1995). Another consequence of aggression is the administration of medications to manage the problem (Sloane, Mathew, & Scarborough, 1991). Aggression has been most typically treated using conventional or atypical antipsychotic medications. Studies have indicated that these medications produce only modest benefits in persons with dementia and carry significant dangers such as increased risk of stroke, exacerbation of cognitive decline, and increased risk of death (Schneider, Dagerman, & Insel, 2005; Sink, Holden, & Yaffe, 2005). Excessive sedation is also a common side effect associated with anti-psychotic medication (Zarit & Zarit, 2007, p. 311). These adverse side effects can result in a reduction in the individual's behavioral repertoire in terms of impairing language, causing gait disturbance that can result in falls, reducing the ability to access preferred events/activities, and causing further confusion and cognitive decline. The difficulty is that individuals with dementia are already experiencing a gradual deterioration in their behavioral repertoire (e.g., language, self-care) due to the disease process itself. It can be argued that treating individuals with medications that can further limit their behavioral repertoire is questionable ethically. Therefore, it is clear that developing restraint-free interventions for managing aggression is very important. The following section will include a review of empirical studies that investigated non-pharmacological interventions for managing aggression in persons with dementia. Procedures and Literature Review An initial search for relevant studies was conducted using the PsychInfo and Ageline electronic databases. Searches involved using various combinations of the search terms dementia, aggression, intervention, treatment and behavior therapy. …

Training and support for nursing home staff reduced neuroleptic drug use and did not increase aggression in residents with dementia

Fossey J, Ballard C, Juszczak E, et al. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ 2006;332:756–61. [OpenUrl][1][Abstract/FREE Full...

Conditioning properties of social subordination in rats: Behavioral and biochemical correlates of anxiety

To develop a socially based model of anxiety, the contextual fear conditioning properties of social defeat were examined in rats. Social threat consisted of exposing intruders to aggressive residents in resident home cage, separated by a partition. During 3 daily encounters, intruders were either defeated or threatened by residents, providing the defeated–threatened (DT) and threatened–threatened (TT) groups respectively. On Day 4, both DT and TT animals were subjected to a social threat only. Additional animals received a 4-day exposure to a novel empty cage (EC group). Further DT, TT, and EC rats were confronted to a different context on Day 4. DT rats exhibited a robust and context-specific anxiety-like response, characterized by significant behavioral and biochemical alterations. DT rats showed increased risk assessment and decreased exploration compared to TT and EC rats that in turn were not different towards each other. DT and TT rats exhibited increased ACTH levels, while only DT rats showed enhanced corticosterone and decreased testosterone levels compared to EC. These differences were context-specific since they were absent confronting animals to a different context and since they were not long lasting. Overall, these data demonstrate the induction of an anxiety-like state in rats through a context conditioning process based upon social factors. The social basis of this paradigm offers good face validity with anxiety disorders, which in humans are mainly related to social factors and associated with HPA axis deregulations. The present procedure may provide a useful experimental model to further investigate the neurobiological mechanisms underlying anxiety-related disorders.

Ethanol exposure during development reduces resident aggression and testosterone in rats

Ethanol exposure during development has been shown to alter social behaviors in people, but the range of deficits is not clear. Using an animal model of Fetal Alcohol Spectrum Disorders, inter-male aggression and testosterone levels were examined in adult rats. Rats were exposed to ethanol during the entire prenatal period and from postnatal day 2 through 10. Ethanol was administered via intragastric intubation. Two other groups consisted of a nontreated control and an intubated control group that was exposed to the administration procedures but not ethanol. Both offensive and defensive aggression were examined in experimental residents and intruders under three different housing conditions for the resident males: (1) with another male, (2) with a pregnant female, and (3) with a female and litter fathered by the experimental animal. When housed with a female and litter, ethanol-exposed rats displayed reduced offensive aggression compared to control groups under the same condition. Defensive aggression in the non-experimental intruders was reduced in this same condition. There were no differences in duration of non-aggressive social behaviors among the groups in any of the housing conditions. Testosterone levels were reduced in ethanol-exposed rats compared to controls. In summary, ethanol exposure over the combined prenatal and postnatal periods reduces aggressive behavior in a condition where aggressive behavior is normally seen. This reduction may be related to lower testosterone levels.

Assessment to Intervention

This first of two papers illustrates how a staff needs assessment can serve as the foundation for ongoing collaborations between long-term care staff and consulting clinical researchers. The needs assessment was an example of a three-phase model of consultation and intervention to improve resident care and reduce staff burden in a psychiatric nursing home unit managing aggressive and disruptive residents. The first phase of the process involved gathering data via a series of semi-structured interviews with 78 staff members of a long-term care unit at the Palo Alto Veterans Hospital. The second phase, discussed in more detail in the second paper, involved implementation of a series of interventions aimed at supporting staff in dealing with disruptive and aggressive behavior. The final phase, which is continuing, is monitoring and refining the interventions based on staff feedback and the results of program evaluation. Such an approach allows interventions to target the concerns and needs of a particular setting.

Neuroendocrine and behavioral response to social confrontation: residents versus intruders, active versus passive coping styles

We investigated in the present study the neuroendocrine correlates in intruder and resident rats of a social confrontation. Adult male Wistar rats (intruders) were introduced into the home cage of a well-trained resident to induce characteristic agonistic interactions including physical attacks prior to separation by a wire mesh. The hypothalamic–pituitary–adrenal (HPA) axis activity and the intrahypothalamic release of arginine vasopressin (AVP) were monitored via chronically implanted jugular venous catheters and microdialysis probes aimed at the hypothalamic paraventricular nucleus (PVN), respectively. Based on the behavioral data collected during the 30-min confrontation, intruders and residents were additionally classified into two different subgroups: intruders which showed almost no freezing behavior (active copers) versus those showing pronounced freezing behavior (passive copers) and residents which were either predominantly aggressive or non-aggressive. The neuroendocrine data show that social confrontation caused a significantly increased secretion of the adrenocorticotropic hormone (ACTH) into plasma in both intruder subgroups, independently of their coping strategy. In contrast, plasma ACTH in residents was increased in response to social confrontation in non-aggressive animals only, whereas aggressive residents failed to mount an ACTH response. Interestingly, plasma AVP decreased in response to social confrontation in active intruders. As measured in microdialysates, the two groups of residents and passive intruders failed to show significant changes of intra-PVN release of AVP. In contrast, an increased release of this neuropeptide within the PVN could be monitored for active intruders. The data of the present study suggest that the different interpretation of an aversive encounter results in differences in the neuroendocrine response and intrahypothalamic vasopressinergic signaling in intruders versus residents.

Intensity of aggressive interactions modulates testosterone in male marmosets

Androgen is associated with the expression of male-typical behavior, including aggressive behavior, but high levels of androgen may be incompatible with other behavioral systems, such as paternal care. In a variety of species of birds that display paternal care, testosterone (T) levels in males are maintained at low levels, and these levels rise only in response to direct agonistic challenges. This idea has not been thoroughly studied in mammals with biparental care, and we exposed male marmosets ( Callithrix kuhlii), a monogamous and biparental primate to aggressive interactions with unfamiliar intruders. Urinary levels of T and cortisol (CORT) were monitored prior to and following these interactions. Baseline T was not correlated with variation in aggression in either residents or intruders, and CORT was not affected by the encounters. However, males responded to an encounter with male intruders with changes in T that correlated with the level of aggression displayed by the resident male during the trial. Encounters with male intruders that elicited high frequencies of aggressive displays by the male resident were associated with increased T 2–6 h and 24 h following the encounter, and encounters that had few aggressive displays resulted in no change or a decrease in T concentrations. Intruders did not demonstrate a significant relationship between T and aggression. Thus, the magnitude of the hormonal response is dependent on the intensity of aggression during a male–male encounter, suggesting that elevated androgens are likely to be a consequence, rather than a cause, of aggressive interactions in marmosets.

AGGRESSION TOWARD STAFF By Nursing Home Residents: FINDINGS FROM A GROUNDED THEORY STUDY

Aggressive behaviors by nursing home residents are common and can result in injury to both staff and residents. In addition, such aggressive behavior may lead to resident abuse by staff. This article describes a grounded theory study of nursing home staff response to aggressive residents and explores the problem of aggressive behaviors by nursing home residents, the conditions and context of aggression, and strategies staff use to prevent and manage aggression. To effectively deal with resident aggression, staff must become proactive, which involves three dynamic and interactive processes: practicing vigilance, intuiting, and strategizing. This article details these processes as well as the strategies staff use to deal with aggressive behaviors and makes specific recommendations for handling aggression toward staff.

A Study on Aggressive Behavior Among Nursing Home Residents with Cognitive Impairment

With a sample of cognitively impaired nursing home residents and nursing staff, the following were examined 1) the proportion and nature of aggressive behavior, 2) the frequency and types of aggressive behavior, 3) the difference between the residents who demonstrate aggressive behavior and those who do not demonstrate aggressive behavior (age, mental status, functional status, and pain, length of nursing home stay), and 4) nursing staff responses to aggressive behavior by residents. A cross-sectional descriptive study design was used. Data were collected from cognitively impaired nursing home residents (N=205) and nursing staff (N=60) at two nursing homes using Ryden Aggression Scale I and II, Mini-Mental State Exam, Modified Barthel Index, Verbal Descriptor Scale, and aggressive behavior management questionnaire. Data were analyzed using descriptive statistics including t-test. About 62.9% residents were found to be aggressive and 38.5% were both physically and verbally aggressive. Pushing, making threatening gestures, hitting, slapping, cursing/obscene/vulgar languages, making verbal threats were occurred frequently. Aggressive residents were significantly older, had more cognitive impairment, had more pain, and stayed longer in the nursing home when compared with non-aggressive residents. Considerable proportion of nursing staff responded to aggressive behaviors inadequately. Aggressive behavior among cognitively impaired nursing home residents is prevalent thus needs to be prevented and reduced. Along with environmental modification, educational programs for nursing staff and family caregivers need to be developed and implemented so that they can have extensive knowledge and skills to manage aggressive behaviors.

Behavioral, physiological, and endocrine responses of starlings to acute increases in density

One potential stressor to vertebrates both in the wild and in captivity is the presence of numerous individuals in a confined space. To examine the effects of increased conspecific density in birds, we simultaneously measured cardiac, behavioral, and endocrine responses of European starlings ( Sturnus vulgaris) to acute crowding. A cage containing a resident bird was outfitted with a trap door that allowed for the introduction of intruder birds (one, three, or five birds) without human interference. The resident bird was implanted with a subcutaneous heart rate (HR) transmitter, behavior was videotaped through a two-way mirror, and blood samples were taken at the end of each treatment to determine plasma corticosterone (CORT) concentrations. Resident starlings significantly increased both general activity and aggressive behaviors while decreasing preening following the initiation of elevated conspecific density. Intruder starlings increased feeding, drinking, and aggressive pecking rates, but postintrusion feeding rates decreased as intruder number increased. Preening decreased in both residents and intruders following the intrusion. HR increased in the resident starlings at the time of intruder introduction, with an increase in the magnitude of this response directly correlating with increasing intruder number. The CORT response to increased density was dependent on social role (resident or intruder), since increasing density did not alter CORT levels in resident birds, but resulted in elevated CORT 30 min following the five-intruder introduction in the intruder birds. Together, these data suggest that increased conspecific density is a significant acute stressor in starlings which is capable of inducing aggression in both residents and intruders. Furthermore, it elicits different responses from different physiological and behavioral systems, and behavioral responses such as feeding and general activity may be density-dependent. The data specifically illustrate that cardiac and behavioral activation can be independent of CORT release, and the CORT response of starlings to increased conspecific density is dependent on social role and degree of the increase in density.

Behaviour of Young Growing Pigs in a Resident‐Intruder Test Designed to Measure Aggressiveness

AbstractA total of 125 growing pigs (47 days old) were tested for aggressive responses on two occasions using a resident‐intruder (R‐I) design. Our aims were twofold: (1) to attempt to replicate earlier work on pigs showing that resident aggression is a consistent individual characteristic, unaffected by weight or sex of the resident or intruder and (2) to develop behavioural measures to characterise the wide range of aggressive responses in the test. Resident pigs, housed since birth with littermates, were placed individually in a divided‐off portion of their home pen, and a smaller, unfamiliar intruder (approximately 66% of the resident's weight) was introduced. The test ended 5 min after the first investigation of the intruder by the resident or when one of the pigs began to attack the other (by delivering a sudden, rapid series of bites). On days 1 and 2, 33.6% and 43.2% of tests, respectively, ended in an attack by a resident. Intruder attacks were rare. Pigs were consistent in whether they attacked or not over the two tests, although attack latencies for pigs attacking in both tests were not correlated. Females were more likely to attack and attacked more quickly than males on the first test day but not in the second test or overall. Intruder sex had some effect on the test outcome (males were attacked more rapidly in the second test only). Resident and intruder weight had no effect. Aggressive pigs (meaning pigs that attacked vs. pigs that did not and fast‐attacking pigs vs. slow‐attacking pigs) showed a number of differences in behaviour during the R‐I test: (1) they took longer to make initial contact with the intruder in their first test; (2) they showed a higher frequency of aggressive acts (single head knocks, bites, and shoves); (3) they spent a greater proportion of the test engaging in social contact with the intruder rather than non‐social behaviours; (4) their social behaviour involved more postures directed toward the head as opposed to flank‐ or rear‐directed postures or re‐establishing social contact; and (5) they showed closer physical contact with intruders during social encounters, as characterised by their lower head positions. Some of these behavioural measures could be used to improve the measuring power of the test in the future. Improved behavioural measures would enable aggressiveness scoring among pigs that did not attack instead of classifying them all together as “non‐attacking.” Aggr. Behav. 28:401–415, 2002. © 2002 Wiley‐Liss, Inc.

Effects of resource distribution on activity and territory defence in house mice, Mus domesticus

How much an animal invests in defending a territory depends, in part, on the quality, quantity and distribution of resources, but do animals target their investment in defence within the territory according to the location of different resources? We examined whether wild-caught male and female house mice increased aggression towards intruders of the same or opposite sex when in areas containing their food/water or nest site. Pairs of resident mice were established in enclosures consisting of two areas. In split enclosures, food and water were in one area and a nest site in the other, while in clumped enclosures all resources were in one area with no resources in the other. Residents of both sexes were quicker to attack intruders, and were more aggressive, in areas containing resources than in an area containing no resources. There was no difference in aggression between areas containing food/water, a nest site or both. The effect of resources on territorial defence was due largely to changes in aggression against intruders of the opposite sex. Residents, especially males, attacked intruders of their own sex more than those of the opposite sex. This bias was much stronger when no resources were present, owing to low aggression against opposite-sex intruders in the absence of resources. There were no differences in intruder aggression, and the relative size of the intruder (heavier or lighter than the resident) had no effect on resident aggression. Residents also spent less time out of their nest in clumped enclosures owing to low activity in the nonresource area.

When should a territory resident attack?

Models of territorial defence tend to omit two characteristics of many territorial systems: repeated intrusions by the same individual and the learning processes of residents and intruders. Here we present state-dependent, dynamic models of feeding territories, designed to investigate temporal patterns of resident aggression towards intruders that are capable of spatial learning. We compare two types of models: (1) a nomadic intruder model, in which intruders never visit the same territory twice, and (2) a single, repeat intruder model, in which an intruder may repeatedly intrude into a given territory but is less likely to do so after being attacked. These two models produce qualitatively and quantitatively different patterns of aggression by residents. For instance, residents with intruders that may repeatedly intrude have high initial attack rates, regardless of initial probability of intrusion, but their attack rates decline over time. In contrast, residents in the nomadic intruder model do not attack intruders if intrusion rates are moderately high, and their attack rates are constant and high for most of the period of territory tenure. In addition, residents of both nomadic and repeat intruder scenarios stopped attacking intruders for a short period before voluntarily abandoning their feeding territories. The results of our models suggest that repeated intrusions and learning processes have a dramatic effect on territorial defence.

Nurse stress associated with aggression in people with dementia: its relationship to hardiness, cognitive appraisal and coping.

This study examined the relationship between aggressive behaviour displayed by people with dementia and nurse stress. This was achieved by re-examining the relationships between the hardy personality (total hardiness), primary appraisal (challenge and threat appraisal), secondary appraisal (coping options available), and coping methods (action and palliative coping) from the perspective of nurse stress in response to aggressive behaviour displayed by people with dementia. One hundred and two nurses from 15 nursing homes and hostels were sampled by way of a questionnaire. Hierarchical regression was performed to analyse the strong hypothesized relationships between the variables examined. Results indicated that resident aggression was significantly related to an increase in nurse stress (M=34.79, SD=7.93). Of the variables examined, only threat appraisal was significantly related to nurse stress (beta[94]=0.48, P < 0.05). Perceiving the possibility of aggressive behaviour by the resident as threatening was found related to a high stress level in nurses sampled.

Effectiveness of Special Care Unit (SCU) placements in reducing physically aggressive behaviors in recently admitted dementia nursing home residents

Using a sample of new dementia admissions who entered selected nursing facilities December 1992 through June 1994, this paper compares special care dementia units (SCUs) to non-specialized (traditional) nursing home care in their effectiveness in reducing physically aggressive behaviors within six-months of placement. Findings indicate that SCUs admit younger and more highly aggressive residents. Our results indicate that when differences in age and baseline levels of disruptive behaviors are controlled, SCU placement showed no positive or negative effect on the frequency of aggressive behaviors. Rather than SCU placement, it was the increased use of psychotropic medications and the reduction in the use of physical restraints that showed a relationship with lower levels of physically aggressive behaviors. While SCUs do not appear to be the hoped for panacea with regard to reducing physically aggressive behaviors, they still appear to serve a useful function within the broader context of the provision of services for residents with dementia within the nursing home.

Nursing Home Resident Abuse by Staff: Exploring the Dynamics

ABSTRACTThis paper explores the dynamics of nursing home (NH) resident abuse by NH staff. It presents partial findings from a grounded theory study about NH staff response to aggressive residents and focuses on NH staff not able to care for aggressive NH residents without detrimental consequences to themselves or the residents they cared for, including abuse of NH residents. Symbolic Interactionism provides the theoretical framework. Classic grounded theory approach was used to analyze data which included semi-structured interviews with NH staff and abuse investigators. Two types of abusive NH staff are identified, the reactive and sadistic abuser. Additional investigations are needed to enhance understanding of the dynamics of abuse of residents by institutional staff and to further develop prevention and intervention programs.

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.