Aggression in the Elderly

Is any type of violent behaviours directed toward harming or injuring another INTENT Verbal cursing, threats (24%) Physical grabbing, pinching, kicking, hitting, biting Tasks that require close contact like bathing may lead to aggression Note: prior history of aggression is a great predictor

Physical Symptoms that can lead to Aggression

COPD Brain tumor Stroke Seizure Disorder Poly pharmacy Pain UTI Depression Substance Abuse/Alcohol CNS infection

Why a Resident Becomes or Is Aggressive?

Can occur for no reason, no stimulus just happens Common response to perceived threat May be a long term personality trait May be unpredictable If caregiver insists on routine or is impatient or acts irritated Can occur if the residents is restless, upset, fatigued, in pain, hungry, thirsty, or frustrated May be a self defense mechanism May be related to medication use

Circumstances Leading to Aggression

Losing independence Too much activity, over stimulation (paging system) Loss of Freedom Relocation to new facility, changes in room, routine Fear Sundowning Catastrophic Reactions Poor lighting, no differentiation in colours leading to room entrances

Balance Demands and Capabilities

If Demands and Capabilities are not equal, this may cause catastrophic reactions and behavioural problems.

Demands

Capability

Aggression & Psychosis in the Elderly

AGGRESSIVE NONAGGRESSIVE
Physical
Pacing

Physical
Hitting

Verbal
Threatening

Verbal
Yelling

Kicking
Biting

Swearing

Tapping
SSRIs

Calling out
Trazodone Carbamazepine

ANTIPSYCHOTICS

Stress and Dementia

Strong need for security World unpredictable and frightening Fear and embarrassment Debilitating anxiety Need to gain control Past Coping Mechanisms?

The Environment
Sensory Overload Too many people Noise level Sudden Movements Startling noises Unable to recognize noises or people Feel vulnerable and insecure

Our Approach
Pressure to get task done Talking too fast Asking too many questions Not giving the person time to respond Can startle when approached from behind Unexpected touch Nonverbal communication

Our Approach
Know the life story of the person Look for clues why person is distressed Provide soothing music Talk in calm voice Is the person in pain? Upset by something or someone around them Need for one-on-one attention Use distraction Try music, massage, quiet reading

ABC Intervention
A = antecedent What happened before the behaviours, clues, triggers B = define the behaviour What is happening, what did the resident do, describe the action, when, where and around who C = consequences What happened in the environment or the behaviour of other people because of the behaviour

Strategies
Remain calm Be flexible Explain everything you are doing to the resident Give the resident a sense of control over body and personal space Avoid situations that lead to aggressive behaviours Keep objects that could be used to hurt someone out of reach

Strategies Contd
Glasses and hearing aides Medications, especially if new Check for tight clothing, pain, need for bathroom Stick to familiar routine Plan activities when person is rested Break tasks into small manageable steps

Prevention Strategies
Limit choices Approach from front, use name Set the mood and the tone Give the person time to respond Use life story Know stressful time of day Acknowledge feelings, comforting touch

More Strategies
Regular toileting schedule Clothing is dry and comfortable One caregiver able to connect Consistent reliable routine Explore what need is being expressed Consistent staffing Communication Strategies Keep environment simple Meals one food item at a time, one utensil Clothing one outfit Activity offer one activity

Physical Struggle What to Do?

Give resident space dont come in and take away space Will not last forever, resident will be exhausted Teamwork get help immediately and avoid a physical struggle You will feel fear and anger. Act to calm everyone so no one gets hurt. Dont respond with abuse of your own or try to punish the resident

Act, Do Not React:

1. 2. 3. 4. 5. Be Alert Be Prepared Know the Resident Initiate Rescue or Patrol Intervention Defuse Confrontation and Aggressive Action 6. Deep breathe and Time

How to Prevent Violence

Consistency keep changes to a minimal Distraction used to get the resident to a different thought or behaviour Know your strengths and limits may need help because you are not good at diffusing the situation or you get angry Speak in calm and comforting voice No sudden movements to startle the resident Dont argue or ask why are you angry? Avoid crowds or loud noises

Plan of Action
Remove other residents witnessing the aggression May leave the resident alone if they become aggressive when you are trying to help them and then re-approach Use another staff members Watch tone of voice or body language Eye contact, reassuring, gentle touch

When Something is Lost

Fear loss of a valuable possession Acknowledge the feelings being expressed Offer to help the person to look Have a duplicate replacement Learn favorite hiding places Gentle approach Offer meaningful distraction

Problems with Dressing

Difficulties with gross and fine motor skill loss of balance and ability to do buttons Task to complicated Unclear instructions Use same area to dress and undress If able to choose clothing only give two choices Lay clothing out in sequence apraxia Visual cues for sequencing Clothing one size larger, velcro, comfortable, non skid shoes

Want to Go Home
Expressing a need A place of comfort, security, control Not necessarily a place Acknowledge feelings being expressed Use life story to develop meaningful distraction that will provide comfort Redirect the person with music, activity, exercise

Problems with Eating

Use bowls rather than plates Only use one utensil Serve finger foods Use bright placemats to distinguish plate Dont overwhelm with entire meal. One dish at a time

Possible Causes for Aggression during Bathing

Different sensation to hot and cold and water Lack of privacy Room temperature too cold Water too hot or cold Water too deep Fear of falling, being hurt Being rushed Fear of washing hair, soap Not wanting to be naked Too overwhelming, forgets routine of bathing

Aggression During Bathing

Use hand held showers watch stream of water does not frighten the resident Bath seats and keep resident covered until water begins, may need to wash under the sheet Be calm and reassuring, dont startle the patient Remember modesty and privacy Know past bathing times Warm bathroom Simplify task, one step at a time Let them feel the water before going into tub/shower

Pharmacology
Atypical antipsychotics - (ie, clozapine [Clozaril], risperidone [Risperdal], olanzapine [Zyprexa], and quetiapine fumarate [Seroquel]) dec. extrapyramidal side effects (eg, parkinsonism, tardive dyskinesia). Neuroleptic treatment - start with a low dose (eg, 0.5 mg of haloperidol or 1 mg of risperidone) and administer it on a regular basis rather than attempting to treat specific episodes of agitation. Anticonvulsants carbamazepine, divalproex sodium (Depakote) are effective in treating behavioral disturbances in dementia and have a different side-effect profile than that of neuroleptics.

Medications to Treat Aggression in the Elderly

Aggression

Yes
Psychotic Features

Anti Psychotics

No
Mood Features

Yes

Anticonvulsants, Anti Psychotics Lithium, Antidepressants

No
Anxious Features

Yes

Anticonvulsants, Anxiolytics, Antidepressants

No
Non Specific

Yes Episodic ? No
Trials using non Anti Psychotics First

Anticonvulsants, Beta Blockers, Lithium

Pharmacologic Options in Dementia (daily maintenance dosage)

Risperidone (Risperdal) 0.25 2.0 mg (official indication for dementia in Canada) Olnazapine (Zyprexia) 2.5 10 mg Quetiapine (Seroquel) 25 100 mg (higher in Schizophrenia) Mild/Moderate Agitation Trazodone (Dysyril) 25 100 mg Divalproex sodium (Epival) 250 - 1500 mg Carbmazepine (Tegretol) 100 - 600 mg Avoid long term use of Benzodiazepines

Restraints
Chemical and Physical Physical can increase aggression Chemical low maintenance dose Watch high potency anti psychotic agents like Haloperidol

What the Nurse Can Do?

Debrief to learn what went well, what could be improved upon Talk about the situation crisis counseling, EAP Know that you are not to blame Seek additional training and information Activities outside work to boast morale

Anorexia and Bulimia

Anorexia
Means lack of appetite (incorrectly named) Life-threatening restriction of caloric intake 85% women, 25% relapse, 5% die 3/1000 young women in grade 9 12 Stems from a distorted body image

Theories
FREUDIAN eating substitutes for sex FAMILY struggle for independence LEARNING societys ideal body image BIOLOGICAL genetic, damage by hypothalemus

Symptoms
Amenorrhea (no period) Dry cracking skin Constipation Increased heart rate Lanugo (fine hair on your body) Immature features

Anorexia in the Elderly

What Is Anorexia? It is prolonged loss of appetite that leads to severe weight loss. Anorexia is not a normal consequence of aging; it is a significant symptom requiring treatment.

Anorexia in Older Adults

Markedly diminished appetite in persons with depression and in those grieving losses An older person stops eating, they deny being hungry and refrain from eating. Distorted body image and do not see themselves seriously underweight. Deny suicidal ideation. Note: may see a lot of binging and purging in older adult but laxative use may be an example Food refusal can represent a hunger strike or need to regain some control over their lives.

Why Changes in Appetite?

Diminished sense of taste and smell Zinc deficiency produces absence or distorted sense of taste Inability to shop and prepare food Decreased pleasure with food Poor dentition and ill-fitting dentures Poverty, loneliness and social isolation Pulmonary and cardiac diseases, cancer, dementia, and alcohol problems; contributing factors include depression and certain medications such as chemotherapeutic drugs.

Warning Signs of Anorexia

Deliberate self-starvation with weight loss Fear of gaining weight Refusal to eat Denial of hunger Constant exercising Greater amounts of hair on the body or the face Sensitivity to cold temperatures Absent or irregular periods Loss of scalp hair A self-perception of being fat when the person is really too thin

Women and Anorexia in the Older Adult

Drive to be thin thought of thinness Want independence and control Say Im full or not hungry or Im feeling sick
Men are often angry Control issues Usually triggered by major stressful event

Men and Anorexia in the Older Adult

Bulimia
BU = ox + LIMOS = hunger Hungry like an ox Gross overeating (binge) and induced vomiting (purge) Affects women in their middle 20s 90% women choose easy to eat foods Family history of obesity and alcoholism Foods eaten quickly and without tasting This kind of eating will be accompanied by feelings of anxiety, guilt and remorse

Understanding the Illness

Food is plentiful in our country but desire to be thin to be accepted Unmet needs what does the person really want A false front do well in life but have inadequacies Need for control

Why Bulimia Occurs?

Sexual abuse or late sexual trauma Putting on a lot of weight in puberty Having a mother who is concerned about wt and dieting Major life event (divorce, death) Hostility in families (violence, hatred) Addictions in Families (alcohol)

 Well disguised and hidden problem from family Disappearing to the bathroom after a meal, running bathwater or playing the radio at high volume. Strange night bird behaviour, staying up and going to the kitchen after everyone else has gone to bed. Going for unexpected walks or drives at night. A bulimic tries to get rid of people, or have them go to bed, so that they can binge. Disappearance of large quantities of food, or overeating, without apparent sign of weight gain. Finding food wrappers hidden behind chair cushions or under beds. Unexplained irritability and mood swings.

Recognizing Bulimia

Signs and Symptoms of Bulimia

Vomiting, abusive use of laxatives or water pills, fasting and extreme exercise Binge eating followed by purging Excessive, rigid exercise regimen Creation of complex lifestyle schedules or rituals to make time for binge-and-purge sessions

Emotional Effects of Bulimia

Shame and guilt Depression Low self-esteem Impaired family and social relationships Perfectionism "All or nothing" thinking Work problems Much time planning binging and purging Decreased socialization

Physical Symptoms
Swelling of the cheeks or jaw area Sore throat Calluses on the back of the hands and knuckles (from self-induced vomiting) Discoloration, staining, or deterioration of tooth enamel (caused by stomach acid) Broken blood vessels in the eyes Brittle hair or nails; dry or sallow skin Stomach pain Vitamin and mineral deficiencies, electrolyte imbalance Weakness or fatigue Chronic irregular bowel movement and constipation from laxative abuse Dehydration Loss of menstrual cycle Swelling of the lower legs and feet or loss of sensation in the hands or feet (from malnutrition or dehydration) Heart attack

Why Binge and Purge?

Hunger Feeling Bad Fat Feelings Situations ( I was bad I ate the cake, go for it)

Treatment Goals
Stabilize body chemical Restore normal eating patterns Determine emotions behind eating Assertive and confidence building

Treatment of Bulimia
Involves and Multidisciplinary Team Psychiatrist, Physician, Nurse, Dietitian Goals of Treatment Psychoeducation about the medical implications of bulimia Identification of triggers for binging and purging behavior Interrupting the "rituals" of bulimic episodes Challenging weight and body image beliefs Improving self-esteem and ability to communicate needs and feelings

Nursing Care of the Anorexic and Bulimic Patients

Work with a multidisciplinary team physician, psychiatrist, psychologist, nurse, dietitian Treat existing medical problems, electrolytes, fluid deficits, bowel problems Daily weight Multivitamin Rapport and trust must be encouraged Close observation and monitoring of food eaten IV therapy, TPN, Enteral feeding tube Improve coping, body image and self esteem through therapy Therapy family, individual, behaviour modification, group therapy

Nursing Care
Monitor weight daily in same clothes Limit physical activity Allow pt to see food as medicine Non-judgmental Cease purging, Limit food choices in beginning 1200 cal diet, increase fluid intake Monitor and record food eaten Monitor vital signs and electrolytes Help teach relaxation and coping strategies Patient must feel that she is in control of the treatment Make contract and patient can have privileges based on weight gain Allow pt to verbalize feeling around weight gain Health teaching: dehydration, hypoglycemia Administer SSRI PROZAC. Other SSRIs (wt gain) Discuss feelings. Do not comment on wt. or appearance