Violence in Older Persons: Part II
Part II-Occurrence in Hospitals and Pharmacological/Behavioral Treatment of Agitation, Agression, and Violence
Dr. Ryan Hall is an Affiliate Instructor at the Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, FL, and is a 2006 Rappeport Fellow of the American Academy of Psychiatry and the Law; Dr. Richard Hall is Courtesy Clinical Professor of Psychiatry, University of Florida, Lake Mary, and Affiliate Professor, Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, FL; and Ms. Chapman is Research Assistant to Dr. Richard Hall.
This is Part II of a two-part article on violence committed by older persons. Part I (published in the May issue of Clinical Geriatrics) reviewed the forensic aspects of violence in older persons, incidents that lead to arrest, court-ordered psychiatric evaluations, involuntary hospitalizations, partner abuse, and sexual misconduct. Part II discusses situations in which healthcare professionals are likely to encounter violent and disruptive behavior in the elderly, as well as available treatment options.
For multiple reasons, hospital staffs are at increased risk for becoming the recipient of violence from older patients due to changes in their health. Conditions such as delirium (eg, sundowning), dementia, unidentified substance abuse (eg, alcohol withdrawal), disrupted sleep cycles while hospitalized, acute and chronic pain, which may not be readily identified (eg, bladder infections), and decreased sensory perception (eg, visual, auditory) while in a strange environment have all been shown to predispose staff to violent assaults.1-5 Other medical factors leading to an increased risk for aggression, which are similar to conditions reported in the violent forensic population, include recent or past head injuries, poor diabetic control, malnutrition, and seizures.1,2,6
Patients with dementia often have difficulty understanding what is happening around them. Misperceptions, anxiety, fear coupled with a decreased ability to communicate, and a reduced frustration tolerance make for a dangerous and explosive mix.7 Additional environmental factors often found in hospitals that can cause problems with patients with dementia are increased noise levels, overcrowding, frequently changing caretakers, lack of space to roam, poor lighting, rapidly changing environments (emergency room, to intensive care unit, to ward), and audible sounds from medical equipment. These factors, coupled with the disinhibiting or confusing effects caused by new medicines or metabolic derangement, may provoke fearful assaults on staff.
General hospitals account for 11% of all reported episodes of workplace violence.6 Nurses and aides are at greatest risk for being injured by violent patients. They are the individuals who spend the most time in close physical proximity to patients and who address their dependency needs, such as bathing, toileting, and transfers.8 In a British study of nurses working on geriatric units, approximately 50% of the nurses reported being assaulted during the previous year.2 Other hospital locations where staff are at risk for attack include the psychiatric ward, emergency department, and wards where patients are helpless and dependent, such as the orthopedic and burn units and the neurosurgical wards.2,8 There is debate in the literature over whether male or female nurses are at greater risk for being attacked by patients. Some studies suggest that female nurses are at greater risk of injury because of their smaller size.8,9 Others find that male nurses are actually at an increased risk because they are more often asked to intervene in the care of patients considered to be violent.9-11 An Australian study by Hegney et al10 showed that male nurses were at greater risk of being attacked on general medical units, but that female nurses were much more likely to be assaulted on geriatric units.
It is important for hospital staff to be able to identify when a patient is becoming agitated or is at greater risk for becoming aggressive. A two-stage threat assessment paradigm works best for general hospital patients. The first stage assesses subtle escalations of verbal and/or physical posturing, indicating that the patient is agitated. The second stage is when the patient is no longer able to be redirected or shows a lack of ability to control his/her behavior6,12 (Table I). Unfortunately, it is difficult to recognize when an incident of violence or aggression is imminent for older patients. Many of these patients have frontal lobe dysfunction, low frustration tolerances, or other impulse control problems, which lead them to sudden and unpredictable levels of aggression. For example, the first author took care of a 70-year-old woman who was suffering from dementia and was referred to a specialty psychiatric unit by her nursing home. She would nicely ask her doctors and nurses to stand beside her, and then she would aggressively grab for their lab coat pockets and tear them off for no clear or discernable reason. This case highlights the importance of staff having a basic familiarity with a patient’s behavior both before and during a hospital admission and using that information to assess the risk of predictable or unpredictable violence (Table II).
Hospital medical and surgical units frequently have difficulty managing older patients who are agitated. Often, these patients are bedbound and are receiving IV fluids, which become problematic when administered to partially restrained patients who are delirious or have dementia, and who do not comprehend why their movement is restricted or the necessity for receiving IV treatment. Environmental changes such as re-orientation by staff, frequent visits from family, introduction of familial “sitters,” and reduced levels of environmental stimulation are often helpful. If these attempts are not successful, additional strategies include placing the patient closer to the nurses station (sometimes in a reclining chair at the nurses station), providing a distracting activity such as folding towels, or providing a higher level of one-to-one observation with a full-time “sitter.” If these interventions are not successful, one moves to the use of physical restraints and psychotropic medications to prevent the patient from harming him/herself or others. When it comes to using restraints, the least restrictive level should be used.1 Generally, the hierarchy of restraints goes from a Posey vest or reclining chair with or without a lockable tray (eg,“geri-chair”), to two-point restraint (eg, both wrists), to three-point restraint (eg, both wrists and one leg), to four-point restraint (eg, both wrists and both legs). Physical restraints have the potential of exacerbating agitation in the elderly and need to be used with great caution.1 Restraining older patients with low or unstable blood pressure in a sitting position may be dangerous and could cause syncope or stroke.
Hospital geriatric psychiatric units may be better suited than general medical or surgical wards to manage older patients who are agitated, especially those with dementia. These units are usually set up with a large, easily supervised common area, which allows patients with dementia an opportunity to safely wander. While still supervised, the increased mobility helps to decrease the agitation caused by an inability to move about freely, and the panic and alarm that such confinement may trigger.
Pharmacological Treatments for Agitation, Aggression, and Violence
The two classic medications that have been used to treat aggression in the elderly are benzodiazepines for acute aggression and neuroleptics for long-term agitation and aggression.1,13,14 (Table III lists some general behaviors and acts of physical aggression associated with agitation.) Each medication has a side-effect profile that can make its use in older persons difficult. As mentioned earlier, it is often best to try environmental and behavioral approaches first to control aggression and agitation and to rule out medical causes of delirium, such as a urinary tract infection in acute cases, before resorting to the use of new psychotropic medications.
Benzodiazepines are generally metabolized through the liver, with the notable exceptions of oxazepam and lorazepam (renal metabolism with minimal liver metabolism). Benzodiazepines are metabolized more slowly by the elderly than by younger individuals, resulting in higher blood levels for a given dose/body weight.15-17 The terminal half-life and duration of effect are enhanced, so these drugs may have a greater impact on a patient’s cognitive abilities. Benzodiazepines can also lead to worsening of memory problems, produce hypotension, increase the risk of falls, and produce a state of dependence, which could result in seizure if they are suddenly stopped or withdrawn too quickly.1 In addition, they may disinhibit a well-functioning patient and produce a paradoxical worsening of aggression or precipitate a delirium.1,18 In certain situations (eg, alcohol withdrawal, hysterical agitation), benzodiazepines can reduce agitation in an acute care setting. They are less effective when used for the long-term reduction of aggression in a nursing home environment.14,19
Neuroleptics, both typical and atypical, can result in the side effects of dystonia, postural hypotension, exacerbation of closed-angle glaucoma, akathisia (eg, physical restlessness), neuroleptic malignant syndrome, sedation, cardiac conduction delays (prolonged QTc), increased risk of cerebrovascular events, and paradoxical worsening of cognitive function.1,15-17,19,20
The decision to start pharmacological treatment for agitation related to dementia has recently become more complicated with the addition of a black box warning for risperidone and other neuroleptic agents used for patients with dementia.21,22 A recent meta-analysis published in The Journal of the American Medical Association found an increased odds ratio for death of 1.54 (confidence interval [CI], 1.06-2.23; P = 0.02) with a risk difference of 0.01 (CI, 0.004-0.02; P = 0.01) for individuals treated with atypical neuroleptics versus controls.19 This finding may not apply only to atypical neuroleptics. Although the 2002 Cochrane review on haloperidol found that haloperidol effectively treated aggression with no findings of increased mortality in individuals with dementia, the meta-analysis from The Journal of the American Medical Association reported a mortality odds ratio of 1.68 (CI, 0.72-3.92; P = 0.23) for haloperidol based on two studies.13,19 A retrospective cohort study (n = 22,890) by Wang et al23 also found the typical neuroleptics to have the same, if not a higher, mortality risk than the atypical neuroleptics. A recent Cochrane review on the use of atypical neuroleptics for agitation and psychotic features in patients with Alzheimer’s disease found that risperidone significantly improved both conditions, while olanzapine improved only agitation.20 The Cochrane review also found a significant incidence of cerebrovascular events and extrapyramidal symptoms for both medications.20 In 2006, Schneider and colleagues21 reviewed the efficacy and side effects of the atypical neuroleptics for all types of dementias. They found that risperidone and aripiprazole showed improvement on the efficacy rating scales, but olanzapine did not.21 This meta-analysis also found that the greatest benefit from neuroleptic medications, which they described as “modestly effective,” occurred when they were used in patients with severe dementia as compared to patients with milder forms of dementia.21 There was no indication of an increased risk of falls, self-injury, or syncope in the neuroleptic-treated group versus the control population.
Although there does appear to be an increased mortality (an FDA alert revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients based on pooled data from 17 studies that averaged 10 weeks in duration and used varying atypical neuroleptics22) associated with the use of neuroleptics for the treatment of agitation and violent behavior in persons with dementia, physicians need to remember that there are risks for not providing these treatments to patients who are still aggressive after environmental and behavioral attempts to calm and control them have failed.20,21,23,24 Violent patients can hurt themselves and others. Violent and agitated older patients are at increased risk for falling, becoming malnourished, not having their activities of daily living attended to as frequently as needed, becoming isolated, and having health complications from the refusal of medication. In pooled study data (n > 1100), risperidone was more effective in reducing violent behavior and psychosis in geriatric patients with dementia (mixed population group of Alzheimer’s, vascular, and other dementias) than placebo while maintaining a similar safety profile (total adverse events reported for risperidone [84.3%] vs placebo [83.4%]), with exceptions for somnolence (21.6% vs 13%), peripheral edema (11.6% vs 3.4%), fever (7.9% vs 3.6%), urinary problems (14.5% vs 11.5%), extrapyramidal symptoms (16.3% vs 11.6%), and cerebrovascular events (3.9% vs 1.6%).25,26 In the safety profile study, 4.4% of the patients taking risperidone died during the 12-week study period as compared to 3.4% of those taking placebo.25
Before starting neuroleptics, physicians need to have a risk/benefit discussion with the patient, and, where indicated, the patient’s family or guardian. Current data suggest that patients taking atypical neuroleptics sustain a three-to-fourfold increase in their risk for cerebrovascular incident.20,25 Thus, for every nine to 25 individuals with dementia helped by these medications, one may die sooner due to the medication.19
For the last ten to 15 years, other medications such as the selective serotonin reuptake inhibitors (SSRIs), trazodone, anticonvulsant medications (eg, valproic acid and carbamazepine), antagonists to the glutamate N-methyl-D-aspartate receptor (eg, memantine), and the acetylcholinesterase inhibitors have been tried as treatments for aggression in the elderly.14,27,28 Although there have been some promising case reports, open-label trials, and even a few placebo-controlled trials, none of these medications have been consistently found to be as effective (“moderately”) as neuroleptics for the treatment of acute or prolonged agitation and aggression in patients with severe dementia.14
Selective serotonin reuptake inhibitors, particularly sertraline and citalopram, have been helpful in the subpopulation of patients with dementia who are also suffering from depression (approximately 25-30% of all Alzheimer’s dementias) but have not been shown to be particularly beneficial for patients with just dementia.14,29-32 The particular improvements noted in patients with dementia who are depressed include improvement in patient mood, decreased behavioral disturbances, and decreased caregiver distress.30-32 Improvement in cognitive function has been reported in some studies and seems more likely to occur in women treated with SSRIs; however, additional research is needed to better identify the characteristics of those patients who demonstrate significant improvements in cognitive function following SSRI treatment.30-32
Valproic acid appeared effective in 66% of case reports and open-label trials, but the placebo-controlled trials reported mixed results.14,27,33-35 The latest Cochrane review and the review by Sink et al of valproic acid in patients with dementia for control of agitation did not find enough evidence to recommend its use.14,33
Memantine and acetylcholinesterase inhibitors have been shown to have little beneficial effect on cognitive abilities, activities of daily living functioning, and maintenance of behavioral functioning in six-month studies.36,37 Neither class of medication has demonstrated efficacy for decreasing aggression or violence once agitation is present.36,37
Staffs in hospitals are frequently the victims of geriatric violence usually perpetrated by individuals suffering from delirium, dementia, or another medical illness. Environmental behavior management techniques are often effective and should be tried first to reduce aggressive behavior. Helpful techniques include decreasing stimulation, re-orienting the patient to time and place, use of simple one-step directions, staff vigilance, and allowing extra time for tasks to be completed. If aggressive and violent behaviors persist after environmental techniques have been tried, then neuroleptic medication, benzodiazepines, and/or restraints may be needed to protect the patient, staff, visitors, and other patients. Under certain circumstances, such as alcohol withdrawal, benzodiazepines can be used to treat acute agitation but they need to be used with caution due to the risk of a paradoxical reaction, potential worsening of a delirium, and risk for falls in older patients. Restraint and neuroleptic use should not be undertaken lightly. Physicians need to consider the risk/benefit ratio and communicate it clearly to the patient and his/her family/guardian where appropriate. Starting a neuroleptic medication can be a difficult decision since data show a higher mortality rate associated with their use. Conversely, neuroleptic medications such as risperidone have been shown to reduce aggressive and violent behavior in patients with severe dementia. Other classes of medication have not convincingly shown such substantial improvement.
The authors report no relevant financial relationships.
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