Irreversible: dementia related to long standing alcohol use, Alzheimer's disease
When assessing elderly clients with difficult behavior, the fundamental question to ask of the behavior is “why?” Psychiatric and physical illness will produce physical and behavioral symptoms. Learning to ask “why?” may give the care-giver answers to questions about the elderly client’s aggressive behavior leading to treatment of the conditions triggering the difficult behavior.
Criteria: Presence of acute organic brain syndrome
Behavior:
•sudden rise or fall in level of consciousness
•disorientation as to time, place, person
•impairment of recent memory
•auditory hallucinations within the psychic horizon (i.e. within earshot)
•visual hallucinations
Comment:
Sense of time is lost first. Hallucinations indicate functional mental disorder.
Mentally Ill Clients
Statistically, it has been proven that the mentally ill are no more violent than the general population. With the implementation of the Mental Health Initiative (deinstitutionalizing of mentally ill people), the community is encountering mentally ill individuals who were previously cared for in institutions. Without adequate resources such as supportive housing, community dropin centres, and outreach workers, mentally ill individuals tend to become more visible. They are often thrust into crisis because their basic needs are not being met.
Criteria: Acute Anxiety (panic disorders)
Assess for:
•nonverbal behavior, examples: pacing, wringing hands, picking at something, darting eyes, quick erratic movements, or withdrawal
•verbal behavior, examples: talking loudly, quickly or in a demanding voice
•a change in usual behavior
Criteria: Psychiatric Problems
Assess for:
•acute psychiatric illness
•psychotic patients with disrupted thought patterns, poor impulse control
•suffering from delusions and/or hallucinations
•suspiciousness (paranoid, not trusting)
•dual diagnosis (mental illness & chemical dependency)
Criteria: Personality Traits
Assess for:
•personality disorders (paranoid, borderline, antisocial)
•acting out for attention
Comment:
Mental illness does not generally appear to be related to violence in the absence of a history of violent behaviour.
“However, the belief that mental disorder bears some moderate association with violent behavour is both historically invariant and culturally universal.” (Monahan 1992. (10).)
Physical Diagnosis:
Criteria: Seizures or post seizure states (may cause disorientation and confusion)
Comment:
Many people come out of a seizure, angry, confused or fighting. They may not understand a command or recognize a familiar face and may uncharacteristically push someone away that they otherwise recognize.
Criteria: Metabolic abnormalities, drug toxicity, and acute neurologic impairment
Comment: All may trigger agitated or combative conduct.
Risk Factors for aggression in elderly clients:
•impaired cognition
•sensory loss
•immobility
•loss of environmental control
•limited social support
Comment:
Risk is highest during personal care: bathing, dressing, toileting, when client cannot visually recognize caregivers; and during day/night, night/day shifts.
Criteria: Environment/Milieu of Treatment
Comment: There is some research which indicates that the dynamics of assault differ according to the setting. Assaults in a facility may have more to do with the setting than the individual characteristics of the client or the care provider. The combination of a client with a history of violence in a facility setting is the most widely recognized risk scenarios. Community care providers who must visit clients’ homes are also at risk and should not enter a dangerous situation by themselves. Often it may not be the client who is considered dangerous, but the clients’ surroundings. Request for accompaniment of a partner i.e. another care provider are risk reduction approaches.
Environmental Risks in Community Care:
•Isolation of care providers in homes
•Poor lighting
•Limited visibility
•Drug and alcohol related environment
•Restricted exit
•Disruptive nonclients
•High crime area
•Distant parking
Criteria: Sensitivity to disruptive events:
Comment:
Certain events and circumstances may be particularly stressful to patients/clients and may raise their anxiety levels. Events that may lead to violence or aggression include:
•Personal care — feeding, bathing, toileting, mobilizing
•Visits involving family, friends, and the resulting fatigue
•Treatments such as dressing changes or physiotherapy that may cause pain or disrupt visits, rest, or leisure activity (for example, watching television)
•Treatment delays (real or perceived)
•Discharge
