July 25, 2006
Physical aggression, including hitting, shoving, scratching, or abusing others, is a problem behavior in many nursing home residents, including those with Alzheimer's disease and other forms of dementia. Verbal aggression, when residents threaten, scream, or curse at others, can also cause difficulties. Treatment steps aimed at the underlying causes of such behavior may ease aggressiveness and make life easier for both patients and caregivers alike. The findings appeared in last month's issue of the Archives of Internal Medicine, a journal of the American Medical Association.
Researchers studied nursing home residents age 60 and older with Alzheimer's disease and other forms of dementia who resided in one of five states: California, New York, Ohio, Pennsylvania, or Texas. The authors used data from the participants' Minimum Data Set (completed in 2002), a health assessment completed regularly for all residents of nursing homes that receive federal funds. The assessment contains information about the resident's medical condition and ability to carry out everyday activities.
Of 103,344 residents (average age 84 years) who met the criteria for the study, 7,120 (6.9 percent) had been physically aggressive in the week before their assessment, and more than one in 10 had been verbally abusive. After the researchers considered other factors that may play a role in aggression, including age, sex, and the level to which residents were able to perform daily tasks on their own, they found that symptoms of depression, delusions, hallucinations, and constipation were associated with physical aggression. With the exception of constipation, the same factors also contributed to verbal aggression.
Previous studies have linked psychological conditions to aggression, but this study was one of the first to examine the effects of constipation, the authors write. "We chose to study constipation a priori because it is common, modifiable, and recognized by clinicians to be a cause of many non-specific symptoms," the authors write. "It is not clear whether physical aggression may be related to factors that predispose to constipation (e.g., anticholinergic medications such as tricyclic antidepressants), the symptoms associated with constipation, or interventions such as suppositories that may elicit a defensive action by some residents."
"Physical or verbal aggression among nursing home residents with cognitive impairment may be a major cause of distress among staff and other residents injured by the aggressor, as well as to the aggressor," they conclude. "We found that aggressive behavior among residents was associated with depression, delusions, and hallucinations, and that physical aggression was also associated with constipation. All of these factors may be amenable to intervention and, in addition to reducing the morbidity associated with these entities themselves, effective treatment may reduce the risk of violence in nursing homes."
The findings underline the importance of seeking prompt medical treatment for psychological disorders, including depression, hallucinations, and delusions. Many medications are available to help treat these symptoms, though some may carry serious side effects. [See the article, "Drugs to Ease Agitation of Alzheimer's May Pose Risks"] Counseling can also provide benefits for both patients and caregivers.
This study highlights that seniors with Alzheimer's may also benefit greatly if they suffer from constipation. The condition, characterized by infrequent bowel movements with stools that are frequently hard and painful to pass, is common in the elderly. Constipation can arise as a side effect of many medications, including those used to treat depression, pain, or high blood pressure. Lack of fiber in the diet, inadequate fluid intake, lack of exercise, and prolonged inactivity can all contribute to constipation as well.
If an elderly person with dementia develops aggression, agitation, or other behavioral problems, doctors recommend several steps to minimize risks. First, because behavioral problems may arise because of issues unrelated to Alzheimer's disease or dementia, it is important to identify untreated or inadequately treated medical illnesses. Too high a dose of a medication, environmental triggers, or lack of engaging activities are among the conditions that can contribute to behavior problems. Second, doctors need to weigh the risk-benefit ratio of particular treatments, including potent medications, for each individual. Finally, if an antipsychotic drugs has been prescribed, it is important that heath care professionals carefully assess and monitor the situation, since those drugs can have particularly serious side effects.
For more on the management and care of Alzheimer's disease, visit www.ALZinfo.org.
Ralph Leonard; Mary E. Tinetti; Heather G. Allore; Margaret A. Drickamer: "Potentially Modifiable Resident Characteristics That Are Associated With Physical or Verbal Aggression Among Nursing Home Residents With Dementia." Archives of Internal Medicine. Volume 166, June 26, 2006; pages 1295-1300.
Press release: The American Medical Association.