Practice Tips

Residents who exhibit combative behavior in long term care pose care challenges to staff and to other residents. Published studies suggest that resident aggression causes physical and psychological trauma to both staff and other residents. According to HHS (Health and Human Services), nursing homes provide care for an average of 1.5 million residents each day. One study suggests that almost 6% of these residents are physically aggressive each week. Residents entering nursing homes may have underlying psychiatric conditions, cognitive impairment, and dementia, all which may contribute to combativeness. Medicare licensed facilities must adhere to regulatory mandates such as assessment, care planning, and interventions which will reduce the incidence of combative behaviors.

Potential injury to resident and staff must be minimized. Caregiver education and training can enhance knowledge in identification of certain behaviors which may preclude an actual combative episode. By understanding extrinsic and intrinsic factors and triggers which may contribute to the resident's escalation in behaviors, caregivers can implement strategies that will address the resident's predisposition to certain triggers, which in turn can potentially minimize the risk of injury to resident and staff.

Combativeness is not usually directed at the individual caregiver nor is it a personal attack on the caregiver as a person, but, usually, a mechanism the resident uses to communicate a need, want, or desire, when they cannot articulate this verbally.

Resident-to-Resident Aggression (RRA)

Combativeness is not limited to resident-to-staff. Residents may also be aggressive towards other residents. A study of nursing homes in one state revealed that the most frequent sites where RRA occurred was in dining areas and residents' rooms. Triggers for episodes involving RRA include issues with communication (primary language differences), entering the room of another resident, territoriality (sharing common items), inability to communicate needs effectively, such as room temperature, television volume, window shade (closed or open), and lighting. Other factors include roommate conflict, responses to loud noises, and jealousy. Race, ethnicity, and religious affiliation may also trigger RRA. Residents with psychological impairment, who room together and have difficulty communicating or negotiating preferences, have an increased risk of RRA.

Careful resident assessment, along with recognition of individual resident triggers, and observation of extrinsic factors should be carefully considered. These factors may impact RRA and should be utilized when identifying and implementing appropriate interventions.

Resident Combativeness: Contributing Factors

Certain activities and situations may contribute to resident combativeness. The more prevalent activities include: dressing, turning, incontinence care, transfers, and bathing. Residents who are unable to verbalize needs, such as hunger, pain, thirst, toileting needs, body temperature (cold/hot), and sleep pattern disruption may use combative or threatening gestures and words because they are unable to articulate their needs.

Lack of sleep, visual and hearing impairments, physical impairments, disabilities, or lack of control of bodily functions may initiate combative behaviors. The resident's perception of reality may be altered due to cognitive or health issues and they may perceive the most non-threatening assistance by healthcare staff as threatening.

Environmental factors, such as lights, loud noises, television and radio at higher volumes, loud voices, cluttered rooms, and traffic created by staff movement may also trigger combative behaviors in residents. Other triggers include changes in rooms, routines, and roommates. Change of shift can be a difficult time for some residents as well.

Staff should be mindful of their own approaches to residents. Handling residents in a rough, hurried manner or using quick, deliberate movements or gestures can startle residents. Using a loud, directive voice to communicate to the resident can make the resident feel vulnerable and may be perceived as demeaning. This also takes control away from the resident and may escalate combative behaviors.

Strategies to Reduce Combativeness

At the time of admission, an assessment should be done of any prior history of combative behavior. This assessment should detail the type of behavior and any known triggers for this behavior. Often this assessment is done with a family member or the resident’s responsible party. If the resident has a combative episode, it is important to assess the circumstances of the episode. Because the resident may be trying to communicate a need, ignoring the behavior may only serve to escalate the situation because it does not address the resident's need. Another tool utilized in long term care is the Brøset Violence Checklist. The checklist can be used as part of the assessment upon admission to the facility or any time during the resident's stay. As staff becomes more aware of the potential triggers and behaviors, the checklist may intuitively become part of the overall patient assessment. The purpose of the checklist is to assist staff in determining in advance if the resident may be at risk for combative or aggressive behavior so appropriate interventions or strategies can be implemented.

• Evaluate the resident and the situation:
  • What is the resident trying to communicate through the behavior?
  • Is it difficult for the resident to complete tasks?  
  • Do they become confused when trying to perform activities of daily living?
  • What was happening prior to the episode?  Has this occurred before?  Under the same circumstances?
  • Is the resident oriented only to the past and do they become hostile when forced to accept the present?
  • Are there loud noises in the resident's environment?  
  • Is the resident's environment chaotic or busy?
  • Have their physical needs been met (hunger, pain, thirst, toileting, and body temperature (cold/hot), sleep pattern disruption)?
  • Have new medications been introduced?
  • How has location and situation contributed to the behavior (dining placement, activity room placement, residents triggering other residents)?
• Enlist the assistance of family to provide feedback on past behaviors or life experiences that may be contributing to the combative episode.
• Identify what potentially caused the behavior
• Initiate interventions: there may be a need to trial a variety of interventions.
• Activity:
  • Bathing
    • Consider resident past practice and preferences. Do they shower, take a bath, or sponge bath? Modesty factors?
    • Consider timing: Do they bathe at night or in the morning and how often?
    • When is the resident not as stressed and more cooperative? When are they most alert?
    • Consider adjustments: Is room and water temperature comfortable? Does excess noise escalate behavior?
    • Is pain associated with moving a factor? Consider timely administration of pain medication prior to activity.
  • Mealtimes
    • Is the resident dining area by seating preference, or by location/table and by eating companions?
  • Wandering
    • Redirect pacing into productive activity or something purposeful if possible
    • Reassure the resident.
    • Does the resident wander at a specific time of day? Anticipate interventions for that timeframe each day.
  • Sleep Problem Management
    • Address nighttime restlessness.
      • Attempt to improve sleep hygiene. Reduce noise and light, play soothing music.
      • Keep a consistent sleep schedule.
      • Use nightlights.
      • Consider use of a favorite stuffed animal or blanket.
      • Increase activity during the day and monitor napping during the day.
      • Limit caffeine.
  • Toileting
    • Is resident continent? Is the resident unable to maintain continence yet has understanding that they are soiled? This may cause agitation or anger in the resident.
    • Keep a toileting schedule.
    • Avoid constipation. Inactivity and certain medications will promote constipation, which can cause pain, and the resident may exhibit agitation and anger.
  • When confusion and agitation deviates from baseline
    • Consider illness: Urinary tract infection or Pneumonia? Assess accordingly.
    • Medication changes and interactions with current medications?  Note medication side effects, resident behavioral changes. Is there a correlation? Is there a new medication?
    • Cerebral Vascular Accident/Stroke?  Changes may occur in personality. Level of frustration may increase if the resident is unable to express themselves in the manner to which they are accustomed. Speak in a calm, clear manner. Allow adequate time for response.
    • Pain: The resident may be unable to articulate so behavior can become combative or agitated.
    • Hearing loss: Does the resident have an auditory problem or decline in hearing that requires examination? (Unable to understand commands due to decline versus disease progression?)
    • Visual acuity: Does the resident have vision issues or decline? (Frustration or fear from inability to see?)
• Situation:
  • Environmental Adjustments: Modify the environment whenever possible to reduce agitation.
    • Extrinsic factors:
      • Loud/distracting noises: Minimize when possible. Relocate the resident even if temporary.
      • Flooring: Minimize floor glare, choose flooring patterns and colors that are calming.
      • Room temperature: Hot and cold can affect resident comfort.
    • Room Placement
      • Is the resident compatible with his/her roommate?
      • Is the resident territorial (chair, television)?
      • Make rooming changes as needed.
• Prevention/De-escalation:
  • Maintain your composure: Be aware of your emotions, tone, and body language.
  • Approach: Respond calmly and express support, use positive and friendly facial expressions. Always approach the resident from the front, not the back.
  • Active listening: Engage the resident to determine needs when possible.
  • Effective verbal responding: Are you reflecting or paraphrasing to clarify understanding. Use a gentle, relaxed tone.
  • Redirection: Provide options of other activities or places if possible.
  • Stance: Are you at eye level? Are your arms crossed on your chest? Keep arms at sides. Be sure to be at a safe distance if potential for combative behavior exists.
  • Do not initiate physical contact if the resident's behavior is escalating. Touching can trigger violence in some residents.
  • Positioning: Is the resident comfortable? Is the resident repositioned regularly as needed?
  • Allow for adequate time to address the situation.
  • Jumping to conclusions: Input from others on the team is helpful; however, fully assess the resident, situation, and environment.
  • Resident stress management interventions and diversionary activity.
    • Exercise, walking.
    • Calming music.
    • Pet therapy.
    • Favorite doll or blanket.
• Implement the resident care plan interventions and communicate patient needs to staff in order to minimize or eliminate behaviors. When formulating a plan for addressing combative behavior, consider:
  • Work closely with the entire care-giving team including family to develop a plan for successful management, containment and, where possible, prevention of combative incidents.
  • Make your goals realistic. You may not be able to stop all behavior problems, but you may be able to minimize or reduce them. Goals to consider:
    • Attend to safety of the resident with combative behavior,
    • Provide support by having all caregivers stay alert to give aid in combative behavior situations.
    • Increase awareness of behavior that may give clues to the onset of an aggressive act.
    • Strive for containment with efforts to decrease the frequency, intensity, and duration of combative behavior.
• Evaluate staff response to any episode: Was the behavior improved or did it escalate in response to staff response and actions?
• Implement education and training based on findings from episodes. Look for patterns and trends in these episodes. Address needs identified by review of any patterns and trends. It is important to work as a team when addressing a combative episode. Safety of the resident and staff member is paramount. Interventions that have shown success in addressing combativeness should be shared. Staff member's insight in caring for residents is useful to all staff. Adopt approaches which have proven successful in avoiding or minimizing combative behavior.

Summary

Combative episodes affect both residents and staff on many levels. Resident and family satisfaction can be affected by the manner in which combative episodes are handled and addressed by the facility. It is essential that administration support staff communication of successful interventions and strategies to improve overall facility combativeness.

Combativeness in long term care may always be present; however, by implementing staff education and training necessary to identify triggers which increase combativeness, staff may be able to implement strategies to reduce resident combativeness.

1. Potentially Modifiable Resident Characteristics That Are Associated With Physical or Verbal Aggression Among Nursing Home Residents With Dementia, 2006
2. Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff, 2008
3. Workforce Safety & Insurance, 2003
4. The University of Iowa, Iowa Geriatric Education Center, Managing Bathing Challenges in Nursing Home Residents with Dementia, http://www.healthcare.uiowa.edu/igec/publications/info-connect/assets/bathing_challenges.pdf
5. Understanding and dealing with resident aggression: exploring the extent, causes, and impact of aggressive outbursts and how to handle them, 2004
6. Combative Behavior. (2003, June). [Brochure]. Retrieved from http://www.WorkforceSafety.com
7. Alzheimer's Behavior Management, www.helpguide.org, 2012
8. Almvik, R. Woods, P. & Rasmussen, K. (2007), Assessing risk for imminent violence in the elderly; the Brøset Violence Checklist. International Journal of Geriatric Psychiatry, 22, 862-867

References

Almvik, R., Woods, P., & Rasmussen, K. (2007, January). Assessing risk for imminent violence in the elderly: The BrǾset Violence Checklist. International Journal of Geriatric Psychiatry, 22, 826-867. Retrieved from http://www.interscience.wiley.com
Combative Behavior. (2003, June). [Brochure]. Retrieved from http://www.WorkforceSafety.com
Leonard, R., Tinetti, M. E., Allore, H. G., & Drickamer, M. A. (2006, June). Potentially Modifiable Resident Characteristics That are Associated with Physical or Verbal Aggression Among Nursing Home Residents With Dementia. Archives of Internal Medicine, 166, 1295-1300.
Rosen, T., Lachs, M. S., Bharucha, A. J., Stevens, S. M., Teresi, J. A., Nebres, F., & Pillemer, K. (2008, August). Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from focus Groups of Nursing Home Residents and Staff. Journal of the American Geriatric Society, 56(8), 1398-1409.
Russell, D., Barston, S., & White, M. (n.d.). Alzheimer's Behavior Managment [Brochure]. Retrieved from http://www.helpguide.org
Soreff, S., & Siddle, D. (2004, March). Understanding and dealing with resident aggression: Exploring the extent, causes, and impact of aggressive outbursts and how to handle them. Nursing Homes/Long Term Care Management, 58-60.
The University of Iowa, Iowa Geriatric Education Center, Managing Bathing Challenges in Nursing Home Residents with Dementia, http://www.healthcare.uiowa.edu/igec/publications/info-connect/assets/bathing_challenges.pdf