Cynthia D. Steele, RN, MPH
The Copper Ridge Institute
The Johns Hopkins University
Prevention and Management of Aggression
 Complex and difficult
 Support confidence and vigilance, not fear
 Provide skills and coach routinely
 Coaching means demonstration with the aggressive
patient
 IF you are not willing to “get wet”, why should they?
Loyalty and Support
It is unacceptable to abuse residents and it is also
inappropriate for you to be abused.
We can solve the problems, but you must report it
promptly after one incident
Challenges
 Dementia units are the answer
 Victim blaming
 Turnover
 Transferring the patient
 Poor discharge instructions to the receiving staff
 Taking time to observe and be social first
 Lack of communication
 Create a common language and a Routine and safe place for
reporting and discussing behaviors.
 The nurses “don’t ever listen”
 Be a coach and “get wet” If you are asking them to change
their behavior, you must be willing to try it first. They will
not believe you. The aides must not be routinely blamed.
 The Cynthia D. Steele, RN, MPH Caring Hands Award for
Excellence in Care by Nursing Assistants, $1,000 award,
recognition, status
 Recognize success, usually one person who “never has a
problem”
AD Uncomplicated, Complicated
Categories of Misbehaviors
 Physical
 Verbal
 Sexual
 Exit seeking
 Others?
Significance
 Common
 Alienation
 Risk of institutionalization
 Risk of discharge
 Increase in cost of care
Caregivers Perspective
 Most common recipient
 Deliberate acts by a “bad patient”
 Random, unprovoked
 Tolerance varies greatly
 Demoralization
 Many belief systems
A Dementia Sensitive Culture
 Educate everyone
 Use the same language
 Consistency of approach
 Confidence in ability to maintain safety
 Minimize impact of behavior problems
Behavior Problems:
and Risk Factors
 Cognitive impairment
 Psychiatric disorders
 Physical illness, Delirium
 Environmental press
 Caregiver approach
*often multi-factorial
Origins
The 5 D Process
 Describe the behavior
 Decode it
 Design a plan
 Determine if it works
 Document, document, document
Cognitive Risk Factors:
The 4 A’s
 Amnesia: short term memory and learning
 Aphasia: communication
 Apraxia: coordination
 Agnosia: recognition
Environmental risk factors
 Under/over stimulation
 Noise
 Activity of peers
 Cues and mis-cues
 Temperature
Environmental Adaptation
 Shelter from chaos
 Structure, routine, familiarity
 Activity program
Caregiver approach
 Miscommunication
 Rushing
 Threatening
 Inflexibility
 Too many persons talking and touching
General Approaches
 Adjust expectations to abilities
 Identify and treat psychiatric conditions
 Give vigilant medical care
 Adjust environmental press
 Fine-tune caregiver approach
 Trial and error important
Aggression
 Any behavior, physical or verbal that causes or has the
potential to cause harm to self, others or objects
“Handle with Care”
Keenan and Steele, 1995
 Cycle of escalation
 Response at each level
 Make a plan
 One person talking
 Safe Attire
 Body position
 Safe holds and releases
Cycle of Escalation
 Calm
 Anxious
 Angry
 Hostile, threatening
 Aggression
Micro-Cues
 Facial flushing
 Pacing
 Tension in muscles
 Gestures
Response to Escalation
 Anxious
 Angry
 Hostile
 Aggression
listen, comfort
give space,
monitor
make a plan
allow to defuse if safe, if not, use
non-offensive physical control
Make a Plan
 Communication essential
 Working together often more efficient
 Who will talk?
 Who will do care?
Stance and Body Position
1) Relaxed posture
2) Eye level with the
patient
3) “How-can-I-help”
rather than “Youmust-do”
4) Body language
should convey
choices not control
Safety Zone
1) Far enough
away so you
won’t get hurt…
but
2) During care,
you’re never in
the safety zone!
3) Constant
vigilance is
required.
Attire

How you dress…
1) Avoid dangling hair,
id tags, jewelry…
2) Wear footwear that
favors movement.
3) Approaching patient?
Remove glasses and
watch
High Risk Situations
The Geri-Hold
Common Examples
 Showering: Mrs. X due for shower
 Has hx of biting and kicking
 You reach across her to get the shampoo, she bites
Exit seeking
 Mrs. R. sees you go out the door and attempts to follow
you
 She says “I have to go to the bus stop for my kids”
Dressing
 You tell Mr. G. to hold up his arms so you can pull over
a sweatshirt
 He shoves you when you try to put the shirt on
Transfers
 Mrs. X has just returned from her dental appt,
 She is sitting in a wheelchair and needs to be
transferred to a geri chair or recliner
 She hits and kicks
Approach
to
the
Psychotic
Patient
 Not useful
Reality  Often useful
orientation
Arguing
Reasoning
Threatening
Empathy
Reassurance
Offering to help
Distraction
“Don’t
sit
on
my
Mother!”
 Not useful
“There  Often useful
is no one here”
“Just calm down”
“What is upsetting
you?”
“May I sit down?”
Remove the chair
“I always wait for my husband to
come
home
to
eat!”
 Not helpful:
 Helpful:
“You know he is
dead”
“I told you he isn’t
coming”
“You’d better eat
or I’ll have to take
the food away”
“Let’s get started
and I’ll watch for
him”
“I’ll keep a plate
of food warm for
him”
“I am sure he is
alright”
Conclusions
 Caring for dementia clients is challenging
 Adjust expectations to abilities
 Use success of others
 Trial and error is important
 Joining “their world” can be fun