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Recognising the needs underlying aggressive behaviour in people with dementia

Louise Appleton writes about her experience as part of a team who developed a range of person-centred diagnostic tools to better support residents at Kensington Park Aged Care Home, a high-care facility in Perth.

Kensington Park, operated by Hall & Prior, is a secure 48-bed residential aged care facility in Perth which specialises in dementia care. In 2009, Kensington Park was experiencing some persistent problems with distress among the people living there. This manifested as aggression towards caregivers, with 10 to 15 recorded incidences of aggressive behaviour per month.

Originally published in the Australian Journal of Dementia Care print edition,
Vol 2 No 2, April/May 2013

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One of the common assumptions about dementia is that it comes with behavioural and psychological symptoms (BPSD), one of which may be aggression. Research has indicated that aggression can be managed by modifying the behaviour of the caregiver or modifying the environment (Byrne 2005). I suspected pain as a cause of the behaviour, as I had recently completed my Masters in Louise and Jovydeveloping a pain management guideline for residents with cognitive impairment and it seemed feasible that it might be related to pain. Rather than treating the dementia as the problem, we decided to investigate the links between aggression, pain, sleep and comfort, and look into identifying the causes of the aggressive behaviours so that they could be addressed holistically.

The resulting project, Innovative approaches to improve behaviour management of residents with dementia, spanned two years (2009-2011) and included developing a pain audit tool and a sleep assessment tool. We used these tools to help us better support the residents alongside other strategies that addressed aggressive behaviours, including the introduction of music and exercise therapy. The result of this program was that episodes of aggression declined to one or fewer incidents per month within 12 months.

Aggression, dementia and pain

It is well documented in literature that fatigue and ongoing pain can exacerbate aggressive behaviour. Aggressive behaviour in people with dementia is linked to both internal factors (depression, psychosis, pain) and external factors (caregiver behaviour, environmental situation, social contact) (Cipriani et al 2011). A study led by Professor Mark Kunik of the Houston Centre for Quality of Care and Utilisation Studies found similar factors influencing the amount of aggression experienced by caregivers of people with dementia. The study, conducted between September 2003 to June 2005, found that of 215 people, 89 (41 per cent) developed aggressive behaviours. The study noted that: “In individual models, high baseline mutuality [ie carer-client rapport] decreased risk of aggression; high burden and pain increased risk. Increases in depression and pain and declines in total mutuality also increased risk. In a full model and step-wise model, high levels of baseline caregiver burden, worst pain, and decline in mutuality over time increased risk of aggression” (Kunik et al 2010). The need for good rapport was especially important to bear in mind while working with the residents of Kensington Park: as well as dementia, many people living there have accompanying mental health issues, such as bipolar disorder, schizophrenia, or other complicating psychological factors.

Studies have also shown that untreated pain is common in residential aged care facilities (Takai et al 2010; McAuliffe et al 2012). The 2012 literature review led by Linda McAuliffe drew from information in previous studies, and reported: “… pain-related agitation often leads to inappropriate treatment with neuroleptics or sedatives rather than analgesia (Geda & Rummans 1999), which can have the effect of masking symptoms related to pain (Kovach et al 1999)” (McAuliffe et al 2012).

We began this work by forming a multidisciplinary team which included Kensington Park’s clinical nurse manager Jovy Tesani; the director of nursing Catherine Barlow; myself (a nurse practitioner) and the quality co-ordinator Julie Beaton, as well as assisting occupational therapists and assistants. We agreed to first focus on pain assessment and management. I wanted to follow my hunch that the aggression was due to pain, so developed the original pain assessment tool that included looking at analgesia being given to cognitively impaired residents.

The majority of residents were being prescribed medication as a PRN dose (which means ‘as required’). However, this was not effective in treating people’s pain regularly because highly cognitively impaired people cannot verbally communicate their need to a nurse. The Abbey Pain Scale, a tool to assess pain levels in people with dementia who are unable to verbalise their needs in a meaningful way, was chosen so that staff were able to assess our residents by their non-verbal behavioural signs. The assessment is carried out twice: an hour before analgesia, then an hour after analgesia, and behaviour is recorded.

We consulted the tool’s author, Professor Jenny Abbey, to obtain the most recent information on the scale and, in particular, if there were any developments of the tool for use in residential aged care. An up-to-date assessment tool was obtained and implemented in February 2010. This allowed the assessment to take place over one day with observation of the resident after analgesia had been given and a broader understanding of the resident’s pain control could be described.

To ensure the assessment was performed appropriately, education in the use of the tool was given through training sessions for care staff. The staff were fantastic: they could see we were aiding the discomfort felt by the people living at Kensington Park. With the help of the care staff, we carried out a pain audit that reviewed every resident within the home and included their co-morbidities against the analgesia prescribed.

Sleep, complementary therapy and the ‘Rainbow Club’

Following the pain audit, we developed a sleep assessment tool to assess residents’ sleep patterns. The sleep audit reviewed every resident within the home and included their co-morbidities against the analgesia prescribed. The recognition of sleep as an important adjunct to care delivery benefits the life of the resident during the day. Awareness of the importance of sleep during the study allowed the day and night staff to be part of the management of this disorder.

We also implemented a range of other non-pharmacological interventions. This included music during the day to help the residents rest and relax. Research into music was completed before the project started, in regards to the benefit of music for a resident with dementia. Evidence indicated that music of a particular type (Baroque music) was of benefit to residents in the home (Foster 2009). We played Baroque music, but also tried gentle instrumental music. Music was implemented on a daily basis in different places around the facility, and an evaluation form was developed for the nurses to assess the effect of the music.Kensington_park

With analgesia in place and with the aid of non-pharmacological intervention including massage, heat packs and care staff’s understanding of the individual needs of the resident, results at the three-to-six month mark indicated that there was relief of pain and discomfort. In concert with this, episodes of aggression towards caregivers began to decrease.

Another initiative that came about as a part of the project was the ‘Rainbow Club’, the nickname for a group-meal setting which was developed to better support residents during mealtimes. The concept was to create a more social, interactive mealtime experience for residents who were not eating enough. People with advanced dementia can sometimes forget what they are doing at the table, or may have difficulty handling utensils. In the Rainbow Club model, an occupational therapy assistant sits with a small group of people and offers prompts for them to eat, as well as encouraging conversation throughout the meal. The relaxed social atmosphere and personal attention helps these people keep their focus on the food and has resulted in them eating more.

The results

Since the implementation of the programs at Kensington Park – the pain audit, the sleep audit, the music and complementary therapies to support pain intervention and assist with rest and relaxation – the incidences of aggressive behaviour have declined and there’s now a greater sense of happiness and restfulness amongst those living in the facility. The decrease in aggressive behaviour has been significant in terms of the welfare of care staff.

One of the measurable outcomes of the program has been a sharp reduction in the amount of anti-psychotic medications that are being prescribed, which has many benefits for residents and their families. Less use of anti-psychotics means that residents are more alert, do not experience side-effects and experience fewer falls. In December 2010, 27 of the 48 residents were taking anti-psychotic medications. By September 2011, the number of people taking anti-psychotics had decreased to 12.

Anecdotal evidence has included feedback from staff, who say the residents seem more rested and participate in activities for longer. The results regarding the reduction of aggression and decrease in the use of anti-psychotics to treat BPSD were well-documented. Hall & Prior is now implementing our tools broadly throughout its 19 residential care homes in WA and NSW.

This project showed that it was possible to better support residents’ needs by looking at the broader picture and working on the underlying causes of the behaviour, not only the dementia itself. We considered the underlying causes of the agitation and were able to progressively improve the lives of our residents and care staff over the course of one year.

Louise Appleton is a nurse practitioner at Hall & Prior. For more information on the Kensington Park project, please contact Ellen Thurley at: ethurley(at)hallprior.com.au


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