Clinical Geriatrics

Part II-Occurrence in Hospitals and Pharmacological/Behavioral Treatment of Agitation, Agression, and Violence

Dr. Ryan Hall is an Affiliate Instructor at the Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, FL, and is a 2006 Rappeport Fellow of the American Academy of Psychiatry and the Law; Dr. Richard Hall is Courtesy Clinical Professor of Psychiatry, University of Florida, Lake Mary, and Affiliate Professor, Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, FL; and Ms. Chapman is Research Assistant to Dr. Richard Hall.

This is Part II of a two-part article on violence committed by older persons. Part I (published in the May issue of Clinical Geriatrics) reviewed the forensic aspects of violence in older persons, incidents that lead to arrest, court-ordered psychiatric evaluations, involuntary hospitalizations, partner abuse, and sexual misconduct. Part II discusses situations in which healthcare professionals are likely to encounter violent and disruptive behavior in the elderly, as well as available treatment options.

Hospital-Based Violence
For multiple reasons, hospital staffs are at increased risk for becoming the recipient of violence from older patients due to changes in their health. Conditions such as delirium (eg, sundowning), dementia, unidentified substance abuse (eg, alcohol withdrawal), disrupted sleep cycles while hospitalized, acute and chronic pain, which may not be readily identified (eg, bladder infections), and decreased sensory perception (eg, visual, auditory) while in a strange environment have all been shown to predispose staff to violent assaults.1-5 Other medical factors leading to an increased risk for aggression, which are similar to conditions reported in the violent forensic population, include recent or past head injuries, poor diabetic control, malnutrition, and seizures.1,2,6

Patients with dementia often have difficulty understanding what is happening around them. Misperceptions, anxiety, fear coupled with a decreased ability to communicate, and a reduced frustration tolerance make for a dangerous and explosive mix.7 Additional environmental factors often found in hospitals that can cause problems with patients with dementia are increased noise levels, overcrowding, frequently changing caretakers, lack of space to roam, poor lighting, rapidly changing environments (emergency room, to intensive care unit, to ward), and audible sounds from medical equipment. These factors, coupled with the disinhibiting or confusing effects caused by new medicines or metabolic derangement, may provoke fearful assaults on staff.