Aggression in Persons with Dementia: Use of Nursing Theory to Guide Clinical Practice

With approximately four million people in the United States today diagnosed with dementia, one of the most devastating problems faced by caregivers and patients is dealing with aggressive behavior. Aggression occurs in half of persons diagnosed with dementia and is associated with more rapid cognitive decline, increased risk of abuse, and caregiver burden. This paper uses the Need-driven Dementia-compromised Behavior (NDB) model to explain aggression and discusses therapeutic approaches to care that combines non-pharmacological and pharmacological interventions targeting both the management of aggression crisis and preventing its future recurrence. A clinical algorithm guided by the NBD model is provided for practitioners.

Introduction

There are approximately four million people in the United States today who are diagnosed with dementia. Current estimates indicate that these numbers will approach fourteen million by the year 2050, making dementia a major public health concern in the 21st century.¹ Dementia affects memory, attention, language, and judgment, and these symptoms are referred to as the cognitive symptoms of dementia. Some of the most challenging and devastating problems caregivers and clinicians face, however, are the non-cognitive symptoms of dementia that more than 90% of persons with dementia experience over the course of the illness.2, 3 Non-cognitive symptoms include a heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors, of which aggression is of major concern to caregivers.4, 5 Aggression is defined as any physical or verbal behavior that has the effect of harming or repelling others, and includes behaviors such as hitting, kicking, and screaming.⁶ Aggression occurs in half of persons diagnosed with dementia and is associated with more rapid cognitive decline, increased risk of abuse, and caregiver burden.4, 7, 8 Additionally, aggression results in earlier nursing home placement and contributes significantly to the costs of long-term care.9, 10

The current management of aggression is, at best, moderately successful, even in controlled trials.11, 12 The reasons for this limited effectiveness are the nonlinear interactions between risk factors for aggression, various factors that trigger the behaviors, and the focus on pharmacological interventions during crisis to the exclusion of preventative interventions.13, 14 Currently, there is no miracle pill that manages aggression, and there is no fixed approach to every person who exhibits aggression. Because aggression is so common in persons with dementia and carries a high risk for poor health outcomes, it is essential that caregivers and clinicians understand best approaches to intervention that weigh the benefits and risks of using non-pharmacological interventions to prevent aggression and at the same time initiate pharmacological and non-pharmacological interventions during crisis.

In this paper we describe a clinical algorithm, guided by a nursing model, for the care of persons in nursing homes who exhibit aggression and who have moderate to severe cognitive impairments; stages of dementia when aggression is most likely to be exhibited. We begin with a discussion of the Need-driven Dementia-compromised Behavior model that conceptualizes aggression within a nursing perspective and considers the range of factors that are associated with the behaviors in nursing home settings.¹⁵ We then review a template for identifying aggressive behaviors, their triggers, and general approaches to intervention. We present evidence for non-pharmacological and pharmacological interventions and review the most frequently prescribed drugs for aggression, antipsychotic medication.