Long-Term Care Survey Alert

Prevent unnecessary 'take downs' and accusations of abuse.

When a resident lashes out with physical aggression, staff has to select the best strategy to keep the resident and others safe.

And "take downs" where staff holds the resident down or physically removes him from an area should always be the intervention of absolute last resort, emphasizes Joanne Lax, an attorney with Dykema Gossett PLLC in Bloomfield Hills, MI. Why? Physical intervention can potentially hurt the resident or the staff involved in what could turn into a melee. And surveyors could construe the intervention as abuse if staff uses force out of keeping with what's needed to control the behavior -- or if the technique is not appropriate for use with frail elders, Lax cautions.

The bottom line: Use physical intervention only in extraordinary situations that have escalated to the point of posing imminent danger to residents or staff, Lax says.

The Crisis Prevention Institute teaches healthcare staff to use a quick decision-making process to decide whether the danger or risk posed by a person's behavior is riskier than putting their hands on the person. For example, "someone screaming and waving his hands isn't more dangerous than a staff person stepping in and putting their hands" on him, says Judith Schubert, president of the firm in Brookfield, WI.

An alternative: Ask these critical questions, she advises:

1. Who am I? A staff person working alone? Someone with a good rapport with the person acting aggressively?

2. Who is the client/patient? An individual who has acted in this way before? What did we do in that case? What works for this person?

3. Do we have any advanced directives or case planning for this person and this type of behavior? Is this a person who responds better to someone else on my team?

4. What do I want to happen right now? "I want this person to put the chair down. I want social worker Alison, who has a better rapport, to come in, etc."

Suppose someone is coming toward you with a chair. In that case, you're looking at a risk that may exceed that of a physical intervention, says Schubert. In that case, ask yourself how you can escape safely without putting your hands on the person. If that's not possible or the patient is endangering others, ask how you can use physical intervention to manage the person as safely as possible, Schubert suggests.

It's a good idea to trend aggressive episodes by collecting data about the following, suggests Michael Partie, president of Therapeutic Options Inc.:

• When the episodes occurred (date, time);

• Who was present (staff, other patients/clients);

• Environmental antecedents (instructions by staff, denying requests, intrusions in personal space, etc.).

Also look at what the resident may be getting out of physical aggression. Is she getting her way or becoming the center of attention? Does someone with substance abuse issues receive sedating medication after an aggressive episode?

Standard strategies for managing aggression in people with dementia involve preventing outbursts by maintaining a calm environment. Also reduce environmental stressors as much as possible and engage the person in tasks commensurate with his cognitive abilities, Lax says. "If an outburst nonetheless occurs, re-direction or a brief 'time out' are often the strategies of choice," she adds.

"In contrast, individuals who are aggressive because of anger or frustration with their life circumstances will not benefit from those strategies," Lax says. In fact, such interventions may inflame the person if he considers them to be condescending, she warns.

Instead: Engage these aggressive residents in daily activities that restore true meaning and purpose to their lives, Lax suggests.

"Individuals with primary mental illness often require psychiatric intervention for appropriate medications and therapy. They need a strong activities plan, supervision and re-direction to avoid situations that can cause outbursts," Lax says.

Editor's note: Read parts 1 and 2 of this story set on preventing and managing resident aggression in the previous Long-Term Care Survey Alert available in the Online Subscription System archive.