Aggressive behaviour in elderly people with ... - Wiley Online Library

INTERNATIONAL JOURNAL OF GERIATRIC

PSYCHIATRY,

VOL.

8: 457472

(1993)

AGGRESSIVE BEHAVIOUR IN ELDERLY PEOPLE WITH DEMENTIA: A REVIEW VIKRAM PATEL

Registrar, The Maudsley & Bethlem Royal Hospitals, Denmark Hill9London SE5 8AZ, UK TONY HOPE*

Honorary Consultant & Senior Lecturer, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX

SUMMARY The progressive degeneration of the brain seen in dementia is often accompanied by behaviourai disturbances. Aggressive behaviour is one of the most serious of these disturbances and is a common cause for psychiatric referral, admission to hospital and drug treatment. In this article, we discuss the conceptual issues associated with defining aggressive behaviour in cognitively impaired patients. We then review the aetiology, epidemiology, methods of assessment, and management of aggressive behaviour in elderly people with dementia. KEY WORDS-Dementia, behaviour. Alzheimer’s disease, aggressive behaviour, aggression, review.

Dementia is a clinical syndrome characterized by global deterioration of intellect occurring in clear consciousness. Alzheimer’s disease accounts for 6O-8OYO of cases in the elderly (Berg et al., 1987). Behavioural disturbances are common in dementia (Rosin, 1977;Prinsley, 1985;Teri et al., 1988; Hope, 1992), and carers commonly bring the patient to the physician, not because of the memory problems themselves, but because of a crisis created by behavioural disturbances (Barnes and Raskind, 1980; Silver and Yudofsky, 1987). Aggressive behaviour is one of the most serious behavioural disturbances associated with a dementing illness. It is a cause of great distress to carers even in the absence of physical violence (Ware et al., 1990). It is the most common cause of referral to a psychogeriatric service and one of the most frequent causes for admission to a nursing home or hospital (Margo et al., 1980; Clarke et al., 1981; Reisberg et a/., 1987). For patients in institutional care, aggressive behaviour is a serious management problem requiring a high ratio of staff to residents (Cohen-Mansfield and Billig, 1986; Winger et al., 1987). The purpose of this article is to examine the conceptual issues and to review the recent work on aggressive behaviour in elderly people with dementia .

* Author to whom correspondence should be addressed. 0885-6230/93/060457-16$13.00 0 1993 by John Wiley & Sons, Ltd.

CONCEPTUAL ISSUES The question of what is to count as aggressive behaviour in the setting of dementia is by no means straightforward. In the early stages of developing a rating scale (Pate1 and Hope, 1992a) we found considerable disagreement among nurses in the ratings they made. A major reason for this was that different nurses understood different things by ‘aggressive behaviour’. Some nurses would rate a behaviour as aggressive only if they thought the demented person had intended to harm, whereas other nurses rated harming behaviour even when the person was too cognitively impaired for the concept of ‘intention’ to be meaningful. The terms ‘aggression’, ‘aggressiveness’, and ‘aggressive behaviour’ are all in common use. Each term, however, has different connotations. ‘Aggression’ refers to the underlying theoretical concept. ‘Aggressiveness’ refers to the disposition (Edmunds and Kendrick, 1980) and is best reserved for the personality trait (Buss, 1961). The term ‘aggressive behaviour’ should be reserved for the overt acts themselves. In the setting of dementia, it is, we believe, most appropriate to focus assessment on aggressive behaviour. This is because it is usually inappropriate in people with significant cognitive impairment to make assessments using self-report Received30 November 1992 Accepted 28 January 1993

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questionnaires. It is the overt behaviour which can be most reliably and meaningfully measured. Definitions of behaviour can be either functional or topographical (Barlow and Hersen, 1984).Topographical definitions emphasize the observable motor aspects of the behaviour whereas functional definitions emphasize the purpose and consequences of the behaviour (Slater, 1980). The inclusion of ‘intent to harm’ is a crucial element in functional definitions of aggressive behaviour (Berkowitz, 1964; Moyer, 1976; Baron, 1980; Siann, 1985). However, in dementia, because of the cognitive impairment it can be very difficult to assess the person’s intentions, and indeed it may not be meaningful to ascribe intention. We therefore recommend that functional definitions of aggressive behaviour be avoided in the study of dementia. Topographical definitions are also problematic. The main question is the level at which to define the aggressive movements. At one extreme one might specify simple movements such as raising the arm. The problem with studying simple movements is that they are unlikely to prove interesting and may have nothing to do with aggression. At the other extreme are complex types of behaviour which can be difficult to identify without making an evaluation of the person’s intention. In the definition given below we focus more on the consequences of the behaviour than on its motivation. A further issue is what range of behaviour is to be included. Most writers in this field include verbal as well as physical aggression as relevant but the boundaries of aggressive behaviour remain unclear. We suggest the following definition for aggressive behaviour to be used as a guide for work with people with dementia (Patel, 1990; Patel and Hope, 1992a): Aggressive behaviour is an overt act, involving the delivery of noxious stimuli to (but not necessarily aimed at) another object, organism or self, which is clearly not accidental.

The key elements in this definition are:

Overt: The behaviour must be observable and should require minimal subjective interpretation. Delivery of noxious stimulus: The noxious stimulus could be either physical or psychological and can therefore include verbally as well as physically aggressive behaviour. Not necessarily aimed at: This is to specify that the delivery of the noxious stimulus need not have

been aimed at the target, ie the presence or absence of intent or a goal is not relevant to the definition. Organism, object or self: Thus a behaviour delivered to other organisms (such as kicking someone), objects (such as destroying property) or oneself (such as self-mutilation) all qualify as aggressive behaviour. Not accidental: This involves a certain degree of subjective judgement; however, it is an essential component, in order to exclude behaviour such as falling and hurting oneself or others accidentally. In our experience it is less difficult to identify behaviour as accidental than it is to judge intent to harm. This definition does not solve all problems as to which types of behaviour are to be included and which excluded. In carrying out empirical work it is necessary to identify a range of specific types of behaviour which are to be incorporated into the assessment schedule. The most difficult boundary problem is concerned with verbally aggressive behaviour. A decision needs to be made, for example, as to whether verbal abuse is a sufficiently noxious stimulus to be included. In our work and that, for example, of Wistedt et al. (1990) such behaviour is included as aggressive. However, there is room for disagreement. The terms ‘agitation’ and ‘disruptive behaviour’ are used extensively in the literature on behaviour in dementia, and they overlap with the concept of aggressive behaviour. These terms are, however, problematic because of their very wide range and fuzzy boundaries. As both Cohen-Mansfield (1989) and Taft (1989) have shown, ‘agitation’can cover excessive walking, various types of aggressive behaviour, shouting, repeated plucking, and indeed ‘any other behaviour which does not conform to norms of social conduct’ (Cohen-Mansfield et al., 1989). A further disadvantage of this term is that it has connotations with both observable behaviour and inner emotions such as anxiety (Taft, 1989). ‘Disruptive behaviour’ is even less clear and can cover any change in behaviour which can cause problems for carers or can potentially harm the patient or the environment (Silliman et al., 1988).

AETIOLOGY Aggression is not a homogeneous phenomenon, and attempts to conceptualize all violent behaviours as being qualitatively similar are likely to obscure important aetiological variables that are

AGGRESSIVE BEHAVIOUR IN DEMENTIA

specific to particular kinds of violent behaviour (Mungas, 1983). In any one individual several causes might operate. We will consider aetiological theories under three categories: biological, psychological, and environmental. Biological factors

Damage to the central nervous system can lead to aggressive behaviour through a number of mechanisms. Theories tend to be either in terms oflocation of brain damage or in terms of damage to specific neurotransmitter systems (see below). Lesions to the amygdala (Hitchcock, 1979; Shibata et al., 1986), the hypothalamus, the cingulum and the temporal lobes (Moyer, 1976; Kaada, 1967; Weiger and Bear, 1988) have all been implicated in causing aggressive behaviour. All these areas can be the site of pathological changes in Alzheimer’s disease. Lesions of the frontal lobes can be associated with a range of changes in personality which can often include an increase in aggressive behaviour. Hill (1964) has proposed that one way in which brain damage can lead to increased aggressive behaviour is through the failure of normal mechanisms which inhibit such behaviour. In other words, the underlying tendency to aggression is released by the damage. Van der Dennen (1984) has proposed that lesions of the brain can cause two distinct types of pathological aggression; outbursts of impulsive, relatively uncontrollable anger (‘paroxysmal rage’) and assaultiveness due to delusional beliefs or hallucinations often associated with emotions of fear and terror. The complex relationship between brain damage and aggressive behaviour has led to Yudofsky and colleagues (1990) proposing a new diagnostic category of ‘organic aggressive syndrome’ encompassing aggressive behaviour judged to be aetiologically related to central nervous system lesions, regardless of their location and cause. For a review of brain damage and aggressive behaviour, see Valzelli (1981) and Weiger and Bear (1988). Theories relating aggressive behaviour with reduction in neurotransmitter function have focused on 5-hydroxytryptamine (5-HT or serotonin). Significant correlations have been reported between a history of suicidal behaviour, history of aggressive behaviour and low CSF 5-HIAA levels in general psychiatric populations (Brown et al., 1982; Lidberg et al., 1985; Van Praag et al., 1986). Similarly, correlations between low 5-HT and GABA function and an increased cholinergic and catecho-

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laminergic drive with aggressive behaviour have also been reported (Brown et a/., 1979; Tardiff, 1987). There are conflicting reports on the status of the serotonergic system in dementia. Decreased levels of CSF 5-HIAA have been reported (Volicer et al., 1985; Parnetti et al., 1987) as have decreased postmortem brain 5-HT levels (Winblad et al., 1982; Palmer et al., 1988). However, other studies have shown no such decreased levels (Davies, 1983; Degrell et al., 1985). The explanation may be that there is variation between individuals. If this is the case, it would be of particular interest to know whether aggressive behaviour is seen in those patients with reduced 5-HT function. In a small retrospective study, Palmer and colleagues (1988) did find an association between aggressive behaviour and 5-HT reduction in Alzheimer’s disease. The different roles of different types of 5-HT receptor make it unlikely, however, that any simple relationships will emerge (Lawlor et al., 1989). Good reviews of serotonergic function in dementia are given by Whitford (1986) and Thienhaus et al. (1985). If reduced 5-HT levels in the brain are one cause of aggressive behaviour in dementia then drugs which increase 5-HT functioning might be expected to reduce such behaviour. There is some evidence that this is the case. Trazodone, which has a preferential 5-HT reuptake blocking action, and buspirone, a 5-HT agonist, have both been reported to be effective in controlling aggressive behaviour in patients with dementia (eg Wilcock et al., 1987). The antiaggressive effect of lithium has also been linked to its effect on 5-HT function (Sheard, 1975; Wickham and Reed, 1987). A significant number of violent acts are committed by individuals in whom ictal activity can be demonstrated and in whom anticonvulsants are effective (Monroe, 1975). The possibility therefore arises that some aggressive behaviour in patients with dementia is related to such ictal activity. This could be one explanation for the effectiveness of carbamazepine in aggression (Yatham and McHale, 1988), and specifically in a select group of patients with dementia (Risse and Barnes, 1986; Yudofsky et al., 1987). However, the effectiveness of carbamazepine may also be due to its enhancing effect on brain 5-HT (Yang et al., 1989). Biological factors independent of the dementing illness can also disrupt brain function. O’Connor (1987) in a retrospective analysis of 70 patients with dementia and behavioural disturbances concluded that in more than half the cases the disturbed behaviour was related to disease other than

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dementia itself and that a good response was obtained with appropriate treatment. The sudden appearance of aggressive behaviour in a patient with dementia may be due to the superimposition of an acute confusional state (delirium) (Granacher, 1982; Moss et al., 1987; Thomas, 1988). These are common in the elderly, and can be precipitated by numerous causes (Grimley-Evans, 1982).As Barnes and Raskind (1980) have noted, elderly patients, particularly those already suffering from dementia, are susceptible to developing an acute confusional state in the presence of almost any superimposed physical illness. It has been reported that aggressive behaviour secondary to an acute confusional state can, on occasion, lead even to homicidal or suicidal acts (Trick and Tennent, 1981). Neuroleptics, which are the most frequently administered class of drugs for aggressive behaviour, and benzodiazepines, may on occasion worsen the behavioural disturbance through precipitating an acute confusional state (Risse and Barnes, 1986). Some drugs can directly cause aggressive behaviour. Thus, increased impulsiveness with benzodiazepines (also called paradoxical disinhibition) may occur even with moderate doses (Volicer and Herz, 1985).

approached by another patient are frequent triggers of aggressive behaviour (Meyer et al., 1991). Aggressive behaviour occurring during intimate care could also be a defensive reaction to threatening intrusions of personal space and independence (Gilleard, 1984). Psychological treatments can, sometimes, precipitate an aggressive response (Woods and Britton, 1977). There have been several studies of the prevalence of psychotic symptoms in dementia, although the cognitive impairment can make identification of both delusions and hallucinations problematic. Burns et al. (1990a) reported a prevalence of delusions of 15.7% and of persecutory ideation of 20% among a mixed inpatient, outpatient and day patient sample of subjects with dementia. Cummings et al. (1987) reported that 30% of a sample of outpatients with a clinical diagnosis of Alzheimer’s disease and 40% of those with multiinfarct dementia had delusions. Jeste et a1 (1992) studied community outpatients with a clinical diagnosis of Alzheimer’s disease and found that 28% were suffering delusions at the time of assessment. Hallucinations are also reported as common in dementia. Bums et al. (1990b) found that 13% of their sample experienced visual hallucinations and 10% experienced auditory hallucinations. Furthermore, 19% had misidentified images or people in the year preceding assessment. Hallucinations were Psychologicalfactors reported in 17% of the sample studied by Jeste et Psychological reactions to a new environment, to al. (1992). The prevalence of psychotic symptoms may vary being ill and to becoming increasingly forgetful may precipitate aggressive behaviour in early with the degree of cognitive impairment. However, dementia where insight has not yet been lost. The evidence on this point is conflicting. Some studies catastrophic reaction may be an example of suggest that psychotic symptoms are more common aggressive behaviour caused by this means. This with increasing impairment (Cooper et al., 1991; term refers to emotional responses precipitated by Gilley et al., 1991; Jeste et al., 1992). Others, howtask failure (Goldstein, 1952) and can include vio- ever, have found no such relationship with regard lent responses such as hitting and physical resis- to delusions (Burns et al., 1990a; Cummmings e f tance to care (Yudofsky et al., 1990). The high al., 1987). Jacoby and Levy (1980) reported that frequency of aggressive behaviour during intimate delusions were less common the greater the degree care may be partly related to task failure. This beha- of atrophy as measured by CT scan. The reason vioural disturbance needs further evaluation and for the conflicting evidence may be variation in the criteria used to identify delusions. On a priori ethological analysis. The impaired ability to communicate can lead to grounds one might expect that well-formed increasing frustration and aggressive behaviour in delusions might become less common as the response to both internal stimuli such as pain and dementia progresses, but delusions related to cogniexternal stimuli such as noisy or unfamiliar sur- tive impairment more frequent. Anecdotal evidence suggests that aggressive roundings (Leibovici and Tariot, 1988). Aggressive behaviour often occurs in the context of interperso- behaviour is sometimes directly related to delusions nal interactions (Ryden, 1988) and may partly be and hallucinations particularly when the content due to misinterpretation of the actions of the carer. concerns suspiciousness, stealing and threats of Indeed, being asked to do something or being bodily harm. In addition, systematic studies have

46 1


shown that patients who suffer psychotic symptoms are more likely to be aggressive (Rovner et al., 1986; Lopez et al., 1991). A further study has shown a direct relationship between persecutory delusions, hallucinations and illusions with physical aggressions in dementia (Deutsch et al., 1991). The role of depression in causing aggressive behaviour in dementia is unclear. Several studies of the prevalence of depression among people with dementia have been carried out (for example Burns et al., 1990c; Rovner et al., 1989; Patterson et al., 1990). These give an estimated prevalence in the region of 20%. A good review of depression (and psychosis) in Alzheimer’s disease is given by Wragg and Jeste (1989). In non-demented people it is well known that agitation and irritability can be a feature of depression. The question therefore arises as to whether aggressive behaviour in people with depression may sometimes be a feature of an ‘agitated’ depression. A central difficulty in answering this question is that once the dementia is sufficiently severe to prevent patients from clearly describing their mood the identification of depression has to rely purely on behavioural evidence. There is a danger of circular argument: the ‘agitated’ behaviour is taken as evidence for depression. Agitation is, for example, an item in the Cornell Scale for Depression in Dementia (Alexopoulos et al., 1988). Neither does a response of the behaviour to antidepressant medication solve the problem because the medication may affect the behaviour directly through its effect on transmitters (Hope et al., 1991; Liston et al., 1987). Some authors have suggested that aggressive behaviour in dementia represents an exacerbation of premorbid personality traits (Zarit et al., 1985). Many types of behaviour perceived by relatives as representing radically new and abnormal patterns may be a perpetuation of previous well-established behaviour, in which the manner of presentation has been altered by disease (Shomaker, 1987). Alternatively, behavioural disturbances may be seen as a part of the ‘personality change’ induced by organic brain damage in dementia (Rubin et al., 1987). Hamel et al. (1990) found a relationship between premorbid aggressiveness and a troubled relationship with the carer and the level of aggressive behaviour after the onset of dementia. Ware et al. (1990) found that in 58% of their community-based subjects, aggressive behaviour was seen by the principal carer as an exaggeration of premorbid personality traits.

Environmentalfactors

There is increasing evidence that environmental factors play an important role in precipitating aggressive behaviour in dementia. Noise, inadequate lighting and moving to unfamiliar places can trigger the behaviour (Silliman et al., 1988). Carers can become irritable and aggressive themselves, which in turn can worsen the behavioural problem (Ware et al., 1990);indeed, as many as 22% of carers in one study reported that they had been aggressive towards the patient (Ryden, 1988). There is evidence that a small group of staff in residential settings are the victims of repeated assault, and it has been suggested that they may have a management style which is subtly adversarial (Cooper and Mendonca, 1989). Anderson (1970) studied ‘disturbed behaviour’ on two wards and found evidence for the aetiological importance of both nursing techniques and ward design; similarly, a recent study highlighted the effect of ward milieu on disturbed behaviour in patients with dementia (Minde et al., 1990).

PREVALENCE Most studies of the prevalence of aggressive behaviour in dementia are flawed by the lack of both a clear definition of the behaviour and a reliable method for assessment. Figures for the prevalence of aggressive behaviour are likely to be affected by the severity of the dementia within the population being studied. Most of the evidence suggests that, in general, the greater the degree of cognitive impairment, the more frequent, and more severe is the aggressive behaviour (Teri et al., 1988; Nilsson et al., 1988; Burns et al., 1990d; Cohen-Mansfield et al., 1990), although there are also studies which have failed to find any relationship (Hamel et al., 1990). Aggressive behaviour tends to be more common in the daytime and especially in the morning (perhaps because this is when intimate caring activities are most frequent) (Pate1 and Hope, 1992b; Meyer et al., 1991). Meyer et 01. (!??!) report an increased prevalence of aggressive behaviour in the winter months and propose a seasonal variation similar to that reported in some affective illnesses. Haller et al. (1989) compared a group of patients with dementia admitted to hospital because they had been violent at home with a similar group of non-violent patients. They found that there was no difference between the two groups

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residents had a diagnosis of organic brain syndrome. Rovner and colleagues (1986) reported that 76% of residents in an intermediate-care nursing home demonstrated at least one behavioural problem; 40y0 demonstrated five or more types of disturbed behaviour. The most common types of disturbed behaviour were: disruptive; being noisy; restless; verbally and passively aggressive behaviour. Chandler and Chandler (1988) reported that 48% of residents showed aggressive and agitated behaviour, whereas Winger et al. (1987) reported that some kind of aggressive behaviour occurred in 91% of the residents. In summary, studies on institutionalized patients show a high prevalence of aggressive behaviour in dementia, and in general psychogeriatric populaHospital samples tions, patients with dementia account for most of Burns et al. (1990d), using a definition of aggressive the aggressive behaviour. behaviour limited to actual physical harm, found an overall prevalence of 20% in their elderly inpatient sample. We studied hospitalized psychogeria- Community samples tric patients using the RAGE (Patel and Hope, Problems of aggressivebehaviour are also common 1992b) and found that nearly half the sample was among community-based patients with dementia. at least mildly aggressive over a 3-day period. Fif- The evidence contradicts the common assumption teen per cent of this sample was rated as showing that the majority of those patients who are signifieither moderately or severely aggressivebehaviour. cantly aggressive are in institutional care. Thirty Rabins et al. (1982) reported that 47% of their per cent of Reisberg et al.’s (1987) sample of 57 mixed sample of in- and outpatients showed physi- outpatients with a diagnosis of Alzheimer’sdisease cal violence, while 71% were demanding and criti- were ‘violent’, this being one of the most common cal. On the whole, patients with dementia account behavioural disturbances observed. Between 20 for a significant majority of assaults and aggressive and 50% of families in some studies have reported behaviour in elderly inpatient settings (Tardiff and physical violence as a ‘serious’care problem (Argyll Sweillam, 1979; Rovner et al., 1986; Patel and et al., 1985; Colerick and George, 1986). Ryden Hope, 1992b), although there is evidence that such (1988) using the Ryden Aggression Scale reported patients, while being more aggressive,are less likely a prevalence of verbal aggression in 49%, physical to be physically violent (for example using danger- aggression in 46% and sexual aggression in 17% ous weapons) than non-cognitively impaired psy- of 183 community-based patients. Hamel et al. chotic patients (Petrie et al., 1982). (1990) using the same rating scale found that 57% Despite the high overall prevalence of aggressive of their sample of 213 patients living at home were behaviour, the frequency of injuries sustained by verbally aggressive and 34% were physically victims is low (Patel and Hope, 1992b). Most aggressive. Swearer et al. (1988) assessed 129 outpaaggressive behaviour tends to be directed to carers tients using the Behaviour Severity Rating Scale such as ward staff, rather than to objects or to self in conjunction with telephone interviews. They (Nilsson et al., 1988;Patel and Hope, 1992b; Meyer found that 51% of the sample had angry outbursts et al., 1991). and 21% showed assaultive behaviour.

with regard to gender, ethnic group and social class. However, married patients and those who lived with a family were overrepresented in the violent group, perhaps because of the availability of a potential victim and because there are fewer social inhibitions to violence against close relatives. There are no clear relationships between aggressive behaviour and either the sex or age of the patient (Donat, 1986), nor is there any clear relationship with the degree of dependency on nursing staff (Patel and Hope, 1992b). Estimates of prevalence are available for patients in hospitals, in nursing homes and those living at home in the community. We will consider these separately.

Nursing home samples

Zimmer et al. (1984) in a survey of skilled nursing facilities for the elderly found that 22.6% of the residents had ‘serious’ behavioural problems including physical aggression, self-harm, resisting care and verbal aggression. Two-thirds of these

CLASSIFICATION Aggressive behaviour in dementia can be broadly classified into four categories: verbal aggressive behaviour; physical aggressive behaviour; sexual aggressive behaviour; and self-abusive behaviour


(Ryden, 1988). These categories further comprised a number of types of behaviour which can be classified in two ways: either by the type of act or by the setting in which the behaviour occurs (Table 1). Ware et al. (1990) proposed a classification based mainly on setting (such as intimate care) on the grounds that this may relate more closely to aetiological factors than does the nature of the aggressive act itself. Thus, their classification includes categories such as ‘occurring during intimate care’ and ‘occurring at night’. Burgio et al. (1988) use a functional classification, viz ‘acting out behaviour’ (including both verbal and physical aggression), ‘aberrant behaviour’ (such as screaming and self-injury) and ‘excess disability’, which is a behaviour in excess of that which would exist purely on the basis of the patient’s functional incapacity. A problem with this classification is the difficulty in identifying the category to which a particular behaviour belongs. Furthermore, the ascription of behaviour as, for example, acting out is problematic in the setting of dementia. We (Patel and Hope, 1992a) divided the construct of aggressive behaviour into its component types, for example shouting and abusing (types of verbal aggression); kicking and destroying property (types of physical aggression); pushing others, deliberately breaking ward discipline (types of antisocial behaviour). Factor analytic studies support a distinction between verbal aggression and physical aggression (Cohen-Mansfield and Billig, 1986;Patel and Hope, 1992a). In the latter study, a third factor consisting of antisocial acts such as pushing others emerged. An analysis of the types of aggressive behaviour reveals that being uncooperative or resisting help is the most common type of behaviour observed and verbal aggressive behaviour is much more frequently encountered than physical aggression (Cohen-Mansfield, 1986, Hamel et al., 1990; Patel and Hope, 1992b). Irritability is also common and seems to be unrelated to premorbid personality traits (Burns et a[., 1990e). Among the types of physical behaviour, biting, scratching, spitting, hitting and kicking are the most frequent; destroying property, being sexually offensive, inflicting serious injuries, and self-harm are rare (Patel and Hope, 1992b). ASSESSMENT Much of the current literature on aggressive behaviour in dementia is handicapped by the lack of a

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Table 1. Two ways of classifying aggressive behaviour 1. Based on the setting in which the behaviouroccurs During intimate care As a response to the misinterpretation ofevents, or the intention of others As a response to being prevented from undertaking an inappropriate task As a response to instructions In response to the aggressive behaviour of others In order to attract attention, or to gain an end Occurring at night Secondary to paranoid beliefs Irritability (not situation-specific)

2. Based on the type of behaviour Verbal aggressive behaviour Shouting, yelling or screaming Swearing or using abusive language Argumentative or demanding Being sarcastic, critical or derogatory Threatening to harm Physical aggressive behaviour Pushing or shoving Biting Kicking Hitting Spitting Pinching Scratching Destroying property Other Antisocial behaviour, eg deliberately tripping someone Being uncooperative or resisting help Sexually aggressive behaviour Attempting to harm self

reliable and valid method for assessing the behaviour (Cohen-Mansfield and Billig, 1986; Nilsson et al., 1988), although an increasing number of instruments have been developed in recent years. Assessment is important for good management and if it is inadequate it may lead to inappropriate medication or dangerous polypharmacy (Salzman et al., 1972; Kushnir, 1987). Bertilson (1983) described four ways of assessing aggressive behaviour: individual case studies; personality assessment; interviews; and behavioural assessment. The methods which can be used include clinical assessment, selfreport inventories, interviews, observation-based rating scales and direct observation. Unstructured clinical assessment has been the most frequently used method in published treat-

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ment studies. However, Lion et al. (1981) have shown that such unstructured observations document five times fewer aggressive episodes than structured daily ward reports. Self-report inventories have been used extensively in studies on human aggressive behaviour (eg Buss and Durkee, 1957). However, these are of little value in dementia, mainly because the cognitive impairment precludes patients cooperating in completing self-report inventories, and partly because these measures do not correlate well with aggressive behaviour (Edmunds and Kendrick, 1980). There is only one personality inventory which is relevant to the study of aggressiveness in people with dementia. This is the inventory of Brooks and McKinley (1983), which was developed to study personality changes following head injury. It consists of a number of analogue scales with bipolar adjectives (such as ‘even tempered’ and ‘quick tempered’ or ‘irritable’ and ‘easygoing’). This inventory is designed to be completed by a relative and has been used by Petry et al. (1988, 1989) to compare patients with dementia and non-demented controls. The Present Behavioural Examination (PBE) (Hope and Fairburn, 1992) is the only semistructured interview covering a wide range of behaviour for use with people suffering from dementia. It is designed to be administered to the principal carer. It has subsections on aggressive behaviour and information is collected on behaviour over a 28-day period. This subsection has been used in a community-based study of aggressive behaviour in dementia (Ware et al., 1990). Psychometric data on interrater and test-retest reliability have been published (Hope and Fairburn, 1992). Observation-based rating scales designed to be completed by carers are less time-consuming to administer than semistructured interviews. Global behaviour rating scales such as the Geriatric Rating Scale (Plutchik et al., 1970) or the Psychogeriatric Dependency Rating Scale (Wilkinson and GrahamWhite, 1980) have been widely used in studies of dementia. Although such scales contain some items on aggressive behaviour, these are generally too few for the scales to be useful in studies which focus on the behaviour. Furthermore, aggressive behaviour has been demonstrated to cluster into discrete factors independent from other behaviour and cognitive functions (Smith et al., 1977; Hersch et al., 1978; Gilleard, 1984). For these reasons, and because of the increasing availability of specific measures of aggressive behaviour, these global

behaviour scales are not recommended for the study of aggressive behaviour in dementia. In recent years, a number of observer rating scales specifically designed for measuring aggressive behaviour have been developed. These are summarized in Table 2. Of the 23 items of the Rating of Aggressive Behaviour in the Elderly (RAGE) (Pate1 and Hope, 1992a) 19 are specific types of behaviour; the remaining represent the consequences of the behaviour or the interventions used to control it. The behavioural items are rated on a four-point scale of frequency. A ‘global aggression score’ can be obtained by adding all the ratings. The psychometric properties of the scale have been extensively investigated. The scale is sensitive to change and is suitable as an outcome measure in treatment studies. The Ryden Aggression Scale (RAS) (Ryden, 1988) is a similar rating scale but is designed for use in community-based patients. Reliability data have been reported for the overall scale and subscales but there are no validity data. The Staff Observation Aggression Scale (SOAS) (Palmstierna and Wistedt, 1987; Nilsson et al., 1988) is different in that it is not a measure of aggressive behaviour over a given period of time. Instead, it provides an analysis of an individual aggressiveepisode. The severity of the aggressive behaviour is measured in part by the measures taken by the staff to control the behaviour. Since such methods are greatly influenced by ward policies, the severity rating will reflect such policies as much as the behaviour itself (Soloff, 1987). The Social Function and Aggression Scale (SDAS) (Wistedt et al., 1990) was designed, unlike the SOAS or OAS, to cover the total range of mild, moderate and severe aggressiveness. Unlike the other scales it is rated by psychiatrists, presumably on the basis of interviews with care staff. The Overt Aggression Scale (OAS) (Yudofsky et al., 1986), like the SOAS, measures individual aggressive episodes and gives an emphasis to physical aggression. It has been designed for use in a general psychiatric population. Aggressive behaviour is divided into four categories: verbal aggression, and physical aggression against self, objects and people. Behaviour severity is measured on the basis of qualitative worsening of behaviour in individual categories, for example, ‘breaking objects’ scores higher than ‘throwing objects down’. In addition, like the SOAS, intervention used to control aggressive behaviour is used as a measure of its severity. The Modified Overt Aggression Scale (Kay et al., 1988) overcomes some of the psychometric weaknesses of the OAS by upgrading the

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Table 2. Observer rating scales for aggressive behaviour in dementia Rater

No. of items

Special points

Patel and Hope (1992a) Psychogeriatric

Care staff

23

Observations over 3 days. Best used with ward checklist

RAS

Ryden (1988)

Community-based elderly patients

Carer 25 Subscales for physical aggression, verbal aggression and sexual aggression. Observations over 1 week to 1 year

SOAS

Palmstierna and Wistedt (1987)

Psychogeriatric inpatients

Care stafF(nurses)

3 categories

Does not include verba1 aggression. A measure of severity of individual aggressive acts

SDAS

Wistedt et al. (1990)

?Psychiatric patients

Psychiatrist

11

Observations over 3-7 days

OAS

Yudofsky et al. (1986) General psychiatric patients

Care staff

4 categories

A measure of severity of individual aggressive acts

Modified OAS

Kay et al. (1988)

4 categories

Based on OAS but designed to have better psychometric properties

CohenMansfield Agitation Inventory

Cohen-Mansfield Nurses (1 989) ?Psychogeriatric patients

29

Only half items cover aggressive behaviour

Nurses

4

Scale

Reference

RAGE

Disruptive Mungas et al. (1989) Behaviour Rating Scale

Target population

General psychiatric patients Care staff

Institutional patients with dementia

Only 2 items concern aggressive be haviour

nominal rating scale to an ordinal five-point scale aggressive items is also provided. The severity of representing increasing levels of aggression, pro- the behaviour is measured on the basis of the nature viding operational definitions for each category of of the intervention in response to the behaviour. behaviour, adding new items such as suicidal Ratings are made on behaviour over a 7-day period. behaviour and introducing a total weighted score. A ‘total disruptive score’ is obtained by adding the These scales are suitable for differentiating assaul- four ratings. There are some data on the psychotative patients (Armstrong, 1983) in general psychi- metric properties of the scale. There are few studies reported which make use atric settings, but their value in the elderly requires further clarification. The Cohen-Mansfield Agi- of direct observation in the study of aggressive tation Inventory (Cohen-Mansfield, 1989) covers a behaviour. Direct observation was used in a small wide range of ‘agitated’ behaviour and only half validation study for the RAGE (Patel and Hope, the items directly pertain to aggression. The 1992a). Cohen-Mansfield et al. (1989) developed remainder cover activity disturbances (wandering), the Agitation Behaviour Mapping Instrument to hoarding and abnormal eating. The Disruptive record observational data on specific categories of Behaviour Rating Scale (Mungas et al., 1989) con- ‘agitated’ behaviour (including aggressive behavsists of four items (‘dimensions of disruptive behaviour) as well as social and physical aspects of the iour’), each rated on a five-point scale, two of which environment. The instrument employs the ABC concern aggression. A checklist of 13 specific method of behavioural analysis (ie antecedents,

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behaviour and consequences) and uses stratified random time sampling method (ie each patient is observed for 3 consecutive minutes in each hour over a 24-hour period). Observers require training and a high interobserver agreement is reported. Vaccaro (1988) reports using observational data to test the efficacy of operant procedures in institutionalized elderly aggressive patients. The methodological issues raised by the observational assessment of behaviour have been reviewed by Barlow and Hersen (1984) and Pate1 and Hope (1992c). MANAGEMENT Aggressive behaviour in dementia can pose major management problems. Management will depend on the aetiology of the behaviour so that a thorough clinical assessment of the patient is necessary. The first stage in the assessment is confirmation of the dementing illness. Any treatable cause for the dementia clearly needs appropriate management. The second stage is to consider whether the aggressive behaviour is the result of physical disease additional to the dementia such as an acute confusional state. If there is no clear treatable underlying disease which may be causing the aggressive behaviour, then management must be directed at the behaviour itself and its consequences. Both psychosocial and physical treatments need to be considered. Useful practical accounts of the psychological and environmental treatments are given by Stokes (1987), Knopman and Sawyer-DeMaris (1990) and Garland (1991). Skews (1988) reports a training programme developed specifically for nursing staff in order to help with the management of aggressive patients. Silliman et af. (1988) emphasize the importance of involving the family in the treatment of patients living at home. Carers benefit from support groups and self-help books (eg Woods, 1989). The importance of early recognition of an impending crisis, the use of a reassuring and gentle voice, approaching an aggressive patient slowly and calmly, the value of distracting the patient or removing oneself from the same room and the judicious use of touch and non-threatening postures are some of the ways in which carers can help reduce the risk of aggressive behaviour (Teri and Logsdon, 1990). Staff and carers need to use positive and clear language when communicating with the patient, and attempt to identify possible needs and feelings that underlie the behaviour (Cohen-

Mansfield, 1989). Stokes and Goudie (1990) emphasize the importance of being sensitive to possible ‘concealed meanings’ present in apparently confused speech in reducing disruptive behaviour. The alteration of the ward environment to allow for more personal space for patients and the use of behavioural measures such as positive reinforcement have also been advocated (Minde et al., 1990; Vaccaro, 1988). A variety of drugs have been used in the management of aggressive behaviour in dementia. ‘Agitated’ demented patients (which includes those showing aggressive behaviour) receive more medication and suffer more falls than non-agitated patients (Cohen-Mansfield, 1986). Most reports of drug treatments are anecdotal, with poor description of the target behaviour and scanty details about the patient (Schneider and Gleason, 1989); furthermore, good outcome measures have only become available in the past few years. There are a number of comprehensive reviews of drug treatments (Risse and Barnes, 1986; Volicer and Herz, 1985; Salzman, 1988; Leibovici and Tariot, 1988). Major tranquillizers are the most frequently used group of drugs and their use has been well reviewed elsewhere (Wragg and Jeste, 1988; Devenand et al., 1988; Sunderland and Silver, 1988; Helms, 1985; Tune et af., 1991). A range of major tranquillizers has been evaluated including thioradazine (Stotksy, 1984; Kirven and Montero, 1973; Barnes et al., 1982; Risse et al., 1987; Ather et al., 1986), haloperidol and other butyrophenones (Fuglum et al., 1989; Lovett et al., 1987; Fisher et al., 1983; R i s e et af.,1987; Steele et al., 1986),zuclopenthixol (Fuglum et al., 1989; Nygaard et al., 1987), pimozide (Kushnir, 1987) and trifluoperazine (Lovett et al., 1987). A meta-analysis of double-blind trials of a major tranquillizer and placebo has shown that the former are significantly more effective (Schneider et al., 1990). However, major tranquillizers are not necessarily specific in managing aggressive behaviour and indeed may often act simply by sedating the patient. In some cases, they may lead to worsening of the behaviour. Further, the elderly are especially susceptible to other sideeffects of these drugs, and these often have a delayed onset due to the low-dose treatments used; thus it is important to monitor patients frequently (Tune et al., 1991). A variety of other psychotropic drugs have been used to treat aggressive behaviour in dementia. Virtually all the reports involve small case series or case reports and there is little standardization of

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the definition or measurement of the target behaviour (Schneider and Sobin, 1991). A number of drugs which enhance 5-HT activity have been found to be of value, including trazodone and tryptophan (Wilcock et al., 1987; Simpson and Foster, 1986; Patterson and Srisopark, 1989; Greenwald et al., 1986; Pinner and Rich, 1988), fluoxetine (Sobin et al., 1989) and buspirone (Colenda, 1988; Tiller et al., 1988). Other drugs which have been reported as effective include carbamazepine (Patterson, 1988; Leibovici, 1988; Marin and Greenwald, 1989; Gleason and Schneider, 1990), propranolol (Stewart et al., 1987; Sorgi et al., 1986; Weiler et al., 1988) and warfarin (Walsh, 1989). There is a growing literature on the use of benzodiazepines such as clonazepam (eg Freinhar and Alvarez, 1986) and diazepam (eg Kirven and Montero, 1973). It appears that short-term use (4-8 weeks ) is superior to placebo and potent shortacting drugs such as oxazepam are superior to longacting ones (Stern et al., 1991). Whether it is the half-life or the potency which is important is unclear. However, benzodiazepines are problematic in the demented elderly because they tend to accumulate and exacerbate confusion. Low-dose major tranquillizers are at least as effective in reducing aggressive behaviour and generally safer. Yudofsky et al. (1990) classify aggression as either acute or chronic. They suggest that major tranquillizers (especially haloperidol) or short-acting benzodiazepines should be the mainstay in the management of acute aggression, whereas propranolol and serotonergic agents are recommended for chronic aggression. Because of the high frequency of side-effects from major tranquillizers, these authors recommend that these drugs should be used in the management of chronic aggression only if there is evidence that psychotic symptoms are a factor causing the behavioural disturbance. Despite the large number of studies, there is little information relating either patient characteristics or the type of aggressive behaviour with the most effective drug treatment. CONCLUSIONS Aggressive behaviour in dementia is one of the most serious disturbances and poses a major management problem for carers and clinicians. It is a common reason for admitting patients to hospital and for the use of drug treatments. Despite this, it is only recently that there have been systematicinves-

tigations into the nature, causes and types of such behaviour. The concept of ‘aggression’ is problematic in cognitively impaired people because it is unclear whether the intention to harm can be formed or reliably assessed. We recommend the use of definitions of aggressive behaviour which emphasize the observable aspects of individual types of behaviour and which avoid the notion of ‘intent’. Several rating scales and other instruments for the assessment of aggressive behaviour in dementia have been developed in recent years. However, few have been shown to be valid and reliable. Given the diverse aetiology of aggressive behaviour, future progress is likely to depend on developing a variety of different approaches to treatment based on careful analysis of the behaviour. The time is ripe for detailed research on the nature, aetiology and treatment of aggressive behaviour in dementia. ACKNOWLEDGEMENTS We are grateful to Sandra Cooper for help in tracking down the growing literature on this subject. VP was on a Rhodes Scholarship for part of the period in which this review was written, and TH was in receipt of a Wellcome Trust Training Fellowship and Medical Research Council Special Project Grant to enable research to be carried out on behavioural problems in dementia. REFERENCES Alexopoulos, G. S., Abrams, R. C., Young, R. C. and Shamoian, C. A. (1988) Cornell Scaie for depression in dementia. Biol Psychiat. 23,211-284. Anderson, J. F. (1970) A study of disturbed behaviour in patients with dementia in two hospital populations. Gerontol. Clin. 12,4944. Argyll, N., Jestice, S. and Brook, C. P. B. (1985) Psychogeriatric patients: Their supporters’ problems. Age Ageing 14,355-360. Armstrong, S . (1983) Assaults and impulsive behaviour in general hospitals: Frequency and characteristics.In Assaults in Psychiatric Facilities (J. R. Lion and W. H. Reid, Eds). Grune & Stratton, Orlando. Ather, S. A., Shaw, S. H. and Stoker, M. J. (1986) Comparison of chlormethiazole and thioradazine in agitated confusional states of the elderly. Acta Psychiatr. Stand. Suppl. 329,73,81-91. Barlow, D. H. and Hersen, M. (1984) Single Case Experimental Designs: Strategies for Studying Behaviour Change. Pergamon, Oxford.

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