Abstract
In 2005, a report from the United Nations Populations Division noted that the number of individuals aged 60 years and older is expected to nearly triple, increasing from 672 million in 2005 to almost 1.9 billion by 2050. Currently the elderly population in developed countries has surpassed the number of individuals under the age of 14 years, and by the year 2050 it is anticipated that there will be two elderly persons for every child. Population aging is thus anticipated to precipitate a situation in the United States where health care needs for older-adult populations may exceed care access and availability. This may be particularly pressing in the case of mental health conditions accompanied by behavior that put individuals at physical risk.
It has been reported that 27% of all workplace violence occurs in nursing homes. Aggressive behavior by older individuals with mental disorders incurs substantial humanitarian and financial burden on patients, families and society at large. This review will address aggression in elderly populations with general medical conditions that include delirium, toxic states and drug-drug interactions as well as in populations with dementing illness, mood and anxiety disorders and psychotic disorders. A pragmatic approach optimizing safety and quality of life for individuals, families and caregivers is stressed. Lastly, recommendations for future research in late-life aggressive behavior are provided.
Keywords: Elderly, aggression, delirium, dementia
Introduction and Background
Aggressive behavior amongst the elderly population is a significant problem in the community and in institutions. The relative paucity of information on the subject and the projected aging trends globally, particularly in developed countries such as the United States, are indicative that there is increasing need for additional research. In 2005, a report from the United Nations Populations Division noted that the number of individuals world-wide aged 60 years and older is expected to nearly triple, increasing from 672 million in 2005 to almost 1.9 billion by 2050 [1]. Currently the elderly population in developed countries has surpassed the number of individuals under the age of 14 years, and by the year 2050 it is anticipated that there will be two elderly persons for every child [1]. According to the U.S. Census Bureau, the percentages of people aged 60 and over are projected to increase from 16.8% of the U.S. population in 2005 to 25.1% in 2030 [3].
Prevalence of aggressive behavior in elderly persons differs drastically amongst studies. In institutional settings, Zimmer reported aggressive behavior occurring in 8.3% of patients [4], whereas Winger reported 91% [5]. Prevalence rates for community settings differ from 1% [6] to 47% [7]. This wide range of prevalence can be attributed to researchers’ diverse definitions of aggressive behaviors as well as sampling methods and sample composition. The definitions of aggressive behavior amongst studies have included tantrum-like behaviors, physical aggression, self-injurious behavior, property destruction, and verbal abusiveness. The divergence of prevalence reports can also be attributed to the use of differing methods, including standardized scales to evaluate aggressive behaviors. Common standardized measures of aggression include, but are not limited to, the Cohen-Mansfield Agitation Inventory (CMAI) [8], the Rating Scale for Aggressive Behavior in the Elderly (RAGE) [9], and the Ryden Aggression Scale [7]. Additionally, researchers derive their data from varying sources including incident reports [10], caregiver report [11], patient interview [12], or review of the medical record [13].
Aggressive behavior and agitation are a non-specific group of behaviors that can occur in the context of many different clinical conditions. Phenomenologically there are several behavioral syndromes which may overlap with aggression or agitation, including restlessness, hyperactivity, fidgetiness and akathisia as well as vegetative symptoms such as changes in sleep and sleep cycles.
The functional nueroanatomy and the neurochemical basis of agitation have not been clearly elucidated. A model proposed by Sachdev and Kruk [14] posits agitation as a disturbance in multiple brain circuits involving the limbic system, the striatum, the globus pallidus, and disinhibition in neurons of the thalamocortical tracts and brain stem. Because of the involvement of multiple and differing parts of the brain, various neurotransmitters may be at least partially responsible for some of the behaviors observed in agitated states. For example, in the case of agitated depression there is an increase in serotonergic responsivity with a decrease in GABA [15]. In mania and acute psychosis there is an increase in dopamine, in dementia there is a decrease in GABA, in panic disorder and GAD there is an increase in norepinephrine and a decrease in GABA with a decrease in dopamine and an increase in norepinephrine in the case of akathisia [15].
The impact of aggressive behaviors can be very detrimental to the elderly aggressor, as well as caregivers. Studies have indicated that as much as 20% of caregivers for people with dementia report physical violence as a serious problem [16]. These behaviors may result in physical danger to those in close proximity to the aggressor, to the caregiver, or to the aggressor themselves.
In addition, those who commit these behaviors often elicit reactions from others that exacerbate the behavior. According to Patel and Hope, aggressive behaviors cause the greatest impact on the elderly and their caregivers [17]. It has been found that caregivers who have been physically abused by their care receivers are more likely to act abusively in return [18]. In addition, aggressive behavior is one of the most frequent causes for institutionalization among the elderly and increases the requirement for drug therapy and hospitalization [19].
The health care professional facing a clinical situation in which aggressive behavior is present is confronted with two tasks: assess the clinical situation and treat the individual/manage the environment. The detail involved in the evaluation is determined by the circumstances surrounding the patient and the urgency demanded by the characteristics of the symptoms.
Many times the professional facing these issues has to act quickly without all the information available in order to guarantee the safety of the patient or the people surrounding the patient. The first step is to determine if the patient is suffering a delirium. In general terms delirium can be defined as a transient, potentially catastrophic or life threatening syndrome caused by severe and acute physiological changes in the brain. Delirium is commonly seen in medical conditions or toxic states due to medications or drug interactions.
Elderly individuals with chronic impairment in cognition and behavior caused by neurological damage or degeneration may have dementia. Both delirious and demented patients may exhibit a variety of psychiatric and/or neurological signs and symptoms with clear manifestations of irritability, agitation, aggression, fear, anger, suspiciousness, cognitive impairment, sleep-wake cycle disruption and extra sensibility to stimuli.
Elderly individuals who exhibit aggression and behavior symptoms may also suffer from mood, anxiety or psychotic disorders as will be discussed in this topic. Appropriate assessment and treatment of these psychiatric conditions will reduce /resolve aggressive behavior and is generally associated with improvement in symptoms and functional status. Therapeutic approaches aimed to optimize safety and enhance quality of life are needed to address and decrease aggressive behaviors irrespective of underlying cause. It is important for caretakers to uphold the dignity of the care receivers to the maximum level possible and respect their rights of privacy.
In summary, population aging is anticipated to precipitate a situation in the United States where health care needs for older-adult populations may exceed care access and availability. This may be particularly pressing in the case of mental health conditions accompanied by behavior that puts individuals at physical risk. Aggressive behavior by older individuals with mental disorders incurs substantial humanitarian and financial burden on patients, families and society at large.
This review will address aggression in elderly populations with general medical conditions that include delirium, toxic states and drug-drug interactions as well as dementing illness, mood and anxiety disorders and psychotic disorders. A pragmatic approach with optimizing safety and quality of life for individuals, families and caregivers is stressed. Lastly, recommendations for future research in late-life aggressive behavior are provided.
Aggression in Elderly Patients with Medical Conditions
Elderly patients are more likely than younger patients to have a number of health problems [20]. These medical conditions often lead to an increased number of prescriptions, increased hospitalizations, and an increased number of prescribing medical specialists. The ageing brain has less "cerebral reserve" and is more sensitive to minor and major alterations in physiology. Elderly patients are likely to react differently to a vast array of medical conditions, from minor infections to major surgery, compared to their younger counterparts. The result of multiple medical conditions, medications, and an alteration in physiology is often delirium; aggressive behavior can be a manifestation of this delirium. Understanding delirium and its management is essential to a positive outcome for an aggressive elderly patient with medical conditions.
Delirium and Toxic States
Delirium is an acute disturbance in consciousness and cognition that is causally linked to physiologic changes and is especially common in older populations. In adults, as age increases, vulnerability for delirium increases as well, with the highest incidence in those aged 60 years and older [21]. Additional factors that increase the risk for delirium are cognitive disorders, recent surgery, specific medical conditions, and certain medications. Delirium is typically transient and reversible, thus the etiology needs to be thoroughly investigated as quickly as possible once a diagnosis is reached. The rate of delirium in the general population is difficult to assess; most studies on prevalence of delirium focus on specific hospital referrals or specialized hospitalized populations. Across these studies, delirium is evident in 5-44% of patients aged 65 years and older on medical/surgical wards or in long term care facilities [22-25]. Specialized populations with higher rates of delirium include those patients with recent coronary artery bypass grafting (CABG), recent hip replacement, advanced cancer, or on mechanical ventilation in the intensive care unit [26-28]. Delirium is important to identify and treat, as it is associated with mortality in 25% of patients [29] and also contributes to longer hospitalizations and increased cost of hospitalization [30, 31].
Delirium is characterized by impairment of consciousness and cognition, developing over a short period of time, and explained by a change in physiologic condition. The disturbance in consciousness can be a decrease in ability to focus and/or difficulty sustaining or shifting attention. The disturbance in cognition can manifest as disorientation, perceptual changes, alteration in memory function, or changes in language ability. This cognitive impairment must not be better explained by preexisting, established, or evolving dementia. These changes in consciousness and cognition must have developed over a short period of time (hours to days) and tend to fluctuate over the course of a day. A prodrome is frequently described in the hours to days leading up to florid delirium, characterized by restlessness, irritability, sleep disturbance, and distractibility; a review of the patient record/caregiver report may reveal subtle symptoms building over the course of a few days. A diagnosis of delirium is reached if the changes in consciousness and cognition are noted in response to a physiological change, such as medical condition, administered medication, or illegal substance use or withdrawal. When diagnosing delirium, an etiology needs to be identified (e.g. delirium due to hepatic encephalopathy). Delirium due to multiple etiologies can be diagnosed if several factors seem to be contributing; if no clear etiology is evident, a diagnosis of delirium not otherwise specified is warranted [32].
Delirium can be described as hypoactive or hyperactive, based on psychomotor behavior, and is frequently under recognized and under diagnosed [33]. Delirious patients with relative alertness, though continued clouding of consciousness (hyperactive delirium) are more likely to experience hallucinations, delusions, and illusions, as well as to exhibit agitation [34]. Hypoactive delirium is frequently misdiagnosed as depression, whereas hyperactive delirium is frequently misdiagnosed as new onset psychosis or behavioral problems. Delirium is a reversible cause of mental status changes, thus needs to be explored when evaluating aggression in an elderly patient with medical conditions. When delirium is superimposed on preexisting dementia, patients demonstrate more aggressivity, agitation, delusions, anxiety, and hallucinations as compared to their non-demented counterparts [35]. Although dementia can present with behavioral problems, any abrupt onset of change in aggression or agitation could be delirium and warrants investigation.
Diagnosing delirium involves recognizing clinical features, as well as a thorough mental status exam and complete physical and neurological exams. The potential contributing medical factors need to be explored through laboratory tests and brain imaging. Electroencephalogram (EEG) typically shows diffuse slowing, though this is a nonspecific finding and most useful when a previous EEG is available (or repeating EEG after delirium resolves). A mental status exam needs to include attention and concentration tasks, evaluation of short and long term memory, visuoconstructual ability, abstraction, and language tasks including writing and naming.
Once delirium has been diagnosed, prompt identification and prioritization of potential contributing etiologies is essential; etiology can be singular (less than 50% of cases) or multifactorial, averaging 2-6 contributing factors per patient [22]. Etiologic categories of delirium include: autoimmune, cardiac, cerebrovascular, drug intoxication, drug withdrawal, hypoxic, infection, metabolic disturbance, neoplastic disease, and traumatic [36]. Medications, especially opiates, benzodiazepines, and drugs with anticholinergic properties, can precipitate delirium. Table 1 illustrates medications commonly associated with delirium.
Table 1. Medications Commonly Associated with Delirium.
|
Analgesics |
opiates (esp. meperidine), salicylates |
|
Antibiotics |
acyclovir, ganciclovir, aminoglycosides, amphotericin B, cephalosporins, interferon, isoniazid, metronidazole, rifampin, sulfonamides, vancomycin |
|
Anticholinergics |
antihistamines, antispasmodics, atropine, benztropine, phenothiazines, tricyclic antidepressants |
|
Anticonvulsants |
Phenobarbital, phenytoin, valproic acid |
|
Anti-inflammatories |
corticosteroids, NSAIDs |
|
Antineoplastic Drugs |
asparaginase, 5-fluorouracil, methotrexate, procarbazine, tamoxifen, vinblastine, vincristine |
|
Antiparkinsonian Drugs |
amantadine, bromocriptine, levodopa |
|
Cardiac Drugs |
beta-blockers, captopril, clonidine, digitalis, lidocaine, methyldopa, procainamide, quinidine, tocainide |
|
Sedative-hypnotics |
barbiturates, benzodiazepines |
|
Sympathomimetics |
amphetamines, cocaine, ephedrine, phenylephrine, theophylline |
|
Others |
baclofen, disulfiram, ergotamines, lithium, propylthiouracil |
Management of Delirium
The first step in managing delirium is to treat the underlying medical cause of the symptoms. Depending on the cause and medical condition of the patient, resolution of delirium could take some time; clinical duration is usually 4 days to two months, with an average of 10-12 days [37]. Psychopharmacologic treatment of symptoms may be required as delirium resolves; aggression and agitation of delirious patients are some of the first symptoms requiring treatment due to the need for safety on a medical/surgical unit or in a long term care facility. Antipsychotic medications have been shown to be effective in treating several aspects of delirium, including aggression and agitation. Haloperidol is the most frequently used, as it is a potent antipsychotic with very little anticholinergic or hypotensive side effects; it is also available in intravenous form, allowing for easier administration. Other antipsychotic medications have been shown to be effective in the treatment of delirium: chlorpromazine, droperidol, olanzapine, risperidone, and quetiapine [38]. Short-acting benzodiazepines, preferably lorazepam may be helpful if delirium is related to alcohol withdrawal; longer acting benzodiazepines should be avoided, as they do not seem to improve delirium and can paradoxically worsen aggression and agitation [39]. Other non-pharmacologic treatment can be employed, including redirection and minimizing disruptions to the environment [40]. If the delirious patient is aggressive or agitated, providing a room near the nursing station and a sitter may be necessary; restraints may be used if all other attempts to keep the patient and others safe have failed. The severity of the delirium typically correlates with the length of time for the symptoms to resolve; thus, early identification and treatment of the underlying cause should aid in quicker resolution of the delirium and less need for treatment of symptoms.
Drug-Drug Interactions
One of the most common contributing factors to delirium is drug-drug interactions with associated adverse medication effects. Older patients frequently have multiple medical problems and multiple providers; they are often taking many medications and all providers may not have access to an accurate medication record. Drug-drug interactions are preventable causes of adverse drug events, increased morbidity and mortality, and higher health costs [41, 42]. Studies on the prevalence of drug-drug interactions are scarce, listing the prevalence as 1 to 66% across all age groups [43, 44]. One study focused on drug-drug interactions among the elderly and reported that the average number of prescribed medications per patient was 7.0; each patient had an average of 0.83 drug-drug interactions, with 10% of those listed as major drug-drug interactions [45]. Kohler and colleagues [46] found that the prevalence of drug-drug interactions in the elderly increases as the number of prescriptions increases.
Elderly patients often present to the Emergency Department or to their primary care providers when experiencing a drug-drug interaction [47]. The clinical presentation of medication adverse effect and drug-drug interactions are identical to delirium as described above. If a timeline can be established, relating a change in medication (discontinuation, addition, extra dose, etc.) with mental status changes; the observed delirium can be directly related to a medication effect. Management of delirium caused by a suspected drug-drug interaction should consist of careful examination of recent medication administration and discontinuation, including communication with patient’s providers, caregivers, and pharmacists if possible. Withdrawing or tapering the offending agent or combination is the first step in management of this cause of delirium. Involving the patient’s entire medical team is recommended, as even slight adjustments in offending medications could cause other health problems. As with any delirious state, medication or environmental interventions may be employed to manage the patient on a medical/surgical floor or in a long term care facility.
As the population ages and more drugs are brought to market, the incidence of drug effects and drug-drug interactions may increase. It is important for providers to coordinate care and for patients to have accurate medication information when presenting to providers in emergent or routine settings. The emergence of electronic prescriptions and medical record may help to decrease the incidence; however knowledge of drug-drug interactions is of key importance, especially in treating the older population. Avoidance of drug-drug interactions is one way to effectively prevent delirium in elderly patients.
Aggression in the elderly population is a frequent occurrence on medical and surgical inpatient units, as well as in long term care facilities. In any patient with a sudden onset of mental status changes, including increased aggressive behavior, delirium should be considered high on the list of differential diagnoses. Management of delirium needs to consist of investigation of underlying cause and treatment of symptoms, often including aggression. Physicians and nursing staff working with an aggressive elderly patient need to work as a team to recognize delirium, determine the cause, and support the patient as symptoms resolve. Drug-drug interactions are easily preventable causes of delirium; physicians need to be aware of dangers of medications in the elderly and of drug-drug interactions in this population. Delirium is one of the few reversible causes of mental status change and has dire consequences if overlooked.
