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MICHIGAN STATE UNIVERSITY _ -
JUDITH LYNN JANDERNOA ‘
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THE DEVELOPMENT OF A PROTOCOL FOR
THE MANAGEMENT OF COMBATIVE BEHAVIOR
IN DEMENTED, ELDERLY, LONG-TERM CARE RESIDENTS
by
Judith Lynn Jandemoa

A SCHOLARLY PROJECT
Submitted to
Michigan State University

in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE in NURSING

College of Nursing

1991

ABSTRACT
THE DEVELOPMENT OF A PROTOCOL FOR
THE MANAGEMENT OF COMBATIVE BEHAVIOR
IN DEMENTED, ELDERLY, LONG-TERM CARE RESIDENTS
By

Judith Lynn Jandemoa

The management of combative behaviors in the demented elderly is a difficult task for
primary caregivers. Within this scholarly project, combative behaviors are defined as
physical responses of demented, elderly, long-term care residents to their environment
which endanger the residents and others in the immediate area. A protocol has been
developed for use by primary caregivers in long-term care facilities when demented,
elderly residents exhibit combative behaviors. Interventions are based upon the literature
reporting on factors causing combative behavior in the demented and techniques for its
management. The protocol was developed by applying Hall’s Progressively Lowered
Stress Threshold model to the problem of combativeness in demented, elderly residents.
Plans for both the follow-up once the combative episode is resolved and the
implementation and evaluation of the protocol are presented. The implications of this
scholarly project for professional nursing, advanced nursing practice, and primary care are

discussed.

Unpublished work, Copyright 1992, Judith Lynn Jandemoa

DEDICATION

To my mother, Barbara Hughes, for her faith in God, love of her family, and inner

strength.

To my father, Dr. John Hughes, for his compassion for the sick, dedication to his family,

and wisdom.

iv

ACKNOWLEDGMENTS

I wish to thank Dr. Barbara Given for her guidance and encouragement as my
scholarly project chairperson, and for her commitment to the advancement of the nursing
profession. I would also like to thank Drs. Sharon King and James Kursch for their
continual support and availability as members of my committee. A special thanks to all
three for serving as role models throughout my graduate education.

To Bets Caldwell, I thank her for offering her time and expertise in assisting with the
preparation of my manuscript.

To the Hafner and Christian families, I wish to thank them for loving and caring for
our daughter, Barbara, and for being there whenever we needed them.

I thank my family (Pat, Frances, Phyllis, Daniel, Elizabeth, David, and George) for
their never-ending faith in me.

Lastly, I wish to thank my husband, Paul, for his love and encouragement, and our

daughter, Barbara, for bringing so much love and joy into our lives.

TABLE OF CONTENTS

Page
CHAPTER I: The Problem
Introduction ................................................ 1
Background of the Problem ...................................... 2
Statement of the Problem ...................................... 14
Project Description ........................................... 14
Overview ................................................. 15
Conceptual Framework ........................................ l6
Conceptual Definitions ........................................ 16
The Progressively Lowered Stress Threshold Model .................... 24
Application of the PLST Model to the Problem of Combativeness .......... 35
Schematic Representation of the Conceptual Framework ................. 37

vi

Page

CHAPTER II: Review of the Literature

Introduction ................................................ 43
Factors Related to Combative Behavior ............................ 43
Agitated Behavior ........................................... 43
Disruptive Behavior .......................................... 47
Aggressive Behavior .......................................... 52
Summary of Factors Related to Combative Behavior ................... 55
Management of Combative Behavior .............................. 57
Behavioral Management ....................................... 58
Environmental Management .................................... 64
Communicative Management .................................... 71
Pharmacological Management ................................... 80
Summary of Management of Combative Behavior ..................... 84
Summary of Literature ........................................ 85

CHAPTER III: Protocol for the Management of Combative Behavior in
Demented, Elderly Residents

Introduction ................................................ 88

vii

 

Page

Presentation of the Protocol ..................................... 89
Prevent Physical Injury ........................................ 89
Diminish Agitation ........................................... 91
Promote Comfort and Rest .................................... 101
Follow-up Plan for Primary Caregivers ............................ 105
Conclusion ............................................... 109

CHAPTER IV: Implementation and Evaluation of the Protocol and Its Impact on

Professional Nursing

Introduction ............................................... 110
Implementation and Evaluation of the Protocol ...................... 110
Application of the Conceptual Framework to the Protocol ............... 122
Project Benefits Related to the Nursing Profession .................... 125
Impact on Nursing Education .................................. 125
Impact on Nursing Practice .................................... 129
Impact on Nursing Research ................................... 130
Implications for Advanced Nursing Practice ........................ 133
Implications for Primary Care .................................. 139
Conclusion ............................................... 145

viii

Page

Appendices
Appendix A: Format of the Protocol for Clinical Use .................. 147
Appendix B: Resources Required to Implement and Evaluate the Protocol . . . 154
Appendix C: Letter of Permission to Copyright ...................... 158
List of References ............................................ 159

Figure 1.

Figure 2.

Figure 3.

Figure 4.

LIST OF FIGURES

Page
Stress threshold in normal individuals .................. 29
Progressively lowered stress threshold in adults
with progressive degeneration of the cerebral cortex
(Alzheimers’s Disease and related disorders) ............. 30
A typical day for an adult with a dementing illness
in an unstructured care program ...................... 31
Schematic representation of the conceptual
framework ..................................... 38

CHAPTER I
The Problem
Introduction

America is growing old. The 65 and older age group has increased in size much
more rapidly than the other segments of the United States population--by 54% in the last
2 decades, compared to a 24% increase for those under 65 (US. Senate Special
Committee on Aging, 1985). The reason for this large increase is two-fold. First, there
was a significant jump in the number of annual births in the US. prior to 1920. Second,
improved disease prevention and health care have increased the life expectancy of the
U.S. population. Due to the accelerated annual birth rate after World War II from 1946
to 1962 (the "baby boom"), the 65 and older age group will continue to grow. Hutton
(1988) predicts an increase of 18% in the 65 and older population between 1985 and 1995
alone, and a 51% increase in the 85 and older population. Overall, the 65 and older
population is predicted to grow by almost 5 million between 1985 and 1995 (Keyfitz &
Flieger, 1990).

As the 65 and older segment of the US. population continues to grow, so will the
prevalence of chronic illness. Cross-sectional data have demonstrated that the occurrence
of chronic illness and disabling conditions increases substantially with age. Greater than
4 out of 5 individuals 65 and older have a minimum of one chronic illness, and having
several is not uncommon (US. Senate Special Committee on Aging, 1985).

Contrary to popular belief, the incidence of psychiatric illnesses, which often are

chronic in nature, is lowest in the 65 and older age group. However, cognitive

2
impairment is a significant mental health problem of this age group (Erwin & Skidmore,

1989; U.S. Senate Special Committee on Aging, 1985). In studies by the National
Institutes of Mental Health, mild cognitive impairment was reported in approximately
14% of elderly men and women, and 5.6% of elderly men and 3% of elderly women had
severe cognitive impairment (U.S. Senate Special Committee on Aging, 1985). It is
estimated that some level of cognitive impairment is present in 50 to 75% of elderly
residents in long-term care facilities (Erwin & Skidmore, 1989). Based on these
estimates, it appears that a substantial number of elderly in the United States are

cognitively impaired.

Background of the Problem

Cognitive impairment is one of the essential features of dementia. Dementia is an
organic mental syndrome, that is, "a constellation of psychological or behavioral signs
and symptoms without reference to etiology” (American Psychiatric Association, 1987,
p. 97). Carroll (1989) describes dementia as:

”a global neurological impairment characterized by slowly progressive and
irreversible deterioration of the cognitive functions--speech, abstract
thought, emotion, memory-—and hence of the ability to take care of oneself,
to identify time and place, to relate socially to others, to think and speak
and act in a clear and reasonable way" (p. 5).
Currently, an estimated 1.8 million Americans suffer from severe dementia (Office

of Technology Assessment, 1990). If cure or prevention for the common causes of

3

dementia are not found, it is predicted that by the year 2040 approximately 7.4 million
Americans will be affected by severe dementia (Office of Technology Assessment,
1987).

As dementia progresses, it robs the afflicted individual of the ability to think, plan,
remember, and function as a productive member of society (Hutton, 1988).
Eventually, the individual’s ability to perform activities such as cooking, cleaning, and
shopping, as well as activities of daily living (ADLs), such as bathing, dressing, and
toileting, become so impaired that constant care and supervision are required
(American Psychiatric Association, 1987; Office of Technology Assessment, 1990).

Often, family members will assume the care and supervision of dependent elders,
such as those afflicted with dementia, in order to avoid institutionalization (Buckwalter
& Hall, 1987). The primary caregivers of dependent elders in the community are
generally close relatives, that is, spouses, children, siblings, nieces or nephews (Cohn
& Jay, 1988). Primary caregivers provide the bulk of physical and emotional care and
supervision to demented elders (Office of Technology Assessment, 1990).

Many difficulties are encountered when caring for demented elders, including the
exhibition of problem behaviors. Examples of such problem behaviors are wandering,
incoherent talking, nocturnal disturbances, agitation, and verbal and physical
aggression, including combativeness (American Psychiatric Association, 1987;
Ereshefsky, Rospond, & Jann, 1989; Katzman, 1986; Office of Technology

Assessment, 1987, 1990; Pynoos & Stacey, 1986). Often, these types of behavioral

4

problems are harder to manage and more stressful to caregivers than the demented
individual’s physical and cognitive impairments (Mace, 1990).

Combative behaviors are especially problematic (Carroll, 1989; Mace, 1990; Mace
& Rabins, 1981; Richter, Blass, & Valentine, 1989). Behaviors of demented
individuals which are of a combative nature include hitting or striking out, kicking,
pushing, scratching, pinching, forceful and quick grabbing, and biting (Carroll, 1989;
Mace, 1990; Mace & Rabins, 1981; Mentes & Ferrario, 1989; Struble & Siversten,
1987; Winger, Schirm, & Stewart, 1987; Zirnmer, Watson, & Treat, 1984).

The display of combative behaviors by demented individuals is thought to be
related to several factors. These factors include a progressive decline in cognitive
functions resulting in a decreased ability to use rational problem-solving as an
effective coping mechanism, impairments of judgment and impulse control, and
frustration over the increasing loss of control over the environment (American
Psychiatric Association, 1987; Beck, Baldwin, Modlin, & Lewis, 1990; Katzman,
1986).

Other factors affecting combative behaviors are the demented individual’s
premorbid personality and c0ping style. Physical, interpersonal, and internal
environmental stressors may also exacerbate combative behaviors, for example,
medication side effects, demands by caregivers which exceed the individual’s
functional abilities, and affect (e.g., feelings of loss or depression). Furthermore,

catastrophic reactions, that is, emotional responses to supposed insignificant incidents,

5
may be manifested as combative behaviors (Carroll, 1989; Jarvik & Trader, 1988;

Mace, 1990; Mace & Rabins, 1981).

Regardless of the causes, the occurrence of combative behaviors is distressing to
the demented elder and the caregiver, and puts both individuals at risk for injury and
physical and emotional exhaustion (Carroll, 1989; Mace, 1990; Mace & Rabins, 1981;
Richter et al., 1989). Emotional exhaustion occurs due to a multitude of negative
feelings brought on by combative behaviors, such as fear, anger, rejection, sorrow, and
frustration (Carroll, 1989; Mace, 1990; Mace & Rabins, 1981). Feelings of frustration
and exhaustion in the caregiver may result in negative consequences for the demented
individual, for example, overmedication with sedative or tranquilizing drugs, denial of
services, and a deterioration of the caregiver/carereceiver relationship (Mace, 1990).

The problems associated with combative behaviors can create stress for both the
caregiver and the demented elder. If the amount of stress experienced by the caregiver
results in a significant deterioration of his or her own health, the quality of care
provided to the demented elder may also deteriorate. Therefore, if it is evident that
the caregiver’s physical and emotional health are being compromised, and adequate
family and/or community support services are not available, institutional placement of
the demented elder should be considered (Cohn & Jay, 1988; Richter et al., 1989).

When demented individuals are admitted to a long-term care facility, nursing
personnel become primarily responsible for providing care to and coordinating services
for them (Brannon & Bodnar, 1988; Zimmer et al., 1984). Nursing personnel, who

constitute approximately 89% of full-time nursing home employees (National Center

6

for Health Statistics, 1989), have the most frequent contact with demented residents.
Family members often continue to assume responsibilities in long-term care facilities
such as supplying personal items, providing emotional support and some types of care,
arranging family social events and certain appointments, and managing finances
(Brannon & Bodnar, 1988; Hall, 1988a; Office of Technology Assessment, 1987;
Richter et al., 1989).

The exhibition of combative behaviors by demented elders is a problem in long-
term care facilities as well as in residential homes (Winger et al., 1987; Zimmer et al.,
1984). Behaviors such as striking out, biting, and kicking are especially difficult to
manage and are detrimental to the demented residents themselves and to others in the
immediate area, including nursing staff (Maas, 1988; Winger et al., 1987; Zimmer et
al., 1984).

For demented residents, combativeness may result in physical injury, a decrease in
the amount and quality of care pmvided, social isolation, and functional impairments
(Beck et al., 1990; Hall & Buckwalter, 1987; Pynoos & Stacey, 1986; Rovner,
Kafonek, Filipp, Lucas, & Folstein, 1986; Struble & Siversten, 1987; Winger et al.,
1987). The display of combative behaviors may also promote agitation in other
nursing home residents, as well as increase the potential for fear and injury to other
residents, nursing home staff, and visitors (Ebersole, 1989; Maas, 1988; Marx, Wemer,
& Cohen-Mansfield, 1989).

Many of the effects that combativeness has on nursing staff are similar to those

mentioned earlier for family caregivers. Nursing staff may experience an increased

 

 

 

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PL» 1

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Lou.

7

potential for injury, physical exhaustion, and negative feelings (e.g., fear and
frustration). Nursing staff may also experience burnout, as evidenced by a lowered
staff morale, increased rates of absenteeism and resignation, and physical or verbal
abuse of residents (Beck et al., 1990; Maas, 1988; Mentes & Ferrario, 1989; Office of
Technology Assessment, 1987; Pynoos & Stacey, 1986; Rovner et al., 1986; Winger et
al., 1987). The display of combative behaviors by demented residents may also
increase nursing staff’s awareness of these residents’ distress and indicate the need for
intervention.

Aggressive, defined as "marked by combative readiness" (Mish, 1985, p. 64), is a
word akin to combative used in the literature on problem behaviors associated with
dementia (Chandler & Chandler, 1988; Mentes & Ferrario, 1989; Rovner et al., 1986;
Struble & Siversten, 1987; Zimmer et al., 1984). In the literature reviewed,
researchers used both "combative" and "aggressive" to describe behaviors such as
pushing, hitting, and kicking. Therefore, the following discussion is based upon
studies in which résearchers explored mental illness and behavioral problems in long-
term care facilities, and reported the common occurrence of either aggressive or
combative behaviors, along with a high prevalence of dementia.

Rovner et a1. (1986) conducted a study examining the prevalence of mental
disorders in a nursing home. They found that 78% of the residents were diagnosed
with some type of dementia, and 26% of those residents exhibited active aggression.

A description of behaviors considered to be actively aggressive was not provided.

8
Chandler and Chandler (1988), in studying mental illness in nursing home

residents, reported that 72% of the residents had dementia, and 15% of the demented
residents displayed mild to severe aggressive outbursts. A description of behaviors
considered to be mild or severe aggressive outbursts was not included in the report.

In a study designed to determine the prevalence of behavioral problems in skilled
nursing facilities (Zimmer et al., 1984), it was found that 22.6% of the subjects
exhibited serious behavioral problems, including striking out or biting. Among the
subjects who exhibited serious behavioral problems, 66.5% had diagnoses indicative of
organic brain syndrome.

Winger et al. (1987) studied the prevalence of aggressive behaviors on both an
intermediate-care and a nursing home unit within a VA medical center. Intermediate-
care residents required extensive hospital services, weekly physician visits, and skilled
nursing care, whereas nursing home residents required monthly physician visits, skilled
nursing care, or active rehabilitation. Behaviors such as biting, pushing, and hitting
were considered aggressive behaviors. Within the samples studied, 34% of the
intermediate care and only 9% of the nursing home subjects exhibited g9 aggressive
behavior.

Thus, researchers have reported both a high incidence of dementia and the
common occurrence of aggressive and combative behaviors within long-term care
facilities. Researchers have also reported a high incidence of both physical and
chemical restraint use by nursing staff to control problem behaviors, including

combativeness. Physical restraints include geriatric chairs with locking tables, belt and

9

vest restraints, wrist and ankle restraints (Sloane et al., 1991), and pelvic restraints.
Neuroleptic, anxiolytic, sedative, and hypnotic medications used on a regular basis
constitute chemical restraints (Sloane et al., 1991).

Zimmer et al. (1984) reported that 58% of residents exhibiting serious problem
behaviors (e.g., striking out or biting) received psychotropic drugs on a regular basis,
and 47% had a restraint applied within 30 days preceding the study. Consultation with
a psychiatrist, who may have offered suggestions regarding alternative management
techniques, as well as the judicious use of psychotropic drugs, had occurred for only
14.8% of the residents. Reality orientation was the only other documented
management technique for problem behaviors, and 14% had received this.

Chandler and Chandler (1988) conducted a study examining the prevalence of
medical, neurological, and psychiatric illness in a nursing home. They found a 94%
rate of neuropsychiatric illness in the resident population, and a 72% rate of dementia,
based on DSM-III-R criteria. The primary management techniques documented for
aggressive and agitated behaviors were physical restraints and psychotropic drugs
(50% and 43% of subjects, respectively). Of the total population diagnosed with a
neuropsychiatric illness, only 40% had a history of previous psychiatric consultation or
treatment.

Sloane et al. (1991) performed a study comparing the use of physical and chemical
restraints for the management of demented residents on both specialized dementia
units and traditional nursing home units. On the specialized units, the rates of

physical and chemical restraint use were 18.1% and 45.3%, respectively. On the

10

traditional nursing home units, the rates of physical and chemical restraint use were
51.6% and 43.4%, respectively. Mental impairment was reported as a predictor of
both physical and chemical restraint use. Physically abusive behavior by demented
residents was the factor mpg; significantly related to chemical restraint use.

The high incidence of physical and chemical restraint use documented in these
studies implies that these restraints are used frequently to manage problem, including
combative, behaviors of demented residents. Specific reasons given by nursing staff
for the use of physical and chemical restraints include the following: impaired mental
status; controlling disruptive behavior; preventing harm to residents and staff;
preventing disruption of oriented residents’ environments; inadequate or inexperienced
staff; preventing interference with treatment; or lack of available alternatives (Jencks
& Clauser, 1991; Pynoos & Stacey, 1986; Strumpf, Evans, & Schwartz, 1991; Tinetti,
Liu, Marottoli, & Ginter, 1991; Vladeck, 1980; Zarit, Orr, & Zarit, 1985).

Although physical and chemical restraints are utilized to control combative
behaviors, they can have negative effects on demented, elderly residents. The
application of physical restraints increases the potential for skin abrasions, nerve
damage, and strangulation. The use of physical restraints also fosters immobility and
its complications, including impaired circulation, decubitus ulcers, sensory deprivation,
decreased strength and stability, incontinence, and contractures. Physical restraints
may also increase the manifestation of problem behaviors (Covert, Rodrigues, &
Solomon, 1977; Jencks & Clauser, 1991; Struble & Siversten, 1987; Tinetti et al.,

1991; Office of Technology Assessment, 1987).

11

Chemical restraints may cause an exacerbation of the behaviors for which they
were given, such as agitation. The administration of chemical restraints may also
result in serious side effects, including increased sedation and confusion and tardive
dyskinesia (Jarvik & Trader, 1988; Jencks & Clauser, 1991; Maas, 1988; Office of
Technology Assessment, 1987; Pynoos & Stacey, 1986; Struble & Siversten, 1987;
Strumpf et al., 1991; Vladeck, 1980; Yerian & Pettengill, 1990).

In a descriptive study of physical restraint use in a metropolitan teaching hospital,
elderly patients’ subjective experiences and behaviors related to restraint use were
explored (Strumpf et al., 1991). Elderly patients who were physically restrained
reported experiencing feelings of anger, fear, humiliation, and demoralization.
Behavioral effects of restraint application on elderly patients noted by nurses included
combativeness, agitation, resistance, and hallucinations. A review of the literature on
physical restraints resulted in no literature supporting the view of physical restraints as
effective in controlling problem behaviors and facilitating treatment of the elderly
(Strumpf et al., 1991).

The use of physical and chemical restraints for the management of combative
behaviors can have negative effects not only on demented residents, but on their
families and nursing staff as well. For family members, seeing the negative effects
that physical and chemical restraints have on their loved one may intensify feelings
such as guilt and concern (Maas, 1988). Primary nurses have reported feeling
discomfort and ambivalence when applying physical restraints to the elderly (Strumpf

et al., 1991). Also, the care of residents who have become more dependent and have

12

developed complications due to restraint use (Pynoos & Stacey, 1986) requires
increased amounts of nursing time.

As of October 1, 1990, federal regulations regarding the use of physical and
chemical restraints, based on the Omnibus Budget Reconciliation Act (OBRA) of
1987, amended in 1989, have been in effect. According to these regulations, it is an
infringement of a resident’s rights if appropriate assessments and justification for the
use of a restraint are not documented in the medical records. Any long-term care
facility not in compliance with OBRA regulations can be penalized (Garrard et al.,
1991; Yerian & Pettengill, 1990). Research studies conducted since October 1, 1990
report that some long-term care facilities using restraints are not abiding by the OBRA
regulations (Garrard et al., 1991; Tinetti et al., 1991), and are therefore violating
certain resident’s rights.

It is apparent that employing physical and chemical restraints to manage combative
behaviors of demented long-term care residents can create additional problems for the
residents themselves, their families, and nursing staff. Unfortunately, the majority of
professional and non-professional nursing staff in long-term care facilities have not
been educated regarding the care of demented residents, including the management of
problem behaviors (Maas, 1988). In general, nursing homes employ few staff
members, with the possible exception of social workers, who have been educated
regarding appropriate behavioral interventions, activities, and care approaches for

demented residents (Pynoos & Stacey, 1986; Office of Technology Assessment, 1987).

13

Nurse’s aides, who give more direct patient care than any other group of long-term
care employees, have the lowest level of educational and pre-employment training
related to the care of the elderly (Brannon & Bodnar, 1988; Mentes & Ferrario, 1989;
Office of Technology Assessment, 1987). Furthermore, although federal and state
regulations require intermediate and skilled nursing facilities to provide mandatory
inservice programs, the required programs do not include information for nursing
personnel on the management of demented residents’ problem behaviors (Brannon &

Bodner, 1988; Office of Technology Assessment, 1987).

14

W

Due to a lack of training and education in the care of the demented, including
problem behavior management (Maas, 1988; Struble & Siversten, 1987), a significant
number of long-term care nursing staff may be unaware of alternatives to physical or
chemical restraint use for the management of combative behaviors (Maas, 1988;
Struble & Siversten, 1987). Researchers exploring aggressive and combative
behaviors in cognitively impaired nursing home residents emphasize the need for
educating nursing staff on restraint-free methods of managing these behaviors (Beck et
al., 1990; Mentes & Ferrario, 1987; Rovner et al., 1986; Struble & Siversten, 1987;
Winger et al., 1987; Zimmer et al., 1984).

Because they provide the most care to demented residents and are generally the
first to intervene when combativeness occurs, nursing personnel need an effective plan
for managing combative behaviors. Therefore, the purpose of this scholarly project is
to develop a protocol which primary caregivers in long-tenn‘care facilities can follow

when demented, elderly residents exhibit combative behaviors.

Project Description
The protocol developed will be based on the professional literature related to
combative and aggressive behaviors in demented individuals. Because the demented
individual’s environment plays an influential role in the display of problem behaviors

(Schainen, 1991), special attention will be given to environmental factors related to

 

 

 

15

combative and aggressive behaviors. Suggested interventions for the management of
these problem behaviors will be reviewed.

The protocol will focus on the management of combative behaviors, rather than on
their prevention. Although the prevention of combative behaviors is the ideal goal,
this goal is not always realizable when caring for demented individuals. The protocol
will emphasize the use of management techniques other than physical and chemical
restraints. The project plan does not include the actual implementation and evaluation

of the protocol. However, future testing of the protocol is intended.

my.

This scholarly project consists of four chapters. In Chapter I, the introduction,
background and statement of the problem, and purpose of the project have been
presented. The conceptual framework will be presented, including conceptual
definitions with supporting literature, an explanation of the conceptual model upon
which this project is based, and a discussion of the applicability of the conceptual
model to the problem of combativeness.

In Chapter II a review of the current literature relevant to this project, including
existing research, will be presented. In Chapter III a detailed description of the
protocol will be presented, along with a follow-up plan to prevent or minimize further
combative behavior. Chapter IV will include a proposed plan for the implementation
and evaluation of the protocol, as well as a discussion on the implications of this

project for professional nursing, advanced nursing practice, and primary care.

16
Conceptual Framework

Conceptual Definitions

M-

A protocol may be defined as "a precise and detailed plan for the study of a
biomedical problem or for a regimen of therapy" (Hensyl, 1990, p. 1274). Another
definition for a protocol is ”a written plan specifying the procedures to be followed in
giving a particular examination, in conducting research, or in providing care for a
particular individual" (Como, 1990, p. 976). For the purpose of this project, a
protocol is defined as a detailed, written plan developed to specify the procedures to
be followed in managing the combative, demented, elderly resident within a long-term
care facility.

A clinical protocol is the "transformation of the research base into clinically
relevant knowledge that is precisely defined for practice and that specifies an
intervention with predictable patient outcomes and recommended procedures for its
evaluation” (Horsley, Crane, Crabtree, & Wood, 1983, p. 98). A clinical protocol is
used to implement and evaluate a change in clinical practice, and includes information
related to the following: the need for change, summary and limitations of the research
base, description of the protocol, research-based principles guiding the protocol,
implementation and evaluation of the protocol, summary, and references (Horsley et

al., 1983).

17
Primg Caregiver.

In discussing the responsibilities of relatives caring for the frail or disabled elderly,
Couper (1989) describes the primary caregiver as the individual who is principally
responsible for providing care to or coordinating services for the disabled elder.
Aronson (1988) defines the primary caregiver of a demented individual as the one in
charge, who assumes primary responsibility for care of the demented person on a daily
basis. Primary caregivers of dependent, elderly individuals provide constant, intimate
care which meets these individuals’ physical, emotional, and social needs (Aronson,
1988; Brannon & Bodnar, 1988). Within this project, a primary caregiver is
considered one who is principally responsible for coordinating services or providing
care which is constant and intimate, and meets the demented, elderly, long-term care
resident’s physical, emotional, and social needs.

Litwalk (1985) discusses the role of family members caring for dependent, elderly
relatives at home. He defines the "primary group” as those individuals who provide
services not on the basis of economic rewards, but rather based on affection, duty, or
respect. If the primary group becomes dysfunctional and the disabled elderly
individual is relocated to a long-term care facility, the responsibility of the long-term
care staff is to provide the services previously given by the primary group.

Within long-term care facilities, nursing personnel are primarily responsible for
providing care to, and coordinating services for, demented residents (Brannon &
Bodnar, 1988; Zimmer et al., 1984). Thus, the long-term care resident’s quality of life

is affected by the motivation, skill level, quality, and stability of the nursing personnel

18
(Brannon & Bodnar, 1988). The following is a discussion of the general

responsibilities of different levels of nursing personnel found within long-term care
facilities.

Registered Nurses (RNs) have assumed primary responsibility for managerial
work, that is, providing the resources and environment for the provision of care
(Brannon & Bodnar, 1988). Compared to other nursing personnel, RNs spend less
time giving direct patient care, and more time addressing administrative issues (Office
of Technology Assessment, 1987), for example, nursing documentation, staffing needs,
and inservice development.

Licensed Practical Nurses (LPNs) perform both managerial and direct work, that
is, providing nursing care directly to residents (Brannon & Bodnar, 1988). Examples
of their managerial responsibilities are supervising nurse’s aides, assisting with
inservices, and coordinating services for residents. Direct work responsibilities include
administering medications and monitoring residents for adverse effects, performing
treatments ordered by physicians, and assisting with ADLs (Brannon & Bodnar, 1988).

Nurse’s aides are supervised by RNs and LPNs, and their work revolves around
meeting the immediate needs of residents (Brannon & Bodnar, 1988). Nurse’s aides
comprise the largest single group of long-term care personnel, and spend more time
with residents and provide more direct care than any other group of employees
(National Center for Health Statistics, 1989; Office of Technology Assessment, 1987).

Because the behavioral treatment of chronic mental health problems must be frequent

 

 

 

19

and consistent (Brannon & Bodnar, 1988), nurse’s aides can make a significant
contribution to the behavioral management of demented residents.

An innovation within long-term care facilities has been the utilization of a
Gerontological Clinical Nurse Specialist (GCN S) to enhance the quality of care
provided to residents. The GCNS is a Registered Nurse who has received additional
education and training in the fields of gerontology and primary health care. As a
primary care provider, the GCNS focuses on wellness, on promoting the elderly
client’s and family’s ability to cope with the client’s aging changes, illnesses, and
disabilities, and on supporting and enhancing the elderly client’s strengths (Michigan
State University, College of Nursing, 1985b). The GCNS works closely with long-
term care residents’ physicians, who oversee the residents’ medical care and are vital
members of the health care team.

Thus, it can be seen that nursing personnel and residents’ primary physicians have
important roles and responsibilities related to the coordination and provision of
services to demented, elderly, long-term care residents. Therefore, although family
members often provide some services, within this study nursing personnel and primary
physicians will be considered the primary caregivers of demented, elderly, long-term
care residents.

WM.

Long-term is defined as "occuning over or involving a relatively long period of
time" (Mish, 1985, p. 704). Therefore, a long-term care facility is literally a facility in

which care is provided over a relatively long period of time. A more descriptive

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20

definition of long-term care facilities is "health care facilities that provide 24-hour
supervision, skilled nursing services, and personal care" (Office of Technology
Assessment, 1987, p. 214).

Terms used synonymously with long-term care facility are extended-care facility,
intermediate- and skilled-care facility, and nursing home. Based on federal
regulations, specific services which these facilities must provide to residents include
health care services (i.e., the appropriate levels of nursing and medical care),
rehabilitative and restorative services, social, dietetic, pharmaceutical, laundry, and
housekeeping services, and activities programs. The primary responsibility of long-
term care facilities is to provide both adequate services and appropriately trained
personnel to maintain the residents’ highest achievable levels of physiological,
psychological, and sociological health (American Nurses’ Association, 1975).

Long-term care facilities are the most frequently used institutions for demented
individuals (Office of Technology Assessment, 1987). Research studies have reported
that 65-78% of residents within these facilities exhibit features indicative of dementia
(Chandler & Chandler, 1988; Katzman, 1986; Rovner et al., 1986). Although some
skilled nursing services may be needed, the majority of demented residents require
primarily 24-hour supervision and assistance with ADLs (Office of Technology
Assessment, 1987). Therefore, for the purpose of this study, a long-term care facility
is defined as a health care facility which provides primarily 24-hour supervision and
ADL assistance, as well as skilled nursing, medical, and other required services to

maintain the elderly, demented resident’s highest levels of physiological,

21

psychological, and sociological health. Within this project, terms synonymous with
long-term care facility include nursing home, interrnediate- and skilled-care facility,
and extended-care facility.

Combative Behaviors.

A definition of combative behavior may be derived from the definitions of
combative and behavior. Combative is defined as "marked by eagerness to fight or
contend" (Mish, 1985, p. 262). Behavior is defined as "the response of an individual,
group, or species to its environment" (Mish, 1985, p. 141). Therefore, combative
behavior may be defined as the response of an individual to his environment marked
by an eagerness to fight or contend.

Behaviors exhibited by demented individuals which are considered to be of a
combative nature include deliberate hitting or striking out, kicking, pushing,
scratching, pinching, forceful and quick grabbing, and biting (Carroll, 1989; Mace,
1990; Mace & Rabins, 1981; Mentes & Ferrario, 1989; Struble & Siversten, 1987;
Winger et al., 1987; Zimmer et al., 1984). Behaviors such as these endanger both
demented individuals and others, and may create stress, fear, and exhaustion for
demented individuals and their caregivers (Carroll, 1989; Maas, 1988; Mace, 1990;
Mace & Rabins, 1981; Richter et al., 1989; Zarit et al., 1985).

In a study exploring problem behaviors of nursing home residents (Zimmer et al.,
1984), behaviors considered to be endangering most often involved a physical action
(e.g., deliberate striking, biting, or scratching). Therefore, within this study, combative

behaviors are defined as physical responses of the demented, elderly resident to his or

22

her environment which endanger the resident and others, and may create stress, fear,
or exhaustion for the resident and primary caregivers.

mm.

For the purpose of this project, a definition of demented, elderly resident will be
developed through discussion of each concept individually, that is, dementia, elderly,
and resident. A diagnosis of dementia is considered by the physician if the individual
exhibits a loss of intellectual function resulting in impairments of short and long-term
memory, along with impairments of one or more other cognitive areas, including
abstract thinking, judgment, and higher cortical functions, such as language, motor
activities, recognition of objects, and constructional abilities (American Psychiatric
Association, 1987). The individual may also exhibit behavioral problems, mood and
personality changes, secondary psychiatric symptoms, and affective disorders
(American Psychiatric Association, 1987; Ereshefsky et al., 1989; Katzman, 1986;
Mace, 1990; Office of Technology Assessment, 1987, 1990; Patterson & Whitehouse,
1990).

In order for a diagnosis of dementia to be made, the observed cognitive
impairments must be severe enough to substantially disrupt the individual’s normal
social activities and/or relationships (American Psychiatric Association, 1987). In
addition, a thorough medical history and physical exam, as well as extensive lab work
and possibly diagnostic tests, must be performed to elicit signs/symptoms indicative of
dementia and to rule out all other causes of cognitive impairment (Patterson &

Whitehouse, 1990).

23

An elderly individual is one who is 65 years of age or older, based on the
following delineation of the population: the older population, 55 and older; the
elderly, 65 and older; the aged, 75 and older; and the very old, 85 and older (Erwin &
Skidmore, 1989). A resident is "one who resides in a place" (Mish, 1985, p. 1003).
Therefore, for the purpose of this study, a demented, elderly resident is defined as an
individual 65 years of age or older who resides in a long-term care facility, and has
exhibited an impairment in short- and long-term memory, along with impairments in
one or more other cognitive areas, severe enough to substantially disrupt normal social
activities and/or relationships. The individual may also exhibit behavioral problems,
mood and personality changes, psychiatric symptoms, and affective disorders.

Because the physician must obtain and analyze a significant amount of information
when dementia is suspected, a substantial amount of time may pass before the
diagnosis of dementia is made (Maletta, 1988). Thus, primary caregivers may interact
with individuals who are suspected to have dementia but for whom a diagnosis has not
yet been made. Therefore, the protocol developed within this project may be utilized
with residents who either have been diagnosed with dementia by a physician, or are

suspected to have dementia.

24

The Progressively Lowered Stress Threshold Model
Geri Richards Hall, a GCNS at the University of Iowa Hospitals and Clinics, has

developed a model depicting the effect environmental stressors have on the behavior
of adults with Alzheimer’s disease and related disorders. The model, Progressively
Lowered Stress Threshold (PLST), is conceptually linked to the psychological theories
on stress, c0ping, and adaptation set forth by Coyne and Lazarus (1981), Lazarus
(1966), and Selye (1980). The PLST model is also based upon behavioral and
physiological research on Alzheimer’s disease and related disorders, as well as
literature related to symptom clusters and behavioral states in adults with dementing
illnesses (Hall, 1988a, 1988b; Hall & Buckwalter, 1987).

Hall noted that researchers had grouped losses associated with dementia into three
clusters, including cognitive, affective, and planning losses. Hall also noted that
certain behaviors in demented adults often occurred later in the day or after a
stimulating event, and that the patients appeared uncomfortable and/or distressed. Hall
hypothesized, therefore, that these behaviors were stress-related, and placed them
within a fourth cluster, labeled the PLST group. Behaviors within the PLST group
include catastrophic reactions, purposeful wandering, anxious or agitated behaviors
(including violence), purposeless behaviors, withdrawal or avoidance behaviors, and

compulsive and repetitive behaviors (Hall, 1988a; Hall & Buckwalter, 1987).

25
The assumptions of Hall’s PLST model are as follows:

1. All humans require some control over their person and their
environment and need some degree of unconditional positive
regard.
2. All behavior is rooted and has meaning; therefore, all catastrophic and
stress-related behaviors have a cause.
3. The confused or agitated patient is not comfortable and should be
regarded as frightened. All patients have the right to be comfortable.
4. The patient exists on a 24-hour continuum. Care cannot be planned or
evaluated on an eight-hour shift basis (Hall & Buckwalter, 1987).
According to Hall, demented adults exhibit three basic types of behavior, called
"behavioral states": baseline, anxious, and dysfunctional. These behavioral states are
the foundation of the PLST model (Hall & Buckwalter, 1987). The amount exhibited
of each type of behavior changes as dementia progresses, with dysfunctional behavior
generally increasing until the demented individual is no longer able to respond to the
environment (Hall, 1988b).
Characteristics of each behavioral state are as follows:
1. M1132. A calm state, in which the demented individual’s perceived
stress level is low. The individual is both socially accessible (able to
respond to communications from others and communicate needs) and

cognitively accessible (oriented to, or aware of, the surrounding

26

environment). The individual experiences the maximum levels of
function possible considering losses associated with dementia.
m- The individual begins to perceive offending, stressful stimuli.
The individual attempts to avoid these stimuli, but is still able to react
appropriately to the environment. Caregivers are still able to initiate or
maintain communication with the individual. Behavioral indicators of
increased anxiety include decreased socialization (e.g., loss of eye
contact), increased psychomotor activity (e.g., fidgeting, pacing), and
decreased levels of function.

Dysfunctional. Stressful stimuli are allowed to continue or increase,
and the individual is highly aware of these stimuli. He or she is no
longer able to communicate effectively with caregivers or use the
environment in a functionally appropriate manner (socially and
cognitively inaccessible). The individual experiences a significant
impairment of functional levels, as well as decreased levels of comfort
and safety. Dysfunctional behaviors occur, generally appearing
suddenly and lasting a relatively short period (Hall, 1988a, 1988b; Hall
& Buckwalter, 1987). These behaviors, considered to be stress-related
and labeled the PLST group, include the following: compulsive or
repetitive behaviors, withdrawal or avoidance behaviors, noisy or

purposeless behaviors, confusion, ”sundowner’s syndrome”, agitated or

27
violent behaviors, and catastrophic reactions (Hall, 1988a, 1988b; Hall

& Buckwalter, 1987).

An important concept of the PLST model, stress threshold, was not conceptually
defined in the literature reviewed. A definition of this concept may be derived,
however, from the definitions of stress and threshold. A stress or stressor is defined
as any adverse stimulus, physical, mental, or emotional, internal or external, that tends
to disturb homeostasis, and elicits compensatory reactions in an attempt to regain
homeostasis (Taylor, 1988). Threshold is defined as ”the place or point of entering or
beginning” (Gove, 1986, p. 2383).

Therefore, stress threshold may be defined as the point at which compensatory
reactions begin in response to an adverse internal or external physical, mental, or
emotional stimulus in an attempt to regain homeostasis. For the purpose of this
project, in relation to the PLST model, the stress threshold is the point at which the
demented individual displays compensatory reactions (i.e., combative behaviors) in
response to perceived overwhelming internal or external physical, mental, or emotional
stimuli in an attempt to regain homeostasis.

According to the PLST model, the individual whose cerebral function is intact
maintains a relatively stable stress threshold as time progresses (see Figure 1). The
person with an irreversible dementia such as Alzheimer’s disease, however,
experiences a progressively lowered stress threshold as brain cells degenerate and
cerebral function declines (see Figure 2). This is because, as cerebral function

declines, the demented individual’s ability to accurately receive, process, and respond

28
to stimuli and information decreases (Hall & Buckwalter, 1987; Hall, Kirschling, &

Todd, 1986). Furthermore, the aging process may impede the elderly, demented
individual’s ability to cope with environmental stressors, due to a decrease in mobility
and hormones, sensory losses, and slowed synaptic response times (Hall &
Buckwalter, 1987). The combination of a progressive decline in cerebral functioning
and degenerative changes that occur with aging results in an increased sensitivity to
stressors, a decreased ability to cope effectively with stressors, and an increased
potential for displaying anxious and dysfunctional behaviors (Hall & Buckwalter,
1987).

For the demented individual, consistent or heightened levels of exposure to
stressors increases the potential for the display of anxious, then dysfunctional
behaviors as energy is depleted, fatigue increases, and the stress threshold is exceeded,
as is seen in Figure 2 (Hall, 1988a, 1988b; Hall & Buckwalter, 1987; Hall et al.,
1986). Furthermore, exposure to stressors on a routine basis may push the individual
into a cycle of dysfunctional behavior (see Figure 3), creating risks such as injury,
social isolation, physical and chemical restraint use, and functional impairments (Hall
etal., 1986). Prolonged exposure to high levels of stress may also result in excess
disability, that is, the development of additional functional impairments and losses that
subside when the stress level is diminished (Hall & Buckwalter, 1987).

In addition to the increased risks for demented individuals, the cyclical occurrence
of dysfunctional behaviors may increase both injuries to, and demands on, caregivers,

possibly leading to burnout. Within long-term care facilities, lucid residents exposed

29

Dysfunctional Behavior
(Fight or Flight)

Stress Threshold

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

n” Anxious Behavior

llllllllllllllllllllllll

 

 

Perceived Stressors

 

Normative Behavior

 

EignnLL Stress threshold in normal individuals.

N91; From "Progressively lowered stress threshold: A conceptual model for care of
adults with Alzheimer's disease" by G. R. Hall and K. C. Buckwalter, 1987 , Amh'meufi

Wm, 1(6), p. 402. Copyright 1987, by W.B. Saunders Company.
Reprinted by permission.

Stress
Threshold

I l
Perceived Anxious
Stressors Behavior

      

Normative Behavior

 

 

W- Progressively lowered stress threshold in adults with progressive degeneration of
the cereme cortex (Alzheimer‘s Disease and related disorders).

Nate. From "Progressively lowered stress threshold: A conceptual model for care of adults
with Alzheimer’s disease" by GR Hall and KC. Buckwalter, 1981mm
Nursing, 1(6), p. 403. Copyright 1987, by W .B. Saunders Company. Reprinted by
Permission.

31

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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figure}. A typical day for an adult with a dementing illness in an unstructured care
program.

Ema. From "Progressively lowered stress threshold: A conceptual model for care of
adults with Alzheimer's disease" by GR. Hall and KC. Buckwalter, 1987, Amhimf

Wing, 1(6), p. 403. Copyright 1987 by W.B. Saunders Company.
Reprinted by permission.

32
to dysfunctional behaviors may be negatively affected, for example, through the fear

of harm from violent demented residents (Hall et al., 1986).

Previously, it was believed that demented individuals’ antisocial behaviors such as
combativeness occurred randomly, with management consisting of physically and/or
chemically restraining these individuals and keeping them in a highly stimulating
environment (Hall & Buckwalter, 1987). However, the PLST model proposes that
combative and other dysfunctional behaviors are related to demented individuals’
consistent or heightened exposure to environmental stressors. The hypothesis of the
PLST model is "that normative or baseline behavior and maximum functional levels
can be achieved by supporting losses in a ‘prosthetic manner’, rather than testing
them, thereby increasing stress, and by controlling for the factors related to stress,
which cause excess disability" (Hall & Buckwalter, 1987, p. 402).

Based on this hypothesis, rehabilitative approaches used in the past which tested
the demented individuals’ limited cognitive abilities (e. g., maximizing sensory input,
reath testing, and attempting to retrain lost skills) would increase the frustration and
stress experienced by these individuals. Examples of approaches which would support
losses in a prosthetic manner and decrease stress, as the PLST model proposes, are the
use of reassuring therapies (e.g., validation, reminiscence, or music) and providing the
demented individual with a consistent routine (Hall & Buckwalter, 1987).

In addition to supporting losses prosthetically, normal behavior and maximum
functional levels are promoted by diminishing stress-producing factors in the demented

individual’s environment. For the demented individual, factors related to stress

33

include the following: fatigue; change of environment, caregiver, or routine; internal
or external demands to function beyond the limits imposed by cortical deterioration;
competing, misleading, or overwhelming stimuli; and physical stressors (Hall, 1988a,
1988b; Hall & Buckwalter, 1987).

Interventions to minimize the occurrence of anxious and dysfunctional behaviors
are determined by the demented individual’s stress level. reflected in his or her
behavioral state (Hall & Buckwalter, 1987). The demented individual experiencing
minimal stress exhibits baseline or normative behavior (i.e., he or she is generally
calm, oriented to and aware of the environment, and communicates effectively with
others). Examples of interventions to maintain baseline behavior include providing a
consistent routine, orienting cues, and regular quiet rest periods for the demented
individual (Hall & Buckwalter, 1987).

As the demented individual becomes increasingly aware of stressors, his or her
stress level begins to rise. Anxious behavior is displayed (e.g., stressful situations are
avoided, psychomotor activity increases, socialization decreases, and cognitive,
physical, and emotional functional levels decrease). Interventions to decrease the
potential for further anxious or dysfunctional behavior at this stage include: providing
unconditional, positive regard; carefully observing for messages of increased fatigue,
anxiety, or stress; and modifying and simplifying environmental factors until anxious

behavior ceases (Hall & Buckwalter, 1987).

34

As the demented individual’s awareness of consistent or increased stressors is
heightened, the stress level continues to rise until the stress threshold is exceeded. At
this point dysfunctional behavior is manifested, accompanied by significant
impairments in communication and functional levels and decreased comfort and safety.
In addition to the previously mentioned interventions, interventions at this stage focus
on the following: protecting the demented individual and others from harm,
identifying and eliminating factors aggravating dysfunctional behavior, promoting a
calm environment, establishing trust with the individual, reestablishing communication
with the individual, reorienting the individual to his or her environment, resolving the
dysfunctional behavior, minimizing the individual’s anxiety and promoting comfort,
and promoting rest for the individual (Gugel, 1988; Hall & Buckwalter, 1987;
Hoffman & Platt, 1990; Robinson, Spencer, & White, 1989).

Hall’s PLST model may be utilized to develop educational programs for primary
caregivers of demented adults, and to guide practice and research related to the care of
the demented in a variety of settings, such as home care, day care, acute care, and
long-term care (Hall & Buckwalter, 1987). Various research designs have been used
to test the PLST model, including pretest-postest, repeated measures, and retrospective
chart reviews. The PLST model has been tested in several different settings, including
adult day care and long-term care facilities. Dependent variables utilized to measure
the PLST model’s effectiveness with demented patients have included sleep and

socialization patterns, weight gain, the use of sedatives and tranquilizers, the frequency

35

of agitated behaviors, the functional levels of demented patients, and family

satisfaction with care (Hall & Buckwalter, 1987; Hall et al., 1986).

Application of the PLST Model to the Problem of Combativeness

The PLST model can be utilized to gain further insight into the problem of

combativeness in demented, elderly residents. The risk factors within the PLST model

identified as being stress-producing and aggravating dysfunctional behaviors, such as

combativeness, are commonplace within the environment of the demented resident.

Examples of these risk factors within a long-term care facility are as follows:

1.

m. The hallways are often long, without cues to stop and
rest, encouraging continuous and tiring pacing of the demented
resident (Hall et al., 1986).

Change of environmeng caregiver, or routine. The demented
resident may be moved to another room or an unfamiliar nurse’s
aide may care for the resident.

Internal or external demands to function beyond the limits
imppsed by cortical deterioration. The demented resident may
attempt to write a letter (internal), or the nurse’s aide may ask
the resident to brush his or her teeth (external), although the
demented resident no longer has the cognitive abilities to

perform these tasks.

36
4. CommtingI misleading, or overwhelming stimuli. The demented

resident placed in the dayroom may be exposed simultaneously
to the loud and bright television, the voice on the overhead
paging system, and the confused resident repeatedly asking for
her baby. This may result in increased confusion, fatigue, and
frustration related to the inability to accurately perceive, process,
and respond to these multiple stimuli.

5. Physical stressors. The demented resident may be uncomfortable
due to a tightly-tied restraint but is unable to communicate this
or reposition the restraint.

Because the risk factors identified within the PLST model (Hall, 1988a; Hall &
Buckwalter, 1987) as being stress-producing are present within long-term care
facilities, the potential exists for the display of combative behaviors by demented
residents. According to the PLST model, frequent or heightened levels of exposure to
these risk factors would increase the potential for the demented resident to exceed his
or her stress threshold and manifest combative behaviors.

Consistent exposure to stress-producing factors could result in excess disability, as
well as a vicious cycle of combativeness. A cycle of combativeness would consist of
fluctuations between anxious and combative behavior as the demented residents’ stress
threshold was repeatedly exceeded (Hall & Buckwalter, 1987). Potential
complications of such a cycle could include physical injury, social isolation, physical

and chemical restraint use, and increased functional impairments.

37

Based on the assumptions and concepts within the PLST model, as well as
literature on the management of problem behaviors of the demented (Carroll, 1989;
Maas, 1988; Struble & Siversten, 1987), the goal for primary caregivers managing
combative behaviors should be to assist demented, elderly residents to reestablish their
maximum levels of safety, comfort, and function possible considering the dementing
process.

According to the PLST model, the achievement of this goal would be enhanced if
primary caregivers focused on identifying and eliminating the stressors aggravating
combative behaviors, in addition to controlling the behaviors. Attempting to manage a
problem behavior (e.g., with physical or chemical restraints) without first attempting to
identify and eliminate causative factors may exacerbate the problem behavior (Gugel,
1988). Thus, the resolution of combative behaviors depends on the caregiver’s ability
to identify and eliminate causative factors, as well as to manage the combative

behaviors.

Schematic Representation of the Conceptual Framework

Up to this point, the problems related to combative behaviors of demented, elderly
residents and the utility of Hall and Buckwalter’s (1987) PLST model for gaining an
understanding of the nature of these behaviors have been discussed. Figure 4 is a
schematic representation of the relationships between the problems associated with
combative behaviors of demented, elderly residents, Hall’s PLST model, and the role

of the GCNS.

38

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Within this schematic, each of the three behavioral states of the demented
individual proposed by Hall (Hall & Buckwalter, 1987), that is, baseline, anxious, and
dysfunctional, is represented as a rectangle containing the characteristics of that
behavioral state. The rectangle representing dysfunctional behavior is labeled
combative behavior. The progression of the demented resident’s behavior from
baseline to anxious to dysfunctional as his or her stress level increases, is depicted by
the left to right sequencing of the rectangles, as well as the increasing darkness of the
rectangle borders.

The vertical arrows between each behavioral state represent the perceived
environmental stressors of the demented resident. As the demented resident’s
perception of environmental stressors is heightened, represented by the increasing
number of vertical arrows from left to right, his or her level of stress is increased.
The demented resident’s increasing stress level is represented by the progressive
increase in the width of the horizontal arrows, which represent the demented, elderly
resident’s passage from one behavioral state to the next.

When the demented, elderly resident exceeds his stress threshold, represented as a
broken vertical line between anxious and dysfunctional behavior, combative behavior
may occur. The stress threshold line is broken to indicate the potential for the resident
to return to anxious or baseline behavior if environmental stressors are diminished or

eliminated.

40

The circle connecting anxious and combative behavior represents the cycle of
combative behavior, which develops due to the demented resident’s consistent
exposure to environmental stressors. The circle is broken to indicate its openness to
intervention.

The rectangle representing combative behavior in the demented resident has an
arrow above and below it connecting it to two rectangles, which represent others in the
area surrounding the combative resident (other residents, staff, and visitors at the
facility), and primary caregivers (physicians and nursing personnel).

To the right of the rectangle is a square representing the GCNS as a change agent,
who oversees the implementation and evaluation of a protocol for the management of
combative behavior in demented, elderly, long—term care residents. The arrow from
the GCNS to other primary caregivers signifies the effect the GCNS’s intervention has
on these caregivers (i.e., a change in their behaviors related to the management of
combativeness). The arrows connecting the GCNS to the combative demented resident
and others around him or her signify the effect the GCNS’ intervention has on these
individuals (i.e., the resolution of the resident’s combative behavior and a decrease in
negative outcomes experienced by those involved in the combative episode). The
arrows exiting from the right side of the GCNS square indicate the positive impact
that the protocol development and implementation could have on professional and
advanced nursing practice and primary care, which is discussed in Chapter IV.

Three arrows exit from the rectangle representing primary caregivers of

combative, demented residents. The first, which points toward the stress threshold,

41

represents the primary caregiver’s implementation of the protocol at the point at which
combative behavior may occur (i.e., when the demented resident’s stress threshold is
exceeded). The second arrow, which slants to the left and points to the cycle of
combative behavior, signifies the primary caregiver’s ability to break this cycle and
assist the demented resident to return to baseline behavior, through the use of the
protocol and the appropriate follow-up.

The third arrow, pointing horizontally to the left, signifies the positive impact
which the primary caregiver’s utilization of the protocol would have on the demented
resident, others around him or her, and the primary caregiver. Through the
implementation of the protocol and the appropriate follw-up, the primary caregiver
would decrease the demented resident’s risk for physical injury, discomfort, fatigue,
physical and chemical restraint use, social isolation, and functional impairments. For
others around the demented resident (i.e., other long-term care residents, staff, and
visitors) the primary caregiver’s utilization of the protocol would decrease their risk
for physical injury and negative emotions, such as fear and uncertainty. By utilizing
the protocol, the primary caregiver would also decrease his or her own risk for
physical injury, negative emotions, and physical and emotional exhaustion.

In conclusion, within this chapter the introduction, background, and statement of
the problem, as well as the purpose of this scholarly project, have been presented. A
conceptual framework has also been presented, along with a schematic representation
of the conceptual framework, depicting relationships between the problems associated

with combative behaviors of demented, elderly residents, Hall’s PLST model, and the

 

 

42

GCNS. In the following chapter a review of the literature relevant to this project is

presented.

CHAPTER II
Review of the Literature
Introduction
The purpose of this chapter is to present a review of the literature related to

factors causing combative behavior in the demented and techniques for its
management. Due to the lack of literature specifically discussing combative behavior,
the first section will cover literature related to agitated, disruptive, and aggressive
behavior in the demented. In the second section, the literature related to behavioral,
environmental, communicative, and pharmacological management of problem

behaviors (including combativeness) in the demented will be presented.

Egtors Related to Combative Belgvior

Agitated Behavior

Agitation may be defined as ”inappropriate verbal, vocal, or motor activity that is
not explained by needs or confusion per se" (Cohen-Mansfield & Billig, 1986, p. 712).
Cohen-Mansfield and Billig (1986) defined inappropriate behaviors as those that were
aggressive or abusive toward self or others, excessively repetitive, or opposed accepted
social standards. Combative behaviors (e.g., biting and hitting) were included in
Cohen-Mansfield and Billig’s (1986) examples of agitated behaviors. The following is
a review of the research literature on causative factors of agitation in nursing home

residents.

43

44

Cohen-Mansfield (1986) conducted a study to explore the relationship of agitation
to certain variables and professional staffs’ perceptions of causes of agitation in elderly
nursing home residents. The sample included 66 residents from two skilled units.
The Cohen-Mansfield Agitation Instrument (interrater reliability of .88) measured the
frequency of subjects’ agitated behaviors (including hitting, kicking, and biting). The
Rapid Disability Rating Scale-2 and the Brief Cognitive Rating Scale assessed ADL
and cognitive function, respectively. The rating team also stated their perceptions of
why subjects became agitated.

Using t—tests, no significant differences were found between the agitated and non-
agitated groups in cognitive level, age, or frequency of awakening at night. However,
agitated subjects received significantly more psychotropic medications for agitation (p
< .001) and had a significantly higher incidence of falls (2 < .031) (Cohen-Mansfield,
1986). Because agitated subjects received more medications for agitation, Cohen-
Mansfield (1986) questioned whether these drugs were relieving or aggravating
agitation.

The factors which professional staff related to subjects’ agitation were grouped
into four interrelated categories: moods and needs, events, disabilities, and past
unresolved issues. Factors within these categories included frustration at the loss of
control and the invasion of territory or personal space, loneliness, depression, behavior
of other residents, and discomfort from constipation or restraints. Generalizability of

this study was limited due to the small sample (Cohen-Mansfield, 1986).

45

Werner, Cohen-Mansfield, Braun, and Marx (1989) conducted an observational
study on the relationship between physical restraints and agitation in cognitively
impaired nursing home residents. The subjects exhibited significantly more strange
movements, strange noises, and total agitation when restrained (p < .05), as well as
increases in the amount of aggressive behaviors. The researchers questioned the
effectiveness of physical restraints in quelling agitation.

Cohen-Mansfield, Marx, and Rosenthal (1989) studied the frequency of agitated
behaviors documented by charge nurses over three shifts within a 2 week period. The
sample was 408 nursing home residents who exhibited varying levels of physical and
cognitive decline. The Cohen-Mansfield Agitation Inventory, a nurses’ rating
questionnaire consisting of 29 agitated behaviors (including hitting, kicking, and
grabbing), was used to document agitated behaviors. Interrater reliability for three sets
of raters averaged .92, .92, and .88.

Data analysis indicated that the frequency of agitated behaviors was significantly
different (p_ < .01 to .05) across the three shifts, with subjects exhibiting 3.8, 3.3, and
2.1 different agitated behaviors at least once a week for the day, evening, and night
shifts, respectively. Higher daytime agitation levels were attributed to subjects’
increased activity (Cohen-Mansfield et al., 1989).

Cohen-Mansfield and Marx (1988) examined the relationship between depression
and agitated behavior in 408 nursing home residents (54.4% diagnosed with dementia).
The Cohen-Mansfield Agitation Inventory (Cohen-Mansfield et al., 1989) measured the

frequency of agitated behaviors. The Depression Rating Scale (interrater reliability of

46

.73) measured dimensions of depression. Nursing and social work staff rated subjects,
and relationships between depression, agitation, and other variables were determined.

Aggressive agitated behaviors related significantly to social and activity
dimensions of depression, that is, poor ability to communicate, infrequent and poor
quality of social interactions (2 < .01), and low activity level (p < .05). Aggressive
agitated behaviors were positively related to severity of dementia and negatively
related to gender (Cohen-Mansfield & Marx, 1988).

Hall et al. (1986) conducted a study of 12 Alzheimer’s disease residents in an
intermediate-care facility to evaluate the effect of a low-stimulus unit on their
functional levels. The unit’s therapeutic environment and resident care plans were
based upon Hall’s PLST model (Hall & Buckwalter, 1987). Approximately one-half
of the residents had been discharged from other facilities due to agitated or violent
behavior. Overwhelming and potentially misleading stimuli were minimized on the
unit and scheduled rest periods, consistent routines, and environmental cues were
provided. Subjects were allowed to wander freely on the unit. After 3 months,
changes observed in subjects’ behaviors included increased social interaction,
decreased agitation, wandering, and neuroleptic drug use, and the elimination of
combative behaviors, delusions, and illusions. Limitations of the study included the
short evaluation period and the lack of qualitative and quantitative measurement tools
(Hall et al., 1986).

In summary, the literature reviewed described three different types of agitated

behavior: aggressive (including combative behaviors). physically nonaggressive, and

47

verbal. Dementia and the male gender were factors predisposing to agitation. Factors
precipitating agitation included physical stressors (e.g., medication side effects, fatigue,
or discomfort), overwhelming or misleading stimuli, and changes in routine. Other
factors aggravating agitated behavior were the behavior of other residents and negative
feelings such as frustration, loneliness, and depression. These feelings are often
associated with perceived losses in the areas of control and independence, personal

space and territory, the ability to communicate, meaningful activities, and social

supports.

Disruptive Behavior

Disruptive or problem behaviors are those which are perceived as bothersome
and/or intolerable by observers, elicit negative reactions from others, and/or harm the
offender or his environment (Ebersole, 1989; Sillirnan, Stemberg, & Fretwell, 1988).
Examples of disruptive behaviors are combativeness, yelling, wandering, and refusing
to eat or drink (Ebersole, 1989; O’Connor, 1987). A review of the literature on
factors related to disruptive behavior in the demented follows.

Jackson, Drugovich, Stemberg, Fretwell, and Spector (1987) examined the
relationships between nursing home resident characteristics and disruptive behaviors.
Subjects (131 = 2371) were randomly selected from Rhode Island nursing homes.
Multivariate analyses indicated that a history of disruptive behavior, cognitive status,
gender, and dissatisfaction with one’s support system were significantly related to

disruptive behavior.

48
Teri, Borson, Kiyak, and Yamagishi (1989) studied 56 Alzheimer’s disease

patients and their caregivers to describe the prevalence and types of behavioral
problems found in community-based Alzheimer’s disease victims. The relationships
between behavioral problems and the subjects’ levels of cognitive and functional
impairment were also explored.

The Dementia Rating Scale-Coblentz assessed cognition. Caregivers completed
the newly developed Behavioral Problems Checklist and the Instrumental Activities of
Daily Living and Self-Care Skills tool. Behavioral problems related to cognitive
function were reported most frequently by caregivers, followed by those associated
with activity and emotional distress. Physically aggressive behaviors were not
reported, although verbal aggression and destruction of property were. Male subjects
exhibited significantly more problem behaviors than female subjects (1; < .05). The
level of impairment of conceptual skills approached statistical significance with the
number and persistence of behavioral problems (Teri et al., 1989).

The researchers concluded that behavioral problems were prevalent in community-
based Alzheimer’s disease victims, and that those with decreased conceptual skills
might be less able to problem solve and more prone to display problem behavior.
Limitations of the study included the use of a new measurement tool and the reliance
on caregivers’ reports, which were possibly biased (Teri et al., 1989).

Silliman et al. (1988) presented two case studies in which seveme demented

patients lived with family caregivers who were either verbally abusive or fought

49

frequently with others. In both situations, the demented patients’ disruptive behaviors
diminished upon separation from their caregivers.

O’Connor (1987) performed a reu'ospective study on factors related to the
exacerbation of problem behaviors of demented patients (5 = 70) referred for
admission to a psychiatric hospital over a 21 month period. The behaviors manifested
included physical aggression, severe wandering, and refusal to eat or drink. Data were
collected from clinical records and interviews with relatives. Factors related to
problem behavior exacerbations included drug-induced delirium (8.5%), active physical
illness, such as infections, congestive heart failure, or transient ischemic attacks
(34.4%), psychiatric illness (20%), and premorbid personality problems (43%). In
only 39% of subjects was a worsening of dementia considered solely responsible for
problem behavior exacerbation.

As evidenced in O’Connor’s (1987) study, delirium can exacerbate disruptive
behaviors in demented individuals. Delirium presents as an acute change (usually
occuning over several hours to days) in cognitive function and a clouding of
consciousness, accompanied by disturbances of perception, speech, sleep, and
psychomotor activity. Delirious individuals may display agitation and combativeness
(American Psychiatric Association, 1987; Ereshefsky et al., 1989; Patterson & LeClair,
1989).

Drug intoxication (commonly with anticholinergic drugs, such as anti-
Parkinsonians and antipsychotics) as well as drug withdrawal (e.g., from

benzodiazepines) can induce delirium. Other factors causing delirium include

50

endocrine (e.g., hypoglycemia or hypercalcemia) or metabolic (e.g., organ failure or
dehydration) disturbances, seizures, neoplasms (either by direct mass or remote
effects), trauma (e.g., concussion, subdural hematoma, fracture, or surgery), infections
(e.g., respiratory or urinary tract), and vascular events (Patterson & LeClair, 1989).

According to Ray et al. (1990), disruptive behaviors of nursing home residents are
most frequently associated with a dementing illness. Potentially reversible physical
factors related to disruptive behaviors include drug intoxication, metabolic disorders,
infections, cardiac or brain disorders (e. g., arrhythmias or transient ischemic attacks),
nutritional deficiencies (e.g., B-12, folic acid, or niacin), and hypothermia. Mental
disorders such as depression and chronic or late-onset schizophrenia can result in
disruptive behaviors. Disruptive behaviors can also occur secondary to environmental
or psychosocial changes, for example, changes in lighting or noise level, sensory
deprivation, or the loss of a significant other.

Psychiatric symptoms (i.e., delusions, hallucinations, and illusions) can also
precipitate disruptive behaviors in the demented (O’Connor, 1987; Patterson &
LeClair, 1989). These symptoms may be due to dementia itself, or to other factors,
such as medication side effects, a concurrent psychiatric illness, or sensory losses
(Burnside, 1981; Carroll, 1989; Hussian & Davis, 1985; Patterson & LeClair, 1989).

Researchers have documented the occurrence of psychiatric symptoms and their
relationship to aggressive behavior in demented nursing home residents. Rovner et al.

(1986) reported that active aggression occurred more frequently in the 38% of

51

demented nursing home residents manifesting delusions and hallucinations, compared
to other demented residents in their study.

Morriss, Rovner, Folstein, and German (1990) reported that 20.8% of nursing
home residents displayed delusional behavior. These residents manifested more
cognitive impairment and physical and verbal aggression than other residents in the
study. Nursing assistants recognized delusions in only 19% of the delusional
residents, emphasizing the need to educate long-term care nursing staff on the
recognition and management of residents manifesting psychiatric symptoms.

Another potential cause of disruptive behaviors (including combativeness) in
demented individuals is catastrophic reactions, i.e., ”sudden episodes of strong emotion
that occur in situations that overtax the demented patient’s coping ability" (Howell &
Watts, 1990, p. 431). Stressors such as relocation or a change in caregiver can
aggravate a catastrophic reaction.

In summary, the literature reviewed identified aggressive or combative behavior as
one type of disruptive behavior in the demented. Predisposing factors related to
disruptive behavior included cognitive impairment, a past history of disruptive
behavior or a mental disorder, and the male gender. Suggested physical precipitants of
disruptive behavior included an irreversible dementia and potentially reversible factors
often associated with delirium. The onset of psychiatric disorders (e. g., depression or
late-onset schizophrenia) as well as psychiatric symptoms could also provoke

disruptive behaviors. Finally, the manifestation of disruptive behaviors could be due

52

to environmental or psychosocial changes such as relocation, a change of caregiver, or
a diminished social support system.
Agwsive Behavior

As discussed in Chapter I, the literature on dementia often utilizes the term
aggressive to describe behaviors defined within this study as combative, that is,
deliberate hitting or striking out, kicking, pushing, scratching, pinching, grabbing, and
biting. Due to the lack of research literature on "combative" behavior, the following is
a review of the literature on factors related to aggressive behavior in the demented.

Ryden (1986) and Hamel et al. (1990) performed studies to determine the
frequency and nature of aggressive behavior in community-based demented persons.
Measurement instruments completed by caregivers included the 25-item Ryden
Aggression Scale, the General Health Questionnaire, the Burden Interview, the
Memory and Behavior Problem Checklist, and the Social Interaction Questionnaire.

Analysis of the data indicated that verbally aggressive behavior was reported most
frequently, followed by physically and sexually aggressive behavior, respectively.
Predisposing factors related to aggressive behavior included premorbid aggressive
behavior, greater severity of cognitive impairment, greater frequency of behavioral and
memory problems, and a troubled premorbid caregiver/carereceiver relationship. The
situation most often aggravating aggressive behavior was caregivers telling demented
subjects to "do something" (Hamel et al., 1990; Ryden, 1986).

Beck et al. (1990) performed a descriptive study on 21 nurses’ and 20 nursing

assistants’ perceptions of aggressive behaviors displayed by nursing home residents. A

53

guided interview format was used to obtain information from subjects. Verbal and
physical aggression were reported by 95% and 68% of subjects, respectively.
Physically aggressive behaviors reported included kicking, hitting, and pinching.
Aggressive behaviors were reported to occur most frequently when residents were
receiving ADL assistance and medications. Reasons given for residents’ aggression
included receiving care from a new staff member, acting out for family, wanting
things done their way, unfulfilled requests, illness, homesickness, medications, fear,
confusion, restraints, being a new resident, inability to communicate, and disliking a
roommate.

Meddaugh (1987a, 1990) studied the differences between 14 aggressive and 13
non-aggressive cognitively impaired nursing home residents. Data were collected over
a 5 week period through subject observations, semi-structured interviews, and chart
and incident report reviews. Analysis of the data indicated that compared to
nonaggressive subjects, aggressive subjects were offered fewer choices and were more
nonverbal, socially isolated, cognitively impaired, dependent on others for care, and
emotionally unpredictable. In two situations residents forced a change in their care
through aggressive behavior when other means of communication had failed.

Meddaugh (1987b) described characteristics of abusive nursing home residents and
abused caregivers. The operational definition of abusive behavior was similar to that
of combative behavior. The sample consisted of 72 residents and 97 nurses and aides

in a skilled-care facility. Data were collected through a retrospective chart and

54

incident report review spanning a 3 month period and were analyzed using descriptive
statistics.

The highest rate of abuse occurred in severely confused subjects and subjects who
received less support from significant others. There were more abusive acts toward
nurses’ aides (18 vs. 2 for RNs and 6 for LPNs), and 35.3%, 26.3%, and 21% of
abusive incidents occurred during the day, evening, and night shifts, respectively. It
was suggested that abusive residents were more confused and acting out due to
feelings of rejection and loneliness, and that subjects were more abusive when
receiving ADL assistance from aides (Meddaugh, 1987b).

To summarize, researchers have suggested that aggression is a behavior problem
manifested by both community- and institutionally-based demented individuals.
Predisposin g factors related to aggression included the male gender, a greater severity
of cognitive impairment, a greater frequency of behavioral and memory problems, and
a premorbid aggressive personality or troubled caregiver/carereceiver relationship.

Causative factors of aggressive behavior discussed within the literature included
negative feelings such as fear, rejection, loneliness, and frustration. These feelings
may be related to other suggested causative factors such as unmet needs, social
isolation, restrictions on behavior and choice, dependency in ADLs, and the inability
to communicate. Other causative factors of aggressive behavior discussed within the
literature included a change of environment or caregiver, illness, restraints, and

increased activity and stimuli.

55
Summary of Factors Related to Combative Behavior

In conclusion, no research literature was found which specifically addressed
combativeness in the demented elderly. However, combative behaviors were discussed
within the research literature on agitated, disruptive, and aggressive behaviors in the
demented. Predisposing factors related to aggressive and combative behaviors include
a greater severity of cognitive impairment, a greater frequency of behavioral or
memory problems, a past history of aggressive behavior or a mental disorder, a
troubled premorbid caregiver/carereceiver relationship, and the male gender.

Possible precipitants of aggressive and combative behaviors were also identified in
the literature reviewed. Many of these precipitants can be placed within the categories
of stress-producing factors identified by Hall. These categories are: changes in the
environment, caregiver, or routine; demands to function beyond the limits imposed by
cortical deterioration; overwhelming, competing, or misleading stimuli; physical
stressors; and fatigue (Hall, 1988a; Hall & Buckwalter, 1987).

Changes in the environment which are associated with increased agitation and
aggression include relocation, sensory deprivation, and changes in physical factors
such as lighting and noise. Factors such as an unfamiliar caregiver or an inconsistent
daily routine may also heighten agitation in the demented.

The fact that demented subjects were more aggressive when told to ”do
something" suggests that caregivers at times expect the demented to perform beyond

their mental and physical capabilities. Aggression may also be an expression of the

56

anger and frustration experienced by the demented as mental and physical capabilities
deteriorate.

A greater frequency of aggressive and combative behaviors both during the day
and on regular nursing units within long-term care facilities suggests that high levels
of overwhelming and competing stimuli aggravate these behaviors. Misleading stimuli
such as the overhead paging system could precipitate psychiatric symptoms resulting
in aggression in demented nursing home residents.

Physical stressors related to combativeness include the progression of an
irreversible dementia and factors often related to delirium (e. g., drug intoxication or
withdrawal, metabolic or endocrine disorders, and infections). Discomfort and fatigue
may also aggravate combative behaviors.

The development of psychiatric disorders such as depression and late-onset
schizophrenia could precipitate aggressive behaviors. Psychiatric symptoms due to
dementia, psychiatric disorders, sensory losses, or medication side effects could also
result in aggressive behaviors.

A relationship between negative feelings such as frustration, anger, loneliness,
boredom, and depression and the occurrence of agitated, disruptive, and aggressive
behaviors was suggested in the literature reviewed. The literature also supported an
association between these negative feelings and the losses experienced by the
demented elderly. Examples of these include losses of control, independence, personal
space and territory, the ability to communicate, meaningful activities, significant

others, and an adequate social support system.

57

Thus, factors have been identified that are related to combative behaviors in
demented residents. Nursing staff intervening during a combative episode often
respond to the combative behavior, ignoring the factors provoking such behavior
(Ebersole, 1989). In such situations the caregivers’ response (e.g., physically
restraining the resident) may result in only temporarily halting the behavior or in
increasing its frequency and intensity (Gugel, 1988). In order to effectively manage
combative behaviors, therefore, caregivers must focus on both eliminating any

aggravating factors and on controlling the combative behaviors.

Mment of Combative Behavior

Although the management of the physical and cognitive impairments of dementia
is demanding, perhaps the most difficult task for caregivers is tolerating and managing
problem behaviors (Mace, 1990). Severe problem behaviors such as combativeness
can jeopardize both the demented elder’s and caregiver’s safety and result in physical
and emotional exhaustion. Because the use of several approaches has been
recommended to manage problem behaviors (Eirner, 1989; Maletta, 1988) the
following discussion will focus on behavioral, environmental, communicative, and
pharmacological interventions for the management of combative behavior in the

demented elderly.

58
Behavioral Management

Behavioral therapy is defined as "any intervention that attempts to change the
frequency, intensity, duration, or location of a specific behavior or set of behaviors
through systematically varying antecedent stimuli or consequential events" (Hussian &
Davis, 1985, p. 15). Behavioral therapy has been suggested as an effective approach
for the management of geriatric behavioral problems, including combativeness
(Ebersole, 1989). The following is a discussion of behavioral therapy principles and
techniques relevant to the management of combative behaviors in demented residents.

The first step toward managing a problem behavior is specifically defining the
problem or ”target" behavior (Gugel, 1988). Once the target behavior is defined, the
frequency, duration, and intensity of the behavior are observed and recorded (Hussian
& Davis, 1985). An accurate description of the target behavior provides a standard
upon which to evaluate the effectiveness of behavioral interventions (Ebersole, 1989).

Because behavior is largely a reaction to environmental stimuli, antecedents (i.e.,
events occurring just prior to the target behavior) are also identified. When
identifying antecedents of combativeness, it is important to identify both external,
observable antecedents, such as excessive noise and internal, nonobservable
antecedents, such as delusions or hypoglycemia (Hussian & Davis, 1985).

Consequents (i.e., events immediately following the target behavior) should also
be identified (Hussian 81. Davis, 1985). Combative behavior may occur because of
reinforcing consequents, defined as events which increase the probability of the

recurrence of the behavior (Ebersole, 1989; Gugel, 1988; Hussian & Davis, 1985;

 

 

59

Janosik & Davies, 1989; Letemendia, 1985). Examples of reinforcing consequents
related to combativeness include escape from an undesirable activity and gaining
attention (Chafetz, 1988; Hussian & Davis, 1985; Letemendia, 1985).

Once the combative behavior has been evaluated, behavioral techniques may be
utilized to reduce its occurrence. Due to impairments in memory, comprehension, and
learning, some behavioral techniques are not appropriate for the demented resident
(Hussian & Davis, 1985; Letemendia, 1985). Behavioral techniques considered
effective for reducing aggressive behaviors in the demented include extinction, time
out, and distraction (Hussian & Davis, 1985; Letemendia, 1985).

Extinction focuses on preventing the reinforcing consequents that immediately
follow a problem behavior (Chafetz, 1988; Hussian & Davis, 1985). For example, if a
demented resident displayed combative behavior, the caregiver would avoid reinforcing
the behavior by avoiding physical or verbal contact with the resident. The caregiver
would remain calm, not take the aggressive behavior personally, and leave the
situation if feelings such as anger or fear surfaced (Chafetz, 1988; Hussian & Davis,
1985; Letemendia, 1985).

Time out involves either removing all reinforcers from the combative resident’s
environment (e.g., attention from others or participation in a desired activity), or
relocating the resident to a room devoid of reinforcers (Hussian & Davis, 1985;
Letemendia, 1985). This technique would be implemented immediately following the
combative behavior, with the caregiver briefly describing to the resident the behavior

necessitating time out, the length of the time out period, and the criteria for ending it.

60

A suggested length for time out is five minutes, after which the resident would return
to previous activities (Hussian & Davis, 1985). In addition to preventing further
reinforcement of combative behavior, time out may also provide temporary relief from
expectations causing frustration in the demented resident (Ebersole, 1989).

Distraction is a behavioral technique which is particularly successful with
demented persons due to their shortened attention span (Hussian & Davis, 1985).
Depending on the severity of cognitive impairment, distraction may be the only
effective behavioral intervention for combativeness. Distraction involves shifting the
demented resident’s attention from the combative behavior to an appropriate behavior
which the resident enjoys and which is incompatible with aggression and the
associated feelings of anger, fear, or resentment. The combative behavior is ignored,
and the resident is engaged in the distracting behavior long enough to allow aggressive
feelings and tendencies to abate (Hussian & Davis, 1985; Letemendia, 1985).

In addition to reducing the target behavior, behavioral therapy focuses on
increasing appropriate behavior, primarily through reinforcing such behavior (Gugel,
1988; Hussian & Davis, 1985; Letemendia, 1985). Suggestions related to the use of
reinforcement with the demented include presenting reinforcers immediately after the
appropriate behavior and using multiple reinforcers (e. g., praise and touch). Also,
individualized and primary reinforcers (i.e., those immediately satisfying needs) are
most effective in maintaining appropriate behavior. Finally, reinforcement should be
strong and consistent and may need to be continued indefinitely to sustain appropriate

behavior (Gugel, 1988; Hussian & Davis, 1985).

 

 

.— i.

61
Although behavioral therapy has been suggested for the management of combative

and other problem behaviors of the demented, the bulk of literature on this topic was
empirical. A literature review of the research related to the behavioral management of
combative and several other problem behaviors of the demented follows.

Rosberger and MacLean (1983) studied whether or not educating staff on a long-
terrn care unit in behavioral management techniques could reduce the behavioral
problems of a 79-year-old female resident (post-CVA). The resident’s behavioral
problems included kicking or tripping others and pushing her table or wheelchair into
others.

An initial educational meeting was held with staff followed by a 1 week baseline
assessment of target behaviors, which indicated that the resident’s problem behaviors
were attention-seeking behaviors. Phase I of treatment involved the use of differential
social reinforcement. Staff were instructed to provide social reinforcement (e. g.,
attention, conversation) for appropriate behaviors and to walk away or ignore the
resident when she displayed target behaviors. Phases II and III of treatment consisted
of gradually involving the resident in group activities while continuing differential
social reinforcement (Rosberger & MacLean, 1983).

Within 3 weeks the frequency of target behaviors decreased to 0 to l per week
compared to baseline frequencies of 3 to 16 per week. Staff observed that the subject
was using more appropriate verbalizations and initiating positive interactions. It was
concluded that behavioral intervention had markedly reduced the resident’s problem

behaviors and increased appropriate behaviors (Rosberger & MacLean, 1983).

 

62

Wisner and Green (1986) studied the effectiveness of cognitive-behavioral
techniques in decreasing angry outbursts of a 73-year-old male nursing home resident
diagnosed with multi-infarct dementia. Nursing staff on all shifts were trained on the
use of a 10 point Likert-type scale rating angry episodes as mild, strong, or severe.

Treatment included exclusion from eating meals in the dining room if angry
outbursts occurred and a self-controlled time out whenever the subject began to
experience uncontrollable anger. The subject and nursing staff kept a record of his
angry behavior and the senior researcher met weekly with the subject to discuss
possible alternative reactions and solutions to anger and to provide reinforcement for
attempts at changing behavior (Wisner & Green, 1986).

Review of the data indicated that during the baseline assessment, 11 angry
outbursts occurred in 14 days, and more than 50% of these were rated as strong to
severe. In contrast, during the treatment period 4 angry outbursts occurred in 42 days,
with 25% of these rated as strong and 75% as mild. It was concluded that the
cognitive-behavioral interventions used had assisted the subject in controlling his
anger. A limitation of the study was the lack of data amenable to statistical analysis
(Wisner & Green, 1986).

Baltes and Lascomb (1975) studied whether or not behavioral techniques could
diminish the screaming behavior of an 80-year-old female nursing home resident
diagnosed with confusion and paranoia. A 2 week baseline assessment of the target
behavior was performed, followed by a 1 week treatment period (six, 1 hour sessions)

in which the subject’s behaviors other than screaming were reinforced immediately

63

and consistently with social and tangible reinforcers. The occurrence of the target
behavior resulted in a modified time out in which reinforcers were removed. After
treatment ended a second assessment of target behavior was performed.

Analysis of the data indicated that during treatment screaming behavior decreased
to a mean frequency of 5 screams per 5 minutes at peak times, compared to 21 during
baseline. After treatment was discontinued, screaming behavior dramatically increased
to between 35 to 55 times at peak times, and the subject displayed behaviors such as
pleading, reaching out, hitting, and kicking (Baltes & Lascomb, 1975).

Birchmore and Clague (1983) explored the effect of a behavioral intervention in
reducing a 70-year-old blind and demented female nursing home resident’s shouting
behavior. A baseline assessment of the target behavior was done followed by the
behavioral intervention, which consisted of stroking the subject’s back when she was
quiet and ceasing stroking when she began vocalizing. Treatments were conducted
over approximately 4 weeks for four, 10 minute periods each day. The amount of
time vocalizing during treatments was recorded.

A comparison of the frequency of vocalizations indicated that vocalizations
occurred from 8.5 to 10.0 minutes per 10 minute intervals during baseline and from
.25 to 5.5 minutes per 10 minute intervals during treatment. Staff stated that the
subject was quieter on treatment days. The researchers concluded that the use of
differential social reinforcement did reduce the subject’s shouting behavior (Birchmore

& Clague, 1983).

64

In summary, the literature reviewed supports the use of behavioral management
techniques to reduce combative and other problem behaviors in demented nursing
home residents. The behavioral techniques of extinction, time out, distraction, and
differential reinforcement appear effective in reducing various problem behaviors.
However, the benefits of utilizing behavioral management techniques must be weighed
against the risks related to the ethical treatment of the institutionalized elderly. For
example, in Baltes and Lascomb’s (1975) study, the withdrawal of the behavioral
treatment (consisting of social and tangible reinforcers) resulted in a dramatic increase
in the target behavior, as well as the occurrence of pleading and reaching out
behaviors. The effectiveness of behavioral management techniques hinges upon
nursing staff’s ability to collect data, consistently apply behavioral interventions, and
evaluate their effectiveness, as well as stast levels of enthusiasm and cooperation
(Hussian & Davis, 1985).

Environmental Management

Generally speaking, the elderly, due to age-related physical and psychological
changes, are more sensitive to their environment than are younger adults (Minde,
Haynes, & Rodenburg, 1990). This sensitivity is exacerbated in the demented elderly,
who also experience a progressive decline in cerebral function resulting in a decreased
ability to accurately receive and process environmental stimuli (Hall & Buckwalter,
1987).

In the demented elderly, normal behavior and maximum functional levels are

achieved by minimizing stress-related factors within the environment and by

65
supporting losses (Hall & Buckwalter, 1987). However, minimal research has been

done addressing the manipulation of environmental factors to promote maximum
functioning of the demented (Minde et al., 1990). A review of the literature
discussing environmental interventions to diminish stress-producing factors within the
demented resident’s environment follows.

Hall (1988a) suggested environmental interventions to minimize demented
residents’ exposure to the stressor groups identified within the PLST model (Hall &
Buckwalter, 1987). Techniques to minimize fatigue include providing residents with
scheduled time out and rest periods and cues to assist in distinguishing between naps
and bedtime, involving residents in shorter activities, and planning the most taxing
activities in the morning.

Because environmental changes can increase frustration and confusion in
demented residents, it is important to maintain consistency in their physical
environment, caregivers, and routines. Changes which must occur should be simple
and gradual, and demented residents should be observed for anxious or dysfunctional
behavior indicating the need for assistance in coping with the change (Hall, 1988a).

Environmental modifications which diminish overwhelming, competing, or
misleading sensory stimuli are needed to enhance demented residents’ abilities to
interpret and cope with their environment. Such modifications include providing
quieter areas, simpler and smaller group activities, and an environmental decor

reminiscent of home (Hall, 1988a).

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Because attempting to rejuvenate lost abilities through retraining and testing only
exacerbates the frustration experienced by demented residents, assistance should be
given to support losses in mental, physical, and emotional function. For example,
reality therapy should be used with demented residents only if topics to which the
resident can relate are discussed (Hall, 1988a).

Physical stressors causing pain, acute illness, or other physiological alterations in
demented residents can exacerbate dysfunctional behaviors such as combativeness
(Hall, 1988a). Interventions must be taken, therefore, to eliminate physical stressors
such as adverse drug reactions, bowel irnpactions, or infections. Demented residents
manifesting either new or exacerbated dysfunctional behavior should receive a physical
exam to determine if physical factors are involved (Hall, 1988a).

According to Pynoos and Stacey (1986) changes within long-term care facilities
which would promote maximum function and discourage problem behavior include the
provision of appropriate levels of environmental stimulation, specific orienting cues, an
environment promoting individuality and privacy, and adequate staff to address both
physical and psychosocial needs and to encourage autonomy.

Maas (1988) suggested that the traditional nursing home unit was not furnished
with either the appropriate environmental structures or the necessary staff to provide
the special care needed by demented residents. Therefore, the placement of demented
residents on special care units with environmental modifications promoting safety and

maximum function and staff trained in the care of the demented was advocated.

 

67
Benson, Cameron, Humbach, Servino, and Gambert (1987) performed a

prospective study on the functioning of 32 demented residents to determine the impact
of relocation from a traditional long-term care unit to a specialized dementia unit. The
unit was designed to decrease the demands placed on demented residents’ limited
cognitive abilities. Special features included orientation boards throughout the unit
and color coding of residents’ rooms with their names and pictures outside the doors.

For each subject a researcher completed a rating scale assessing levels of mental,
emotional, and ADL function. Subjects were also assessed with the New York State
Department of Health Long-term Care Placement Form, Medical Assessment Abstract.
Each subject was assessed prior to and 4 and 12 months after admission to the
dementia unit (Benson et al., 1987).

All data were statistically analyzed utilizing paired t-tests. Compared to scores
prior to admission, a statistically significant (p < .001) improvement in mental,
emotional, and ADL scores was found at 4 months. This improvement was
maintained at 12 months for both mental and emotional function (p_ < .05) and ADL
function (2 < .005) (Benson et al., 1987).

Cleary, Clamon, Price, and Shullaw (1988) performed a study to measure
functional level changes in 11 demented nursing home residents moved to a Reduced
Stimulation Unit (RSU). The RSU was designed to reduce stimulation and minimize
reliance on memory. Features included the absence of televisions and radios,
consistent daily routines, small group activities, and the freedom of residents to

ambulate, eat, and rest where desired.

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Multiple measurement tools were used and were administered both 3 months prior
to and after the unit’s opening. Analysis of the data indicated a significant
improvement in subjects’ ADL function (p < .005), a significant decrease in agitation
(including combative behavior) and restraint use (p < .001), and increases in family
satisfaction and subjects’ communication abilities after relocation (Cleary et al., 1988).

Minde et al. (1990) discussed environmental changes made on a psychogeriatric
ward housing 36 residents with primary diagnoses of dementia, schizophrenia, and
affective disorders, many whom were placed on the ward due to aggressive and other
inappropriate behaviors.

Two phases of environmental change were initiated by the nursing supervisor.
Changes during Phase I included removing all physical restraints and permitting
resident access to previously restricted areas. Although the number of incidents, falls,
and serious injuries increased the first year, by the second year’s end a significant
decrease (p < .05) had occurred in the percentage of total incidents that were falls and
serious injuries. In addition, staff turnover had decreased by 19.1%, residents were
calmer, more sociable, and sleeping better, and the ward noise level was substantially
reduced (Minde et al., 1990).

Phase II of the environmental changes consisted of changing the decor of the ward
from an institutional to a homelike one, including decorating the dayroom in colonial
style. After a period of initial confusion residents began spending more time in the

dayroom, with residents "adopting" particular chairs and behaving more appropriately

69

and appearing happier and more relaxed. The visitation rate also increased. A
limitation of the study was the lack of a true experimental design (Minde et al., 1990).
Thus, the literature related to modifications of the demented residents’ physical
environment suggests that such modifications can result in increased levels of function

for demented residents and in increased family and staff satisfaction. The
environmental literature reviewed also supports the modification of staffing and
resident socialization patterns to improve resident function and staff satisfaction.

For example, Athlin and Norberg (1987) conducted a study to describe changes in
nursing caregivers’ attitudes toward and interpretations of demented residents’
behaviors when allowed to feed the same residents for 14 meals. The subjects were
two male and two female long-term care nursing staff members. Meals l, 7, and 14
were recorded on videocamera and assessed by a researcher using a modification of
Bamard’s Assessment Feeding Scale. Following the observed meals a researcher
interviewed each subject.

Qualitative analysis of the data indicated that the subjects became more confident
in their ability to interpret residents’ eating behaviors and to communicate with and
understand residents as the study progressed. Subjects also developed a more positive
image of the residents and more job satisfaction. It was suggested that the
organization of care within long-term care facilities be changed so that staff could care
for the same demented residents consistently (Athlin & Norberg, 1987).

Donat (1986) studied factors related to combative incidents between residents in a

330-bed psychogeriauic intermediate-care facility. A survey was conducted of all

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incident reports documenting altercations between residents within a 3 month period.
Analysis of the data indicated that 51% of the altercations occurred between 5 and 8
pm. when staffing levels and activities for residents were lower. The majority of
altercations occurred in the dayroom and hallways.

Residents identified as aggressors manifested significantly more problem behaviors
(p < .01) than the general ambulatory psychogeriatric population. Resident victims
were significantly more cognitively impaired and less mobile and manifested
significantly less problem behaviors (p < .01) than their aggressors (Donat, 1986).

Interventions to decrease altercations on one ward included assigning additional
staff to the ward during the evening hours and separating residents identified as
aggressors and victims into different dayrooms. Compared with the period prior to the
interventions, altercations decreased from an average of 4.7 per week to less than 1
per week. On a similar ward without interventions the frequency of altercations
remained essentially unchanged (Donat, 1986).

In conclusion, the literature reviewed suggested that environmental interventions
be made to diminish demented residents’ exposure to stress-producing factors and to
support functional losses in an anticipatory manner. The implementation of such
interventions creates an environment which facilitates maximum functioning and
normal behavior in these residents (Hall & Buckwalter, 1987).

Positive outcomes from environmental interventions included significant
improvements in mental, emotional, and ADL function, and a decrease in agitated and

combative behaviors accompanied by an increase in appropriate behaviors. Also, a

 

71

significant reduction in physical restraint use, an increase in family satisfaction and
visitation rates, and a decrease in nursing time spent managing problem behaviors
were reported.

Communicative Management

A major challenge for long-term care nursing staff is identifying the needs of
demented residents whose ability to communicate is impaired. Communication, which
can occur through the spoken word, writing, and body language, is defined as "the
transmission and reception of a message between two or more persons" (Harkulich &
Calamita, 1989, p. 97).

The inability of demented residents to express themselves or to comprehend others
can result in feelings of pain, frustration, and embarrassment for both the residents and
their caregivers. The frustration experienced by demented residents may result in
emotional outbursts, including combative behavior (Kotik-Harper & Harper, 1988).

Thus, interventions are needed which will enhance communication between
demented residents and their caregivers. Maintaining communication between
demented residents and nursing staff diminishes the occurrence of problem behaviors
and reassures residents that there are people who will listen and respond to them
(Bartol, 1979). The following section is a review of the literature on techniques which
can enhance communication with the demented resident.

Bartol (1979), Ray et al. (1990), and Robinson et al. (1989) suggested
communication techniques to use with the agitated and/or angry demented resident.

Distracting stimuli are minimized as the resident has a decreased ability to block out

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competing stimuli. The caregiver approaches from the front and gains the resident’s
attention by calling his or her name and stating the caregiver’s name, role, and
purpose. The caregiver assesses the resident for any visual, hearing, or speech
impairments and attempts to compensate for these.

The caregiver looks directly at the resident and speaks at his or her eye level.

The caregiver’s tone of voice should be gentle and calm, projecting a sense of control.
A condescending tone may provoke anger. A low voice pitch is preferable as a higher
pitch conveys stress. Voice volume should be raised only for the hearing impaired as
shouting can upset the demented resident (Bartol, 1979; Robinson et al., 1989).

Communication begins with orienting information. The caregiver speaks slowly
and clearly using short, simple sentences with concrete and familiar words and
phrases. A pause is needed between sentences to allow the demented resident
sufficient time to process and respond to information. The use of other sensory
modalities will assist in the comprehension of messages (Bartol, 1979; Robinson et al.,
1989).

Simple questions with a choice of two answers are used, avoiding open-ended
questions and those relying on memory. If the resident does not respond to a question
it is repeated verbatim. If a response is not obtained despite several repetitions, the
question is rephrased. Frequent and clear reminders during communication will
provide reassurance to the demented person (Bartol, 1979; Robinson et al., 1989).

A non-demanding and non-confrontational approach is used, avoiding ordering the

resident to do something. Directions should be given in a positive manner, avoiding

73

the use of "no" or "don’t". Reasoning or rationalizing is avoided as this could
increase the resident’s frustration and anger due to the inability to think logically (Ray
et al., 1990; Robinson et al., 1989).

Demented residents are keenly aware of others’ verbal and nonverbal messages.
Therefore, feelings such as anger or impatience should not be conveyed by the
caregiver, as these may increase the resident’s agitation and confusion (Robinson et
al., 1989).

Techniques for communicating with agitated demented residents suggested by
Kotik-Harper and Harper (1988) include approaching the resident in a calm and
reassuring manner, reducing environmental stimuli, removing dangerous objects,
conveying feelings of genuine concern and patience, avoiding making unrealistic or
additional demands of the resident, and maintaining consistency between verbal and
nonverbal messages.

For the elderly resident experiencing anxiety due to the loss of control over
behavior, interventions include identifying the resident’s feelings and providing
reassurance regarding the willingness to help control behavior. Once the resident is
receptive to these communications, the caregiver suggests an alternative to combative
behavior and encourages the verbalization of feelings (Burnside, 1981).

Nonverbal communication (touch, facial expression, eye contact, posture, and
spatial position) conveys an individual’s emotions and beliefs, and therefore is as
important as verbal communication. Nonverbal techniques for communicating with

demented residents include the use of touch provided it does not elicit negative

74

responses. The use of eye contact can convey interest and build a trusting
relationship, whereas avoiding eye contact can convey feelings of dislike, guilt, or
boredom (Hoffman & Platt, 1990).

Regarding posture, raised shoulders may convey stress and tension, and arms
folded in front of the body can suggest dislike for another or the need to protect
oneself. Caregivers interacting with demented residents should keep their shoulders
and arms relaxed and down (Hoffman & Platt, 1990).

When caregivers violate demented residents’ personal space without first
establishing trust, residents may withdraw and possibly display catastrophic reactions.
Trust is promoted by approaching the demented resident slowly from the front and
announcing oneself, explaining all procedures, sitting or standing at the resident’s eye
level and making frequent eye contact, and maintaining a relaxed body posture
(Hoffman & Platt, 1990).

Effective communication involves not only sending clear messages, but also being
able to interpret others’ messages. Caregivers should monitor demented residents for
fluctuations in facial expression, eyes, gesture, posture, and vocalization indicating
changing feelings or needs. Techniques to enhance the understanding of nonverbal
messages include responding to the emotional tone of messages and acknowledging
feelings, and considering the context of the behavior (Hoffman & Platt, 1990;
Robinson et al., 1989; Ronch, 1989).

Receptive, nonverbal behaviors of demented residents include a relaxed body,

making eye contact, pleasant facial expressions, extending the hand or a verbal

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greeting, and taking a few steps or leaning toward the caregiver. Behaviors indicative
of nonreceptiveness include backing, turning, or walking away, shying away from
touch, avoiding eye contact or narrowing or closing the eyes, frowning, and increased
signs of anxiety, such as increased motor restlessness and muscle tension (Bartol,
1979).

Due to the emotional lability of demented residents, caregivers should consider
leaving the nonreceptive resident alone for a period. Forcing an interaction with a
nonreceptive resident could aggravate a negative response. The caregiver can
acknowledge the resident’s desire not to interact and follow through on a commitment
to return later. If the resident displays both receptive and nonreceptive behaviors,
communicating concern and affection may increase receptiveness (Bartol, 1979).

Little research literature was found related to techniques for communicating with
the demented. Because of this, in addition to the studies involving demented subjects,
several studies with nondemented subjects which appeared relevant to this project were
reviewed. A review of the research literature related to communicating with demented
residents follows.

DeWever (1977) performed a study on affective touching of nursing home
residents by nurses. The subjects were 99 elderly, white residents from two nursing
homes. The Comfort When Touched Inventory (CI'I), a 28-item instrument, was used
to measure perceived comfort or discomfort from seven types of affective touch. The
researcher administered the CTI to each subject while he or she viewed each of four

photographs depicting a younger or older male or female nurse.

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Data were analyzed using Pearson-product moment correlation, point biserial
correlation, and multiple regression analysis. Based on the data analysis, affective
touching of residents’ arms and faces was recommended, while placing an arm around
residents’ shoulders was discouraged. Male nurses were advised to use discretion
when affectively touching female residents (DeWever, 1977).

Langland and Panicucci (1982) studied the effects of touch on elderly, confused
residents’ verbal and nonverbal responses. The subjects were 32 cognitively impaired
female residents from two intermediate—care facilities randomly assigned to
experimental and control groups. All subjects were given the same verbal request,
with the experimental group also receiving a light touch on the forearm. Utilizing a
tool developed by the researcher, data were collected on subjects’ attention, verbal,
and action responses. Data analysis indicated a significant increase in attention (2 <
.05) for the experimental versus the control group, indicating that touch is important in
gaining attention and developing relationships with confused, elderly residents.

McCorkle (1974) studied the relationship between touch received by seriously ill
patients and the occurrence of positive acceptance responses. Sixty seriously ill,
hospitalized patients were assigned to experimental or control groups. Experimental
group subjects were touched while conversing with the researcher, whereas the control
group subjects were not.

Instruments used to measure verbal and nonverbal responses included the
Interaction Behavior Worksheet and Bale’s Interaction Process Analysis. Analysis of

the data using the Kolmogorov-Smirnov two sample test indicated that significantly

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more patients in the experimental group (p < .01) responded positively to touch. The
researcher concluded that touch was effective in eliciting positive responses from
seriously ill patients and in conveying caring (McCorkle, 1974).

Due to a decreased ability to accurately perceive stimuli, the demented resident
may become agitated and combative when nonthreatening persons invade his or her
personal space (Bartol, 1979). Marx et al. (1989) studied the relationship between
agitated behavior and personal space. Personal space was defined as "the invisible
boundary which each person maintains between himself and others which serves as a
buffer from real or perceived threats" (Marx et al., 1989, p. 1020).

The Agitation Behavior Mapping Instrument (ABMI) was used to observe and
document agitated behaviors of 24 cognitively impaired residents from a 550-bed
nursing home. The ABMI consisted of 20 agitated behaviors categorized as either
verbally nonaggressive (e. g., strange noises, requests for attention), physically
nonaggressive (e.g., repetitious mannerisms, pacing), or aggressive (e.g., biting,
hitting). Interrater reliability averaged .93. The observations were made over 3
months, and during each observation the observer recorded the number of times the
subject exhibited agitated behaviors and the physical distance to the closest individual
(Marx et al., 1989).

Analysis of the data indicated that the subjects exhibited more aggressive
behaviors, strange noises, and requests for attention when touched. Compared to
females, male subjects exhibited more aggressive behaviors when touched. Three

other agitated behaviors (strange movements, picking at things, and repetitious

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mannerisms) were displayed least when the subjects were touched. It was concluded
that staff should consider extending the personal space of aggressive-prone residents
and using touch to distract or comfort residents displaying certain nonaggressive
agitated behaviors (Marx et al., 1989).

Horowitz, Duff, and Stratton (1964) conducted a series of experimental studies
which supported the existence of a personal space and indicated that the personal
space of schizophrenic patients tended to be larger than for nonschizophrenic
individuals. Kinzel (1970) performed an experimental study to compare the size and
shape of personal space between violent and nonviolent prisoners. Analysis of the
data indicated that both the total and rear personal spaces of violent prisoners were
larger than those of nonviolent prisoners.

Essentially, the research reviewed on touch and personal space suggests two
conflicting viewpoints: (a) that touch can enhance communication with demented
residents, or (b) that physical closeness and touch aggravate agitated and aggressive
behavior. Due to the demented resident’s tendency toward emotional lability and
impairments in perception, impulse control, and judgment, discretion should be used
related to the use of touch. Prior to touching the resident the caregiver should attempt
to gain the resident’s attention, establish trust with the resident, and assure that
nonreceptive and/or agitated behaviors are not being displayed.

Hoffman, Platt, Barry, and Hamill (1985) compared the responses of demented and
nondemented, elderly residents to verbal and nonverbal messages. Subjects were 54

residents of two long-term care facilities. The experimental intervention consisted of a

79

researcher approaching each subject in either a positive (relaxed, smiling, speaking
subject’s name in a pleasant tone, clasping hand gently) or negative (frowning,
speaking subject’s name harshly, grasping wrist firmly) manner.

Nonverbal responsivity was measured by changes in posture, head position, facial
expression, and eye contact, and verbal responsivity by responses to questions asked
during the intervention. Data analysis indicated that demented subjects manifested
positive responses to positive messages and withdrawal and discomfort to negative
messages. Demented subjects’ nonverbal communication skills were comparable to
those of nondemented subjects’. A several second delayed response to
communications was noted in demented subjects (Hoffman et al., 1985).

Skews (1988) studied the effects of a positive communicative approach on the
manifestation of aggressive behavior in 34 nursing home residents with varying levels
of dementia. The intervention consisted of all staff using positive verbal and
nonverbal messages when interacting with subjects. Subjects manifesting aggressive
behavior were encouraged to verbalize and express negative feelings in socially
acceptable ways through participation in available physical and social activities.

The intervention was evaluated after two years, and nurses reported that the
frequency and intensity of subjects’ aggression had decreased, subjects were
responding better to nursing interventions for aggression, stafi’ morale and resident
activity participation had increased, and psychotropic drug use for aggression was low

(Skews, 1988). A limitation of this study was the lack of a rigorous research design.

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In summary, based upon a review of the literature related to communicating with
the demented, several important conclusions are made. The first conclusion is that the
demented resident is capable of communicating with others, despite his or her illness.
Second, when communicating with the demented resident, the caregiver should focus
on creating a safe and calm environment, establishing a therapeutic and trusting
relationship, and enhancing the resident’s communication abilities. Third, the
caregiver should utilize nonverbal, as well as verbal, messages when communicating
with the demented resident. Finally, the caregiver should use touch with the agitated
and/or demented resident only after trust has been established with the resident and
nonreceptive behaviors have ceased.

Pharmacological Management

Although different classes of psychotropic drugs have been used to manage severe
behavioral problems associated with dementia, the neuroleptic (i.e., antipsychotic)
drugs have proven most effective (Barnes & Raskind, 1980; Risse, Lampe, &
Cubberley, 1987; Thomas, 1988). The judicious use of neuroleptic drugs may be
warranted for the management of symptoms such as aggressive behavior, severe
agitation, delusions, and hallucinations (Eimer, 1989; Helms, 1985; Wragg & Jeste,
1988). However, these agents are capable of causing serious side effects, many of
which are dose-related and due to their ability to block receptors in the central nervous
system and periphery (Eimer, 1989).

Guidelines for the use of neuroleptics include the identification and documentation

of target symptoms when therapy is initiated and periodically during therapy to

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determine effectiveness. Research on neuroleptic effectiveness indicates no clinical
difference between agents, suggesting that drug selection should be based on the
patient’s medical condition and previous response to agents and the drug’s side effect
profile (Eimer, 1989; Wragg & Jeste, 1988).

Only one neuroleptic should be used at a time and treatment should be time-
limited with periodic attempts to reduce or discontinue administration. Demented
residents should be monitored closely for side effects and drug interactions and
neuroleptic doses or agents adjusted to resolve these problems (Wragg & Jeste, 1988).

Previous reviews of the literature on neuroleptic drug use in the demented suggest
some clinical improvement of severe behavior problems (Eimer, 1989; Helms, 1985;
Wragg & Jeste, 1988). The following is a brief review of the literature related to the
pharmacological management of significant behavioral problems, including
combativeness, in demented residents.

Beardsley, Larson, Burns, Thompson, & Karnerow (1989) examined the use of
psychotropic drugs using data from the 1984 National Nursing Home Survey pretest.
The sample consisted of 526 elderly subjects, 69% having a mental disorder.
Information was collected on psychotropic and other drugs often problematic to the
elderly.

Analysis of the data indicated that 35% of the sample received psychotropic drugs
and less than 10% of these were pm. No documentation of a mental disorder was
found for 21% of subjects on psychotropics, and 23% percent were on two

psychotropic drugs. The concurrent use of psychotropic drugs with drugs known to

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increase the potential of drug-drug interactions was common. It was concluded that
some nursing home residents were at risk for adverse drug reactions and treatment
failure based on their medication regimen (Beardsley et al., 1989).

Beers et al. (1988) studied patterns of psychotropic drug use in 12 intermediate-
care facilities (ICFs) in Massachusetts. Data were collected on prescriptions and
patterns of use for 850 residents over 1 month. Analysis of data indicated that 53% of
subjects received psychotropic drugs (26% were antipsychotics), with 15.2% receiving
two concurrently.

Sedative/hypnotics were given to 28% of subjects, 82% on a regular basis. Long-
acting benzodiazepines (high incidence of toxicity in the elderly) and diphenhydramine
(strong anticholinergic effect) were common. Fourteen percent of subjects received
antidepressants and 61% had no documented diagnosis of depression. Twenty-six
percent of the subjects on antidepressants received Amitriptyline, which has strong
anticholinergic and sedative effects (Beers et al., 1988).

It was concluded that psychotropic drug use was high in ICFs with often
suboptimal agents prescribed. Increased efforts to improve the use of psychouopics
within long-term care facilities were suggested in this study (Beers et al., 1988) and in
Beardsley et al.’s (1989) study.

Avom et al. (1988) conducted a randomized, controlled study to determine the
efficacy of an educational outreach program in reducing excessive psychotropic drug
use within 12 ICFs. The intervention consisted of 3 to 5 educational sessions on

geriatric psychopharmacology presented to residents’ primary physicians, nurses, and

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aides. Analysis of the data indicated that the educational outreach program effectively
reduced the use of psychotropics within ICFs.

Barnes, Veith, Okimoto, Raskind, and Gumbrecht (1982) compared the
effectiveness of Thioridazine, Loxapine, and a placebo in controlling behavioral
disturbances of demented nursing home residents. Subjects were randomly assigned to
three treatment groups and evaluated before and after treatment with several rating
scales. A two-tailed _t_-test was used to determine significant changes in rating scale
scores and analyses of covariance were performed to compare the efficacy of the
different agents.

Analysis of the data indicated significant improvements in anxiety, excitement,
emotional lability, and uncooperativeness with antipsychotic use. It was concluded
that antipsychotics have a ”definite but limited" role in the management of demented
nursing home residents’ behavioral symptoms (Barnes et al., 1982, p. 1170).

Risse et a1. (1987) discussed two case studies in which patients with Alzheimer’s
disease unresponsive to conventional neuroleptic treatment were successfully treated
with very low-dose neuroleptics. In the first case, a 59-year-old agitated dementia
patient manifested substantial behavioral improvement on Haloperidol 0.125 mg. q.d.
In the second case, an 82-year-old demented patient manifesting increased confused,
paranoid, and hostile behaviors experienced diminished behavioral problems on
Thioridazine 5 mg. q.d.

Weiler and Goodman (1987) reviewed the literature on the use of Propranolol for

the management of disruptive behavior. This agent was found to be effective in the

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management of physical and verbal aggression associated with dementia, brain injury,
and schizophrenia. The need for further well-controlled clinical trials was emphasized.

Greendyke and Kanter (1986) performed a double-blind, placebo-controlled
crossover study to determine the effectiveness of Pindolol in treating assaultive and
other problem behaviors of 11 hospitalized, severely demented patients. Data analysis
with the Wilcoxon matched-pairs signed-ranks test indicated that Pindolol was
effective for the management of severe behavioral symptoms associated with dementia
(Greendyke & Kanter, 1986).

In summary, the cautious use of neuroleptic drugs for the management of severe
behavioral problems, including combative behavior, was supported by the literature
reviewed. Further well-designed research studies are needed related to the
effectiveness of neuroleptic, as well as other drugs, in managing severe problem
behaviors. Due to the potentially deleterious effects of neuroleptic and other drugs,

more research is also needed on alternative management techniques.

Summary of Management of Cornbgive Behavior
The majority of literature related to the management of combative behavior in the
demented is empirical, indicating a need for further research. Regarding the
behavioral management of combativeness, the need to assess the problem behavior and
its antecedents and consequents was emphasized. The literature supported the use of
distraction, time out, extinction, and differential reinforcement to decrease problem

behaviors, including combativeness, in the demented.

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Environmental management of problem behaviors focused on decreasing the
demented resident’s exposure to stress-producing factors and on supporting functional
losses. Emphasis was placed on maintaining a consistent environment, minimizing
overwhelming and misleading stimuli, and providing orienting cues.

The literature related to communicating with the combative, demented resident
focused on promoting a safe and calm environment, established a trusting relationship
between caregiver and resident, and minimizing communicative impairments due to
cognitive losses. The importance of nonverbal communication when interacting with
the demented, as well as the use of touch as a communication tool (under certain
circumstances), was stressed.

The pharmacological literature reviewed supported the judicious use of neuroleptic
drugs for the management of persistent combative behaviors in the demented.
Researchers emphasized the need for further research related to the use of neuroleptic
drugs and nonpharmacological management techniques and for increased education of

caregivers on psychotropic drug use.

Summg of Literature

The majority of nursing literature related to combative behaviors of the demented
was empirical. Precipitating factors of combativeness stressed within the nursing
research included: misleading and overwhelming stimuli, environmental change,

physical illness or discomfort, confusion, and negative feelings related to losses.

86

Regarding the management of combative behaviors, the nursing research supported
the use of behavioral techniques such as time out and differential reinforcement and
environmental modifications to diminish stress-producing factors and to promote the
safety and maximum functioning of the demented resident. The greatest amount of
nursing research found was on the use of touch as a method of communicating,
whereas no nursing research was found on the pharmacological management of
combativeness.

In reviewing the literature on factors related to combative behaviors in the
demented and the management of these behaviors, several important issues were
identified. The most important is the lack of research specifically addressing
combative behaviors in the demented. In order to successfully manage combative
behaviors further research is needed on factors aggravating these behaviors and the
effectiveness of different management approaches.

In addition, the literature review raised questions and concerns regarding the
ethical treatment of the institutionalized, demented elderly, primarily related to the use
of psychotropic drugs and behavioral management techniques. Further research is
needed in these areas to determine whether or not the benefits gained from these
interventions outweigh the risks to demented residents.

Finally, there appears to be a great need to educate caregivers of the demented on
factors related to combative behaviors and on effective interventions for the
management of these behaviors. Therefore, the protocol for the management of

combative behaviors in demented residents to be presented in Chapter III will focus on

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identifying factors precipitating combative behaviors, and on effective interventions to

manage these behaviors.

CHAPTER III
Protocol for the Management of
Combative Behavior in Demented, Elderly Residents
Introduction

An innovation in the care of the demented elderly within long-term care facilities
has been the utilization of the GCNS. The GCNS’s primary goal within a long-term
care facility is to enhance the quality of health care provided to the residents. One
way the GCNS promotes quality health care for residents within an institutional setting
is through research utilization. Research utilization is defined as "a systematic series
of activities that can culminate in the change of a specific nursing practice" (Horsley
et al., 1983).

Once a clinical nursing problem has been identified, the first step in the research
utilization process is the review of the relevant research literature, followed by a
synthesis of this literature into a research base. The second step of this process is the
combining of relevant information from the research base into a solution, or clinical
protocol. The third step of research utilization is the implementation of the protocol
via nursing actions administered to clients, and the fourth and final step is the
evaluation of the protocol to determine whether or not expected outcomes were
achieved (Horsley et al., 1983).

The format of this scholarly project is similar to that of the research utilization
process. In Chapter I the problem, that is, the need for a protocol for the management

of combative behavior in demented, elderly residents, was identified. In Chapter II, a

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review and summarization of the literature relevant to this problem was presented.
Within Chapter III, a description of a protocol for the management of combative
behavior in demented, elderly residents, based on the literature reviewed in Chapter II,
will be presented. The appropriate follow-up plan once the acute combative episode is
resolved will also be presented. In Chapter IV , a proposed plan for the
implementation and evaluation of the protocol will be presented. In addition, the
implications of this project for the nursing profession, advanced nursing practice, and

primary care will be discussed.

Presentation of tl_re Protocol

Within this scholarly project, the goal related to intervening with the combative,
demented, elderly resident is to assist the resident in regaining the maximum possible
levels of safety, comfort, and function, considering the dementing process. In order to
- accomplish this goal, a specific set of objectives should be met. Therefore, the
protocol for the management of combative behavior in demented, elderly residents will
be presented via a discussion of these objectives.
Prevent Physical Inju_ry

The first objective when intervening with the combative, demented resident is to
prevent physical injury to the resident and others. A primary caregiver whom the
resident has recognized and communicated effectively with in the past intervenes
during the combative episode. In a descriptive study on aggressive behavior in

cognitively impaired nursing home residents (Beck et al., 1990), 27% of nursing staff

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reported that subjects became aggressive when being cared for by unfamiliar

caregivers. In a study by Athlin and Norberg (1987) subjects who fed the same
severely demented nursing home residents for 14 consecutive meals reported an
increased ability to interpret the residents’ behaviors and to communicate with them.

Demented persons commonly experience impairments of judgment and impulse
control (American Psychiatric Association, 1987). These impairments increase the
demented resident’s potential for harming him or herself and others when agitated.
Therefore, in order to prevent physical injuries, all other residents, visitors, and staff
are removed from the area surrounding the combative resident. Sharp and other
potentially dangerous objects are also removed from the area. No attempt should be
made to move the combative resident until his or her agitation is diminished. In
studying the relationship between agitated behaviors and personal space, Marx et al.
(1989) found that highly agitated, cognitively impaired nursing home residents
displayed significantly more (2 < .05) aggressive behaviors when touched, compared
to when they were more than three feet away from others.

The primary caregiver designates one coworker to remain outside the immediate
area to prevent others from entering. This will protect others from physical injury and
allow the primary caregiver to communicate with the resident without the distraction
of others (Carroll, 1989). The coworker is also to assist the primary caregiver if
needed (e. g., by obtaining a snack to be used as a distractor).

If the primary caregiver’s physical safety is imminently threatened (i.e., the

demented resident is highly combative), the caregiver leaves the immediate area and

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reports the situation to his or her supervisor. Meddaugh (1990) reported the kicking.

hitting, and biting of staff by highly agitated, cognitively impaired nursing home
residents. Because dysfunctional behaviors such as combativeness generally appear
suddenly and last a short period of time (Hall & Buckwalter, 1987), the primary
caregiver returns 10 minutes later to reassess the resident’s behavior and the need for
intervention.

If the primary caregiver’s physical safety is not imminently threatened, he or she
remains in the immediate area to intervene with the agitated resident. The first
objective, preventing physical injury to the resident and others, is achieved if, at the
resolution of the combative episode, neither the demented resident nor others in the
immediate area have received physical injuries.

Diminish Agitation

The second objective for the primary caregiver intervening with the combative,
demented resident is to diminish the resident’s agitation. In order to achieve this
objective, the caregiver promotes a calm environment. First, the primary caregiver
must recognize and control his or her own anxiety. One of the most anxiety-
producing situations for nursing personnel is intervening with the combative patient
(Burnside, 1981). Demented residents are often sensitive to caregivers’ verbal and
nonverbal behaviors conveying anxiety or other negative emotions, and may assimilate
such emotions (Robinson et al., 1989).

Signs and symptoms of anxiety include feelings of nervousness and restlessness, an

increase in voice pitch, rate of speech, or pulse and respirations, trembling hands, and

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shifting feet (Burnside, 1981; Hoffman & Platt, 1990). Anxiety can be minimized

through relaxation techniques such as controlled breathing and deep muscle relaxation.
Techniques such as the identification and alteration of self-defeating thoughts (e.g.,
that the caregiver is incapable of managing the combative episode) can also reduce the
caregiver’s anxiety (Agras, 1984; Perry & Furukawa, 1986).

Once the primary caregiver’s anxiety has been controlled, he or she utilizes
behaviors conveying calmness. The caregiver speaks in a calm and reassuring tone of
voice and uses a normal voice volume. Shouting will not improve the demented
resident’s comprehension of messages and may increase his or her agitation. The
caregiver’s voice pitch should be low, as a higher pitch suggests anxiety (Bartol, 1979;
Hoffman & Platt, 1990).

The primary caregiver’s body posture should be relaxed, with shoulders and arms
down. Raised shoulders can convey stress and tension, and arms folded in front may
convey dislike or a need to protect oneself (Hoffman & Platt, 1990). Body
movements should be slow and easy, as quick movements may startle the demented
resident and increase his or her feelings of anxiety (Porter, Rasmussen, & Burnside,
1981).

In a study by Hoffman et al. (1985) demented nursing home residents who were
approached in a calm, positive manner (pleasant tone of voice, relaxed body posture,
smiling, clasping resident’s hand gently) by the researcher responded positively (e. g.,
turning toward the researcher, smiling). Approaching the residents in a negative

manner (angry facial expression, speaking in a harsh tone of voice, holding resident’s

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wrist firmly) elicited negative responses from the residents (e.g., turning away from
the researcher, acting startled, frowning).

Due to brain dysfunction and/or damage, the agitated, demented resident may
misperceive caregivers as threatening, further increasing his or her agitation (Bartol,
1979; Hoffman & Platt, 1990). Therefore, the primary caregiver also promotes a calm
environment by utilizing behaviors which build trust with the demented resident.
According to Martin and Kirkpatrick (1987), the assessment and management of
aggressive behavior in the elderly client requires the establishment of a therapeutic
caregiver-client relationship.

Because the demented resident’s ability to comprehend others is often impaired,
establishing a trusting relationship may be the only way to get the demented resident
to respond to, and cooperate with, the caregiver (Bartol, 1979). Furthermore, the
demented resident is more apt to attempt communicating his or her needs and feelings
to the caregiver if trust is established (Hoffman & Platt, 1990).

Trust is promoted with the agitated, demented resident first by gaining his or her
attention. If the caregiver does not have the demented resident’s attention, it cannot
be assured that the resident will hear or comprehend what is conveyed, or comply with
directions or requests (Bartol, 1979). In order to gain the elderly resident’s attention
the caregiver approaches the resident slowly from the front, as approaching from the
back or side may startle him or her. The caregiver looks directly at the resident and

enunciates his or her name clearly. This approach will help compensate for any

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hearing or visual deficits the resident may have (Robinson et al., 1989; Porter et al.,
1981).

The caregiver then observes the resident’s verbal and nonverbal behavior to
determine if his or her attention has been gained. In Langland and Panicucci’s (1982)
study on communicating with demented nursing home residents, behaviors considered
indicative of listening included nodding the head up and down, raising the eyebrows,
blinking the eyes, making eye contact, smiling, turning the body toward or touching
the researcher, and responding verbally. Listening behaviors of demented individuals
described by Bartol (1979) included sitting or standing still, repositioning the head to
hear the caregiver better, and leaning forward or moving the body in some manner to
be closer to the caregiver.

If the resident does not display listening behaviors, the primary caregiver should
repeat the resident’s name every few seconds until his or her attention is gained. The
caregiver may need to step closer to the resident and speak louder (not shouting) to
further compensate for any visual and/or hearing impairments (Bartol, 1979).

Once the resident’s attention has been gained, the primary caregiver further
promotes trust by providing orienting information. The caregiver states his or her
name, role, and purpose (e.g., "This is _, your nurse, and I’m here to help you").
The caregiver also explains all of his or her actions before proceeding (Robinson et
al., 1989).

The demented resident’s diminished ability to comprehend and respond to others’

messages is related to memory impairment, a shortened attention span, a decreased

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ability to understand abstract words and phrases, and an impaired ability to process
and respond to auditory and visual messages (Carroll, 1989). In order to facilitate the
demented resident’s comprehension, the caregiver speaks slowly and clearly using
simple words and phrases (Robinson et al., 1989).

The comprehension of messages by the demented resident is also facilitated when
the primary caregiver utilizes nonverbal communication techniques (Robinson et al.,
1989). The ability to understand the nonverbal communications of others is one of the
most basic and reflexive human communication skills. Therefore, it seems probable
that this skill remains at least somewhat intact in demented individuals who can no
longer understand verbal communications (Hoffman, Platt, Barry, & Hamill, 1985).

In order to further promote trust with the demented resident, the primary caregiver
maintains consistency between verbal and nonverbal messages. Sending contradictory
messages fosters disbelief in the resident (Hoffman & Platt, 1990; Robinson et al.,
1989). Trust is also enhanced by spending time with the resident and attempting to
discern what is upsetting him or her, thereby conveying concern for the resident
(Hoffman & Platt, 1990). Making frequent eye contact conveys interest in the
resident, whereas avoiding eye contact may convey guilt, boredom, or a dislike for the
resident. Positioning oneself at the resident’s eye level (preferably sitting) also
conveys a willingness to listen (Ronch, 1989).

In addition to minimizing his or her own anxiety and utilizing behaviors which
convey calmness and build trust, the primary caregiver further promotes a calm

environment by identifying and eliminating factors agitating the resident. According

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to Hall’s PLST model (Hall & Buckwalter, 1987) the demented adult displays

dysfunctional behavior when he or she is overwhelmed by stress-producing factors.
Therefore, in order to effectively resolve the demented resident’s combative behavior,
the caregiver should focus on identifying and eliminating any aggravating factors
(Gugel, 1988).

In order to identify factors aggravating the demented resident’s combativeness, the
primary caregiver first considers the context in which the behavior occurred, that is,
what event immediately preceded the resident’s combativeness (Robinson et al.,
1989)? Behaviors are often a reaction to antecedents, that is, events occurring just
prior to the behaviors (Hussian & Davis, 1985). For example, in a study on
altercations between nursing home residents, Donat (1986) found that residents often
became aggressive when confused, wandering residents entered their personal space.
In a descriptive study on aggressive behavior in cognitively impaired nursing home
residents (Beck et al., 1990) nursing staff reported the highest incidence of aggressive
behavior when residents were receiving personal care, such as being dressed or bathed.

Next, the primary caregiver assesses the external environment for factors possibly
agitating the resident. Overwhelming auditory or visual stimuli (e. g., radios or
televisions), misleading stimuli (e.g., an overhead paging system or fire alarm), or
other stimuli within the external environment (e.g., extremes of light or temperature)
can potentiate dysfunctional behavior in the demented adult (Hall & Buckwalter,

1987). In a study by Cleary et al. (1988) demented subjects who were moved from a

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traditional nursing unit to a Reduced Stimulation Unit (RSU) experienced a significant
(p < .001) decrease in agitated, including combative, behaviors.

The primary caregiver also assesses the agitated, demented resident’s verbal and
nonverbal behaviors to assist in the identification of aggravating factors, including
emotions the resident is experiencing. In the earlier stages of dementia, victims are
generally able to express their needs and feelings both verbally and nonverbally. As
dementia progresses, verbal comprehensive and expressive abilities diminish.
However, nonverbal comprehensive and expressive abilities may persevere through the
end stages of dementia (Carroll, 1989).

The caregiver observes the demented resident closely for changes in vocalizations,
facial expressions, eyes, posture, and gestures indicative of changing feelings and
needs (Hoffman & Platt, 1990; Robinson et al., 1989; Ronch, 1989). For example, an
increase in the demented resident’s voice volume may indicate anger and/or
frustration, whereas an increase in voice pitch or the rate of speech may indicate
anxiety and/or the loss of self control. Close examination of the demented resident’s
facial expressions and eyes may reveal feelings such as pain or fear (Hoffman & Platt,
1990).

The demented resident’s posture can convey receptiveness to the caregiver (e. g.,
body turned toward or away) as well as emotions the resident is experiencing (e.g.,
hunched shoulders may indicate hopelessness and depression). Gestures may be used
by the demented resident to relay messages or to indicate the intensity of an emotion

(Hoffman & Platt, 1990).

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Thus, assessing the demented resident’s verbal and nonverbal behaviors can assist
the primary caregiver in identifying factors aggravating the resident’s agitation. For
example, a female, demented resident might periodically hallucinate that mice are
crawling up her legs. Frightened, the resident begins yelling and repeatedly hitting her
legs. A nurse’s aide, unaware of the resident’s hallucinations, attempts to stop this
behavior. The resident becomes combative, hitting and scratching the aide. By
assessing the resident’s verbal and nonverbal behaviors, the primary caregiver
intervening in this situation determines that the resident is hallucinating.

When assessing for factors agitating the demented resident, the primary caregiver
also asks the resident to communicate what is upsetting him or her. The caregiver
uses a short question with simple words to facilitate the resident’s comprehension
(Robinson et al., 1989). In Hoffman et al.’s (1985) study on the communication
abilities of demented residents, the researchers found that both mildly and severely
demented subjects responded appropriately nonverbally to simple questions, and that
mildly demented subjects also responded appropriately verbally.

The primary caregiver waits 3 to 5 seconds for a response, repeating the question
verbatim if the resident does not respond. In Hoffman et al.’s (1985) study, the
researchers found that demented subjects often manifested a several second delay in
responding to the researcher’s questions, and that at times the researcher had to repeat
a question verbatim in order to elicit a response from subjects.

Residents afflicted with an irreversible dementia, such as Alzheimer’s disease, may

experience expressive and/or receptive aphasia (Bartol, 1979). Therefore, the primary

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caregiver may need to assist the resident in communicating what is agitating him or
her. The following interventions will help the demented resident to communicate:
interpret the resident’s message within the context of the situation; encourage the use
of nonverbal messages, such as gestures; offer words or phrases which seem
appropriate; repeat back what the resident appears to be saying and ask the resident to
shake his or her head yes or no in response; provide encouragement and positive
feedback to the resident; and use writing as a method of communicating (Carroll,
1989).

By considering the context in which the resident’s combative behavior occurred
and assessing the resident’s external environment and verbal and nonverbal behaviors,
the caregiver can identify factors agitating the resident (e.g., a darkened room or a
wandering resident). The caregiver then eliminates or diminishes these factors, as
able.

The caregiver does not attempt to eliminate any aggravating factors within the
resident’s personal space (e.g., a tight physical restraint) until the resident’s agitated
behavior has diminished. As discussed previously, highly agitated, cognitively
impaired residents displayed significantly more (2 < .05) aggressive behaviors when
touched, compared to when they were more than three feet from others (Marx et al.,
1989).

If the primary caregiver is successful in establishing a calm environment during the
combative episode, the demented resident will manifest a decrease in the frequency

and duration of highly agitated behaviors, including combativeness, threatening

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gestures, cursing or other verbal aggression, screaming, throwing things, and pacing.
Other indicators that a calm environment has been established include the primary
caregiver identifying and eliminating the factors aggravating the resident’s agitation,
initiating actions to relieve his or her own anxiety, feeling in control of the situation,
and utilizing behaviors conveying a calm mood. The establishment of trust between
the primary caregiver and the demented resident (as evidenced by the resident
cooperating with the caregiver’s directions and requests, allowing the caregiver to
approach and enter his or her personal space, and communicating his or her needs and
concerns to the caregiver) also suggests that a calm environment has been promoted.

If the resident continues to manifest highly agitated behaviors despite the primary
caregiver’s interventions, the caregiver implements the behavioral technique of
distraction. According to Hall’s PLST model (Hall & Buckwalter, 1987), the display
of anxious and agitated behaviors suggests that the demented resident is becoming
increasingly sensitive to environmental stressors and, therefore, has a greater potential
for displaying further dysfunctional behavior.

Distraction is an effective technique for decreasing agitation in demented residents
due to their shortened attention span (Hussian & Davis, 1985; Robinson et al., 1989).
Distraction consists of shifting the demented resident’s attention from the agitated
behavior to an activity which the resident enjoys. Using food as a method of
distraction is recommended, as demented adults generally respond positively to objects
which satisfy a basic physical need (Hussian & Davis, 1985). The combative episode

should not be discussed during the distracting activity, and the resident should be

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engaged in the activity long enough to allow aggressive feelings to dissipate.
Compared to younger adults, the elderly are slower to recover from emotional stress,
and need sufficient time to allow negative feelings to subside (Hussian & Davis, 1985;
Letemendia, 1985).

If the distraction technique is unsuccessful. and the resident continues to display
highly agitated behaviors, the primary caregiver acknowledges the resident’s desire not
to interact. Attempts to continue interacting will increase the potential for the display
of further combative or other agitated behaviors by the resident (Bartol, 1979). By
acknowledging the resident’s desire not to interact at this time, the caregiver is
respecting his or her freedom of choice. In studying aggression in cognitively
impaired nursing home residents, Meddaugh (1987a, 1990) found that aggressive
episodes were often related to the subjects’ loss of the freedom of choice.

Before leaving the area, the primary caregiver makes a commitment to return in 10
minutes to check on the resident, thereby conveying continual concern for the resident.
The caregiver must follow through on the commitment to return, as failing to follow
through will jeopardize any trust the caregiver has established with the resident
(Bartol, 1979). Upon returning to the area, the caregiver reassesses the resident’s
behavior and the need for intervention.

W

The third and final objective for the primary caregiver managing the combative,

demented resident is to promote the resident’s comfort and rest. This objective is

based upon an assumption of Hall’s PLST model (Hall & Buckwalter, 1987), that is,

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that the confused and agitated demented adult should be regarded as frightened and

uncomfortable. The third objective is also based upon the proposal that the demented
adult who has manifested dysfunctional behavior requires substantial rest to diminish
his or her stress level and to restore energy reserves (Hall & Buckwalter, 1987).

In order to promote the resident’s comfort and rest the primary caregiver first
addresses the resident’s psychological comfort. The caregiver responds to the
emotional tone of the resident’s verbal and nonverbal messages and acknowledges the
resident’s feelings (e.g., stating "you look frightened"). In Hoffman et al.’s (1985)
study on the communication abilities of demented nursing home residents, both mildly
and seveme demented subjects were able to nonverbally communicate their feelings.
Mildly demented subjects were also able to verbally communicate their feelings. By
acknowledging the resident’s feelings, the caregiver is demonstrating concern for and
empathy toward the resident and building trust (Hoffman & Platt, 1990; Robinson et
al., 1989).

The primary caregiver further promotes the resident’s psychological comfort by
utilizing gentle touch once the resident’s agitation has diminished. Langland and
_ Panicucci (1982) reported a significant (p < .05) increase in positive nonverbal
responses (including smiling, nodding the head up and down, blinking, making eye
contact, and touching or turning toward the researcher) in demented subjects touched
on the forearm. The findings of a study on the effects of touch on seriously ill
patients (McCorkle, 1974) suggested that touch can have a calming, comforting effect

on patients (e.g., a decrease in patients’ restless movements).

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Psychological comfort is also promoted by offering the resident verbal reassurance
that actions will be taken to meet his or her needs and to prevent or minimize further
exposure to factors causing agitation. The agitated, demented resident who has lost
control of his or her behavior needs reassurance that someone will help control the
behavior and attend to his or her needs (Burnside, 1980; Robinson et al., 1989).

The primary caregiver managing the agitated, demented resident promotes the
resident’s physical, as well as his or her psychological, comfort. According to Hall’s
PLST model (Hall & Buckwalter, 1987), physical discomfort is a major stressor for
demented adults and can aggravate dysfunctional behavior. Therefore, the caregiver
implements measures to assure the demented resident’s physical comfort, such as
loosening restrictive clothing or physical restraints, assuring that the resident is not too
hot or cold, and providing fluids.

The primary caregiver also promotes the demented resident’s rest. The resident is
placed in a low-stimulus environment, as exposing him or her to multiple, competing
environmental stimuli would increase the resident’ levels of stress and fatigue (Hall,
1988a; Hall & Buckwalter, 1987). The caregiver encourages the resident to nap or
engage in a simple, solitary activity. Lawton (cited in Hall, 1988a) reported that
demented residents given time alone in their rooms manifested higher functional levels
when with others.

Indicators that the primary caregiver has promoted the demented resident’s comfort
include the resident responding positively to gentle touch (e. g., smiling, making eye

contact, turning toward or touching the caregiver, or exhibiting a decrease in restless

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body movements) and manifesting a decrease in the frequency and duration of
behaviors indicative of psychological or physical discomfort, such as moaning or other
verbalizations indicating discomfort and facial expressions indicating discomfort (e. g.,
wincing, grimacing, or tearing of the eyes). Indicators that the primary caregiver has
promoted the demented resident’s rest include the resident engaging in a nap or other
restful activity and returning to his or her baseline mental, physical, social, and
emotional functional levels upon completion of the restful activity.

The protocol presented here is based upon three basic objectives which, if
accomplished, will facilitate the achievement of the protocol’s goal, which is to assist
the combative, demented, elderly resident in regaining the maximum possible levels of
safety, comfort, and function, considering the dementing illness. The primary
caregiver’s successful management of the combative, demented, elderly resident (i.e.,
the resolution of the resident’s highly agitated behaviors without the occurrence of
physical injuries or the use of physical and/or chemical restraints) is an indicator that
the protocol’s goal has been achieved.

This protocol may be utilized by all primary caregivers within a long-term care
facility. Depending upon the situation, it is assumed that modifications in
implementing the protocol will be necessary. For example, if a demented resident
receiving personal care from an unfamiliar nurse’s aide becomes combative, it would
be appropriate for the aide to immediately intervene, rather than attempting to find a

primary caregiver more familiar to the resident. The following section will discuss a

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follow-up plan for primary caregivers once the protocol has been implemented and the

acute combative episode has been resolved.

Follow-up Plan for Primg Caregivers

Once the acute combative episode has been resolved, the primary caregiver who
intervened with the combative resident is responsible for assuring that the appropriate
follow-up is taken to prevent or minimize the reoccurrence of the combative behavior.
The primary caregiver reports the details of the incident to the unit supervisor (LPN or
RN). An incident report may also be required, depending on the facility’s policy.

The primary caregiver should report the time and place of the combative incident,
any observable cues prior to the incident (e. g., fatigue, increased anxiety), what
activity immediately preceded the combative behavior, what were perceived causative
factors, how long the behavior occurred, and what interventions relieved the resident’s
combativeness. Talking with the supervisor about the incident will also help relieve
any tension the primary caregiver is feeling (Martin & Kirkpatrick, 1987; Ray et al.,
1990).

The unit supervisor is responsible for assuring that other nursing staff on the unit
are informed of the incident, as well as the charge nurse and/or nursing administrator.
The unit supervisor also assures that the incident is documented in the resident’s chart.

If the unit supervisor determines that the interventions taken by the primary
caregiver (e.g., loosening a tight restraint, removing a wandering resident from the

combative resident’s room) eliminated the factor(s) aggravating the combative

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behavior, this is also documented in the resident’s chart. The resident’s nursing care
plan is altered, when appropriate, to assure that interventions are taken to prevent
further combative episodes.

If, based on the primary caregiver’s report, the unit supervisor determines that
further follow-up is indicated related to the combative incident, he or she initiates this
follow-up. Further follow—up is indicated if the primary caregiver and unit supervisor
suspect a specific causative factor requiring further intervention, or if the causative
factor remains unknown. ’

An LPN or RN is responsible for the initial assessment to rule out a reversible
somatic, mental, or psychosocial factor aggravating the resident’s combativeness. The
nurse assesses the resident’s chart for any recent changes in ADL function (e.g.,
urination or defecation patterns, food or fluid intake), social function (e.g.,
withdrawal), emotional function (e. g., increased crying or sadness), behavior, sleep
patterns, the resident’s physical environment, or any social or psychological changes
(Martin & Kirkpatrick, 1987; Ray et al., 1990).

The nurse also reviews the resident’s medication record for recent changes in the
medication regimen. The nurse then assesses the resident, beginning with a complete
set of vital signs to detect abnormalities (e.g., an elevated temperature might be
indicative of an infection). The resident’s positioning is observed for any changes
such as guarding or protecting of a body area (indicative of a possible injury), and the
skin is inspected for signs of trauma (redness, bruising, etc.). The abdomen and

bladder are inspected and palpated for distention, the joints are put through their range

107

of motion to detect pain or limitation, and the bones are palpated for irregularities
indicative of trauma. Items such as urinary catheters and physical restraints are
assessed for proper positioning and application (Ray et al., 1990).

If the nurse identifies a factor aggravating the resident’s combativeness which is
amenable to nursing intervention, a nursing diagnosis is formulated (e.g., physical
aggression related to pain secondary to fecal impaction) and the appropriate nursing
interventions are implemented. If the nurse is unable to identify a factor aggravating
the resident’s combative behavior, or if the nursing interventions implemented do not
resolve the combative behavior, the nurse can consult with the GCNS.

Upon receiving a consultation request related to the resident’s combative behavior,
the GCNS conducts a more in-depth assessment to detect any reversible somatic,
mental, or psychosocial causes. The history and physical exam focus on identifying
signs and symptoms indicative of factors possibly aggravating the demented resident’s
combative behavior. If indicated, the GCNS consults with the resident’s primary
physician regarding further diagnostic tests and consultations. If a reversible causative
factor related to the combative behavior is identified, the appropriate medical and
nursing interventions are implemented to eliminate or diminish this factor.

If the GCNS is unable to find a reversible factor causing the resident’s
combativeness and the behavior continues, a behavioral management plan is
implemented (Ray et al., 1990). The behavioral management plan is developed
through consultation with all staff involved in the resident’s care, and contains specific

behavioral objectives and time frames. The plan consists of a baseline behavioral

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assessment, the development and implementation of a care plan, and an evaluation of
the plan with modifications made as needed (Hussian & Davis, 1985; Ray et al.,
1990).

If the behavioral management plan is unsuccessful in controlling the resident’s
combative behavior, and the behavior is endangering the resident and others and/or
interfering with the resident’s care, pharmacological intervention is considered (Ray et
al., 1990). The GCNS consults with the resident’s primary physician regarding the
use of a psychotropic drug to conu'ol the resident’s combativeness.

The antipsychotic drugs are the drugs of choice for severe behavioral problems in
the demented elderly (Maletta, 1988). The choice of an agent for the management of
the resident’s combative behavior is based upon an evaluation of the resident’s current
medications and medical problems, as well as the resident’s previous response to
antipsychotic agents and the agent’s side effect profile (Eimer, 1989; Wragg & Jeste,
1988).

Ray et al. (1990) recommend the use of a nurse-supervised protocol for the
initiation and monitoring of an antipsychotic drug. The GCNS monitors the resident
for behavioral changes indicative of either the agent’s effectiveness in controlling the
combative behavior or adverse side effects related to its use. If the antipsychotic
agent is effective in controlling the resident’s combative behavior, Ray et a1. (1990)
recommend the use of a protocol to periodically attempt withdrawal from the drug

(Ray et al., 1990).

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Conclusion

In summary, within this chapter, a protocol for the management of combative
behavior displayed by demented, elderly residents was presented. A suggested plan of
follow-up to prevent or minimize further occurrences of the behavior was also
presented. The role of the GCNS and other health care professionals in implementing
the protocol and performing the appropriate follow-up was discussed. The protocol
and suggested follow-up for combative behavior presented within this chapter
demonstrate the need for health care professionals to function as a multidisciplinary
team, in order to provide long-term care residents with quality health care.

In the following chapter, a proposed plan for the implementation and evaluation of
the protocol will be presented. In addition, the relationship of the protocol to this
scholarly project’s conceptual framework, as well as the implications of this project
for the nursing profession, advanced nursing practice, and primary care, will be

discussed. The protocol is presented in a format for clinical use in Appendix A.

CHAPTER IV
Implementation and Evaluation of the Protocol and Its Impact on Professional Nursing
Introduction

Within the first chapter of this scholarly project, the problem of the need for a
protocol for the management of combative behavior in demented, elderly, long-term
care residents was identified. In Chapter II, a review and summary of the literature
related to combative behavior in demented adults was presented. Within Chapter III, a
protocol for the management of combative behavior in demented, elderly residents, as
well as a follow-up plan to prevent its reoccurrence, were presented.

In this, the fourth and final chapter, a proposed plan for the implementation and
evaluation of the protocol will be presented. In addition, the application of this
scholarly project’s conceptual framework to the protocol, as well as the implications of
this project for the nursing profession, advanced nursing practice, and primary care,

will be discussed.

Implementation and Evaluation of the Protocol

As discussed in Chapter III, the first and second phases of the research utilization
process are the review of the research literature relevant to an identified clinical
problem and the formation of a protocol based upon this literature. The third and
fourth phases of the research utilization process are the implementation and evaluation
of the clinical protocol. The use of the planned change process is essential when

implementing and evaluating the protocol, as this will muire changes in the behaviors

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l 1 1
of the involved staff members (Horsley et al., 1983). Planned change is defined as "a

conscious, rational, and deliberate process for bringing about change and innovation,
which tends to make those changes more acceptable and beneficial to those involved”
(Horsley et al., 1983, p. 3).

A change agent is defined as ”one who generates ideas, introduces the innovation,
develops a climate for planned change by overcoming resistance and marshaling forces
for acceptance, and implements and evaluates the change" (Lancaster, 1982, p. 20).
Within this project, the change agent facilitating the implementation of the protocol is
the GCNS. The client system, or group who is the focus for the change (Brooten,
1984; Welch, 1979), is the primary caregivers within a long—term care facility. In the
following discussion, it is assumed that the GCNS is employed by a long-term care
facility.

The first step related to the implementation and evaluation of the protocol is
creating a climate for change (Horsley et al., 1983). The GCNS must heighten both
the administrative and clinical nursing staff’s awareness of the need for a change in
their current practices related to the management of combative, demented residents.

In a meeting with nursing administrators, the GCNS could present research
literature to support the need for a change. The literature would be related to the
frequency of chemical and physical restraint use for the management of aggression in
demented residents and the negative outcomes associated with the use of these
restraints. The GCN S would also emphasize the need to implement alternative

interventions for the management of combative behavior in light of recent federal

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regulations restricting the use of chemical and physical restraints. This information
could also be shared with residents’ primary physicians.

In addition, a volunteer group of nursing staff could be formed to review all
incident reports related to combativeness over the past year. The group would
document the negative outcomes from these episodes and formulate ideas on how to
overcome these. This information would then be presented to coworkers, for example,
at a nurses’ meeting or inservice.

The GCNS could also arrange several informal meetings in which nursing staff
were encouraged to express their feelings related to residents’ combative behaviors,
such as fear, anxiety, loss of control, and anger. Staff would also be encouraged to
share their feelings related to the use of chemical and physical restraints, such as guilt
or ambivalence.

In a study in which nursing staff were asked to rate a nurse’s responses to being
hit by a patient (as described in a vignette), approximately 71% of subjects stated the
nurse would have moderate to severe emotional and physical reactions to being hit
(Lanza, 1985). In a study on the effects of physical restraints on elderly hospitalized
patients and their primary care nurses (Strumpf et al., 1991), the nurses reported
experiencing ambivalence and discomfort related to physically restraining their elderly
patients.

The next step related to the implementation and evaluation of the protocol is the
establishment of a cooperative relationship between the GCN S and the nursing staff

(Brooten, 1984). This is a crucial step, as this relationship is the avenue through

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which the clinician’s knowledge and experience will be shared with staff to assist in
the implementation of the protocol (Lippitt, Watson, & Westley, 1958).

A cooperative relationship between the GCNS and nursing staff would be
promoted by remaining open to one another’s ideas, encouraging all nursing staff to
participate in the project, seeking agreement on goals, sharing information, and
keeping channels of communication Open and flowing (Brooten, 1984). The GCNS
would meet initially with nursing administrators to discuss such issues as what tasks
would be required for the protocol’s implementation and evaluation and who might be
willing and qualified to assist with the project. Nursing administrators could help
identify staff who would be enthusiastic about the project and would act as leaders for
others.

The next step toward the implementation and evaluation of the protocol is
specifically defining the problem related to the staff's current management of
combative behavior (Brooten, 1984; Lippitt et al., 1958; Welch, 1979). This would be
achieved by identifying the nursing staff’s current methods of managing residents’
combative behaviors and their knowledge level related to potential causes of these
behaviors in the demented, the most effective management techniques, and the
potential negative outcomes related to chemical and physical restraint use.

Information on the nursing staff‘s management techniques for combative behavior
and their knowledge level related to this behavior could be gained by reviewing
nursing documentation related to combative episodes over the past year, and by

developing and administering a questionnaire to nursing staff exploring these areas.

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By reviewing and synthesizing the information collected, the GCNS and nursing staff
assisting him or her would be able to determine the staff’ 3 learning needs related to
the management of combative behavior in demented residents.

The next task is assessing the environment of the proposed change (Brooten,
1984). The group would evaluate whether or not the facility environment was
supportive of the protocol implementation (e. g., was the administration supportive of
the change, and were the necessary resources available)? The group would also need
to identify potential obstacles to the protocol’s implementation and determine
strategies to overcome these.

One potential barrier to the protocol’s implementation would be a lack of interest
amongst the nursing staff. The staff might feel that there was no need to alter their
current approach to the management of combativeness, and therefore would not be
willing to assume the responsibilities and risks involved with implementing the
protocol. As was discussed earlier in this chapter, the GCNS and others supporting
the protocol’s implementation would utilize strategies to heighten the nursing staffs
awareness of the need for a change in their current management approach to the
combative, demented resident.

Another potential obstacle to the protocol’s implementation would be the
perception by both the administrative and clinical nursing staff that implementing the
protocol would be time-consuming. Generally speaking, most nursing administrators
within the long-term care setting feel pressured to complete their many administrative

duties. The clinical nursing personnel also struggle to meet the multiple needs of their

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elderly residents. Therefore, the GCNS would need to demonstrate to the nursing staff
that the protocol’s implementation could ultimately result in more time for them. If
the protocol was tested and found to be effective, the frequency and duration of
combative episodes would decrease, residents would maintain higher levels of
function, and nursing staff would spend less time caring for combative residents.

Administrative nursing personnel may feel threatened by the GCNS, due to his or
her higher level of educational preparation. Nursing administrators may view the
GCNS’s advanced education as a threat to their job security and authority. The GCNS
could explain to administrative nursing personnel that his or her expertise was in
clinical, rather than administrative, gerontological nursing. The GCNS could also
emphasize the need for teamwork and for the expertise of the nursing administrators in
implementing the protocol.

The long-term care facility’s administrator and medical director might voice
skepticism related to the implementation and evaluation of the protocol. They could,
for example, be concerned about ethical and monetary issues related to performing a
clinical study. Those promoting the testing of the protocol could educate the
administrator and medical director about the benefits of research, and the methods
utilized to obtain informed consent and maintain resident safety and confidentiality.
Furthermore, the potential availability of grants to support the study, the utilization of
resources within the facility to minimize costs, and the potential cost-effectiveness of

the protocol could be discussed with the administrator and medical director.

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Another potential obstacle to the protocol’s implementation and evaluation would
be the time needed by the GCNS to oversee the study. The GCNS would need to
prepare a realistic list of his or her responsibilities and the time frame involved. Prior
to the implementation of the protocol, the GCNS and administration would need to
agree on the amount of time the GCNS would devote to the study.

Once potential obstacles to the implementation and evaluation of the protocol had
been identified and management strategies determined, a plan would be developed for
the implementation and evaluation of the protocol. This is another crucial step, as the
success of any change is dependent upon the extent to which the change has been
carefully planned (Brooten, 1984). First, a committee would be established to assist
the GCNS in the implementation and evaluation of the protocol.

The advantages of establishing a small committee (3-6 people) include the
accomplishment of a greater amount of work within a specified time period, a greater
influence over nursing staff to be involved in the project, and a greater variety of
skills and expertise to facilitate the protocol’s implementation and evaluation (Brooten,
1984). Also, by delegating leadership roles and responsibilities, the GCNS would be
generating enthusiasm for the project and minimizing the nursing staff‘s reliance on
him or her to implement the protocol (Welch, 1979).

As the leader of the committee overseeing the protocol’s implementation and
evaluation, the GCNS would work with committee members to develop a written
master plan. The first step within the master plan should be the provision of a written

description of the protocol (e. g., actions within the protocol, who is to implement it,

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where and when it is to be implemented) and the methods for implementing and
evaluating it (Horsley et al., 1983).

The initial implementation and evaluation of the protocol would be achieved by
conducting a pilot study. The pilot study would involve testing the protocol on one or
two nursing units within the facility to obtain information related to the feasibility of
utilizing the protocol and to determine how the protocol and its implementation might
be improved. Implementation of the protocol on a smaller scale should be done as
carefully as if it were to be implemented on a larger scale, so that problems which
could occur when implementing the protocol on a larger scale are identified (Polit &
Hungler, 1983).

The sample used for the pilot study should reflect the populations sampled in the
protocol’s research base. The sample for the pilot study would consist of male and
female demented, elderly, long-term care residents having a recent history of
combative behavior. A convenience sample would be developed, consisting of all
residents who met the pilot study criteria on one or two nursing units within the
facility (Horsley et al., 1983).

The units chosen for the pilot study should have an adequate number of residents
available who meet the criteria for study inclusion. The units should also have nursing
staff who are willing and able to participate in the pilot study, as well as adequate
staffing to support the study (Horsley et al., 1983).

The independent variable for the pilot study would be the implementation of the

protocol for the management of combative behavior. At least one or more of the

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dependent variables (i.e., resident and/or staff outcomes) to be used in the pilot study
should come from the protocol’s research base (Horsley et al., 1983).

The dependent variables for the pilot study would be related to the expected
resident and staff outcomes of the protocol, including the following: the frequency and
severity of physical injuries, the ability of the primary caregiver to control his or her
own anxiety and to utilize behaviors conveying calmness, the degree to which the
primary caregiver felt in control of the combative situation, the amount of trust
established between the primary caregiver and the resident (measured by the degree to
which the resident cooperated with the caregiver’s directions and requests, allowed the
caregiver to enter his or her personal space, and communicated needs to the caregiver),
the ability of the primary caregiver to identify and eliminate factors agitating the
resident, the frequency and duration of highly agitated behaviors and behaviors
indicative of psychological or physical discomfort manifested by the resident, the
resident’s response to physical touch, the frequency of chemical and/or physical
restraint use, and the resident’s functional levels.

A quasi-experimental research design (lacking at least one of the properties
required for an experimental study, i.e., manipulation, control, and randomization)
would be used for the pilot study (Polit & Hungler, 1983). The research design would
consist of the collection of data related to the dependent variables before and after the
protocol was implemented. Other activities related to planning the pilot study would
be identifying instruments to measure the dependent variables (e.g., incident report and

chart documentation after the combative episode, a questionnaire to be completed by

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primary caregivers who intervened with the combative resident) and determining how
to collect the data (Horsley et al., 1983).

Next, the committee would list all the activities to be completed and all the
resources needed to conduct the pilot study (e. g., personnel, time, equipment, physical
space, etc.). The committee would also determine how to obtain the necessary
resources (Horsley et al., 1983).

In Appendix B is a suggested list of the resources required to conduct a pilot study
of the protocol’s implementation on a 30—bed long-term care unit. The study would
occur over 4 weeks and 10 subjects would participate. The unit’s nursing staff would
remain consistent during the pilot study, and would include one nurse per shift, and
four, three, and two nurse’s aides for the day, evening, and night shifts, respectively.
The committee overseeing the pilot study would include the GCNS, the Director of
Nursing, the Inservice Director, and an LPN and nurse’s aide from the study unit. The
facility would absorb the costs of the study. This resource list was developed through
consultation with the Director of Nursing, Inservice Director, and Office Manager of a
172-bed, long-term care facility in St. Johns, Michigan.

The next step in planning for the pilot study would be the development of a time
schedule, in which deadlines were set for completing activities and obtaining
resources. The responsibilities of committee members in these areas would need to be
specified. The time schedule should be flexible enough to allow for unanticipated

problems (Brooten, 1984; Horsley et al., 1983; Welch, 1979).

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Other activities to be completed by the committee in preparation for the pilot study
would include obtaining approval of the project from the appropriate authorities (i.e.,
Medical Director, Administrator), obtaining consents for resident participation in the
study from responsible parties, determining how to communicate necessary information
to the nursing staff, identifying possible sources of resistance to the protocol’s
implementation and developing strategies to manage these, developing needed
materials (e.g., inservice materials, measurement instruments, data collection forms),
and educating nursing staff who will participate in the pilot study (Brooten, 1984;
Horsley et al., 1983).

Once the committee had sufficiently planned for the protocol’s implementation and
evaluation, the pilot study would be initiated. An individual would be designated by
the committee to function as a coordinator during the pilot study (Horsley et al.,
1983). The GCNS would function well in this role, due to his or her familiarity with
the protocol, active participation in the planning phase, and knowledge related to the
research utilization process.

Responsibilities of the coordinator would include closely monitoring the procedures
of the pilot study, monitoring staff’s responses and suggestions related to the
protocol’s implementation, assuring that communication between those involved
remained open and fluent, identifying obstacles (e.g., missing or inaccurate data,
declining staff morale) and unexpected events and intervening to assure the
continuation of the pilot study (if possible), and reporting regularly to committee

members (Brooten, 1984; Horsley et al., 1983; Welch, 1979).

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During the pilot study, the other committee members would also monitor the
procedures of the study. The full committee would meet weekly to receive updates
from the coordinator and to assist him or her in making decisions (e.g., related to
staff's suggestions for protocol revisions). Other issues to be addressed at these
meetings might include how to implement the protocol on a larger scale and provide
nursing staff with encouragement and positive feedback (Brooten, 1984; Lippitt et al.,
1958).

Upon completion of the pilot study, the data would be analyzed to determine if the
protocol’s implementation resulted in any clinically significant improvement in
, resident or staff outcomes related to combative episodes. Findings indicative of an
improvement in resident and/or staff outcomes with the protocol’s implementation
would support the implementation of the protocol on a larger scale. If the analysis of
the data suggested that revisions of the protocol were needed, the committee would
decide whether or not the resources were available to undertake this project.

The committee would also need to debrief with the staff involved in the study, and
evaluate other areas related to the protocol’s implementation, for example, the
adequacy of the inservice program in preparing nursing staff for the pilot study, and
the accuracy of the timetable developed within the master plan. The GCNS should
also evaluate his or her effectiveness as a change agent. One indicator of the GCNS’s
effectiveness would be the degree to which the nursing staff felt they were responsible

for implementing and evaluating the protocol. An effective change agent is able to

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instill feelings of responsibility and pride in those involved in the change (Brooten,

1984; Horsley et al., 1983; Lippitt et al., 1958; Olson, 1979).

Application of the Conceptual Framework to the Protocol

The purpose of this scholarly project was to develop a protocol which primary
caregivers in long-term care facilities could implement when demented, elderly
residents exhibited combative behaviors. The protocol’s development was guided by
the conceptual framework presented in Chapter I, which is based upon Hall’s PLST
model (Hall & Buckwalter, 1987). The following discussion is on the relevance of the
conceptual framework presented in Chapter I to the protocol presented in Chapter III.

According to Hall’s PLST model (Hall & Buckwalter, 1987), the elderly resident
afflicted with an irreversible dementia experiences a progressive degeneration of brain
cells, often accompanied by degenerative changes that occur with aging (e.g., sensory
losses, slowed synaptic response times, impaired mobility). Due to these changes, the
elderly, demented resident experiences a progressively lowered stress threshold and a
decreased ability to cope effectively with environmental stressors.

Within this scholarly project, the demented resident’s stress threshold has been
defined as the point at which the resident displays compensatory reactions (i.e.,
combative behaviors) in response to perceived overwhelming internal or external
stimuli, in an attempt to regain homeostasis. The demented resident’s regaining of

homeostasis is indicated when he or she returns to normal, or baseline, behavior.

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According to the conceptual framework presented in Chapter I, the demented,
elderly resident within a long-term care facility is frequently exposed to the stress-
producing factors identified in the PLST model (i.e., fatigue, change of environment,
caregiver, or routine, internal or external demands to function beyond the limits
imposed by cortical deterioration, competing, misleading, or overwhelming stimuli,
and physical stressors). Due to his or her diminished ability to cope with these
stressors, continued or heightened exposure to them results in the demented resident
manifesting increased fatigue and anxious and/or agitated behaviors.

If primary caregivers do not intervene to minimize the demented resident’s
exposure to environmental stressors, the resident’s perception of these stressors
escalates, his or her stress threshold is exceeded, and the resident manifests combative
behavior. The combative resident’s levels of comfort, safety, and function are
significantly decreased. It is at this point that the primary caregiver would implement
the protocol for the management of combative behavior presented in Chapter 111. By
implementing the protocol, the primary caregiver would assist the demented resident in
coping with environmental stressors and in returning to baseline behavior (i.e.,
homeostasis).

The goal of the protocol presented in Chapter III is to assist the combative,
demented resident in regaining his or her maximum levels of safety, comfort, and
function possible, considering the dementing illness. In order to achieve this goal, the

primary caregiver follows the interventions presented within the protocol. These

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interventions are focused on the accomplishment of three objectives, which are based
upon the conceptual framework presented in Chapter I.

The first objective, which is to prevent physical injury to the demented resident
and others in the immediate area, is based upon the conceptual framework’s proposal
that the combative, demented resident experiences significant impairments of
functional, including cognitive and emotional, levels. The resulting impairments of
judgement and impulse control increase the potential for the resident to harm him or
herself and others.

The second objective, that is, to diminish the demented resident’s agitation, stems
from the proposal that highly agitated, including combative, behaviors are
compensatory reactions of the demented resident to perceived overwhelming
environmental stressors. Therefore, the primary caregiver implements interventions to
promote a calm environment and to eliminate environmental stressors agitating the
demented resident.

The third objective, which is to promote the demented resident’s psychological and
physical comfort and rest, is based upon an assumption of the PLST model, that is,
that the confused or agitated demented adult is uncomfortable and frightened (Hall &
Buckwalter, 1987). The third objective is also based upon the proposal that the
demented adult who has manifested dysfunctional (e. g., combative) behavior requires
substantial rest to diminish his or her stress level and to restore energy (Hall &

Buckwalter, 1987).

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Thus, it can be seen that the conceptual framework developed in Chapter I is
applicable to the protocol presented in Chapter III. Overall, the conceptual framework
and Hall’s PLST model (Hall & Buckwalter, 1987) upon which it was based, assisted
in the identification of objectives related to the management of combative behavior in
demented, elderly residents. An identified weakness of the conceptual framework,
based upon a review of the literature, is its failure to directly address important
causative factors of combativeness such as psychiatric illness, negative feelings, and
losses experienced by the demented elderly. Although some of these factors are
addressed indirectly (e. g., the loss of adequate social supports may be related to a
change of environment), a modification of the conceptual framework would be

necessary to directly address these causative factors.

Project Benefits Related to the Nursing Profession

Impact on Nursing Education

The information provided within this scholarly project could be utilized to develop
an in-depth educational program for long-term care nursing staff on the management
of combative behavior in the demented elderly. The program would provide staff with
information related to potential causes of combative behavior, negative outcomes
secondary to its occurrence, and the implementation of the protocol to manage
combativeness. The objectives of the protocol could be used to develop sequential

educational sessions for nursing staff. Various teaching methods could be uied, for

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example, presenting case studies, discussing staff’s previous experiences, or role
playing.

There would be both barriers and facilitators for the GCNS educating long-term
care nursing staff on the protocol presented in Chapter HI. Regarding barriers, the
nursing staff might be intimidated by the GCNS’s higher level of educational
preparation. To counteract this, the GCNS would prepare and present inservices to
meet the educational needs of the staff attending (e.g., nurse’s aides, LPNs, or RNs).
In addition, the GCNS would show a sincere interest in meeting the needs of all
nursing staff related to the management of the combative resident, for example, by
offering supplemental reading materials appropriate for the different educational levels
of the staff. The GCNS would also present the protocol in a simple format that
nursing staff could remember and utilize when intervening with the combative,
demented resident.

Another potential barrier to the education of long-term care nursing staff related to
combative behavior management would be the staff’ s lack of knowledge related to the
care of the demented resident, the possible causes of combative behavior in this
resident population, and the negative outcomes related to chemical and physical
restraint use. Therefore, the GCNS would need to provide educational programs in
these areas, prior to educating staff on the use of the protocol presented in Chapter III.

The tendency of long-term care nursing staff to focus on controlling the demented
resident’s combative behavior could hinder their ability to learn the protocol within

this scholarly project. This is because the protocol, rather than focusing on controlling

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the resident’s behavior, is concerned primarily with maintaining the resident and
others’ physical safety, promoting a calm environment (including eliminating factors
possibly agitating the resident), and promoting the resident’s comfort and rest.
Therefore, the GCNS would need to assist the nursing staff in learning new priorities
related to the management of the combative, demented resident.

Although barriers would exist to educating nursing staff on the utilization of the
protocol, facilitators would also be present. For example, the primary caregivers of
demented adults have a need to feel in control of combative situations, rather than
anxious and fearful. Also, long-term care nursing staff want to provide quality nursing
care to their demented residents. Therefore, provided they are educated on the
negative outcomes of physical and chemical restraints, they should be open to
alternative interventions for combativeness.

Furthermore, federal regulations based on the Omnibus Budget Reconciliation Act
(OBRA) of 1987, amended in 1989, mandate that any long-term care facility not
providing adequate documentation supporting the use of restraints be penalized
(Garrard et al., 1991; Yerian & Pettengill, 1990). Therefore, long-term care nursing
staff are looking for alternatives to chemical and physical restraints for the
management of the combative, demented resident. The protocol presented in Chapter
III is an alternative management technique for combativeness which maintains a safe
environment, as well as the demented resident’s maximum levels of function and

comfort.

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resident. By maintaining a positive attitude, the GCNS can instill new hope and
confidence in the nursing staff related to their ability to manage the problem behaviors
of demented residents. As the staff’s knowledge related to the care of demented
residents grows, so will their pride in themselves and the care they provide to long-
term care residents.

Utilizing the conceptual framework upon which this project was based, an
educational program on the management of combative behavior in demented residents
could be expanded to include the prevention of this behavior. The nursing staff could
be taught to use demented residents’ behaviors as an index of their tolerance to
environmental stimuli. The display of anxious or dysfunctional behaviors would
indicate the need to reduce the amount of stimuli within the demented resident’s
environment.

It is also important that nursing students at both the undergraduate and graduate
level are educated related to the management of the combative, demented elderly.
Therefore, educational materials from this project could be incorporated into nursing
schools’ curricula related to the care of the elderly.

If the protocol is tested and found effective in managing combativeness in
demented residents, the protocol could be submitted to nursing journals for
publication. Publication of the protocol would increase its availability to professional
nurses caring for the demented elderly in a variety of settings, and stimulate further

interest in the management of combative behavior in this population.

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Nurse educators within long-term care facilities who were introduced to the
protocol might- be encouraged to develop more educational programs on low-risk
management techniques for disruptive behaviors of demented residents. Programs
which focused on low-risk interventions (e.g., assessing for causative factors and
utilizing distraction) for the management of disruptive behaviors could result in a
decreased use of chemical and physical restraints within long-term care facilities.
W

The long-term goal of this scholarly project is the implementation and evaluation
of the protocol within a long-term care facility. If the protocol was found to be
effective in managing combative behaviors of demented residents, this would support
the development of policies within long-term care facilities related to the use of the
protocol.

Utilization of the protocol within the long-term care setting could minimize
primary caregivers’ anxiety when intervening with the combative,

demented resident. The anxiety experienced by caregivers when a resident is
combative is related (at least in part) to the fear of injury, and to uncertainty regarding
how to control the behavior. The protocol provides primary caregivers with specific
guidelines which, if followed, would minimize the occurrence of injury and assist
caregivers in controlling the combative behavior.

For all primary caregivers, the utilization of the protocol would minimize their risk
for physical injury, negative emotions, and physical and/or emotional exhaustion when

intervening with a combative resident. For the non-professional nursing staff, the

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increased responsibility and accountability afforded to them through their role in the

protocol’s implementation would increase their credibility as important members of the
health care team.

Regarding the professional nursing staff, the proper implementation of the protocol
would require an increased use and further refinement of their clinical knowledge and
skills (e. g., when assessing for causative factors related to the combative behavior).
The suggestions made within this project related to the follow-up for combative
behavior could stimulate creativity in the professional staff, as they endeavored to
develop nursing care plans which utilized the least restrictive techniques for the
management of combative behavior.

In addition, the utilization of the protocol could enhance the quality of health care
provided to combative, demented residents. By correctly implementing the protocol
and instituting the appropriate follow-up, primary caregivers would decrease residents’
risks for injury, discomfort, fatigue, physical and chemical restraint use, social
isolation, and functional impairments related to combativeness. Also, the
implementation of the protocol could decrease the risks to other staff, residents, and
visitors related to combativeness.

Impact on Nursing Research

Again, the long-term goal of this scholarly project is the implementation and
evaluation of the protocol within a long-term care facility. If the protocol’s
implementation on a smaller scale is successful, a larger research study involving

several facilities could be conducted. This would result in a larger sample size,

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possibly allowing the use of a more rigorous research design (i.e., one which utilized
random sampling and experimental and control groups) than the one proposed in this
scholarly project.

Basing the protocol development upon the conceptual framework presented in
Chapter I validates the applicability of nursing theory to practice. Educating nursing
staff on the relationship between the protocol they are implementing and the
conceptual framework upon which it is based could enhance their understanding of the
link between nursing theory and practice. If the protocol was found to be effective in
managing combative behaviors, this would confirm the utility of nursing theory in
improving clinical practice.

Upon completion of the implementation and evaluation of the protocol, the
research findings could be presented to nursing staff who participated in the study
(e.g., at nurses’ meetings and through the posting of a written report). The research
findings could also be disseminated to other professionals caring for the demented
elderly, for example, by submitting the study for publication in nursing journals, or
presenting the research findings at professional conferences.

During the development of this scholarly project, the need for further nursing
research in several areas was identified. For example, the lack of studies on the use of
behavioral techniques for the management of disruptive behaviors indicates the need
for further research in this area. Research is needed related to the effectiveness of
behavioral techniques in controlling disruptive behaviors, as well as the effect varying

levels of cognitive impairment have on demented residents’ responses to behavioral

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techniques. Also, research is needed to determine whether or not the benefits of
behavioral therapy outweigh the risks to demented residents (e.g., the loss of social
and tangible reinforcers if therapy is interrupted or discontinued).

Due to the large number of demented residents within long-term care facilities, the
creation of low-stimulus units within these facilities addresses the needs of only a
small percentage of the demented residents. Therefore, further research is needed to
determine if environmental modifications could be made on a larger scale within long-
term care facilities to enhance all demented residents’ functional levels (e.g., using
permanent assignments for nursing staff or restricting the use of overhead paging
systems).

Further research is also needed related to the communicative abilities of demented
residents. Based upon the literature reviewed, as well as past clinical experiences of
the author, it appears that primary caregivers within long-term care facilities are often
unaware of the ability of demented residents to communicate concerns and feelings,
either verbally or nonverbally. Therefore, the quality of communication between
caregivers and demented residents could be improved through the conduction of
further studies investigating the ability of demented residents to communicate, and
through the dissemination of the research findings to caregivers.

Another potential area of research is the utilization of nurse-supervised clinical
protocols for the initiation and withdrawal of antipsychotic drugs. Research studies
could be conducted to determine whether or not the utilization of such protocols would

result in improved outcomes for demented residents receiving antipsychotic drugs (e.g.,

133

related to the management of disruptive behaviors and the incidence of adverse side
effects).
lrnplications for Advanced Nursing Practice

Advanced nursing practice is defined as ”the deliberative diagnosis and treatment
of a full range of human responses to actual or potential health problems" (Calking,
1984, p. 27). The nurse in advanced practice has specialized knowledge and skills
related to the treatment of human responses, and utilizes diagnostic and treatment
procedures which are supported by rationale (Calking, 1984).

The GCNS providing primary care services to the institutionalized elderly has
assumed an expanded role which affords greater autonomy in practice and requires
greater responsibility and self-discipline. The GCN S functioning in this advanced role
assumes specific role characteristics in order to provide comprehensive, primary health
care services to elderly residents. The following is a discussion of how the GCN S
coordinating the care of demented, elderly residents incorporates these roles into his or
her advanced practice.

The first role the GCNS assumes is that of an assessor. The GCNS collects
subjective and objective data to assist in the identification of causative factors related
to a demented resident’s combative behavior. The GCN S performs the appropriate
history and physical exam, and consults with the resident’s physician regarding any
diagnostic tests. Periodic assessments by the clinician would also be needed to

determine the demented resident’s responses to nursing and medical interventions.

134

The GCN S promoting the implementation and evaluation of a protocol for the
management of combative behaviors is functioning as a change agent. As a change
agent, the clinician fosters an awareness amongst long-term care nursing staff of the
need for a change in their current management practices for combativeness. The
GCNS utilizes his or her special knowledge and skills, as well as planned change
theory, to promote this change.

The GCNS also acts as a change agent by fostering an awareness amongst health
care professionals of the need to change the environment of the institutionalized,
demented elderly. Research studies reviewed within this scholarly project support the
placement of these residents in an environment where stimuli are controlled, staff are
educated on the care of the demented, and programs are provided which meet the
special needs of demented residents.

Within the long-term care environment, one of the most crucial roles of the GCNS
is that of client advocate. As an advocate for the combative, demented resident, the
clinician identifies 'and communicates the resident’s problems and needs to the
appropriate individuals (e.g., physicians or nurses).

The regirnented routines established within long-term care facilities foster
dependence and hasten the loss of the demented resident’s self-care abilities. The
GCNS reinforces to primary caregivers that fostering dependence in the demented
resident increases the resident’s potential for combative behavior due to the loss of

control. The GCNS also emphasizes to primary caregivers that most demented

135

residents can communicate verbally and/or nonverbally, and should be given every
opportunity to do so.

The GCNS also functions as a clinician, utilizing the nursing process as a basis for
practice, and helping professional long-term care nurses managing the combative,
demented resident to perform the appropriate assessment, develop the pertinent nursing
diagnoses, and implement and evaluate a plan of care. The GCNS consults with the
resident’s physician as needed, and makes the appropriate referrals.

The GCNS also functions as a collaborator. When overseeing the management of
a resident displaying frequent combative behavior, the clinician collaborates with other
health care team members (e. g., other nurses, the physician, or social worker) and the
resident’s family. The GCNS may need to organize a team meeting in order to create
a comprehensive management plan. The GCN S also collaborates with health care
professionals from other long-term care facilities to share knowledge related to the
care of the combative, demented resident.

As a consultant, the GCNS shares his or her knowledge and skills related to the
research utilization process and the management of the combative, demented resident
to assist long-term care nursing staff in planning for, implementing, and evaluating a
protocol for combative behavior management. The GCNS also serves as a consultant
to health care professionals in other long-term care facilities related to the care of the
combative, demented resident.

A crucial role for the GCNS providing primary care services to the

institutionalized elderly is that of a coordinator. When coordinating the care for a

136

demented, elderly resident manifesting combative behavior, the GCNS assures that all
necessary interventions are taken to resolve this behavior. For example, the GCNS
may need to consult with the resident’s physician to arrange a psychiatric consultation,
and with the activities director to provide the resident with an acceptable means for
releasing anger.

The GCNS within a long-term care facility also serves as a counselor for both
residents and nursing staff. When intervening in an acute combative episode, the
GCNS attempts to establish communication with the resident and encourage the
resident to express his or her needs or concerns. The GCNS assesses the resident’s
capabilities and resources, and offers whatever assistance is necessary to help the
demented resident cope with identified stressors.

The GCNS also organizes meetings for primary caregivers in which they are
encouraged to openly express their feelings related to combativeness in demented
residents. The nurse clinician assures that confidentiality is maintained, and promotes
various coping strategies by staff to deal with negative feelings related to
combativeness.

As an educator within a long-term care facility, the GCNS assesses the health care
team’s learning needs related to the care of combative, demented residents, and
provides educational programs to meet these needs. For example, the GCNS could
educate nursing, as well as other, professional staff on federal regulations related to

the use of physical and chemical restraints. The clinician also acts as an educator by

137

providing educational programs to health care providers within other facilities on the
management of the combative, demented resident.

The GCNS within a long-term care facility is also an evaluator. He or she is
aware of and practices by accepted standards of nursing practice (e. g., code of ethics
and/or standards of gerontological nursing practice). The GCN S evaluates his or her
(as well as other nurses’) provision of care to residents utilizing these standards, and is
active (through participation in professional nursing organizations) in the development
of further standards of practice related to the care of the elderly.

As a leader among nursing staff caring for the demented, institutionalized elderly,
the GCNS promotes the provision of quality nursing care to long-term care residents
through his or her involvement in state and national nurses’ associations. The GCNS
remains abreast of legislative actions affecting the health care of the institutionalized
elderly, and is active in lobbying for the provision of quality health care services to
this population.

The GCNS also functions as a planner by guiding professional nursing staff in the
development of a master plan for the implementation and evaluation of a protocol for
combativeness. He or she provides expertise in areas such as developing a realistic
time schedule, determining the resources needed and how to acquire these, etc. The
GCNS also works with the professional nursing stafi' to develop comprehensive
management plans for combative, demented residents.

A role model is one who utilizes knowledge, research, service, and accountability

to clients to promote the nursing profession, and whose behavior is worthy of

 

138

emulation by colleagues and clients (Michigan State University, College of Nursing,
1985a). The GCNS who utilizes a protocol to manage an acute episode of
combativeness and is able to control the demented resident’s behavior without physical
or chemical restraints serves as a role model for the facility’s nursing staff. The
GCNS acts as a role model for professional nurses by assuming responsibility for the
appropriate follow-up related to the combative episode. The GCNS also acts as a role
model for professional nurses by basing his or her practice on the nursing process,
utilizing interventions which are supported by rationale, and conducting and utilizing
research in the clinical setting.

The final role of the GCNS providing primary care services to the demented,
institutionalized elderly is that of a researcher and inquirer. The GCNS participates in
the development and conduction of a pilot study testing a clinical protocol through
assisting in activities such as developing the research design, determining the sample
and tools for measurement of the dependent variables, and training staff in the
collection and recording of data.

The GCNS fosters interest in nursing research related to the care of the demented
elderly by demonstrating to other long-term care nurses the application of nursing
theory to clinical practice, educating nurses on the research utilization process, offering
assistance with the development and implementation of clinical studies, and assuring

that nursing research literature is available for staff.

139
Implications for Primapy Care

The GCNS within a long-term care facility provides health promotion, health
prevention, and health maintenance services to residents, as well as health education
and counseling (Michigan State University, College of Nursing, 1985b). As a primary
care provider, the GCNS assists demented residents to cope with and adjust to the
losses experienced secondary to dementia, in order to maintain their maximum levels
of function and independence possible. The following is a discussion of how the
GCNS incorporates the components of primary care into the management of the
combative, demented resident.

According to Silver (1977), primary health care has two dimensions. The first
dimension is the initial contact between the client and the primary caregiver, in which
a decision is made regarding how to manage the client’s health problem. The second
dimension is the primary caregiver’s assumption of responsibility and accountability
for the continuing coordination and management of the client’s health care.

The GCNS intervening with the combative, demented resident first collects
subjective and objective data and formulates a comprehensive management plan. The
GCNS then assumes primary responsibility for coordinating the health care services
needed to implement the plan, and for monitoring the demented resident’s response to
the plan.

The GCNS adjusts the plan as needed to assure that the most effective and least
restrictive interventions are utilized to manage the resident’s combativeness. The

clinician maintains contact with the resident’s other health care providers and family to

140

keep them informed of changes in the management plan and the resident’s responses
to treatment.

The GCNS providing primary health care services within a long-term care facility
is readily accessible to nursing staff and residents. The GCNS is available to assist
nursing staff in managing the acutely combative, demented resident, and in initiating
the appropriate follow-up to prevent further combative behavior. The GCNS serves as
a link between the long-term care nursing staff and primary care physicians, providing
nursing staff with the immediate assistance needed to manage the combative resident,
and providing physicians with the information necessary to determine the appropriate
medical follow-up.

The GCNS within a long-term care facility provides residents with individualized
care, based on their unique health care needs. When intervening with the combative,
demented resident, the clinician identifies the specific intemal and/or external stressors
aggravating the combativeness, and develops an individualized management plan to
assist the resident in coping with these stressors and in regaining maximum levels of
safety, comfort, and function.

The GCNS as a primary care provider promotes management plans for
combativeness which maintain the residents’ maximum levels of physical, mental, and
psychosocial health. The GCNS educates other health care team members on the risks
of physical and chemical resu'aint use (e. g., immobility, increased agitation), and
collaborates with these individuals to create alternative interventions for the

management of combativeness.

141

The GCNS also supports interventions for combativeness which promote demented
residents’ individual strengths and enhance their ability to cope with their losses. For
example, a combative, demented resident whose previous occupation was farming
could be encouraged to work in an outdoor garden. Schwab, Rader, and Doan (1985)
reported on a rehabilitative program for disruptive, demented residents which utilized
exercise, music, and relaxation therapies to assist residents in releasing their fears and
anxieties. Positive resident outcomes from the program included a decrease in the use
of chemical and physical restraints and in disruptive behaviors, and an increase in
social interactions initiated by the demented residents.

As a primary care provider, the GCN S maintains a continuous relationship with the
demented resident manifesting combative behaviors, providing unconditional positive
regard and social interaction for the resident. The GCNS interacts regularly with the
resident, utilizing verbal and nonverbal behaviors conveying interest in and concern for
the resident. Maintaining regular contact with the demented resident is important, in
order to detect any' health-related changes, and to remain familiar to the resident (who
is more likely to communicate and cooperate with a familiar caregiver).

Because primary care services are comprehensive, the GCNS assures that the
appropriate services are provided, including referrals, to thoroughly assess for factors
aggravating the demented resident’s combative behavior, and to develop a
comprehensive management plan for the resident. The GCNS organizes
interdisciplinary team meetings if needed, and monitors the services provided to the

resident by members of the health care team.

142

Primary care services are family-oriented. Therefore, the GCNS encourages the
involvement of family in developing a plan of care for the combative, demented
resident. The GCNS invites the family to interdisciplinary team meetings to gain their
input related to the management of the resident’s combativeness. Family are also
encouraged to actively participate in the management plan, for example, by
accompanying the resident to small group programs which increase the resident’s
exposure to social interaction and positive reinforcement (e.g., reminiscence or
remotivation therapy).

The GCN S counsels family by providing them with an opportunity to voice their
feelings about the resident’s behavior, and by reassuring them that combative
behaviors in the demented are generally not intentional. The GCNS also educates
family on the appropriate procedures to use should their demented relative become
combative.

The GCNS as a primary care provider also considers the health care needs of the
combative, demented elderly within the surrounding community. In a study on the
prevalence of aggressive behavior in community-based, demented elderly, Hamel
(1990) reported that caregivers reported some form of aggressive behavior in 57.2% of
the demented elderly. Physically aggressive behavior was reported in 34.1% of the
demented elderly. Ryden (1986) also studied the prevalence of aggressive behavior in
community-based, demented elderly. In this study, primary caregivers reported that

26.5% of the demented elderly manifested physical aggression.

143

As was discussed in Chapter I, the primary caregivers of the combative, demented
elderly within the community can experience physical injury, as well as deteriorations
in their mental and physical health and in their relationships with the demented
elderly. The community-based demented elderly manifesting combative behaviors can
also suffer physical injury and a deterioration of their relationship with the primary
caregiver, as well as social isolation, overmedication with sedative and tranquilizing
drugs with an increased potential for adverse side effects, and increased functional
impairments (Carroll, 1989; Mace, 1990; Mace & Rabins, 1981; Richter et al., 1989).

For the primary caregiver unable to manage the combative, demented elder at
home, institutionalization may be the only alternative. Adult foster care homes will
not accept demented adults manifesting physical aggression. According to Hamel
(1990), significant (p < .01) predictors of plans for institutionalization of the demented
elderly by their primary caregivers included caring for the more aggressive elderly and
for those who manifested more behavioral and memory problems.

Primary caregivers faced with institutionalizin g their demented loved one face
various problems. For example, within some states health care agencies have
restricted the addition of nursing home beds to reduce Medicaid costs, resulting in an
unmet demand for long-term care beds for the demented elderly living in the
community (Office of Technology Assessment, 1987). Furthermore, both the
demented, elderly individual and the primary caregiver experience negative feelings

such as loss, loneliness, guilt, and anger, when the demented adult is institutionalized.

144

Also, the demented, elderly individual may experience increased agitation and
confusion when he or she is moved to an unfamiliar place with unfamiliar caregivers.
Thus, it is apparent that primary caregivers of the combative, demented elderly

within the community are in need of assistance to prevent or minimize the negative
outcomes associated with combativeness. The protocol for the management of
combative behavior presented in Chapter III, which was developed for the long-term
care setting, could be modified for the home care setting. The three objectives of the
protocol, that is, to prevent physical injury, to diminish agitation, and to promote
comfort and rest, are applicable toward the management of the combative, demented
individual in any setting.

In order to utilize the original protocol for the management of combative behaviors
within the home care setting, some wording would need to be altered. For example,
family member and/or friend would replace coworker and supervisor. Furthermore,
the outcomes utilized to measure the effectiveness of the protocol within the home
care setting would vary somewhat from those utilized in the long-term care setting.

Measurable outcomes of the protocol’s effectiveness applicable to either the long-
terrn care or home care setting include the degree to which primary caregivers feel in
control of the combative situation, the frequency and severity of physical injuries, the
frequency and duration of highly agitated behaviors and behaviors indicative of
psychological and/or physical discomfort manifested by the demented individual, the
frequency of physical and chemical restraint use, and the demented individual’s

functional levels. Other outcomes to measure the effectiveness of the protocol in the

145

home care setting include the following: the mental and physical health of the
caregiver and carereceiver, the type and quantity of health care services utilized (e.g.,
visits to physician, psychiatrist, or counselor, medication consumption, or visits from
home health care agencies), the quality of the caregiver/carereceiver relationship, and
the frequency of relocation (including institutionalization) of the demented, elderly
individual.

lnforrnation related to the successful implementation of the protocol in community
settings (e.g., residential homes, adult foster care homes, adult day care centers) could
be disseminated to primary caregivers of the demented elderly in various ways. For
example, information related to the protocol could be mailed to primary care clinics
and to support groups for the caregivers of the demented. Furthermore, the GCNS
could provide educational programs on combative behavior management to the
primary caregivers of the demented elderly in the community. The GCNS could also
serve as a consultant to these caregivers, assisting in the creation of management plans
for combativeness which maintained the demented elderlys’ maximum possible
functional levels, and prevented their relocation to more restrictive living environments

due to unmanageable combative behavior.

Conclusion
Within this chapter, a proposed plan for the implementation and evaluation of the
protocol (presented in Chapter IID within a long-term care facility was presented. The

relationship between the conceptual framework of this scholarly project and the

146
protocol developed was discussed. The implications of this scholarly project for the

nursing profession, advanced nursing practice, and primary care were also discussed.
It is the author’s hope that, indeed, the protocol will be implemented and evaluated
within a long-term care facility. Nurses in advanced practice, along with other health
care professionals, need to develop innovative ways to manage the behavioral
problems of demented, elderly residents. By developing and testing low-risk
interventions for the management of demented residents’ behavioral problems, health
care professionals can increase the availability of interventions which maintain the

residents’ maximum levels of mental, physical, social, and emotional functioning.

APPENDIX A

147

 

 

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APPENDIX C

158
Appendix C

JanuaryZO. 1992

Patrice Jones
Journal Permission Department
v.8. Saunders Company
Orlando. Florida

32887

Dear Ms. Jones:

I am a graduate nursing student at Michigan State University in
East Lansing. M1ch1gan. I am writing to request permission to
utilize three figures (figures I. 2. and 3) from the December. 3987
Archives of psychlafiF‘CWNUFthg,ul(6). pp. 399-406. The article is
entitled “progressively Lowered Stress Threshold: at Conceptual
Model for Care of Adults with Alzheimer's Disease”. I have
utilized these three figures within my scholarly project text to
present Geri Richard's Hall‘s Progressively Lowered Stress

Threshold model. My completed and bound scholarly project will
partially fulfill the requirements for the degree of Masters of
Science in Nursing at Michigan State UniversStY. I would

appreciate a reply to this reouest at your earliest possible
convenience.

Sincerelv.

W. .1. 9mm. 143W

Judith L. Jandernoa. R.N.. B.S.N.

PERMISSION GRANTED, provided that complete credit is given to the source.
including the W.B. Saunders copyright line. If commercial publication
should result. please contact W.B. Saunders again.

xiv/j; a. was 71%“
7 / Permissions 4;/'
W.B. Saunder Company
Orlando. Florida 32887

Please note that the Grune & Stratton title for which permission is requested
has been assigned to the W.B. Saunders Company.

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