Non-Pharmacological Interventions for Aggression in Persons with Dementia: A Review of the Literature

The Problem of Aggression Studies examining aggression in persons with dementia typically define aggression in terms of a variety of physical (e.g., hitting, pinching, biting) and/or verbal (e.g., cursing, threatening) behaviors. Estimates of the prevalence of aggression in cognitively impaired individuals vary widely from study to study, likely due to variations in definition of aggression and how aggression was measured. These estimates range from 13-86% (Deutsch, Bylsma, Rovner, Steelt, & Folstein, 1991; Hamel, et al, 1990; Lyketosos, et al., 2000; Pavesa, et al., 1992; Ryden, Bossenmaier, & McLachlan, 1991; Swearer, Drachman, O'Donnell, & Mitchell, 1988; Zimmerman, Watson & Treat, 1984). Aggressive behavior is also strongly correlated with greater dependence during self-care (Schreiner, 2001). These numbers suggest that aggression in persons with dementia is a significant problem and becomes more likely as the disease progresses. Aggressive behavior can have serious consequences for persons with dementia as well as their caregivers. Aggressive behavior increases distress and burden for caregivers, which can result in nursing home placement (Hamel, et al., 1990; Ryden & Feldt, 1992). In addition, approximately 50% of nursing assistants have been injured during resident assaults (Gates, Fitzwater, Telintelo, Succop, & Sommers, 2004). Residents may also be at risk of being injured when engaging in aggressive behaviors (Ryden & Feldt, 1992). Aggressive residents in long-term care facilities may be labeled as "difficult" or "combative", which can result in social isolation and modifications in caregiving that can exacerbate problems (e.g., having 2 or 3 caregivers dress a resident instead of just one). Furthermore, due to the aversive nature of working with patients that are aggressive, the relationship between caregivers and patients is compromised, thereby decreasing quality of life for both parties (Ryden & Feldt, 1992). In fact, aggression is a significant source of job-related stress and frustration for professional caregivers (Everitt, Fields, Soumerai, & Avorn, 1991; Hagen & Sayers, 1995). Another consequence of aggression is the administration of medications to manage the problem (Sloane, Mathew, & Scarborough, 1991). Aggression has been most typically treated using conventional or atypical antipsychotic medications. Studies have indicated that these medications produce only modest benefits in persons with dementia and carry significant dangers such as increased risk of stroke, exacerbation of cognitive decline, and increased risk of death (Schneider, Dagerman, & Insel, 2005; Sink, Holden, & Yaffe, 2005). Excessive sedation is also a common side effect associated with anti-psychotic medication (Zarit & Zarit, 2007, p. 311). These adverse side effects can result in a reduction in the individual's behavioral repertoire in terms of impairing language, causing gait disturbance that can result in falls, reducing the ability to access preferred events/activities, and causing further confusion and cognitive decline. The difficulty is that individuals with dementia are already experiencing a gradual deterioration in their behavioral repertoire (e.g., language, self-care) due to the disease process itself. It can be argued that treating individuals with medications that can further limit their behavioral repertoire is questionable ethically. Therefore, it is clear that developing restraint-free interventions for managing aggression is very important. The following section will include a review of empirical studies that investigated non-pharmacological interventions for managing aggression in persons with dementia. Procedures and Literature Review An initial search for relevant studies was conducted using the PsychInfo and Ageline electronic databases. Searches involved using various combinations of the search terms "dementia", "aggression", "intervention", "treatment" and "behavior therapy. …