Q. I am a registered nurse teaching home health aides at a home health care agency. Many of our workers have difficulty working with elderly patients that suffer from disorders that cause them to be physically or verbally abusive and inappropriate towards the aide. What are some strategies I can include in the education program to better prepare the aides for abusive patients?

A. The problem you are raising appears to be all too common. A recent study (Gates et al, Gerontol Nurs 1999;25:12-22) found that violence against caregivers in nursing homes was common, and that many nursing homes did not have policies or procedures in place for preventing it. Home health aides are also at risk, in and outside of the client's home (Durkin & Wilson, Home Healthc Nurse 1999;17:430-35). Violence prevention begins with education, as you know, and that means educating staff about the types of patients and disorders that are highly correlated with the risk of violence (as well as verbal abuse).

For example, in psychiatric patient populations, violence is associated with antisocial, narcissistic, and borderline personality disorders, as well as those with impulse disorders and substance abuse. Signs or predictors of impending violence include the client's use of profanity, speaking in a loud voice, pacing, or showing signs of confusion or delirium. Individuals with known history of damage to the frontal or temporal lobes are also at risk. And perhaps the most important risk factor is a previous history of violent behavior.

In elderly demented populations, whether in nursing homes or in home settings, agitated, aggressive, or violent behaviors are not uncommon. Strategies aimed at modifying these behaviors are discussed in detail by Swanwick in the book, "Behavioral Complications in Alzheimer's Disease", edited by Brian A. Lawlor (American Psychiatric Press, 1995). Strategies include working with the client/patient's family; modifying the client's environment; and using specific behavior modification techniques.

Just to give one example: patients with Alzheimer's Disease are very sensitive to tone of voice, especially when it conveys criticism. If the home health aide is not aware of his or her body language, the client may become agitated, aggressive, or abusive. Conversely, by being aware of such non-verbal cues, the health aide can help calm the client.

For more specific ways of predicting and minimizing violence, see the article by Durkin and Wilson, who are reachable at the VNA of Greater Milford-Northbridge Area, Mendon Mass. 01756. Also see the article "De-escalating verbal aggression in primary care settings" by Anderson & Clarke, in Nurse Pract 1996; 21:95,98, 101-102.

April 2002

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