- You need to add an appropriate introduction to orientate the reader to the topic and provide signposts to other section of the proposal.
- There aren’t enough statistical evidence of issue which includes ethnic, gender;
- Chapter 3 Application of theory to practice
- (1) Identify relevant policies/ strategies/ legislation tackling the health issue and critically assess outcomes based on literature. 2) Identify a case study of service delivery (organization or agency), and address the following: a) Justify selection and present a background of the organisation (services provided and source/s of funding) (b) Identify one specific programme or intervention within your chosen agency /organisation that is relevant to your research question; present its aims; and critically analyse the programme’s strengths and limitations in relation to the identified policies/strategies/ legislation ( Health Students ONLY)
For example if you cite Mind as an organisation for dementia you need to explain the advantages and disadvantages of the organisation, its background, sources of funding, etc… (Refers to 2a, 2b etc …)
You need to correct your references when you there are 2 or more names it is better to use et al. 2010 instead of using &.
The Examination of the Effectiveness of dealing with aggressive behaviour in dementia patients in residential care homes in the UK.
Table of Contents
The Examination of the Effectiveness of dealing with aggressive behaviour in dementia patients in residential care homes in the UK
Violence and aggressive behaviour are major public health concerns within the UK public health system. The problem of aggressive behaviour develops due a combination of different neurobiological, cultural and sociological factors (Cipriani et al. 2011). Aggression as will be defined below is a threatening or assaultive behaviour that is exhibited by patients to other patients or to healthcare professionals or to the environment around them (Cipriani et al. 2011). The UK government has instituted different mechanisms that can be used to tackle the aggression problem among dementia patients. The purpose of this paper is to examine the effectiveness of interventions that have been developed to help deal with the aggression problem in the UK.
Background and Rationale
According to data from the Department of Health, there are almost 670,000 patients living with dementia in the UK. The prevalence is higher in women with women constituting 67% of the patients. There are about 40,000 young people. About 25,000 of these patients are from the black and minority groups (Department of Health, 2013). A big proportion of these patients live in residential care settings (Duxbury et al. 2013). Within the residential care setting, most of the dementia patients display behavioural and psychological symptoms of dementia that include physical and verbal aggression among others (Ballard et al. 2001). In some cases, the aggressive behaviour in dementia patients goes unreported yet they are a manifestation of the distress that the patient may be experiencing.
As it has been mentioned, patients with dementia normally direct aggressive behaviour towards their caregivers (Whatt et al. 2008). This has the effect of affecting the quality of life of both the patient and the caregiver. This is because aggressive behaviour towards caregivers lead to stress, anxiety and burnout (Talerico et al. 2002) thereby limiting their ability to deliver quality care to the dementia patients. This may increase the prevalence of dementia in the UK and create more burdens to the already overburdened public health system. It is estimated that dementia costs about £19 billion per year. It is therefore important that this study is undertaken so that the different reasons that cause aggressive behaviour in dementia patients are identified so that sufficient interventions are determined to reduce such behaviour. In addition, the study will also determine the different strategies that have been implemented to reduce aggressive behaviour and their effectiveness so that the effectiveness and efficiency of such interventions can be improved. The study will focus on identifying the diverse needs of the patients and focusing care delivery on meeting these needs.
- To evaluate the causes of aggressive behaviour in dementia patients in residential care homes in the UK.
- To evaluate the different methods of managing aggressive behaviour in dementia patients in residential homes in the UK.
- To identify agency and link programmes and interventions that have been used to try and reduce the prevalence of aggressive behaviour in dementia patients in residential care homes in the UK.
- To evaluate the effectiveness of intervention of reducing aggressive behaviour in dementia patients in residential care homes in the UK.
Policies/Legislations/Strategies and agency link to the topic of discussion
The dissertation will focus on non pharmacological interventions that have been adopted by the NHS and recommended by NICE. Some pharmacological therapies are also considered in the dissertation.
Different keywords will be used for this search including ‘dementia’, Alzheimer’s disease’, ‘violence’, ‘aggression’ and ‘psychological and behavioural symptoms’, ‘strategies for dealing with aggressive behaviour among dementia patients in residential homes in UK’. The keywords will be entered in different academic databases including MEDLINE, British Nursing Index, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PSYCHLIT, ProQuest, Google Scholar and ERIC (Educational Resources Information Centre) among other databases. More information will be obtained from UK government departments like the NHS and the Department of Health.
- Articles with information on aggressive behaviour among patients in the UK
- Articles published from 1990. This will provide a wide range of information and help in determine the trends for the last 25 years.
- However, while considering the treatments and their effectiveness, information will be collected from the most recent articles.
- Some information relevant to the topic from articles from other countries like the United States, Australia, New Zealand and Canada and other parts of Europe. However, these articles will not be used as source of information for the interventions that have been taken to reduce aggressive behaviour in dementia patients in the UK.
- Articles published in English.
- Articles not published in English language
- Articles or information from articles from other countries not included in the inclusion criteria above
- Any relevant literature that did not follow an ethical procedure in its study
- Articles published before 1990
The research on this dissertation will be performed in an ethical manner and will employ anti-oppressive practices. Much as the research is on dementia patients and their aggressive behaviour, it is understood that these dementia patients are humans who equally deserve respect and honour. In this regard, the researcher will rely only on the body of literature to make conclusions. This means that the research will not be based on stereotypes about dementia patients. The process of research will also not discriminate against these patients or discriminate the patients based on their age or race. Through these practices, it is expected that the recommendations of the research will be those that can be implemented at residential institution level or government level and which will help in improving the quality of care delivered to the patients.
The term aggression and violence may be used interchangeably though they mean different things. Violence may be defined as an instance when the safety and health of a staff is challenged through assaults, threats and abuse while in line of their duty (NHS, 2015). This definition may be applied equally to people with dementia, mental health problems and other patient groups. However, violence is used rarely in literature. The first reason for this is that when the definition of violence is taken like it has been defined by the NHS above, then it would imply that this actions has been done intentionally by the perpetrator. However, this is a concept that is difficult to apply for people with dementia (Pulsford et al. 2006). The other reason why violence is rarely used is that violence involves some form of severity which is often very difficult to define (Astron et al. 2004). This is the reason why dementia care literature mainly uses the terms aggression or aggressive behaviour. These are terms that are less emotive (Pulsford et al. 2006).
Aggressive behaviour in persons with dementia may be defined as destructive actions that the patients may express towards objects, other people or towards themselves (Whatt et al. 2008 p. 721). Patients in residential care homes normally show aggression towards caregivers making it very difficult for nurses and other healthcare professionals to offer care to such patients (Whatt et al. 2008).
Dementia is a term used in describing a disability that is caused by condition or set of conditions that affect the functioning of the brain (Veselinova, 2013). The common symptoms of dementia include impaired cognitive ability, memory loss, mood swings, depression, disorientation and lack of proper physical coordination in the patient (Mitchie et al. 2011). Dementia is a progressive disability which means that the symptoms of dementia gradually increase with time (Nolan, 2012). The symptoms of dementia in an individual depend on the location of the brain that is affected by the condition (Mitchie et al. 2011).
Dementia patients have the same social and psychological needs just like other members of the society. However, due to their relatively lower brain activity, dementia patients may not know how to recognise their needs, device ways of meeting the needs and communicate the needs to caregivers and family members. Aggression could therefore be a way in which these people meet their needs.
Aggressive behaviour in dementia patients is a very complex phenomenon that has different causative factors (Pulsford et al., 2006). The first cause could be that the patient might have had a history of aggression before contracting dementia, aggression being the way in which the individual responds to different situations (Pulsford et al. 2006). In addition, according to a study done by O’Leary et al. (2005), individuals who had a history of conduct disorder before contracting dementia are more likely to be aggressive towards others. In general, the causes of aggressive behaviour may be divided in three which are biological, social and psychological causes. These causes can be modelled into different models.
In the biological model, aggression is attributed to organic pathology with dementia being the cause of this pathology (Cohen-Mansfield et l. 2007). In addition, the study by Wiener et al (2001) assert that all dementia co-morbidities which are mainly biological can also contribute to aggression. The other causes of aggression among dementia patients may include unrelieved pain, discomfort and depression (Nguyen et al. 2008). Biological causes of aggression are best managed and treated through understanding of the different psychological causes over management of the dementia (Bidewell et al. 2010).
The unmet needs model describes how aggression originates from some social or environmental problem. The unmet needs model may intersect with the biological model. For example, there are instances when patients may be neglected making them feel dehydrated, hungry or have problems with their hygiene, medication and other personal maintenance needs which bring about unmet needs (Zieber et al. 2005). In this case, managing aggression can be done by fulfilling the unmet need in the patient. In some instances, the unmet needs must be inferred due to breakup in communication between the patient and the caregiver. Inferring the needs requires careful understanding and analysis of the needs of the patients (Bidewell et al. 2010).
One of the unmet needs that are worth mention for people with dementia is sexual needs. Living with dementia does not change the sexual feelings that individuals have. However, it may change the manner in which the individuals express these feelings. This also changes the manner in which sexuality is perceived by the patient and their partners (Heath, 2012). The sexual rights of dementia patients are sometimes ignored or stigmatised by care professionals (Ward et al. 2013). For example, actions like holding hands, kissing or stroking may be acceptable in care facilities. However, any other action may be met with outrage and shock from care professionals (Heath, 2012). The ignoring of these sexual feelings by those in charge of delivering care to the patients may cause agitation in the patient and lead to aggressiveness (Benbow et al. 2012).
The behavioural model emphasises the role of the environment in influencing behaviour. In this model, it is argued that behaviours are learned and persist because of the reward that is offered by the environment (Bidewell et al. 2010). For example, aggressive patients may receive extra attention within the care facility. This extra attention can reinforce the problematic behaviour within the patient. To manage the behavioural model, it is important that the environmental factors that lead to the behaviour are eliminated and the environmental rewards to the behaviour are suppressed. The behavioural model may also overlap with the unmet needs model because a patient may seek for attention and when such attention is not obtained; this may be an unmet need (Bidewell et al. 2010).
One of the ethical principles or dilemmas that nurses and other caregivers may face while delivering care to such patients is the balance between suppressing environmental rewards and meeting the needs for proper care. This is because there are instances when suppressing the rewards may be interpreted as neglecting the patient (Bidewell et al. 2010). To avoid this dilemma, the health and social care professionals should meet the individual needs of the dementia patients before aggression occurs.
The environmental model links aggressive behaviour to factors that are external to the patient (Bidewell et al. 2010). For instance, the residential care facility may not provide the sensory and social stimuli that they may require. This may result to reflexive attention seeking which can be reinforced. Social and healthcare professionals have a problem of identifying the start of the behaviour. The other form of environmental vulnerability is excessive demand from the patient (Cohen-Mansfield et al. 2007). This may lead to frustration and aggression on the part of the patient. Environmental and behavioural needs model also overlap because the environment may provide the stimuli that may instigate a particular behaviour in a patient (Bidewell et al. 2010). In this regard, aggressive behaviour can be reduced by reducing the expectation of the patient and simplifying the tasks that he or she is expected to perform. This will help in reducing the frustration levels. However, the challenge in this case is to properly design activities and a proper environment that does not evoke demand of new needs while meeting the current needs and reducing stressful demands.
There are other factors of aggression like discomfort, dehydration and pain which are generally treatable. These factors should be considered and addressed in daily care of the patient so that they do not create new needs on the patient (Bidewell et al. 2010). However, care professionals must work with the unmet needs, behavioural and environmental model so as to accommodate all the causes of aggression among the patients. Any management of aggression must consider aggression as an integration of behaviours and not just as a single behaviour. This means that there cannot be one-size-fits-all treatment for management of aggression in dementia patients.
Behavioural and aggressive symptoms are very common among dementia patients in residential care facilities in the UK. Most of the studies have reported that between 40 to 60% of dementia patients have exhibited aggressive behaviours while in care homes (Khan et al. 2011). As has been mentioned, the aggressive behaviour by the dementia patients will have a negative effect on the quality of care that they receive. Aggressive behaviour is more common among men that women patients.
Timely diagnosis of dementia helps in determining the needs that the patients have and how to manage these needs. Diagnosis is based on cognitive and neuropsychiatric symptoms. The most common cognitive symptom is memory loss (Holmes, 2008). This is exhibited in the manner in which the patients may find difficulty in learning new names, new information and details of conversations that they have with caregivers and their families. Other cognitive symptoms include apraxia, aphasia and agnosia (Holmes, 2008). The neuropsychiatric symptoms include thought disorder, perception disorder, and behaviour disorder and affect disorder (Holmes, 2008). There are also mood and anxiety disorders. These neuropsychiatric symptoms make the patient isolate him or herself from the society (Holmes, 2008).
The understanding of these symptoms helps healthcare professionals in better management of the condition so that the disease may not lead to aggressive behaviour. From the discussion on cause models, it can be seen that the neuropsychiatric symptoms are the main risk factors for aggressive behaviour.
Treatment for dementia depends on whether they address the causes or just the behaviour. There are different treatment approaches that have been identified by different researchers. For example, Kong, Evans & Guevara (2009) in their study on no pharmacological interventions for agitation in dementia identified an approach that focused on sensory intervention, social contact with the patient, activities, and modification of the environment, caregiver training, combination and behavioural therapy (Kong et al. 2009 p. 512). In another study on understanding and managing behavioural challenges of dementia care, Ouldred et al (2008) highlight complementary therapy, multi-sensory, music, reminiscence, validation, reality, orientation and cognitive behavioural therapies, modifying the environment and caregiver intervention as the different therapies that can be administered to aggressive dementia patients (Ouldred et al. 2008 p. 245). There are other treatment approaches that have been identified including the biological-neurological approach (Turner, 2005). This approach focuses on the origin of the aggressive behaviour problem. The model focuses on pharmacological management of the condition. The other approach is the psychological-behavioural approach that looks at behaviours in their specific context. Modifying behaviour is achieved through modifying the external environment. The other forms of treatment are discussed below:
Pharmacological treatments are mainly geared at managing pain in dementia patients. This means that pain killers are one of the most common pharmacological treatments (Corbett et al. 2012). Evidence has shown that treatment and management of pain can help in administration of other therapies like behavioural therapy. However, pharmacological treatment should start with a low dosage which should then be stepped depending on the response received from the patient (Husebo et al. 2011). The results from the Husebo study have shown that pharmacological treatment was effective in reducing pain and aggression in the patients. Antidepressant medications are also used in the management of aggression in patients.
Different studies have criticised the effectiveness of pharmacological treatments. The first criticism is the fact that pharmacological medications do not address the reasons for different behaviour (Cohen-Mansfield et al. 2007). The other criticism is that pharmacological treatments may have side effects on the patients (Bidewell et al. 2010). The side effects may be environmental factors for new aggressive behaviours meaning that the pharmacological treatments that have such side effects can be costly for no apparent reason. In addition, pharmacological treatment may be a chemical restraint and may mask other health conditions in the patient (Mott et al. 2005).
It is important to note that almost 180,000 patients with dementia are treated using antipsychotic medications across England (Khan et al. 2011). However, only a paltry 36,000 will experience the benefit for this treatment. This confirms the criticisms on the effectiveness of pharmacological treatments. The NICE guidelines provide that non-pharmacological treatments should be considered first before pharmacological intervention is applied (NICE, 2015).
Reminiscence therapy can be administered to help the patient to relive past positive experiences through the help of photos, films and other available memory aids (Khan & Curtice, 2011). Reminiscence therapy can be done in individual or group setting (Blake, 2013). The individual or group sessions can be used to identify specific themes within the reminiscent therapy. Some of the themes that can be identified include special occasions and school occasions. This form of therapy involves reliving both the good and the bad moments and helping the patient focus on the good moments (Blake, 2013).
Reminiscent therapy is based on the fact that remembering and reliving past experiences is a natural phenomenon that can help in promoting positive emotions and enhances the ability the patient to deal with the present situations (Thorgrimsen et al 2002).
There are different tools that have been developed in reminiscent therapy that are used to encourage the process of reliving the past experiences. These tools if well used can reduce the depressive symptoms in older adults with dementia symptoms thereby reduce the chances of aggression among these patients (Chiang et al. 2009).
Despite its effectiveness, this method is not widely used because of its complexity. To begin with, reminiscent therapy requires the additional training of nursing staff (Blake, 2013). In addition, reminiscent therapy may be a source of other stressors for the dementia patient and may lead to aggressive behaviour if not well handled.
Cognitive behavioural therapy (CBT) focuses on the relationship between the thoughts, feelings and behaviour of the dementia patients (Spector et al. 2012). This form of therapy aims at identifying the personal time-set goals of therapy for the patient and strategies that can be put between the actions. This method can be very effective in reducing anxiety among the patients. In simple terms, cognitive behavioural therapy focuses to challenge the negative thoughts that the patients may have about themselves or their former experiences. This will help in eliminating mood and anxiety disorders that are risk factors for aggression.
One of the limitations of this method when dealing with dementia patients is that people with dementia have diminished cognitive abilities. However, research performed by Spector et al (2003), has shown that the dementia patients can still learn some skills. This means that CBT can be used in an adapted form for such people with cognitive and learning disabilities (Dagnan et al. 2000). In other studies done by Teri et al (1999), there is evidence that CBT can help in reducing anxiety and thereby eliminate any risk factors for aggression among the dementia patients. When properly administered, CBT can result in change in mood, behaviour and cognition among the patients (Kipling et al. 1999). CBT can also increase the participation in pleasurable activities for the patients (Kraus et al. 2008). This will also help in reducing the levels of anxiety among the patients.
To ensure success of the therapy, the healthcare professionals must have realistic expectations for the therapeutic outcomes including the potential outcomes of the treatment based on the personality of the patient (Sadowski et al. 2012). The different issues of treatment should therefore be discussed with the patients and their families before commencement of therapy (Waldemar et al. 2007).
This is a non-pharmacological treatment that involves a physical device that is placed within the body of the patient or near the patient that limits the movement of the patient (Mott et al. 2005). This is a form of therapy that is designed to protect the patient, caregivers and other patients within the facility (Segatore et al. 2001). However, the use of physical restraint is subject to ethical questions of whether it is correct to limit the movement of a patient (Poole et al. 2003). However, despite the ethical issues, there are nurses who do not have a concern of imposing physical restraints on patients. Because of their low effectiveness and the ethical issues, this form of management is not advisable and should be avoided. This can be done by adequately training staff involved in care delivery to patients so that they understand ways of reducing agitation in patients (Testad et al. 2005).
The care facility should be properly designed so that it is not physically or mentally straining to the patients. This will make the dementia patients to have more freedom, choice and autonomy on what they can achieve within the environment (Matthews, Farrell & Blackmore, 1996). The freedom and autonomy should be extended to the activities that the patients do while within the care facility. The relaxed and simplified environment helps in reducing the level of stress and depression within the patient. This includes also allowing the patents to locate some of the facilities for themselves. For example, in a study performed by McGilton et al (2003), they discovered that the residents’ ability to locate some of the facilities like dining room helped in reducing the levels of depression within the patients.
However, the problem with this form of intervention is based on the reduced cognitive abilities of the dementia patients. The patients therefore require additional support so that the intervention may be a success (Detweiler et al. 2008).
Person-centred care should be used as the approach for managing aggression in dementia patients. This means that the views of the patients concerning who should participate in their care delivery should be considered. With the permission of the patient, the relatives and other carers should have an opportunity of determining the nature of care that the patient receives. If the person does not have the capacity of determining who should or should not participate in his or her care delivery, then healthcare professionals should evoke sections of the Mental Capacity Act to determine the extent and nature of care delivered to the patient (NHS, 2015).
The views of the carers should be considered at all moments. This information together with some information obtained from the patient can help in diagnosis and preventing aggression in the patient. The information will also help in determining the capacity of the patient to make independent decisions. This means that there should be good and clear communication between the care provider and the patient (NICE, 2015). Communication will help in dissemination of evidence-based care that focuses on the individual needs of the patients. The care delivered to the patient should also consider other issues like cultural differences (NICE, 2015).
The NHS has developed strategies that can help reduce clinically challenging behaviour among dementia patients. This will increase the reporting of these incidences because some of these incidences go unreported. Some of the aggressive behaviour that the NHS has put in consideration includes grabbing, biting, pinching, scratching, hair pulling, slapping, and kicking, punching and self-injurious behaviour among others. These are behaviours that pose a significant health risk to care professionals, visitors, other patients and even to them. The patients with challenging behaviour should not be stigmatised as this is one of the ways in which the patients could express themselves (NHS, 2015).
According to the proposals, healthcare professionals will be required to improve on their assessment, diagnosis and management of dementia patients who may exhibit aggressive behaviour. This will help in preventing the aggressive behaviour (NHS, 2015). The healthcare professionals are also challenged to improve their understanding of how aggressive behaviour may be related to clinical conditions. This will help in increasing their approach towards management of the patients. This is based on the fact that the increased understanding will help determine whether the aggressive behaviour is due to met or unmet needs (NHS, 2015).
There are specific legislations that relate to prevention and management of aggressive behaviour among dementia patients. Some of the laws include:
The common law: this asserts that healthcare professionals have a duty to provide care to their patients. They must therefore take the necessary steps to ensure that they deliver quality care to their patients and avoid acts of omission that are likely to reduce the quality of care delivered. Some of these acts include neglecting the patients and restraining the movement of the patients.
Equality Act 2010: in this regard, healthcare professionals have a duty of reducing or eliminating the health inequalities that affect different communities. By removing these inequalities, the professionals will improve on the healthcare access. In addition, the delivery of health services should not discriminate against any patient based on age, sex, religion or colour of the skin or any other form of discrimination (NHS, 2015).
Human Rights Act and the European Convention on Human Rights: it is a requirement for all the public authorities in the UK, the NKS included to have actions that are consistent with the Human Rights Act of 1998. The Act together with the European Convention on Human Rights has articles that assert the different rights that patients including dementia patients have. Some of the rights include the right to life, the right not to be tortured physically and psychologically, right to security and liberty of patients, right to respect and for healthcare professionals to provide them with the privacy they need, freedom of expression and prohibition of discrimination (Department of Health, 2013).
The NHS guidelines are similar to the NICE guidelines that do not allow for discrimination or exclusion of dementia patients based on their medical condition (NICE, 2015). Both the NHS and NICE require that health and social care professionals treat the patients and their families with the respect that they deserve. This involves first identifying the needs that these patients have and working towards meeting these needs. This will help in reducing the level of aggression among the patients (NICE, 2015). These guidelines need to be followed by all institutions that support dementia patients.
The case presented above has been effective in reducing aggressive behaviour among dementia patients. However, as will be seen in the recommendations, more capacity needs to be developed and more training should be done to the health staffs who are concerned with management of the dementia patients.
Case study of service delivery
The organisation that will be considered for this case study is Mind. This is a mental health charity in Wales and England. The organisation was selected for the support that it has provided to mental health patients in England and Wales. Mind provides information and support to patients experiencing mental health problems. Mind’s campaign is to improve the quality of services and promote understanding about mental health problems. Mind’s activities are supported through fundraising that are organised by celebrity supporters. The celebrity supporters are passionate about the activities carried on by Mind (Mind, 2015).
The advantage of Mind is that it provides direct support to those who need it. The organisation also has networks at local and national level where members can be recruited. The other advantage of Mind is that it provides training to healthcare professionals to help them identify some problems that patients could be experiencing (Mind, 2015). The disadvantage is that Mind may not have enough resources and capacity to bring about change in England and Wales.
One of the activities chosen for this study is the provision of human-faced reports which were articles that were pieced together and shared widely over the social media. The objective was to engage in the conversation of mental health and provide information on how to support mental health patients. The articles were integrated with a documentary film that also provided information on mental health. This will help in reducing the stigma that is associated with mental illnesses because the articles assert that mental illness has affected everybody and everybody affected needs the compassion and love to help him or her come out of the situation (Mind, 2015). The effectiveness of this programme is yet to be felt even though there have been many Facebook and Twitter conversations on the topic based on the information provided. In the long term, this programme will be effective because it will help in reducing stigmatisation and stereotyping of mental health patients in England and Wales.
The first recommendation is that the government should increase the capacity of residential care homes in the UK. This will help improve the environment conditions of the care settings and improve on the overall approach of delivering care to the dementia patients. Some of the environmental changes that can be made include the colour scheme of the wards and orientation aids among others. For example, the toilet doors can be painted red, more signs should be used for the different places of interest that the patients may want to visit. This will help in easy identification and reduce frustration that may be experienced by the patients (O’Sullivan, 2011). In addition, capacity can also be increased by training more staff so that they are equipped with the latest knowledge and skills on how to identify stressors within the patients and work towards eliminating the factors that may lead to aggressive behaviour. The staff should also be given more training on how they can better cope with people who are aggressive or those who have demonstrated challenging behaviour.
The other recommendation is that care given to dementia patients should be more person-centred. In this case of dementia patients, person-centred care entails gathering the mental, physical and cognitive status of the patients (O’Sullivan, 2011). Other issues that can be gathered in this approach include leisure interests, self-care habits, qualifications, personal history, attitudes, spirituality and social factors. This will increase nursing staff awareness of the individual attitudes, traits and values of the residents. The personal traits also have an influence on how dementia may manifest and it is therefore important that they are understood early in advance so that the nursing staff can know how dementia will manifest in the patients. Person centred care will help nurses and other healthcare professionals to personally understand the dementia patients and focus care towards the individual needs of the patients (O’Sullivan, 2011).
The third recommendation is that the ward environment should be made calm, well-organised and familiar for the patient. This will make this environment be suitably stimulating for the patients (Kerr, 1997). One challenge with this recommendation is that it is difficult to find such ward settings for dementia patients (Cunningham, 2006).
There are many vital lessons that have been learned while working on this dissertation. On the personal side, I have learned the importance of completing assignments in time. This will help me even in my professional field where care delivery should be done in a timely manner. On a professional level, I have learned the manner in which aggressive behaviour among dementia patients affects the quality of care delivered to them. From the different literature, it can be seen that aggressive behaviour leads to burnout and stress. However, as a caregiver I want to create a difference on the quality of care that I will deliver. I would want to deliver the most effective care despite the circumstances that I am faced with. However, as a human, I have to face the fact that there are instances when care delivery may be a threat to my personals security and safety. This means that I have to get a good balance between delivering quality care to the patients and ensuring that I am safe and free from any harm. I will try and minimise the medication errors and other issues that may cause aggressive behaviour among the patients. The dissertation has improved my knowledge on aggressive behaviour and dementia as I have learned of new models and learned how to integrate the models so as to determine the source of aggressive behaviour among the patients. The understanding of the sources of aggressive behaviour will help me get better ways of managing this behaviour within the patients. I have also learned that there are many organisations including NHS and NICE those have provisions that can help reduce the prevalence of aggressive behaviour among dementia patients. However, it is important that these institutions work together so that they develop common strategies and points of action that can help the dementia patients. It is also important that health and social care professionals follow the regulations to the later. This will help in improving the quality of care delivered.
In conclusion, there are around 670,000 patients living with dementia in the UK (Department of Health, 2013). Most of these patients live in residential care settings (Duxbury, Pulsford et al. 2013). This dissertation has discussed the effectiveness of dealing with aggressive behaviour in dementia patients in residential care homes in the UK. Patients living with dementia express different aggressive behaviour symptoms based on the fact that they cannot easily express themselves. The aggressive behaviour is a way in which the patients express their feelings and emotions. The aggressive behaviour affects the quality of care that these patients receive. This is because aggressive behaviour leads to stress, anxiety and burnout among the staff (Talerico et al. 2002). Ethical and anti-oppressive methods have been used while performing the search for the dissertation. This means that the dementia patients have been seen as humans and there has not been any stereotype against these patients that has been expressed in this dissertation.
There are different biological, environmental, psychological and social causes of aggressive behaviour among dementia patients. These causes can be divided into different models including the biological model, the environmental model; the unmet needs model and the behavioural model. All these models explain the source of aggressive behaviour and may overlap. This means that aggressive behaviour within a dementia patient may not be due to one reason but may be due to different reasons which must be clearly understood by care professionals.
Behavioural and aggressive symptoms are very common among dementia patients in residential care facilities in the UK. Most of the studies have reported that between 40 to 60% of dementia patients have exhibited aggressive behaviours while in care homes (Khan et al. 2011). As has been mentioned, the aggressive behaviour by the dementia patients will have a negative effect on the quality of care that they receive. Aggressive behaviour is more common among men that women patients.
It is important that dementia is diagnosed early in advance so as the causative reasons for aggression can be identified. Dementia is characterised by different symptoms including cognitive and neuropsychiatric symptoms. The most common cognitive symptom is memory loss (Holmes, 2008). This is seen in the manner in which the patients lose their memory and find difficulty in learning new names and new locations. Other cognitive symptoms include apraxia, aphasia and agnosia (Holmes, 2008). The neuropsychiatric symptoms include thought disorder, perception disorder, and behaviour disorder and affect disorder (Holmes, 2008). There are also mood and anxiety disorders. These neuropsychiatric symptoms make the patient isolate him or herself from the society (Holmes, 2008).
There are different strategies that have been used to manage aggressive behaviour in dementia patients in the UK. The strategies range from pharmacological and no pharmacological therapies. The NICE recommends that no pharmacological interventions be considered first before any drug is administered. Pharmacological treatments have been criticised for the side effects and for the fact that they do not clearly identify the source of aggressive behaviour. The side effects may lead to regeneration of aggressive behaviour in the patient. The different no pharmacological interventions that can be used include reminiscent therapy, cognitive behavioural therapy, physician restraint and having a good care environment. These strategies have different levels of effectiveness depending on how they are administered on the patients.
Astrom S., Karlsson S., Bucht G. et al. (2004) Staff’s experience of the management of violent
incidents in elderly care. Scandinavian Journal of Caring Sciences, 18, pp. 410–416.
Benbow, S.M.& Beeston, D. (2012). Sexuality, aging and dementia. International
Psycho geriatrics, 24(7), pp. 1026-1033.
Bidewell, J.W. & Chang, E. (2010). Managing dementia agitation in residential care. Dementia,
10(3), pp. 299-315.
Blake, M. (2013). Group reminiscence therapy for adults with dementia: a review. British
Journal of Community Nursing, 18(5), pp. 228-233.
Chiang, K-J., Chu, H. & Change, H-J et al (2009). The effects of reminiscence therapy on
Psychological well-being, depression, and loneliness among the institutionalized aged, International Journal of Geriatric Psychiatry, 25(4), pp. 380-388.
Cipriani, G., Vedovello, M., Nuti, A. & Di Fiorino, M. (2011). Aggressive behaviour in patients
with dementia. Correlates and management. Geriatrics & Gerontology International, 11, pp. 408-413.
Cohen-Manfield, J., Libin, A. & Marx, M.S. (2007). No pharmacological treatment of agitation:
A controlled trial of systematic individualised intervention. Journal of Gerontology, 62A(8), pp. 908-916.
Corbett, A., Hubeso, B. & Ballard, C. (2012). Discomfort in dementia: identifying and managing
pain. Nursing & Residential Care, 14(9), pp. 462-467.
Cunningham, C. (2006). Understanding challenging behaviour in patients with dementia.
Nursing Standard, 20(47), pp. 42-45.
Dagnan, D., Chadwick, P. & Proudlove, J. (2000). Toward an assessment of suitability of people
with mental retardation for cognitive therapy. Cognitive Therapy and Research, 24(6), pp. 627–636.
Department of Health. (2013, November). Dementia: A state of the nation report on dementia
care and support in England. Retrieved April 24, 2015, from Department of Health: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/262139/Dementia.pdf
Detweiler, M. B., Murphy, P. F., Myers, L. C., & Kim, K. Y. (2008). Does a wander garden
influence inappropriate behaviours in dementia residents? American Journal of Alzheimer’s Disease and Other Dementias, 23, pp. 31–45.
Duxbury, J., Pulsford, D., Hadi, M. & Sykes, S. (2013). Staff and relatives’ perspectives on the
aggressive behaviour of older people with dementia in residential care: a qualitative study. Journal of Psychiatric & Mental Health Nursing, 20, pp. 792-800.
Heath, H. (2012). Intimate relationships for people with dementia. Nursing & Residential Care,
14(11), pp. 593-596.
Holmes, C. (2008). Dementia. Psychiatric Aspects of General Medicine, 36(9), pp. 467-470.
Husebo, B.S., Ballard, C., Sandvik, R., Nilsen, O.B & Aarsland, D. (2011). Efficacy of treating
pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. British Medical Journal, 343(7816), pp. 193-
Kerr, D. (1997). Down’s syndrome and dementia: Practitioner’s guide. Birmingham: Venture
Khan, F. & Curtice, M. (2011). Non-pharmacological management of behavioural symptoms of
dementia. British Journal of Community Nursing, 16(9), pp. 441-449.
Kipling, T., Bailey, M. & Charlesworth, G. (1999). The feasibility of a cognitive behavioral
therapy group for men with mild to moderate cognitive impairment. Behav Cogn Psychother, 27, pp. 189–193.
Kong, E. H., Evans, L. K., & Guevara, J. P. (2009). Nonpharmacological intervention for
agitation in dementia: A systematic review and meta-analysis. Aging & Mental Health, 13, pp. 512–520.
Kraus, C., Seignournel, P., Balasubramanyam, V., Snow, L., Wilson, N.L., Kunik, M.E., Schulz,
M.D. & Stanley, M.A. (2008). Cognitive behavioural treatment for anxiety in two patients with dementia: two case studies. Journal of Psychiatric Practice, 14(3), pp. 186-192.
Matthews, E. A., Farrell, G. A., & Blackmore, A. M. (1996). Effects of an environmental
manipulation emphasizing client-centred care on agitation and sleep in dementia sufferers in a nursing home. Journal of Advanced Nursing, 24, pp. 439–447.
McGilton, K. S., Rivera, T. M., & Dawson, P. (2003). Can we help persons with dementia find
their way in a new environment? Aging & Mental Health, 7, pp. 363–371.
Michie, V., Morris, C., Baker, L., Collier, F. & Marshall, T. (2011). Level 2 Health and Social
Care Diploma. London: Hodder Education.
Mind. (2015). Retrieved May 3, 2015, from Mind: http://www.mind.org.uk/
Mott, S., Poole, J., & Kenrick, M. (2005). Physical and chemical restraints in acute care: Their
potential impact on the rehabilitation of older people. International Journal of Nursing Practice, 11, pp. 95–101.
NHS. (2015). Meeting needs and reducing distress. Retrieved April 25, 2015, from NHS:
NHS. (2015). Symptoms of dementia. Retrieved April 25, 2015, from NHS:
NICE. (2015). Dementia: Supporting people with dementia and their carers in health and social
care. Retrieved April 25, 2015, from NICE: https://www.nice.org.uk/guidance/cg42/chapter/guidance
Nolan, Y. (2012). Dementia Work Based Learning Level 2 Award Certificate Diploma. Essex:
Pearson Education Limited.
Nguyen, Q., & Paton, C. (2008). The use of aromatherapy to treat behavioural problems in
dementia. International Journal of Geriatric Psychiatry, 23, 337–346.
Ouldred, E., & Bryant, C. (2008). Dementia care. Part 2: Understanding and managing
behavioural challenges. British Journal of Nursing, 17, pp. 242–247.
O’Sullivan, G. (2011). Ethical and effective: Approaches to residential care for people with
dementia. Dementia, 12(1), pp. 111-121.
Poole, J., & Mott, S. (2003). Agitated older patients: Nurses’ perceptions and reality.
International Journal of Nursing Practice, 9, pp. 306–312.
Pulsford, D. & Duxbury, J. (2006). Aggressive behaviour by people with dementia in residential
care settings: a review. Journal of Psychiatric and Mental Health Nursing, 13, pp. 611-618.
Richards, K.C., Algase, D. & Beck, C. (2008). Factors associated with aggressive behaviour
among nursing home residents with dementia. The Gerontologist, 48(6), pp. 721-731.
Sadowski, C.H. & Galvin, J.E. (2007). Guidelines for the management of cognitive and
behavioural problems in dementia. Journal of the American Board of Family Medicine, 25(3), pp. 350-366.
Spector, A., Orrell, M., Lattimer, M., Hoe, J., King, M., Harwood, K., Qazi, A. & Charlesworth,
- (2012). Cognitive behavioural therapy (CBT) for anxiety in people with dementia: study protocol for a randomised controlled trial. Trials, 13, pp. 197-203.
Spector, A., Thorgrimsen, L., Woods, B., Royan, L., Davies, S., Butterworth, M. & Orrell, M.
(2003). Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised Controlled Trial. British Journal of Psychiatry, 183, pp. 248–254.
Talerico, K., Evans, L., & Strumpf, N. (2002). Mental health correlates of aggression in nursing
home residents with dementia. The Gerontologist, 42, pp. 169–177.
Teri, L., Logsdon, R., Uomoto, J. & McCurry, S.M. (1999). Behavioural treatment of depression
in dementia patients: a controlled clinical trial. Journal of Gerontology, 52, pp. 159–166.
Testad, I., Aasland, A. M., & Aarsland, D. (2005). The effect of staff training on the use of
restraint in dementia: A single-blind randomised controlled trial. International Journal of Geriatric Psychiatry, 20, pp. 587–590.
Thorgrimsen, L., Schweitzer, P & Orrel, M. (2002). Evaluating reminiscence for people with
dementia: a pilot study. Arts in Psychotherapy, 29(2), pp. 93-97.
Turner, S. (2005). Behavioural symptoms of dementia in residential settings: A selective review
of nonpharmacological interventions. Aging & Mental Health, 9, pp. 93–104.
Veselinova, C. (2013). Dementia awareness; providing person-centred care. Nursing &
Residential Care, 15(9), pp. 622-626.
Waldemar, G., Dubois, B. & Emre, M. et al. (2007). Recommendations for the diagnosis and
management of Alzheimer’s disease and other disorders associated with dementia: EFNS guideline. European Journal of Neurology, 14, pp. e1–26.
Ward, R.F. & Manchip, S. (2013). ‘Inappropriate’ sexual behaviours in dementia. Reviews in
Clinical Gerontology, 23, pp. 75-87.
Whall, A.L., Colling, K.B., Kolanowski, A., Kim, H.J., Hong, G.S., DeCicco, B., Ronis, D.L.,
Wiener, P. K., Kiosses, D. N., Klimstra, S., Murphy, C., & Alexopoulos, G. S. (2001). A short-
term inpatient program for agitated demented nursing home residents. International Journal of Geriatric Psychiatry, 16, pp. 866–872.
Zieber, C. G., Hagen, B., Armstrong-Esther, C., & Aho, M. (2005). Pain and agitation in long-
term care residents with dementia: Use of the Pittsburgh Agitation Scale. International Journal of Palliative Nursing, 11, pp. 71–78.