Abstract: Aggression and Dementia in the Inpatient Hospital Setting (Society for Social Work and Research 20th Annual Conference - Grand Challenges for Social Work: Setting a Research Agenda for the Future)

Schedule:

Saturday, January 16, 2016: 9:45 AM

Meeting Room Level-Meeting Room 13 (Renaissance Washington, DC Downtown Hotel)

* noted as presenting author

Tracy C. Wharton, PhD, LCSW, Assistant Professor, University of Central Florida, Orlando, FL

Lisa Macri, MSW, Doctoral Student, University of Central Florida, Orlando, FL

Lisa Seyfried, MD, Assistant Professor, University of Michigan-Ann Arbor, Ann Arbor, MI

Leslie Dubin, LMSW, Licensed Clinical Social Worker, University of Michigan-Ann Arbor, Ann Arbor, MI

David Hanauer, MD, Associate Professor of Pediatrics and Communicable Diseases & Assoc Professor of Information, University of Michigan-Ann Arbor, Ann Arbor, MI

Helen C. Kales, MD, Associate Professor, University of Michigan-Ann Arbor, Ann Arbor, MI

Background:

Although management of dementia and prevention of aggressive behaviors in the inpatient hospital setting are important issues, data on their frequency are lacking. This study provides insight into demographics and begins an exploration of factors related to aggression in this population. We hypothesized that the majority of incidents of aggression by individuals with dementia in this setting occurred during delirium states.

Methods:

This was a cross-sectional study of electronic medical records (EMR) of a large public hospital (45,000 discharges/year). EMRs were reviewed using the EMERSE search tool, which searches text data in all identified records. Of the 14,080 adults aged 60+ who spent at least 24 hours at the hospital during the one year study time frame, we examined the EMR of the first 4,000 patients and every 10^th person through 14,080 who met these criteria (N=5,008). Once screened with EMERSE, records were reviewed by the PI and other clinical members of the research team to identify deliriums and understand contextual situations in which aggression occurred.

Results:

Ten percent (n=505) had a diagnosed or suspected dementia noted in the record; approximately 25% (n=105) of these had reports of aggressive incidents in their medical record. Sixty-one percent (n=64) of aggression incidents occurred during delirium states. There was no difference in the mean age of the larger group of dementia patients, compared to the group with aggression (both 78 yo). Those who had incidents of aggression were 49% male (versus 46% of the total group with dementia), 79% white, and 13% black (reflecting the entire sample). Less than one-third of the known dementia patients (n=154) were given cognitive screens to assess their current status. When aggressive behaviors appeared, less than half had a screener attempted to assess current status; if formal assessment of delirium occurred, it was rarely documented in the EMR, despite the documentation of either rapid decline into classic symptoms or a clinical observation of delirium.

Conclusions:

It appears that delirium is the leading reason for aggressive behaviors in hospitalized patients with dementia. Our data suggest that demographic differences do not predict aggression, although adequate documentation of dementia diagnoses or cognitive testing conducted were inconsistent in the EMR. Studies suggest that low-cost, nonpharmacological interventions may be the most effective intervention for managing disruptive behaviors and preventing delirium. Consistent delirium prevention and assessment may be key to preventing aggression incidents in this population.

Implications for Social Work Practice:

Social workers in the healthcare system are ideally placed and trained to advocate for a more holistic understanding of patient needs and more patient-centered approach to inpatient intervention. Delirium prevention and management of confusion and aggressive behavior begins in the residential setting, both before a patient presents to the emergency service and after hospital discharge, where opportunities to educate, support, and empower families are easily identified. Hospital based social workers can support providers within the system in utilizing nonpharmacological interventions to disrupt or prevent aggression, and in expanding systematic assessment and documentation of delirium states in the medical record.