Improving the assessment of risk for imminent aggression in older adults in residential facilities

Aggressive behavior by older adults living in residential facilities occurs commonly, and negatively impacts caregivers, other residents, and sometimes visitors. A precondition of aggression prevention efforts is accurate identification of high-risk individuals and interactions. To this end, elucidation of early warning signs and specification of proximal causes, processes and high-risk interactions is critical. Structured risk assessment instruments have been shown to improve prediction of imminent aggression in inpatient mental health care settings, and these instruments have been applied to various other populations and settings; however, there is little evidence regarding their validity in older adult populations. This paper reviews literature that has sought to identify the proximal causes and processes associated with aggressive behavior in older adults; this includes premorbid personality, cognitive impairment, language impairment, social functioning, mental health, functional dependency, sensory impairments, and pain. Given that the proximate causes and processes leading to aggression in older adults seem to differ in subtle ways from acute mental health inpatients, further examination (and possible modification) of existing risk assessment instruments for use in older adults is warranted. This paper identifies six factors that may improve utility and predictive validity when applying extant risk assessment instruments with older adults in residential facilities: confusion/disorientation, resistiveness to care, social disengagement, fear, symptoms of depression, and uncontrolled pain or discomfort.