Early Detection of Agressiveness in A Long Term Care Unit

Philippe H. Robert, Old Age Psychiatry, Memory Center, Nice, France, Robert Moulias, Hopital Charles Foix, Ivry-sur-Seine, France, Jean-Marie Leger, Universite de Limoges, Limoges, France, Bruno Vellas, Hopitaux de Toulouse Alzheimer's Center, Toulouse, France, Jean Pierre Clement, Psychogeriatry, University of Limoges, Limoges Cedex, France, Claude Jeandel, Internal Medicine & Geriatric Service, CHU Hopital La Colombiere, Montpellier, France, and Paul-Henri Chapuy, Hopital des Charpennes, Lyon, France.

Neuropsychiatric symptoms occur in the majority of persons with dementia over the course of the disease. Among these symptoms agitation and aggressiveness are frequent and disturbing in patients living in long term care unit (LTCU). The aim of the OCEAAN IV (Observatoire des Conduites diagnostiques et therapeutiques des Etats d’Agitation et d’Agressivite) study was to develop an instrument, the OCEAAN Warning Score (OWS) for helping nurses and clinician to predict agitation and aggressiveness in residents. The OWS include 5 items : Being oppositional, refusing any activity / diurnal hyperactivity / verbal aggressiveness / shooting during the day / sexually provocative behavior. Each item is rated on a five points scale (0 being absent and 4 being severe). 166 elderly subjects (mean age 85 ; SD ~ 6,2) were evaluated with the OWS during the first week of their inclusion in the LTCU. 28 days after this initial evaluation each patient was evaluated by a psychiatrist and classified into one of two subgroups; with clinically significant behavioral disturbances (B +) or without clinically significant behavioral disturbances (B-).

Results: At the time of the inclusion the mean OWS score was 3.7 ± 3.6 for the overall population. After 28 days, 32% of the patients had presented significant behavioral disturbances (B+). More specifically behavioral disturbances were observed in 18.1 % (n =13 ) of patients with an OWS lower than 3, in 38.5 % (n =20 ) of patients with an OWS between 3 and 7, and in 61.9 % (n =13) of patients with an OWS higher than 7 (Chi 2 : p<0,0001, Armitage : p<0,001). For a score level of 3, the OWS had the following characteristics; sensitivity 0.66, specificity 0.65, positive predictive value 0.46, negative predictive value 0.73. For a score level of 7, the OWS had the following characteristics; sensitivity 0.28, specificity 0.91, positive predictive value 0.62, negative predictive value 0.73. Logistic regression analysis including all the clinical parameters confirm the interest of the score predictive value for the occurrence of agitation (odd ratio 5.2 [ 1.56 ; 17] for values between 3 to 7 and odd ratio e10.5 [ 2.26 et 48.6] for value higher than 7. Inter and intra individual reproducibility analysis were statistically significant (p<0,001) with kappa coefficient respectively of 0.5 [0.27 ? 0.76] and 0,88 [0.72-1.04].

Conclusion: The OCEAAN Warning Score (OWS) is a reliable tool for assessing aggressiveness and agitation at a preclinical or mild intensity stage therefore represents an additional tools for nurses and clinicians.