Early Detection of Aggressiveness in A Long Term Care Unit
Philippe H. Robert, MD
Old Age Psychiatry, Memory Center
Nice, France

Investigators have developed an instrument for identifying preclinical or mild intensity aggressiveness and agitation. The OCEAAN Warning Score (OWS) is reliable and easy to administer in a long-term care setting, a study shows. The instrument may be a useful tool for nurses and other clinicians who work with individuals in nursing homes and other long-term care facilities.

Agitation and aggressiveness can be disturbing for long-term care residents, caregivers and clinicians alike. These neuropsychiatric symptoms frequently occur among individuals with dementia living in long-term care facilities. This is apparent in data from a recent study by the OCEAAN (Observatoire des Conduites diagnostiques et therapeutiques des Etats d’Agitation et d’Agressivite) project. Of 900 randomly selected nursing or retirement home residents in France, 766 had symptoms of agitation and aggressiveness. Of those cases, 61% had a triggering factor initiating symptoms, and 55% received medication for these symptoms.

Investigators undertook the OCEAAN IV study to develop an instrument to help nurses and other clinicians predict agitation and aggressiveness and agitation in elderly individuals under long-term care. This OCEAAN Warning Score (OWS) includes 5 items, each of which is rated on a 5-point scale as follows:


OCEAAN Warning Score (OWS): 5 Items
(Logistic regression from the OCEAAN III questionnaire: Schadler, 1997)



Being oppositional, refusing any activity
Diurnal hyperactivity
Verbal aggressiveness
Shouting during the day
Sexually inappropriate behavior
0 --------------------------20
0 = Absent  1 = Occasionally  
2 = Sometimes
3 = Frequent  4 = Always



In a study, investigators used the OWS scale to evaluate 166 elderly subjects (mean age 85). The aim of the study was to see if the OWS could predict later aggressiveness or agitation. Each subject received the OWS evaluation during the first week of inclusion in the long-term care unit. Twenty-eight days later, a psychiatrist determined whether or not that subject had clinically significant behavioral disturbances.

The mean OWS score at time of inclusion was 3.7 out of 20 possible points. Over the following 28 days, 32% of the elderly subjects exhibited significant behavioral disturbances.

Analysis of the entire patient population showed a correlation between increasing OWS score and increasing risk: investigators reported behavioral disturbances in only 18.1% of residents with an OWS below 3, compared with 38.5% of residents with an OWS between 3 and 7. Of the residents with an OWS over 7, 61.9% exhibited behavioral disturbances.

The sensitivity, specificity and positive/negative predictive values of specific OWS scores are as follows:


OWS Parameters


Score
7
3
Sensitivity
.28
.66
Specificity
.91
.65
Positive predictive value
.61
.46
Negative predictive value
.73
.80




In a concurrent validity study, investigators found significant inter-rater reliability (R = 0.7, p < 0.0001) and high test-retest reliability (R = 0.96, p < 0.001). Concurrent validity with the Cohen-Mansfield Agitation Inventory (CMAI) was also favorable (R = 0.08, p < 0.001).

Based on these findings, Dr. Robert and colleagues believe that residents who have an OWS score below 3 are at only moderate risk for later behavioral disturbances. Scores between 3 and 7 should alert nurses and other clinicians to a high potential for problems. Scores over 7 suggest a major risk for behavioral disturbances. In this case, clinicians might begin to consider the pharmacologic or non-pharmacologic interventions that could be appropriate.

Dr. Robert said the scale is very easy to administer. One evaluation may take approximately 5 minutes. This is in contrast to the CMAI, which is longer and more specific for research or specialist evaluation. The OWS could represent a new way for nurses and other clinicians to assess agitation and aggressiveness risk rapidly and objectively.


 

Reporter: Andrew Bowser