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.
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