How to Approach Aggressive Behavior
Some people with frontotemporal degeneration (FTD) may never experience a period of anger or aggressive behavior. Enough do however, that these symptoms can influence consideration for facility admission and may complicate care. A few people with FTD will become violent. It is essential that family and professional caregivers partner to find the right combination of environment, behavioral interventions and medications to ensure safety and maximize compassionate care.
Aggression in behavioral variant FTD
John Brown is a 56-year-old principal owner of a large farming operation in the Midwest. He lived with Mary, his wife of 36 years, on the main farm and two of his children also farm property owned by the family. He is a robust, easy-going, friendly man. Two years ago things started to change. John began buying properties in a luxury resort area and became sexually suggestive to women. He had an on-going affair with a woman and gave her thousands of dollars. Mary and her eldest son tried to complete taxes on the farms and found unexplained losses in excess of a million dollars. John was not able to provide an explanation so they pursued a diagnosis and learned he had behavioral variant FTD.
The family was charged with stopping him from driving, traveling alone, spending, continuing the relationship with the mistress, as well as monitoring his hypersexuality. John had no insight into his condition. He became incensed about having his wife limit his activities and responded with rage. At first it was verbal but quickly escalated to threatening Mary physically. The children filed an affidavit with the county magistrate to have John admitted to a psychiatry unit because he was a danger to himself and others.
In the hospital, John was confused and did not understand what had happened. He made sexual advances to women patients and staff. He became aggressive with staff and another male resident. He was placed on quetiapine to calm his aggression and citalopram to suppress his libido. Between the medications and highly structured and low-stimulus environment, John did well and was ready for discharge in three weeks. Mary wanted to take John home because she felt he was much better, despite his anger towards her when she visited. Mary was strongly advised by all providers to place him in a facility.
Mary toured multiple facilities searching for one that would accept John and understand FTD. The assisted living facility (ALF) that she selected conducted a thorough preadmission assessment that included the family, psychiatric staff and John. They assessed emotional and behavioral symptoms common to FTD and noted helpful interventions.
Once admitted, the staff met with Mary and their family on a regular basis, consulted with psychiatry about monitoring medications and developed a specific plan of care to address John’s behaviors, interventions and interests. Due to John’s stabilized behaviors, Mary decided to bring him home for a long weekend over Thanksgiving. The stay went badly with behavior escalating and culminated when Mary found John calling his mistress in California. He returned to the ALF where he did well in the low-stress, structured environment.
- What prompted John’s family to seek facility placement?
- What type of pre-admission assessment was conducted by the ALF?
- What interventions did staff use related to John’s aggressive and sexual behaviors?
1. What prompted John’s family to seek facility placement?
- John’s impaired judgment and disinhibited behavior (excessive spending, hypersexual behavior) created serious risk and were impossible for family to contain in the home and community.
- Mary’s efforts to limit John’s behaviors triggered verbal and physical aggression toward her causing him to become a danger to himself and others.
- Safety necessitated an in-patient hospital stay. John responded positively to the structured environment, and the provider advised placement.
2. What type of pre-admission assessment was conducted by the ALF?
- An in-person assessment that included John, Mary and other family members, and the psychiatric staff
- Assessment of current emotional and behavioral symptoms:
- Change in personality
- Hyperoral behaviors
- Overwhelms easily
- Emotional blunting
- Hyperactive behaviors
- Impulsive acts
- Inability to control/adjust behaviors
- Repetitive behaviors
- Hypersexual behaviors
- Verbal agitation
- Physical agitation
- Physical aggression
- Noted recent interventions (behavioral, environmental, medications) that curbed history of aggressive behavior as reported in in-patient admission.
3. What interventions did staff use related to John’s aggressive and sexual behaviors?
- Family and social worker oriented the ALF to John’s diagnosis, behaviors and care needs. The social worker helped to orient facility staff to John’s special needs and avoidance of excessive stimulus.
- Family reminded staff of John’s impairment in judgment despite robust, healthy appearance.
- People with FTD are often sensitive to CNS medications and experience side effects. A good rule in FTD is to avoid benzodiazepines due to the propensity for decreasing inhibitions and paradoxical reactions.
- Special communication techniques included:
- approach in a calm, non-confrontational manner
- do not use logic or argue
- limit specific choices
- redirect with discussion concerning farming
- limit environmental noise and stimulation
- stop task and re-approach if John becomes frustrated
- provide a structured schedule based on John’s routine and interests, e.g., early riser, shower in the evening and country music played before retiring
- The staff was in-serviced on John’s possible sexual advances towards them and other residents, and how to manage/avoid them without triggering aggression. Interventions included:
- track behaviors for symptoms, triggers and effective approaches
- remain calm (do not overreact)
- redirect to an activity of interest, (e.g., music and gardening)
- do not ask questions about the behavior
- avoid statements that may be misinterpreted by John (e.g., “It’s time to go to bed.”). Note name and phone number of mistress to be aware of possible contact.
Troubles & Tips
Accessing Psychiatric Services
Q: What can be done to minimize the need for or decrease the stress in receiving psychiatric in-patient care?
A. The most challenging behavioral issues in FTD may require psychiatric in-patient care but it can be difficult to access. Appropriate psychiatric beds may not be available and preapproval of psychiatric in-patient care for a neurological condition is not guaranteed. Facility staff can take steps to minimize the need for in-patient care and improve the quality of care of FTD residents.
Recommendations include the following:
- Upon move-in, review the resident’s insurance and benefits for behavioral health coverage, such as out-patient and in-patient psychiatric services. This will inform options for care.
- Obtain the services of a psychiatrist with experience and interest in FTD to collaborate on an out-patient basis to help avoid hospitalization. Encourage a psychiatrist without FTD experience to recognize the unmet need.
- Expertise and diligence is needed to monitor and re-evaluate the medications used to address behavioral symptoms in FTD. Maintain a detailed list of all medications that the resident takes over time as a key component of any care transition program and to reduce hospital readmission.
- Understand the involuntary commitment laws, become familiar with resources such as Crisis Intervention and familiarize those resources with FTD. This will ease the process if involuntary commitment becomes necessary.
- On-going communication between the family, facility staff, psychiatry and other professional staff is essential. The keys are open communication and an agreed-upon plan of care concerning behaviors, challenges, changes and interventions.