Prevalence of challenging behaviour among older in-patients: a pilot study

Older people occupy two-thirds of in-patient beds in acute general hospitals. Pre-existing mental health disorders are independent predictors of poor outcomes such as increased mortality and length of stay, loss of independent function and higher rates of institutionalisation. ¹ Disruptive behaviour can have a negative effect on the nursing and other healthcare staff and can affect the quality of care provided to other patients on the ward. ² There are no published studies on the prevalence of behavioural problems in older in-patients in the UK.

We conducted a pilot study to determine the prevalence of challenging behaviour in older people on two care of the elderly wards in an acute general hospital. Patients aged 65 years and older were included. The Crichton Royal Behavioural Rating Scale (CRBRS) ³ was used to identify patients with challenging behaviour. The CRBRS is a descriptive scale designed to assess patients on psychogeriatric wards. The main scale items are mobility, orientation, communication, cooperation, restlessness, dressing, feeding, mood and continence. Each modality has a score of between 1 and 5, where 1 is normal and 5 is the most abnormal. The scores for cooperation, restlessness and sleep are those that provide information on the prevalence of challenging behaviour. Patients with a score of 2 or more for restlessness or sleep, or 4 or more for cooperation are considered to have a challenging behaviour.

The scale was completed separately for daytime and night-time by interviewing nursing staff completing the respective shifts. Medical notes were examined to identify any previous mental health problems and to determine whether the patients were on psychiatric medication. The study was approved by the trust's clinical governance department.

In total, 58 patients were studied (47 males). Mean age was 81 years (range 66–96). Challenging behaviour was identified in 16 patients (29%) according to the CRBRS criteria: 5 scored for restlessness only; 3 for restlessness, sleep disturbance and cooperation; 1 scored for sleep disturbance and cooperation, and 1 for sleep disturbance only. Of the 58 patients studied, 21 had a known psychiatric history before admission (14 dementia, 6 depression, 1 schizophrenia). Of the 16 patients with challenging behaviour, 8 had dementia and 1 had schizophrenia; 6 patients did not have a history of a psychiatric disorder. A history of dementia was significantly more common among patients with challenging behaviour (P = 0.008). Aggressive behaviour was seen in 48% of patients in this group and was not seen among patients not scored to have challenging behaviour. Wandering was seen in 25% of patients with challenging behaviour.

We conclude that a significant number of elderly patients admitted to our hospital had challenging behaviour. Dementia seemed to be associated with challenging behaviour, and aggressive behaviour was seen in a significantly large proportion of patients. A larger study is warranted.