Abstract
Background
Aggression occurs frequently within health and social care settings. It can result in injury to patients and staff and can adversely affect staff performance and well‐being. De‐escalation is a widely used and recommended intervention for managing aggression, but the efficacy of the intervention as a whole and the specific techniques that comprise it are unclear.
Objectives
To assess the effects of de‐escalation techniques for managing non‐psychosis‐inducedaggression in adults in care settings, in both staff and service users.
Search methods
We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and 14 other databases inSeptember 2017, plus three trials registers in October 2017. We also checked references, and contacted study authors and authorities in the field to identify additional published and unpublished studies.
Selection criteria
We included randomised controlled trials (RCTs) and quasi‐RCTs comparing de‐escalationtechniques with standard practice or alternative techniques for managing aggressive behaviour in adult care settings. We excluded studies in which participants had psychosis.
Data collection and analysis
We used the standard methodological procedures expected by Cochrane.
Main results
This review includes just one cluster‐randomised study of 306 older people with dementia and an average age of 86 years, conducted across 16 nursing homes in France. The study did not measure any of our primary or secondary outcomes but did measure behavioural change using three measurement scales: the Cohen‐Mansfield Agitation Inventory (CMAI; 29‐item scale), the Neuropsychiatric Inventory (NPI; 12‐item scale), and the Observation Scale (OS; 25‐item scale). For the CMAI, the study reports a Global score (29 items rated on a seven‐point scale (1 = never occurs to 7 = occurs several times an hour) and summed to give a total score ranging from 29 to 203) and mean scores (evaluable items (rated on the same 7‐point scale) divided by the theoretical total number of items) for the following four domains: PhysicallyNon‐Aggressive Behaviour, such as pacing (13 items); Verbally Non‐Aggressive Behaviour, such as repetition (four items); Physically Aggressive Behaviour, such as hitting (nine items); and Verbally Aggressive Behaviour, such as swearing (three items). Four of the five CMAI scales improved in the intervention group (Global: change mean difference (MD) −5.69 points, 95% confidence interval (CI) −9.59 to −1.79; Physically Non‐Aggressive: change MD −0.32 points, 95% CI −0.49 to −0.15; Verbally Non‐Aggressive: change MD −0.44 points, 95% CI −0.69 to −0.19; and Verbally Aggressive: change MD −0.16 points, 95% CI −0.31 to −0.01). There was no difference in change scores on the Physically Aggressive scale (MD −0.08 points, 95% CI −0.37 to 0.21). Using GRADE guidelines, we rated the quality of this evidence as very low due to high risk of bias and indirectness of the outcome measures. There were no differences in NPI or OS change scores between groups by the end of the study.
We also identified one ongoing study.
Authors’ conclusions
The limited evidence means that uncertainty remains around the effectiveness ofde‐escalation and the relative efficacy of different techniques. High‐quality research on the effectiveness of this intervention is therefore urgently needed.
Plain language summary
Using de‐escalation to prevent violence in aggressive people
Review questions
Do de‐escalation techniques help to calm down adults who are being aggressive in care settings? Which techniques work best?
Background
There are many reasons why people may be aggressive in care settings, including mental or physical illness. People can use a range of techniques to help someone who is behaving aggressively to calm down, including talking to the person and interpreting non‐verbal gestures and body language. This approach is referred to as de‐escalation. Although it is widely taught and used, we know very little about how effective de‐escalation is, or whichtechniques work best.
Study characteristics
We looked for all available evidence on this topic, finding just two studies. One of these included 306 people with dementia and an average age of 86 years, living in 16 nursing homesin France. The second study is still in progress and did not provide results for the review.
Key results
The study did not assess areas important to us, such as the number of injuries sustained by staff or residents. It did, however, measure the impact of staff training on residents’ level ofaggression three months after the end of the training. Some measures of physical and verbalaggression showed reductions, but not all.
Quality of the evidence
The reliability of evidence available in the one included trial is very low and did not address important questions such as injury. Therefore, we cannot say whether de‐escalationtechniques are effective.
Currentness of evidence
The evidence is current to September 2017.
