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Ask the Mental Health Expert Archives 2001-2004

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Elderly with a Child's Mentality

Q. I currently work in residential home for men and women with learning disabilities. We have a client who is 67 but he has the mental age of a three year old. He has began targeting one member of staff and becoming very aggressive towards her. He has no concept of time and or memory and can't understand why he is being asked go to his bedroom to calm down etc.

We are really pulling our hair out over this one as we cannot understand why he targets just her, as she treats him as all of our staff does. Is there anything we can do? Please help!

A. This does sound like a disturbing situation. I think the first question to look at is whether this aggressive behavior represents a change in this resident's usual habits. If so, I would definitely do a very thorough medical and neurological evaluation, to see if some recent organic cause (e.g., recent sub-clinical stroke, endocrine abnormality, onset of dementia, etc.) might underlie this misbehavior. I doubt very much that you will find out why this resident is targeting the particular staff member--it could be that her physical appearance is triggering some very old memory, and that the resident is confusing her with someone in his past.

Or perhaps there has been some covert behavior on the part of this staff person that has been upsetting to the patient. (I don't mean to cast aspersions, but such things are seen in residential settings, as I'm sure you know). If you have access to a good neurobehavioral consultant (e.g., a behavioral neurologist, or neuropsychologist), I would start there.

He or she might be able to suggest some behavioral modification strategies that would reduce this resident's aggressive behaviors. In the mean time, if the resident tends to be predictably violent only around this staff member, I would certainly do everything possible to separate them until the problem is resolved. Some anti-aggression medications would certainly be worth considering. This might include one or more of the following: selective serotonin reuptake-inhibiting antidepressants [SSRIs], such as sertraline or fluoxetine; buspirone, lithium, anticonvulsants (such as gabapentin or valproate); propranolol, nadolol, and clonidine.

The atypical antipsychotic, risperidone, might also be useful in low doses. If there is a sexually aggressive component to this resident's behavior, a trial on medroxyprogesterone [Depo-Provera] might also be worth considering. A geriatric psychiatrist or neuropsychiatrist would probably be the best consultant on these medication issues. I hope things improve soon for you and your staff.

February, 2001

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