In certain older adult subpopulations, e.g. those with dementia or cognitive impairment, aggression would appear to be commonplace, particularly in inpatient settings (Winstanley and Whittington, Reference Winstanley and Whittington2004; Stewart et al., Reference Stewart, Knight and Johnson2008). Healthcare professionals have a spectrum of different techniques they may employ to avoid and manage aggression (National Institute of Clinical Excellence, 2005). Aggression may manifest itself in many forms, but physical assault is particularly troublesome as this may have many deleterious effects on the victim's health. The displays of such behavior increase the likelihood that more intrusive measures, such as physical intervention and/or administration of psychotropic medication, are used by the responding healthcare professionals (NICE, 2005).

One method of dealing with physical assault is physical intervention, or physical restraint. Physical intervention involves a team of trained staff, usually two or more, applying physical techniques to restrict or move the aggressive patient so that safety is restored in the clinical setting (NICE, 2005). It is imperative that healthcare staff use physical intervention as an absolute last resort, when all other less intrusive interventions – for example, de-escalation – have failed (NICE, 2005). Clearly there is a risk that the application of physical intervention may cause pain or injury to the assailant, something which needs to be avoided if at all possible (NICE, 2005). It would appear that the majority of physical intervention training courses teach generic techniques, which largely consider the needs of adults who have no presenting physical ailments. Despite this, injury rates among working age adults from the application of physical intervention have been reported to be as high as almost one in every five incidents of physical intervention. Thus, the application of physical intervention in older adults may cause injury to a considerable number of recipients when one considers the often more complex physical presentation of this population (Stubbs et al., Reference Stubbs, Yorston and Knight2008). For this reason, we believe that physical intervention techniques should be adapted appropriately to consider the complex needs of this population. Physiotherapists may provide screening assessments to identify any pre-existing physical ailments and work in conjunction with a specialist physical intervention tutor to advise the clinical team on appropriate adaptive techniques to reduce the risk of the application of the techniques causing pain and/ or injury (Stubbs et al., Reference Stubbs, Yorston and Knight2008). Stubbs and colleagues (Reference Stubbs, Yorston and Knight2008) reported that this approach resulted in considerably lower levels of injury to patients (2%), which is considerably lower than injury rates reported in working age adults.

We believe that physiotherapists have an integral role in helping to reduce the risk of injury to aggressive older adults from the application of physical intervention. In a recent national survey, Stubbs (Reference Stubbs2010) revealed that a quarter of physiotherapists working in mental health had concerns that the application of physical intervention would have a deleterious effect on the recipient's health. In this national survey, (response rate 65%), the mental health physiotherapists were asked to make recommendations for safer application of physical intervention in the psychiatric population within which they were working. Some of the physiotherapists (n = 15) working in older adult psychiatry made recommendations about the safe application of physical intervention in this patient group. Eight of them stated that wrist flexion to induce pain compliance should not be used, but that passive holds at the wrist and above the wrist joint should be implemented instead. We concur that this should be adopted, since the risk of causing a colles fracture, for instance, is elevated in this population.

Seven physiotherapists expressed concerns about the application of neck flexion and advised that this should be avoided wherever practicable; something which we believe is a better solution. Ten physiotherapists expressed concerns about the risk of shoulder subluxation from the application of the techniques. Indeed, three physiotherapists reported that they were actively treating an older adult following an injury of this nature. Clearly, with the changes in muscle tone and sensation, the shoulder is vulnerable to injuries of this nature. Previous research in this population (Stubbs et al., Reference Stubbs, Yorston and Knight2008) has demonstrated that the upper limb is injured most frequently following the application of physical intervention. This has also been demonstrated in adults with acquired brain injury who may also experience similar changes in muscle tone and sensation. For this reason, we recommend that end of range movements should not be used and that internal and external rotation should be avoided wherever possible, since such movements are known to increase the likelihood of causing an individual pain and/or subluxation.

Finally, eleven physiotherapists strongly recommended that “going to the floor” should be avoided at all costs. We agree with this, since previous research by the first author has demonstrated that older adult psychiatric inpatients have a high incidence of osteoporosis and osteopenia. The “takedown” to the floor may result in fracture, with the hip being particularly vulnerable. Fractures to the hip are associated with much morbidity and mortality and indeed many die following such trauma. For this reason, we agree that going to the floor should be avoided at all costs.

In summary, older adult psychiatric inpatients may display severe aggressive behavior and physical intervention should be used as a last resort to manage this behavior (Stewart et al., Reference Stewart, Knight and Johnson2008). The application of physical intervention is complex in this population and in this letter we make some provisional recommendations to reduce the risk of causing pain and/ or injury to the aggressive older adult.