At an assisted living facility in New York State, a small crowd had gathered at the entrance to the dining hall at noon, waiting for the doors to open. As one researcher observed, a woman, tired and frustrated, asked the man in front of her to move. he didn’t seem to be listening.
“Come on, lets go!” she yelled—and pushed her walker into him.
In Salisbury, Md., a woman woke up in the dark to find another resident in her bedroom at an assisted living complex. Her daughter, Rebecca Addy-Twaits, suspected that her 87-year-old mother, who had dementia and could become confused, was hallucinating about the encounter.
But the man, who lived down the hall, returned half a dozen times, sometimes during Mrs Addie-Twaites’ visits. He never threatened or harmed her mother but “she has a right to her privacy”, Ms Addie-Twaites said. He reported the incidents to administrators.
In long-term care facilities, residents sometimes yell at or threaten each other, hurl insults, invade colleagues’ personal or living space, search and take other people’s belongings. They can hit or kick or push.
Or worse. Eilon Caspi, a gerontologist at the University of Connecticut, scoured news coverage and coroner’s reports and found 105 deaths of long-term care residents over 30 years that resulted from incidents involving other residents.
The true number is higher, he said, because such deaths don’t always get media attention or are not reported in detail to authorities.
“We have this extraordinary paradox: the institutions, nursing homes and assisted living facilities that care for the most vulnerable members of our society are some of the most violent in our society,” said Karl Pillemer, a Cornell University gerontologist who has studied resident – resident conflict for years.
Outside of psychiatric hospitals and youth facilities, he said, “nowhere else do one in five residents engage in some kind of violent incident every month.”
That number — 20.2 percent of residents were involved in at least one verified incident of resident-to-resident abuse in a month — comes from a landmark study he and several co-authors published in 2016 that involved more than 2,000 residents in 10 cities and suburban nursing homes in New York State.
“It’s ubiquitous,” said Dr. Pillemer. “Regardless of the quality of the house, there are similar prices.”
In May, the same group published a follow-up study looking at resident-to-resident aggression in assisted living. The researchers expected to find a lower prevalence, since most assisted living residents are in better health with less cognitive impairment compared to those in nursing homes, and most live in private apartments with more space.
Based on data from 930 residents in 14 large New York State facilities, the numbers were indeed lower, but not by much: About 15 percent of assisted living residents were involved in resident-to-resident aggression within a month.
Studies classify most resident-to-resident aggression as verbal—about 9 percent of nursing home residents and 11 percent in assisted living experienced fights, insults, threats or accusations.
Between 4 percent and 5 percent experienced physical events: others hit, grabbed, pushed, threw objects. A small percentage of incidents were classified as unwanted sexual comments or behavior. The “other” category included unwanted entry into rooms and apartments, acquisition or destruction of property, and threatening gestures.
Some residents experienced more than one type of aggression. “It would be considered abuse if it happened in your home,” Dr. Pilmer said.
Those most likely to be involved are younger and ambulatory, “able to move and get hurt,” Dr. Pilmer said. Most had at least moderate cognitive impairment. The studies also found that incidents occurred more often in specialist dementia units.
“Memory care has positives, but it also puts residents at greater risk of aggression,” Dr. Pilmer said. “More people with brain disease, people who are not inhibited, are gathered in a smaller space.”
Because so many of the instigators and victims have dementia, “sometimes we can’t tell what started things,” said Leanne Rorick, director of a program that trains staff in intervention and de-escalation. “An instigator is not necessarily someone with malicious intent.”
A resident may get confused about which room is hers or throw a tantrum if someone asks her to be quiet in the TV room. In one instance Ms Rorick observed, a resident resisted staff’s attempts to calm her down when she believed someone had taken her baby – until she was reunited with the doll she loved and calm returned.
“These are people with severe brain disease who are doing the best they can with their remaining cognitive abilities in situations that are stressful, scary and crowded,” Dr. Caspi said. Residents may experience pain, depression or drug reactions.
However, in a population of frail people in their 80s, even a slight push can cause injuries: falls, fractures, lacerations and emergency room visits. Residents also suffer psychologically from feeling stressed or insecure in what is now their home.
“Are you half asleep and someone is hovering over your bed?” said Mrs. Rorick. “With or without dementia, you can start kicking.”
Some of the changes advocates have long sought to improve long-term care could help reduce such incidents. “In many cases, they are preventable with proper assessments, proper monitoring, enough staff who are properly trained and have the knowledge to redirect and diffuse these issues,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long- Term. Care.
Facilities are generally understaffed, a problem exacerbated by the Covid-19 pandemic, so staff members rarely witness aggression. In both nursing homes and assisted living, the Cornell studies showed that resident-to-resident abuse occurred more often when aides’ caseloads were higher.
Adequate staffing would allow workers to keep a watchful eye on residents. So would remodeling the facilities to avoid long hospital-like corridors that make monitoring difficult. Private rooms could reduce roommate arguments. Taking measures such as opening the dining rooms a few minutes earlier can help avoid disturbances and overcrowding.
(The new Medicare mandates will require staffing increases at most nursing facilities if a provider lawsuit doesn’t overturn them, but won’t affect assisted living, which is regulated by states.)
Meanwhile, “the first line of defense has to be education on this particular issue,” Dr. Pilmer said. The Cornell-developed program “Improving Resident Relations in Long-Term Care,” which provides online and in-person training programs for staff members and administrators, has demonstrated that nursing home workers are more informed after training, are better able to recognize and report aggressive incidents.
Another study found that falls and injuries were reduced after training, although due to the small sample size, the results did not reach statistical significance.
“We’re helping people understand why this is happening, the specific risk factors,” said Ms. Rorick, who directs the training program, which has been used in about 50 facilities across the country. “They tell us that education helps them stop and do something about it. Things can escalate quickly when ignored.”
