Personal conflicts, even violence, are not uncommon in long-term care

At an assisted living facility in New York State, a small crowd gathered at the entrance to the dining room at lunchtime, waiting for the doors to open. As one researcher observed, a woman, tired and frustrated, asked the man in front of her to move; she didn't seem to have heard.

“Come on let's go!” she screamed—and she pushed the walker at him.

In Salisbury, Maryland, 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 her 87-year-old mother, who suffered from dementia and could become confused, was hallucinating the encounter.

But the man, who lived down the hall, returned half a dozen times, sometimes during Mrs. Addy-Twaits' visits. He never threatened or harmed her mother, but “she has a right to her privacy,” Ms. Addy-Twaits said. He reported the incidents to the administrators.

In long-term care facilities, residents sometimes yell or threaten each other, hurl insults, invade other residents' personal or living space, go through other residents' belongings and take them. They may slap, kick or push.

Or worse. Eilon Caspi, a gerontologist at the University of Connecticut, analyzed news coverage and coroner reports and identified 105 long-term care resident deaths over 30 years resulting from incidents involving other residents.

The real number is higher, he said, because such deaths do not always receive 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 among the most violent in our society,” said Karl Pillemer, a gerontologist at Cornell University who studied the residents-a. -residence conflict for years.

Aside from psychiatric hospitals and youth residential facilities, he said, “it's nowhere else that one in five residents is involved in some type of aggressive incident every month.”

That number – 20.2% of residents were involved in at least one verified incident of resident-to-resident mistreatment within a month – comes from a landmark study published by him and several co-authors in 2016, which involved more of 2,000 residents in 10 urban and urban areas. suburban nursing homes in New York State.

“It's ubiquitous,” Dr. Pillemer said. “No matter the quality of the home, there are similar rates.”

In May, the same team published a follow-up study on resident-on-resident aggression in assisted living facilities. The researchers expected to find a lower prevalence, as most assisted living residents are in better health with less cognitive impairment than 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-on-resident assaults within a month .

Studies classify most resident-to-resident assaults as verbal: About 9 percent of residents in nursing homes and 11 percent in assisted living facilities have experienced angry arguments, insults, threats or accusations.

Between 4% and 5% suffered physical events: others hit, grabbed, pushed, threw objects. A small percentage of events were classified as unwanted sexual comments or behaviors; the “other” category includes unwanted entry into rooms and apartments, the theft or damage of property and the carrying out of threatening gestures.

Some residents experienced more than one type of assault. “It would be considered abuse if it happened in your home,” Dr. Pillemer said.

Those most likely to be involved are younger and able to walk, “able to move and put themselves in harm's way,” Dr. Pillemer said. Most had at least moderate cognitive impairment. The studies also found that incidents occurred more often in specialized dementia units.

“Memory care has positive elements, but it also puts residents at greater risk of assault,” Dr. Pillemer said. “More people with brain diseases, uninhibited people, gather in a smaller space.”

Because so many, both perpetrators and victims, suffer from dementia, “sometimes we can't say what started things,” said Leanne Rorick, director of a program that trains staff on intervention and reduction of dementia. voltage. “An initiator is not necessarily someone with malicious intent.”

A resident may be confused about which room is hers, or angry if someone asks her to be quiet in the TV room. In one case observed by Ms. Rorick, a resident rebuffed staff attempts to calm her when she believed someone had taken her baby, until she was reunited with the doll she loved and her calm returned.

“These are people with severe brain disease, doing the best with their remaining cognitive abilities in stressful, scary, overcrowded situations,” Dr. Caspi said. Residents may face pain, depression, or reactions to medications.

Yet, in a population of fragile people over eighty, even a slight push can cause injuries: falls, fractures, lacerations and visits to the emergency room. Residents also suffer psychologically because they feel anxious or unsafe in what is now their home.

“Are you half asleep and someone is hovering over your bed?” Ms. Rorick said. “With or without dementia, you might start kicking.”

Some of the changes that advocates have long sought to improve long-term care could help reduce such incidents. “In many situations, they can be prevented with proper assessments, proper monitoring, and sufficient staff who are properly trained and equipped with the knowledge to redirect and diffuse these problems,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term. She cares.

Facilities are generally understaffed, a problem exacerbated by the Covid-19 pandemic, so staff members rarely witness assaults. In both nursing homes and assisted living facilities, Cornell studies showed, resident-to-resident mistreatment occurred more often when caregivers' workload was higher.

Sufficient staffing would allow workers to keep a watchful eye on residents; the same goes for reconfiguring facilities to avoid long hospital-like corridors that make monitoring difficult. Private rooms could reduce disputes between roommates. Taking measures such as opening dining rooms a few minutes early could help prevent jostling and congestion.

(The new Medicare mandates will require staffing increases at most nursing facilities, if a lawsuit by providers doesn't overturn them, but it won't affect assisted living, which is regulated by states.)

In the meantime, “the first line of defense needs to be education on this specific issue,” Dr. Pillemer said. The Cornell-developed “Improving Resident Relationships in Long-Term Care” program, which provides online and in-person training programs for staff members and administrators, has shown that nursing home workers are more knowledgeable after training, more capable of recognizing and reporting aggressive behavior. accidents.

Another study found that falls and injuries decreased after training, although, due to the small sample size, the results did not reach statistical significance.

“We help people understand why this happens, the specific risk factors,” said Ms. Rorick, who directs the training program, which has been used in about 50 facilities nationwide. “They tell us the training helps them stop and do something about it. Things can escalate quickly when ignored.

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