At lunchtime in a nursing home in New York state, a small crowd gathered at the entrance to the dining room, waiting for the doors to open. As researchers observed, one tired and irritated woman asked the man in front of her to move seats, but he didn't seem to listen.
“Let's go!” she yelled, pushing the walker towards him.
In Salisbury, Maryland, a woman in an assisted living facility woke up in the dark to find another resident in her bedroom, and her daughter, Rebecca Addie Twaites, suspected that her 87-year-old mother, who suffers from dementia and can be confused, was hallucinating the events.
But the man, who lives across the hall, returned about a half-dozen times, sometimes while Addie Twaits was visiting. Although the man never threatened or harmed her mother, “she has a right to privacy,” Addie Twaits said. She reported the incidents to administrators.
In long-term care facilities, residents may yell, threaten, or call each other names, invade other residents' personal or living spaces, or rummage through and take other people's belongings. They may also hit, kick, or push.
Or it's even worse: University of Connecticut gerontologist Eilon Caspi looked at news reports and coroner's reports and found that over a 30-year period, 105 long-term care facility residents died in incidents involving other residents.
He said the actual number is much higher because such deaths do not always receive media attention and are not detailed to authorities.
“There's a striking contradiction: The institutions, nursing homes and senior housing that are supposed to care for the most vulnerable people in society are some of the most violent institutions in society,” said Karl Pillmer, a Cornell University gerontologist who has long studied resident-resident conflicts.
Outside of psychiatric hospitals and juvenile residential facilities, “nowhere else is this happening where one in five residents are involved in some kind of violent incident each month,” he said.
The figure – 20.2 percent of residents had been involved in at least one confirmed incident of resident-on-resident abuse within a one-month period – came from a landmark study he and several co-authors published in 2016 that looked at more than 2,000 residents in 10 urban and suburban nursing homes in New York state.
“This is something that happens everywhere,” Dr. Pilmar says. “It doesn't matter the quality of the home, you'll see similar rates.”
In May, the same team published a follow-up study on resident-to-resident aggression in assisted living facilities. Because most assisted living residents are in better health and have less cognitive impairment than nursing home residents, and most live in large, single-room apartments, the researchers expected aggression to be lower.
Based on data from 930 residents in 14 large facilities in New York state, the numbers were certainly low, but not by much: About 15 percent of nursing home residents had engaged in an act of resident-on-resident violence within the past month.
The study found that the majority of resident-on-resident aggression was classified as verbal, with around 9% of nursing home residents and 11% of assisted living residents experiencing angry arguments, insults, threats or accusations.
Between 4% and 5% experienced physical violence, including hitting, grabbing, pushing, throwing objects, etc. A small number of incidents were classified as unwanted sexual comments or actions, and the “other” category included trespassing in rooms or apartments, theft or damage to property, and threatening gestures.
Some residents have experienced multiple types of violence, which “would be considered abuse if it happened in your own home,” Dr Pilmer said.
Dr Pillmer said those most likely to be involved were young, ambulatory people “who are likely to move around and get into dangerous situations”. Most of them had at least moderate cognitive impairment. The study also found that incidents occurred more frequently in specialist dementia wards.
“Memory care has its upsides, but it also increases the risk of residents becoming aggressive,” Dr. Pilmar said. “You have a lot of people with brain diseases and low inhibitions, and you're putting them in close quarters.”
Because so many perpetrators and victims have dementia, “sometimes you don't know what started it,” said Leanne Rorick, director of a program that trains staff in intervention and de-escalation. “The perpetrator isn't necessarily a malicious person.”
Residents may become confused about which room is theirs or become abusive when told to be quiet in the TV room. In one case, Ms. Rorick observed, a resident believed someone had taken her baby and resisted staff's attempts to quiet her down, but calmed down when she was reunited with a beloved doll.
“These are people with severe brain disorders who are struggling to maximize their remaining cognitive abilities in situations of stress, fear and overcrowding,” Dr. Caspi said. Residents may also be dealing with pain, depression and reactions to medication.
Yet in a facility housing frail residents in their 80s, even a gentle push can lead to falls, fractures, lacerations and emergency room visits, leaving residents feeling insecure, unsafe and suffering psychologically in the facilities that are now their homes.
“What would you do if you were half asleep and you saw someone crawling around on your bed? Whether they had dementia or not, they might start kicking their legs.”
Many of the reforms advocates have long called for to improve long-term care could help reduce such incidents. “In many cases, these incidents could be prevented with proper assessment, proper oversight, and adequate staff who are properly trained and knowledgeable to redirect and mitigate these issues,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care.
Facilities are generally understaffed, an issue exacerbated by the coronavirus pandemic, and staff are unlikely to witness violent acts: A Cornell University study found that in both nursing homes and senior housing, resident-on-resident abuse is more common in those with higher caregiver caseloads.
With enough staffing, staff can keep a close eye on residents, and facilities can be reorganized to avoid long hospital-like hallways that make monitoring difficult. Private rooms might reduce conflicts between residents. Strategies like opening dining rooms a few minutes earlier might help prevent jostling and overcrowding.
(The new Medicare mandate would require most nursing homes to increase staffing unless overturned by a provider lawsuit, but it would not affect state-regulated nursing homes.)
Meanwhile, “the first line of defense needs to be training on this specific issue,” Dr. Pillmer said. The “Improving Resident Relations in Long-Term Care” program developed by Cornell University offers online and in-person training programs for staff and managers, and has been shown to improve the knowledge and ability of nursing home staff to better recognize and report aggressive incidents.
Another study found a reduction in falls and injuries after training, but the results did not reach statistical significance due to a small sample size.
“We help people understand why this happens, the specific risk factors,” said Rorick, who directs the training program used in about 50 facilities nationwide. “They say it helps them take pause and address it. If ignored, it can get worse very quickly.”