At an assisted living facility in upstate New York, a small crowd had gathered at the entrance to the dining room at lunchtime, waiting for the doors to open. As one researcher observed, one woman, growing tired and frustrated, asked the man in front of her to move; he didn’t seem to listen.
“Come on let’s go!” she shouted and pushed her walker towards 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 that 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 a half-dozen times, sometimes during Addy-Twaits’ visits. He never threatened or hurt her mother, but “she has a right to her privacy,” Addy-Twaits said. She reported the incidents to administrators.
In long-term care facilities, residents sometimes yell or threaten each other, hurl insults at each other, invade other residents’ personal or living space, rummage through and take other residents’ possessions. They may hit, kick or push.
Or worse. Eilon Caspi, a gerontologist at the University of Connecticut, searched news coverage and forensic reports and identified 105 deaths of residents in long-term care facilities over 30 years that resulted 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 centers that care for the most vulnerable members of our society are some of the most violent in our society,” said Karl Pillemer, a gerontologist at Cornell University who has studied from resident to resident -Conflict for years.
Aside from psychiatric hospitals and youth residential facilities, he said, “it doesn’t happen anywhere else that one in five residents is involved in some type of aggressive incident every month.”
That figure — 20.2 percent of residents were involved in at least one verified incident of resident-to-resident mistreatment in a month — comes from a landmark study he and several co-authors published in 2016, which involved more than 2,000 residents in 10 urban and suburban nursing homes in New York State.
“It’s ubiquitous,” Dr. Pillemer said. “No matter the quality of the housing, there are similar rates.”
In May, the same team published a follow-up study looking at aggression among assisted living residents. The researchers expected to find a lower prevalence, since most assisted living residents are in better health and have less cognitive decline 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 certainly 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 assaults between residents as verbal: About 9 percent of residents in nursing homes and 11 percent in assisted living experienced angry arguments, insults, threats or accusations.
Between 4 and 5 percent encountered physical events: others hit, grabbed, pushed, threw objects. A small percentage of events were classified as unwanted sexual comments or behavior; the “other” category included unwanted entry into rooms and apartments, taking or damaging possessions, and making threatening gestures.
Some residents encountered more than one type of aggression. “It would be considered abuse if it happened in your own home,” Dr. Pillemer said.
Those most likely to be affected are the youngest and most ambulatory, “able to move around and put themselves in danger,” Dr. Pillemer said. Most had at least moderate cognitive impairment. The studies also found that incidents occurred more frequently in specialist dementia units.
“Memory care has positive elements, but it also places residents at greater risk for assault,” Dr. Pillemer said. “More people with brain diseases, people who are disinhibited, congregate in a smaller space.”
Because so many initiators and victims have dementia, “sometimes we can’t say what started it,” said Leanne Rorick, director of a program that trains staff in intervention and de-escalation. “An initiator is not necessarily someone with malicious intentions.”
A resident may be confused about which room is theirs or lash out if someone asks them to be quiet in the TV room. In one case Rorick observed, a resident fought against staff’s 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 serious brain diseases doing the best they can with their remaining cognitive abilities in stressful, frightening, crowded situations,” Dr. Caspi said. Residents may be dealing with pain, depression or reactions to medications.
Still, in a population of frail 80-year-olds, even a slight push can cause injuries: falls, fractures, lacerations, and visits to the emergency room. Residents also suffer psychologically, feeling anxious or unsafe in what is now their home.
“You’re half asleep and someone is hovering over your bed?” Mrs. Rorick said. “With or without dementia, you might start kicking.”
Several of the changes advocates have long sought to improve long-term care could help reduce such incidents. “In many situations, they can be prevented with proper screening, proper follow-up, and enough staff properly trained and knowledgeable to redirect and diffuse these problems,” said Lori Smetanka, executive director of National Consumer Voice for Quality Long-Term. Careful.
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 that mistreatment among residents occurred more frequently when attendee caseloads were higher.
Sufficient staffing would allow workers to monitor residents; So would reconfiguring the facilities to avoid long hospital-style hallways that make monitoring difficult. Private rooms could reduce disputes between roommates. Taking measures such as opening dining rooms a few minutes earlier could help prevent jostling and congestion.
(The new Medicare mandates will require staffing increases at most nursing facilities, if a lawsuit from providers doesn’t overturn them, but they won’t affect assisted living, which is regulated by states.)
In the meantime, “the first line of defense should be training on this specific topic,” Dr. Pillemer said. The Cornell-developed program “Improving Relationships with Residents in Long-Term Care,” which offers online and in-person training programs for staff members and administrators, has shown that nursing home workers are more knowledgeable after training and are more capable of recognizing and reporting aggressive situations. incidents.
Another study found that falls and injuries decreased after training, although due to low sample size, the results did not reach statistical significance.
“We help people understand why this happens, the specific risk factors,” said Rorick, who directs the training program, which has been used at about 50 facilities across the country. “They tell us that the training helps them stop and do something about it. “Things can get worse quickly when ignored.”