While the results haven’t been published yet, a new study out of Cornell University suggests that up to 20% of elderly nursing home residents experience verbal or physical abuse at the hands of other residents.
Resident-To-Resident Abuse Common In New York
Spending a full month in ten different New York nursing homes, doctors led by Karl Pillemer and Mark Lachs used accident reports, medical charts, staff and resident interviews and in-person observation to determine the prevalence of resident-to-resident mistreatment. In all, 2,011 residents were assessed. Nearly 1 out of every 5 residents were involved in an incident of resident-to-resident abuse over the course of only four weeks.
The researchers chose skilled nursing facilities that were comparable in quality of care, staffing levels and inspection history to the average home nationally.
What Does Mistreatment Look Like?
Known collectively as “resident-to-resident elder mistreatment,” these aggressive, unwarranted behaviors include:
- verbal abuse
- physical abuse
- inappropriate sexual behavior
- invasions of privacy
In essence, resident-to-resident elder mistreatment includes “any unwelcome behavior that had the potential to lead to physical or psychological distress in the person on the receiving end,” CBS News writes.
Breaking Down The Numbers
A full set of data from the paper hasn’t been released yet, but preliminary findings are available. Verbal abuse was most common, affecting 16% of the residents:
- verbal threats,
- bossing other residents around,
- racial or ethnic slurs
Invasions of privacy, like entering another resident’s room without permission or consent and rifling through another person’s possessions, impacted 10.5% of the residents who were mistreated. A handful of other inappropriate behaviors, including offering unwanted help and making threatening gestures, are also included in that 10.5%. Physical incidents, which the doctors characterized as instances of:
- hitting or striking,
- scratching or
occurred in 5.7% of cases, while sexual forms of abuse, from exposing one’s genitals to touch other residents inappropriately, affected 1.3% of the residents involved.
The study concluded that “nearly one in five nursing home residents were involved in at least one negative and aggressive encounter with one or more fellow residents over the previous four weeks,” according to a Cornell press release. The team’s full results will be presented November 8 at the Gerontological Society of America’s annual symposium.
An “Under-Recognized Problem”
Lachs says his study is the first of its kind. Prior to its publication, no other researchers had attempted to look at the problem of resident-to-resident abuse in a systematic way.
Previous studies have tended to focus on the abuse committed by nursing home staff members, but Lachs believes resident-to-resident mistreatment may be an even “more frequent threat to residents.” It is, however, chronically under-reported, the researcher says, both by residents and nursing homes. Staff members, for one thing, can actively avoid residents who exhibit aggressive behaviors or become the victims of abuse themselves. In the opposite direction, nurses can become desensitized to resident-to-resident mistreatment, just as they become desensitized to shouting and yelling.
Identifying resident-to-resident mistreatment can be difficult, however, even for well-trained nursing home staff members. Not every outburst is targeted, for example. Shouts can often be heard in the halls of assisted living facilities and nursing homes, and while profanities or abusive language aren’t uncommon, these eruptions of apparent aggression aren’t always directed toward other residents. Even when they are, and an outburst is clearly meant to target another person in the room, that other person may not respond to the insulting language.
Dementia & Aggression
Although Lachs and Pillemer didn’t differentiate between instigators and victims of resident-to-resident mistreatment, the study has insights on which elders are most likely to be involved in this type of abuse.
As one would expect, dementia and mood disorders, common among elderly patients, are implicated in the problem. Residents involved in resident-to-resident abuse were more likely to live in dementia-centered special care units. But it’s not severe cases of these conditions that are at the root of resident-to-resident mistreatment. In fact, the residents most likely to be involved are actually “less cognitively and physically impaired” than their co-residents. They’re also younger and tend to be white.
Even so, “people who typically engage in resident-on-resident abuse are somewhat cognitively disabled but physically capable of moving around the facility. Often, their underlying dementia or mood disorder can manifest as verbally or physically aggressive behavior. It’s no surprise that these individuals are more likely to partake in arguments and shouting matches, and pushing and shoving, particularly in such close, crowded quarters,” study co-author Karl Pillemer MD says.
While aggression can be a consequence of worsening dementia, most dementia patients don’t become physically or verbally abusive. In 2012, German researchers found that around 29% of dementia patients engage in either physically or non-physically aggressive behavior, much of which could be due to increasing depression. Opening the scope of our inquiry to behavioral disorders generally, we find a far higher prevalence. Studies suggest that between 30% and 90% of dementia patients experience some degree of psychological or behavioral change, from anxiety and agitation to psychosis and disinhibition.
Protecting Elders From Other Elders
This isn’t a criminal issue, Lachs says. While abusive staff members “should be arrested, fired and prosecuted,” a stern punitive approach isn’t likely to solve the problem of resident-to-resident mistreatment. Dementia patients, after all, are just as much the victims of their condition as the people harmed by abusive behavior.
Unfortunately, we just don’t have the research to devise adequate strategies for combatting resident-to-resident abuse. Not yet, at least. But Lachs has a few ideas based on his own time in nursing homes.
Noise and poor lighting can aggravate residents, especially ones with dementia, so one possibility is to create bright, calming spaces for residents. Designing spaces to be easily-navigable, rather than frustratingly cluttered, may help, too. Using materials that dampen sound in communal rooms is a potential improvement, but we’ll also have to ensure that nurses can still hear residents down the hall.
Lessons From The Classroom
Help may also come from a surprising source. Lachs thinks that high schools, and specifically the way educational institutions have tackled bullying in recent years, may provide valuable lessons for nursing homes.
In a recent review of school-based anti-bullying programs, criminologists at Cambridge University found that, on balance, these programs work. Anti-bullying initiatives reduce both bullying behavior, by an average of 20% to 23%, and victimization (being bullied) by around 17% to 20%.
While resident-to-resident mistreatment is understudied, Lachs and Pillemer have been on the case for a while. Along with some colleagues, the two doctors have even developed a training program, called SEARCH, to help nursing home staff members intervene effectively after abusive behavior is spotted.
Here are the core principles:
- support injured residents until help arrives
- listen to all involved residents’ perspectives on situations
- validate resident fears and frustrations when mistreatment occurs
- evaluate what actions are needed
- monitor resident behavior
- evaluate and support residents involved in or who have observed an event, because mistreatment can be upsetting to all
- verbally try to stop the incident
- call other staff and / or security to help
- move and / or separate individuals
- seek medical treatment when indicated
- notify the nursing supervisor and administrator
- contact families if appropriate
- document the event in the resident care plan
- initiate the facility protocol for reporting mistreatment
- Care Plan
- consider both initiator and victim
- care plan to prevent mistreatment in the future
- medical and / or psychiatric evaluation
- monitor residents to avoid future incidents
- Help to Avoid
- check for adequate staff in congregate (communal) settings
- check for crowding
- educate residents about dementia-specific behaviors, e.g., rummaging
- separate residents with history of negative interactions with one another
While most of these steps seem self-explanatory, if not obvious, they’re obviously time-consuming, and nursing home staff members have many duties to attend to. But they also work. At least that’s the conclusion of one pilot study conducted at five New York City nursing homes between July 2008 and December 2011. As you might expect, training staff members in the SEARCH principles resulted in more reports of resident-to-resident mistreatment. After a 6-month-period, nursing home units trained in SEARCH had reported 580 incidents of resident-to-resident abuse. Units who hadn’t received the training reported only 79 incidents.