US study — violence common among nursing home residents

COLUMBUS, Ohio–When people talk about abuse in nursing homes, they generally are referring to staff members victimizing the elderly.

But researchers say an even more pressing, prevalent problem might be the violence that can — and does — erupt between residents.

According to a new study by Cornell University, nearly one in five people living in nursing homes is involved in at least one aggressive encounter each month.

“These altercations are widespread and common in everyday nursing-home life,” said Karl Pillemer, PhD, a professor at Cornell and at the Weill Cornell Medical College and a co-author of the study.

Staff often unaware

Resident-to-resident mistreatment is under-reported to the point that, at some long-term-care centers, “staff members seem almost unaware,” Pillemer said.

Nursing homes provide care for about 1.5 million older Americans nationwide, including about 90,000 in Ohio. By 2030, the number of U.S. adults 65 and older will more than double, to about 71 million.

Research has mostly focused on older adults who have been mistreated by their family and caregivers in the community or by staff members in nursing homes, said Dr. Mark Lachs, who is the other author of the report and a professor of medicine at Cornell’s medical college.

But resident-on-resident violence is a much bigger problem, with consequences that can be just as devastating, he said.

In addition to cuts, bruises and broken bones, verbal and psychological violence can lead to depression and feelings of hopelessness — and, in worst-case scenarios, death, said Lachs, a practicing geriatrician.

Last month, for example, a 66-year-old woman strangled her 57-year-old roommate at a Georgia nursing home. Staff members reported hearing arguing late at night.

“There are a number of these murders every year, and it’s not something to be taken lightly,” Lachs said.

As part of the study, the Cornell team examined patient records at 10 nursing homes in New York. The group also interviewed residents and direct-care employees such as aides. Research assistants spent two to six months at the centers recording incidents they saw.

Of the more than 2,000 residents, 16 percent were involved in verbal incidents such as cursing, screaming or yelling; about 6 percent were involved in physical violence, including hitting, kicking or biting; and 1 percent were involved in sexual encounters such as exposing one’s genitals, touching other residents or attempting to gain sexual favors.

Another 11 percent experienced incidents such as residents walking into their rooms uninvited or going through their possessions. All of the events were “unwelcome with a high likelihood of causing physical or psychological distress,” Lachs said.

Residents also commonly take out their aggression on nursing-home employees, which is the subject of another Cornell study, he said.

Younger residents who have dementia or a mood disorder, but are physically healthy enough to move around, are more likely to be involved in aggressive incidents, he said. Depression also seems to be a factor.

Crowded Conditions

Crowded conditions, understaffing and ongoing conflicts between residents can fuel conflicts, he added.

Laura Mosqueda, MD, a practicing physician and director of the National Center on Elder Abuse, said nursing-home residents often have complicated medical and behavioral conditions that can cause personality changes. But Mosqueda cautioned against treating these incidents as typical abuse situations, with clear perpetrators who need to be punished.

“These are some of society’s most-vulnerable citizens, and in many ways, the aggressor and the aggressee are both victims,” said Mosqueda, who also teaches at the University of Southern California’s medical college.

When incidents arise, nursing-home workers should try to trace the warning signs and underlying causes to prevent future altercations, she said.

If, for example, inadequate staffing is part of the problem, then the center should hire more employees and consider paying them more to keep them. If two residents don’t get along, they shouldn’t be living in the same room or eating at the same table.

Beverley Laubert, Ohio’s long-term-care ombudsman, said the state receives relatively few complaints about resident-to-resident violence. But it has caused serious problems for a few nursing homes.

In August, state health officials moved 37 residents from a Gahanna nursing home that had been plagued by resident assaults, including hitting, punching, shoving and kicking.

And in February, a long-troubled nursing home in southwestern Ohio that had more registered sex offenders than any other in the state closed because of repeated violations that included not reporting suspected sexual abuse.

“It’s not always an easy thing to handle,” Laubert said.

Once, she said, she walked up to a nursing-home resident, and he started to yell at her.

“Staff snapped back, ‘Stop it, stop it,’ when a more-proper response would have been to say, ‘ John, this is Bev,’ so he would have known to trust me,” she said.

Mental Illness “No Excuse”

Having high numbers of residents with behavioral problems and mental illnesses can be especially difficult, said Peter Van Runkle, the executive director of the Ohio Health Care Association, a nursing-home industry group. But it’s no excuse, he said.

“We have folks who don’t intentionally do the things they do,” Van Runkle said. “But the reality is, none of it is acceptable, and our goal is for it not to ever happen.”

The keys, he said, are determining any history of aggression before a resident moves in, figuring out what might cause a resident to become violent and having plans in place to prevent future outbursts.

“Facilities are very aware of the problem,” said Jane Straker, a senior researcher at the Scripps Gerontology Center at Miami University who has studied resident-on-resident abuse.

The questions are, whether nursing homes will do more to find ways to reduce residents’ mistreatment of one another and whether there is enough pressure from state and other officials for them to try, the Cornell researchers said.

Mosqueda of USC agrees. “One of the challenges is, we have a system where it is up to nursing homes to pretty much police themselves,” she said.

The Cornell team recommends that nursing homes train staff members to recognize and report mistreatment, provide guidelines for when incidents occur and use approaches that consider the individual needs and abilities of the residents.

“I think the answer lies with thoughtful behavior interventions that don’t rely on drugs,” Lachs said.

Elders newsbeat reporter Encarnacion Pyle wrote this story for The Columbus Dispatch with support from the Journalists in Aging Fellows Program of the Gerontological Society of America and New America Media, sponsored by the Silver Century Foundation.