Personal Conflicts, Even Violence, Are Not Uncommon in Long-Term Care

At an assisted living facility in New York State, a small crowd had gathered at the dining room entrance at lunchtime, waiting for the doors to open. As a researcher observed, one woman, growing tired and frustrated, asked the man in front of her to move; he didn’t appear to hear.

“Come on, let’s get going!” she shouted — and pushed her walker into him.

In Salisbury, Md., a woman awoke in the darkness to find another resident in her bedroom in an assisted living complex. Her daughter, Rebecca Addy-Twaits, suspected that her 87-year-old mother, who had dementia and could become confused, was hallucinating about the encounter.

But the man, who lived down the hall, returned half a dozen times, sometimes during Ms. Addy-Twaits’s visits. He never menaced or harmed her mother, but “she’s entitled to her privacy,” Ms. Addy-Twaits said. She reported the incidents to administrators.

In long-term care facilities, residents sometimes yell at or threaten one other, lob insults, invade fellow residents’ personal or living space, rummage through others’ possessions and take them. They can swat or kick or push.

Or worse. Eilon Caspi, a gerontologist at the University of Connecticut, has searched news coverage and coroners’ reports and identified 105 resident deaths in long-term care facilities over 30 years that resulted from incidents involving other residents.

The actual number is higher, he said, because such deaths don’t always receive news media attention or are not reported in detail to the authorities.

“We have this extraordinary paradox: the institutions, nursing homes and assisted livings who care for the most vulnerable members of our society are some of the most violent in our society,” said Karl Pillemer, a Cornell University gerontologist who has studied resident-to-resident conflict for years.

Aside from psychiatric hospitals and residential youth facilities, he said, “it doesn’t happen anywhere else that one in five residents are involved in some kind of aggressive incident every month.”

That number — 20.2 percent of residents were involved in at least one verified incident of resident-to-resident mistreatment within a month — comes from a landmark study he and several co-authors published in 2016, involving 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 home, there are similar rates.”

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

The studies classify most resident-to-resident aggression 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 percent and 5 percent encountered physical events: others hitting, grabbing, pushing, throwing objects. A small percentage of events were classified as unwanted sexual remarks or conduct; 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 involved are younger and ambulatory, “able to move around and get into 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 places residents at greater risk for aggression,” Dr. Pillemer said. “More people with brain disease, people who are disinhibited, are congregated in a smaller space.”

Because so many among both initiators and victims have dementia, “sometimes we can’t tell what started things,” said Leanne Rorick, director of a program that trains staff in intervention and de-escalation. “An initiator is not necessarily someone with malicious intent.”

A resident might be confused about which room is hers, or lash out if someone asks her to be quiet in the TV room. In a case Ms. Rorick observed, a resident fought off staff attempts to quiet her when she believed someone had taken her baby — until she was reunited with the doll she cherished and calm returned.

“These are people with serious brain disease, doing the best they can with their remaining cognitive abilities in situations that are stressful, frightening and overcrowded,” Dr. Caspi said. Residents may be coping with pain, depression or reactions to medications.

Still, in a population of frail people in their 80s, even a slight push can cause injuries: falls, fractures, lacerations and emergency room visits. Residents suffer psychologically, too, from feeling anxious or unsafe in what is now their home.

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

A number of the changes that advocates have long sought to improve long-term care could help reduce such incidents. “In many situations, they’re preventable with proper assessments, proper monitoring, enough staff who are trained properly and have the knowledge to redirect and diffuse these issues,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care.

Facilities are generally understaffed, a problem exacerbated by the Covid-19 pandemic, so that staff members rarely witness aggression. In both nursing homes and assisted living, the Cornell studies showed, resident-to-resident mistreatment occurred more often when aides’ caseloads were higher.

Sufficient staffing would allow workers to keep watchful eyes on residents; so would reconfiguring facilities to avoid long hospital-like corridors that make monitoring difficult. Private rooms could reduce roommate disputes. Taking steps like opening dining rooms a few minutes earlier might help prevent jostling and congestion.

(New Medicare mandates will require staffing increases in most nursing facilities, if a providers’ lawsuit doesn’t overturn them, but won’t affect assisted living, which is regulated by states.)

Meanwhile, “the first line of defense needs to be training on this specific issue,” Dr. Pillemer said. The Cornell-developed program “Improving Resident Relationships in Long-Term Care,” which provides online and in-person training programs for staff members and administrators, has demonstrated that nursing home workers are more knowledgeable after training, better able to recognize and report aggressive incidents.

Another study found that falls and injuries declined after training, although because of low sample size, the results didn’t 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 they’re ignored.”