Resident Aggression and Abuse in Assisted Living

Abuse and Neglect in Nursing Homes: The Role of Serious Mental Illness

BACKGROUND AND OBJECTIVES

Nursing homes (NH) are serving a large number of residents with serious mental illness (SMI). We analyze the highest ("High-SMI") quartile of NHs based on the proportion of residents with SMI and compare NHs on health deficiencies and the incidence of deficiencies given for resident abuse, neglect, and involuntary seclusion.

RESEARCH DESIGN AND METHODS

We used national Certification and Survey Provider Enhanced Reports (CASPER) data for all freestanding certified NHs in the continental United States from 2014 to 2017 (14,698 NHs; 41,717 recertification inspections; 246,528 deficiencies). Differences in the number of deficiencies, a weighted deficiency score, the deficiency grade, and the facility characteristics associated with deficiencies for abuse, neglect, and involuntary seclusion were examined in High-SMI. Incidence rate ratios (IRR) and odds ratios (OR) were reported with 95% confidence intervals.

RESULTS

High-SMI NHs did not receive more deficiencies or a greater weighted deficiency score per recertification inspection. Deficiencies given to High-SMI NHs were associated with a wider scope, especially Pattern (IRR:1.03;[1.00, 1.07]) and Widespread (IRR:1.07;[1.02, 1.11]). High-SMI NHs were more likely to be cited for resident abuse and neglect (OR:1.49;[1.23, 1.81]) and the policies to prohibit and monitor for abuse and neglect (OR:1.18;[1.08, 1.30]) in comparison to all other NHs.

DISCUSSION AND IMPLICATIONS

Although resident abuse, neglect, and involuntary seclusion are rarely cited, these deficiencies are disproportionately found in High-SMI NHs. Further work is needed to disentangle the antecedents to potential resident abuse and neglect in those with mental healthcare needs.

Factors associated with resident-to-resident elder mistreatment in nursing homes

BACKGROUND

Resident-to-resident elder mistreatment (RREM) in nursing homes has serious physical and psychological consequences, but factors related to RREM occurrence remain unclear. This study identifies individual and environmental characteristics associated with involvement in RREM episodes.

METHODS

The design was an observational study carried out in five urban and five suburban New York state nursing homes randomly selected on the basis of size and location. The sample consisted of 2011 residents in 10 facilities; 83% of facilities and 84% of eligible residents participated. RREM and potential correlates were identified through resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports.

RESULTS

A multivariate analysis controlling for relevant covariates found that individuals involved in RREM incidents exhibit milder dementia, show behavioral symptoms, and are less functionally impaired. Although special care units (SCU) for dementia have benefits for residents, one potential hazard for SCU residents is elevated risk for RREM.

CONCLUSIONS

Interventions to prevent and intervene in RREM incidents are greatly needed. The correlates identified in this research point to the need for targeted interventions, specifically for residents with milder impairment and with behavioral symptoms and individuals in SCUs.

Domestic Violence in Residential Care Facilities in New South Wales, Australia: A Text Mining Study

BACKGROUND AND OBJECTIVES

The police are often the first to attend domestic violence events in New South Wales (NSW), Australia, recording related details as structured information (e.g., date of the event, type of incident, premises type) and as text narratives which contain important information (e.g., mental health status, abuse types) for victims and perpetrators. This study examined the characteristics of victims and persons of interest (POIs) suspected and/or charged with perpetrating a domestic violence related crime in residential care facilities.

RESEARCH DESIGN AND METHODS

The study employed a text mining method that extracted key information from 700 police recorded domestic violence events in NSW residential care facilities.

RESULTS

Victims were mostly female (65.4%) and older adults (median age 80.3). POIs were predominantly male (67.0%) and were younger than the victims (median age 57.0). While low rates of mental illnesses were recorded (29.1% in victims; 17.4% in POIs), 'dementia' was the most common condition among POIs (55.7%) and victims (73.0%). 'Physical abuse' was the most common abuse type (80.2%) with 'bruising' the most common injury (36.8%). The most common relationship between perpetrator and victim was 'carer' (76.6%).

DISCUSSION AND IMPLICATIONS

These findings highlight the opportunity provided by police text-based data to provide insights into elder abuse within residential care facilities.

Simulation and coaching to prevent aggressive events in aged care: A pilot study

OBJECTIVES

Evaluation of simulation and coaching training to change ​the self-efficacy of aged care workers to prevent and manage workplace aggressive events.

METHODS

Seventeen aged care workers from a community and residential aged care service provider completed education modules and two half-days of simulation using actors and real-life scenarios, with real-time coaching. Carer self-efficacy to identify, prevent and manage anxiety and aggression was measured before, following and six months after training.

RESULTS

After training, participants reported significant improvements in preparedness to prevent and manage aggression, identify and manage triggers in their own behaviour, deflect and alter other triggers, and felt safer in the workplace. Six months after training, participants' self-efficacy remained above baseline for all measures and remained significantly improved for feeling safer in the workplace.

CONCLUSION

This pilot study supports high-fidelity simulation and coaching to improve the self-efficacy of aged care workers to prevent and manage workplace aggressive events.

Resident-to-resident elder mistreatment (R-REM) intervention for direct care staff in assisted living residences: study protocol for a cluster randomized controlled trial

Background

Resident-to-resident elder mistreatment (R-REM) is defined as negative and aggressive physical, sexual, or verbal interactions between (long-term care) residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical and/or psychological harm and distress. R-REM has been established as a serious problem that has a negative impact on the safety, physical well-being, and quality-of-life of residents living in nursing homes. Although there are no in-depth studies, there is evidence that it is prevalent in assisted living residences and associated with a variety of person, environmental, and facility characteristics. The authors conducted the first systematic, prospective study of resident-to-resident elder mistreatment in nursing homes and developed an intervention for direct care staff to enhance knowledge of R-REM and increase reporting and resident safety by reducing falls and associated injuries. The study aim was to examine the effects of this intervention in assisted living residences. The primary distal outcome is falls and injuries, and the key process outcomes are staff knowledge and reporting.

Methods

Twelve larger licensed assisted living residences with special care dementia units in two New York State regions will be enrolled on a rolling basis and randomized to intervention or usual care. Data derived from five sources, (1) resident interviews, (2) staff informants, (3) observational data, (4) chart, and (5) incident/accident report data, will be collected at baseline and 6 and 12 months with respect to 1050 residents (750 “downstate” and 300 “upstate”). The intervention is three training modules delivered on-site after baseline data collection for front line staff on all shifts in facilities randomized to the intervention. Modules relate to recognition, management, and reporting of resident-to-resident elder mistreatment.

Discussion

Given the movement toward alternative congregate living arrangements for older individuals with significant comorbidities, including cognitive impairment; it is critical to enhance resident safety measured by falls, accidents, and injuries and staff knowledge related to recognition, reporting, and treatment of resident-to-resident aggressive and related negative interactions in such settings. This project is important in developing approaches for ameliorating and preventing R-REM in assisted living residences and enhancing resident safety and quality of life.

Trial registration

ClinicalTrials.gov NCT03383289. Registered on 26 December 2017

Resident-to-resident aggression in Norwegian nursing homes: a cross-sectional exploratory study

Background

Resident-to-resident aggression in nursing homes is a public health problem of growing concern, impacting the safety, health and well-being of all residents involved. Despite this, little research has been conducted on its occurrence particularly in large-scale national studies. The aim of this study was to explore the extent and nature of resident-to-resident aggression in Norwegian nursing homes, as reported by nursing staff.

Methods

We conducted a cross-sectional exploratory study, where nursing staff in 100 randomly selected Norwegian nursing homes completed a pen and paper survey measuring how often they had observed incidents of resident-to-resident aggression during the past year. These rates were separated according to nursing home size, location and units of workplace.

Results

Of the 3693 nursing staff who participated (response rate 60.1%), 88.8% had observed one or more incidents of resident-to-resident aggression during the past year, with acts of verbal and physical aggression being the most commonly reported. Nursing staff working in dementia special care units, larger nursing homes and nursing homes located in suburban/urban municipalities, reported more incidents of resident-to-resident aggression than staff in short-term and long-term units, small institutions, and nursing homes located in rural municipalities.

Conclusions

This is the first national study of resident-to-resident aggression in Norwegian nursing homes and is one of the largest surveys worldwide exploring the extent and nature of resident-to-resident aggression in long-term care settings. Overall, we found a high occurrence of all types of aggression, suggesting a need for strategies to improve residents’ safety and quality of life in nursing homes.

Gender differences in presentation and management of behavioral and psychological symptoms associated with dementia among nursing home residents with moderate to severe dementia

Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.

Prevalence and nature of resident-to-resident abuse incidents in Australian residential aged care

OBJECTIVES

To determine the prevalence of resident-to-resident abuse (RRA) in aged care facilities and to explore the nature, contributing factors and outcomes of abuse incidents.

METHODS

Retrospective cohort study of residents in 13 aged care facilities between 1 January and 31 December 2017, using data extracted from organisational incident reports.

RESULTS

A total of 169 RRA incidents were recorded, representing 0.56 incidents per 1000 bed days. 7.6% of residents were targets, and 6.9% exhibited aggression, in one or more RRA incidents over one year. In the majority of incidents (152, 89.9%), the aggressor had a cognitive impairment. Impacts on targets were mostly minor. The most common aggressor intervention was behaviour management (142; 84.0%).

CONCLUSIONS

Resident-to-resident abuse was found to be lower than in other reports. Typically, it involves residents with cognitive impairment and does not result in serious harm. Managing behavioural symptoms associated with cognitive impairment is critical in preventing and managing RRA.

Preventing The Abuse Of Residents With Dementia Or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review

Purpose

The main objective of this study was to investigate abuse of residents with either dementia or Alzheimer’s disease in long-term care settings, to identify facilitators and barriers surrounding implementation of systems to prevent such occurrences, and to draw conclusions on combating the issue of abuse.

Patients and methods

A systematic review was conducted using the Medline, CINAHL, and Academic Search Ultimate databases. With the use of key terms via Boolean search, 30 articles were obtained which were determined to be germane to research objectives. The review was conducted and structured based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Residents with dementia or Alzheimer’s disease are at greater risk of abuse. The growing population could increase this problem exponentially. The most common facilitators were the introduction of policies/programs in the facility, education, and working conditions. The most cited barriers were poor training, lack of research, and working conditions in the long-term care setting.

Conclusion

The examples given would be useful in minimizing the potential for abuse in the long-term care setting. Leadership can take an active role in the prevention of abuse of the elderly through their actions, education of employees, and changes in the work environment.

Resident-to-Resident Aggression in Long-Term Care: Analysis of Structured and Unstructured Data From the National Violent Death Reporting System, 2003-2016

Aging adults are at risk for multiple types of abuse including emotional, sexual, or physical abuse. Adults in skilled nursing or assisted living facilities might be particularly vulnerable to injury, including fatal injury resulting from incidents of resident-to-resident aggression (RRA). The purpose of this research is to report findings from the multistate National Violent Death Reporting System (NVDRS) related to fatal RRA incidents between years 2003 and 2016. We analyzed structured categorical data and unstructured narrative data on 101 identified fatal RRA incidents among individuals aged 65+. Findings included that victims average 16 years older than exhibitors and dementia diagnoses are present in most cases. Qualitative analysis revealed that events are described as both unexpected and preventable. Training to improve long-term care staff recognition and reporting of RRA events may potentially improve prevention and provide more accurate trend data. NVDRS data provide a useful source to follow trends in fatal RRA going forward.

The "Violent Resident": A Critical Exploration of the Ethics of Resident-to-Resident Aggression

Resident-to-resident aggression is quite prevalent in long-term care settings. Within popular and empirical accounts, this form of aggression is most commonly attributed to the actions of an aberrant individual living with dementia characterized as the "violent resident." It is often a medical diagnosis of dementia that is highlighted as the ultimate cause of aggression. This neglects the fact that acts of aggression are influenced by broader structural conditions. This has ethical implications in that the emphasis on individual aberration informs public policy strategies for prevention with a focus on restricting the freedom of individuals using behavioural modification, drugs, or other restraints with the intent to protect others from harm. A more ethical approach requires attention to the structural conditions of long-term care that both foster aggression and constrain prevention efforts. To this end, we turn to a model of relational citizenship that offers a theory of embodied selfhood and relationality as essential to human dignity, thus entailing human rights protections. The application of an ethic based on this model offers a more holistic prevention strategy for resident-to-resident aggression by drawing attention to the critical need and obligation to promote human flourishing through system level efforts.