By Nell Lake
For Eileen, who is disabled and reliant on a wheelchair to get around, life in a nursing home isn't easy. Particularly when it comes to the other residents: “There’s this guy," she says. "He made advances to me all the time. I did not want his advances. Many times I had to take my grabber and actually strike him to get him to leave me alone.” Another resident, Eileen says, is a “real bully. She has terrorized quite a few people. She tries to boss people around. She says harassing things.”
In coping with this type of hostile behavior, Eileen (who asked not to be identified) has plenty of company. New research released last week shows that aggression among residents in nursing homes is widespread and “extremely high rates of conflict and violence” are common, according to study author Karl Pillemer, professor of gerontology in medicine at Weill Cornell College of Medicine in New York. His stark findings, presented at the annual meeting of the Gerontological Society of America: One in five people living in the nursing facilities studied was involved in at least one “negative and aggressive encounter” with another resident during a four-week period.
“In most environments — say my work environment at a university — someone yelling at me angrily is so unusual that it would keep me up all night worrying about it,” Pillemer says. Yet such conflict in nursing homes appears to be routine.
Abuse and Mistreatment
As part of the study, researchers examined patient records at ten nursing homes in New York state, interviewed staff and residents, and recorded incidents through direct observation. In a sample of more than 2,000 residents, 16 percent were involved in incidents of cursing, screaming, or yelling; about 6 percent in physical violence such as hitting, kicking, or biting; one percent in “sexual incidents, such as exposing one’s genitals, touching other residents, or attempting to gain sexual favors”; and 10.5 percent in events researchers labeled “other” — residents entering rooms uninvited, for example, or rummaging through others’ belongings.
Abuse and mistreatment of the elderly in general — in their homes and in nursing facilities — is a serious and growing problem. The elder population is burgeoning; the number of vulnerable elderly is increasing; more and more people need care—and nursing homes are often understaffed. Because abuse is usually hidden, data on abuse is difficult to gather. The problem is very likely vastly underreported, according to the National Center on Elder Abuse. Surveys tend to miss elders who don’t have a phone, who are too frail to answer it, or who can’t respond truthfully about their situations because their abusers are present. Research finds that at least one in ten elderly people who live at home experience abuse each year, according to the National Center on Elder Abuse. (This figure does not include financial mistreatment.)
The great majority of abusers in these cases are family members. Rates of abuse are especially high among elders with dementia: as many 50 percent of people with Alzheimer’s and other dementing diseases may be mistreated.
Abuse of elders by staff in nursing homes is also pervasive. One survey of certified nursing assistants found that 17 percent of CNAs had physically abused residents, 51 percent had yelled at them, and 23 percent had insulted or sworn at them.
Crowded Conditions and Understaffing
Resident-on-resident aggression has received less study and publicity — but “it happens all the time,” says Diane Menio, executive director of the Center for Advocacy for the Rights and Interests of the Elderly in Philadelphia. Pillemer’s study found that the residents involved tend to be among the more active and cognitively intact in a nursing home — they’re the ones who are more engaged.
Mild to moderate dementia is clearly a factor in much of the aggression, however, because it causes disinhibited behavior. Other factors, Pillemer says, include:
• Crowded conditions: The study found higher rates of mistreatment in more crowded facilities, and in areas within facilities where residents were more densely gathered.
• Understaffing: The study found higher rates of resident-on-resident aggression in nursing homes with lower staff-to-resident ratios.
• Nursing-home workers who are inured to the problem: “Staff can become somewhat blinded to this,” Pillemer says, “because of the frequency with which it occurs.”
• Conflict’s cyclical nature: “The negative behavior and effects are contagious,” Pillemer says. “Seeing these incidents causes other residents to be fearful, anxious, concerned—and that can lead to more of the behavior.”
The prevalence of such aggression raises questions about how well U.S. nursing homes are meeting the great and growing need for compassionate, skillful long-term care. In many ways, aggression among nursing home residents is more complicated than other forms of elder abuse. When a family member or nursing-home worker abuses a vulnerable elder, the perpetrator is clear. But resident-on-resident aggression is more systemic and much less clear cut.
It needs to be addressed, many experts believe, not by thinking in terms of perpetrator, victim, and punishment, but by looking at causes and prevention — by improving care. Laura Mosqueda, a practicing geriatrician and director of the National Center on Elder Abuse, believes that nursing homes should be seen as responsible for easing aggression. “Let’s not forget that the people [in this study] … are some of the most vulnerable members of our society. Even if they’re the ones who are ‘perpetrating’ some of this, they’re not the ones who should be held accountable,” Mosqueda says.
If, for example, inadequate staffing is linked to the problem, as the study found, then facilities should hire more staff, she says.
Mosqueda, Pillemer, and others say that staff need to better understand the root of the problems. For instance, Pillemer asks, “Is someone being aggressive because they’re in pain? Are they being aggressive because they’re hungry or bored? Personalizing the care for residents, understanding why they [become aggressive], and looking for individual solutions are very important.”
Alison Hirschel, the elder law attorney for the Michigan Poverty Law Program and director of the Michigan Elder Justice Initiative, agrees. She cites cases in which relatively simple adjustments by nursing-home staff eased elders’ “difficult behaviors.” One man, a former police officer, had worked the night shift for decades before going into a nursing home. Staff expected him to sleep at night; but he found this impossible, and became frustrated and aggressive. Eventually the nursing aides figured out what would help. They gave him a clipboard and allowed him to wander around his unit at night. His frustration and challenging behaviors eased.
Another woman, who’d lived in an abusive orphanage as a child, did better when treated in ways that didn't trigger terrifying memories. And a blind resident needed to hear from staff the steps they’d take as they bathed her.
Such adjustments by staff require knowledge of residents’ emotional needs and of their life histories — not just of residents’ medical charts. Acquiring such knowledge takes greater effort and skill, but Pillemer says that workers are generally eager to learn how to better address aggressive behaviors. “Staff feel very powerless to deal with this,” he says. “They don’t quite know how to handle it.”
He believes that better training for nursing-home workers is essential to help them deal with aggression more skillfully, to protect residents and to keep themselves safe. “These violent and aggressive and conflictual incidents are extraordinarily stressful for staff,” he says. Workers, too, are at risk of being injured.
Hirschel, the lawyer, acknowledges that not all difficult behavior can be solved through simple, compassionate adjustments to residents’ treatments and circumstances.
“Residents with these behaviors do have a negative impact on other residents,” she wrote in an email, and “sometimes these issues are really intractable and challenging for even the most skilled and thoughtful staff.”
Diane Menio, the elder advocate in Philadelphia, tells a story about her own experience with “problem behavior” in nursing homes — her mother’s. Menio’s mother had Lewy-Body dementia (which can cause hallucinations) and lived in a facility at the end of her life. The staff at the facility loved her mother, Menio says, and saw her as “a sweetheart.” But one day, in a dining area, Menio’s mother threw water from her glass at a woman sitting at the same table. The woman had been bothering her mother. Not long after, staff sat the same woman next to Menio’s mother, who again threw water.
“So they wanted to medicate my mother” with a psychotropic drug, Menio says. This, Menio believed, was misguided. She asked the staff to keep the two women separate, and her mother never threw water again.
Menio’s story highlights a tricky issue. In 1987, a federal law declared that residents have "the right to be free" from both physical and chemical restraints when these are not required for treating medical symptoms.
The law was responding, in part, to practices in nursing homes such as tying “difficult” residents to beds or chairs.
No More Bullying
Today antipsychotic drugs are still used in nursing homes, usually therapeutically but sometimes as “chemical restraints” in response to difficult behaviors. With reform, such use has declined. While the Weill Cornell study illuminates the problem of resident-on-resident aggression, Mosqueda says, this shouldn’t mean “we end up putting people back in restraints.”
As with many complex issues, the first step toward easing resident-on-resident aggression, many experts agree, is greater recognition and understanding of the problem. Pillemer recalls the days when bullying in schools was considered normal — a dynamic that kids needed to tolerate and learn to deal with. “The idea that we’d even tell our parents [about being bullied] was inconceivable,” he says.
“Now things have changed, and standards have changed, and schools are taking on no-bullying policies. I think the same thing needs to happen in the nursing home context. The goal of this study was to show that this is a very frequent phenomenon — a disturbing and potentially damaging phenomenon for probably everybody in the nursing home setting. We need to begin the search for good solutions.”
Nell Lake, a journalist and magazine writer, wrote the new book, “The Caregivers: A Support Group’s Stories of Slow Loss, Courage And Love” in which she chronicles the lives of family caregivers over two years. She lives in Western Mass.