More staffing, training could reduce deaths from dementia-related resident-on-resident violence, researcher says

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Eilon Caspi, Ph.D.
Eilon Caspi, Ph.D.

Addressing staffing and training issues could help reduce the number of deaths from resident-on-resident incidents involving assisted living and nursing home residents with dementia, says the author of a recently published study on such incidents.

Eilon Caspi, Ph.D., a research associate in the University of Minnesota School of Nursing, based his assessment on the review of more than five years of newspaper articles and other media reports as well as medical examiner documents, deficiency statements and plans of correction accessible via the Centers for Medicare & Medicaid Services, policy reports and other materials. His findings were published online ahead of print May 31 by the Journal of Elder Abuse & Neglect.

“To my knowledge, it is the first study in U.S. and Canada on these fatal incidents in the context of dementia,” Caspi, who also is the founder and director of Dementia Behavior Consulting LLC, told McKnight's Senior Living. “I believe that the preliminary findings from this pilot exploratory study could inform long-term care homes' efforts to prevent injurious and tragic incidents in similar circumstances and keep vulnerable and frail residents safe.”

Through his research, Caspi found 103 resident-to-resident incidents involving people with dementia (cases in which someone with dementia was the initiator or victim or in which all involved had dementia) that led to 105 deaths between 1988 and 2017 (in two of the incidents, two residents died). Forty-two of the deaths happened across 22 U.S. states, with the other deaths occurring in Canada, Australia, New Zealand and Singapore. Almost all of the deaths occurred in assisted living communities or nursing homes.

The findings point to opportunities for staffing adjustments, training and even building and design changes, Caspi said.

For instance, the most common place and time for the reported resident-on-resident incidents was inside resident bedrooms (59%), and a “substantial portion” of the incidents occurred between roommates, Caspi found.

“The [long-term care] setting is the residents' home and their bedroom is their last frontier of privacy,” he wrote. “Policies, procedures, and practices related to roommate assignment, monitoring, and thoughtful and timely reassignment need to be regularly examined by administrators, managers, nurses, social workers, and direct care staff members. [Long-term care] homes unable to afford to renovate or rebuild their bedrooms (i.e., to shift from shared to private bedrooms) might still be able to reconfigure and rearrange the shared bedrooms in ways that increase roommates' sense of privacy and minimize conflicts between them.”

Caspi also found that the most common setting for resident-on-resident incidents (44.5%) was in the evening — between 5 and 11 p.m.

“Evenings in many [long-term care] homes are typically characterized by lower staffing levels, reduced active presence of managers, lower activity programming and increased tiredness and irritability among a subgroup of residents with dementia,” he wrote. “The cumulative effects of these factors may contribute to enhanced level of harmful [resident-to-resident incidents] during the evening hours. Taking proactive, anticipatory, preventive measures could assist in minimizing these negative effects.”

More than two-thirds (62%) of the incidents were not witnessed by staff members, he said. “Lack of adequate supervision of residents engaged in [resident-to-resident incidents] may be related to understaffing,” Caspi wrote.

In assisted living, a payroll-based journal system like the one used by nursing homes could help “inform the development of policies, guidelines and legislation to ensure provision of adequate staffing levels,” he wrote, noting that assisted living is the fast-growing residential care option for older adults in the United States and is the setting of choice for almost half of those with dementia.

The most common types of physical contact were “push-fall” incidents (44%) and head and / or face beatings (22%), he found. On average, those on the receiving end of the physical contact died in 16 days, although one-fourth died on the same day as the incident.

This study, Caspi told McKnight's Senior Living, “is a call for a larger and more rigorous study on this disturbing but grossly under-recognized phenomenon.”

“Sadly, I was able to track about 10 additional deaths due to these incidents since I completed the analysis of these 105 incidents late last year... Every week or two, I am learning about a new fatal incident,” he said.

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