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Abused at the Nursing Home

Physical violence is on the rise in long-term care facilities

Elder abuse doesn't just involve family members, caregivers or gold-digging strangers. Now, long-term nursing staffers are wrestling with an increasing and little-discussed phenomenon: resident-to-resident violence (RRV).

It's just what its name suggests: a fellow patient physically, emotionally or sexually abuses another resident. This has led to murder, most notably in Minnesota and Massachusetts, and can cause severe physical injuries and emotional distress.

"Anyone who works in long-term care will tell you it's an incredibly common problem," says Mark Lachs, M.D., an RRV expert and professor of medicine at Weill Cornell Medical College who spoke on the issue at the Gerontological Society of America's annual science conference in November.

"You're asking people who may never have had a roommate, or at least not for decades, to share space and communal property, like the remote control," Lachs says. "But more compellingly, well over 50 percent of nursing home residents have dementia and-or behavioral disturbance."

Certain forms of dementia can also affect the frontal lobes of the brain and may produce a phenomenon called disinhibition. That means people may no longer watch what they say because of societal constraints and blurt out their biases or act impulsively. That may take the form of racial remarks, verbal and physical aggression when they have to wait in line, for instance, or hypersexual behavior that may also be caused by brain injury.

Sometimes confused Alzheimer's residents who wander into other people's rooms or area become victims. Throw in physically strong, emotionally disturbed young patients — some with post-traumatic stress disorder (PTSD), who now live in long-term care facilities alongside vulnerable, frail elders — and the problem is compounded. "We're probably going to see even more of an increase in RRV as people come back from war with PTSD and get admitted to nursing homes," predicts Susan Sifford, an assistant professor of nursing at Arkansas State University studying resident-to-resident aggression. "Today, almost half the time it occurs, it is not witnessed by staff and may have been able to be prevented."

On the front lines are long-term care staff, particularly certified nursing assistants, who are coming up with seat-of-their-pants strategies to prevent RRV. This includes knowing residents well, including what they like and don't like, figuring out where to sit them at meals so they're not next to someone they don't get along with, and distracting them when they sense tension. What is needed, say professionals, are evidence-based strategies to decrease RRV's frequency and impact. They want to know when are the high-risk times and what are the causes, which may include wandering, staffing and overcrowding.

"In the same way we've developed interventions for disruptive behavior in long-term care like wandering and agitation, we should be doing the same for resident-to-resident aggression that threatens the quality of life and safety of others," maintains Lachs, who is studying the prevalence of RRV in 10 long-term care facilities. "You wouldn't yell at your pancreas because it isn't making insulin. In some ways, it's unfair to blame the aggressor for what is neurologic brain disease."

In the future, Lachs worries about RRV incidents occurring in assisted living facilities and other locales. "As boomers age," he says, "they don't want to be in long-term facilities, so there will be other housing options like assisted living or continued care retirement communities that tend to have less staff. And that means possibly greater potential for resident-to-resident aggression."

Sally Abrahms writes on aging and boomers for national magazines, newspapers and websites. She is based in Boston.

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