Frank Piccolo sustained severe injuries to his face and head after a woman with dementia entered his bedroom and hit him repeatedly with an activity board. Theresa Piccolo, CC BY-NC-ND^[12]

These interactions don’t just result in injuries^[13] and deaths^[14] among residents. They also leave behind devastated families who then must fight for answers^[15] and accountability from nursing homes.

Making matters worse, government reports^[16], research studies^[17] and media coverage^[18] commonly describe these episodes with words that stigmatize people with dementia. Researchers, public officials and journalists tend to label the incidents as “abuse^[19],” “violence” and “aggression.” They call a resident involved in an incident a “perpetrator” or an “aggressor.” News outlets described the attack on Piccolo by the woman with dementia as “aggressive” or “violent.” And when reporting on the phenomenon^[20] in Canada, the Toronto Star called it “abuse.”

Getting to the root of the real problem

Most incidents, however, do not constitute abuse. A growing body of evidence suggests the true cause of these injuries and deaths is inadequate care and neglect on the part of care homes. Specifically, there is a lack of the specialized care that people with dementia require.

Two of every three residents involved in these incidents^[21] have dementia. One study found that the rate of these episodes was nearly three times higher^[22] in dementia care homes than in other long-term care homes. A recent study also found an association^[23] between residency in a dementia care home and higher rates of injurious or fatal interactions between residents.

But for these residents, the conflicts occur mostly when their emotional, medical and other needs are not met. When they reach a breaking point in frustration related to the unmet need, they may push or hit another resident. My research in the U.S. and Canada has shown that “push-fall” episodes^[24] constitute nearly half of fatal incidents.

Another U.S. study found that as residents’ cognitive functioning declined, they faced a greater likelihood^[25] of injury in these incidents. Those with advanced dementia were more susceptible to inadvertently “getting in harm’s way,” by saying or doing things that trigger angry reactions in other residents.

The Centers for Disease Control and Prevention has stated that what it calls “aggression” between residents is not abuse^[26]. Instead, the CDC noted that these episodes may result when care homes fail to prevent them by taking adequate action. And a study on fatal incidents^[27] in U.S. nursing homes has shown that many residents were “deemed to lack cognitive capacity to be held accountable for their actions.”

An undercover yearlong investigation into nursing homes in Ontario, Canada, revealed shocking instances of abuse and neglect by staff members.

How incidents often occur

In one study, researchers examined situational triggers^[28] among residents with cognitive impairments. The strongest triggers involved personal space and possessions. Examples include taking or touching a resident’s belongings or food, or unwanted entries into their bedroom or bathroom. The most prevalent triggering event was someone being too close to a resident’s body.

That study also found that crowded spaces and interpersonal stressors, such as two residents claiming the same dining room seat, could lead to these episodes. My own work^[29] and a different Canadian study^[30] came to similar conclusions.

Other research shows that when residents are bored or lack meaningful activity^[31], they become involved in harmful interactions^[32]. Evenings and weekends can be particularly dangerous, with fewer organized activities and fewer staff members and managers present. Conflicts between roommates^[33] are also common and harmful.

Residents with dementia who are meaningfully engaged in activities are less likely to become involved in harmful incidents with other residents. Morsa Images/DigitalVision via Getty Images^[34]

A growing body of research suggests that most incidents between residents are preventable. A major risk factor, for example, is lack of adequate supervision, which often occurs when staff are assigned to caring for too many residents with dementia. One U.S. study found that higher caseloads^[35] among nurses’ aides were associated with higher incident rates.

And with poor staffing levels^[36] in up to half of U.S. nursing homes, staff members do not witness^[37] many incidents. In fact, one study found that staff members missed the majority of unwanted bedroom entries^[38] by residents with severe dementia.

Residents with dementia are not to blame

In most of these situations, the person with dementia does not intend to injure or kill another resident. Individuals with dementia live with a serious cognitive disability. And they often must do it while being forced to share small living spaces with many other residents.

Their behavioral expressions are often attempts to cope with frustrating and frightening situations in their social and physical environments. They are typically the result of unmet human needs paired with cognitive processing limitations.

Understanding the role of dementia is important. But seeing a resident’s brain disease as the main cause of incidents is inaccurate and unhelpful. That view ignores external factors that can lead to these incidents but are outside of the residents’ control.

Frank’s wife, Theresa, didn’t blame the woman who injured her husband or the staff. She blamed the for-profit company operating the nursing home. Despite its revenue of $2 billion in the year before the incident, it failed in its “duty to protect^[39]” Piccolo. “They did not keep my husband safe as they are required to do,” she said.

Authors: Eilon Caspi, Assistant Research Professor of Health, Intervention, and Policy, University of Connecticut

Read more https://theconversation.com/conflicts-between-nursing-home-residents-are-often-chalked-up-to-dementia-the-real-problem-is-inadequate-care-and-neglect-173750