Study of deaths from resident-to-resident incidents in dementia offers insights to inform policy and prevention

First analysis of fatalities in U.S. and Canada reveals patterns, renews call for government to track, study, and address phenomenon

Analyzing the incidents between residents in dementia in long-term care homes may hold the key to reducing future fatalities among this vulnerable population, according to a new research from the University of Minnesota School of Nursing. Gathered from media accounts and death review records, the exploratory study by Eilon Caspi, PhD is the first to examine the circumstances surrounding the death of elders as a result of resident-to-resident incidents in dementia in the United States and Canada.

Despite growing concerns about the projected growth in the number of people with dementia and the expected rise in resident-to-resident incidents, the phenomenon is not currently being tracked by the two largest federally mandated clinical and oversight systems in nursing homes in the U.S.

“The fact that we are not capturing and tracking this phenomenon represents a major missed opportunity for learning and prevention of these incidents,” says Caspi, the study’s author and a research associate at the School of Nursing. “We need to develop a data-driven national action plan to reduce these incidents and ensure that frail and vulnerable residents will remain safe in the last years of their lives. Delivery of evidence-based staff training programs to improve understanding, prevention, and de-escalation of these episodes is urgently needed.”

Among Caspi’s findings:

• Nearly half (44 percent) of all fatalities were the results of physical contact classified as push-fall. “Many of the injuries consisted of hip fractures or head or brain injuries and on average it was slightly more than two weeks from the incident to their passing, which speaks volumes to the frailty and vulnerability of this population.”

• While men and women equally died as a result of these incidents, three-quarters of exhibitors were men. “The most common exhibitor-target dyad was man to man (approximately 50 percent) followed by man to woman (24 percent) and woman to woman (21 percent). Woman to man accounted for only 4 percent of the dyads. While more research is needed to examine the role of gender in injurious and fatal episodes, the preliminary findings may have implications for more targeted interventions.”    

• More than half (59 percent) of all incidents took place inside bedrooms and 43 percent involved roommates. “The bedroom is the last frontier of privacy for people in dementia. Policies, procedures, and practices related to roommate assignment and monitoring need to be thoughtful and revisited regularly and we need to explore all avenues for reducing to the minimum possible the use of shared bedrooms or at a minimum increasing roommates’ sense of privacy and security. In addition, stronger measures to prevent residents’ unwanted entries into other residents’ bedrooms (including the use of assistive technology) could reduce these incidents.”

• Evenings (44 percent) were the most common time for incidents to occur, with 38 percent of all incidents occurring on weekends. 62 percent were reportedly not witnessed by staff. “While incidents occur at virtually all times, evenings and weekends appear to be especially vulnerable time periods. Taking proactive, anticipatory, preventative measures and increasing staffing levels, the active presence of managers, and meaningful engagement during the evenings and weekends could reduce the incidence.”

Caspi points out that his findings are not meant to suggest that residents with dementia are inherently “aggressive,” “abusive,” “violent,” or “dangerous.” He cautions that adopting this view could run the risk of stigmatizing an already stigmatized population.

Labeling a person with dementia using these terms assumes that these behavioral expressions are intentionally initiated to harm another person when the majority of individuals in mid-to-late stages of dementia do not initiate these expressions without a distressing situational trigger. Caspi says they often engage in these episodes when their human needs and situational frustrations are not met in a timely manner by dedicated but understaffed, undertrained, and undersupervised direct care staff members.

The study, “The circumstances surrounding the death of 105 elders as a result of resident-to-resident incidents in dementia in long-term care homes,” appears in the current issue of the Journal of Elder Abuse & Neglect.

Source of Research Support

The author would like to thank Theresa Piccolo for her generous support of this study. The research article is dedicated to the memory of her husband Frank Piccolo, Toronto, Canada.