Seniors Hurting Seniors
Aggression in the Care Setting
What Can We Do?
Dr. Michael Wilkins-Ho
Quality Forum
February 28, 2...
Objectives

A Tragic Story and a Coroner’s Report
Scope of the Issue
Contributing Factors and Triggers
Prevention and Inte...
A Tragic Story
Jack Furman was from Fort
MacLeod, AB.
He volunteer 70 years ago to join
an elite commando squad, the First
Special Servic...
Furman was typical of his 1800-member First Special
Service Force - rarely discussed what they did in
wartime Italy and Fr...
In their kit was the V-42 combat
knife specially designed for the
special force.
Pointed hilt capable of crushing a
skull ...
On each body was then left a calling card “Das dicke
ende kommt noch!” – “the worst is yet to come!”
German soldiers spoke...
Furman came back to Canada a war hero.
He had a long happy marriage to Meryl, his childhood
sweetheart.
They didn’t have k...
Furman was grateful for the good life back in Canada
that he has made the Canadian government the sole
beneficiary of this ...
Made friends with Susan Riedler who visited often to
make sure he was eating and took his medicine.
He once chased her out...
In August 2013 in his home, Furman was shown a
plaque commemorating a brutal mountain battle,
“Monte la Defensa,” which in...
Bill May was an 85 year old retired executive of a glass
company near Vernon, BC.
He was “quick with a joke.”
He married t...
May was Furman’s roommate at the
Polson Residential Care dementia unit.
There were no reported signs of
aggression by Furm...
Furman now remains at the 47bed Hillside Psychiatric Centre
in Kamloops

“with measures available to address any risk he m...
A Coroner’s Report
Ontario Coroner’s Case: History

Date of Death: September 4, 2011
Reason for Review
The GLTCRC was asked to review the cir...
Ontario Coroner’s Case: History

The woman was admitted to the long-term care home on
March 27, 2011, with advanced dement...
Ontario Coroner’s Case: History
% On April 1, 2011, the woman was seen scratching a male
resident, so she was redirected.
...
Ontario Coroner’s Case: History

On August 4, 2011, she was transferred from a mixed
ward to a female-only ward.
Ontario Coroner’s Case: History

On August 31, 2011, at 2000 hours, the woman was
ambulating using her walker in the hallw...
Ontario Coroner’s Case: History

The woman was admitted to the local hospital on
August 31, 2011 and had a surgical repair...
Ontario Coroner’s Case: History

The individual who pushed the woman was another
ambulatory female resident, aged 70 years...
Ontario Coroner’s Case: History

January 17, 2011 was the first recorded incident of the
70-year-old female pushing another...
Ontario Coroner’s Case: History

Reports were submitted for these incidents, as well as
times when the woman hurt staff mem...
Ontario Coroner’s Case: Post Mortem

% Cause of death was severe coronary artery disease
with evidence of congestive heart...
Ontario Coroner’s Case: Discussion

This is the case of an 87-year-old severely demented
woman who was pushed by another r...
Scope of the Issue
About 750 000 Canadians are
living with dementia (15% of
Canadians 65 years and older)
This number is expected to
rise to ...
A May 2012 report of Ontario’s long-term care task
force on resident care and safety found that in 2011,
57% of the abuse ...
W5 Research: Counting Canada’s care home homicides.
Published Friday, September 27, 2013
http://www.ctvnews.ca/w5/w5-resea...
W5 Research: Counting Canada’s care home homicides.
Coroners and Chief Medical Examiners in every province
and territory p...
When all the data
was in, six
provinces
combined
reported 53
homicides for
various periods
between 1990 and
August 2013; f...
There have been 25
homicides in
Ontario’s long-term
care facilities
between 2001 and
2011.
And at least 60
nursing home
ho...
W5 Research: Counting Canada’s care home homicides.

But the prevailing trend revealed points to a crisis in how
our socie...
Contributing Factors and Triggers
Scant literature on the prevalence, key characteristics and
outcomes of resident-to-resident aggression (RRA) or
violence ...
RRV is defined as the delivery of noxious stimulus by
one resident to others that is clearly not accidental.
(Patel and Hop...
RRV specific triggers
(Lachs et al., 2007; Rosen et al., 2008)

calling out

jealousy

territoriality

disinhibition

roomm...
Resident-to-Resident Violence Triggers in Nursing Homes.
Snellgrove, Susan et al.
Clinical Nursing Research. 22(4) 461-474...
Resident-to-Resident Violence Triggers in Nursing Homes.
Snellgrove, Susan et al.
Clinical Nursing Research. 22(4) 461-474...
Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus
Groups of Nursing Home Residents and Sta...
Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus
Groups of Nursing Home Residents and Sta...
35 different types of
physical, verbal, and
sexual RRA described.

Resident-to-Resident Aggression in Long-Term
Care Facili...
Most frequent in dining
room and residents’
rooms, and in the
afternoon (although
occurred regularly in
the facility at al...
29 antecedents identified as
instigating episodes of
RRA.
Most common was calling
or making noise.

Resident-to-Resident Ag...
Racism, ethnic stereotyping, and religious differences
contributed to RRA.
Many residents are not used to closely interacti...
What triggered Jack Furman?
frustration?
loss of privacy?
fear of change?
late-onset post-traumatic stress
and wartime flas...
Prevention and Intervention
1. Education
2. Staff and support
3. Environment
4. Person-Centred Care
Prevention and Intervention: Education

A staff intervention targeting resident-to-resident elder
mistreatment (R-REM) in l...
Prevention and Intervention: Education

There was a significant increase in knowledge post-training,
controlling for pretra...
Prevention and Intervention: Education
The objective was to evaluate the impact of a newly
developed R-REM training interv...
Prevention and Intervention: Staff and Support
Ontario Coroner’s Case
Recommendation 1:
To the Ministry of Health and Long-...
Prevention and Intervention: Staff and Support
Ontario Coroner’s Case
Recommendation 3
LTC homes are reminded of the MOHLTC...
Prevention and Intervention: Environment
Staff should assist in residents in maintaining a
maximum amount of control over t...
Prevention and Intervention: Environment

Dutch doors can secure a resident in while allowing
monitoring by staff.
Eliminat...
Prevention and Intervention: Person-Centred Care

Staff identified 25
self-initiated
techniques to
address the
problem.

Res...
Prevention and Intervention: Person-Centred Care
www.bcbpsd.ca
A Final Thought...
G8 countries:
France
Germany
Italy
Japan
Russia
United Kingdom
United States
Canada
Thank You
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Dr. Michael Wilkins-Ho

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E4 - Seniors Hurting Seniors: Aggression in Care Settings - What Can We Do?

  1. 1. Seniors Hurting Seniors Aggression in the Care Setting What Can We Do? Dr. Michael Wilkins-Ho Quality Forum February 28, 2014
  2. 2. Objectives A Tragic Story and a Coroner’s Report Scope of the Issue Contributing Factors and Triggers Prevention and Intervention
  3. 3. A Tragic Story
  4. 4. Jack Furman was from Fort MacLeod, AB. He volunteer 70 years ago to join an elite commando squad, the First Special Service Force. Trained to leap from planes, climb mountains, detonate explosives, launch amphibious assaults and survive behind enemy lines in wartime Europe. Jack Furman, age 95
  5. 5. Furman was typical of his 1800-member First Special Service Force - rarely discussed what they did in wartime Italy and France – even with their spouses. When asked about wartime details, Furman would answer “None of your business.” In 2010, during the association’s Italian tour, dementia became evident. Furman reminisced over coffee with a fellow soldier of the time when Allied soldiers were caught on the beach at Anzio, Italy. The Special Force’s task was to break the stalemate. Night patrols would take out sentries of machine gun emplacements.
  6. 6. In their kit was the V-42 combat knife specially designed for the special force. Pointed hilt capable of crushing a skull and a double edged stiletto blade for silent kills. “You’d take that damn knife and you’d exterminate the a German sentry.” “I wanted to fill my pants, but I couldn’t – I had to do it again.”
  7. 7. On each body was then left a calling card “Das dicke ende kommt noch!” – “the worst is yet to come!” German soldiers spoke of the “black devils”, a term the soldiers made their own as the Devil’s Brigade. As a young man, Furman said he couldn’t stand the sight of animals being killed for food. Furman took machine-gun fire to the neck and chest.
  8. 8. Furman came back to Canada a war hero. He had a long happy marriage to Meryl, his childhood sweetheart. They didn’t have kids. Moved to Hope, BC, and they built a a motel from the ground up. They operated it until they retired to Hope, BC where they built a home with a view of the lake.
  9. 9. Furman was grateful for the good life back in Canada that he has made the Canadian government the sole beneficiary of this will. He was robust and able to walk without a cane in his 90’s. He refused to leave his home. Sometimes in his later years he’d sit waiting for Meryl to return, not remembering she died nine years ago.
  10. 10. Made friends with Susan Riedler who visited often to make sure he was eating and took his medicine. He once chased her out of the house, then forgot he did when she returned. “Those goddamned Germans…they shot me.”
  11. 11. In August 2013 in his home, Furman was shown a plaque commemorating a brutal mountain battle, “Monte la Defensa,” which inspired the 1968 movie, “The Devil’s Brigade.” Engraved message “December 3, 1943 Ridge 368 Monte la Defensa, First Special Service Force suffered a 40% casualty rate. NEVER FORGET.” Furman said, “That’s darn nice.” Furman was assessed by the Health Authority and moved to Polson Residential Care in August 2013.
  12. 12. Bill May was an 85 year old retired executive of a glass company near Vernon, BC. He was “quick with a joke.” He married the “love of his life,” Bonnie. They were together for 57 years until her death in 2007. They had three sons, Phil, Paul and Scott.
  13. 13. May was Furman’s roommate at the Polson Residential Care dementia unit. There were no reported signs of aggression by Furman at Polson Residential Care but a few days after Furman moved in, he killed May. The second-degree murder charge was stayed on November 27, 2013 - three months after it was laid after extensive review of medical and psychiatric records. Canadian criminal law recognizes that the morally innocent should not be convicted.
  14. 14. Furman now remains at the 47bed Hillside Psychiatric Centre in Kamloops “with measures available to address any risk he might present to other patients, to staff or to himself.”
  15. 15. A Coroner’s Report
  16. 16. Ontario Coroner’s Case: History Date of Death: September 4, 2011 Reason for Review The GLTCRC was asked to review the circumstances surrounding the death of this 87-year-old woman who died as the result of injuries received following an assault by another resident in a licensed long-term care home.
  17. 17. Ontario Coroner’s Case: History The woman was admitted to the long-term care home on March 27, 2011, with advanced dementia, ischemic heart disease and congestive heart failure. At the time of admission, the woman was using a walker to ambulate and required some assistance with her activities of daily living. She did not understand why she was admitted to the facility; she did not feel she had any health issues and wanted to go home. Sometimes she would refuse care by staff.
  18. 18. Ontario Coroner’s Case: History % On April 1, 2011, the woman was seen scratching a male resident, so she was redirected. % On April 5, 2011, the family requested that the woman be transferred to another unit as she was expressing fear of the male residents. On May 11, 2011, a male resident wandered into the woman’s room and climbed into her bed. The male was removed and the woman would not settle for the rest of the night. On May 15, 2011, she spent the night wandering in and out of other residents’ rooms.
  19. 19. Ontario Coroner’s Case: History On August 4, 2011, she was transferred from a mixed ward to a female-only ward.
  20. 20. Ontario Coroner’s Case: History On August 31, 2011, at 2000 hours, the woman was ambulating using her walker in the hallway. Staff witnessed her stop to talk to another resident and during the conversation, she was pushed. The woman fell, striking her head on the wall and hitting her hip on the railing. She remained on the floor with a shortened and externally rotated left hip. The physician at the long-term care home ordered that the woman be transferred to hospital for assessment. The woman’s family reported the August 31, 2011 assault to police.
  21. 21. Ontario Coroner’s Case: History The woman was admitted to the local hospital on August 31, 2011 and had a surgical repair of the fractured hip on September 2, 2011. She suffered perioperative hypotension and elevated troponins and was thought to have had a myocardial infarction. The woman died on September 4, 2011.
  22. 22. Ontario Coroner’s Case: History The individual who pushed the woman was another ambulatory female resident, aged 70 years. She had been admitted to the long-term care home in 2009 and her medical history included dementia with paranoid episodes, multiple falls and hypothyroidism. Her medications included: rivastigmine, mirtazipine, risperidone and rabeprazole.
  23. 23. Ontario Coroner’s Case: History January 17, 2011 was the first recorded incident of the 70-year-old female pushing another resident. Her family arranged for an outside agency to sit with her for an hour twice weekly, which seemed to help settle the woman. On April 7, 2011, she passed the same resident she had pushed earlier in the year, and made that resident angry. The woman was redirected. On May 13 and 15, 2011, the woman pushed two different residents to the floor.
  24. 24. Ontario Coroner’s Case: History Reports were submitted for these incidents, as well as times when the woman hurt staff members who were helping her with activities of daily living. The woman was given quetiapine as needed, which was helpful on some occasions, but at other times, she became more agitated.
  25. 25. Ontario Coroner’s Case: Post Mortem % Cause of death was severe coronary artery disease with evidence of congestive heart failure as a complication. The hip fracture was considered a significant contributing factor due to the trauma and major surgery. Manner of death was homicide.
  26. 26. Ontario Coroner’s Case: Discussion This is the case of an 87-year-old severely demented woman who was pushed by another resident and fractured her hip from the fall. She had peri-operative hypotension and elevated troponins and died two days post-operatively, on September 4, 2011. The resident that pushed the decedent was subsequently seen by psychiatry on September 12, 2011 and admitted to a behavioural unit on September 19, 2011. She returned to the long-term care home on November 1, 2011.
  27. 27. Scope of the Issue
  28. 28. About 750 000 Canadians are living with dementia (15% of Canadians 65 years and older) This number is expected to rise to 1.4 million by 2031 (Alzheimer’s Society of Canada) Estimated annual cost of dementia in direct and indirect healthcare and lost family income of caregivers is $33 billion. Expected to reach $ 293 billion by 2040.
  29. 29. A May 2012 report of Ontario’s long-term care task force on resident care and safety found that in 2011, 57% of the abuse and neglect incidents (1568 of 2273) studied in long-term care were resident-to-resident encounters (the rest were staff-to-resident or residentto-staff).
  30. 30. W5 Research: Counting Canada’s care home homicides. Published Friday, September 27, 2013 http://www.ctvnews.ca/w5/w5-research-counting-canadas-care-home-homicides-1.1473825#ixzz2qyx8tikW
  31. 31. W5 Research: Counting Canada’s care home homicides. Coroners and Chief Medical Examiners in every province and territory provided statistics. Important caveat was that the numbers do not establish culpability. When a coroner says “homicide” it’s not a determination of guilt, it’s a constitution of fact that the actions of one person resulted in the death of another. Accidents are not included. The tragic stories behind the statistics include a son strangling his mother in a mercy killing, an altercation involving a man visiting his wife in a nursing home and residents dying in fires deliberately set by other residents.
  32. 32. When all the data was in, six provinces combined reported 53 homicides for various periods between 1990 and August 2013; four provinces reported zero, so did the three territories. Combined numbers from Coroners, CMEs and media reports; 2012 and 2013 omitted due to incomplete data for Ontario, Manitoba and Alberta.
  33. 33. There have been 25 homicides in Ontario’s long-term care facilities between 2001 and 2011. And at least 60 nursing home homicides across Canada in the last 12 years.
  34. 34. W5 Research: Counting Canada’s care home homicides. But the prevailing trend revealed points to a crisis in how our society cares for people living with dementia.
  35. 35. Contributing Factors and Triggers
  36. 36. Scant literature on the prevalence, key characteristics and outcomes of resident-to-resident aggression (RRA) or violence (RRV) in nursing home settings. The literature has overwhelmingly focused on violence that is directed by residents towards caregivers, or vice versa. Prediction and prevention important because of consequences including physical and/or chemical restraint and physical and/or emotional harm.
  37. 37. RRV is defined as the delivery of noxious stimulus by one resident to others that is clearly not accidental. (Patel and Hope, 1992)
  38. 38. RRV specific triggers (Lachs et al., 2007; Rosen et al., 2008) calling out jealousy territoriality disinhibition roommate incompatibility competition for material resources impatience intrusion into private spaces loneliness dementia. abandonment
  39. 39. Resident-to-Resident Violence Triggers in Nursing Homes. Snellgrove, Susan et al. Clinical Nursing Research. 22(4) 461-474. 2013. Semistructured interviews with 11 certified nurses’ assistants in Arkansas to provide insight into factors, including unmet needs that may trigger.
  40. 40. Resident-to-Resident Violence Triggers in Nursing Homes. Snellgrove, Susan et al. Clinical Nursing Research. 22(4) 461-474. 2013. Active triggers intrusive behaviours such as wandering into a resident’s personal space taking belongings Passive triggers (internal and external environment) boredom competition for attention communication difficulties
  41. 41. Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff. Rosen et al., J Am Geriatr Soc 2008 Collocating nursing home residents with behavioral disturbances increases the potential for RRA
  42. 42. Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff. Rosen et al., J Am Geriatr Soc 2008 OBJECTIVES: To more fully characterize the spectrum of resident-to-resident aggression (RRA). DESIGN: A focus group study of nursing home staff members and residents who could reliably self-report. SETTING: A large, urban, long-term care facility. PARTICIPANTS: Seven residents and 96 staff members from multiple clinical and nonclinical occupational groups.
  43. 43. 35 different types of physical, verbal, and sexual RRA described. Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff. Rosen et al., J Am Geriatr Soc 2008
  44. 44. Most frequent in dining room and residents’ rooms, and in the afternoon (although occurred regularly in the facility at all times). Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff. Rosen et al., J Am Geriatr Soc 2008
  45. 45. 29 antecedents identified as instigating episodes of RRA. Most common was calling or making noise. Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff. Rosen et al., J Am Geriatr Soc 2008
  46. 46. Racism, ethnic stereotyping, and religious differences contributed to RRA. Many residents are not used to closely interacting with those of other backgrounds, and LTC facilities are often multicultural, especially in urban areas. Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff. Rosen et al., J Am Geriatr Soc 2008
  47. 47. What triggered Jack Furman? frustration? loss of privacy? fear of change? late-onset post-traumatic stress and wartime flashbacks?
  48. 48. Prevention and Intervention 1. Education 2. Staff and support 3. Environment 4. Person-Centred Care
  49. 49. Prevention and Intervention: Education A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial. International Journal of Nursing Studies 50 (2013) 644–656 Teresi et al.
  50. 50. Prevention and Intervention: Education There was a significant increase in knowledge post-training, controlling for pretraining levels for the intervention group significantly increased recognition of R-REM and longitudinal reporting in the intervention as contrasted with the control group. Conclusions: A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long-term care facilities. A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial. International Journal of Nursing Studies 50 (2013) 644–656 Teresi et al.
  51. 51. Prevention and Intervention: Education The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM. The design was a prospective cluster randomized trial with randomization at the unit level. A sample of 1405 residents from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial. International Journal of Nursing Studies 50 (2013) 644–656 Teresi et al.
  52. 52. Prevention and Intervention: Staff and Support Ontario Coroner’s Case Recommendation 1: To the Ministry of Health and Long-Term Care (MOHLTC) and the Ontario Association of LTC Physicians: Residents who are assessed as a danger to other residents should be given priority to receive timely intervention, including admission to a behavioural unit as appropriate, to optimize the behaviour of the resident. Recommendation 2: LTC homes are reminded that if a resident is assaulted by another resident and sustains injuries that may constitute a criminal offence, the a assault should be reported to the local police.
  53. 53. Prevention and Intervention: Staff and Support Ontario Coroner’s Case Recommendation 3 LTC homes are reminded of the MOHLTC’s High Intensity Needs Funding program, and the availability for supplemental staffing and preferred accommodation for residents with severe behavioural issues. Recommendation 4 LTC homes are reminded to contact their Local Health Integration Network for assistance and information about behavioural support programs and training available in their community.
  54. 54. Prevention and Intervention: Environment Staff should assist in residents in maintaining a maximum amount of control over their personal space, belongings, and environment Overstimulation in the form of loud noises, crowding, and perceived extreme temperatures may lead to RRV. Allow for adequate space for residents to move around, spaces in which residents can escape from noise and adequate clothing for cold-natured residents may decrease RRV. Resident-to-Resident Violence Triggers in Nursing Homes. Snellgrove, Susan et al. Clinical Nursing Research. 22(4) 461-474. 2013.
  55. 55. Prevention and Intervention: Environment Dutch doors can secure a resident in while allowing monitoring by staff. Eliminating multiple-bed rooms should be a priority.
  56. 56. Prevention and Intervention: Person-Centred Care Staff identified 25 self-initiated techniques to address the problem. Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff. Rosen et al., J Am Geriatr Soc 2008
  57. 57. Prevention and Intervention: Person-Centred Care www.bcbpsd.ca
  58. 58. A Final Thought...
  59. 59. G8 countries: France Germany Italy Japan Russia United Kingdom United States Canada
  60. 60. Thank You

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