Dementia-Related Resident-on-Resident Violence Strains Elder Care

Healthcare facilities are no strangers to workplace violence and patient harassment. However, for patients and care home residents with dementia, addressing the risk of violence can be especially challenging.

Dementia is a complex condition that impairs brain functions involved in impulse control, fear responses, and threat perception, which can raise the risk of aggressive behavior. Other conditions—including pain, stress, medication side effects, and other physical or emotional distress—can trigger significant and dangerous reactions, according to the National Institute on Aging. In nursing homes, this is often directed toward other residents and can cause serious harm, NPR reported. 

An in-depth study of 14 assisted living facilities in New York estimated that one in seven residents experienced aggression—including verbal, physical, or sexual acts—within a month. A separate study of 10 New York nursing homes estimated that one in five residents experienced an altercation in a month. These assailants are disproportionately likely to have dementia.

Verbal aggression was the most common form, but physical aggression also occurred frequently in both settings. The nursing home study found that the rates of resident-to-resident elder mistreatment (R-REM) were 9.1 percent for verbal, 5.2 percent for physical, and 5.3 percent for other types of R-REM such as invasion of privacy or menacing gesures. In some extreme cases, the victim of R-REM abuse died.

“Since the start of 2024, the federal Centers for Medicare & Medicaid Services has faulted nursing homes at least 700 times for failing to protect residents from physical, sexual, or verbal abuse by other residents, CMS inspection reports show,” reported KFF Health News. “…In the first three months of this year, CMS cited nursing homes more often for resident-to-resident abuse than for any other type of abuse, neglect, or exploitation, including abuse by employees, the reports show.”

Of the 2.2 million people living in assisted living or nursing facilities, approximately 900,000 have Alzheimer’s disease or another form of dementia. A KFF Health News examination of court records, police reports, and state and federal inspection records found that altercations involving a resident with dementia often erupt after danger signals are missed or ineffectively addressed. Not every clash can be averted, because people with dementia can experience unpredictable shifts in behavior as the condition changes.

But dementia consultant and researcher Eilon Caspi told KFF Health News, “In the vast majority of incidents, there are warning signs in the months, weeks, days, hours, and sometimes minutes and seconds prior.”

A 2016 nursing home study found that there were higher rates of R-REM on units with higher caseloads, and higher R-REM rates in winter months, when residents are usually relegated to smaller indoor spaces due to cold weather.

Doctors, researchers, and resident advocates told KFF Health News that “long-term care homes should employ strategies to reduce the risk of altercations, including closer supervision of residents at high risk, relocating them closer to nursing stations, separating residents with repeated conflicts, and adjusting roommate assignments or seating in shared spaces.” Staff should be alert to residents’ triggers so they can intervene quickly before behavior escalates. Some residents could benefit from having a one-on-one aide, but many facilities lack the staff for dedicated supervision.

The research noted that quality of life and security in nursing home facilities has dramatically improved in recent decades, although there is more work to be done.

“Not long ago, residents who wandered in nursing homes were routinely restrained. Gradually, the deleterious effects of this practice were recognized, and innovative strategies were created to manage that behavior, such as the creation of designated areas where patients could ambulate freely and safely,” the 2016 nursing home study said. “Future research in R-REM should similarly focus on deleterious effects of these behaviors on residents and staff, and identify the specific provocateurs of R-REM at all levels—patient, context, staff, facility, and an overall societal acculturation to aggressive behaviors in the nursing home—so that successful interventions can be developed and tested to mitigate this understudied phenomenon.”