Murder in mind: increasing cases of dementia, changing populations contribute to rise in resident-to-resident violence in long term care facilities.

During his time at Tiffany House, an assisted living complex in Fort Lauderdale, Fla., Felix Freed had no better friend than his next-door neighbor, Bess Kleinman.

In recent months, the 72-year-old Freed and the 90-year-old Kleinman had bonded, acting at times like an old married couple, sometimes like an endearing brother and sister. They ate meals together. They took walks together He helped her up the steps and unlocked the door to her room. As each succumbed to mental and physical disorders, they shared a private world, sitting alone together and chatting about things only they understood.

No one understands why, on an early Thursday morning in May 2001, Freed pulled a plastic bag over his best friend's head and suffocated her. All officials know is that Freed, in a daze, called the night security guard on the facility's intercom.

"I've done something terrible, " he said quietly. "I killed Bessie and I don't know why."

Broward County Assistant Public Defender George Reres, who defended Freed against a first-degree murder charge and successfully kept him out of prison until the accused died in June I 2003, considers the case one of the most heartbreaking he's ever handled. "It was horrible," Reres said. "You could see him battling himself when he tried to think about it. You could see how bad he felt... It's as if after it happened, a light clicked back on and he said to himself, 'Oh no. What's happened here?'"

Tiffany House officials did not return telephone calls by press time.

A nursing home resident has a 1-in-400 chance of being injured by another resident, according to experts. A resident attacking, sometimes killing another resident, often due to dementia, is an incident that is expected to become an even bigger problem as the nation's population ages, according to Dr. Donna Cohen, professor of psychiatry and behavioral sciences at the University of South Florida's Department of Aging and Mental Health in Tampa, Fla.

Cohen has studied elder abuse issues for more than 15 years, authored several reports and testified before Congress on the subject. The matter tends to be downplayed due to lack of qualitative data, she said, "But given that our nursing home population is relatively stable and getting older, and the various issues that exist--[such as] staff training, morale and number of homes cited for placing residents at 'dangerous' risk--I would bet my nickel that a national study would show an increase in resident-to-resident violence."

By the Numbers

According to the Administration on Aging [AOA]'s annual Long Term Care Ombudsman Report, there were 3,746 reported cases of resident-to-resident abuse at U.S. long term care facilities in 2002, up from 3,569 in 2001. These numbers, the most recent available, might seem statistically small when measured against the fact that nationwide there are roughly 1.5 million persons age 65 or older in nursing homes and another 800,000 in assisted living facilities, according to the American Health Care Association. But the ombudsman's 2002 numbers represent a 48 percent increase in resident-to-resident incidents since the agency began tracking data in 1996.

In theory, the resident violence totals should be much greater, experts note. But there's a gray area in what a facility defines as violence worth reporting.

More often than not, it's only the worst offenses that make it into the facilities' incident logs, according to Cohen. "Unless [an incident] results in something pretty awful, it may not get reported," she said.

According to the U.S. General Accounting Office's July 2003 study, "Nursing Home Quality: Prevalence of Serious Problems," 20 percent of homes originally deemed deficiency free by state investigators were found to actually have "serious, quality-of-care" issues when reviewed by federal surveyors. A 2001 report by the GAO pegged it an even worse 29 percent.

Researchers from Yale Medical School in New Haven, Conn., in conjunction with the Massachusetts Department of Public Health, released this past February the nation's first study on resident-to-resident violence. Published in the Journal of the American Medical Association, "Resident-to-Resident Violent Incidents in Nursing Homes" focused on 1,132 injury reports--some not necessarily from violence--in Massachusetts facilities serving 110,000 residents statewide during 2000.

Roughly 1-in-4 incidents, or 294 of 1,132, resulted in "serious" injuries intentionally caused by another resident, according to the study's co-author, Paul Dreyer, associate commissioner at the Massachusetts Department of Public Health in Boston. "Serious" injuries are those in which signs of injury are present, such as a bruise, fracture, dislocation or hematoma.

Researchers are now expanding their study to a national level, according to Dreyer. That survey's authors expect the results to mirror the Massachusetts findings. "It'll be a couple years before they put anything together," Dreyer said. "But we have no reason to think that our nursing home population's unique from the rest of the nation."

The national ombudsman's data support Dreyer's assertion: From 1996 to 2002, 1-in-400 nursing home residents nationwide sustained resident-inflicted injuries, according to AOA. In the Massachusetts study, that figure was 1 in 374.

The Culprits

The precipitator of violence is usually a random event, according to Cohen. That event, something as simple as ignoring a call light or feeding a resident the wrong meal, combines with a series of social, physical and mental health risk factors to trigger a "catastrophic reaction," she said.

Factors contributing to resident violence include an increasing number of dementia cases among the elderly, shared housing among the elderly and other populations, greater depression among seniors, inadequate patient screening and staff training, and insufficient Medicaid reimbursements:

* Rising dementia among the elderly. When Felix Freed was questioned by Tiffany House staff, he eventually revealed that he killed Bess Kleinman because he "heard voices," according to a Fort Lauderdale, Fla. police report.

Freed was on medication for dementia and depression, but staff did not consider him dangerous, according to the police report.

Cohen said this scenario could play itself out many times over in the future as the number of people with dementia continues to increase.

"You can have somebody with dementia who is agitated, psychotic, having delusions--thinking the neighbor next to them is someone from the enemy who's going to kill them," she said. "Or they may begin to perceive that person as threatening for many reasons.... You just never know."

Dementia patients already make up a sizeable portion of the long term care patient load. According to "Dementia Care in Assisted Living and Nursing Homes," a November 2003 study by Sheryl Zimmerman, co-director of the University of North Carolina at Chapel Hill's Program on Aging, Disability and Long Term Care, dementia afflicts up to 64 percent of the assisted living residents and half of the nursing home residents in the report's four-state, 45-facility survey area. Up to another 30 percent of nursing home residents are not considered to have dementia but have symptoms of cognitive impairment, Zimmerman said.

The American Health Care Association estimated that 42 percent of nursing home patients nationwide suffered from dementia in 2000. The Alzheimer's Association projects that by 2025 the disease will afflict approximately 6.5 million seniors--a 44 percent increase from the 4.5 million affected in 2000. By 2050, the number will climb from 11 million to 16 million people, or a 144 percent to 256 percent gain from 2000.

* An "unhealthy mix" of elderly and mentally ill sharing the same housing. Jeanne del Castillo Csurgay generally was happy with her rife at Crystal Manor, an assisted riving facility in Pompano Beach, Fla. She liked the accommodations, enjoyed the company of the other seniors at the facility and had fun taking part in various recreational activities.

But there was one thing she didn't enjoy. A 58 year-old mentally disturbed resident who repeatedly entered her room and allegedly "bothered" her The alleged "bothering" turned fatal in October 1998, when the 74 year-old Csurgay somehow sustained a head wound and later died from a subdural hematoma, or blood clot on her brain.

The 58-year-old man was suspected of hitting Csurgay on the head with her own walker but wasn't charged due to a lack of eyewitnesses, according to Raul Romaguera, a partner in the law firm of Romaguera, Baker, Dawson, Bringardner & Dias in Palm Beach, Fla., who represented Crystal Manor in an ensuing wrongful death lawsuit. Florida state officials shut down Crystal Manor a few months after the incident, Romaguera said.

Romaguera is convinced that Csurgay should never have been exposed to that danger. "[Facilities] should never mingle mentally [ill] patients with elderly patients," he said. "It's a recipe for disaster."

Differences in physical strength and cognitive skills can make the mix dangerous for the elderly, according to Judy Dockery, an ombudsman in Evansville, Ind. A nursing home staff often is not qualified to handle such a diverse clientele, she said.

Claire Wheeler, vice president of clinical affairs for the Massachusetts Extended Care Federation in Newton Lower Falls, Mass., agrees that a mixed population is a delicate matter. "Whenever you have community living, the opportunity for events to happen certainly escalates," she said. "When you mesh different personalities, especially those with underlying illnesses or problems, you're bound to have some type of altercation."

But the financial element can be too enticing for long term care facilities to ignore, Romaguera said. "The states provide facilities with a certain amount of dollars per day, making it attractive to the [long term care facilities] to take in that kind of patient," he said.

* A changing nursing home population. Newer additions to the nursing home scene, and a contributor to the rising violence therein, include aging convicts, convicted sex offenders and younger people with drug addictions, Dockery said.

Part of the population shift comes from a lifestyle change among residents' adult children, Dockery said. "People used to keep family members at home, and now for whatever reason, they can't," she said. "Whenever anyone couldn't be at home with a relative, or family couldn't care for them, they just went to the nursing home."

A June 2002 report on aggressive behavior of Indiana long term care residents by the Alzheimer's Association and the Indiana Governor's Task Force on Alzheimer's Disease proposed the creation of several regional facilities to treat violent, cognitively impaired persons. The report confirmed there was a problem with resident aggression in long term care but received little attention from the state legislature, according to Dockery. "There was no money to fix the problem," she said, "so it really didn't go anywhere."

* More people suffering from undiagnosed depression. Depression is a common affliction among the long term care population, experts note. According to Zimmerman's 2003 "Dementia Care" study, 24 percent of assisted living residents and 27 percent of those in nursing homes experienced depression.

Slightly more than half of the depressed individuals--52 percent--were under medication to treat that depression, according to Zimmerman. In addition, only 28 percent of the afflicted were receiving professional counseling.

Cohen said the problem is worse than studies indicate. Doctors fail to diagnose nearly 80 percent of depression cases in older people and more than half among all ages because the disorder is often mistaken for a physical ailment, she said.

While depression typically affects twice as many women as men, men are four times more likely to commit suicide due to depression--and often in conjunction with a murder-suicide, said Sen. Larry Craig, chairman of the U.S. Senate Special Committee on Aging. "Men often won't talk about the issues they face," he said

* Inadequate patient screening procedures. In September 2002, Roy Schrack and his roommate, Leon Engstat, finished breakfast and headed back to their room at Country Meadows, an assisted living facility in Wyomissing, Pa. As Schrack started through the doorway Engstat pulled him back. "This is my room," Engstat said, tugging on the other man's shirt. They struggled briefly and fell. Engstat, 71, landed on top of the 91-year-old Schrack; Schrack broke his hip and went to the hospital. He died of pneumonia several days later.

According to Det. David Yoch, a criminal investigator with the Wyomissing Police Department, Engstat was not diagnosed with dementia. Yoch believes this was a mistake. "This is a guy who didn't know who the president of the United States was, or what day of the week it was," Yoch said.

No charges were filed against Engstat, Yoch said. Country Meadows officials declined to comment.

* Inadequate staff training. Long term care staff may help cause resident violence without realizing it, Cohen said. Sometimes, it's because the staff hasn't been trained in how to properly manage the residents.

Cohen recalls an incident in a Florida nursing home where two attendants carried a belligerent elderly resident into the shower room. "It turns out he was a Holocaust survivor. It's obvious why he didn't want to go into the showers."

Unfortunately, the resident's history wasn't relayed to the staff, Cohen said.

* Lower Medicaid reimbursements and additional federal policies. Long term care facilities often cite that existing Medicaid reimbursement rates are insufficient to cover their true costs. That shortfall prevents nursing homes from acquiring and retaining adequate staff, according to elder law attorney Robert Abrams, former chair of the New York State Bar Association's Health and Elder Law sections, and currently chief executive officer of MyZiva.net, a nursing home research group in Lake Success, N.Y.

According to MyZiva's September 2003 study, "Government Dilemma," nursing homes in states with the lowest Medicaid reimbursement rates "tended to have staffing levels that were substantially lower" than the national average of 3.84 hours of nursing coverage per patient per day. In the 20 states with the nation's lowest reimbursements, 77 percent of nursing homes had staffing levels below the national average.

That's bad news for dementia-capable facilities, which need a greater degree of staff coverage to ensure safety of all residents, according to Richard Mollot, associate director of the Long Term Care Community Coalition in New York City. "There's just no way you can always see and be in tune with someone who is having emotional problems or giving outbursts," Mollot said. "Who's to know what's going on during the other hours? It goes undetected because no one's there to see anything."

Preventive Measures

Knowledge is the key to preventing abuse.

"Unless you know precipitated types of behavior for every resident and you keep them away from other residents, you may not be able to stop certain kinds of incidental behavior," according to Scott Mager, national coordinating panel counsel for Fort Lauderdale, Fla.-based CNA Healthpro, the nation's largest carrier of long term care insurance.

While it may be impossible to prevent all resident violence due to medical and mechanical limitations, experts note there are ways to reduce the odds:

(1) Screen all incoming residents. Cohen recommends that all residents have background screenings upon admission and every six months thereafter.

When performing initial screenings, focus on the resident's mental history and life at their most recent residence, Cohen said. Ask the resident and family members direct questions about their history, such as: "Did they ever strike you?" "Did you strike them?" "Any kicking, stabbing, biting, hitting?" or "Any history of alcohol or drug abuse?"

Because family members are often embarrassed or reluctant to talk about these issues, it's important to ask questions, Cohen said.

Once you determine if the resident has a violent history, it's easier to narrow down whether you want that person--or if you can properly care for them, Cohen said.

(2) Remember the MDS. When it comes to making an accurate diagnosis, the evaluator's bible is the MDS--Minimum Data Set, according to Mager. The MDS is a head-to-toe physical given to the resident upon their admission to the facility.

In the document, physicians "assess every imaginable aspect of that person's condition," including how likely they are to fall, act out and commit abuse, or turn into an elopement risk, Mager said.

Findings from the MDS are placed on the resident's care plan--the second most important document in evaluating a resident's health, according to Mager. It's here that facility staff determines what can be done to improve a violent resident's behavior, he said. It's also where staff can make the wrong choice.

(3) Recognize "common traits" among typical perpetrators. Aggressors in resident-to-resident violence cases share several traits, according to Cohen. They are almost always male and usually younger than the victim, she said.

It's also common for an aggressor to be a former policeman, fireman or military officer. "These are individuals who know how to kill, know how to handle weapons and have a sense of dominance and control," Cohen said.

The resident also typically displays increasingly erratic or violent behavior, or has a history of such. Often, this behavior is unnoticed or ignored, according to Cohen.

[4] Know the "typical" victim. "When we first started [the Yale/Massachusetts Public Health study], what we were concerned about was this image of a very frail, little old lady--90 years old and weighing 90 pounds getting victimized by essentially stronger males," Dreyer said. "But that's not what we found Men were actually the victims most of the time."

Dreyer said male residents, usually cognitively impaired, are the ones who are more likely to "wander" in a facility and "put themselves in other peoples' faces"

Confrontations typically involved two residents with dementia, Dreyer said.

Wheeler said another likely victim is anyone who is "disruptive, confused or that might perform a repetitive activity that becomes annoying to someone else."

To set a good example for residents, employees need to keep their cool, according to Lamberti.

[5] Monitor resident behavior. For several months in 2003, 80-year-old Joe Bruscia, a dementia-afflicted resident of Alpine Court Memory Care in Eugene, Ore., repeatedly wandered into his neighbor's room to visit with 86-year-old Ruby Kuykendall. Ruby's husband, 86-year-old Frank Kuykendall, also suffering from dementia, didn't take kindly to these intrusions. According to a Eugene, Ore., Police Department report, Frank used a handgun he kept in his room to fatally shoot Bruscia, Ruby and himself on Nov, 28.

While acknowledging that there was no way staff at Alpine Court could have predicted such a "tragic" incident, Cohen said it might have been avoided with better monitoring of the conflict. Alpine Court officials declined to comment.

Indeed, many cases of resident violence stem from repeated instances that no one noticed or considered serious, according to Janet Wells, director of public policy for the National Citizens' Coalition for Nursing Home Reform in Washington, D.C.

Mark Miller, elder rights specialist for the National Center on Elder Abuse in Washington, D.C., said his organization works with facility administrators to help properly train CNAs on how to identify potentially troublesome situations. "We try to make them more aware of when someone is becoming more agitated, about how to spot someone who seems to be overly frustrated on a particular day," he said, "and to make sure that information gets passed on to the next shift ..."

"Ask your staff, 'How do you know it's going to be a bad day for Mr. Smith?' Get them talking about it and try to figure out, 'OK, when he's doing this, maybe he should eat in a smaller group or in his room today.' That way, he's not banging his plate over someone's head because that person are the last french fry."

[6] Ingenuity also helps. Dreyer recalls a case where one resident received bruises on her arms because she tried to take food from another resident's plate. "It turned out the person doing the slapping was always worried about her food being poisoned," Dreyer said. "So, the facility staff convinced her that this other lad, the grabber, was her personal food taster. It was a clever way to solve the problem."

[7] Check for weapons. In the triple slaying at Alpine Court, Eugene, Ore., police investigators claim that Kuykendall used a gun he kept in his room. Unlike nursing homes, laws generally do not prohibit small firearms in assisted living facilities because they're considered apartments not retirement facilities, according to Cohen. But some ALFs do have policies against guns and other weapons, she said.

Even so, such policies aren't perfect. The small size of some weapons, such as a low-caliber handgun, a pocket knife or a dining fork, makes enforcement of restrictions difficult, according to law enforcement officials.

Cohen said staff should attempt to find and remove any weapons from residents' rooms. They should also ask families to assist, as they often have better access than staff to a resident's belongings and know of potential hiding places for weapons.

Family members should also be informed of the facility's no-weapons policy in addition to having it presented to them in writing, Cohen advised.

But don't forget other environmental control methods, she said. "Many things can be made into a weapon," Cohen said. "Residents have been killed with the big ash trays that are sometimes in the common areas of the facility. Oxygen tanks, anything heavy should be tied down."

[8] Keep residents entertained. In general, the busier residents are, the happier they tend to be, according to Toby Edelman, an attorney for the Center for Medicare Advocacy Inc. in Washington, D.C. "Get them tired out from performing a meaningful opportunity and they're less likely to cause problems," she said.

Tasks can range from something elaborate--Edelman recalls when one nursing home took a number of its residents on a trip to Israel--to a simple action like a maintenance man taking residents with him to the hardware store, she said.

In the Works

Recently enacted or proposed legislation designed to help reduce violence in long term care facilities

California: in November 2003, state lawmakers approved AB 634 by Sacramento Assemblyman Darrell Steinberg, which makes elder abuse settlements public unless attorneys can show why information should remain confidential. Prior to the bill, which became law this past January, virtually all settlements were subject to non-disclosure.

Massachusetts: In February, the state Department of Health issued new requirements to prevent nursing home residents from injuring each other. Nursing homes must design programs to prevent resident-to-resident violence, screen for potential victims and aggressors, train staff in violence prevention programs, and report and investigate all cases of suspected resident-to-resident violence.

Missouri: In June 2003, Gov. Bob Holden signed SB 556, increasing accountability for neglect and abuse claims on long term care facilities Facilities fined for violations must now pay those fines; the previous law allowed facilities to avoid fines if cited problems were corrected at time of reinspection. SB 556 also increases the criminal penalty from misdemeanor to felony for nursing home administrators who conceal abuse and neglect.

New Mexico: In March. Gov. Bill Richardson signed SB 401, the "Granny Cam" bill, which authorizes families of nursing home residents to install video cameras in the residents' rooms at their own expense. Residents must be offered the video camera option when they move into the facilities.

New York: In May, Attorney General Eliot Spitzer created the Patient Protection Section, a new unit within the state's Medicaid Fraud Control Unit to respond to allegations of elderly neglect and abuse in nursing homes. The unit's duties include investigating institutions for evidence of abuse and neglect, handling prosecution of applicable cases and working with me state Department of Health, ombudsman programs, community, groups and nursing home industry to reform facilities and make them safer for the elderly, according to Spitzer.

Oregon: Following a triple slaying at a Eugene. Ore., Alzheimer's care center [see "The Culprits," page 15] in December 2003, lawmakers have begun drafting new administrative rules requiring the state's 2,392 senior care facilities to ban firearms. Facility administrators would be required to inform prospective residents of the ban and ask if they intend to bring weapons with them. The regulations will not address enforcement, according to Oregon Office of Licensing and Quality Care Administrator Cynthia Hannum.

The Elder Justice Act: Introduced by Sen. John Breaux, D-La., S. 333 is under debate in Congress. The bill amends the Social Security Act by adding the section "Elder Justice," establishing definitions for abuse, elder, direct care, long term care, long term care facility, caregiver, exploitation, vulnerable adult and neglect as they apply to elderly persons. The bill also defines bodily injury and criminal sexual abuse as they pertain to senior citizens, and establishes an Elder Justice Coordinating Council to examine me problem of abuse of the elderly,

The Help Efficient, Accessible, Low Cost, Timely Healthcare (HEALTH) Act: Former y known as H.R. 4280, by U.S. Rep. Jim Greenwood, R-Pa., this bill limits the filing of health care lawsuits to three years after the date of incident, allocates damages in proportion to a party's degree of fault and puts limits, not caps on punitive damages. In May, this bill was merged with H.R. 4279, The Small Business Health Fairness Act of 2004, and passed by the House. Now under consideration by the Senate.