Resident Aggression and Abuse in Assisted Living

Abstract

This article estimates the prevalence and identifies risk factors of resident aggression and abuse in assisted living facilities. We conducted multivariate analyses of resident-level data from an analytic sample of 6,848 older Americans in the 2010 National Survey of Residential Care Facilities. Nationwide, 7.6% of assisted living residents engaged in physical aggression or abuse toward other residents or staff in the past month, 9.5% of residents had exhibited verbal aggression or abuse, and 2.0% of resident engaged in sexual aggression or abuse toward other residents or staff. Dementia and severe mental illness were significant risk factors for all three types of resident aggression and abuse. Resident aggression and abuse in assisted living facilities is prevalent and warrants greater attention from policy makers, researchers, and long-term care providers. Future research is needed to support training and prevention efforts to mitigate this risk.

Keywords

residential care facilities dementia resident aggression physical abuse verbal abuse

Introduction

Elder abuse is a growing public health concern in the United States that has warranted greater attention among federal and state policy makers, researchers, and long-term care providers (Healthy People 2020, 2015). This issue is more alarming due to the aging of the Baby Boom generation and expected future growth in the population of older Americans. The 2010 Census estimated that 13% of the population included persons aged 65 and above. That proportion is expected to reach 20% by the year 2050 (Werner, 2011). Life expectancy, which rose from 79.5 years in 2010 to 84.8 years in 2015, and a declining birth rate are contributing factors in the rising proportion of older Americans.

The purpose of this article is to estimate the prevalence and identify risk factors of engaging in resident aggression and abuse in assisted living facilities. Measuring the prevalence of resident aggression and abuse in assisted living facilities is needed to better understand the scope of the problem. Identifying strategies to mitigate and prevent resident aggression and abuse can help to improve social well-being and progress toward achieving public health objectives.

Background Context

Many older adults with chronic illness and disabilities require assistance in performing activities of daily living (ADLs) and may have other unmet social support needs. Because such individuals are vulnerable to elder abuse, society has a moral obligation to develop policies and programs that can mitigate or prevent abuse in vulnerable populations, including older adults living in residential care facilities. Residents in assisted living settings may be particularly vulnerable to mistreatment because of cognitive impairments, behavioral symptoms, or physical limitations (Castle & Beach, 2011).

Definition of Assisted Living

Assisted living and other residential care facilities have grown rapidly in the United States since the 1980s. This growth has occurred in response to concerns about resident quality of care in nursing homes as well as consumer preferences for greater choice of long-term care settings (Zimmerman et al., 2003). In 2010, more than 730,000 Americans were living in residential care settings with at least four beds (Park-Lee et al., 2011). A frequently cited definition from the Assisted Living Quality Coalition (1998) refers to assisted living as “a congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance, activities, and health-related services (p.65).” All assisted living facilities provide at least two meals per day and represent a viable long-term care option for adults who need some help with everyday activities, such as eating, bathing, or dressing, but do not require round-the-clock skilled nursing care (Golant, 2004).

Small residential care facilities with fewer than 10 beds are known as personal care homes or group homes and differ from assisted living settings because of size. Also, small residential care facilities have a greater share of young residents (below 65 years of age) than in large assisted living facilities (Gimm, Kitsantas, Cantiello, & Carle, 2014). Assisted living facilities are state-regulated residential long-term care settings that provide supportive care for ADLs, and include older adult residents with dementia. Prior studies found that about 42% of assisted living residents nationwide had some form of dementia (Gimm & Kitsantas, 2016; Zimmerman, Sloane, & Reed, 2014).

Resident-to-Resident Aggression

An operational definition for resident-to-resident aggression which emerged from a national group of experts was the following: “Negative, aggressive, and intrusive verbal, physical, sexual, or material interactions between long-term care residents in a community setting that would likely be unwelcome and potentially cause physical or psychological distress or harm to the recipient” (McDonald et al., 2015, p.157). Resident aggression and elder abuse have negative health consequences. These consequences include higher rates of injuries, physical pain, depression and anxiety, and increased mortality risk (Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998; Pillemer, Connolly, Breckman, Spreng, & Lachs, 2015). A prior study found an association of resident abuse and increased use of health care services as well as increased risk of morbidity (Dong, 2011). Nursing home residents have incurred clinically significant injuries due to resident abuse and aggression (Lachs & Pillemer, 2015). Injuries resulting from resident abuse and aggression can pose a substantial financial burden for victims. Empirical evidence has shown that direct medical costs associated with these violent injuries have added more than US$5.3 billion to the nation’s annual health expenditures (Mouton et al., 2004). Given the expanding scope of this public health issue, the 2015 White House Conference on Aging (WHCOA) made the reduction and prevention of elder abuse, which includes resident-to-resident abuse, a top priority goal for the future of aging policy (Pillemer et al., 2015).

Prior studies in the literature have looked at nursing home resident-to-resident abuse. For example, one study found that 42 out of 747 older adults placed in nursing homes around New Haven, Connecticut, were subject to police investigations for incidents of resident-to-resident abuse (Lachs, Bachman, Williams, & O’Leary, 2007). Another study in Massachusetts examined 294 serious injuries due to nursing home resident-to-resident abuse and found that injured residents were more likely to be cognitively impaired (Shinoda-Tagawa et al., 2004). Other literature reviews have examined the problem of sexual aggression in nursing homes and other types of resident-to-resident abuse in nursing homes (Ferrah et al., 2015; Rosen, Lachs, & Pillemer, 2010; Rosen, Pillemer, & Lachs, 2008). However, relatively few studies have examined resident abuse and aggression in assisted living settings (Castle, Ferguson-Rome, & Teresi, 2015). Although prior studies have found that victims of resident-to-resident aggression are likely to be female or cognitively impaired, less is known about the personal characteristics of residents who exhibit aggressive behavior (McDonald et al., 2015).

Definitions of Elder Abuse

Wide variation in how elder abuse is defined by states and local organizations has greatly complicated efforts to measure the prevalence of abuse. Perpetrators of such abuse can include family caregivers, residential care facility staff, another resident, or a stranger. For example, the American Medical Association (AMA) uses a very broad and well-cited definition of elder abuse that constitutes “an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult” (AMA White Paper on Elderly Health, 1990; Stiles, Koren, & Walsh, 2002). In contrast, alternative definitions specify the intent of actions or setting. For example, the National Academy of Sciences described elder abuse as “intentional actions that cause harm or the risk of harm due to a caregiver’s failure to satisfy the elder’s basic needs and safe living conditions” (National Research Council, 2003). Another study defined abuse as “an intentional overt act, which entails or threatens harm, or the curtailment of physical activities or emotional battering directed at a non-institutionalized person aged above 60 years" (Levenberg, Milan, Dolan, & Carpenter, 1983). Moreover, definitions of abuse in the literature may include references to maltreatment, mistreatment, or neglect (Castle et al., 2015).

Although states vary in their definitions of abuse, there is a growing consensus among researchers and practitioners that five actions represent abuse (Lachs & Pillemer, 2004; Laumann, Leitsch, & Waite, 2008; Pillemer et al., 2015). These actions would include (a) physical abuse, including acts that cause physical pain or injury; (b) psychological abuse, including acts that cause emotional pain or injury; (c) sexual abuse, defined as non-consensual sexual contact of any kind; (d) financial exploitation, which involves any misappropriation of an older adult’s money or property; and (e) neglect, which includes self-neglect or a caregiver’s failure to meet a dependent older adult’s needs. The focus of our study is on physical, verbal, and sexual abuse between residents (or residents and staff). However, financial exploitation and neglect were not included in the survey questions.

Prevalence of Elder Abuse

Despite the confusion of varying definitions of elder abuse, large-scale population surveys of community-dwelling adults aged 60 years or above have provided some empirical evidence of the scope of the problem. A statewide survey of 4,000 older community-dwelling adults in New York found a 7.6% prevalence rate of any elder abuse and a 4.7% prevalence rate of financial exploitation (Peterson et al., 2014). A national survey of 3,000 older community-dwelling adults found a 9.0% prevalence rate of verbal abuse (Laumann et al., 2008). Another well-cited study using a national survey of 5,700 community-dwelling adults found a 1-year prevalence rate of 4.6% for emotional abuse, 1.6% for physical abuse, and 0.6% for sexual abuse (Acierno et al., 2010).

However, relatively few studies in the United States have estimated prevalence rates of resident aggression and abuse in assisted living settings (Castle et al., 2015). Using a limited telephone survey of 700 relatives of persons who were long-term care residents in Michigan, one study found a 10% prevalence of emotional abuse within assisted living facilities (Page, Conner, Prokhorov, Fang, & Lori, 2009). Another study using a limited sample of complaints to the Arizona Health Department found that the likelihood of substantiated physical abuse was higher in larger facilities, but psychological abuse and neglect were more likely to occur in smaller facilities (Phillips & Guo, 2011).

Conceptual Models

Various theories and conceptual models have appeared in the literature to classify abuse and its context (Burnight & Mosqueda, 2011). Abuse of older adults can be perpetrated by the victim, a trusted other, a stranger, or an acquaintance (Anetzberger, 2005). In the context of assisted living and residential care facilities, a number of potential abusers (i.e., other residents, family members, nurse aides) may inflict harm on older adults, which may lead to outcomes such as isolation, fear, or morbidity (Castle et al., 2015).

One popular theory to explain elder abuse is the caregiver stress model, which focuses on adult caregivers as the primary source of abuse. In this model, the victim depends on the caregiver who becomes overwhelmed, frustrated, or abusive due to stress caused by the continuous caretaking needs of older adults (Burnight & Mosqueda, 2011). However, some researchers view elder abuse as a multidimensional phenomenon that should take into account different types of social interactions such as resident-to-resident abuse and environmental factors (Jackson & Hafemeister, 2011, 2013).

An alternative theory that is applicable to elder mistreatment comes from the socio-ecological model, which has been used to understand violence prevention (Centers for Disease Control and Prevention [CDC], 2015). The socio-ecological model considers the risk factors associated with experiencing or perpetrating violence at four levels (i.e., individual, relationship, community, and societal). The first level identifies education, income, and substance abuse affecting an individual’s attitudes and behaviors leading to violence. The second level examines an individual’s relationships with family members and peers that may increase the risk of abuse. At the community level, importance is placed on the setting (i.e., neighborhood, facility) where social relationships form. The fourth level recognizes social and cultural norms, which may encourage violence (CDC, 2015). Our study focused on individual factors that were associated with resident aggression and abuse.

Design and Methods

Data Source

We conducted a secondary analysis of the resident data files from the 2010 National Survey of Residential Care Facilities (NSRCF), which was administered by the U.S. National Center for Health Statistics. The NSRCF collected data on U.S. adult residents living in assisted living and other residential care settings by conducting proxy interviews with facility administrators. The survey included state-regulated facilities with at least four licensed beds, and at least one resident living in the facility. Eligible facilities provided 24-hr supervision and personal care services with at least two meals per day. However, the survey did not include facilities that only served adults with severe mental illness (SMI) or developmental disabilities.

The 2010 NSRCF used a stratified two-stage probability design to identify administrators in 2,302 residential facilities, and was conducted between March and November 2010. After this first stage of selecting facilities from a sampling frame of 39,635 facilities, the NSRCF obtained resident-level information through face-to-face interviews with facility administrators. However, residents were not directly interviewed for the survey. In the second stage, residents were randomly selected from each facility. On-site interviews were completed on 2,302 facilities with a weighted response rate of 81%. This resulted in a nationally representative sample of 8,094 adult residents. Detailed information about the survey design and sampling frame can be found elsewhere (Moss, Harris-Kojetin, & Sengupta, 2011). We restricted the analytic sample to older adults who were at least 65 years, which yielded a final sample of 6,848 residents.

Measures

In this study, the three outcome variables were residents exhibiting physical, verbal, or sexual abuse in the past month. We assessed these three types of resident aggression and abuse because questions on financial exploitation and neglect were not included in the survey. The survey questions asked whether in the past 30 days, the resident had exhibited any of the following behaviors: (a) verbally threatening other residents or staff, (b) being physically aggressive toward other residents or staff, and (c) making unwanted sexual advances toward other residents or staff. Therefore, the survey question indicates only when the resident is the source of aggressive behavior.

Independent variables for the analysis included several demographic characteristics. Resident age was categorized as 65 to 74, 75 to 84, or at least 85 years old. Race/ethnicity categories included non-Hispanic White, non-Hispanic Black, Hispanic, and Asian/Other. The marital status classifications were currently married, divorced/separated, widowed, and never married. We also included a measure of Medicaid coverage for residents.

Resident functional status was based on the number of limitations in ADLs, which included assistance with bathing, dressing, eating, transferring, and using the toilet. In this study, the ADL count measure had a range from zero to five. We accounted for whether a resident had any prior falls in the past year or lived in a community that allowed the temporary provision of skilled nursing services.

Chronic health conditions for residents were assessed by documentation provided by facility administrators in response to the following question: “As far as you know, has a doctor or other health professional ever diagnosed the resident with any of the following conditions?” We included the following health conditions as independent covariates in the logistic regression models because they provided the most consistent information available in the data: Alzheimer’s disease or other dementias, cancer, chronic obstructive pulmonary disease (COPD) and allied health conditions (e.g., asthma, chronic bronchitis, and emphysema), congestive heart failure (CHF) and other cardiac conditions, depression, osteoporosis, diabetes, cancer, stroke, and SMI.

Statistical Analysis

Bivariate statistics were used to examine the personal characteristics of older assisted living residents who engaged in physical, verbal, or sexual abuse relative to non-abusers in the analytic sample. Second, logistic regression analyses were conducted to determine the effect of various resident demographic and health characteristics on the likelihood of physical, verbal, or sexual abuse in the past month among older residents. A diagnostic check for multicollinearity was also conducted prior to the logistic regression analyses. We used the standard convention of a 5% level of significance in our analyses. Estimated odds ratios (ORs) and 95% confidence intervals were computed using STATA, Version 13 (Stata Corporation, College Station, Texas). All survey data were weighted to account for the complex study design of the 2010 NSRCF (Moss et al., 2011).

Results

Table 1 provides a summary of personal characteristics in the analytic sample’s residents. Nationally, an estimated 7.6% of residents (65 years or older) engaged in physical abuse toward other residents or staff in the past month, and 9.5% of residents had engaged in verbal abuse toward other residents or staff in the past month. Finally, a relatively small proportion (2.0%) of residents had engaged in sexual abuse toward other residents or staff members in the past month.

Table 1.

Descriptive Characteristics of Residents (65 Years or Older).

	Weighted percentage	Linearized SE	95% CI
	Weighted percentage	Linearized SE	Lower	Upper
Elder abuse outcomes
Physical aggression or abuse	7.6%	0.004	0.068	0.085
Verbal aggression or abuse	9.5%	0.005	0.086	0.105
Sexual aggression or abuse	2.0%	0.002	0.017	0.025
Demographics
Age (65-74 years old)	9.4%	0.005	0.085	0.103
Age (75-84 years old)	30.3%	0.007	0.289	0.317
Age (85+ years old)	60.4%	0.008	0.588	0.619
Male	27.4%	0.007	0.261	0.287
Non-Hispanic White	92.8%	0.005	0.918	0.936
Black	2.8%	0.003	0.023	0.033
Hispanic	2.9%	0.003	0.023	0.035
Other race/ethnicity	1.6%	0.002	0.013	0.021
Marital status and insurance
Currently married	14.2%	0.005	0.132	0.152
Divorced or separated	7.8%	0.004	0.071	0.087
Widowed	69.9%	0.007	0.684	0.713
Never married	8.1%	0.004	0.073	0.089
Medicaid coverage	14.7%	0.007	0.133	0.162
Number of ADL limitations
Zero	23.1%	0.008	0.216	0.248
One	20.3%	0.006	0.191	0.216
Two	16.9%	0.006	0.157	0.181
Three	15.7%	0.006	0.146	0.168
Four	17.6%	0.006	0.165	0.189
Five	6.3%	0.004	0.056	0.070
Health conditions
Any falls	15.5%	0.006	0.144	0.167
Cardiac conditions	37.2%	0.008	0.356	0.388
Asthma and respiratory conditions	14.6%	0.006	0.135	0.158
Diabetes	16.3%	0.006	0.152	0.174
Osteoporosis	22.4%	0.007	0.210	0.239
Stroke	11.3%	0.005	0.104	0.123
Cancer	11.5%	0.005	0.106	0.125
Depression	26.2%	0.007	0.248	0.277
Dementia	45.8%	0.009	0.440	0.475
SMI	3.8%	0.003	0.033	0.044

Note. Number of observations = 6,848. Population size = 638,742. ADL limitations included bathing (74.7%), eating (22.4%), dressing (54.3%), transferring (13.9%), and using the toilet (36.8%). CI = confidence interval; ADL = activities of daily living; SMI = severe mental illness.

With respect to demographic characteristics, a majority (60%) of the analytic sample included older residents at least 85 years old. Approximately 30% of residents were 75 to 84 years old. Women comprised nearly three fourths (73%) of residents in the sample. Also, the vast majority of residents (93%) were non-Hispanic Whites. With respect to functional status, 20% had exactly one ADL limitation and 57% of the sample had multiple ADL limitations. Although roughly one quarter (26%) of residents in the sample had depression, nearly one half (46%) of residents had some form of dementia, including Alzheimer’s disease. A much smaller proportion (4%) of residents had SMI.

Table 2 provides findings from the multivariate analysis of physical abuse in the past 12 months. Male residents had an increased likelihood of (OR = 1.61, p < .01) engaging in physical abuse compared with females. Also, residents with a greater number of functional limitations (OR = 1.39, p < .001) were more likely to engage in physical abuse. Some health conditions were also significant factors. For example, depression increased the likelihood of physical abuse (OR = 1.31, p < .05). Residents with dementia had a fivefold increase in the likelihood of engaging in physical abuse (OR = 5.45, p < .01) and residents with several mental illness had nearly a threefold increase in the likelihood of physical abuse (OR = 2.95, p < .01).

Table 2.

Multivariate Analysis of Physical Abuse Among Residents (65 Years or Older).

	OR	p value	95% CI
	OR	p value	Lower	Upper
Age (65-74 years) (ref. = 85+ years)	1.29	.236	0.848	1.952
Age (75-84 years old)	1.17	.230	0.905	1.511
Male (ref. = female)	1.61	.001	1.218	2.116
Divorced or separated (ref. = currently married)	1.16	.541	0.726	1.840
Widowed	0.93	.653	0.662	1.295
Never married	1.04	.866	0.630	1.731
Black (ref. = non-Hispanic White)	1.33	.310	0.765	2.324
Hispanic	0.87	.666	0.475	1.610
Other race/ethnicity	1.13	.736	0.549	2.340
Medicaid coverage	1.26	.121	0.940	1.691
Any falls	1.60	.001	1.223	2.097
Number of ADL limitations	1.39	<.001	1.286	1.499
Cardiac conditions	0.92	.488	0.727	1.164
Asthma and respiratory conditions	1.22	.201	0.901	1.642
Diabetes	0.95	.743	0.703	1.286
Osteoporosis	0.79	.145	0.581	1.083
Stroke	0.89	.518	0.615	1.278
Cancer	0.65	.023	0.448	0.942
Depression	1.31	.030	1.027	1.683
Dementia	5.45	<.001	4.074	7.295
SMI	2.95	<.001	1.864	4.675
Constant term	0.01	<.001	0.005	0.013

Note. Number of observations = 6,848. Population size = 638,742. OR estimates are weighted. OR = odds ratio; CI = confidence interval; ADL= activities of daily living; SMI = severe mental illness.

Table 3 provides findings from the multivariate analysis of verbal abuse in the past 12 months. Residents with a greater number of functional limitations (OR = 1.21, p < .001) were more likely to engage in verbal abuse. Some health conditions were also significant factors. Residents with dementia had nearly a fourfold increase in the likelihood of engaging in verbal abuse (OR = 3.85, p < .001). Residents with several mental illness had nearly a threefold increase in the likelihood of verbal abuse (OR = 2.89, p < .001). These results for verbal abuse are robust at a higher level of significance (p < .001).

Table 3.

Multivariate Analysis of Verbal Abuse Among Residents (65 Years or Older).

	OR	p value	95% CI
	OR	p value	Lower	Upper
Age (65-74 years) (ref. = 85+ years)	1.28	.174	0.898	1.811
Age (75-84 years old)	1.10	.439	0.865	1.396
Male (ref. = female)	1.26	.075	0.977	1.637
Divorced or separated (ref. = currently married)	1.21	.357	0.808	1.806
Widowed	0.88	.421	0.646	1.200
Never married	1.26	.294	0.820	1.927
Black (ref. = non-Hispanic White)	1.34	.245	0.818	2.197
Hispanic	0.84	.600	0.448	1.591
Other race/ethnicity	1.22	.567	0.623	2.370
Medicaid coverage	1.21	.166	0.923	1.590
Any falls	1.47	.005	1.125	1.929
Number of ADL limitations	1.21	<.001	1.132	1.299
Cardiac conditions	1.01	.940	0.813	1.251
Asthma and respiratory conditions	1.07	.595	0.824	1.402
Diabetes	1.25	.101	0.957	1.634
Osteoporosis	0.88	.352	0.673	1.151
Stroke	1.03	.853	0.757	1.400
Cancer	0.86	.373	0.626	1.192
Depression	1.40	.001	1.142	1.712
Dementia	3.85	<.001	3.049	4.866
SMI	2.89	<.001	1.923	4.335
Constant term	0.02	<.001	0.013	0.028

Note. Number of observations = 6,848. Population size = 638,742. OR estimates are weighted. OR = odds ratio; CI = confidence interval; ADL= activities of daily living; SMI = severe mental illness.

Table 4 provides findings from the multivariate analysis of sexual abuse in the past 12 months. Male residents had more than a sevenfold increase in the likelihood (OR = 7.64, p < .001) of engaging in sexual abuse compared with females. Residents with a greater number of functional limitations (OR = 1.14, p < .05) were more likely to engage in sexual abuse. Some health conditions were also significant factors. Residents with dementia had nearly a twofold increase in the OR of engaging in sexual abuse (OR = 1.83, p < .01). Residents with several mental illness had nearly a threefold increase in the likelihood of sexual abuse (OR = 2.95, p < .01).

Table 4.

Multivariate Analysis of Sexual Abuse Among Residents (65 Years or Older).

	OR	p value	95% CI
	OR	p value	Lower	Upper
Age (65-74 years) (ref. = 85+ years)	1.25	.511	0.638	2.467
Age (75-84 years old)	1.60	.060	0.980	2.625
Male (ref. = female)	7.64	<.001	4.512	12.953
Divorced or separated (ref. = currently married)	1.92	.098	0.886	4.153
Widowed	1.27	.432	0.699	2.308
Never married	0.98	.965	0.416	2.313
Black (ref. = non-Hispanic White)	0.53	.171	0.211	1.319
Hispanic	0.47	.211	0.146	1.531
Other race/ethnicity	1.48	.587	0.357	6.176
Medicaid coverage	1.15	.564	0.717	1.840
Any falls	0.94	.838	0.535	1.661
Number of ADL limitations	1.14	.040	1.006	1.295
Cardiac conditions	1.16	.463	0.779	1.734
Asthma and respiratory conditions	1.03	.918	0.602	1.757
Diabetes	1.85	.004	1.213	2.811
Osteoporosis	0.95	.870	0.513	1.760
Stroke	1.12	.712	0.617	2.029
Cancer	1.04	.904	0.549	1.969
Depression	1.27	.339	0.781	2.049
Dementia	1.83	.013	1.136	2.933
SMI	2.95	.002	1.486	5.867
Constant term	0.00	.000	0.001	0.004

Note. Number of observations = 6,848. Population size = 638,742. OR estimates are weighted. OR = odds ratio; CI = confidence interval; ADL= activities of daily living; SMI = severe mental illness.

Discussion

Our study on the national prevalence of resident aggression and abuse in assisted living in the United States builds on prior findings from two large-scale studies on elder abuse in the community that used nationally representative samples (Acierno et al., 2010; Laumann et al., 2008). One-year prevalence rates for elder abuse were in the range of 7.6% to 11% in the population aged 60 years and above (Pillemer et al., 2015). Similarly, our population of 6,848 residents 65 years and older in assisted living settings had a 7.6% prevalence rate of physical abuse and 9.5% rate of verbal abuse.

Another key finding is the association between dementia and resident aggression. In our study, dementia was a significant contributing factor in all three outcomes. Physical abuse had the highest association with dementia with an OR of 5.45, followed by verbal abuse with an OR of 3.85 and sexual abuse with an OR of 1.83. These results show that dementia raises the likelihood of inflicting as well as provoking a resident to engage in physical, verbal, and sexual abuse in assisted living settings and are consistent with prior studies in nursing home settings (Shinoda-Tagawa et al., 2004). Therefore, interventions should focus on prevention initiatives to minimize the aggressive behavior of residents with dementia.

Dementia is characterized by a progressive decline in cognitive function, which may interfere with daily activities and frequently involves behavioral disturbances. Some behavioral and psychological symptoms of dementia can lead to aggression. Executive control and memory processes degenerate with age. Dementia can compromise the self-monitoring processes that allow individuals to recognize their own adverse behavior (Pillemer et al., 2015). Furthermore, dementia has large financial implications. One recent study estimated that average total cost per patient with dementia (US$287,038) was significantly greater than individuals affected by cancer (US$173,383) because of nursing home and informal care costs (Kelley, McGarry, Gorges, & Skinner, 2015). This not only implies high social costs for residents with dementia but also places a burden on other residents who have expressed higher rates of dissatisfaction living with or near dementia patients (Lachs et al., 2007). These findings warrant further research and development to inform aspects that trigger violent behaviors in this population. Moreover, awareness of this issue should be increased among caregivers and nursing home staff along with equipping them with tools to manage mistreatment before it occurs.

Policy Implications

Based on these study findings, increased training on abuse detection and prevention is needed for caregivers and staff in assisted living facilities. Currently, nurse aides and direct care workers provide the most “hands-on” care for residents in nursing homes and assisted living (Castle et al., 2015). However, in a testimony to the U.S. Senate Committee, Dr. Catherine Hawes identified low staffing levels and inadequate staff training as considerable contributors to elder abuse in nursing homes (Bern-Klug & Sabri, 2012). Today, provisions of the Affordable Care Act require nursing home staff to be specifically trained in abuse prevention and dementia care.

Relatively few studies address the type of training, content, and instrument that could aid in detecting and reporting resident aggression and abuse. One study attempts to bridge this gap by developing a resident aggression and abuse measure to advance identification of this harmful behavior and evaluate interventions (Ellis et al., 2014). Further research in this direction is needed to identify risk factors for resident aggression and abuse, documenting incidents, and devising strategies to lower its incidence. Also, more research is needed on community and organizational factors associated with this type of behavior. Taking it beyond detection and reporting, efforts should also be concentrated around prevention of resident abuse prior to its occurrence. One such study issued a call for action by developing competencies for certified nursing assistants (CNAs) to improve abuse prevention in nursing homes (DeHart, Webb, & Cornman, 2009). Social service departments in nursing home and assisted living facilities can also be a critical link in fulfilling this role by providing in-service training to staff about resident rights, abuse detection and prevention (Bern-Klug & Sabri, 2012).

Study Limitations

This study had several data limitations. First, the use of a cross-sectional national survey and non-experimental design precludes any causal inferences. Second, only incidents of resident aggression and abuse that facility staff had observed were recorded. Therefore, the prevalence of resident aggression and abuse in the national survey is likely to be a lower bound estimate if additional incidents occurred but were unobserved by facility staff. Third, the severity of abuse is unknown in the study. If only the most severe cases of verbal, physical, or sexual abuse are reported, the prevalence rates of resident aggression and abuse in this study are also likely to be lower bound estimates.

Conclusion

Prior studies have found evidence of resident abuse in nursing homes (Pillemer et al., 2011; Pillemer & Finkelhor, 1988; Pillemer & Moore, 1989). Our findings build on this knowledge base with nationally representative estimates of resident aggression and abuse in assisted living settings. In conclusion, this study provides evidence of the prevalence of resident aggression and abuse in assisted living facilities. Given the rising prevalence of dementia and aging population in the United States, resident aggression and abuse is a growing problem that warrants more attention from policy makers, researchers, and long-term care providers. Furthermore, dementia and SMI were significant risk factors for physical, verbal, and sexual abuse in residential care settings. Future research is needed to develop better methods for identifying residents at greater risk of engaging in abuse as well as supporting ongoing training and prevention efforts to mitigate this risk.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Gilbert Gimm, PhD, is an associate professor in the Department of Health Administration and Policy at George Mason University. His areas of research focus include aging and disability policy, health services research, program evaluation, and payment reforms.

Syeda Chowdhury, MHA, is a graduate research assistant and student in the Department of Health Administration and Policy at George Mason University. Her research focus includes measuring and improving health care quality, risk management, and patient safety.

Nicholas Castle, PhD, is a professor in the Department of Health Policy and Management at the University of Pittsburgh. His research focus is on quality of care in nursing homes and assisted living. His previous studies have examined staffing levels, staff turnover, resident satisfaction, and safety. He is also a fellow of the Gerontological Society of America.

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