Senior-to-senior aggression common in US nursing homes

Up to one in five residents involved in unpleasant, sometimes inappropriate confrontations, N.Y. study suggests.

22 nov 2014—Elderly adults who live in nursing homes may commonly deal with aggressive or inappropriate behavior from fellow residents, a new study suggests.

The study of 10 centers in New York state found that, in the space of just one month, nearly 20 percent of residents were involved in some type of incident with a fellow resident.

Most often, it was a verbal clash, with someone yelling or cursing at another resident. In other cases, the incidents involved hitting or kicking—or, in a small percentage, inappropriate touching.

"We discovered that this is a much more prevalent problem than any of us realized," said researcher Karl Pillemer, a gerontology professor at Weill Cornell Medical College in New York City.

Results of the study were presented at a recent meeting of the Gerontological Society of America. Findings from studies presented at meetings are generally considered preliminary until they've been published in a peer-reviewed journal.

Pillemer's research also zeroed in on the residents who were most likely to be involved in incidents. "Typically," Pillemer said, "they were people who were in the moderate stages of dementia, but were still physically able to get around."

That makes sense, according to Dr. Laura Mosqueda, a geriatrics specialist who was not involved in the study. Mosqueda directs the National Center on Elder Abuse at the University of Southern California, in Los Angeles.

Nursing home residents with dementia commonly become confused, and may act out aggressively—but only if they have the physical capacity to do so, explained Mosqueda.

"I think the point this study raises is, who's responsible or accountable for this behavior?" Mosqueda said. "It's not the residents. In my view, it's the owners and people running the facilities. Do they have enough staff with the appropriate training?"

Still, Mosqueda also cautioned against an alarmist interpretation of the findings.

She noted that one of the more common forms of "aggression" in this study was "unwelcome entry" into another resident's room or going through another person's possessions.

"I'm not saying that behavior is OK," Mosqueda said. But, she added, it's common for dementia patients to become confused and unintentionally wander into a room that is not theirs.

For the study, Pillemer's team randomly selected 10 nursing homes in New York state that housed more than 2,000 residents altogether. Through staff interviews, surveys of residents and direct observation, the researchers estimated that over one month, nearly 20 percent of residents were involved in at least one incident of aggressive or inappropriate behavior.

Overall, 16 percent were involved in a verbal clash, while 10.5 percent had an invasion-of-privacy issue. Almost 6 percent were involved in a physical incident, like kicking, biting or hitting; and just over 1 percent experienced a sexual incident, like inappropriate touching, according to the researchers.

Pillemer said his team did not try to distinguish between "perpetrator" and "victim."

"It's often difficult to know," he noted. "And when you're talking about people with dementia, the traditional terms of 'perpetrator' and 'victim' don't hold up anyway."

One surprise, Pillemer said, was that men and women were equally likely to be involved in these incidents. "We'd suspected that it might be more common among men, but that wasn't the case," he said.

Pillemer added that the findings highlight an issue for nursing home administrators to address. Facilities need not only enough staff members, but also adequately trained ones, he said.

"We believe that the first line of defense is appropriate staff training," Pillemer said. He added that right now, staff often feel frustrated by incidents between residents, but "relatively helpless" in preventing them.

Beyond training, Pillemer said nursing homes could look at their design, and see whether "crowding" in hallways or shared areas could be minimized. "They could also pay attention to how they assign roommates," he said. "Are there some residents who are likely to do better without a roommate?"

As for families, Pillemer and Mosqueda said awareness of the issue is key. "I'd suggest visiting often and spending time not only in your family member's room, but also the public areas," Mosqueda said. If you notice a problem, tell the staff, she advised.

Pillemer agreed, adding, "If your family member complains of being bullied or being scared of another resident, take it seriously and tell the staff."

"Remember," Pillemer noted, "the staff is probably as concerned about these issues as you are."

More information: The U.S. National Institute on Aging has advice on choosing a nursing home.

Review Compares Quality of Care at Nursing Homes

Not-for-profit facilities found to deliver better care for commonly reported quality measures

06 aug 2009-- Not-for-profit nursing homes, on average, deliver higher quality care than for-profit nursing homes, although many factors influence this relation among individual institutions, according to a study published Aug. 4 in BMJ.

Vikram R. Comondore, M.D., of the University of British Columbia in Vancouver, Canada, and colleagues analyzed the results of 82 observational studies and randomized controlled trials that investigated quality of care in not-for-profit versus for-profit nursing homes from 1965 to 2003.

The researchers note that 40 of the studies concluded that not-for-profit nursing homes provided higher quality care; three studies concluded that for-profit nursing homes did. The remaining studies had less consistent findings. The researchers also found that not-for-profit facilities delivered higher quality care than for-profit facilities for two of the four most commonly reported quality measures: lower pressure ulcer prevalence (odds ratio, 0.91) and more or higher quality staffing (ratio of effect, 1.11). Results also favored not-for-profit facilities for physical restraint use and fewer deficiencies in regulatory assessments, although those results were not statistically significant.

"Although the average effect is clear, that effect probably varies substantially across situations," the authors write. "The variability is probably explained, in part, by a variety of factors that vary within categories of for-profit and not-for-profit homes, including management styles, motivations, and organizational behavior. Given their variability, the results do not imply a blanket judgment of all institutions."

Abstract
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Editorial

Diabetes Epidemic Now Poses Challenges for Nursing Homes

By Serena Gordon

06 jan 2009-- More and more people with diabetes are living to older ages, thanks to medical advances. But the long-term facilities, such as nursing homes, that care for aging Americans may not be ready for the additional challenges that come with treating patients with diabetes.

"We need to spend appropriate time to think of a way to successfully provide care for people with diabetes as they enter their elder years, and we're just beginning to understand how to do that," said Dr. Paul Strumph, vice president and chief medical officer for the Juvenile Diabetes Research Foundation.

Although as many as one in four nursing home residents has diabetes, not all are getting care that meets the American Diabetes Association's goals for community-dwelling adults, according to a recent study.

The study, published in Diabetes Care, found that while 98 percent of nursing home residents with diabetes had their blood glucose levels monitored, only 38 percent met short-term glucose goals.

The better news from the study was that 67 percent of the nursing home residents with diabetes met their long-term glucose control goals, which meant they scored less than 7 percent on their A1C tests. A1C is a measure of long-term blood sugar control.

"One of the key differences in managing diabetes in a nursing home is that it's often not the condition of primary importance," said Helaine Resnick, director of research at the Institute for the Future of Aging Services for the American Association of Homes and Services for the Aging.

Resnick said one of the concerns she had with the study findings was that no one has yet to come up with specific guidelines for caring for elderly people with diabetes. Glucose control goals for someone who's 40 and living at home may well be different than for someone who's 85, cognitively impaired, and living in a long-term care facility, she said.

"Diabetes medications are designed to lower glucose levels, which can prevent complications from developing in diabetic people. But, when you take medicines to lower blood glucose, it can go too low, which can be extremely dangerous, especially for older adults," Resnick said, noting that it's difficult to find "the appropriate balance between keeping sugars low with the risk of keeping it too low."

Strumph pointed out that the needs of older people with diabetes may be different as well. People with type 1 diabetes and people with type 2 diabetes who need insulin often choose to use an insulin pump when they're younger, but pumps may not be the best choice for someone who's older and not as aware, he said.

"Someone in a nursing home could pull out a pump site and not know. In that case, you may want to be on a longer-acting insulin instead. We haven't yet defined what the ideal insulin [regimen] is for someone in a facility with a fairly predictable schedule," Strumph said.

Both Strumph and Resnick said it's important for family members, the nursing home resident, and the staff to come up with a realistic care plan.

"Families need to become more actively involved in working with care teams, and that's true for diabetes and for other conditions. Ensure that the facility understands the family's and the resident's preferences. Is your mother more interested in keeping her blood glucose control tight and risk [low blood sugar]? Or is it better for her to ease up on glucose control and work more on quality-of-life issues? Resnick said.

"Families have to be very involved, and the communication needs to be ongoing, because people's values can change," she added.

More information

For tips on selecting a nursing home, visit the AARP Web site.

Government website rates nursing homes

WASHINGTON, 10 dec 2008 – Americans got a hand in the difficult and often emotional task of choosing a nursing home on Thursday, with the first-ever federal government website that rates the facilities for quality.

The Centers for Medicare & Medicaid Services, which oversees the Medicare and Medicaid insurance programs that often pay for nursing home care, said its website rates 15,800 nursing homes that participate in the public insurance system.

"In this first round of quality ratings, about 12 percent of the nation's nursing homes received a full five-star rating while 22 percent scored at the low end with one star," CMS said in a statement.

"The remaining 66 percent of facilities were distributed fairly evenly among the two, three and four star rankings."

Measures that are assessed include the percent of residents who have bed sores after their first 90 days in the home, the number of residents whose mobility worsened after admission and whether residents received recommended medical care.

The site, at www.medicare.gov, will be updated monthly and also includes staffing levels and whether the facility is for-profit or not-for-profit.

"The new website improvements also include links to information for community-based alternatives to nursing homes that may be of great interest to families," said Thomas Hamilton, who helped develop the new system.

"Around 3 million Americans depend on nursing homes at some point during each year to provide life-saving care," CMS administrator Kerry Weems said in a statement.

"Most of those individuals are enrolled in Medicaid or Medicare and we all bear a special responsibility to protect their health and welfare," he said.

Private equity companies purchase nursing homes, but care does not suffer

BOSTON, Mass. 11 sept 2008--In recent years, private equity investors have increasingly targeted nursing homes as investment opportunities. Spurred by investigative reports and anecdotal evidence that these deals led to worsened quality of care, many companies have found themselves under increased federal scrutiny.
But according to a new study, such conclusions may be premature. Private equity purchases of nursing homes—many of which result in administrative and corporate restructuring—have not caused quality of care to decline significantly to date. In fact, in some aspects, the quality of care has improved.
"This is an early look at what happens after these purchases," says Harvard Medical School assistant professor David Stevenson, who co-authored the paper with associate professor David Grabowski. "Many of the transactions we looked at were just a few years old, so it's hard to draw definitive conclusions about these types of deals. However, our results paint a more positive picture than had emerged previously."
These findings appear in the September/October issue of the journal Health Affairs.
Starting around 2000, a number of private equity groups began purchasing nursing home chains, mostly in states like Florida and Texas, where litigation was more common than in other states. As a result of these transactions, and to buffer themselves against costly litigation expenses, many of the nursing homes were divided into sub-companies, decentralizing ownership so that, for example, the same "company" didn't own both the property and operations. As a result, if a patient were to sue for medical negligence, it would be more difficult to pursue property assets.
Investigative reporting, such as a 2007 front page article in the New York Times, looked at patient care in these homes both before and after these corporate purchases. It concluded that such restructuring had weakened patient care, which in turn led to increased attention and Congressional hearings on the topic.
"We wanted to study this issue in a quantitatively rigorous way, for example controlling for broader trends within nursing home markets and particular facilities over time," says Grabowski. "The attention to these transactions and the issues they raise is important, and we hoped our study would provide a comprehensive and accurate view of what was happening."
Stevenson and Grabowski examined a range of nursing home outcomes and compared the quality of care in private equity purchased nursing homes to those that had not undergone these transactions.
The researchers looked at various indicators including nurse and aide staffing, survey deficiencies, and a range of resident outcomes including the prevalence of catheter use, urinary tract infections, weight loss, restraint use, pressure ulcers, residents' ability to take care of their own daily needs, and range of motion loss.
When the data were analyzed, the researchers found scant evidence to suggest that the overall quality of resident care had declined substantially following these purchases. Some factors, such as RN staffing, did in fact decline. But others, such as aide staffing, catheter use, UTIs, weight loss, and pressure ulcers, actually improved.
"After taking facility and market trends into account, we did not find a substantial drop in the quality of care delivered in these nursing homes overall," says Stevenson.
The researchers caution that these findings are preliminary, given the recent nature of many of these transactions. In addition, they emphasize that it is still important to consider a range of issues around ownership transparency and accountability that extend beyond private equity investment.
"Our study provides an initial snapshot that is somewhat reassuring," says Stevenson. "But the attention on these deals and the corporate structures that emerge from them still has broader value. Most of all, we need to be confident that residents are positioned to receive high quality care and that there is sufficient recourse in cases where they do not—regardless of who owns the nursing home."
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This study was funded by the J. W. Kieckhefer Foundation, who had no role in study design; in the collection, analysis, and interpretation of data; or in the writing of the report.
Full citation:
Health Affairs, September/October, Vol. 27, number 5 "Private Equity Investment And Nursing Home Care: Is It A Big Deal?" David G. Stevenson and David C. Grabowski, Harvard Medical School, Department of Health Care Policy, Boston, MA

What I Wish I’d Done Differently

By Jane Gross
8 july 2008--Looking back on the last few years of my mother’s life, with 20/20 hindsight and the belated knowledge that came from four years of reporting about aging for The New York Times, my single biggest mistake was not finding a doctor with expertise in geriatrics to quarterback her care and attend to the quality of her life, not merely its length.
Given the crisis in supply and demand — too many old people and too few geriatricians — I may not have succeeded. But if I had, many of our crises might have been avoided. Those include unnecessary trips to the emergency room that left her in worse shape than she had been beforehand. It also includes surgery to remove a benign tumor from the outside of her spinal cord after it had already done the worst of its damage and with no regard for her advanced age.
It was after that surgery that she took a precipitous nosedive, moving to a nursing home and suffering a series of T.I.A.’s, or very small strokes, which eventually left her paralyzed, incontinent, unable to speak and barely able to swallow. Later, both Dr. Roseanne Leipzig at Mount Sinai Medical Center in New York City and Dr. Dennis McCullough at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., told me that no doctor familiar with the physiology and psychology of the elderly would have operated on her without at least a discussion of the special risks to the aged.
My second biggest mistake was accepting the conventional wisdom that nursing homes are terrible places, to be avoided under any and all circumstances, and that assisted-living communities, with their pleasant apartments and other amenities, could accommodate my mother’s needs until the end of her life. Assisted-living facilities do offer an ever more expensive list of add-on services, including private duty, around-the-clock assistance. But too often they cannot meet the needs of deteriorating patients, forcing a series of relocations, each more destabilizing than the last.
State licensing regulations are wildly inconsistent in terms of how much additional help must be available in an assisted-living facility, even for those willing and able to pay for it. And any reputable facility will admit, sometimes only under stiff questioning of the director rather than the sales staff, that without an on-site skilled nursing facility or a dementia unit, many residents will wind up too ill, too frail or too cognitively impaired to live out their lives there.
If I had it to do all over again, I would plan for the worst and seek out a not-for-profit nursing home that met my standards. Many have assisted-living apartments on site, less attractive than those at for-profit chains like Sunrise and Atria, but offering a smoother transition if and when skilled nursing becomes essential.
My third mistake was being gleeful when my mother, then in her mid-70s, chose to sell her house on Long Island, flee the snow and the need to drive, and move to a retirement complex in Florida. Now when she didn’t answer the phone, I assumed, there would be someone to check up on her. She would have grab bars in the shower and a pull cord for emergencies. I wouldn’t be so frightened all the time.
What never occurred to me is that once my mother no longer had a home, we lost the option of setting her up with home care. Eventually too incapacitated to live out her days in assisted living and unwilling to move in with either of her children, a nursing home was her only choice — a happy one, as it turned out, but not in the early going, for any of us.
My fourth mistake was not understanding the limits of a long-term care insurance policy that had cost us about $7,000 a year because of my mother’s advanced age when we purchased it. It would have paid for retrofitting her own home, or even mine. It would have paid for 24/7 home health attendants. But it was virtually useless in an assisted-living apartment, and once my mother was in a nursing home, the policy benefit wasn’t ours to spend.
As long as my mother still had assets and could pay for her $14,000 a month room, the insurance benefit went to the nursing home and reduced her bill accordingly. When she ran out of money, in fairly short order, she was eligible for Medicaid, not because she was old but because she was impoverished. Then the insurance benefit went to the federal government.
All of these mistakes would have mattered less if the trajectory of my mother’s decline had been different. But that trajectory, alas, is unknown and unknowable but for its certain ending. So every decision we made — residential, medical, financial — was a crapshoot that changed the landscape for the next decision, usually by limiting options I didn’t even realize we had. There’s no way around this uncertainty, no way of knowing what’s going to happen next so you can plan accordingly. But physicians, social workers, case managers, lawyers and financial advisers with expertise in old age are the best guides. And haste, often the result of panic, is the enemy.

Serious Deficiencies in Nursing Homes Are Often Missed, Report Says

By ROBERT PEAR
WASHINGTON, 16 may 2008 — Nursing home inspectors routinely overlook or minimize problems that pose a serious, immediate threat to patients, Congressional investigators say in a new report.
In the report, to be issued on Thursday, the investigators, from the Government Accountability Office, say they have found widespread “understatement of deficiencies,” including malnutrition, severe bedsores, overuse of prescription medications and abuse of nursing home residents.
Nursing homes are typically inspected once a year by state employees working under contract with the federal government, which sets stringent standards. Federal officials try to validate the work of state inspectors by accompanying them or doing follow-up surveys within a few weeks.
The accountability office found that state employees had missed at least one serious deficiency in 15 percent of the inspections checked by federal officials. In nine states, inspectors missed serious problems in more than 25 percent of the surveys analyzed from 2002 to 2007.
The nine states most likely to miss serious deficiencies were Alabama, Arizona, Missouri, New Mexico, Oklahoma, South Carolina, South Dakota, Tennessee and Wyoming, the report said.
More than 1.5 million people live in nursing homes. Nationwide, about one-fifth of the homes were cited for serious deficiencies last year.
“Poor quality of care — worsening pressure sores or untreated weight loss — in a small but unacceptably high number of nursing homes continues to harm residents or place them in immediate jeopardy, that is, at risk of death or serious injury,” the report said.
Nursing homes must meet federal standards as a condition of participating in Medicaid and Medicare, which cover more than two-thirds of their residents, at a cost of more than $75 billion a year.
The study was done at the request of Senators Charles E. Grassley, Republican of Iowa, and Herb Kohl, Democrat of Wisconsin, who is chairman of the Senate Special Committee on Aging.
Mr. Grassley and Mr. Kohl have introduced a bill to upgrade nursing home care and increase the penalties for violations of federal standards. The maximum fine, now generally $10,000, would be increased to $25,000 for a serious deficiency and $100,000 for one that resulted in a patient’s death.
The senators are pushing to have their bill included in a package of Medicare changes that Congress is expected to pass next month.
But the American Health Care Association, a trade group for nursing homes, opposes the Grassley-Kohl bill in its current form.
Bruce A. Yarwood, president of the association, said: “We should not be increasing fines, adding auditors and encouraging a ‘gotcha’ mentality. We should be testing new, less punitive ways to measure and improve the quality of care.”
Influential consumer groups support the bill. David P. Sloane, senior vice president of AARP, the lobby for older Americans, said it was “one of the most significant nursing home reform initiatives” in two decades.
Under the bill, nursing homes would have to provide consumers and the government with more information about their owners and “affiliated or related parties,” including any individual or company that had a role in managing their operations.
Lewis Morris, chief counsel to the inspector general of the Department of Health and Human Services, said he had often been frustrated in trying to identify the owners of nursing homes that provided substandard care.
“We have found nursing home residents who were grossly dehydrated or malnourished,” Mr. Morris said. “We’ve found patients with maggot infestations in wounds and dead flesh. We’ve found residents with broken bones that went unmended.”
After discovering such problems, the federal government has required some companies to sign compliance agreements, monitored by outside experts. “Our experience shows that such compliance programs do improve the quality of care,” Mr. Morris said.
The Bush administration said it agreed with the findings of the accountability office and would supervise state inspectors more closely.
“We fully endorse and will implement all the G.A.O. recommendations,” Vincent J. Ventimiglia Jr., an assistant secretary of health and human services, said in written comments on the report.

Eye Exams Overlooked for Nursing Home Residents

BIRMINGHAM, Ala., July 9 -- Two-thirds of nursing home residents here did not receive regular eye exams despite the fact that 57% of the residents had evidence of visual impairment.
Moreover, about 90% had insurance that would have covered eye care, according to findings published in the July issue of Archives of Ophthalmology.
Cynthia Owsley, Ph.D., M.S.P.H., of the University of Alabama at Birmingham, and colleagues, studied habitual visual acuity, contrast sensitivity, spectacle use, and eye care utilization among 380 residents of 17 nursing homes.
Eighty-two percent of the residents had Medicaid or Medicare or both and "90% had some form of health insurance," Dr. Owsley wrote.
No more than 10% of the nursing home residents had good vision, whereas "about 46% of the sample had visual acuity worse than 20/60," and close to 10% had visual acuity of 20/200 or worse, Dr. Owsley wrote.
All residents were 55 or older, English-speaking, and had scores of 13 or more on the Mini-Mental State Examination.
About a third of the 380 study participants had MMSE scores of 23 or higher (scores of 23-26 are considered borderline dementia) and two-thirds had scores ranging from 13 to 23, indicating mild to moderate Alzheimer's disease.
When only residents with MMSE scores of at least 24 were considered, the vision impairment rate was about 34%, Dr. Owsley wrote.
Eighty percent of residents were women and more than half were 60 to 89 years of age; 42.6% were octogenarians.
In addition to a review of medical records to confirm vision exams, participants and a family member or guardian were interviewed about spectacle use and utilization of eye care services.
Among the findings:
Ninety-six percent of participants said they had used spectacles at some point in their lives and 78% used them at the time of the study.
For 66% of residents, there was no information about eye exams in their medical records.
Based on the medical records, 8.2% had glaucoma in one or both eyes, 3.1% had diabetic retinopathy, 32.5% had cataracts, and 4.6% had age-related macular degeneration.
Nursing home records indicated that 93% had agreed to permit the nursing home to provide eye care for the resident.
Twenty percent of the residents said their most recent eye exam had occurred more than two years prior to the study interview, and 30% could not recall an eye exam. Only 43% said they had had an eye exam within the preceding two years.
Dr. Owsley conceded that asking nursing home residents -- especially a sample in which a high percentage had evidence of cognitive impairment -- to recall eye exams was unlikely to provide exact measurement.
But the fact that the medical record "contained no record of or reference to an eye examination for 66% of enrollees" adds credibility to the residents' recall she said.
A strength of the study was its use of multiple measures and a wide selection of nursing homes.
"The findings underscore the need to better understand the causes of high visual impairment rates in nursing home residents and to evaluate interventions to improve the visual status of this population," Dr. Owsley concluded.
The research was funded by the Retirement Research Foundation, the EyeSight Foundation of Alabama, Pearle Vision Foundation, and the National Institutes of Health. Dr. Owsley disclosed no financial conflicts.Primary source: Archives of OphthalmologySource reference: Owsley C et al "The Visual Status of Older Persons Residing in Nursing Homes" Arch Ophthalmol. 2007; 125 (7): 925-930.

Nursing Homes' Use of Antipsychotics Varies Widely

A Canadian study, published in Archives of Internal Medicine, finds wide variation in the use of antipsychotic drugs across nursing homes.
The investigators reviewed use of the drugs in about 47,000 residents of nearly 500 Ontario nursing homes in December 2003. Overall, 32% of residents were given an antipsychotic drug, ranging from 21% in the nursing homes in the lowest quintile of use to 44% in the highest.
Those in the nursing homes with the highest rates were three times more likely to be dispensed an antipsychotic drug, compared with those in the facilities that dispensed the least. A similar threefold difference in rates was seen both in residents with psychoses or dementia and those without.
The authors said their data suggest that "the decision to prescribe an antipsychotic therapy appears to be related to the nursing home environment" rather than the treatment's clinical indication.

http://firstwatch.jwatch.org/cgi/content/short/2007/410/3?rss=1