Seniors Hurting Seniors

Aggression in the Care Setting

What Can We Do?

Dr. Michael Wilkins-Ho

Quality Forum

February 28, 2014

Objectives

A Tragic Story and a Coroner’s Report

Scope of the Issue

Contributing Factors and Triggers

Prevention and Intervention

A Tragic Story

Jack Furman was from Fort MacLeod, AB.

He volunteer 70 years ago to join an elite commando squad, the First Special Service Force.

Trained to leap from planes, climb mountains, detonate explosives, launch amphibious assaults and survive behind enemy lines in wartime Europe. Jack Furman, age 95

Furman was typical of his 1800-member First Special Service Force - rarely discussed what they did in wartime Italy and France – even with their spouses.

When asked about wartime details, Furman would answer “None of your business.”

In 2010, during the association’s Italian tour, dementia became evident.

Furman reminisced over coffee with a fellow soldier of the time when Allied soldiers were caught on the beach at Anzio, Italy. The Special Force’s task was to break the stalemate. Night patrols would take out sentries of machine gun emplacements.

In their kit was the V-42 combat knife specially designed for the special force.

Pointed hilt capable of crushing a skull and a double edged stiletto blade for silent kills.

“You’d take that damn knife and you’d exterminate the a German sentry.”

“I wanted to fill my pants, but I couldn’t – I had to do it again.”

On each body was then left a calling card “Das dicke ende kommt noch!” – “the worst is yet to come!”

German soldiers spoke of the “black devils”, a term the soldiers made their own as the Devil’s Brigade.

As a young man, Furman said he couldn’t stand the sight of animals being killed for food.

Furman took machine-gun fire to the neck and chest.

Furman came back to Canada a war hero.

He had a long happy marriage to Meryl, his childhood sweetheart.

They didn’t have kids.

Moved to Hope, BC, and they built a a motel from the ground up.

They operated it until they retired to Hope, BC where they built a home with a view of the lake.

Furman was grateful for the good life back in Canada that he has made the Canadian government the sole beneficiary of this will.

He was robust and able to walk without a cane in his 90’s.

He refused to leave his home.

Sometimes in his later years he’d sit waiting for Meryl to return, not remembering she died nine years ago.

Made friends with Susan Riedler who visited often to make sure he was eating and took his medicine.

He once chased her out of the house, then forgot he did when she returned.

“Those goddamned Germans…they shot me.”

In August 2013 in his home, Furman was shown a plaque commemorating a brutal mountain battle, “Monte la Defensa,” which inspired the 1968 movie, “The Devil’s Brigade.”

Engraved message “December 3, 1943 Ridge 368 Monte la Defensa, First Special Service Force suffered a 40% casualty rate. NEVER FORGET.”

Furman said, “That’s darn nice.”

Furman was assessed by the Health Authority and moved to Polson Residential Care in August 2013.

Bill May was an 85 year old retired executive of a glass company near Vernon, BC.

He was “quick with a joke.”

He married the “love of his life,” Bonnie.

They were together for 57 years until her death in 2007.

They had three sons, Phil, Paul and Scott.

May was Furman’s roommate at the Polson Residential Care dementia unit.

There were no reported signs of aggression by Furman at Polson Residential Care but a few days after Furman moved in, he killed May.

The second-degree murder charge was stayed on November 27, 2013 - three months after it was laid after extensive review of medical and psychiatric records.

Canadian criminal law recognizes that the morally innocent should not be convicted.

“with measures available to address any risk he might present to other patients, to staff or to himself.”

Furman now remains at the 47-bed Hillside Psychiatric Centre in Kamloops

A Coroner’s Report

Ontario Coroner’s Case: History

Date of Death: September 4, 2011Reason for ReviewThe GLTCRC was asked to review the circumstances

surrounding the death of this 87-year-old woman who died as the result of injuries received following an assault by another resident in a licensed long-term care home.

Ontario Coroner’s Case: History

The woman was admitted to the long-term care home on March 27, 2011, with advanced dementia, ischemic heart disease and congestive heart failure.

At the time of admission, the woman was using a walker to ambulate and required some assistance with her activities of daily living. She did not understand why she was admitted to the facility; she did not feel she had any health issues and wanted to go home. Sometimes she would refuse care by staff.

% On April 1, 2011, the woman was seen scratching a male resident, so she was redirected.

% On April 5, 2011, the family requested that the woman be transferred to another unit as she was expressing fear of the male residents.

On May 11, 2011, a male resident wandered into the woman’s room and climbed into her bed. The male was removed and the woman would not settle for the rest of the night.

On May 15, 2011, she spent the night wandering in and out of other residents’ rooms.

Ontario Coroner’s Case: History

On August 4, 2011, she was transferred from a mixed ward to a female-only ward.

Ontario Coroner’s Case: History

On August 31, 2011, at 2000 hours, the woman was ambulating using her walker in the hallway.

Staff witnessed her stop to talk to another resident and during the conversation, she was pushed. The woman fell, striking her head on the wall and hitting her hip on the railing. She remained on the floor with a shortened and externally rotated left hip. The physician at the long-term care home ordered that the woman be transferred to hospital for assessment. The woman’s family reported the August 31, 2011 assault to police.

Ontario Coroner’s Case: History

The woman was admitted to the local hospital on August 31, 2011 and had a surgical repair of the fractured hip on September 2, 2011. She suffered perioperative hypotension and elevated troponins and was thought to have had a myocardial infarction. The woman died on September 4, 2011.

Ontario Coroner’s Case: History

The individual who pushed the woman was another ambulatory female resident, aged 70 years. She had been admitted to the long-term care home in 2009 and her medical history included dementia with paranoid episodes, multiple falls and hypothyroidism. Her medications included: rivastigmine, mirtazipine, risperidone and rabeprazole.

Ontario Coroner’s Case: History

January 17, 2011 was the first recorded incident of the 70-year-old female pushing another resident. Her family arranged for an outside agency to sit with her for an hour twice weekly, which seemed to help settle the woman.

On April 7, 2011, she passed the same resident she had pushed earlier in the year, and made that resident angry. The woman was redirected. On May 13 and 15, 2011, the woman pushed two different residents to the floor.

Ontario Coroner’s Case: History

Ontario Coroner’s Case: History

Reports were submitted for these incidents, as well as times when the woman hurt staff members who were helping her with activities of daily living.

The woman was given quetiapine as needed, which was helpful on some occasions, but at other times, she became more agitated.

% Cause of death was severe coronary artery disease with evidence of congestive heart failure as a complication. The hip fracture was considered a significant contributing factor due to the trauma and major surgery.

Manner of death was homicide.

Ontario Coroner’s Case: Post Mortem

This is the case of an 87-year-old severely demented woman who was pushed by another resident and fractured her hip from the fall. She had peri-operative hypotension and elevated troponins and died two days post-operatively, on September 4, 2011.

The resident that pushed the decedent was subsequently seen by psychiatry on September 12, 2011 and admitted to a behavioural unit on September 19, 2011. She returned to the long-term care home on November 1, 2011.

Ontario Coroner’s Case: Discussion

Scope of the Issue

About 750 000 Canadians are living with dementia (15% of Canadians 65 years and older)

This number is expected to rise to 1.4 million by 2031 (Alzheimer’s Society of

Canada)

Estimated annual cost of dementia in direct and

indirect healthcare and lost family income of caregivers is

$33 billion.

Expected to reach $ 293 billion by 2040.

A May 2012 report of Ontario’s long-term care task force on resident care and safety found that in 2011, 57% of the abuse and neglect incidents (1568 of 2273) studied in long-term care were resident-to-resident encounters (the rest were staff-to-resident or resident-to-staff).

W5 Research: Counting Canada’s care home homicides.

Published Friday, September 27, 2013

http://www.ctvnews.ca/w5/w5-research-counting-canada-s-care-home-homicides-1.1473825#ixzz2qyx8tikW

Coroners and Chief Medical Examiners in every province and territory provided statistics.

Important caveat was that the numbers do not establish culpability. When a coroner says “homicide” it’s not a determination of guilt, it’s a constitution of fact that the actions of one person resulted in the death of another.

Accidents are not included.

The tragic stories behind the statistics include a son strangling his mother in a mercy killing, an altercation involving a man visiting his wife in a nursing home and residents dying in fires deliberately set by other residents.

W5 Research: Counting Canada’s care home homicides.

Combined numbers from Coroners, CMEs and media reports; 2012 and 2013 omitted due to incomplete data for Ontario,

Manitoba and Alberta.

When all the data was in, six provinces combined reported 53 homicides for various periods between 1990 and August 2013; four provinces reported zero, so did the three territories.

There have been 25 homicides in Ontario’s long-term care facilities between 2001 and 2011.

And at least 60 nursing home homicides across Canada in the last 12 years.

But the prevailing trend revealed points to a crisis in how our society cares for people living with dementia.

W5 Research: Counting Canada’s care home homicides.

Contributing Factors and Triggers

Scant literature on the prevalence, key characteristics and outcomes of resident-to-resident aggression (RRA) or violence (RRV) in nursing home settings.

The literature has overwhelmingly focused on violence that is directed by residents towards caregivers, or vice versa.

Prediction and prevention important because of consequences including physical and/or chemical restraint and physical and/or emotional harm.

RRV is defined as the delivery of noxious stimulus by one resident to others that is clearly not accidental.

(Patel and Hope, 1992)

RRV specific triggers (Lachs et al., 2007; Rosen et al., 2008)

calling out

territoriality

roommate incompatibility

impatience

loneliness

abandonment

jealousy

disinhibition

competition for material resources

intrusion into private spaces

dementia.

Resident-to-Resident Violence Triggers in Nursing Homes.Snellgrove, Susan et al. Clinical Nursing Research. 22(4) 461-474. 2013.

Semistructured interviews with 11 certified nurses’ assistants in Arkansas to provide insight into factors, including unmet needs that may trigger.

Active triggers

intrusive behaviours such as wandering into a resident’s personal space

taking belongings

Resident-to-Resident Violence Triggers in Nursing Homes.Snellgrove, Susan et al. Clinical Nursing Research. 22(4) 461-474. 2013.

Passive triggers (internal and external environment)

boredom

competition for attention

communication difficulties

Collocating nursing home residents with behavioral disturbances increases the potential for RRA

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff.Rosen et al., J Am Geriatr Soc 2008

OBJECTIVES: To more fully characterize the spectrum of resident-to-resident aggression (RRA).

DESIGN: A focus group study of nursing home staff members and residents who could reliably self-report.

SETTING: A large, urban, long-term care facility.

PARTICIPANTS: Seven residents and 96 staff members from multiple clinical and nonclinical occupational groups.

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff.Rosen et al., J Am Geriatr Soc 2008

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff.Rosen et al., J Am Geriatr Soc 2008

35 different types of physical, verbal, and sexual RRA described.

Most frequent in dining room and residents’ rooms, and in the afternoon (although occurred regularly in the facility at all times).

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff.Rosen et al., J Am Geriatr Soc 2008

29 antecedents identified as instigating episodes of RRA.

Most common was calling or making noise.

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff.Rosen et al., J Am Geriatr Soc 2008

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff.Rosen et al., J Am Geriatr Soc 2008

Racism, ethnic stereotyping, and religious differences contributed to RRA.

Many residents are not used to closely interacting with those of other backgrounds, and LTC facilities are often multicultural, especially in urban areas.

What triggered Jack Furman?

frustration?

loss of privacy?

fear of change?

late-onset post-traumatic stress and wartime flashbacks?

Prevention and Intervention1. Education2. Staff and support3. Environment4. Person-Centred Care

Prevention and Intervention: Education

A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial.

International Journal of Nursing Studies 50 (2013) 644–656Teresi et al.

There was a significant increase in knowledge post-training, controlling for pretraining levels for the intervention group significantly increased recognition of R-REM and longitudinal reporting in the intervention as contrasted with the control group.

Conclusions: A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long-term care facilities.A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial.International Journal of Nursing Studies 50 (2013) 644–656Teresi et al.

Prevention and Intervention: Education

A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial.International Journal of Nursing Studies 50 (2013) 644–656Teresi et al.

The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.

The design was a prospective cluster randomized trial with randomization at the unit level.

A sample of 1405 residents from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not.

Prevention and Intervention: Education

Prevention and Intervention: Staff and SupportOntario Coroner’s CaseRecommendation 1:

To the Ministry of Health and Long-Term Care (MOHLTC) and the Ontario Association of LTC Physicians: Residents who are assessed as a danger to other residents should be given priority to receive timely intervention, including admission to a behavioural unit as appropriate, to optimize the behaviour of the resident.

Recommendation 2:

LTC homes are reminded that if a resident is assaulted by another resident and sustains injuries that may constitute a criminal offence, the a assault should be reported to the local police.

Prevention and Intervention: Staff and SupportOntario Coroner’s Case

Recommendation 3

LTC homes are reminded of the MOHLTC’s High Intensity Needs Funding program, and the availability for supplemental staffing and preferred accommodation for residents with severe behavioural issues.

Recommendation 4

LTC homes are reminded to contact their Local Health Integration Network for assistance and information about behavioural support programs and training available in their community.

Staff should assist in residents in maintaining a maximum amount of control over their personal space, belongings, and environment

Overstimulation in the form of loud noises, crowding, and perceived extreme temperatures may lead to RRV.

Allow for adequate space for residents to move around, spaces in which residents can escape from noise and adequate clothing for cold-natured residents may decrease RRV.

Prevention and Intervention: Environment

Resident-to-Resident Violence Triggers in Nursing Homes.Snellgrove, Susan et al. Clinical Nursing Research. 22(4) 461-474. 2013.

Prevention and Intervention: Environment

Dutch doors can secure a resident in while allowing monitoring by staff.

Eliminating multiple-bed rooms should be a priority.

Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff.Rosen et al., J Am Geriatr Soc 2008

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

Prevention and Intervention: Person-Centred Care

Prevention and Intervention: Person-Centred Care

www.bcbpsd.ca

A Final Thought...

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