NURSING home residents are at risk of injury and death from assaults carried out by other patients as violence increasingly becomes an everyday part of care.
While the Royal Commision into Aged Care Quality and Safety hears harrowing cases of neglect and abuse, researchers believe many assault cases, some even resulting in death, may go unreported every year because of a loophole in the reporting system.
Although the headline-grabbing image is of a vulnerable patient harmed by a nursing home staff member, many assaults are instead the result of aggression between residents as facilities grapple with increasing numbers of violent dementia patients.
In 2017-18 there were 241,723 people in permanent aged care with the average age at admission being 82 for men and 84.5 for women.
It is well recognised that the population is ageing and there is a preference for older people to remain at home with support until they are no longer able to look after themselves. This is resulting in a much older nursing home population with a higher incidence of cognitive decline such as dementia.
Some residents display high levels of aggressive behaviour and about 90 per cent of staff have also been subjected to some form of assault including hitting, kicking and pushing.
Last year a 90-year-old man died after a fight with 77-year-old man in a dementia ward at a Wollongong nursing home and a 102-year-old man was charged over an alleged aggravated indecent assault of a 94-year-old woman at an aged care facility in Sydney’s east.
Two people die as a result of aggression between nursing home residents each year and about 4000 nursing home assaults are reported to the Department of Health. But these numbers are unlikely to represent a true picture of the situation as nursing home operators have discretionary powers to not report resident-to-resident assault to the department and the police if the aggressor has dementia and a behaviour management plan is put in place within 24 hours of the allegation.
A survey of nursing home staff by the NSW Nurses and Midwives Association revealed more than 20 per cent of respondents had witnessed resident-to-resident assault including hitting, pushing, kicking and verbal abuse, once or twice a week; research that mirrors figures from the US.
The survey report also quotes Canadian research which highlights that violence has become a normalised part of long term care and that resident-to-resident assault is an urgent and persistent issue.
Professor Joseph Ibrahim from the Health, Law and Ageing Research Unit at the Monash University Department of Forensic Medicine explained to The Senior that the lack of reporting requirements meant there was no way of knowing the scale and severity of the problem.
Professor Ibrahim said research had identified 28 deaths resulting from aggression between residents in Australia from 2000-2013 but he believed this to be only “the tip of the iceberg”.
Some deaths of residents could be explained as falls-related and some might happen downstream – “say someone has a broken hip and dies a month later,” he said.
In the analysis conducted by Professor Ibrahim and PhD candidate Briony Murphy, almost 90 per cent of those involved in resident-to-resident aggression had a dementia diagnosis.
The research showed most exhibitors of aggression were male (85.7 per cent), often younger than their target and more recently admitted to the nursing home.
What value does society place on our older population?... by ignoring this issue we are devaluing our older population and subjecting them to a life where fear of attack becomes an unacceptable part of daily life.
The Nurses and Midwives Association report said the lack of urgency to find a solution to the problem goes to heart of the issue around ageing: “What value does society place on our older population?”
It adds: “The World Health Organisation recognises that older people often experience violation of their rights at a societal and institutional level simply due to their age. Quite simply, by ignoring this issue we are devaluing our older population and subjecting them to a a life where fear of attack becomes an unacceptable part of daily life.
“It would be inappropriate to criminalise people with cognitive impairment for committing acts of physical or verbal violence as they are essentially ‘blameless’, being affected by a brain disease rather than carrying out intentional ill will.
“However, there must be an effective system in place to keep both aged care residents and staff protected from physical or verbal assault.”
Professor Ibrahim said research had shown facility design was important in preventing violence.
“A place that allows you freedom of movement and a homely environment that helps keep you calm and engaged is a big plus, but that is difficult for a lot of facilities to achieve.”
Having staff formally trained in managing a person with dementia was also important, he said. “They need to know how to engage with their residents in a way that is non-threatening and which addresses their worries.”
“We really shouldn’t be surprised. If you have two people who are cognitively impaired, they’re not going to have the social skills to negotiate a dispute between themselves.”
Professor Ibrahim said there could be many triggers for the violence.
“A person with dementia might be trying to communicate something, they might be scared or bored, it might be that they have pain, or they’re constipated, or they’re not usually up in the middle of the day because they used to be a night shift worker, or a particular time of the day is associated with family or friends visiting and no one has turned up so now they’re anxious and the only way they can express this is by restlessly wandering about the place.
"They might be hungry but don’t know where to go for food or if they find food and eat it, people say it’s against the rules.
“Everyday behaviours which people assume a person with dementia is doing deliberately often have hidden meanings which competent staff with the training would be able to assess and put strategies in place to manage.
“We really shouldn’t be surprised. If you have two people who are cognitively impaired they’re not going to have the social skills to negotiate a dispute between themselves.”