Preventing Resident-to-Resident
Aggression in Dementia
Dwayne E. Wall
Eilon Caspi Ph.D.
Geriatrics & Extended Care Data & Analyses Center, Providence VAMC
Annual NICE Knowledge Exchange, Toronto, May 21, 2014
Sponsored by Institute for Life Course and Aging,
University of Toronto
The Role of Language
Old Culture
Problematic behaviors
Disruptive behaviors
Behavior symptoms
Neuropsychiatric symptoms
New Culture
Expressive Behaviors
Behavioral Expressions
Reactive behaviors
Responsive behaviors
White Paper: Dementia Care: The Quality Chasm (2013). National Dementia Initiative.
Caspi, E. (2013). Time for change: Persons with dementia and “behavioral
expressions,” not “behavior symptoms.” JAMDA, 14(10), 768-769.
RRA in dementia is over a century-long problem
"…when walking about
groped the faces of other
patients, and was often
struck by them in return."
Source: Lock (2013). The Alzheimer’s Conundrum:
Entanglements of Dementia and Aging. Princeton
University Press.
Auguste D. Year: 1901
Quotations
(Caspi, 2013)
• “This is a matter of serious concern. It happens
very often and will be fatal.” – Resident
• “Some of them really get afraid of him, and when
I say get afraid…I mean get afraid…When they
see him coming, they don’t want to sit in the
dining room…” – CNA
• “I am afraid that he will hurt someone when we
don’t see it…especially someone frail whom he
can take down with one blow.” – CNA
Serious Consequences
Negative consequences for:
Target resident
Exhibitor
Witnesses
Staff
Family members
Visitors
LTC residence
Society
+ Substantial cost implications…
Serious Consequences
Target Residents
• Psychological: frustration, anger,
anxiety, fear, sadness, depression, social
isolation, avoidance of activities and
dining room
• Physical: Injuries and accidents: falls,
dislocations, bruises or hematomas,
reddened areas, fractures, lacerations,
abrasions (Shinoda-Tagawa et al. 2004)
• Deaths (numerous reports in the media)
Frank Piccolo
Guiding Principles
• Aggressive behaviors in persons with dementia are usually expressions
of unmet needs (Whall & Kolanowski, 2004; Sifford, 2010)
• They usually have meaning, purpose, and function to the resident
• Attempts at communication
• Attempts at gaining control over threatening/unwanted situation
• Attempts at preserving dignity
•
Barometers for tolerance to stressful stimuli…
(Smith et al. 2004)
Unmet Needs
• They have the same needs as we do…
The difference?
They have difficulty identifying or meeting their needs or
expressing them verbally
• They become distressed for the same reasons we do
The difference?
They are less and less able to tolerate and cope with the
stress in their environment…
Responsive Behaviors
Definition
“A response to something negative, frustrating, or confusing in
the person’s environment
It places the reasons or triggers for challenging behaviors
outside, rather than within, the individual,
thereby recognizing that problems in the social and physical
environment can be addressed and changed”
Lisa Loiselle (2004) - Murray Alzheimer’s Research & Education Program
Guiding Principles
• The cumulative effects of multiple factors – intersect
with the resident’s cognitive and other impairments –
leading to RRA
• Aggressive behaviors tend to manifest in patterns
(e.g. time of day, location, events, people, things)
• A small number of residents account for a large portion
of RRA (Malone et al., 1993; Negley & Manley, 1990; Allin et al. 2003;
Almvik et al. 2007; Bharucha et al. 2008)
Guiding Principles
• “The best way to handle aggressive behaviors is to
prevent them from occurring in the first place”
(Judy Berry, Lakeview Ranch)
• “Understand the meaning of the sequence that led to
the aggressive behavior” (Cohen-Mansfield et al. 1996)
• Situational triggers and early warning signs can be
identified in the majority of RRA episodes (Caspi, 2013;
Snellgrove, 2013)
• Triggers may be: Remote, immediate, internal…or any
combination of these…
Guiding Principles
• Interdisciplinary assessment is critical for identifying
contributing factors, causes & triggers – the basis for
individualized intervention
• A comprehensive, proactive, & well-coordinated
intervention must be applied consistently at multiple
time points and levels of the organization to achieve a
sustainable prevention effect
• Commitment by everyone at all levels of the
organization and beyond…
Anticipatory Care Approach
“Actions taken before the usual time of onset of a
particular need or problem in order to prevent or
moderate the occurrence of the problem”
(Kovach et al. 2005)
Interventions are more effective when
implemented before peak level of agitation
Smith et al. (2004)
Case Example
(Catherine Unsino)
• Every day at 6:00pm a resident becomes aggressive
(slamming drawers & throwing books across room) and
screams: “I need a line, I need a line, I need a line.”
• Staff couldn’t understand what he meant…
• Life history: He was a traveling businessman who used
to call his wife every night to tell her “Good night” and
“I love you.”
• Intervention: Staff let him call his wife before 6:00pm
• Outcome: The behavior was eliminated, he was calm,
and psychotropic medications were avoided…
Walking Group Intervention
(Holmberg, 1997)
• Concerns about “wandering” during early evening
hours causing RRA on dementia unit
• Intervention: Immediately after dinner volunteers
led 30-minute walking group for 3 consecutive days
• Compared to 4 days without walking groups
• Outcome: Reduction of 30% in aggressive incidents
during 24 hours after walking… (RRA & resident-staff)
Case Example
(Johnston 2000)
Horticulture group activity in VA Medical Center – a group of veterans
are transplanting blooming tulips…
Mr. W became pale, tremulous, agitated, hyperventilated, and
assaulted another resident…
He was physically restrained and returned to the locked unit
Conversation revealed: Became distressed on seeing the tulips
Life history: During his army service in WWII (1943-5) several of his
platoon were killed after being cornered in a tulip field…
Case Example
(Moniz-Cook et al. 2001)
Jack, 89 years old, late stage Alzheimer’s
“Aggressive” toward staff, residents, visitors…but
can’t verbalize his concern…
Observation (2-month): Total of 19 episodes
Usually: Grabbing, pulling & shaking others
Staff were unable to identify the trigger…
Case Example (Cont.)
Observation (4-day): Only one attack on the psychologist as she put on
her green coat prior to leaving…
Life history: Jack belonged to a fishing community where the color
green was believed to be unlucky b/c of its association with death…
Intervention (20-month): No green clothes policy
Outcome: Only 1 episode – when a new staff didn’t redirect Jack from
the room where a visitor dressed in green…
Behavior reframed: Jack was trying to protect others from the
harmful effects of the green clothes…
Reflection Question
“If you had the perfect pill that could take away these behaviors…without side
effects…would you give it to these people…even when you know that the pill
will not address the unmet needs that cause the behavior?”
Professor Cohen-Mansfield, as cited by Dr. Allen Power
Conceptual Framework
Prevention of Resident-to-Resident Aggression (RRA) in Dementia
Contributing*
Factors,*Causes,*&*
Triggers*
Assessment*
Development*of*
Individualized*
Intervention*
Prevention*&*
De6Escalation*
Strategies*
Reduction*of*RRA*
Ineffective*
Intervention*
Contributing Factors, Causes, & Triggers
Permission to use the picture was received from JDC-ESHEL (Photographer Moti Fishbain)
Contributing Factors, Causes, & Triggers
Resident’s Background Factors
 Male
 Prior occupation
 Pre-morbid personality
 Aggression prior to admission
 Poor quality of relationships
 Depression
 bvFTD; VaD; Early-onset AD; CTE (D Pugilistica), TBI, Korsakoff S
 Mental illness (e.g. Schizophrenia, Bipolar)
 PTSD
 Delusions and hallucinations
 Substance abuse
Contributing Factors, Causes, & Triggers
Physiological/Medical & Functional Factors
 Pain
 Constipation
 UTI
 Incontinence
 Memory loss (short-term memory deficit)
 Visuospatial disorientation (Wayfinding difficulty)
 Impaired ability to communicate
 Sleeping problems / Fatigue
 Hearing/vision loss
Contributing Factors, Causes, & Triggers
Situational Causes and Triggers
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Frustration
Boredom
Invasion of personal space
Seating arrangement
Intolerance of another’s behavior
Repetitive speech
Competition for resources
Unwanted entry into bedroom
Conflicts b/w roommates
Racial/ethnic comments/slurs
Contributing Factors, Causes, & Triggers
Factors in Physical Environment

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Noise
Crowdedness
Lack of privacy and private away areas
Inadequate landmarks/signage (wayfinding difficulties)
Hallways (too narrow; “dead ends”)
Inadequate lighting & glare
Too cold or hot
Indoor confinement
TV
Elevators
Contributing Factors, Causes, & Triggers
Staff and Organizational Factors


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Low staff-resident ratio
Lack of training (Dementia care & RRA-specific)
Inappropriate approaches (“Elderspeak”)
Inattentiveness to early warning signs & triggers
Burnout
Underreporting
Poor quality of documentation/assessment
Tense relationships
Staff-resident language/cultural mismatch
Prevention and De-escalation Strategies
• Strategies at regulatory/oversight, emergency,
and law enforcement levels
•
•
•
•
Procedures & strategies at organizational level
Proactive measures
Immediate strategies during episodes
Post-episode strategies
Strategies at the regulatory/oversight,
Emergency, & Law Enforcement Levels
•
•
•
•
Address RRA in regulations
Require adequate number of hours of activities per day
Increase state inspectors focus on RRA
Ombudsman (training, reporting standards, complaint
categories)
• “NH Compare” should track verbal, physical, sexual RRA
• Require by law to inform residences on paroled offenders
• Increase involvement of Medicaid Fraud Control Units
Strategies at the regulatory/oversight,
Emergency, & Law Enforcement Levels
• Improve Coroner/Medical Examiner practices
(workloads; training; data repository)
• Improve practices related to death certificates
• Increase collaboration b/w police & state
survey agencies
• Train first responders (medical emergency
staff & law enforcement personnel)
Need for Adequate Reimbursement
• Address inadequate reimbursement mechanism
(e.g. disincentive to prevent RRA):
“In the current reimbursement system you get more
money if someone’s behavior is out of control. So
what’s the incentive to do it?”
– Judy Berry,
Lakeview Ranch
• “Non-pharmacological interventions should be
reimbursed in the manner pharmacological
interventions are” (Cohen-Mansfield, 2000)
Consensus Guidelines
(Howard et al. 2001; American Geriatrics Society, 2003)
• The 1st line of treatment of behaviors in nursing home
residents with dementia is non-pharmacological
(personalized) approach
• Unless there is an immediate risk for harm or when the
person is in severe distress…
• Psychotropic medications are:
* Not effective for most PwD and may cause harm
* They mask the need underlying the behavior…
* Very expensive
Serious Mental Illness
• The reality: Many with serious mental illnesses
(e.g. Schizophrenia) live in nursing homes…
• Strengthen collaboration b/w mental health
centers/specialists & LTC homes
• Develop specialized housing solutions for persons
with serious mental illness (Harvey, 2005; Leff et al. 2000)
MDS 3.0
• Add RRA-specific questions to MDS 3.0
• Currently, it is not possible to identify the target of
aggressive behaviors (Section E – Behavior)
• Major missed opportunity to shed light on RRA
Caspi, E. (2013). M.D.S. 3.0 – A giant step forward but what about
items on resident-to-resident aggression? JAMDA, 14(8), 624-625.
Procedures & Strategies at
Organization Level
• Employ the right people & support them!!!
• Train staff in:
AD-specific communication techniques (Feil & de Klerk-Rubin, 2012)
RRA-specific recognition and prevention strategies
(Teresi et al. 2013)
•
•
•
•
•
Address RRA in Policies and Procedures
Maintain adequate staff-resident ratio
Recruit volunteers to strengthen supervision
Promote empathy and compassion b/w residents
Hold Resident & Family Council Meetings
Procedures & Strategies at
Organization Level
• Set realistic admission criteria
• Conduct pre-admission behavioral evaluation
• Put preventive measures for newly admitted residents
(e.g. Buddy System, Lakeview Ranch, MN)
• Improve roommate selection (monitor existing assign.)
• Strengthen reporting policy & quality documentation
• Collaborate and seek input from family members
Proactive Measures
•
•
•
•
•
Be constantly alert. Watch residents vigilantly!
Be proactive! “Stop the vicious cycle of reactivity” (Zgola, 1999)
Regularly move around the unit (avoid tendency to congregate…)
Remove or secure objects used as weapons
Physical environment (address described above factors & triggers)
• Identify and address early warning signs of distress (Caspi, 2012)
• Assess risk of imminent violence using Brøset Violence Checklist
(Almvik & Woods, 1999; Almvik et al. 2007)
• Proactively identify & address unmet needs before they escalate...
Proactive Measures
• Proactively identify and address physical discomfort/medical needs
(e.g. Discomfort Scale (DS-DAT) – Hurley et al. 1992)
• Recognize & treat pain (assessment tools in LTC residents with
dementia – Hadjistavropoulos et al. 2010)
• Be informed about previous altercations…
• Work as a team!
• Enhance communication b/w staff and managers
• Build close trusting relationships with residents
Implement consistent assignment (staff-resident)
• Know the life history of residents (20 reasons) (Caspi, 2014a)
Find out what makes him/her lose temper/become angry
Close Trusting Relationship
Permission to use: this image received from Ofir Ben Natan, ESHEL, Israel
Proactive Measures
•
•
•
•
•
Structured/consistent routine (but be flexible…)
Engage residents in meaningful activities
Monitor content on TV
Ensure managers present (esp. evenings; weekends)
Train staff in non-violent self-protection techniques
• Install emergency call buttons & use hand-held radios
• Use assistive technology (e.g. Vigil Dementia System)
(Kutzik et al. 2008)
• Care-Media technology (Bharucha et al. 2006)
Meaningful Activities
• [ADD PICTURES OF ENGAGEMENT IN
ACTIVITIES]
Permission to use: this image received from Ofir Ben Natan, ESHEL, Israel
Experts’ Opinion
“Activities are the main weapon against behavior
difficulties and violent behavior” – Dr. Paul Raia
“If a person with dementia is engaged in a meaningful
activity, the person can not simultaneously be exhibiting
problematic behavior” – Dr. Cameron Camp
Unless there’s…
Unmet medical need, fatigue, or remote trigger from the past. Something
negative or irritating in the physical environment (TV content, glare, or crowding)
could also trigger behavioral expressions during activities. Activities that are not
planned well or not delivered professionally and lack of skilled guidance, cueing,
and encouragement may also contribute to anxiety and behavioral expressions.
Structured Activities
•
Music therapy / Music-based activities / Listening to favorite music (Film: Alive
Inside)
•
Physical activity (Exercise / Taking a walk together / Dancing)
•
Art Therapy (water colors) / Simple crafts (clay; wood craft);
Museum visits (MoMA Alzheimer’s project; ARTZ)
•
Aroma Therapy / Massage Therapy (English Rose Suites)
•
Therapeutic gardening (Planting flowers or herbs on a raised flower bed)
•
Pet therapy (Animal-assisted therapy) (Lakeview Ranch)
•
Reconnecting with nature / Bird watching (e.g. “Bird Tales” program) / Fishing /
Visiting the zoo / botanical gardens
•
Spiritual /religious activities
Study on Activities in LTC Residences
(Casey, in press)
• 36 LTC homes; 406 residents; 82% with dementia
• Compared structured activity time with unstructured time
Findings
Unstructured time
More disengaged (“doing nothing”), anxious, agitated, sad...
Structured activity time
Less anxious, more engaged, and happier
“Left on her own and becomes
anxious and agitated”
• A study in two dementia units on a group of 12 residents
with the highest levels of behaviors (Caspi, 2014b)
• Findings: The residents developed negative emotional
states and various behaviors when left alone for too long…
• Became worried, restless, frustrated, anxious, fearful, sad,
irritable, angry, and aggressive…
• Hygiene problems & risky behaviors
• When engaged in meaningful activities, they had much
less negative experiences and much more positive
experiences…
Expert’s Opinion
“If I have one message about dementia-related behavior…it is:
Assume people are scared. They live in a world that doesn’t make sense to
them. They don’t know who to trust and they are looking for reassurance
that they are in the right place, doing the right thing, and that someone
knows how to find them. That explains a lot of the behaviors.
If you think about that each time you see someone who looks like they are
behaving uncharacteristically or aggressively, you’ll do fine.”
– Professor Lisa Gwyther, Alzheimer’s Research Center, Duke University
Source: HealthCare Interactive: Online Dementia Training
Permission to use: this image received from Ofir Ben Natan, ESHEL, Israel
Permission to use the image received from Dr. Cathy Greenblat,
author of the book: Love, Loss, & Laughter: Seeing Alzheimer’s Differently (2011
Permission to use the image received from Dr. Cathy Greenblat,
author of the book: Love, Loss, & Laughter: Seeing Alzheimer’s Differently (2011
Permission to use the image received from Dr. Cathy Greenblat,
author of the book: Love, Loss, & Laughter: Seeing Alzheimer’s Differently (2011)
The reality is that LTC residents are not engaged in
meaningful activities most of the time…
As shown in research:
Cohen-Mansfield et al. (1992)
Burgio et al. (1994)
Schreiner et al. (2005)
Wood et al. (2005)
“A wise lawyer will first approach the activity
director and ask: ‘How did you engage the
resident in a way that would have prevented
the violence/injury against my client?’”
– Dr. Paul Raia
Immediate Strategies During Episodes
“The behavior can not be
changed directly,
only indirectly by changing
either our approach or
the person’s physical
environment”
– Dr. Paul Raia
Immediate Strategies During Episodes
• “Engage in a swift, focused, decisive, firm, and coordinated
intervention” (Soreff, 2012)
• Immediately defuse “chain reactions” (Anxiety is contagious!)
• Redirect resident(s) from the area
• Offer the person to take a walk together
• Distract/divert to a different activity / change the activity
• Refocus/switch topic to his/her favorite conversation topic
• Position, reposition, or change seating arrangement
Immediate Strategies During Episodes
•
•
•
•
•
Physically separate residents
Avoid conversations in loud/crowded places
Slow down!
Never approach from behind/side… Usually from the front
Establish eye contact (unless threatening/culturally
inappropriate)
• If he starts to walk away, don’t try to stop him right away
(Berry, 2012)
• Maintain a safe distance (slightly beyond striking range)
• Speak at the level of the eyes
• Speak with…not at the resident
Immediate Strategies During Episodes
• Stay calm! They will “mirror” your emotional state (Sturm et al 2013) and
respond to the unspoken (your body language & tone of voice…)
• Be sincere. Many with dementia are able to detect insincerity…
•
Avoid smiling during tense episodes
• Be firm and direct (rather than angry or irritated)
• Identify & address underlying needs behind the behavior
• Use short, simple, familiar words/sentences & one-step directions
• Never ignore the emotions of a resident… Encourage expression of
feelings (fear; anger; frustration) but in a safe location...
Immediate Strategies During Episodes
• Encourage a compromise
• “Save face”
• Never argue, reason, correct, or criticize a resident with dementia
• Acknowledge & agree even if he/she is incorrect (unless unsafe)
• “Validate the subjective truth, internal reality, & feelings of the person, no
matter how illogical, chaotic, or paranoid...” (Feil & de Klerk-Rubin, 2012)
• Avoid Reality Orientation (in mid-to-late stage Alzheimer’s)
• Avoid questions that challenge the short-term memory
• Listen to feelings, not facts; Respond to emotions, not behavior
• Turn negatives into positives; Avoid using words: “No” & “Why?”
Immediate Strategies During Episodes
•
•
•
•
“Never command/demand. Instead ask for their help” (Berry, 2012)
Provide frequent reassurance; Apologize sincerely
Ask the person for permission
It is (usually) not intentional. Try not to take it personally
• “If what you are doing is not working, STOP! Back off – Give the
person some space and time. Decide of what to do differently. Try
again!” (Teepa Snow). Don’t leave resident(s) alone when unsafe!
•
•
•
•
Seek assistance from co-workers (esp. those resident trusts)
Be consistent in approach (across staff, shifts, & weekends)
Notify interdisciplinary team and physician re episodes
Promote restraint-free care environment (Flaherty, 2004; Wang &
Moyle, 2005; Möhler et al. 2011; Tilly & Reed, 2006)
Post-Episode Strategies
•
Reassurance, reassurance, reassurance!
•
De-briefing procedures and meetings (“360-degree” approach)
•
Document the sequence of events & triggers (Behavior Log – Caspi, 2013)
•
Seek emotional support from a trusted co-worker/supervisor
•
Consult with nurse/physician (first aid; evaluate medical cause; change in meds)
•
Inform & consult with family re episode and psychological/physical state
•
Evaluate need for change in seating arrangement or bedroom/roommate
•
In extreme circumstances (e.g. potential for immediate harm), consider transfer to
psychiatric hospital / neurobehavioral unit for evaluation
•
Provide detailed, reliable, and timely written report on RRA episodes as required
in the regulations governing your residence
Assessment is Key
•
•
•
•
•
•
Comprehensive
Interdisciplinary
Person-directed / Whole person
Life course perspective
Needs-based
Persistent
Implement: Assessment-based
Anticipatory Care Approach
Toolkit:
• Recognizing Early Warning Signs (Caspi, 2012)
• Rating Anxiety in Dementia (RAID) scale (Shankar et al. 1999)
• Discomfort Scale in Dementia of Alzheimer’s Type (Hurley et al. 1992)
• Behavioral Log (Caspi, 2013)
• R-REM Instrument (11-item) (Teresi et al. 2013)
• Brøset Violence Checklist (Almvik et al. 2007)
• Interdisciplinary Screening Form (RRA & dementia-specific) (Caspi)
• Behavior Intervention Plan Form (Dr. Paul Raia)
“You have formed a theory then?”
Behavioral Log
Date
When? Where?
_/_/_ Time
Who?
Why?
Location Who
Cause /
was
Trigger
there?
Intervention
Outcome
Suggestion
Describe
intervention,
if any
Describe
outcome
Make a
suggestion
for future
What? Detailed description of the behavior and what happened (sequence of events)
BEFORE and AFTER the behavior:
______________________________________________________________________
______________________________________________________________________
Persistent use of a behavioral log enables to identify patterns,
causes, and triggers – the basis for individualized intervention
To receive the full version of the Behavioral Log, please email me
Will was hitting residents for
apparently no reason…
(Raia, 2011)
Keeping a behavioral log showed:
The hitting occurred only in the activity room [Where?]
Never at night [When?]
Never struck the same person twice [Who?]
Only on sunny days but not on all sunny days [What?]
Only if he sat on one side of the room [Where?]
The sun was glaring in his eyes. He thought the residents
were playing with the light switch… [Why?]
Intervention: Drawing down a shade when he is in the room
Outcome: Hitting discontinued; Psychotropic meds avoided…
Looking into the future
“Due to the retirement of the baby boomers
and the estimated growth of elders with
dementia, we are going to see increasing
incidence of resident-to-resident violence.
There will be more and more pressure from
family members and advocacy groups to keep
the residents safe.” – Dr. Paul Raia
Closing Quotation
“The world is a dangerous place; not because
of those who do evil, but because of those who
look on and do nothing.”
– Albert Einstein
Questions
Permission to use: this image received from Ofir Ben Natan, ESHEL, Israel
References
Allin, S. J., Bharucha, A., Zimmerman, J., Wilson, D., Roberson, M. J., Stevens, S., et al. (2003). Toward the automated assessment of behavioral disturbances
of dementia. Paper presented at the meeting of the Fifth International Conference on Ubiquitous Computing and the Second International Conference on
Ubiquitous Computing for Pervasive Healthcare Applications, Seattle, WA.
Almvik, R. & Woods, P. (1999). Predicting inpatient violence using the Brøset Violence Checklist (BVC). International Journal of Psychiatric Nursing Research,
4(3), 498-505.
Almvik, R. Woods, P. & Rasmussen, K. (2007). Assessing risk for imminent violence in the elderly: The Brøset Violence Checklist. International Journal of
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Berry, J. (2012). Dementia care training manual. Lakeview Ranch. Dementia Care Foundation.
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Research and Practice. Published OnlineFirst Sep 4 2013.
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Caspi, E. (2013). M.D.S. 3.0 – A giant step forward but what about items on resident-to- resident aggression? [Letter to the Editor]. Journal of the American
Medical Directors Association, 14(8), 624-625.
References (cont.)
Caspi, E. (2013). Behavioral Log: A critical tool for understanding and preventing reactive behaviors among long-term care residents
with dementia. [Available from Eilon upon request]
Caspi, E. (2014a). Why do we need to know the early life history of older persons with dementia? URL: http://tinyurl.com/l6p6ux4
Caspi, E. (2014b). Does self-neglect occur among older adults with dementia when unsupervised in Assisted Living? An exploratory,
observational study. Journal of Elder Abuse and Neglect, 26(2), 123-149.
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handbook of clinical gerontology (pp. 375-397). London: Sage Publications.
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Cohen-Mansfield, J., Marx, M., & Werner, P. (1992). Observational data on time use and behavior problems in the nursing home. The
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Literature Reviews
Rosen, T., Pillemer, K., & Lachs, M. (2007). Resident-to-resident
aggression in long-term care facilities: An understudied problem.
Aggression and Violent Behavior, 13, 77-87.
Rosen, T., Lachs, M.S., & Pillemer, K. (2010). Sexual aggression
between residents in nursing homes: Literature synthesis of an
underrecognized problem. Journal of the American Geriatrics
Society, 58, 1070-1079.
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