preventing resident-to-resident aggression in dementia eilon caspi ph.d. geriatrics & extended care...

Preventing Resident-to-Resident Aggression in Dementia Eilon Caspi Ph.D. Geriatrics & Extended Care Data & Analyses Center, Providence VAMC Annual NICE Knowledge Exchange, Toronto, May 21, 2014 Dwayne E. Wall

Sponsored by Institute for Life Course and Aging, University of Toronto

The Role of Language 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 Alzheimers 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 afraidI mean get afraidWhen they see him coming, they dont want to sit in the dining room CNA I am afraid that he will hurt someone when we dont see itespecially 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 persons 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 Alzheimers Research & Education Program

Guiding Principles The cumulative effects of multiple factors intersect with the residents 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, internalor 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 couldnt 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 Alzheimers Aggressive toward staff, residents, visitorsbut cant 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 didnt 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 behaviorswithout side effectswould you give it to these peopleeven 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

Contributing Factors, Causes, & Triggers Permission to use the picture was received from JDC-ESHEL (Photographer Moti Fishbain)

Contributing Factors, Causes, & Triggers Residents 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 Frustration Boredom Invasion of personal space Seating arrangement Intolerance of anothers 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 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 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 someones behavior is out of control. So whats 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 1 st 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 Brset 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 theres 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 Alzheimers 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

Experts Opinion If I have one message about dementia-related behaviorit is: Assume people are scared. They live in a world that doesnt make sense to them. They dont 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, youll do fine. Professor Lisa Gwyther, Alzheimers 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 Alzheimers Differently (2011

Permission to use the image received from Dr. Cathy Greenblat, author of the book: Love, Loss, & Laughter: Seeing Alzheimers 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 persons 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, dont try to stop him right away (Berry, 2012) Maintain a safe distance (slightly beyond striking range) Speak at the level of the eyes Speak withnot 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 Alzheimers) 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). Dont 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; Mhler 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 C aspi, 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 Alzheimers Type (Hurley et al. 1992) Behavioral Log (Caspi, 2013) R-REM Instrument (11-item) (Teresi et al. 2013) Brset 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 DateWhen?Where?Who?Why?InterventionOutcomeSuggestion _/_/_TimeLocationWho was there? Cause / Trigger 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 Brset 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 Brset Violence Checklist. International Journal of Geriatric Psychiatry, 22, 862-867. Berry, J. (2012). Dementia care training manual. Lakeview Ranch. Dementia Care Foundation. Bharucha, A. J., Vasilescu, M., Dew, M. A., Begley, A., Stevens, S., Degenholtz, H., & Wactlar, H. (2008). Prevalence of behavioral symptoms: Comparison of the Minimum Data Set assessments with research instruments. Journal of the American Medical Directors Association, 9(4), 244-250. Bharucha, A. J., London, A.J., Barnard, D., Wactlar, H., Dew, M.A., & Reynolds, C.F. (2006). Ethical considerations in the conduct of electronic surveillance research. The Journal of Low, Medicine, & Ethics, 34(3), 611-619. [CareMedia] Burgio, L.D., Scilley, K., Hardin, J.M., Janosky, J., Bonino, P., Slater, S.C., & Engberg, R. (1994). Studying disruptive vocalization and contextual factors in the nursing home using computer-assisted real-time observation. Journal of Gerontology, 49(5), 230-239. Casey et al. (in press). Computer-assisted direct observation of behavioral agitation, engagement, and effect in LTC residents. JAMDA. Caspi, E. (2013). Aggressive behaviors between residents with dementia in an assisted living residence. Dementia: The International Journal of Social Research and Practice. Published OnlineFirst Sep 4 2013. Caspi, E. (2012). Recognizing Early Warning Signs of Responsive Behaviors in Persons with Dementia. URL: http://tinyurl.com/kz8m8a6http://tinyurl.com/kz8m8a6 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/l6p6ux4http://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. Cohen-Mansfield et al. (1996). Wandering and aggression. In L.L. Carstensen, B.A. Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology (pp. 375-397). London: Sage Publications. Cohen-Mansfield, J. (2000). Nonpharmacological management of behavioral problems in persons with dementia: The TREA model. Alzheimers Care Quarterly, 1(4), 22-34. Cohen-Mansfield, J., Marx, M., & Werner, P. (1992). Observational data on time use and behavior problems in the nursing home. The Journal of Applied Gerontology, 11(1), 111-121. Feil, N. & de Klerk-Rubin, V. (2012). The validation breakthrough: Simple techniques for communicating with people with Alzheimers- type dementia. (3rd ed.). Baltimore: Health Professions Press. Flaherty, J. (2004). Zero tolerance for physical restraints: Difficult but not impossible. Journal of Gerontology, 59A, 919-920. Johnston, D. (2000). A series of cases of dementia presenting with PTSD symptoms in World War II combat veterans. JAGS, 48, 70-72. Hadjistavropoulos et al. (2010). Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities. Physiotherapy Canada, 62, 104-113. Harvey, P.D. (2005). Schizophrenia in late life: Aging effects on symptoms and course of illness. Washington, DC: American Psychological Association.

References (cont.) Holmberg, S.K. (1997). Evaluation of a clinical intervention for wanderers on a geriatric nursing unit. Arch of Psychiatric Nursing, XI(1), 21-28. Hurley, A.C., Volicer, B.J., Hanrahan, P.A., Susan, H., & Volicer, L. (1992). Assessment of discomfort in advanced Alzheimers patients. Research in Nursing and Health, 15, 369-377. Kovach, C.R., Noonan, P.E., Schlidt, A.M., & Wells, T. (2005). A model of consequences of need-driven dementia-compromised behavior. Journal of Nursing Scholarship, 37(2), 134-140. Kutzik, D.M., Glasscock, A.P., Lundberg, L., & York, J. (2008). Technological tools of the future. In S.M. Golant & J. Hyde (Eds.). The assisted living residence: A vision for the future. Baltimore, MD: The Johns Hopkins University Press. Leff, J. et al. (2000). The TAPS Project: A report on 13 years of research, 1985-1998. Psychiatric Bulletin, 24, 165-168. Malone, M. L., Thompson, L. S., & Goodwin, J.S. (1993). Aggressive behaviors among the institutionalized elderly. Journal of the American Geriatrics Society, 41, 853-856. Mhler, R., Richter, T., Kpke, S., & Meyer, G. (2011). Interventions for preventing and reducing the use of physical restraints in long-term geriatric care. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD007546. Moniz-Cook, E. Woods, R.T., & Richards, K. (2001). Functional analysis of challenging behavior in dementia: The role of superstition. International Journal of Geriatric Psychiatry, 16, 45-56. Negley, E.N. & Manley, J.T. (1990). Environmental interventions in assaultive behavior. Journal of Gerontological Nursing, 16(3), 29-33. Raia, P. (2011). Habilitation Therapy in dementia care. Age in Action, 26(4), 1-5. Schreiner, A.S., Yamamoto, E., & Shiotani, H. (2005). Positive affect among nursing home residents with Alzheimers dementia: The effect of recreational activity. Aging and Mental Health, 9(2), 129-134. Shankar et al. (1999). The development of a valid and reliable scale for rating anxiety in dementia (RAID). Aging & Mental Health, 3(1), 39-49. Shinoda-Tagawa, T., Leonard, R., Pontikas, J., McDonough, J.E., Allen, D., & Dreyer, P.I. (2004). Resident-to-resident violent incidents in nursing homes. Journal of the American Medical Association, 291(5), 591-598.

References (cont.) Sifford, K.S. (2010). Caregiver perceptions of unmet needs that lead to resident-to-resident violence involving residents with dementia in nursing homes (Unpublished doctoral dissertation). University of Arkansas. Smith, M., Gerdner, L.A., Hall, G.R., & Buckwalter, K.C. (2004). History, development, and future of the Progressively Lowered Stress Threshold: A conceptual model for dementia care. Journal of the American Geriatrics Society, 52(10), 1755-1760. Snellgrove, S.Beck, C., Green, A., McSweeney, J.C. (2013). Resident-to-resident violence triggers in nursing homes. Clinical Nursing Research, 22(4), 461-474. Soreff, S. (2012). Violence in the nursing homes: Understandings, management, documentation, and impact of resident to resident aggression. In V. Olisah (Ed.), Essentials Notes in Psychiatry. InTech: Open Access Sturm, V., Yokoyama, J.S., Seeley, W.W., Kramer, J.H., Miller, B.L., & Rankin, K.P. (2013). Heightened emotional contagion in mild cognitive impairment and Alzheimers disease is associated with temporal lobe degeneration. Proceedings of the National Academy of Sciences, 110(24), 9944-9949. Teresi, J.A., Ocepek-Welikson, K., Ramirez, M., Eimicke, J.P. Silver, S., Van Haitsma, K., Lachs, M.S., & Pillemer, K. (2013b). Development of an instrument to measure staff-reported resident-to-resident elder mistreatment (R-REM) using item response theory and other latent variable models. The Gerontologist, [Advance Access published February 28, 2013] Teresi, J.A., Ramirez, M., Ellis, J., Silver, S., Boratgis, G., Kong, J., Eimicke, J.P., Pillemer, K., & Lachs, M. (2013). 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, 644-656. [Staff Training] Tilly, J. & Reed, P. (2006). Dementia care practice recommendations for assisted living residences and nursing homes. Alzheimer's Association. Wang, W.W., & Moyle, W. (2005). Physical restraint use on people with dementia: A review of the literature. Australian Journal of Advanced Nursing, 22(4), 46- 52. Casey et al. (in press). Computer-assisted direct observation of behavioral agitation, engagement, and effect in LTC residents. JAMDA. Whall, A.L., & Kolanowski, A.M. (2004). The need-driven dementia-compromised behavior model A framework for understanding the behavioral symptoms of dementia. Aging & Mental Health, 8(2), 106-108. Wood et al. (2005). Activity situations on an Alzheimers disease special care unit and resident environmental interactions, time use, and affect. American Journal of Alzheimers Disease and Other Dementias, 20(2), 105-118. Zgola, J.M. (1999). Care that works: A relationship approach to persons with dementia. Baltimore: The Johns Hopkins University Press.

List of Studies on RRA Caspi, E. (2013). Aggressive behaviors between residents with dementia in an assisted living residence. Dementia: The International Journal of Social Research and Practice. Published OnlineFirst Sep 4 2013. Castle, N.G. (2012). Resident-to-resident abuse in nursing homes as reported by nurse aides. Journal of Elder Abuse & Neglect, 24(4), 340-356. Holmberg, S.K. (1997). Evaluation of a clinical intervention for wanderers on a geriatric nursing unit. Arch of Psychiatric Nursing, XI(1), 21-28. Lachs, M., Bachman, R., Williams, & OLeary J. R. (2007). Resident-to-resident elder mistreatment and police contact in Nursing Homes: Findings from a population-base cohort. Journal of the American Geriatrics Society, 55(6), 840-845. Malone, M. L., Thompson, L. S., & Goodwin, J.S. (1993). Aggressive behaviors among the institutionalized elderly. Journal of the American Geriatrics Society, 41, 853-856. Negley, E.N. & Manley, J.T. (1990). Environmental interventions in assaultive behavior. Journal of Gerontological Nursing, 16(3), 29-33. Pillemer, K., Chen, E.K., Van Haitsma, K.S., Teresi, J., Ramirez, M., Silver, S., Sukha, G., & Lachs, M.S. (2011). Resident-to-resident aggression in nursing homes: Results from a qualitative event reconstruction study. The Gerontologist. Advance Access published November 1, 2011.

List of Studies on RRA (cont.) Rosen, T., Lachs, M. S., Bharucha, A. J., Stevens, S. M., Teresi, J. A., Nebres, F., & Pillemer, K. (2008). Resident-to-resident aggression in long-term care facilities: Insights from focus groups of nursing home residents and staff. Journal of the American Geriatrics Society, 56(8), 1398-1408. Shankar et al. (1999). The development of a valid and reliable scale for rating anxiety in dementia. Aging & Mental Health, 3(1), 39-49. Shinoda-Tagawa, T., Leonard, R., Pontikas, J., McDonough, J.E., Allen, D., & Dreyer, P.I. (2004). Resident-to-resident violent incidents in nursing homes. Journal of the American Medical Association, 291(5), 591-598. Sifford-Snellgrove, K.S., Beck, C., Green, A., McSweeney, J.C. (2012). Victim or initiator? Certified nursing assistants perceptions of resident characteristics that contribute to resident-to-resident violence in nursing homes. Research in Gerontological Nursing, 5(1), 55-63. Sifford, K.S. (2010). Caregiver perceptions of unmet needs that lead to resident-to-resident violence involving residents with dementia in nursing homes (Unpublished doctoral dissertation). U of Arkansas. Snellgrove, S.Beck, C., Green, A., McSweeney, J.C. (2013). Resident-to-resident violence triggers in nursing homes. Clinical Nursing Research, 22(4), 461-474. Teaster, P. B., Ramsey-Klawsnik, H., Mendiondo, M. S., Abner, E., Cecil, K., & Tooms, M. (2007). From behind the shadows: A profile of sexual abuse of older men residing in nursing homes. Journal of Elder Abuse and Neglect, 19(1), 29-45. Zhang, Z., Schiamberg, L., Oehmke, J. et al. (2011). Neglect of Older Adults in Michigan Nursing Homes. Journal of Elder Abuse and Neglect, 23, 58-74.

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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