Conflict in nursing homes is a surprisingly common occurrence among patients, especially those suffering from dementia. Resident-to-resident incidents are typically defined as negative, aggressive, and intrusive verbal, physical, material, and sexual interactions between patients, which can lead to psychological distress and physical harm. In some extreme and unfortunate cases, they can end in tragedy.

Such was the case of Frank Piccolo, a retired high school chemistry professor from Canada who in his later years developed dementia and was moved to a Toronto nursing home by his family. One evening in 2012, Frank was attacked by another resident, a woman who also had dementia. The woman hit Frank on the head and face with a wooden activity board, badly injuring him. Frank died three months later.

Although such extreme cases are rare, even minor conflicts between residents can have a significant psychological and physical toll on patients. But despite the serious nature of these incidents, they remain understudied and largely unaddressed across the more than 15,000 nursing homes found in the United States.

Until now, both government reports and media coverage have been content to chalk these incidents up to inevitable conflicts owed to interactions between mentally ill people. Residents involved in violent incidents are often called “perpetrators” or “aggressors”.

However, gerontologist and dementia behavior specialist Eilon Capsi strongly thinks otherwise. In a recent article, Capsi argues that home care violence among dementia patients is typically the result of unmet human needs, paired with their cognitive limitations. As such, the real problem is inadequate care and neglect. The real problem is the nursing homes themselves.

“Growing body of evidence suggests the true cause of these injuries and deaths is inadequate care and neglect on the part of care homes. Specifically, there is a lack of the specialized care that people with dementia require,” Capsi argued.

Some of the research supporting these assertions includes a 2004 study by the Harvard School of Public Health, which found the rate of violent incidents between residents was nearly three times higher in dementia care homes than in other long-term care homes. Meanwhile, another study supports this observation, finding higher rates of injurious or even fatal interactions between residents in dementia care homes than in other care homes.

These findings may startle many family members currently considering a care home for relatives showing signs of dementia. However, there are good care homes where conflict is minimal thanks to proper staffing with trained professionals and adequate care.

Violent conflict occurs mostly when the patients’ emotional, medical, and other needs are not properly met. All that pinned up frustration is let out during a breaking point, which may result in a patient pushing or hitting another resident.

In 2018, Capsi undertook a study in which he used publicly available information (primarily newspaper articles and death review reports) to identify patterns pertaining to the circumstances surrounding the death of 105 elders as a result of these incidents. The researcher found that nearly half of fatal incidents were associated with frustrating psychological triggers. And these triggers are much more common in dementia care homes since those with advanced dementia are more likely to inadvertently say or do things that may anger other residents, another study from the U.S. found.

The strongest triggers included those pertaining to violations of personal space and possessions. These include taking or touching a resident’s belongings or food, or unwanted entries into their bedroom. Crowded spaces may also lead to two residents claiming the same space, such as a dining room seat.

A stale and uneventful care home can also trigger violent outbursts among dementia residents just as well as crowded and busy institutions. Research shows that lack of meaningful activity and generally feeling bored can raise the pressure among residents, contributing to harmful interactions. Evenings and weekends are particularly dangerous.

“In most of these situations, the person with dementia does not intend to injure or kill another resident. Individuals with dementia live with a serious cognitive disability. And they often must do it while being forced to share small living spaces with many other residents,” Capsi said.

The researcher calls for raising the standards of dementia care homes in order to stave off the number of these preventable incidents that can lead to tragedies like Frank’s story. This includes increasing staff and improving training such that patients receive the care and attention they rightly deserve and need to live a dignified life.

“Understanding the role of dementia is important. But seeing a resident’s brain disease as the main cause of incidents is inaccurate and unhelpful. That view ignores external factors that can lead to these incidents but are outside of the residents’ control,” he concluded.