To design effective interventions to manage and prevent RRA, we must move beyond descriptive epidemiology to explore risk factors that are associated with RRA aggression and victimization. Shinoda-Tagawa and colleagues began this investigation for victims, despite the study's methodological limitations, and identified male gender, behavioral disturbance (especially wandering), moderate functional dependency, and cognitive impairment as potential risk factors.
Although no literature directly addresses factors that characterize perpetrators of nursing home RRA, there is research that applies indirectly to this topic. A recent study, which also used data from the national Minimum Data Set for nursing homes, found that both verbally and physically aggressive behavior in nursing home residents was associated with depressive symptoms, delusions, and hallucinations, and that physically aggressive behavior was also associated with constipation (Leonard et al., 2006
). Multiple studies have suggested that much physically aggressive behavior among demented residents occurs in response to intrusion into personal space (Bridges-Parlet, Knopman, & Thompson, 1994
; Ryden, Bossenmaier, & McLachlan, 1991
). Problems such as psychiatric illness, alcoholism, and substance abuse are known to play an important role in many forms of family violence and probably are significant risk factors for RRA.
Cognitive impairment is likely to be a significant risk factor for both being a perpetrator and a victim of RRA. In the literature on elder abuse in community settings, cognitive impairment has been posited as an important potential risk factor for being a victim of elder mistreatment (Lachs & Pillemer, 1995
). In a nine-year observational cohort study of elder abuse risk factors, Lachs and colleagues (1997)
found that cognitive impairment, and worsening cognitive impairment in particular, conferred a five-fold risk of mistreatment in victims. In addition, the dementia patient's disruptive and disturbing behaviors themselves may be a trigger for abuse. Indeed, abuse by dementia caregivers appears often to occur in the context of frustration regarding care-recipient aggression (Pillemer & Suitor, 1992
), and similar findings have emerged regarding staff abuse of residents in nursing homes (Pillemer & Moore, 1989
). Most important, in the nursing home setting, multiple patients with dementia and dementia-related behavioral problems are usually congregated, creating frequent opportunities for impaired perpetrators and impaired victims to engage with one another and even exchange roles.
Further, characteristics of the nursing home physical plant and the residents' immediate environment may also have an effect on RRA, particularly for cognitively impaired residents, and research is needed to explore these potential risk factors in more detail. An examination of residents in Veterans Administration nursing homes found a higher frequency of aggressive behavior in larger nursing homes and hypothesized that crowding was the cause (Rudman, Bross, & Mattson, 1994
). One study comparing high and low density dementia units found that the cognitively impaired residents in the unit with more residents and limited space exhibited more disruptive behavior (Morgan & Stewart, 1998
). Studies in inpatient psychiatric facilities also found that the high density and crowding was correlated with violent episodes (Ng et al., 2001
; Nijman & Rector, 1999
). Sloane and colleagues (1998)
found that, in dementia special care units, environmental factors such as maintenance of public areas and cleanliness of halls, facility policy factors like use of physical restraints, and staff treatment factors such as nurse involvement with residents had an effect on levels of resident agitation.
Studies examining commingling of demented and non-demented residents found that non-impaired residents living with or near dementia residents suffered an alteration in mental and emotional status (Wiltzius, Gambert, & Duthie, 1981
) and had higher rates of dissatisfaction with their living situation (Teresi, Holmes, & Monaco, 1993
). Although RRA was not investigated in these studies, features that seemed to contribute to dissatisfaction and demoralization included agitated behaviors, noise, and other disturbances reported to be caused by suite or unit mates, suggesting that these might be triggers for abuse.
In addition to these factors, staffing and levels of training once an RRA perpetrator and victim are identified, and the proficiency of staff in separating two residents who engage in RRA may influence the subsequent prevalence of repeat events. Further, institutional attentiveness to these episodes, such as the willingness to reassign roommates, floors, dining partners, or establish programs to combat RRA, will certainly affect RRA chronicity in a facility.