Minnesota Nursing magazine

Eilon Caspi

Tracking the untracked

Study tallies deaths from resident-to-resident incidents with dementia
Steve Rudolph

Auguste Deter, a 51-year-old woman who had begun experiencing changes in her personality, was admitted to an asylum in Frankfurt, Germany on Nov. 25, 1901.

She would later become known as the first person identified with what we now know as Alzheimer’s disease. During her residency, she was hit repeatedly by other residents when she invaded their personal space.

More than a century after Deter’s death much has been learned about Alzheimer’s disease, which is currently estimated to impact 5.7 million Americans and projected to rise to 14 million by 2050. Very little has been done to date to study and ultimately prevent injurious and fatal incidents between residents with dementia in long-term care homes.

Eilon Caspi, PhD, a research associate at the School of Nursing, is determined to change that.

Lacking a national database to draw from, Caspi gathered information from media accounts and death review records to conduct the first exploratory study surrounding the death of elders as a result of residentto- resident incidents in dementia in the United States and Canada.

“The fact that we are not capturing and tracking this phenomenon represents a major missed opportunity.”
– Eilon Caspi, PhD, School of Nursing research associate

After analyzing 105 deaths he uncovered preliminary patterns, something he hopes will lead to further study and reduce future injuries and fatalities among this vulnerable population.

Among Caspi’s observations was that more than 40 percent of all fatalities were the result of what was classified as a push-fall contact.

“Many of the injuries consisted of hip fractures or head or brain injuries and on average it was slightly more than two weeks from the incident to their passing, which speaks volumes to the frailty and vulnerability of this population,” said Caspi.

He also discovered how frequently the incidents occurred in the evenings and on weekends (44 percent and 38 percent respectively). Nearly twothirds were reportedly not witnessed by staff. A related finding revealed that 59 percent of fatal incidents occurred inside bedrooms and more than 40 percent involved roommates.

“In some of the cases I examined, the residents were considered best friends,” said Caspi, who has been studying this phenomenon for over a decade. “We have to remember that dementia is progressive and even a friend may reach a breaking point. All you need is one push to cause a major and irreversible physical injury to a frail resident.”

Caspi hopes his research prompts the Centers for Medicare and Medicaid Services, the Center for Disease Control and Prevention Division of Violence Prevention, the U.S. Office of Inspector General and the U.S. Government Accountability Office to conduct the first national investigation of injurious and fatal resident-to-resident incidents in this country.

“The fact that we are not capturing and tracking this phenomenon represents a major missed opportunity for learning and prevention of these incidents and developing strategies to ensure that frail and vulnerable residents will remain safe and free from physical and psychological harm in the last years of their lives,” said Caspi.

Caspi’s article, The circumstances surrounding the death of 105 elders as a result of resident-to-resident incidents in dementia in long-term care homes, was published in the August-October issue of Journal of Elder Abuse & Neglect.