Participant Materials

Nursing Response to Elder Mistreatment

Participant Materials

3. Scope and Nature of Elder Mistreatment

Purpose

This module provides nurses with basic information on elder mistreatment, including prevalence and incidence, types of mistreatment, sign of possible mistreatment by type and distinguishing signs of possible mistreatment from common changes associated with aging, disease-related changes and medication-related changes. Family violence in later life, elder sexual abuse and institutional elder mistreatment are discussed in some detail.

Learning Objectives

By the end of this module, participants will be able to:

· Discuss the scope and nature of elder mistreatment;

· Discuss the incidence and prevalence of domestic and institutional elder mistreatment;

· Describe characteristics of victims and perpetrators of elder mistreatment;

· Describe signs of different types of possible elder mistreatment;

· Describe how common changes in aging, disease, chronic conditions and medications can mask or be misinterpreted as mistreatment; and

· Discuss family violence in later life, elder sexual abuse and elder mistreatment in institutional settings.

Case Study Introduction

Case study

Mrs. Kennedy, an 87-year-old widow, arrived at the hospital emergency department (ED) by ambulance accompanied by her neighbor, Judy. Judy had noticed that her neighbor’s mail box was full and Mrs. Kennedy’s cat roaming outside the house for a couple days. Mrs. Kennedy did not answer Judy’s repeated phone calls. Judy did not remember seeing Mrs. Kennedy’s son around for the last week. While Mrs. Kennedy is mentally alert, she is physically frail and uses a walker to get around. She also has macular degeneration and suffers from emphysema. Mrs. K. depends on her son, who lives with her, to help with her daily activities—meal preparation, cleaning/home maintenance, bathing, dressing and administering her medications. Due to her concerns, Judy peered in Mrs. Kennedy’s window and saw her neighbor lying on the floor. She called 911.

Upon examination in the ED, Mrs. Kennedy was diagnosed with a broken hip, dehydration, malnutrition, hypertension and pneumonia complicated by emphysema. Her hygiene was poor; she had soiled herself and had not bathed in a couple days. There were purplish-colored bruises on her arms, legs and torso.

When the nurse asked Mrs. Kennedy about how she was caring for herself at home, Mrs. Kennedy reluctantly admitted that she had not seen or heard from her son for the last week; she had been trying to care for herself, but was unable to do so. Mrs. K. said that, while she was able to get herself to and from the bathroom, she had little energy for anything else. She reported that she fell on her way to the bathroom yesterday and could not get up to call for help. She also said that she had not been able to find her medications. When asked how long her son had been gone and how often these absences occurred, Mrs. Kennedy evasively replied that her son tries to do his best to help her, but that he needed a break from her and had his own problems. She mentioned that he was trying to kick a drug habit and had difficulty holding a job; that she writes him checks from time to time to help him financially. When asked about her bruises (especially the bruises on her torso), Mrs. Kennedy denied that her son ever deliberately hurt her.

Questions for the attending nurse to consider:

? What are the patient issues in this case?

? What do you currently know that helps you address these issues?

? What do you still need to know to respond to these issues?

Key Points

In the course of their interactions with patients, nurses may suspect elder mistreatment in either domestic (community) or institutional settings. The term elder mistreatment describes intentional acts by a caregiver or “trusted other” that cause harm or serious risk of harm to a vulnerable older adult and/or omission of acts wherein a caregiver or trusted other fails to meet basic needs of a vulnerable older adult.[1]

Vulnerable older adults—those who have a diminished capacity for self-care and self-protection—are often easy targets for perpetrators.[2]

Elder mistreatment may take place over a long period of time and only become apparent to others at certain times (e.g., when the patient is brought to the hospital with a severe injury).

It can be difficult to distinguish elder mistreatment from problems that occur due to progression of aging, disease or chronic conditions.

To respond in these cases, nurses involved need clarifying data to further detect or rule out elder mistreatment (gathered in the course of screening, medical history taking, complete examination and discussions with others who present with the patient).

Data on Elder Mistreatment[3]

Consider the following questions:

? What misconceptions about the extent and nature of elder mistreatment have you seen held as truth in your work setting or in your communities?

? How do these misconceptions impact interactions between patients and healthcare providers and subsequent interventions?

Key Points

No one knows precisely how many older adults are mistreated—surveillance is limited and the problem remains greatly hidden.

Best available estimates on prevalence:[4]

· Between 1 and 2 million Americans age 65 or older have been injured, exploited or otherwise mistreated by someone on whom they depended for care or protection.[5] (2003)

· Between 2 and 10 percent of older adults 65+ are victims of some form of abuse or neglect.[6] (2004)

Reporting and Risk Factors[7]

-Elder mistreatment is rarely reported. Some estimates include: one in 14 incidents of domestic elder mistreatment comes to the attention of authorities (1988);[8] for every case of elder mistreatment reported, five cases go unreported (1996);[9] and 8.3 cases of abuse are reported for every 1000 older Americans (2006).[10]

-Who are the victims? Abuse of Aged 60+, 2004 Survey of Adult Protective Services found two thirds of victims were women (often 80+). Elder mistreatment occurs among people of all cultural and ethnic backgrounds and socioeconomic levels. Victims are usually socially isolated and live in close proximity to or with their perpetrators. Victims usually have personal relationships with their perpetrators. Often, victims are dependent on their perpetrators for assistance with daily activities. Just as important to note, however, is the fact that perpetrators may be dependent on their victims for housing, money, etc.

-Who are the perpetrators? They are usually family members, most likely an adult child or the victim's spouse or partner who serves in the caregiver role. Two-thirds of perpetrators fall into this category.[11]

· One study showed that two-thirds of perpetrators were spouses and one-third were adult children.[12] Similarly, Abuse of Aged 60+, 2004 Survey of Adult Protective Services indicated that 33 percent of perpetrators were adult children.

· Common characteristics of perpetrators of elder mistreatment: a history of mental illness and/or substance abuse; excessive dependence on the older adult for financial support; and a history of violence within or outside of the family.[13]

-Risk Factors. Potential risk factors include the social context for the victim/perpetrator relationship (e.g., isolation); offender characteristics (see above); victim characteristics (e.g., dependence on others for care); living arrangements (e.g., shared) and relationship of perpetrator to victim (e.g., spouse or child); and power and control dynamics (level of dependence of victim/abuser, caregiver stress, guardianship/power of attorney, etc.).[14]

- Note on caregiver stress. “The concept that caregiver stress is a primary cause of elder abuse has been a prevailing theory for decades. The belief has been that stressed caregivers become overwhelmed and lash out at elders when care giving and life circumstances become too difficult…. There are cases where caregiver stress has caused an isolated incident of emotional or physical abuse…. However, too often abusers will describe being overwhelmed and stressed as an excuse so they will not be held accountable for their behavior. Often the abuse is not an isolated incident but part of a combination of emotional and physical abuse, isolation, threats, coercion and manipulation so the abuser gets his or her way. Professionals need to use caution and look for possible power and control dynamics in elder abuse cases rather than assuming stress or poor family dynamics are the cause. Unfortunately, elder abuse remedies that help with cases truly caused by stress can be dangerous for victims when power and control dynamics are present. Caregiver stress blames the victim, by implying that if the victim were not so hard to care for, the abuse would not occur. Too often remedies then focus on how to help the abuser feel less stressed rather than focusing on the safety needs of the victim. And finally social services remedies are often utilized without considering criminal justice interventions that hold the abuser accountable. In most cases, a stress-free abuser does not make the victim any safer.”[15]

-Intentional versus unintentional injuries and neglect. Intentional mistreatment involves a conscious and deliberate attempt to inflict harm or injury. Unintentional mistreatment occurs when an action inadvertently results in harm to the person. Unintentional mistreatment is usually due to ignorance, inexperience and/or a lack of caregiver ability/desire to provide proper care.[16] Whether intentional or unintentional, however, mistreatment can have serious detrimental outcomes for older individuals and should be addressed. *It is not up to the nurse/healthcare provider to determine whether mistreatment is intentional or unintentional.*

Signs of Possible Elder Mistreatment

Key Points

Below are examples of signs of types of possible elder mistreatment, in addition to reports by the patient.[17] See Module 7 for more on indicators.

Signs of possible emotional/psychological mistreatment

Note that these emotions and behaviors may be present with any type of mistreatment.

· Sudden agitation or confusion;

· Constant crying;

· Problems with sleep;

· Sudden changes in appetite or significant changes in weight;

· Unexplained withdrawal from activities;

· Depression, listlessness and/or non-responsiveness;

· Apathy/helplessness;

· Unusual behavior usually attributed to dementia (e.g., sucking, biting and rocking);

· Vague, chronic and/or non-specific complaints (e.g., victim may partially or vaguely disclose mistreatment to gauge reaction and the trustworthiness of the responder);

· New onset thoughts of suicide or self harm;

· New onset of fear or anxiety around caretaker or in general;

· New pattern in use/misuse of alcohol and drugs; and

· Implausible explanations of events.

Signs of possible neglect by others:

· Dehydration (as evidenced by low urinary output, dry/fragile skin, dry/sore mouth, apathy, lack of energy and mental confusion)

· Malnutrition and weight loss

· Poor personal hygiene, inappropriate dress and unkempt appearance;

· Skin breakdown/pressure ulcers;

· Unattended/untreated health problems (e.g., as seen by exacerbation of chronic diseases despite a care plan);

· Missed health appointments or delays/lack of follow through with medical care;

· Medication mismanagement (e.g., as seen by empty or unmarked bottles or outdated prescriptions);

· Hazardous or unsafe living condition/arrangements (e.g., improper wiring, no heat or no running water);

· Absence of assistive devices, such as dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces or commodes;

· Unsanitary living conditions (e.g. dirt, fleas or lice on person, soiled bedding, fecal/urine smell, inadequate clothing);

· Implausible explanations of events and/or injuries; and

· Any of the above with emotional/psychological/behavioral signs.

Signs of possible physical abuse

· Bruises in certain locations[18] (e.g., neck, ears, genitals, buttocks, soles of the feet or trunk) or pattern injuries (i.e., bruises or marks in the shape of fingers, wrap-around bruising on arms, legs and torso) not typically associated with accidental bruising in older adults;

· Welts, lacerations and abrasions;

· Open wounds, cuts, punctures, bite marks and other untreated injuries;

· Black eyes, broken eyeglasses/frames, bald spots where hair has been pulled out, rope marks and other physical signs of being subjected to punishment or being physically restrained;

· Bone fractures, broken bones and skull fractures;

· Sprains, dislocations and internal injuries/bleeding;

· Injuries not consistent with the history provided and significant unexplained injuries;

· Laboratory findings of medication overdose or under-utilization of prescribed drugs;

· Repeated accidental injuries and frequent trips to the hospital emergency department (or missed health appointments or delays/lack of follow through with medical care);

· Implausible explanations of events and/or injuries; and

· Any of the above emotional/psychological/behavioral signs.

Signs of possible sexual abuse

· Bruises around the breasts or genitalia;

· Unexplained sexually transmitted diseases or genital infections;

· Unexplained vaginal or anal bleeding;

· Torn, stained or bloody underclothing;

· Implausible explanations of events and/or injuries; and

· Any of the above emotional/psychological/behavioral signs.

Signs of possible abandonment

· Desertion of a vulnerable older adult at a hospital, a nursing facility or other similar institution;

· Desertion of a vulnerable older adult at a public location;

· Implausible explanations of events and/or injuries; and

· Any of the above emotional/psychological/behavioral signs.

Signs of possible financial exploitation

· Older person signing financial documents she/he does not understand;

· Sudden changes in bank account or banking practice (e.g., unexplained withdrawal of money by a person accompanying the vulnerable older adult);

· Inclusion of additional names on an older person's bank signature card;

· Unauthorized withdrawal of a person's funds using ATM card;

· Abrupt changes in a will or other financial documents;

· Unexplained disappearance of funds or valuable possessions;

· Substandard care being provided or bills unpaid despite the availability of adequate financial resources;

· Discovery of an older person's signature being forged for financial transactions or for the titles of her/his possessions;

· Sudden appearance of previously uninvolved relatives claiming their rights to an older person's affairs and possessions;

· Unexplained sudden transfer of assets to a family member or someone outside the family;

· Provision of services that are not necessary;

· Implausible explanations of events; and

· Any of the above emotional/psychological/behavioral signs.

Signs of possible violation of personal rights

· Forcible eviction or placement in a nursing home;

· Loss of decision-making power; new power of attorney or guardianship in place

· Loss of privacy;

· Implausible explanations of events and/or injuries; and

· Any of the above emotional/psychological/behavioral signs.

Behavioral signs of possible perpetrators: for example, minimize or deny abuse of the vulnerable older adult; blame the victim for being clumsy or difficult; are charming and helpful OR abusive to health care or other professionals (e.g., “I’ll call your supervisor” or “I’ll sue you.”); act loving to victim in professional’s presence; answer for the victim; say the victim is incompetent, unhealthy or crazy; refuse to allow visitors to see/speak to the older person alone or for health care providers to complete care; agree to a health care plan but never follows through; use the system against the victim by threatening “their rights;” turn family members against the victim; threaten suicide or harm to loved ones or a family pet; take/do not let victim purchase or use/hides certain items; and, talk about how good the victim has it or how ungrateful the victim is.[19]