Elder mistreatment is a widespread problem in our society that is often under-recognized by health care professionals. As a result of growing public outcry over the past 20 years, all states now have abuse laws that are specific to older adults; most states have mandated reporting by all health care professionals. The term “mistreatment” includes physical abuse and neglect, psychological abuse, financial exploitation and violation of rights. Poor health, physical or cognitive impairment, alcohol abuse and a history of domestic violence are some of the risk factors for elder mistreatment. Diagnosis of elder mistreatment depends on acquiring a detailed history from the patient and the caregiver. It also involves performing a comprehensive physical examination. Only through awareness, a healthy suspicion and the performing of certain procedures are physicians able to detect elder mistreatment. Once it is suspected, elder mistreatment should be reported to adult protective services (HHS fact sheet, 2005). It is estimated that over 2 million older adults are mistreated each year in the United States.
Elder mistreatment first gained attention as a medical and social problem about 20 years ago, when the term “granny battering” first appeared in a British medical journal. Since that time, elder mistreatment has become a matter of concern not only in the United States, but throughout the world. This heightened awareness has followed a growing awareness of child and spousal abuse. Nevertheless, because of differing definitions, poor detection and under-reporting, the extent of elder mistreatment is unknown. These same factors make the collection of data difficult and its accuracy questionable. Published studies estimate that the prevalence of elder mistreatment ranges from 1 to 5 percent (Healthy people, 2010). Most health care professionals are reluctant to address domestic violence. However, physicians are in an ideal position to detect and manage mistreatment, as they may be the only person outside the family/caregiver role who regularly sees the older adult.
In addition, the physician is the most likely person to order the testing, hospital admissions and support services that are sometimes needed to correct elder mistreatment. This paper will discuss the clinical, ethical and legal issues regarding elder mistreatment. The various forms of elder mistreatment are defined, including ways to identify patient and caregiver risk factors, and history and physical findings that suggest a diagnosis of elder mistreatment. Finally, a systematic approach to patient evaluation, documentation and reporting of suspected cases will be reviewed.
Reasons elder abuse may be missed or not reported by health care professionals include unfavorable attitude toward older adults (ageism), little information in medical literature about elder mistreatment, reluctance to attribute signs of mistreatment (disbelief),isolation of victims (patient not seen often by physicians/health care providers), subtle presentation (i.e., poor hygiene or dehydration), reluctance/fear of confronting the offender, reluctance to report mistreatment that is only suspected, mistreated person requests that abuse not be reported (patient/physician privilege), lack of knowledge about proper reporting procedure, fear of jeopardizing relationship with hospital or nursing facility
Types of elder abuse
Physical Abuse- occurs when a person is touched in an inappropriate way, such as hitting, punching, kicking, slapping, and pushing. Physical abuse often leaves marks on the person’s body: bite marks, bruises, welts, and burn marks. Marks are often left on arms, wrists, face, neck, and abdomen area; Emotional/Psychological Abuse- occurs when a person is demeaning to another person. A person may treat the elder like a child or call them names. An elder may seem unusually depressed or may talk bad about themselves; Sexual abuse- among an elder occurs when sexual contact is made without consent. It also occurs when an elder is incapable of making such a decision, and is rape; Financial abuse- occurs when a person or persons take advantage of an elderly person financially.
This includes stealing money, lying about how much the elder needs for certain care, or cashing the elder’s checks without permission; Neglect/Abandonment- occurs when the elder is not being properly cared for, such as not being fed, bathed, and properly medicated. This is also when the elder is being ignored. The care giver refuses to give care to the individual (Physical abuse of the elderly, 2005).
Elder Mistreatment: Definitions and Classifications
In an effort to increase physicians’ awareness, facilitate accurate detection and promote further research, the American Medical Association published a position paper on elder mistreatment in 1987. This paper proposed a standard definition: “‘Abuse’ shall mean an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Abuse includes intentional infliction of physical or mental injury; sexual abuse; or withholding of necessary food, clothing, and medical care to meet the physical and mental needs of an elderly person by one having the care, custody or responsibility of an elderly person” (HHS fact sheet, 2005). Elder mistreatment may take many forms. Types of elder mistreatment are often classified as physical abuse and neglect, psychological abuse, financial exploitation and violation of rights. A major obstacle to prevention of and intervention for elder mistreatment is a lack of awareness on the part of physicians and other health care professionals (LA4Seniors, 2005).
Risk Factors and Prevention
Cognitive impairment and the need for assistance with activities of daily living are important risk factors for elder mistreatment. Caregiver burnout and frustration can lead to elder mistreatment. Substance abuse by the caregiver or the patient, especially abuse of alcohol, significantly increases the risk of physical violence and neglect. Psychological and character pathology in the caregiver and patient are also major risk factors. Prevention of elder mistreatment is difficult and depends as much on the social support network as on the medical network. Preventing elder mistreatment involves identifying high-risk patients and caregivers, and attempting to address the underlying issues. Screening patients and caregivers before placement can be helpful, when it is feasible. Helping patients obtain county or state assistance can also help reduce some high-risk situations.
Risk Factors for Elder Mistreatment
Older age, lack of access to resources, low income, social isolation, minority status, low level of education, functional debility, substance abuse by caregiver or by elderly person, psychological disorders and character pathology, previous history of family violence, caregiver burnout and frustration, and Cognitive impairment. History- Recognizing mistreatment is often difficult. The older adult may be unable to provide information because of cognitive impairment. The history is sometimes difficult to obtain from the victim, for fear of retaliation by the abuser. This retaliation can come in the form of physical punishment or threats of violence and abandonment. Older adults are often fearful of being placed in a nursing facility, and some may prefer to be abused in their own home rather than be moved to such a facility (LA4Seniors, 2005). The mistreated older adult often presents with somatic complaints. Physicians should ask older patients about rough handling, confinement and verbal or emotional abuse. Subtle or confusing complaints may actually be indicative of mistreatment.
It is important to recognize that abuse and neglect are most often discovered during routine visits at the physician’s office or in the long term care facility. Generally, the patient should be interviewed without the caregiver(s) present. Cognitive impairment may limit the ability to obtain an accurate history. It is important to ask general questions about conditions in the home or nursing facility. The physician should try to obtain an accurate view of the patient’s daily life, including meals, medication, shopping and social outlets (HHS fact sheet, 2005). It is also important to ask the patient about the nature and quality of the relationship with the caregiver. It may be helpful to ask questions such as, “How do you and the caregiver get along?” and “Is the caregiver taking good care of you?” It is critical to assess the patient’s mental status for indicators of depression or alcohol and substance abuse. A discussion of the patient’s financial situation may be appropriate.
If issues of mistreatment are raised, the caregiver should be interviewed as well. The physician must be careful not to over interpret or to make suggestive comments, especially when the patient is cognitively impaired. Essential Features of the History in the Assessment of Mistreated Elders Medical problems/diagnoses, detailed description of home environment (adequacy of food, shelter, supplies), accurate description of events related to injury or trauma (instances of rough handling, confinement, verbal or emotional abuse), history of prior violence, description of prior injuries and events surrounding them, description of berating, threats or emotional abuse, improper care of medical problems, untreated injuries, poor hygiene, prolonged period before presenting for medical attention, depression or other mental illness, extent of confusion or dementia, drug or alcohol abuse, quality/nature of relationships with caregivers.
Physical Examination and Laboratory Tests
The physical examination is often used as legal evidence of mistreatment. Laboratory and imaging studies should be performed to confirm any suspicious findings in the history and physical examination. The presence of dehydration and malnutrition can be established with simple laboratory tests such as a complete blood count and measurement of blood urea nitrogen, creatinine, protein and albumin levels. Radiographic studies provide evidence of old and new fractures. Unfortunately, proving that a fracture was caused by abuse can be difficult (HHS fact sheet, 2005). Role of advance nurse and nursing intervention strategies-
The nurses can play a vital role as a case finder, manager, advocate, educator, researcher and caregiver to physically abused elderly and family or caregiver in a given community. Inform the decision makers about the magnitude, trends and characteristics of violent deaths; and, evaluate and continue to improve by educating the patient and the care giver, and if is necessary reporting the abuser to the authorities. Nurses should involve the case managers and the social workers, document all the findings accurately and report the mistreatment case as soon as possible.
Documentation of all findings may be entered as evidence in criminal trials or in guardianship hearings. Documentation must be complete, thorough and legible. Such circumstances dictate that there is a “chain of evidence.” This need mandates a careful collection of physical evidence, which is critical in cases of suspected sexual or physical abuse. Laboratory data and, when possible, photographs should be used for verification of written documentation.
Management of elder mistreatment first involves discussing the situation with the patient, if feasible. The patient should be allowed to play a role in the ultimate resolution, if he or she is able to do so. First, the competency of the patient should be determined. Local and state social services have different methods of addressing mistreatment. Social workers from hospitals, clinics or long term care facilities are valuable resources and should be able to assist with these services. Multidisciplinary teams can be very effective. These teams typically include geriatricians, social workers, case management nurses and representatives from legal, financial and adult protective services.
Multidisciplinary teams are often more effective in problem-solving and provide a forum for discussion with participants involved in the older adult’s care. Senior advocacy volunteer groups are also helpful. A senior advocate can provide information to the abused person and enable access to resources from community programs and social services.
Basic Features of the Physical Examination
Head- Traumatic alopecia or other evidence of direct physical violence; poor oral hygiene; Skin- Hematomas, welts, bite marks, burns, decubitus ulcers; Musculoskeletal- fractures or signs of previous fractures; Neurological- cognitive impairment that is a risk factor for mistreatment and influences management decisions regarding competency; Genito rectal- poor hygiene, inguinal rash, impaction of feces; General- weight loss, dehydration, poor hygiene, unkempt appearance (LA4Seniors, 2005).
All health care providers (physicians, nurses, social workers, etc.) and administrators are mandated by law to report suspected elder mistreatment. The laws differ from state to state; physicians should determine the specific requirements in their states. Any other person may also report suspected abuse and neglect. All reporters are immune from civil liability if they act in good faith and without malice. They are also protected from termination of employment. Health care providers can be found to be negligent if they fail to report the suspected mistreatment. Penalties can include fines, imprisonment or loss of licensure. Reports of suspected elder mistreatment should be given to the state or county division of adult protective services. In the absence of such services, the reporter should contact the county extension office or the state’s office of child and family services. In addition, any Area Agency on Aging would be able to provide assistance in reporting suspected mistreatment.
The National Domestic Violence Hotline (telephone: 800-799-SAFE) or the Older Women’s League (telephone: 800-825-3695) could also help. Contacting the police is always an option, especially in an urgent situation (HHS fact sheet, 2005). In the event that the older adult is a resident of a long term care facility, a separate mechanism often exists for investigating suspected mistreatment through the state agency that surveys these facilities. Identifying the appropriate avenue for investigation can be done through the available adult protective service agency or the state department of child and family services (Elder Abuse, 2005). Once suspected mistreatment has been reported, the responsible agency will assign a social worker to investigate the case. The social worker will provide an accurate description of the home or nursing-facility environment.
After assessment, the social worker may provide insight into some possible solutions to the problem and information about available resources. Unlike cases of child abuse, if the older adult is competent to make decisions, he or she may refuse intervention. If the older adult is not competent to make decisions, a guardian can be appointed by the state. The guardian can then direct care as needed until the problem is satisfactorily resolved. Injury Prevention- In healthy people there is no precise data specific for elder abuse, but these are related data from that site. The target rate for physical assault by intimate partner is 3.3 physical assaults per 1,000, and the baseline is 4.4 physical assaults per 1,000. The target rate for annual rate of rape is 0.7 rapes or attempted rapes per 1,000 persons, and the base line is 0.8 rapes or attempted rapes per 1,000 (Health people, 2010).
Objectives from Healthy People 2010
Reduce injuries, disabilities, and deaths due to injuries and violence, and educating the primary care givers about the signs and symptoms of abuse or mistreatment, and educating them about alternative coping mechanisms. Several themes become evident when examining reports on injury prevention and control, including acute care, treatment, and rehabilitation. First, injury comprises a group of complex problems involving many different sectors of society. No single force working alone can accomplish everything needed to reduce the number of injuries. Improved outcomes require the combined efforts of many fields, including health, education, law, and safety sciences. Second, many of the factors that cause injuries are closely associated with violent and abusive behavior (Health people, 2010).
Violence and Abuse Prevention
Violence in the United States is pervasive and can change quality of life. Reports of children killing children in schools are shocking and cause parents to worry about the safety of their children at school, and if the problem is untreated the aggression later on will turn on the parents or older adults. Reports of gang violence make people fearful for their safety. Although suicide rates began decreasing in the mid-1990s, prior increases among youth aged 10 to 19 years and adults aged 65 years and older have raised concerns about the vulnerability of these population groups. Intimate partner violence and sexual assault threaten people in all walks of life (Elder Abuse, 2005). Violence claims the lives of many of the Nation’s young persons and threatens the health and well-being of many persons of all ages in the United States.
On an average day in America, 53 people die from homicide, and a minimum of 18,000 persons survive interpersonal assaults, and as many as 3,000 persons attempt suicide (Elder Abuse, 2005). Elderly, females, and children continue to be targets of both physical and sexual assaults, which are frequently perpetrated by individuals they know. Examples of general issues that impede the public health response to progress in this area include the lack of comparable data sources, lack of standardized definitions and definitional issues, lack of resources to establish adequately consistent tracking systems, and lack of resources to fund promising prevention programs.
Adults aged 65 years and older are at increased risk of death from fire because they are more vulnerable to smoke inhalation and burns and are less likely to recover. Sense impairment (such as blindness or hearing loss) may prevent older adults from noticing a fire, and mobility impairment may prevent them from escaping its consequences. Older adults also are less likely to have learned fire safety behavior and prevention information, because they grew up at a time when little fire safety was taught in schools, and most current educational programs target children (Healthy people, 2010).
To reduce the number and severity of injuries, prevention activities must focus on the type of injury—drowning, fall, fire or burn, firearm, or motor vehicle. Understanding injuries allows for development and implementation of effective prevention interventions. Some interventions can reduce injuries from violence-related episodes. For instance, efforts to promote awareness in society can help reduce the risk of assault, intentional self-inflicted and elder neglect and abuse. Higher taxes on alcoholic beverages are associated with lower death rates for some categories of violent crime, including mistreatment, abuse, and rape (Healthy people, 2010).
Healthy People Objectives
This organization encourages the Individuals, groups, and other organizations to use this framework and integrate it into their current programs, events, publications, and meetings, schools, colleges, and civic organizations to undertake activities in order to further the health of all members of their community. It is a national initiative that aims to improve the health of all Americans and eliminate disparities in health. Reducing the prevalence and overall number of people who suffer from different variety of diseases, and increase concerns for the nation’s elderly, and to reduce the overall rate of elder abuse, prevent its associated health problems, and educating the care givers and enhancing their coping mechanisms and alternative modalities to deal with the related stress. Health care providers can encourage their patients to pursue healthier lifestyles and to participate in community-based programs. By following the national objectives, individuals and organizations can build an agenda for community health improvement and can monitor results over time.
Healthy People objectives have been specified by Congress as the measure for assessing the progress of the Indian Health Care Improvement Act, the Maternal and Child Health Block Grant, and the Preventive Health and Health Services Block Grant. Healthy People objectives have been used in performance measurement activities (Healthy people, 2010). Many objectives focus on interventions designed to reduce or eliminate illness, disability, and premature death among individuals and communities, and to educate the care giver regarding recognizing elder abuse, and prevention modalities; others focus on broader issues, such as improving access to quality health care, strengthening public health services, and improving the availability and dissemination of health-related information.
Each objective has a target for specific improvements to be achieved by the year 2010. Together, these objectives reflect the depth of scientific knowledge as well as the breadth of diversity in the Nation’s communities. More importantly, they are designed to help the Nation achieve Healthy People 2010’s two overarching goals and realize the vision of healthy people living in healthy communities (Healthy people, 2010).
Interim Progress toward Year 2000 Objectives
Numerous objectives addressed injury prevention in Healthy People 2010. Twenty-six objectives were specific for unintentional injuries, and 19 objectives were specific for violence prevention. By the end of the decade, targets had been met for 11 objectives. Unintentional injury objectives showing achievement were unintentional injury hospitalizations, residential fire deaths, nonfatal head injuries, spinal cord injuries, nonfatal homicide poisonings, and pedestrian deaths. Violence prevention objectives that met their targets were, suicide, weapon carrying by adolescents, conflict resolution in schools, and child death review systems.
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