Want to know more

ELDER MISTREATMENT AND ABUSE

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Overview

Elder abuse and neglect, or elder mistreatment, aside from a social and legal problem, is an enormous health care problem that can lead to long term health consequences, including death. Elder mistreatment includes physical, psychological, financial, and sexual abuse, as well as caregiver neglect and self-neglect.

An interdisciplinary assessment and intervention plan for actual or potential elder abuse and neglect is essential to ensure the safety and health of older adults in any clinical setting. Assessment and intervention should be directed toward both the victim and the alleged perpetrator.

 
Back to top

Definitions

Assessment Intervention Examples
Physical abuse The use of physical force that may result in bodily injury, physical pain, or impairment. Hitting, beating, pushing, shoving, shaking, slapping, kicking, burning, inappropriate use of drugs and physical restraints.
Emotional/Psychological abuse The infliction of anguish, pain, or distress through verbal or nonverbal acts. Verbal assaults, insults, threats, intimidation, humiliation, harassment, and enforced social isolation.
Sexual abuse Any form of sexual activity or contact without consent, including with those unable to provide consent. Unwanted touching, rape, sodomy, coerced nudity, and sexually explicit photographing.
Financial abuse/exploitation The illegal or improper use of an elder's funds, property, or assets. Cashing a person's checks without authorization or permission, forging a signature, misusing or stealing money or possessions, coercing or deceiving a person into signing any document, and the improper use of conservatorship, guardianship, or power of attorney (defined below).
Caregiver neglect The refusal or failure to fulfill any part of a person's obligations or duties to an older adult, including social stimulation. Refusal or failure to provide life necessities such as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety.
Self-neglect The behavior of an elderly person that threatens his/her own health or safety. Disregard of one’s personal well-being and home environment. Refusal or failure to provide oneself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions.

(National Center on Elder Abuse, 2005; Wagner, Greenberg, & Capezuti, 2002).

Definitions of Related Terms

Conservatorship: A situation in which a court declares an individual unable to take care of legal and financial matters and appoints another individual, known as a conservator, to do so.

Guardianship: A situation in which a court declares an individual unable to take care of personal matters, such as health, safety, and therapeutic treatments, and appoints another individual, known as a guardian, to do so.

Power of Attorney: A document that gives another person legal authority to act on your behalf.

Types of Elder Abuse
National Center on Elder Abuse. (2005). The basics: Major types of elder abuse.
http://www.elderabusecenter.org/default.cfm?p=basics.cfm

 
Back to top

Background/Epidemiology

All 50 states and the District of Columbia have Adult Protective Services (APS) statutes that establish APS programs for identification and investigation of elder abuse and neglect. (Capezuti, Brush & Lawson, 1997).

Neglect of older adults accounts for 60 to 70% of all elder mistreatment reports made to Adult Protective Services and usurps over 50% of all APS resources. (Fulmer, Paveza, Vandeweerd, Guadagno, Fairchild et al, 2005).

In 2003, state long term care ombudsman programs nationally investigated 20,673 complaints of abuse, gross neglect, and exploitation on behalf of nursing home and board and care residents. Among seven types of abuse categories, physical abuse was the most common type reported. (U.S. Administration on Aging, 2003; National Association of State Units on Aging, March 2005).

According to the best available estimates, between one and two million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection. (National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect, 2003; National Association of State Units on Aging, March 2005).

The National Elder Abuse Incidence Study (NEAIS) estimated in 1996 more than half a million new cases of elderly people, aged 60 and over, experienced abuse, neglect, and/or self-neglect in domestic settings. Of this estimate, over five times as many incidents of mistreatment went unreported to local APS agencies (The National Center on Elder Abuse at The American Public Human Services Association, 1998).

The NEAIS found that female elders are abused at higher rates than male elders and that those over 80 years old are mistreated two to three times their proportional numbers in the elderly population; About 90% of the incidents of mistreatment had a perpetrator known to the victim (The National Center on Elder Abuse at The American Public Human Services Association, 1998).

Estimates of the frequency of elder abuse range from 2% to 10% based on various sampling, survey methods, and case definitions. (Lachs, & Pillemer, 2004).

Total reports of elder and vulnerable adult abuse for people of all ages represent a 19.7% increase from the 2000 Survey. Of the 565,747 reports, 253,426 reports were for those 60 years of age and older. Women made up 65.7% of elder abuse victims and 52.7% of alleged perpetrators (Teaster, & Dugar, 2005).

Current estimates put the overall reporting of financial exploitation at only 1 in 25 cases, suggesting that there may be at least 5 million financial abuse victims each year. Wasik, J. F. (March/April 2000); (National Association of State Units on Aging, March 2005).

Official national statistics are lacking as a national prevalence study has yet to be done; however; many independent studies on the incidence and prevalence of elder abuse and neglect have been conducted.

 
Back to top

Risk Factors

Caregiver stress
Childhood trauma
Cultural sanctions against seeking help to care for elder
Delirium
Dependency of abuser on victim for housing and finances
Dependence of elder on caretaker for assistance with activities
Family history of violence
Financial strain
Increased age
Isolation of the caregiver or victim
Lack of close family ties
Mental illness in family members/caretakers
New, worsening, or prolonged depression
New, worsening, or prolonged physical impairment
Poverty/Lack of financial resources
Progressing dementia
Shared living arrangement
Substance abuse in family members/caretakers
Unsafe living situation

(Adapted from Wagner, Greenberg, & Capezuti, 2002, Table 18-2, pg. 322).

 
Back to top

Assessment/Screening Tools

Try this: Elder Abuse and Neglect Assessment http://www.hartfordign.org/publications/trythis/issue15.pdf

Indicators of Abuse (IOA) Screen
http://www.uihealthcare.com/depts/med/familymedicine/research/geriatrics/
eldermistreatment/indicators.pdf Reis, M. & Nahmiash, D. (1998). The Gerontologist, 38(4), 471-480. Copyright © The Gerontological Society of America. Reproduced by permission of the publisher.

Risk Assessment Instruments http://www.elderabusecenter.org/default.cfm?p=riskassessment.cfm
Wolf, R. (2000, Updated 2003). Risk assessment instruments. Special Research Review Section, National Center on Elder Abuse Newsletter.

Assessment and Intervention
An interdisciplinary assessment and intervention plan for actual or potential elder abuse and neglect is essential to ensure the safety and health of older adults in any clinical setting. Assessment and interventions should be directed towards both the victim and the alleged perpetrator.

Interview patient separately from the alleged abuser and/or caregiver(s). Note any discrepancies in the information given.

Assessment and Intervention of Elder Abuse and Mistreatment
Type of Abuse/Mistreatment Questions to Assess Type of Mistreatment Physical Assessment and Signs and Symptoms
Physical abuse Has anyone ever tried to hurt you in any way?
Have you had any recent injuries?
Are you afraid of anyone?
Has anyone ever touched you or tried to touch you without permission?
Have you ever been tied down?


Suspected evidence of physical abuse (i.e., black eye) ask:
-How did that get there?
-When did it occur?
-Did someone do this to you?
-Are there other areas on your body like this?
-Has this ever occurred before?		 Assess for:
Bruises (more commonly bilaterally to suggest grabbing), black eyes, welts, lacerations, rope marks, fractures, untreated injuries, bleeding, broken eyeglasses, use of physical restraints, sudden change in behavior.

Note if a caregiver refuses an assessment of the older adult alone.

Review any laboratory tests. Note any low or high serum prescribed drug levels.

Note any reports of being physically mistreated in any way.
Emotional/Psychological abuse Are you afraid of anyone?
Has anyone ever yelled at you or threatened you?
Has anyone been insulting you and using degrading language?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?		 Assess cognition, mood, affect, behavior.
Assess for:
Agitation, unusual behavior, level of responsiveness, and willingness to communicate.

Delirium

Dementia

Depression

Note any reports of being verbally or emotionally mistreated.
Sexual abuse Are you afraid of anyone?
Has anyone ever touched you or tried to touch you without permission?
Have you ever been tied down?
Has anyone ever made you do things you didn't want to do?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?		 Assess for:
Bruises around breasts or genital area, sexually transmitted diseases, vaginal and/or anal bleeding or discharge, torn, stained, or bloody clothing/ undergarments.

Note any reports of being sexually assaulted or raped.
Financial abuse/exploitation Who pays your bills? Do you ever go to the bank with him/her? Does this person have access to your account(s)? Does this person have power of attorney?

Have you ever signed documents you didn’t understand?
Are any of your family members exhibiting a great interest in your assets?
Has anyone ever taken anything that was yours without asking? Has anyone ever talked with you before about this?		 Assess for:
Changes in money handling or banking practice, unexplained withdrawals or transfers from patient's bank accounts, unauthorized withdrawals using the patient's bank card, addition of names on bank accounts/cards, sudden changes to any financial document/will, unpaid bills, forging of the patient's signature, appearance of previously uninvolved family members.

Note any reports of financial exploitation.
Caregiver neglect Are you alone a lot?
Has anyone ever failed you when you needed help?
Has anyone ever made you do things you didn’t want to do?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?		 Assess for: Dehydration, malnutrition, untreated pressure ulcers, poor hygiene, inappropriate or inadequate clothing, unaddressed health problems, non-adherence to medication regimen, unsafe and/or unclean living conditions, animal/insect infestation, presence of lice and/or fecal/urine smell, soiled bedding.

Note any reports of feeling mistreated.
Self-neglect How often to you bathe?
Have you ever refused to take prescribed medications?
Have you ever failed to provide yourself with adequate food, water, or clothing?		 Assess for:
Dehydration, malnutrition, poor personal hygiene, unsafe living conditions, animal/insect infestation, fecal/urine smell, inappropriate clothing, non-adherence to medication regimen.
All Types   See Physical Assessment below table.
Adapted from Wagner, Greenberg, & Capezuti, 2002, Tables 18-4, 18-5, 324-325; National Center on Elder Abuse, 2005.

 
Back to top

Physical Assessment

Adapted from Wagner, Greenberg, & Capezuti, 2002, Table 18-5, 325.

General appearance

  • Hygiene, cleanliness, and appropriateness of choice of clothes and accessories

 

Vital signs

  • Orthostatic blood pressure and pulse
  • Height and weight (obtain baseline and monitor over time)

 

Skin

  • Facial injuries
  • Bite marks
  • Pressure ulcers
  • Dehydration: Dry and poor turgor
  • Wrist or ankle lesions from inappropriate use of restraints

  • Bruises, new or at any stage of healing: Location, length, width, depth, shape, color, odor, exudate, surrounding area, and approximate duration. Color indicates original date of bruise: 0-2 days, swollen and tender; 0-5 days, red-blue; 5-7 days, green; 7-10 days, yellow; 10-14 days, brown; 2-4 weeks, clear.10

  • Consider possible causes of bruises: bilateral bruises on upper arms may indicate forcible holding, grabbing, or shaking; bilateral bruises on thighs may indicate sexual assault.

  • Note imprint injuries that retain the shape of an object, such as a belt buckle, iron, or hand.

  • Burns: Note object imprint, such as an iron, rope, or cigarette burn.

 

Head

  • Injuries, hematomas, lacerations, and abrasions.

 

Eyes

  • Papilledema that may be related to a head injury sustained from a fall during an abusive episode

 

Breasts

  • Excoriation and/or fungal infections

 

Musculoskeletal

  • Pain, gait, new or old fracture noted on physical exam or x-ray

 

Neurological

  • Impairments in strength, balance, gait, sensory perception

 

Genital/rectal

  • Vaginal or rectal discharge or bleeding
  • Genital, rectal, or urinary irritation, injury, infection, or scarring
  • Presence of sexually transmitted disease
  • Lice

 

Psychological

 

Medications (Want to Know More)

  • Prescription
  • Over-the-counter
  • Sedatives
  • Narcotics

 

 

Photograph findings when possible.

 
Back to top

Interventions/Care Strategies

(Daly, 2004); (Fulmer, Guadagno, & Bolton, 2005); (American Medical Association, May 2006, Diagnostic and Treatment Guidelines on Elder Abuse and Neglect, 1992)

 

  • Identify risk factors
  • Report findings to Adult Protective Services and/or other agency as mandated per state
  • Develop and implement safety plan, such as safe home placement/discharge, hospital admission, and/or protective court order
  • Collaborate with interdisciplinary team members to provide information on services, such as social work, counseling, legal assistance
  • Provide a written list of emergency numbers and referrals
  • Educate patient that the incidence of elder mistreatment tends to increase in frequency and severity over time.
  • Assist patient in obtaining assistive devices, such as eyeglasses and/or hearing aides to maximize communication and functional abilities
  • If patient lacks decision-making capacity discuss financial management, conservatorship, guardianship, and/or protective court orders with Adult Protective Services
  • Regularly assess for caregiver stress (Link to Family Caregiving-Want to Know More) using a valid, reliable tool, such as:
  • Provide support patients, caregivers, and staff
  • For suspected sexual abuse, follow organizational guidelines for the assessment, evaluation, and documentation of rape
  • For suspected financial abuse/exploitation, suggest direct deposit of checks
  • For suspected caregiver neglect, refer caregiver to drug/alcohol rehabilitation programs as needed; suggest respite care; provide caregiver and patient support; provide information on caregiver and/or staff member counseling, support groups, and stress management programs; decrease staff burden by developing coping strategies for dealing with difficult patients and family members; reward good care.
  • Develop a follow-up plan within a specific time frame for all interventions.

 

Intervention and Case Management
Diagnostic and Treatment Guidelines on Elder Abuse and Neglect, October 1992, American Medical Association, pp. 13-14.

Prevention
Prevention of elder abuse includes legislation, education, respite, social support, batterer interventions, and money management programs.

Intervention and Case Management.pdf
Back to top

Expected Outcomes

Patient
Removal from harmful or potentially harmful situation if chooses or is decisionally incapacitated to choose.
Safety addressed.

Decrease in risk factors for elder abuse and neglect.

Decrease in their caregiver’s stress.

Maintenance of support systems. Safe guarding of valuables/money.

 

Caregiver
Caregiver stress assessed.

Caregiver stress decreased.

Treatment of mental health conditions, including illicit drug and/or alcohol use.

Respite care arranged as needed.

 

Health Care Provider
Documentation complete, including history, physical exam, treatments provided, referrals made, and reporting done.

Risk factors identified that may lead to elder abuse and neglect.

Alleged or suspected elder abuse and neglect identified and reported based on state laws and, if applicable, patient choice.

 

Institution
Education provided to staff for identifying and treating possible victims of abuse and neglect.

Written policies and procedures utilized relating to the handling of alleged or suspected elder abuse and neglect.

Potential victims of abuse or neglect identified.

Evaluation of the caregiving situation and housing environment included in discharge planning.

Policies and procedures that meet Joint Commission on Accreditation of Healthcare Organizations (JCHAO) Standards addressing victims of possible abuse or neglect.

Information reported to the appropriate authorities.

List maintained in the emergency department of community agencies that provide or arrange for evaluation and care of victims of abuse and neglect.

 

Follow-up Monitoring
Patient safety.

Caregiver stress.

Communication with Adult Protective Services.

Collaboration with interdisciplinary team members.

 
Back to top

References

American Medical Association Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. (1992). pp. 13-14. Retrieved August 16, 2005 from the American Medical Association website: http://www.ama-assn.org

Capezuti. E., Brush, B. L., & Lawson, W. T. III. (1997). Reporting elder mistreatment. Journal of Gerontological Nursing, 23(7), 24-32.

Daly, J. M. (2004). National Guideline Clearinghouse/Agency for Healthcare Research and Quality. Guideline for elder abuse prevention. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core. Retrieved January 19, 2006 from http://www.guideline.gov

Fulmer, T., Guadagno, L, & Bolton, M. M. (2005). Elder Mistreatment. In K. D. Melillo & S. C. Houde (Eds.). Geropsychiatric and mental health nursing (pp. 337-346). Massachusetts: Jones and Bartlett Publishers, Inc.

Fulmer, T., Paveza, G., Vandeweerd, C., Guadagno, L., Fairchild, S., Norman, R., Abraham, I., & Bolton-Blatt, M. (2005). Neglect assessment in urban emergency departments and confirmation by an expert clinical team. Journal of Gerontology: Medical Sciences, 60A(8), 1002-1006.

Lachs, M. S., & Pillemer, K. (October, 2004). Elder abuse. The Lancet, 364, 1192-1263.

National Association of State Units on Aging. (March, 2005). Fact Sheet National Center on Elder Abuse: Elder Abuse Prevalence and Incidence. Retrieved January 20, 2006 from http://www.elderabusecenter.org/pdf/publication/FinalStatistics050331.pdf. Results from some of the major prevalence and incidence studies conducted in the United States.

National Center on Elder Abuse. (Updated September 20, 2005). The basics: Major types of elder abuse. Retrieved January 21, 2006 from http://www.elderabusecenter.org/default.cfm?p=basics.cfm

National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect. (2003). Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America. Washington, DC.

Quinn, M. J., & Tomita, S. K. (1997). Elder abuse and neglect (2nd ed.). New York: Springer Publishing Company, Inc., p. 171.

Teaster, P. B., & Dugar, T. A. (2005). The 2004 Survey of Adult Protective Services: Abuse of Adults 60 Years of Age and Older. [abstract]. The Gerontologist, Special Issue, 591.

The National Center on Elder Abuse at The American Public Human Services Association in Collaboration with Westat, Inc. (1998). The National Elder Abuse Incidence Study. Prepared for The Administration for Children and Families and The Administration on Aging in The U.S. Department of Health and Human Services.

 

U. S. Administration on Aging. (2003). National Ombudsman Reporting System Data Tables. Washington, DC.

Wagner, L., Greenberg, S., & Capezuti, E. (2002). Elder Abuse and Neglect. In. V. T. Cotter, & N. E. Strumpf (Eds.). Advance practice pursing with older adults: Clinical guidelines (pp. 319-332). New York: McGraw Hill.

Wasik, J. F. (2000). The fleecing of America’s elderly. Consumers Digest, March/April.

Caregiver Strain Index.pdf Elder Abuse and Neglect Assessment.pdf
Back to top