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Screening for Mistreatment of Older Adults

Fulmer, Terry PhD, RN, FAAN

AJN, American Journal of Nursing: December 2008 - Volume 108 - Issue 12 - p 52–59
doi: 10.1097/01.NAJ.0000341885.07694.48
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The mistreatment of older adults can take many forms, including abuse, neglect, financial exploitation, and abandonment. Reporting suspected mistreatment is mandated in most states, but many clinicians have little or no training in recognizing the indicators of mistreatment and so most cases go unreported. The Elder Assessment Instrument provides a way for nurses to screen older adults for possible mistreatment and can be used in most clinical settings. For a free online video demonstrating the use of this instrument, go to http://links.lww.com/A321.

Reporting suspected mistreatment is required in most states, but most cases aren't reported. The Elder Assessment Instrument is one way for nurses to screen older adults and can be used in most settings.

Terry Fulmer is the Erline Perkins McGriff professor and dean of the College of Nursing at New York University in New York City. She is also a codirector of the John A. Hartford Foundation Institute for Geriatric Nursing.

Contact author: terry.fulmer@nyu.edu.

How to Try This is a three-year project funded by a grant from the John A. Hartford Foundation to the Hartford Institute for Geriatric Nursing at New York University's College of Nursing in collaboration with AJN. This initiative promotes the Hartford Institute's geriatric assessment and screening tools, Try This: Best Practices in Nursing Care to Older Adults: www.hartfordign.org/trythis. The series will include articles and corresponding videos, all of which will be available for free online at www.nursingcenter.com/AJNolderadults. Nancy A. Stotts, EdD, RN, FAAN (nancy.stotts@nursing.ucsf.edu), and Sherry A. Greenberg, MSN, GNP-BC (sherry@familygreenberg.com), are coeditors of the print series. The articles and videos are to be used for educational purposes only.

Routine use of Try This tools or approaches may require formal review and approval by your employer.

The Elder Assessment Instrument can alert nurses to signs of abuse, neglect, and exploitation.

Screening for Mistreatment of Older Adults: Erratum

We inadvertently omitted the financial disclosure statement. This article should have included the following statement saying, "The authors of this article have no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity."

This erratum is published in the March 2009 issue of AJN.

Eva Allen is 89 years old and lives with her two sons in a small apartment in Brooklyn, New York. (This case is a composite based on my clinical experience.) She comes to the ED at 4 pm by ambulance and is transported by wheelchair to the exam room. Ms. Allen had a stroke seven years ago, which resulted in paralysis to her left side, and she needs help moving from the wheelchair to the stretcher. Her sons, ages 49 and 52, are already in the waiting room.

Figure. No caption a...

The emergency medical technician (EMT) says he was called to the apartment by one of the sons, who said his mother had fallen. While examining her in the apartment, the EMT noted that Ms. Allen had what appeared to be a new bruise above her eye and bilateral bruising in various stages of healing on her torso. When asked about the bruises, Ms. Allen told the EMT that she had lost her balance and fallen. Both of her sons were highly agitated and very concerned about their mother. Her blood pressure and pulse were normal and she had no fever.

When the nurse who examines Ms. Allen in the ED asks her how she got the bruises on her torso, Ms. Allen says that her sons can be "rough with" her. When asked why her sons treat her this way, she says, "Leave my boys alone. They're good boys. They take good care of me except when I can't hold my urine, and then they get really mad at me and sometimes get rough with me." The physician examines Ms. Allen and notes that she has a urinary tract infection but is otherwise medically stable. The ED nurse, who is concerned that Ms. Allen might have been abused by her sons, asks the staff social worker to perform a family assessment. The nurse also decides to use the Elder Assessment Instrument (EAI) to gain a clearer picture of whether—and if so, how—Ms. Allen has been mistreated.

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Web Video

Watch a free online video demonstrating the use of the Elder Assessment Instrument at http://links.lww.com/A321.

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A Closer Look

Get more information on why it's important for nurses to screen for mistreatment in older adults.

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Try This: Elder Mistreatment Assessment

This is the instrument in its original form. See page 57.

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THE ELDER ASSESSMENT INSTRUMENT

The EAI is a 41-item assessment instrument that was first published in 1984; it has been refined and adapted over time for specific clinical settings and research purposes. No doubt it will continue to evolve as care providers increase their knowledge of how to assess mistreatment in older adults. (For more information on the importance of assessing abuse and neglect in older adults, see Why Screen for Mistreatment in the Elderly?1,2 page 54.)

In the early 1980s many states passed legislation requiring health care professionals and agencies to report the mistreatment of elderly patients. In 1980 an interdisciplinary team at Beth Israel Hospital in Boston was formed to develop an instrument that would allow clinicians to screen elderly patients suspected of suffering any type of mistreatment, including abuse, neglect, exploitation, or abandonment (see Elder Mistreatment: Four Subtypes, page 55). Reporting laws at that time encouraged hospital administrators to develop care protocols for elderly patients suspected of being victims of mistreatment. Items selected for inclusion in the EAI were derived from the literature on causes of elder mistreatment, which explores theories of dependency, cognitive decline in older adults, the psychopathology of caregivers, and economics. Items addressed in the EAI also incorporate indicators of mistreatment that have appeared for decades in the literature on child abuse and spousal battery.

The EAI has seven sections that help the clinician review signs and symptoms as well as other indicators of abuse, neglect, exploitation, and abandonment. (See the Elder Assessment Instrument, page 57.) Some indicators of possible mistreatment include unexplained bruises or burns, unaccounted-for losses of financial resources or property, and extremely poor hygiene despite having a caregiver. In addition, abandoning a severely cognitively impaired patient who is unable to describe her or his condition at the ED indicates mistreatment. The last section of the EAI is for comments; there the clinician can explain why she or he is interpreting a clinical sign or symptom in a particular way.

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Elder Mistreatment: Four Subtypes

Abuse. Conduct by a responsible caregiver or another person that constitutes "abuse" under the applicable federal or state law, such as kicking, punching, slapping, or burning.

Neglect. An act of omission by a responsible caregiver that constitutes "neglect" under the applicable federal or state law, such as withholding food, medication, hygienic assistance, or health care.

Exploitation. The inappropriate use of resources for personal gain, such as use of the person's home without consent, use of her or his money for personal expenses, and withdrawal of care until funds or property are given.

Abandonment. A caregiver's precipitous withdrawal of care, services, or companionship.

Adapted from Panel to Review Risk and Prevalence of Elder Abuse and Neglect, et al., editors. Elder mistreatment: abuse, neglect, and exploitation in an aging America. National Research Council. Washington, D.C.: National Academies Press; 2003.

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Why Screen for Mistreatment in the Elderly?

Mistreatment is a broad term meant to reflect the outcomes that occur when a person is abused, neglected, exploited, or abandoned. Elder mistreatment has been defined by the National Research Council as either of the following1:

* intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder

* failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm

Only a small percentage of cases are ever reported. The National Research Council, in summarizing the available research, estimated that the number of Americans age 65 or older who have been "injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection" is between 1 million and 2 million.1

Most states require health care professionals to report suspected abuse. But it's up to agencies and hospitals to determine how they can best assess for abuse and follow up in their respective settings. Since the 1980s, the research necessary for generating screening instruments has gained only modest ground.2 Identifying mistreatment in the elderly often falls to clinicians who are unfamiliar with the critical areas of inquiry and what constitutes a positive screen for such abuse.2 The Elder Assessment Instrument (EAI) was developed to meet the needs of practicing nurses. Most nurses won't overlook an egregious case of elder mistreatment, but they may not routinely or systematically screen for it. The EAI was devised to provide nurses with an organized and efficient way to perform a first-level screening in suspected cases of mistreatment of elderly patients. To view the portion of the online video in which nurses discuss the problem of elder mistreatment, go to http://links.lww.com/A323.

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ADMINISTERING THE EAI

This instrument should be used one-on-one with the patient to determine if the possibility of mistreatment exists. It's designed to indicate the need for further assessment and doesn't definitively detect abuse or mistreatment. Rather, it gathers information that can contribute to the clinician's understanding of the patient. Also, definite evidence of a single indicator (such as fracture) can constitute strong suspicion of abuse, but in the case of certain other indicators more than one may be required before a referral can be made. For example, an older adult with poor hygiene, tattered clothing, poor skin integrity, and inadequate nutrition should be referred, but one with poor hygiene alone might not need immediate referral.

The EAI is administered by interview and physical assessment. Some variables require information from the patient and others call for the nurse to use clinical judgment. Nurses will need to find a private place to conduct the screening, where family caregivers can't listen to or prompt the patient in any way. The older adult needs to feel that she or he can speak freely and candidly. Start with less sensitive questions and then proceed, probing deeper as necessary depending on the patient's response. Such a progression might resemble this: "You live with your daughter. Do you get along well? Does she help you or arrange for others to help you? Do you ever feel that she's rough with you or yells at you?" (To view the section of the online video in which a nurse demonstrates the use of the EAI with a patient, go to http://links.lww.com/A322.)

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INTERPRETATION AND FOLLOW-UP

The EAI doesn't result in a score. According to state laws as well as best-practice protocols, it's the responsibility of all nurses to do brief screenings for elder mistreatment and to seek support from more qualified colleagues when they're unsure of how to handle complex cases. In most cases, the clinician should contact the local adult protective services (APS) agency or a geriatric care team if the patient does poorly on the "General Assessment" section of the EAI (concerning clothing, nutrition, hygiene, and skin integrity) or if there are assessments other than "no evidence" in any of the sections dealing with possible abuse, neglect, exploitation, or abandonment.

Ms. Allen had evidence of poor hygiene and poor skin integrity. There was also evidence of bruising and lacerations, and old fractures were seen on an X-ray of her upper torso. The bruises were in various stages of healing, suggesting that they weren't the result of one incident. And a stage-III pressure ulcer was located on her coccyx. The nurse and the social worker concurred that there was evidence of mistreatment.

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CHALLENGES IN INTERPRETING THE ASSESSMENT

Cultural differences between patients and caregivers may lead to an erroneous suspicion of mistreatment. For example, a nurse might observe an older adult and caregiver having an aggressive conversation that includes shouting; some cultures would consider such behavior acceptable, whereas others might consider it verbal abuse (such aggressive verbal interaction isn't directly assessed by the EAI). Views on the financial or personal autonomy of older adults, their right to make decisions on their own, or the amount of respect they deserve may also differ among cultural or socioeconomic groups. No research has been done on how cultural differences can affect the interpretation of the EAI, but it's important to ask the older adult whether she or he feels a certain behavior or type of care is appropriate.

Cognitive impairment presents a particular challenge. Caring for a cognitively impaired patient can be very frustrating and may contribute to an atmosphere in which abuse or neglect is more likely to occur. In addition, caring for cognitively impaired older adults may permit opportunistic caregivers and others to exploit them. In assessing such patients, some sections of the EAI might be harder to complete if the patient is not able to describe her or his symptoms and what has caused them; in these cases, nurses should rely on close observation of the patient's physical and emotional cues, such as flinching in the presence of the caregiver, and on their own clinical experience, as well as on information gathered from family members or others.

Fear of false accusations. Clinicians sometimes worry that they will falsely accuse someone of mistreating an elderly patient and disrupt the patient's living situation. For example, if an older adult is living with a daughter who is neglectful, it will take careful analysis to determine whether the caregiving can be improved before the person is taken out of the home and away from the family. Often an interdisciplinary team, a social worker, or a hospital administrator will make this decision. Many older adults who show evidence of mistreatment are afraid they'll be removed from their homes and placed in long-term care. Even if the care at home is neglectful, the older adult may prefer to stay with family rather than move to an unfamiliar setting. This fear should be acknowledged and addressed.

The area of exploitation is fraught with challenges. If a patient indicates that she or he had to "give" personal, valued items to a home care attendant in order to be taken to the toilet, an urgent and immediate referral to an APS agency should be made. Since interpreting such an event can be complicated and may require detailed investigation by a case worker or lawyer, it's important to be as specific as possible in reporting all details of physical and psychological abuse or neglect.

Is the mistreatment intentional? If an older woman who has an advanced pressure ulcer is being cared for by a husband who doesn't know about regularly turning her from side to side, few nurses would consider this neglect. Again, a team approach to handling this situation would be best, and variables such as whether the caregiver is a voluntary helper or a paid professional should be examined. On the other hand, if an older man who has had severe weight loss reports that his daughter keeps little food in the house despite his repeated requests, the nurse has reason to ask social services or legal assistance to investigate.

Looking out for Ms. Allen. Since the patient's EAI screening showed a number of areas of concern, the nurse and social worker called in the elder mistreatment team for further review. The team recommended that a home care worker be hired to help Ms. Allen with activities of daily living, thus lessening her caregivers' burdens, which can cause or exacerbate mistreatment. The team also recommended that the APS agency's hotline be called to provide follow-up for Ms. Allen upon discharge. The APS agency was able to arrange for a home care worker to visit her twice per week to provide the recommended care and monitor her for signs of mistreatment.

Some settings, especially smaller community hospitals, are unlikely to have an elder abuse team, in which case the postscreening referral should be made directly to the APS agency. Although laws and responding agencies differ by state, hotlines that offer guidance and resources are now available in most states (see www.ncea.aoa.gov/NCEAroot/Main_Site/Find_Help/Help_Hotline.aspx for a listing by state).

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COMMUNICATING THE FINDINGS

Talk to the patient. Positive results on the EAI are a serious matter and need to be communicated very carefully to patients and families. Begin with the patient. In the case of Ms. Allen, the nurse might say, "Ms. Allen, I'm worried about you, because I know your sons have been physically abusive. I'm afraid that you might be injured again. Here is my phone number. You can always call if you need to, but let's also consider whether we can make any plans right now. For example, you can call 911 if you're afraid someone is going to hurt you. You can also call the hotline number written on this paper."

Ms. Allen rejected the social worker's recommendation that a case be filed against her sons and that they be pursued through legal channels.

The geriatric care team can also suggest that a patient use a medical alert service to contact help if she or he feels endangered. And if the patient is cognitively impaired and the suspected abuser is the presenting care provider, the APS agency should be contacted to devise and enact a plan that will ensure the older person's safety and prevent the caregiver from continuing the mistreatment or acting in retribution.

The family. The results of the assessment should also be communicated to the family when doing so will not compromise the patient's safety. The nurse might say, "I'm concerned that your mother is very frail and needs a great deal of care. Do you feel that you're able to provide the care she needs, or do you need help in your home?" This allows the nurse to bring up the topic of caregiver burden and strain (for more on assessing the effects that caring for a family member can have on the caregiver, see "Helping Those Who Help Others," September). If the family caregiver denies strain, the nurse can point out the evidence indicating that the older patient's needs aren't being met and express concern about the patient's well-being. Such conversations require sensitivity, and attention should be paid to both verbal and nonverbal feedback from family members.

In a case like Ms. Allen's, when the nurse or geriatric care team will need to report the suspected abuse to the appropriate agency, it's important to anticipate how family members will perceive this information. Ms. Allen's sons were contacted by the APS agency and informed that the APS worker, in consultation with the elder mistreatment team, had recommended that a home care worker visit their mother twice per week to alleviate some of their caregiver burden and to monitor her well-being.

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CONSIDER THIS

What evidence shows that the EAI helps detect cases of mistreatment and abuse of the elderly? Three pilot studies of the original instrument were conducted over the course of several months to test its feasibility, readability, interrater reliability, and content validity.3 The internal consistency reliability (Cronbach α coefficient) was 0.84 in a sample of 501 screenings, and the test–retest reliability was 0.83. However, the EAI sometimes erroneously suggests elder mistreatment that careful review disproves.4 For example, a nurse finding a bruise on an older adult's arm might suspect abuse even though the patient denies it; further investigation might then reveal that the patient is on a high dose of an anticoagulant or has some other condition that predisposes her or him to bruising.5

The evidence supports the reliability and validity of the EAI in screening for elder mistreatment in the clinical setting.

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Watch It!

Go to http://links.lww.com/A321 to watch a video demonstrating the use and interpretation of the Elder Assessment Instrument. Then see the health care team plan preventive strategies.

View this video in its entirety and then apply for CE credit at www.nursingcenter.com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.

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Online Resources

For more information on this and other geriatrics screening and assessment tools and best practices go to www.ConsultGeriRN.org, the clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program. The site presents authoritative clinical products, resources, and continuing education opportunities that support individual nurses and practice settings.

Visit the Hartford Institute site, www.hartfordign.org, and the NICHE site, www.nicheprogram.org, for additional products and resources. Go to www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.

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REFERENCES

1. Panel to Review Risk and Prevalence of Elder Abuse and Neglect, et al., editors. Elder mistreatment: abuse, neglect, and exploitation in an aging America. National Research Council. Washington, D.C.: National Academies Press; 2003.
2. Fulmer T, et al. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc 2004;52(2):297–304.
3. Fulmer TT, O'Malley TA. Inadequate care of the elderly: a health care perspective on abuse and neglect. New York: Springer; 1987.
4. Fulmer T, et al. Neglect assessment in urban emergency departments and confirmation by an expert clinical team. J Gerontol A Biol Sci Med Sci 2005;60(8):1002–6.
5. Mosqueda L, et al. The life cycle of bruises in older adults. J Am Geriatr Soc 2005;53(8):1339–43.

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