Elder abuse

Screening, intervention, and prevention

In Brief

Signs and symptoms of elder abuse are often mistaken for those of normal aging or declining health. This article details how to assess for abuse and discusses what nurses should do if they know or suspect an older adult is a victim.

Figure

IN 2000, ADULTS age 65 and older accounted for 12.5% of the U.S. population. By 2050, they'll account for an estimated 25% of the U.S. population.¹

Up to 2 million older adults are victims of abuse in the United States annually.² By one estimate, for every case of elder abuse or neglect that's reported, five aren't. In fact, 84% of elder abuse cases are never reported to any adult protective service agency.³

As baby boomers age, the incidence of elder abuse is likely to increase.⁴ This article will offer valuable information on how to screen patients for elder abuse, help them get the help they need, and provide them with resources to prevent elder abuse from happening.

Nearly all in the family

Some 90% of elder abuse cases are committed by a family member. Perpetrators are typically financially dependent on the older adult, substance abusers, or experiencing untreated mental health problems.⁵ More than 80% of elder abuse cases aren't reported by older adults because of shame, self-blame, fear of reprisal, fear of a loss of independence, concerns about retaliation, not knowing their rights, or not knowing where or how to get help.^4,6 Elder abuse can be especially difficult to identify because many older adults are socially isolated.

According to the first National Study of Elder Abuse, elder abuse reports to adult protective services (APS) increased 150% between 1986 and 1996.⁵ Some theorized that this massive increase indicates greater community awareness resulting from elder abuse educational programs, but it may simply reflect the growing number of older adults.^3,5

A 2009 National Adult Protective Services Association survey revealed that elder abuse reports to APS agencies in 2009 increased by 24%, while state APS budgets were cut by 14%. Increased reports of abuse were blamed in part on reduction in APS staff, hiring freezes at APS agencies, less in-home care, decreased 24-hour response capability, reduction or elimination of certain types of investigations, and less time to investigate.⁷ Additionally, the increased number of older adults over the last several years increases the likelihood of abuse or neglect.⁵

Professional responsibility

Elder abuse is any intentional action by a caregiver or person in a trusted relationship with an older adult that causes harm or the serious risk of harm, or the failure of a trusted caregiver to protect an older adult from harm or satisfy basic needs for survival.⁴ Self-neglect results when vulnerable adults are unable or unwilling to adequately and safely care for themselves and refuse assistance to do so.⁴ Because there is no perpetrator, self-neglect differs from other forms of abuse. As such, some experts don't consider self-neglect the same as elder abuse, neglect, and exploitation.^4,8

No federal law specifically dedicated to preventing elder abuse exists. Inconsistencies in elder abuse definitions between states make it hard to gain a clear description of what constitutes abuse. Additionally, no uniform elder abuse reporting system exists in the United States. As a result, no national standard for defining, identifying, reporting, or investigating elder abuse exists at this time.²

As mandatory reporters of abuse and neglect, healthcare providers have both an ethical and legal responsibility to advocate for victims of abuse by screening, identifying, and reporting cases of abuse.^9-11 Because many physicians, nurses, and other healthcare professionals have little or no education regarding abuse and violence, they may not feel qualified to assess older adults for abuse and believe that they don't make a difference.^12,13 Some may believe that victims of abuse should take responsibility to remove themselves from abusive situations.¹¹ Education and training to help healthcare professionals recognize signs of abuse and intervene appropriately are essential.^9,11

Thirty-nine states specifically mandate that healthcare professionals report cases of abuse. Eleven states (Delaware, Florida, Indiana, Mississippi, New Hampshire, New Mexico, North Carolina, Tennessee, Texas, Utah, and Wyoming) mandate that any person suspecting or witnessing elder abuse report it. North Dakota doesn't set elder abuse apart and mandates reporting any abuse.¹⁴ In 42 states, anyone who fails to report elder abuse may face misdemeanor charges, fines, or even imprisonment.

Besides criminal penalties, failure to report elder abuse can result in civil action for pain and suffering. Additionally, healthcare professionals who don't report cases of abuse risk professional disciplinary action, possibly including loss of their professional license to practice.

Many healthcare professionals are reluctant to report suspected abuse unless they have proof. But mandatory reporting usually protects those who report suspected abuse by maintaining the reporters' anonymity and freeing them from concerns of litigation.

Recognizing elder abuse

Elder abuse can take the form of physical, sexual, psychological, or financial abuse, and neglect.

• Physical abuse is the use of physical force that results in physical injury, pain, or impairment. It includes not only hitting or pushing, but also inappropriate use of drugs, restraints, or confinement.^15,16
• Sexual abuse is nonconsensual sexual contact with an older adult and involves physical sex acts, forcing an older adult to view sex acts or pornographic material, or forcing an older adult to disrobe.^15,16
• Psychological abuse uses verbal or nonverbal means to cause emotional pain or distress. Verbal psychological abuse includes ongoing intimidation, ridicule, humiliation, scapegoating, or blaming. Nonverbal psychological abuse includes isolation, threatening behavior, and ignoring an older adult.^15,16
• Financial abuse is the unauthorized use of property, assets, or funds and includes misuse of an older adult's credit cards or accounts, forging signatures, identity theft, stealing checks and cash, and financial investment and charity scams.^15,16
• Neglect is the failure of a caregiver to fulfill an obligation or responsibility to care for an older adult. Neglect can be intentional or unintentional and also includes self-neglect.^15,16 In the United States, self-neglect accounts for 40% to 50% of all elder abuse cases referred for APS each year.¹⁷

Risk factors for abuse

A combination of economic, psychological, physical, and social factors perpetuates elder abuse. An older adult's progressive cognitive and physical decline may increase a caregiver's responsibilities and tax the patience of even the most caring individual. Caregiver stress and burnout can trigger abusive behavior. See Recognizing patients and families at risk for factors to be aware of in both older adults and their caregivers.

Signs and symptoms of abuse

Many cases of elder abuse are overlooked when signs of abuse are mistaken for changes associated with aging or declining health. Injury and illness can mask or mimic signs of elder abuse. Bone loss, weight loss, overmedication, and nonadherence to medication regimens can result in disorientation, somnolence, fractures, and exacerbation of chronic illnesses. Many abused older adults can't provide accurate information about their injuries due to cognitive impairments from dementia or depression.^4,6

Depression, confusion, fearfulness, changes in behavior, and loss of sleep are common signs and symptoms of any type of elder abuse.^16,18,19 Suspect elder abuse if you observe significant delays between the time an injury occurs and the time treatment is requested; if the patient's and caregiver's explanations are contradictory or vague; or if the patient repeatedly visits the ED, uses a variety of facilities, or changes healthcare professionals frequently.^11,16,18,19

Table: Recognizing patients and families at risk^{7 , 9 , 11 , 14 , 15}

Certain signs and symptoms are associated with specific types of abuse as well.

• Suspect physical abuse when injuries can't be explained or are in different stages of healing; fractures, abrasions, ecchymoses, burns, or wounds are present; or diagnostic study results conflict with the history and physical assessment findings.^11,16,18,19
• Suspect sexual abuse if the older adult has ecchymoses involving the breasts or genitalia, unexplained vaginal or anal bleeding, stained or torn undergarments, a preoccupation with sex, or a sexually transmitted infection.^11,16,18,19
• Suspect psychological abuse if the older adult patient states that he or she is verbally abused; acts withdrawn or unusually depressed, fearful, agitated, or confused; has a sudden change in behavior or alertness; or, in the presence of any of the preceding signs, denies any incidents of abuse.^11,16,18,19
• Suspect financial abuse if the patient has sudden changes in finances, unpaid bills that were supposed to be paid by others, depleted bank account balances, a suddenly written or changed will, documents with signatures that don't match the signature of the older adult, or documents signed by an older adult who's unable to write or comprehend the transaction. Lack of affordable amenities, excessive reimbursement/payouts for care and companionship, and/or failure to provide basic needs are signs that nurses can observe and report. Document who was present, what, when, and where you observed or were told about such incidences. ^11,16,18-20
• Suspect neglect if the patient has an unusual weight loss, is malnourished or sedated, exhibits poor hygiene and grooming, or has unmet medical needs.^11,16,18,19

Screening for elder abuse

Once you suspect abuse, you're obligated to perform a thorough abuse assessment.²¹ The Elder Assessment Instrument (EAI), which is appropriate for all clinical settings, reviews signs, symptoms, and subjective complaints of elder abuse and neglect. It includes general assessment items, such as clothing and skin integrity; possible abuse indicators, such as lacerations and fractures; possible neglect indicators, such as malnutrition and urine burns; possible exploitation indicators, such as inability to account for money/property; and possible abandonment indicators, such as evidence that the patient is left alone in an unsafe environment for extended periods of time without adequate support.²² The EAI has no “score,” but any positive evidence without clinical explanation, subjective complaints of abuse communicated by an older adult, or a healthcare provider's suspicions of abuse or neglect warrant referral to social services.^22,23

Various instruments are available to identify elder abuse, each with its own strengths and weaknesses. See Screening tools for a list of some currently available.

Interventions

If you suspect that one of your patients is a victim of elder abuse, determine if the patient is in imminent danger, can talk openly about suspected abuse without fear of retribution, is cognitively able to make decisions about his or her own care, or is likely to be abused again. You also need to determine if the degree of abuse and/or risk for abuse is high, future abuse can be prevented, and if the patient's well-being can be assured. Notify authorized reporting agencies to ensure your patient's safety. This may mean admitting the patient to a hospital or providing alternative living arrangements.^10,16,21

Besides interviewing and obtaining a history from the patient and caregivers, focus your assessment on evidence of specific types of abuse, adequacy of care, and the relationship between the patient and caregivers. Identifying the dynamics of an older adult's relationship with caregivers may provide clues to elder abuse. Some examples include the care recipient exhibiting verbal, physical, combative, aggressive, or sexual behaviors toward the caregiver. The caregiver has concerns about becoming violent, perceives a lack of support, feels emotionally burdened and “burned out,” is caring for young and old dependents, and suffers from low self-esteem.^9,10,16

Identify any issues of safety and vulnerability such as consequences patients face when they disagree with caregivers, episodes of uninvited physical contact or being forced to do things they don't want to do, signing documents without understanding what they are, and having possessions taken without permission.¹⁰

If you perceive that a patient is hesitant about speaking about abuse in the presence of a caregiver, question your patient alone. When caregivers are abusers, questioning patients in their presence isn't likely to expose abuse. Questioning caregivers and patients separately provides an opportunity to identify inconsistencies regarding abuse.

Assure privacy and confidentiality for both the patient and caregivers by interviewing them separately, and interview and examine the patient first.^10,12

Accurately and objectively document all your findings according to facility policy. Your documentation of physical findings, patients' and suspected abusers' statements (using direct quotes), and physical evidence may be used in future legal proceedings.¹²

Prevention

Preventing elder abuse can be difficult because older adults who are being abused don't readily report or acknowledge the abuse. Educational programs can guide caregivers, health professionals, and social service workers to better serve older adults who are being abused. Standardized practice guidelines and protocols for screening for abuse can assist health professionals in identifying risk factors and signs of abuse.¹⁵

Providing community education programs can increase elder abuse awareness. Reports of elder abuse increase in states that require elder abuse awareness programs and mandate reporting elder abuse.¹² Incorporating topics related to elder abuse into nursing curricula and offering continuing-education opportunities for health professionals can bring elder abuse to the forefront and provide improved knowledge and greater resources for screening and prevention.

Keeping patients safe

You can play a critical role in screening and intervening in cases of elder abuse. Developing and adhering to national, state, and institutional elder abuse practice guidelines and protocols will ensure elder abuse isn't overlooked or misdiagnosed, and foster proactive interventions for those at risk for being abused, those at risk for becoming an abuser, and those who need protective services.^15,19

Screening tools²⁴

Brief Abuse Screen for the Elderly: http://bit.ly/BASEScreen

Caregiver Abuse Screen: http://bit.ly/CASEScreen

Elder Abuse Suspicion Index: http://bit.ly/EASIScreen

Elder Assessment Instrument: http://bit.ly/EAIScreen

Health Attitudes toward Aging, Living Arrangements, Finances: http://bit.ly/HALFScreen

Hwalek-Sengstock Elder Abuse Screening Test:http://bit.ly/HSEAST

Indicators of Abuse Screen: http://bit.ly/IOAScreen

Questions to Elicit Elder Abuse: http://bit.ly/QEEAScreen

Screen for Various Types of Abuseor Neglect, Screening Tools and Referral Protocol:http://bit.ly/STRPScreen

Vulnerability to Abuse Screening Scale:http://bit.ly/VASSScreen