
Elder Abuse: Is it Safe to Grow Old in America? By Barbara Moynihan, PhD, APRN and Rita Hammer, PhD, RN, CS
AN ELDERLY male arrives at a local police department describing a scenario of physical and mental abuse suffered at the hands of his two sons over a period of years. On this occasion, the physical abuse has been significant. He has been beaten and slammed into the bathroom sink for using one of the son's towels. He describes also mental abuse in the form of isolation, not being allowed to socialize or even to leave the house. He tells of the sons beating him because they need his Social Security check and his small retirement pension. They are both unemployed and residing with him. Unfortunately, the elderly gentleman will later regret having called the police and will not want to press charges because they are, after all, his children and he does not want to see them jailed. The cycle of abuse and a return to the abusive environment will continue through many more beatings.
As shameful to a civilized society as it may seem, this scenario is played out again and again in households across America every day. While images of physical abuse come to mind immediately when one hears the term elder abuse, other more covert forms of abuse can also seriously compromise the elder's quality of life. That abuse should occur during a time when elders should be reaping the rewards of longevity, namely a peaceful, comfortable, safe and loving environment in which to contemplate the memories of a lifetime is particularly disturbing. For example, it may not even be safe for elders to fully express their individuality and the nuances, which make up their uniqueness, whether in dress, personality or lifestyle. This very uniqueness may be a trigger for abuse, neglect or exploitation by those to whom the elder is dependent or in some way connected. The underreporting of elder abuse is a problem of national concern that demands the attention of every professional who has contact with this population.
Prevalence of Elder Abuse
Although it is difficult to establish exact numbers, the incidence of elder abuse and exploitation is of a magnitude that is staggering. More than 800,000 cases of domestic elder abuse are reported annually.1 Estimates indicate only 1 in 5 cases are reported or detected.2 One study that surveyed caregivers revealed that 45 percent admitted to performing some sort of abuse while entrusted with the care of an elder.3 Considering the rapidly expanding numbers of elders in the population, these figures can only be expected to rise.
Definitions of Elder Abuse
There is no uniform definition of elder abuse. In broadest context it encompasses physical injury, sexual, verbal, psychological and emotional abuse, as well as neglect and exploitation. Physical, sexual, verbal, psychological and emotional abuse refer to the willful infliction of physical pain, injury or mental anguish, or the willful deprivation by a caregiver of services that are necessary in order to maintain a state of holistic health. Neglect refers to situations in which elders, who are not able to provide for themselves the, services that are vital in order to preserve their health and yet do not receive these services from the individuals entrusted with their care. Exploitation of elders occurs when another individual, frequently the caregiver, takes advantage of an elder for personal or monetary gain. Abuse, neglect and exploitation can occur in isolation or independently, but frequently occur together.
Contexts of Elder Abuse
While abuse occurs in many contexts and in many venues, the elderly widow or widower living with adult children represents the population most at risk for suffering physical, emotional and/or psychological abuse. Other risk factors include impoverishment, physical or mental illness and a lack of support systems. Elder populations also at risk include those who reside at home alone, with caregivers, in residential facilities, correctional facilities as well as in day care centers. One venue that has only recently become of concern is the sexual abuse of the elderly, particularly those residing in secured facilities. As the prison population ages along with the general population, these individuals become more vulnerable and less able to protect themselves and are much less likely to seek help.
It falls upon the healthcare workers, the mandated reporters, to be particularly skillful and vigilant in terms of assessing every elder encountered in any venue for the obvious as well as the less obvious signs of abuse. The forensic nurse is in a unique position, armed with already fine-tuned assessment and communication skills, to provide the additional knowledge and skills related to the legal and ethical specifics that can help to identify, support and intervene with and for the vulnerable elder.
Profile of the Perpetrators
Family members. While there is a tendency to sweep this category under the rug, alarming national law enforcement data indicate family members are the most common perpetrators of abuse of elders.4 Such cases are particularly difficult for law enforcement to respond to because the parent, who is the victim, often may be confused or unable to remember the underlying facts, does not even report the crime or cooperate with an investigation because she or he is too ashamed of what occurred, desires to treat the theft as a "family matter" or, out of compassion and grief, does not want to see the child prosecuted and punished. Investigations involving family members are further complicated because of the existence of long-standing, complex family dynamics sometimes coupled with substance abuse issues and other dysfunctional behavior.
Caregivers. Caregivers can be family members or professional healthcare workers such as home healthcare aides, physicians, nursing home certified nursing assistants, nurses, administrators, and support staff. Physical, psychological and emotional abuse can result when the caregiver is also a family member and may be stressed beyond his or her ability to cope. In many cases the abuser has a history of social and legal problems that includes substance abuse. Often the elder victim is alone with a caregiver and susceptible to financial crimes without even knowing that they have been committed. In other cases, the caregiver is quite blatant about the financial abuse, which can involve large sums of money but more frequently involves only a small fixed income of the elder.
The Dynamics of Abuse
Many factors acting in concert can be involved in the development of an elder abusive situation. It is important to remember that the situation of elder abuse is primarily a function of the characteristics of the perpetrator, the majority of whom are male, and only secondarily a function of the victim, the majority of whom are female. Family dynamics are important in helping the nurse to understand the situation. Is the adult child engaging in "payback" for a real or perceived troubled relationship with the parent in earlier years? Is the adult child the so-called "black sheep" of the family, often feeling neglected and unloved in the face of other siblings? Was the entire family system characterized by dysfunction? Frequently the perpetrator has a history of substance abuse therefore the dynamics of the dependent personality must also be considered.
INDICATORS OF ELDER MISTREATMENT
- Poor personal hygiene
- Over-medication or under-medication
- Falls resulting from lack of adequate precautions or assistance
- Skin tears, bruises, contusions, or lesions
- Bone fractures
- Significant weight loss or gain
- Dehydration
- Disorientation
- Burns in unusual locations
- Pain and/or itching or signs of genital trauma
- Difficulty walking or sitting
- Loss of interest in self, environment, others
- Withdrawal, agitation, depression
- Confusion
- Excessive fear, insomnia, nightmares
- Presence of venereal disease
- Absence of hearing aids, eyeglasses, dentures, prosthese
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Other factors include socio-economic level, unemployment, the presence of chronic/terminal illness, being a member of the "sandwich generation," and caregiver stress. Often overlooked is the spouse who has a long history of abusive behavior that continues into old age. Some of the important dynamics contributing to the underreporting (and thus the under treatment) of elder abuse include denial, reluctance to disclose, traditional reliance on self to solve problems, the perception of available services or the lack of supportive services, language and cultural barriers and the notion of "suffering in silence" versus revealing "family shame."
Interventions
There are many interventions that nurses and forensic nurses in particular can initiate in order to protect the elderly, but the single most important one is first to recognize a potentially unsafe environment. It is important to remember when assessing the elder that the victim's perception of abuse may not be consistent with the professional classification of abuse types.5 There has been little research done that attempts to focus on the victim's perspective rather than the clinician's. Help seeking behaviors by elders both formally and informally differ widely according to individual value systems and cultural practices. These differences must be taken into account during any assessment.
Although the indicators of abuse are many they can easily be attributed to problems other than abuse. However, certain indicators are considered to be red flags and should raise one's index of suspicion. These include the behavior of client, particularly when noted to be acting withdrawn, anxious, fearful, or suicidal and when there are obvious signs of physical neglect or abuse. More difficult to determine are signs or indicators of sexual abuse which may be masked for a variety of reasons which include shame, embarrassment and fear. Once abuse or neglect in any form has been identified, the services of the multidisciplinary team must be coordinated. These include the appropriate nursing and medical personnel, counseling services, the Department of Protective Services, the criminal justice system, the ombudsman, other family members assessed to be supportive and an effective case management team.
Often the responsibility for ensuring the safety of the elder is placed on the elder rather than on the abuser. Victims are often counseled regarding strategies that may be helpful in protecting themselves however the main focus of counseling must be directed at assisting the abuser to stop the abusive behavior and develop more appropriate coping strategies. Elder abuse is against the law and the criminal justice system frequently is the most powerful deterrent to this unacceptable behavior. Group or family counseling may be helpful in selected situations, however individual counseling for the abuser is essential in order for the abuser to develop appropriate strategies for dealing with his or her stresses and behavior.
There are few assessment tools that can easily and reliably screen the elder for a potentially abusive situation. However, one such tool is the Indicators of Abuse (IOA) Screen. This tool is not a self-report instrument. It must be administered by a professional and requires approximately two to three hours to complete correctly. Some interesting research findings that have resulted from the use of this tool confirm the theory that abuse is strongly related to caregivers personal and emotional problems. It also cites financial dependence of caregiving on care recipient as an important risk factor to be considered when assessing families. The presence of family conflict and insufficient social support was also noted. These findings further alert nurses to the potential danger, which may be lurking within otherwise seemingly safe environments for elders.
Summary
As a member of the multi-disciplinary team charged with coordinating care and ancillary services for the elder client, the forensic nurse is in a unique position and may be the first person to recognize indicators that one of the most fragile of clients may be in trouble. This insight can result in alerting other team members (social workers, physicians, ombudsman) and mobilizing a united effort to address these concerns and/or findings. Preservation of the rights of this most venerable and vulnerable client population is a responsibility of all health care professionals. Erikson6 has said that it is important that elders continue to grow and to stay vitally involved in life in their advancing years. He describes this developmental task as one that reinforces generativity rather than stagnation. As experts in assessment nurses can broaden the umbrella of safety for clients by optimizing the skills and services of all members of the multi-disciplinary team with the goal of ensuring that generativity triumphs over stagnation and that all of our elders are living in comfort and safety and not in fear and thus are free to continue to grow well into their "old age."
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Barbara Moynihan, PhD, APRN, is an associate professor of nursing and director of the MSN in forensic nursing at Quinnipiac University in Hamden, Conn. |
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Rita Hammer, PhD, RN, CS, is professor of nursing and academic coordinator of the MSN in forensic nursing at Quinnipiac University.
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