Elder Abuse - A Hidden Epidemic (Part 1)

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    Vulnerable older adults face high risks of physical, psychological, sexual, financial, and other forms of abuse or exploitation. Too often, these abuses go undetected or are disregarded after they are discovered. Understanding what elder abuse is can help the elderly who are suffering. This is Part 1 of a two-part series.

    Emmalee Miller, age 82, is brought into the Emergency Department by a concerned neighbor. The patient is a widow with mild Alzheimer's dementia, who used to live alone in her own house until about three months ago, when her unemployed son came to live with her. The frail elderly woman has a disheveled appearance with tattered soiled clothing. She acts frightened and withdrawn. A physical examination reveals that Mrs. Miller is dehydrated, malnourished, and mentally confused. The nurse notes a 10 cm purple hematoma on the left side of her face, numerous bruises in various stages of healing on her lateral right arm and on her posterior torso, and three dime sized burned areas on her upper inner thigh. The nurse strongly suspects elder abuse.

    Frail, dependent elders are highly vulnerable to anyone who might take advantage of them. Elder abuse is any action or inaction that results in harm/ loss or endangers the welfare of people age 65 and above. Elder mistreatment is a general term for abuse, neglect, and exploitation. It can include physical abuse or neglect, psychological abuse, financial or fiduciary abuse, self-neglect, or the inappropriate use of medications, restraints, or confinement.

    Like Emmalee, the 'typical' abused elder is a female over the age of 75, who is socially isolated, suffers from chronic health conditions, is in the lower socioeconomic strata, and lives with her abuser(s). Common characteristics of abusers are as follows: family member (majority of cases); male; impairments such as mental illness and substance abuse; poor social network; history of family violence; legal/ financial issues; and, dependent on the older adult. The most frequently identified perpetrators are adult children, followed by a spouse, long term care facility staff, or other relatives.

    Elder abuse/ mistreatment is the least reported form of domestic violence. The prevalence of elder mistreatment is difficult to accurately gauge since many cases go unreported. It is estimated that for every one case of elder abuse reported to authorities, about five more go unreported. One reason may be that normal and common age-related changes mask or mimic markers of abuse. The best available data indicate that each year between 1 and 2 million older Americans are injured, neglected, exploited, or otherwise mistreated by someone on whom they depended for care or protection. The number of cases of elder mistreatment will undoubtedly increase over the next four decades, as the population ages.

    Laws vary from state to state, but elder abuse may be broadly categorized as:

    Physical Abuse - Any action that results in physical pain, injury, or impairment is considered physical abuse. An estimated 0.5 to 4.3 percent of older adults are physically abused annually. This includes, but is not limited to: striking, beating, handling with unnecessary roughness, purposeful injury, unreasonable physical restraint, sexual assault, and deprivation of food or water.

    Neglect - The most common form of elder mistreatment is neglect. Neglect is the failure to take care of the needs of an elderly person. This includes, but is not limited to: failure to provide nourishment, hydration, hygiene, clothing, shelter, medical care, and protection from injury. Self-neglect is common among frail elders who live alone. Indicators of self-neglect are malnourishment, dehydration, falls, poor hygiene, and inadequate clothing.

    Psychological (Emotional) Abuse - This can be difficult to identify and prevent. In psychological abuse, an elderly person is treated in a way that causes emotional pain or distress. This can range from extremes of verbal abuse, coercion, and accusation to more subtle tactics such as manipulation, intimidation, withholding attention, and a general lack of patience and respect. Emotional abuse is damaging in that it wears away the elderly individual's self-confidence, self-worth, and self-esteem. Frail, dependent elders often have little means to defend themselves from the constant humiliation and verbal assaults.

    Sexual Abuse - Sexual elder abuse is non-consensual sexual contact with an elderly person without the elder's consent. Such contact can involve unwelcome sexual touching, physical sex acts, forcing an older person to view pornography or watch sex acts, and making an elder undress against her will.

    Financial (Fiduciary) Abuse - In these tough economic times, crimes and financial exploitation against vulnerable older adults are among the fastest growing in the country. Many seniors across the U.S. suffer financial abuse at the hands of friends, family members, telemarketers, unscrupulous TV evangelists, people they meet on the Internet, and financial services employees. Financial abuse or exploitation is misappropriation of an elder's property or identity by means of trickery, manipulation, or exploitation. This includes, but is not limited to: making unauthorized withdrawals from an elderly person's account, cashing an elderly person's Social Security check and keeping part or all of it, forcing an elderly person to suddenly change her will, falsifying claims, or diverting funds and assets. Financial exploitation by a family member is reported annually by 5 to 6 percent of older people.

    Healthcare Abuse - This is harsh treatment of elderly patients by healthcare personnel. Most of the time, this type abuse is not intentional, but results from frustration and lack of self-control on behalf of harried healthcare workers. Caring for the needs of frail dependent older adults can be unrelentingly stressful. When staffing is inadequate, the frustration can grow to a boiling point, manifesting in many harmful ways. This includes, but is not limited to: excessive force in treatment, intimidation by yelling or humiliation, ignoring a patient's needs, rushing a patient through a meal, inappropriate use of medications, restraints, or confinement, and depriving an elderly patient of food, water, and medications.

    Part 2 of this two-part series will discuss ways to identify elder abuse, common presentations, and mandatory reporting requirements. Please stay tuned.

    References:

    Adult Protective Services in North Carolina
    Elder Abuse Prevalence and Incidence
    Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America
    Residential Abuse
    What Is Elder Abuse?
    Last edit by VickyRN on Jul 31, '12
    Joe V, ctmed, TheCommuter, and 2 others like this.

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  2. About VickyRN

    VickyRN is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is faculty in a large baccalaureate nursing program in North Carolina.

    VickyRN has '16' year(s) of experience and specializes in 'Gerontological, cardiac, med-surg, peds'. From 'Under the shadow of His wings...'; Joined Mar '01; Posts: 12,044; Likes: 6,439.

    Read more articles from VickyRN

    8 Comments so far...

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    I am looking forward to where you are going to take this. I am sure a lot of us have our own stories of abuse situations we have witnessed if you spend anytime in the job field from CNAs to Nurse Practitioners to Therapists. Particularly, I want to hear about healthcare abuse.

    While real abuse and the abusers probably have a special place in Hades, some articles I have read and some standards border on a modern day "witch hunt" for us medical professionals. I read an article on this many years back on a site for nursing assistants that claimed even petty stuff like accidentally giving someone the wrong salad dressing was abuse!

    Also... what about call lights? I know some patients that want a person there to fluff pillows, empty urinals when they are completely mobile, etc. I have seen articles where not answering a call light because someone else needed my help more is considered abuse.

    And.. what of violent patients. No, I am not talking the harmless little old lady with dementia that grabs and pinches. The nursing home patients I am seeing lately are younger, more aggressive, stronger, with multiple psych issues in a setting that used to be the sole domain of the frail and elderly. However, unlike a psch ward, as a nursing home we have no tools to deal with this because this is thier "home". restraints are forbidden. Keeping the resident away from others to prevent harm is considered "punishment" and "isolation". If they go out on pass and get 2 dollar bottles of cheap Heavenly Hill Whiskey and threaten to beat the crud out of other residents or staff, we can only report to the DoN.
    TiddlDwink, NyteshiftLVN, TurtleCat, and 1 other like this.
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    Quote from ctmed
    I am looking forward to where you are going to take this. I am sure a lot of us have our own stories of abuse situations we have witnessed if you spend anytime in the job field from CNAs to Nurse Practitioners to Therapists. Particularly, I want to hear about healthcare abuse.

    While real abuse and the abusers probably have a special place in Hades, some articles I have read and some standards border on a modern day "witch hunt" for us medical professionals. I read an article on this many years back on a site for nursing assistants that claimed even petty stuff like accidentally giving someone the wrong salad dressing was abuse!

    Also... what about call lights? I know some patients that want a person there to fluff pillows, empty urinals when they are completely mobile, etc. I have seen articles where not answering a call light because someone else needed my help more is considered abuse.

    And.. what of violent patients. No, I am not talking the harmless little old lady with dementia that grabs and pinches. The nursing home patients I am seeing lately are younger, more aggressive, stronger, with multiple psych issues in a setting that used to be the sole domain of the frail and elderly. However, unlike a psch ward, as a nursing home we have no tools to deal with this because this is thier "home". restraints are forbidden. Keeping the resident away from others to prevent harm is considered "punishment" and "isolation". If they go out on pass and get 2 dollar bottles of cheap Heavenly Hill Whiskey and threaten to beat the crud out of other residents or staff, we can only report to the DoN.
    All excellent points and real issues being faced in nursing homes today.
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    Whats the most fustrating part for me with long term care is staffing issues. So many nursing homes work under staffed and the company makes them work under staffed to save on cost. The last nursing home I worked at had five CNA and 2 nurses to the floor to take care of 70 + people. While there was five to six other nurses completely capable of getting off their duffs and anwsering lights that did not because they had to work in the office. Then to top it off, the company would not provide the briefs and hyigene supplies for us to do our job correctly.

    Somethings maybe more preventable with long term care if companies did not staff us so poorly and provided the things need to take care of the patients. One CNA is not capable of covering a floor of 30 patients, doing twelve showers, plus activities, feeding, and tolieting needs. Many of these nurses and aids work long physical shifts with no lunches or breaks. They are burnt out and feel like they have no options on how to change the conditions of the place they are working.

    Yes, sometimes a call light goes unanwsered because that person is safe. I have to take care of all my patients even the ones who are not able to speak, push a button or move around the room. The nurse and cna cannot be in four places at once and sometime it takes longer the five mintues to do what we need to do. It might be time to push for a higher Nurse and staffing to patient ratio not including offices staff.

    Witch hunt I think so but I think its because people are wanting to line pockets instead of fix the problem....
    TiddlDwink and VickyRN like this.
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    Quote from rlockd
    Whats the most fustrating part for me with long term care is staffing issues. So many nursing homes work under staffed and the company makes them work under staffed to save on cost. The last nursing home I worked at had five CNA and 2 nurses to the floor to take care of 70 + people. While there was five to six other nurses completely capable of getting off their duffs and anwsering lights that did not because they had to work in the office. Then to top it off, the company would not provide the briefs and hyigene supplies for us to do our job correctly.

    Somethings maybe more preventable with long term care if companies did not staff us so poorly and provided the things need to take care of the patients. One CNA is not capable of covering a floor of 30 patients, doing twelve showers, plus activities, feeding, and tolieting needs. Many of these nurses and aids work long physical shifts with no lunches or breaks. They are burnt out and feel like they have no options on how to change the conditions of the place they are working.

    Yes, sometimes a call light goes unanwsered because that person is safe. I have to take care of all my patients even the ones who are not able to speak, push a button or move around the room. The nurse and cna cannot be in four places at once and sometime it takes longer the five mintues to do what we need to do. It might be time to push for a higher Nurse and staffing to patient ratio not including offices staff.

    Witch hunt I think so but I think its because people are wanting to line pockets instead of fix the problem....
    Oh god, 1 CNA to floor! Now back 2006 to around 2010, I made tons of money (well, at least a better living wage for a CNA 2-5 dollars more than going rate of 10 here) because the big wigs up in Baton Rouge were on a warpath about poor facility staffing. It worked for a bit. The better places would pay agency rates rather than face the wrath of the state of Louisiana Dept of Health and Hospitals who was possibly propped up with FEMA money. However, those programs have been cut for 'austerity" measuses and some state run facilities have now been privatized. Since the facilities no longer fear state auditors on the tail unless something really messed up happens, they cut back agency AND are not as concerned if a CNA has too many patients. After all, the folks in the office or on the board do not have to work the floor. No complaints no foul. (Though you bet if something really does happen, they are going to be looking for "fault" to keep themselves clean and the money pumping!)

    I am wondering if lack of supplies is a form of abuse. I have been having to dry folks off with bed spreads because towels are rare!

    This is the first time since many of the agencies went belly up I have been forced to work directly for a facility. I did not realize how tragic some of this is. The folks that own these places are usually 2 states away and have out of state management companies run them. So, there is a total disconnect.
    TiddlDwink, TheCommuter, and VickyRN like this.
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    It's so sad that children or spouses, the ones the elderly first turn to for help, are actually the perpetrators...
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    Quote from amygarside
    It's so sad that children or spouses, the ones the elderly first turn to for help, are actually the perpetrators...
    Tragic indeed. In the case of the grown chidlren, there is often a cycle of abuse going on. The children grew up in an abusive environment. In the case of the spouse being abusive, sometimes the spouse has dementia. I once took care of an elderly woman in the ED who broke down in tears as she related how her loving husband of 50 years was becoming violent and belligerent due to progressing Alzheimer's dementia. She was his sole caregiver.
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    depends on the kids. The elders husband or wife that died, and left them alone to fend for themselves, was usually the one that took care of the financial. AND its usually money that starts the abuse. Remember these elders come from a different generation. that what causes senior abuse. I have seen too much of the elders that have money, or a nice place to live, then out of the wood work, after years of no show, suddenly the offspring appear, wanting to see how they can get the money, or 'inherit' the house!
    VickyRN likes this.
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    Quote from royhanosn
    depends on the kids. The elders husband or wife that died, and left them alone to fend for themselves, was usually the one that took care of the financial. AND its usually money that starts the abuse. Remember these elders come from a different generation. that what causes senior abuse. I have seen too much of the elders that have money, or a nice place to live, then out of the wood work, after years of no show, suddenly the offspring appear, wanting to see how they can get the money, or 'inherit' the house!
    Very true. I have witnessed this also. Financial abuse (fiduciary abuse) is common and growing.


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