Redefining "Abuse"

Article about the term "Abuse" as it pertains to geriatric citizens and residents of long term care facilities. It focuses on the abuse between elder and caregiver and how it is often overlooked in healthcare today. The article proposes redefining abuse in hopes of increasing awareness of the multifaceted nature of abuse. Nurses General Nursing Article

Redefining "Abuse"

Abuse, within the context of geriatrics and especially long-term care, is a well-documented global phenomenon. Geriatric citizens are already a marginalized and oppressed demographic, so it's not surprising that abuse is interwoven throughout the lives of these individuals. There is a plethora of research available documenting this phenomenon and suggesting and identifying key contributing factors within the context of caregiver abuse towards individuals. However, what is surprising is the lack of research and attention on elder abuse of family and caregivers themselves.

Before moving forward, it is important to have a clear understanding of what defines "abuse". The term abuse is used quite frequently when dealing with geriatric clients, especially in a healthcare setting. However, it is unclear as to whether or not the individuals using this term have a very clear understanding of what defines abuse.

The Merriam Webster dictionary outlines five definitions of the word abuse. These include: "1) a corrupt practice or custom, 2) improper or excessive use or treatment, 3) a deceitful act, 4) language that condemns or vilifies usually unjustly, intemperately and angrily and 5) physical maltreatment".

When people think of abuse, they generally think of physical violence; however, this is the 5th definition of abuse, according to Merriam Webster. So it is clear that abuse is more dynamic and complex than simply "violence". In terms of geriatrics and "elder abuse", The Ontario Network for the Prevention of Elder Abuse uses the WHO's definition, defining elder abuse as a "single or repeated acts, or lack of appropriate action, occurring within a relationship where there is an expectation of trust, which causes harm or distress to an older person."

Considering these definitions, one can see the complexity in the term "Abuse". The Ontario Network for Prevention of Elder Abuse also outlines numerous types of abuse, from physical to sexual and financial. However, when examining the numerous definitions and examples of abuse collectively, an overlying group of themes can be seen and thus help paint a complete picture of what really constitutes "Abuse". Using these themes to create a holistic and comprising definition of abuse would give a similar definition to this; "subjective or objective representation of mistreatment (whether verbal, physical or sexual in nature) causing an individual physical, emotional and/or moral distress and discomfort and creating unhealthy relationships between abuser and abused".

The term abuse and the idea of abuse itself need to be redefined to be more including of, not only elders, but of those caring for elders. Elders are generally viewed as ones whom which are enduring abuse and never the ones of who inflict the abuse. However, this is not always the case; therefore, it is important to approach the topic of abuse with an open mind and understanding and to not immediately assume the "stereotypical" scenarios.

Many times it is the caregiver who suffers, not only abuse, but also emotional and sometimes financial distress, as they are placed in a situation in which they must not only care for, but also support their loved ones. The National Initiative for Care of the Elderly (or NICE) have created a caregiver abuse screening tool for use by healthcare personnel to screen for possible elder abuse; however, there is no initiative in place to screen for the opposite.

Furthermore, physical aggression and violence is all too common against those caring for individuals suffering dementia. Dementia is becoming a common diagnosis amongst the elder population, especially those individuals older than 80 years of age (Lobo, et al., 2000) and is becoming a specialist area, requiring added skills and knowledge. The introduction of the Gentle Persuasive Approach (GPA), which is becoming a mandatory course for most caregivers caring for the aged in both institutions and in community, has proven that fact. Though GPA can improved how we care for those suffering dementia and can provide solutions to mitigate common aggressive and non-aggressive dementia behaviours, it does not completely solved the physical (and verbal) violence that can present in some demented people.

It is unrealistic to assume that the abusive behaviour associated with certain individuals suffering dementia can be completely solved or "cured" (unless of course a cure for dementia is found!) but recognition of this phenomenon and its significance to caregivers should be considered. That's not to say that support does not exist for caregivers struggling with violent behaviour, but there seems to be insufficient recognition of the psychological and physical impact this has on all caregivers.

Respite care is something commonly offered to those caregivers caring for loved ones in the home setting, especially when caregiver "burnout" is suspected. However, this is only a short term solution for a long term problem. Respite care may provide a day (or days) free from abuse and stress, however, the psychological and physical impact will remain and eventually become further exacerbated when respite care ends. Respite care also does not acknowledge the root causes of caregiver "burnout" and is really only a band-aid solution.

That said, dementia is not a necessary prerequisite for physical and verbal abuse of family and caregivers. Sometimes, elders may exhibit abuse towards family and caregivers despite being fully competent and cognizant of their actions. The reasons for this are many and vary; for example, it may be that they wish to maintain control of their situation, internally acknowledging their reliance on the caregiver for basic activities and being resentful. These individuals may also be resentful in general of their aging and declining health. Or, it may just be as simple as it is who they are. Not everyone is kind and caring!

Furthermore, abuse can stem from the individual utilizing and controlling the caregiver's finances. Sometimes, these individuals have little to no life savings and rely on a family member (who may be their caregiver) in order to provide for them financially. Sometimes, these individuals may take advantage and control the finances of their caregivers. This is sometimes dependent on the caregiver enabling the individual, but it can quickly spiral out of control.

There is much progress to be made in the area of defining abuse, identifying abuse and understanding abuse. However, the current trend in abuse, within the context of geriatrics, seems to be placing too much emphasis on elders and their being abused, and neglecting the possibility that it is they who is the abuser. This can be detrimental for healthcare personnel, as they may miss the opportunity to screen and identify caregivers who are being abused. It is already known that abuse can lead to feelings of oppression, isolation and distress; therefore, it is vital that we identify these issues and intervene appropriately. The best way to do this, may be to redefine abuse and how we look at abuse in the healthcare community. Though redefining abuse will not solve all of the problems that exist in terms of geriatric and elder care, it may provide a means to better understand, acknowledge and accept the problems that exist within the care of elders.

References

Lobo, A., Laurner, L., Fratiglioni, L., Anderson, K., Carlo, A., Breteler, M., . . . Hofman, A. (2000). Prevalence of dementia and major subtypes in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group. Neurology,54(11).

Merriam-Webster Dictionary (n.d.). Retrieved March 24, 2015, from Abuse | Definition of abuse by Merriam-Webster

Nicenet - National Initiative for the Care of the Elderly. (n.d.). Retrieved March 24, 2015, from Nicenet - National Initiative for the Care of the Elderly

ElderAbuseOntario.com. (n.d.). Retrieved March 25, 2015, fromElderAbuseOntario.com

steven007

About steven007, BSN, MSN

Steven, BSN, MSN, RN

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I have seen this (a friend caring for an abusive family member). We naturally think about the vulnerability created by age (and yes, that's very real). This points out the vulnerability to abuse created in some cases by caring.

Specializes in Gerontology, Med surg, Home Health.

For abuse to occur there needs to be be intent. A person with dementia has no intent to harm. I suggest you redefine your terms.

Specializes in Hospice.

There may not be intent any longer, but the behaviors persist and have the same effect as intentional abuse. How would you redefine the dynamic?

How do you support caregivers, whether family or staff, who are the targets of abusive behavior?

These questions aren't random snark - I'm really interested in your thoughts, since I and my crew deal with this on a daily basis.

For abuse to occur there needs to be be intent. A person with dementia has no intent to harm. I suggest you redefine your terms.

There may be some legal or policy and procedure manual that says somewhere there needs to be intent, but I don't believe all definitions of abuse come to that same conclusion. Many define abuse as misuse or mistreatment.

I think one concept that is probably relevant is that the target of whatever type of abuse finds it hard or impossible to escape the behavior they are being abused by.

In this case feelings of care, moral duty, familial relationship or job description are the factors that bind the target to the person exhibiting abusive behavior.

Whether the person doing it knows what they are doing or not, the issue here is the effect it has on others. Their intent may be as simple as doing whatever they need to do to avoid something they don't want but something that others have determined that they need: prevention of elopement, wound care, life saving medical care that someone has determined it is legal to give them even if they are refusing.

I too would be very interested to hear how you would define this.

Specializes in Psychiatry.

Hi CapeCodMermaid,

Actually, intent is not a requirement for abuse outside of legal situations. The only time intent matters is if you take an abuse case to court, the courts must prove "criminal intent" or "intent of harm".

All of the terms used in this article are the current standard terms applied to abuse from various sources including the Merriam Webster Dictionary.

Also, the article isn't only about people with dementia (and dementia doesn't always equate abuse!) but also those who are cognizant of what they are doing. I suggest you read the article more thoroughly :).

Thanks for your interest and reading nonetheless!

Specializes in Psychiatry.

Hey heron,

These are great questions you've posed! And I wish I could give you an answer to them, but unfortunately I can't.

I wish to raise awareness. The first part of addressing a problem is recognizing it and I feel that the abuse some caregivers received is not recognized.

I would be interested in hearing other people's ideas regarding these questions though!

Thanks for all your comments!

For abuse to occur there needs to be be intent. A person with dementia has no intent to harm. I suggest you redefine your terms.

I agree with this in terms of patients with Dementia. Most times they are acting in what they believe is self defense. They don't remember who we are and why we are in their "home". If they were A&Ox3, most of them would not be striking staff.

Honestly, some of the nurses and aides I work with take it too personally. I have a resident that spews hateful comments when she is in a mood but I don't take it personally. She isn't of sound mind at the time. My grandfather was a wonderful man but when he was in the late stages of dementia, you would have never known it. He hit staff and called them names. He wasn't really fighting them because he didn't know who they were. He was fighting people from his past.

Specializes in Hospice.

@CaringGerinurse: you make good points, but I think you oversimplify things a bit.

First, an intellectual understanding of the disease process only goes so far when you've just been kicked, verbally abused or lied about out of sheer malice. The experience can be intensified if the caregiver is currently being abused in other areas of his/her life. Even if the caregiver is a survivor of past abuse, there can be a certain element of ptsd that makes particular behaviors difficult to tolerate regardless of one's "understanding".

Secondly, we're not just talking about time-traveling elders who get frightened in situations they don't understand. We also have to deal with people for whom abusiveness has been a life-long behavior which is now enhanced by the disinhibition common in dementia.

IOW, it ain't that simple. Neither professional nor family caregivers have the option of leaving the abusive patient. I read the OP as acknowledging this and asking for ways to support caregivers so that they are able to stop taking it personally.

I want to be clear that, in my opinion, the workplace is NOT a therapy group. If someone is being abused or suffering from ptsd from past experiences, they need more help than a job can or should provide.

I do believe, however, that there are reasonable, "job-appropriate" measures that can be taken to help workers cope and care properly for people with these problematic issues.

Specializes in Psychiatry, Community, Nurse Manager, hospice.

On this site I have seen a lot about "abuse" which is really not abuse. Unsympathetic care, and irritability while providing care are not abuse. I think the standard should be higher for professionals than for family members who provide care, but I have seen people label un-professionalism as abuse. It isn't.

If we really want to help people have healthy relationships, we need to curb our usage of the word abuse, and our judging attitudes toward the people we want to help. Family dynamics are complicated and often rife with conflict. Conflict is not abuse. Major stressors on caregivers can lead to frayed nerves, and temper outbursts which are only compounded by abuse witch hunts.

The solution is not to define unsavory behavior in elders as abuse, but to stop the judging and start supporting. When we use the term abuse, we separate compassion from the person who is losing their temper and we stop helping them. I am not suggesting that a caregiver who puts bruises on her mother, who truly abuses an elder, should not be punished. But one who simply yells or name-calls, or otherwise acts out in frustration that does not cause significant harm should not be labeled an abuser. Why is caregiver respite not addressing "the underlying issue"? We decided that there was such a thing as "underlying issue" when we stopped having compassion and decided to see overworked caregivers as monsters. If the research has shown that giving caregiver respite improves health for all concerned, why is there a need to find an underlying issue?

So yes, I think we need to redefine abuse. But not this way. Abuse is a crime. It is not committed by a demented person who has no idea what they are doing. It is not a loss of temper, nastiness or inappropriate language. Abuse causes significant harm to the person who receives it, and warrants intervention from law enforcement. Family conflict is when family members fight, name call, it might even involve minor physical altercation, but no one gets hurt. In the case of paid caregivers, the standard should be higher, but abuse is still abuse and inappropriate behavior is unprofessional, and should be corrected without legal intervention.

Specializes in Psychiatry.

Hi Invitale,

Thanks for your feedback. I wish to address one thing first; unfortunately current research on respite care isn't so promising in terms of enhancing caregiver outcomes :(. I am not sure which research you are referring to, but I have read a few recent studies and they really didn't show any qualitative or quantitative results that were statistically significant in terms of positive outcomes for caregivers. I feel like any positive outcomes from respite care is the result of placebo effect. Healthcare providers view respite care as a godsend and this transcends onto users of respite care. Thus, because healthcare professionals recommend and praise it, patients and caregivers see only good that can come for it.

And I feel your analysis of the term abuse is very cold, unforgiving and not compassionate. For someone who seems to be heavily advocating compassion, it does not reflect in your use of the term abuse. In fact, your entire comment seems kind of vitriolic.

And I am not sure the moral of your comment in the first place? So... what, a caregiver being physically and verbally abused by a demented parent or spouse should suck it up and remain compassionate? Let the spouse or parent continue to violently beat them but the minute that this caregiver does not show compassionate, they are an "over-worked monster"?

Also, you're focusing too heavily on dementia. Dementia does not always equate abuse. Some people are just nasty people, whether mentally cognizant or not.

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