elder abuse(redirected from Behavioral indicators)
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Elder abuse is a general term used to describe harmful acts toward an elderly adult, such as physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, and neglect, including self-neglect.
Results from the National Elder Abuse Incidence Study, funded in part by the Administration on Aging, suggest that over 500,000 people 60 years of age and older are abused or neglected each year in the United States. It was also found that four times as many incidents of abuse, neglect, or self-neglect are never reported, causing researchers to estimate that as many as two million elderly persons in the United States are abused each year. In 90% of the cases, the abusers were found to be family members and most often were the adult children or spouses of those abused. In addition, equal numbers of men and women have been identified as the abusers. However, women, especially those over 80 years of age, tend to be victimized more than men.
Elder abuse can take place anywhere, but the two main settings addressed by law are domestic settings, such as the elder's home or the caregiver's home, and institutional settings, such as a nursing home or group home. In general, there are five basic types of elderly abuse: physical, sexual, emotional or psychological, financial, and neglect. Data from National Center on Elder Abuse indicates that more than half of the cases reported involve some kind of neglect, whereas 1 in 7 cases involve physical abuse. It is considered neglect when a caretaker deprives an elderly person of the necessary care needed in order to avoid physical or mental harm. Sometimes the behavior of an elderly person threatens his or her own health; in those cases, the abuse is called self-neglect. Physical abuse refers to physical force that causes bodily harm to an elderly person, such as slapping, pushing, kicking, pinching, or burning.
About 1 in 8 cases of elderly abuse involve some form of financial exploitation, which is defined as the use of an elderly person's resources without his or her consent. The National Center on Elder Abuse defines emotional and psychological abuse of a senior as causing anguish, pain, or distress through verbal or nonverbal acts, such as verbal assaults, insults, intimidation, and humiliation, for example. Isolating elderly persons from their friends and family as well as giving them the silent treatment are two other forms of emotional and psychological abuse. Any kind of non-consensual sexual contact with an elderly person that takes place without his or her consent is considered sexual abuse.
Causes and symptoms
Elder abuse is a complex problem that can be caused by many factors. According to the National Center on Elder Abuse, social isolation and mental impairment are two factors of elder abuse. Studies show that people advanced in years, such as in their eighties, with a high level of frailty and dependency are more likely to be victims of elder abuse than people who are younger and better equipped to stand up for themselves. Because spouses make up a large percentage of elder abusers, at least 40% statistically, some research has been done in the area, which shows that a pattern of domestic violence is associated with many of the cases. The risk of elder abuse appears to be especially high when adult children live with their elderly parents for financial reasons or because they have personal problems, such as drug dependency or mental illness. Some experts have speculated that elderly people living in rural areas with their caretakers may have a higher risk of being abused than city dwellers. The idea behind this theory is that the opportunity exists for the abuse to occur, but there is less likelihood that the abuser will be caught. More research in this very important area is needed in order to illuminate the relationship between these factors.
The National Center on Elder Abuse identifies the following as signs of elder abuse:
- Bruises, pressure marks, broken bones, abrasions, and burns may indicate physical abuse or neglect.
- Unexplained withdrawal from normal activities and unusual depression may be indicators of emotional abuse.
- Bruises around the breasts or genital area, as well as unexplained bleeding around the genital area, may be signs of sexual abuse.
- Large withdrawals of money from an elder's bank account, sudden changes in a will, and the sudden disappearance of valuable items may be indications of financial exploitation.
- Bedsores, poor hygiene, unsanitary living conditions, and unattended medical needs may be signs of neglect.
- Failure to take necessary medicines, leaving a burning stove unattended, poor hygiene, confusion, unexplained weight loss, and dehydration may all be signs of self-neglect.
Diagnosis and treatment
The National Committee for the Prevention of Elder Abuse notes that Adult Protective Services (APS) caseworkers are often on the front lines when it comes to elderly abuse. People being abused or those who believe abuse is taking place can turn to their local APS office for help. The APS routinely screens calls, keeps all information confidential, and, if necessary, sends a caseworker out to conduct an investigation. In the event that a crisis intervention is needed, the APS caseworker can arrange for any necessary emergency treatment. If it is unclear whether elder abuse has taken place, the APS caseworker can serve as a liaison between the elderly person and other community agencies.
According to the National Committee for the Prevention of Elder Abuse, "professionals in the field of aging are often the first to discover signs of elder abuse." Providing encouragement and advice, they play a critical role in educating others with regard to the needs of the elderly. They not only provide valuable support to the victims of abuse, but they also monitor high-risk situations and gather important information that can help validate that abuse has taken place.
Some people might think that a person who has cognitive impairment might be unable to describe mistreatment; however, that is not the case. In fact, guidelines set by the American Medical Association call for "routine questions about abuse and neglect even among patients with cognitive impairment in order to improve the identification of cases and implement appropriate treatment and referral." Rather than an inability to describe mistreatment, what might stop an elderly person from reporting abuse is a sense of embarrassment or fear of retaliation. To complicate matters, differences exist among cultural groups regarding what defines abuse.
Therefore, most states have established laws that define elder abuse and require health care providers to report any cases they encounter with penalties attached for failing to do so. Indeed, statistics show that health care providers, for example, report almost 25% of the known cases of elder abuse. Therefore, physicians play a very important role in identifying and treating elders who have been abused. And yet, in an article published by the Journal of the American Geriatrics Society, Dr. Conlin pointed out that only 1 of every 13 cases of elder abuse are reported by physicians. There may be several reasons for this. In some cases, the problem may simply go unnoticed, especially if the physician has no obvious reason to suspect any wrongdoing. In other cases, the patient may hide or deny the problem.
In recent years, much media attention has been focused on elderly abuse that takes place in institutional settings. Anyone who believes that a loved one is being abused while in a nursing home or other institutional setting should contact the authorities for assistance immediately.
The mortality rate of an elderly person who has been mistreated is higher than the mortality rate of an elderly person who has not experienced abuse. Nonetheless, numerous success stories exist regarding successful interventions. Social workers and health care professionals, as well as concerned citizens from a variety of backgrounds, have played a key role in identifying and obtaining treatment for abused elders.
Planning for the future is one of the best ways to avoid elder abuse. Consider a variety of retirement options, ones that will encourage safety as well as independence. It is important to stay active in the community. Avoiding isolation minimizes the likelihood that abuse will occur. Seek professional counsel when necessary; it is important for everyone to know their rights and to be advocates on their own behalf.
Clarke, M. E., Pierson, W. "Management of elder abuse in the emergency department." Emergency Medical Clinics of North America 17 (1999): 631-644.
Conlin, M. "Silent suffering: a case study of elder abuse and neglect." Journal of the American Geriatrics Society 43 (1995): 1303-1308.
Lachs, M. S., Willimas, C. S., O'Brien, S., Pillemer, K. A., Charlson, M. E. "The mortality of elderly mistreatment." Journal of the American Medical Association 280 (1998): 429-432.
Administration on Aging "Elder Rights & Resources. Elder Abuse." Administration on Aging 10 December 2004 Administration on Aging, Department of Health and Human Services. 1 April 2005 http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/Elder_Abuse_pf.asp.
American Medical Association "Featured CSA Report: AMA Data on Violence Between Intimates (I-00): Elder Abuse." American Medical Association January 2005 American Medical Association. 1 April 2005 http://www.ama-assn.org/ama/pub/category/13577.html.
National Center on Elder Abuse "The Basics: Major Types of Elder Abuse." National Center on Elder Abuse 15 May 2003 National Center on Elder Abuse. 1 April 2005 http://www.elderabusecenter.org/.
National Center on Elder Abuse "Elder Abuse: Frequently Asked questions." National Center on Elder Abuse 23 March 2005 National Center on Elder Abuse. 1 April 2005 http://www.elderabusecenter.org/.
National Committee for the Prevention of Elder Abuse "The Role of Professionals and Concerned Citizens." National Committee for the Prevention of Elder Abuse March 2003 National Committee for the Prevention of Elder Abuse. 1 April 2005 http://www.elderabusecenter.org/.
misuse, maltreatment, or excessive use.
child abuse see child abuse.
domestic abuse abuse of a person by another person with whom the victim is living, has lived, or with whom a significant relationship exists. The abuse may take the form of verbal abuse, sexual abuse, physical battering, or psychological (emotional) unavailability. Abuse is a learned behavior and has an escalating cycle; abusive behavior cuts across all racial, ethnic, educational, and socioeconomic boundaries.
drug abuse see drug abuse.
elder abuse maltreatment of an older adult, ranging from passive neglect of needs to overt mental, physical, or sexual assault.
physical abuse any act resulting in a nonaccidental physical injury, including not only intentional assault but also the results of unreasonable punishment.
psychoactive substance abuse substance abuse.
sexual abuse any act of a sexual nature performed in a criminal manner, as with a child or with a nonconsenting adult, including rape, incest, oral copulation, and penetration of genital or anal opening with a foreign object. The term also includes lewd or lascivious acts with a child; any sexual act that could be expected to trouble or offend another person when done by someone motivated by sexual interest; acts related to sexual exploitation, such as those related to pornography, prostitution involving minors, or coercion of minors to perform obscene acts.
substance abuse a substance use disorder characterized by the use of a mood or behavior-altering substance in a maladaptive pattern resulting in significant impairment or distress, such as failure to fulfill social or occupational obligations or recurrent use in situations in which it is physically dangerous to do so or which end in legal problems, but without fulfilling the criteria for substance dependence. Specific disorders are named for their etiology, such as alcohol abuse and anabolic steroid abuse. DSM-IV includes specific abuse disorders for alcohol, amphetamines or similar substances, cannabis, cocaine, hallucinogens, inhalants, opioids, PCP or similar substances, and sedatives, hypnotics, or anxiolytics. See also drug abuse.
the physical or emotional abuse, including financial exploitation, of an elderly person, by one or more of the person's children, nursing home caregivers, or others.
a reportable offense of physical, sexual, psychological, or material abuse, as well as violation of the rights of safety, security, and adequate health care of older adults. Contributing factors may include economic considerations, interpersonal conflicts, health, and dependency. Often the abused person denies that abusive acts occur and feels helpless and resigned to abuse. Health care workers are required to report suspected abuse, and perpetrators may be subject to criminal charges. Also called abuse of the elderly.
observations Manifestations are dependent on the form of abuse. Physical abuse signs include cuts; lacerations; bruises; welts; black eyes; broken bones and sprains; dislocations; injury incompatible with history; broken eyeglasses; torn clothing; physical signs of punishment or restraint; laboratory findings of medication overdose or underuse of prescription drugs; elder report of being hit, slapped, kicked, or maltreated; and caregiver's refusal to allow visitors to see elder alone. Sexual abuse signs include bruises around the breasts or genitalia; unexplained venereal disease or genital infections; unexplained vaginal or rectal bleeding; torn, stained, or bloody underclothing; and elder report of being assaulted or raped. Emotional abuse signs include emotional upset or agitation; hesitation to speak; extreme withdrawal; unusual behavior usually attributed to dementia; implausible stories; and reports of being verbally or emotionally abused. Neglect signs include dirty appearance; presence of feces and/or urine; environmental safety hazards; dehydration; malnutrition; untreated bed sores; poor personal hygiene; untreated health care problems; and elder report of mistreatment. Abandonment signs include desertion of an elder at a public institution or location such as a hospital, clinic, or shopping center, and elder self-report of abandonment. Signs of exploitation include unusual, sudden, or inappropriate activity in bank accounts; signatures on checks that do not resemble the older person's signature; unusual concern by caregiver that an excessive amount of money is being spent on care of the older person; numerous unpaid bills; overdue rent; abrupt changes in a will or other financial documents; unexplained disappearance of funds or valuable possessions; and unexplained or sudden transfer of assets to a family member or someone outside the family. Signs of self-neglect include dehydration; malnutrition; untreated or improperly attended medical conditions; poor personal hygiene; hazardous or unsafe living conditions; inappropriate or inadequate clothing; and overall lack of self-care. Diagnosis is typically made by social service, health care, and legal experts after history, investigation, and physical examination. Laboratory tests and drug screening may be done to determine the extent of malnutrition, dehydration, and medication drug levels. Severe injury, disfigurement, and death are all complications of chronic or severe physical abuse.
interventions Obvious signs of abuse are reported to the local authorities for immediate investigation and elder protection. If the elder is perceived to be in immediate danger, elder protection should be sought through the local Adult Protective Services or the county Department of Social Services. If signs are vague or inconsistent, observations are documented and reported to appropriate local authorities for investigation.
nursing considerations Nurses serve as a frontline resource for the detection, intervention, and prevention of elder abuse. This includes the identification of high-risk dependent elder relationships, such as those where an elder is dependent on caretakers; elders with functional impairments; previous history of abuse or neglect; evidence of substance abuse or polypharmacy; signs of depression; and lack of or limited financial and/or support resources. The nurse needs to do a thorough assessment for signs of coercive caretaker arrangements or lack of caretaker skills, identification of family crises that could trigger abuse or neglect, and identification of signs of abuse or neglect. All evidence should be carefully documented and reported to appropriate sources. The nurse is also instrumental in assisting elder and family to seek respite care services, counseling, and support groups. Social agency referrals are needed for financial and functional assistance (e.g., housekeeping, cooking, and shopping). Skill-building workshops for family members, coordinated care of elderly needs, public education about the problem, and coordination among state agencies and service providers are all mechanisms for prevention. Education includes caregiver instruction about alternative forms of venting frustrations and information about available community resources.
elder abuseElderly abuse, geriatric abuse, senior abuse Geriatrics Physical or psychological mis/maltreatment of an elderly person by a family member or other close associate, in the form of physical injury, restraint, financial exploitation, threats, ridicule, insult or humiliation, forced physical or social isolation, or change in living arrangements. See Domestic violence, Elder neglect.
Features of elder abuse
• Physical violence Intent to cause bodily harm: Hitting, slapping, or striking with objects, resulting in bruises, abrasions, fractures, burns
• Emotional/psychological abuse Intent to cause mental or emotional pain or injury: Verbal aggression, statements that humiliate or infantilize, insults, threats of abandonment or institutionalization
• Material exploitation -an 'optional' form of EA–misappropriation of money or property, theft of social security checks, changing person's last will and testament, and so on (NEJM 1995; 332:437ra)
*EA is an act of commission, defined in an arbitrary and somewhat nebulous fashion; in the current absence of a consensus definition; some experts prefer to use alternative terms, eg inadequate care of the elderly or mistreatment of elderly, which include acts of commission and omission, do not assign blame and at the same time are 'politically correct'
Indicators of elder abuse
• Physical indicators Alcohol or substance abuse, burns, bruises, contusions, decubital ulcers, dehydration, duplication of medication, fecal impaction, fecal incontinence, lacerations, malnutrition, poor hygiene, repeated hospital admissions, urine burns/excoriations
• Family/caregiver indicators Elder not allowed to speak without 'supervision' by family member/care giver (FM/CG), obvious absence of supervision, aggressive behavior toward elder, indifference or anger toward elder, FM/CG accuses elder of deliberate incontinence, unwillingness of FM/CG to comply with services provided, previous history of elder or alcohol and/or substance abuse, or mental illness, or conflicting accounts of incidents by the family, supporters, and victims
• Behavioral indicators Agitation, anger, anxiety, confusion, depression, disorientation, fear, hesitation to talk openly, implausible stories, isolation, non-responsiveness, withdrawal (AMN 6/1/92, p17)
el·der a·buse(el'dĕr ă-byūs')
The physical or emotional abuse, including financial exploitation, of an old person, by one or more of the person's children, nursing facility caregivers, or any others.
el·der a·buse(el'dĕr ă-byūs')
Physical or emotional maltreatment, including financial exploitation, of an elderly person.
n the infliction of physical, sexual, or emotional trauma on an elder.