Social Issues and Elder Abuse

Authors: A. Flemmer, DNP, AGNP, Reviewed by E. Hopson, RN, MSN-Ed, CNE, & L. Templeton, DNP

Elder Abuse Definition

World Health Organization (WHO) Definition:
"A single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person."

Overview of Elder Abuse

Complex Combination of Factors:
  - Psychological, social, and economic factors contribute to elder abuse.
  - The mental and physical conditions of both the victim (the abused) and the perpetrator (the abuser) affect the occurrence of elder mistreatment.
  - Can occur in various settings; however, most older adults live in the community.

Types of Elder Abuse

Physical Abuse:
  - Infliction of pain or injury
  - Physical coercion
  - Use of physical or chemical restraint
  - Examples include slapping, shoving, severe beatings, and restraining with ropes or chains.
  - Over- or under-medicating the elder.
  - Deprivation of food.
Psychological/Emotional Abuse:
  - Infliction of mental anguish through:
    - Name-calling
    - Intimidation and threats
  - Actions that create fear, mental anguish, and emotional pain or distress.
Financial/Material Abuse:
  - Illegal or improper exploitation and/or use of funds or resources, such as:
    - Fraud
    - Taking money under false pretenses
    - Forgery
    - Spending the older adult's money without their knowledge or permission.
Sexual Abuse:
  - Non-consensual contact of any kind with an older person, including:
    - Sexual exhibition
    - Rape
    - Inappropriate touching
    - Any unwanted sexualized behavior.
Caregiver Neglect:
  - Refusal or failure to fulfill a caregiving obligation, which includes:
    - Intentionally failing to meet the physical, social, or emotional needs of the elder.
    - Failing to provide adequate food, water, clothing, medications.
    - Assistance with activities of daily living and help with personal hygiene.

Reporters of Elder Abuse

Who Reports Elder Abuse:
  - Family members (20%)
  - Hospitals (17%)
  - Police (11%)
  - Most frequent reporters of self-neglect are hospitals and friends/neighbors.

High-Risk Populations

Most Vulnerable Victims:
  - Older adults over 80 years of age are the most frequent victims across all categories of abuse.
  - White female elders are particularly vulnerable.
  - Elders unable to care for themselves, those with mental impairment/confusion, and those who are depressed are at greater risk.

Risk Factors Leading to Elder Abuse

Factors Related to Abusers:
  - Dependency of the abuser on the victim for financial assistance, housing, and other forms of support.
  - Presence of mental illness and substance abuse issues (alcohol or drugs).
  - Living with the elder and the elder being socially isolated.
  - Continued domestic violence when the perpetrator is a spouse.
Other Contributing Risk Factors:
  - Caregiver burden and stress; while most research relates to physical abuse, little support exists relating caregiver stress to physical abuse specifically.
  - Highest percentage of elder abuse is neglect.
  - Dementia or demanding personalities of the older adult increase risk.
  - Theory suggesting that adult children who have been abused in their childhood may also abuse their frail parents.
  - Ill, frail, disabled, mentally impaired, or depressed elders are at increased risk.

Profile of Abusers

Characteristics of Abusers:
  - Predominantly white males
  - Most perpetrators are within the 41-59 age group.
  - Often the elderly caregivers themselves and family members (90% of cases) with 47% adult children and 19% spouses.

Self-Neglect in Elders

Self-Neglect Common Traits:
  - Behaviors that pose threats to their own health and safety.
  - Approximately two-thirds of self-neglecting elders are aged 75 and older, predominantly in the oldest old category (>80 years).
  - Most affected are white females who have difficulties caring for themselves.

Symptoms of Abuse

Physical Abuse Symptoms:
  - Bruises or grip marks
  - Repeated unexplained injuries
  - Dismissive attitudes or statements about injuries
  - Refusal to visit the same emergency department for repeated injuries
Emotional or Psychological Abuse Symptoms:
  - Uncommunicative and unresponsive behavior
  - Unreasonably fearful or suspicious demeanor
  - Lack of interest in social contacts
  - Chronic physical or psychiatric health problems
  - Evasive responses during discussions
Financial Abuse or Exploitation Symptoms:
  - Discrepancy between life circumstances and estate size
  - Large withdrawals from bank accounts, switching of accounts, or unusual banking activity
  - Mismatched signatures on checks and the elder’s signature
Sexual Abuse Symptoms:
  - Unexplained vaginal or anal bleeding
  - Torn or bloody underwear
  - Bruised breasts
Neglect Symptoms:
  - Sunken eyes or weight loss
  - Extreme thirst
  - Presence of bed sores

Underlying Causes of Elder Abuse

Family Dynamics:
  - Discord and stress stemming from the older adult’s presence
  - Long-standing patterns of violent interactions
  - Social isolation of both the elder and caregivers intensifies risks.
  - Increased financial burden for caregivers can heighten stress levels.
Caregiver Issues:
- Factors include caregiver stress, absence of proper mental or emotional wellness, addiction, job loss, financial dependency on the elder, and past violent behavior.
- Caregivers often lack appropriate training and struggle to balance their needs with their elder’s needs.
Cultural Factors:
  - Devaluation of older adults contributes to abuse prevalence.
  - The familial secrecy surrounding domestic issues may prevent abuse from being addressed.
  - Social isolation can both instigate and perpetuate abuse.

Prevention of Elder Abuse

National-Level Response in the U.S.:
- A fully developed system for reporting and addressing elder abuse.
- Cooperation from entities such as the Adult Protective Services Agency, National Center on Elder Abuse, National Committee for the Prevention of Elder Abuse, and Association of State Adult Protective Services Administrators.
Legal Obligations:
- 43 states mandate professionals to report suspected cases of elder abuse.
Educational Initiatives:
- Fundamental to preventing abuse and fostering public awareness of the issue.
Supportive Measures:
  - Respite care to relieve caregiving stress by providing short-term care for the elder.
  - Importance of social contact for both the elderly and caregivers to manage tensions.
  - Counseling for caregivers facing behavioral or personal challenges.

Assessment for Elder Abuse

Initial Steps:
  - Conduct interviews with the patient and caregiver separately.
  - Utilize general screening questions to establish rapport and gather information.
  - Obtain a detailed history covering living arrangements, financial status, and family dynamics.
  - Perform a comprehensive physical, cognitive, and emotional examination.

Laboratory Tests for Elder Abuse Assessment

Recommended laboratory tests include:
  - Monitoring electrolytes
  - Serum albumin levels
  - Checking drug levels.

Management of Elder Abuse

Reporting Mandatory Incidents:
  - Reporting elder abuse incidents to protective services is required by law.
  - Legal definition of mandated reporters includes those responsible for care of elders or dependent adults, regardless of compensation status.
  - Website for more details: www.elderabuse.com
Immediate Danger Considerations:
- If the patient is in immediate danger, hospital admission may be warranted (specific ICD codes exist).
- If there is no immediate risk, investigate possible causes for reported abuse, such as lack of education or resources.

Resources for Further Information

Useful Websites:
  - Instructions and resources on elder abuse and prevention can be found at:
    1. http://www.elderabusecenter.org/pdf/family/caregiver.pdf (Preventing Elder Abuse by Family Caregivers)
    2. http://www.elderabusecenter.org/default.cfm?p=wheretoreportabuse.cfm (Reporting elder abuse)
    3. http://www.elderabusecenter.org/default.cfm?p=lawslegislation.cfm (Laws concerning elder abuse prevention)
    4. http://www.preventelderabuse.org/issues/culture.html (Cultural factors in elder abuse)
    5. http://www.hartfordign.org/publications/trythis/issue14.pdf (Measuring caregiver strain)
    6. http://www.hartfordign.org/publications/trythis/issue15.pdf (Elder Abuse and Neglect Assessment tool)