Elder Mistreatment Dr.DoHA RASHEEDY ALY Lecturer of Geriatric MedicineDepartment of Geriatric and Gerontology Ain Shams University
Elder mistreatment: Involves acts of commission oromission that result in harm or threatenedharm to the health or welfare of an elderlyperson by a caregiver or other trustedperson
OR• “Intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder.OR:• “Failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm”
• The definitions exclude violence by strangers.• There must be a trusting relationship between an older person and the abuser.• Willful (attempts harm) non- willful (lack of skill, burnt out caregiver)
Who is the abuser?• Partner, adult child or other relative.• Friend, neighbour or visitor• Patient or resident• Health care provider, caregiver or other social or support worker.• Person managing an older person’s affairs (e.g. Attorney or guardian).• Self (self neglect)
Where does elder abuse take place?• Home.• Nursing home.
Epidemiology• Increases as world is ageing.• Ranges from 1.5 – 6% across different population.• Underreporting ? (only less than 10% cases are reported)• Abuse is manifested differently in different culture and ethnic groups.
Barriers to report elderly mistreatment Lack of awareness (especially among health care professionals). Health care workers may feel uncomfortable discussing the topic with their patients or may fear offending their patient’s caregivers. Knowing that there are few effective avenues to address the problem once it is identified. lack of satisfaction with the response by the authorities Ageism and negative stereotyping of the elderly. It is often difficult to distinguish subtle symptoms of mistreatment from symptoms of chronic physical and mental illnesses. Social isolation of the patient, Cognitive impairment. The elderly persons fear of threatening the relationship with the caregiver and feeling that there is nowhere else to go, that nothing can be done to help. The shame in admitting abuse by ones own family.
Risk Factors For Elderly Mistreatment• Factors in the victim.• Factors in the abuser.• External factors as living arrangements, external stress and social isolationBut, THERE IS NO EXCUSE FOR ABUSE
Types of Abuse• Physical• Psychological• Sexual• Violation of Rights• Neglect• Financial exploitation
Physical abuse• Physical abuse is the use of force that results in physical injury, pain, or impairment and may include hitting, shoving, shaking, slapping, kicking, pinching, and burning. Additionally, the inappropriate use of drugs and physical restraints, force feeding, and physical punishment.
SEXUAL ABUSE• nonconsensual sexual contact of any kind or sexual contact with a person incapable of giving consent. It includes unwanted touching, sexual assault, and sexual battery.• Primary evidence of sexual abuse includes bruising of the perineal region or presence of semen. Secondary evidence includes new onset of a sexually transmitted disease, blood, or purulent discharge
PSYCHOLOGICAL ABUSE• infliction of anguish, emotional pain, or distress through verbal or nonverbal acts. It includes verbal assaults, insults, threats, intimidation, humiliation, , name-calling or harassment, silence treatment.• Psychological abuse also includes statements that humiliate or infantilize the elderly person.
TYPES OF NEGLECT• Active Neglect: intentional failure of a care-giver to fulfill his/her care–giving responsibilities• Passive Neglect: Unintentional failure of a care-giver to fulfill his/her care–giving responsibilities• Self Neglect: The older person not providing his/her own essential needs
VIOLATION OF RIGHTS• Abandonment: desertion of an elderly person for whom one has agreed to care for, “dumping” a cognitively impaired elder at an emergency room with no identification• denial of privacy• participation in decision-making.
FINANCIAL EXPLOITATION• is the illegal or improper use of an elderly person’s funds, property, or assets.• It may include cashing checks without authorization, forging an elderly person’s signature, misusing elderly person’s money or possessions, deceiving an elderly person into signing a document such as a contract or will, or improper use of guardianship or power of attorney, medical fraud.
Is Elder Abuse a Crime?• Physical, sexual, and financial/material abuses are considered crimes.• Certain emotional abuse and neglect are subject to criminal prosecution.• SELF-NEGLECT IS NOT CONSIDERED A CRIME.
Indicators for elder mistreatmentPhysical Signs:-• Multiple injuries, especially of different ages; bruises, welts, cuts, abrasions;• Scalds & burns, especially sock & glove patterns;• Genital Injuries• Poisoning especially if recurrent• Sexually transmitted diseases;• Patterned bruising;• Unexplained failure to thrive;• Poor hygiene;• Dehydration or malnutrition;• Fractures, especially if in specific patterns;
Behavioral Indicators• Fear of particular person• Appears worried and/or anxious• Becomes easily irritable or upset• Appears depressed or withdrawn• Avoids physical eye or verbal contact with carer or service provider.• Difficulty in walking or sitting• Pain or itching in genital area• Recoiling from being touched• Fear of bathing or toileting
Indicators of Financial Abuse• Lack of money for necessities• Depletion of savings• Disappearance of possessions• Sale of property by older person who seems confused about the reasons for the sale
Indicators of Neglect & Acts of Omission• Malnourishment or dehydration• Poor personal hygiene• Clothing in poor repair• Absence of appropriate dentures, glasses or hearing aids• Left unattended for long periods• Medicines not purchased or administered
Indicators of Self Neglect• Reclusive, filthy and unhealthy living environments• Collecting and/or hoarding rubbish• Poor personal hygiene• Inappropriate or unusual clothing• Menagerie of pets
INSTITUTIONAL ABUSEfailure of an organization to provide anappropriate and professional service.Indicators:• Low staff morale• High staff turnover• High sickness rates• Excessive hours worked and frequent use of agency staff• Lack of consideration for Privacy• Lack of care with personal clothing (including loss of clothes, being dressed in other peoples’ clothes, dirty or unkempt, spectacles not clean, wearing other peoples’ spectacles, hearing aids or teeth)
• Poor hygiene with noticeable smell of urine• Residents in dirty clothing and/or bed linen• Inappropriate use of equipment• Over reliance on sedating medication, catheterisation and enemas• Lack of communication between staff, staff and residents and staff and relatives
• Effective management requires a multidisciplinary approach that covers broad areas of• medical treatment,• mental health care,• social services, and• legal assistance.
Prevention• Education is the cornerstone of preventing elder abuse.• Respite care essential in reducing caregiver stress• Social contact & support the elderly, family members & caregivers.• Counseling for behavioral or personal problems in the family play a significant role.• If there is a substance abuse problem, treatment is first step in preventing violence against older family member.
Identification of suspected cases• Physicians should learn to recognize the common signs and symptoms of elder abuse, many of which can be subtle.• Health care provider may be the only contact of the elder other than the abuser.• When the physician suspects a problem, he should conduct a thorough history and physical exam, and the caretaker should be asked to leave the examining room during the interview.
• Victims may not expose truth immediately, instead asking directly, physician should begin with questions about nature of relationship with the caregiver, conditions of the home, and circumstances surrounding her physical signs and symptoms.• Assess patient safety , if unsafe hospital admission is warranted.• Develop a plan-of-care to promote functional independence
Assessment• Medical• Cognition• Mood• Functional• Decision making capacity.• Home assessment• Documentation of signs of abuse
• Reporting• APS• Community services• guardianship
Provide the Pt: Education: Promote the social attitude that no one should be subjected to violent, abusive, humiliating, or neglectful behavior. Educate about the special needs and problems of older adults and about the risk factors for abuse. Provide resources accessible for geographic areas and on-going and emergent support. Respite care: Temporary rest and “time off” is essential in reducing caregiver stress, a major contributing factor in elder abuse. Social contact and support: Encourage being part of a social circle or support group. Having other people to talk to is an important part of relieving tensions. Many times, families/ friends can share solutions and provide informal respite for each other. Abuse is less likely to go unnoticed when there is a larger social circle, “more eyes” on the Pt. Counseling: Encourage changing lifelong patterns of behavior and finding solutions to problems emerging from current stressors. If there is a substance abuse, behavior problem in the family, treatment is the first step in preventing violence against the older family member. Address mental illness issues. Professionals and Community should: Keep a watchful eye out for family, friends, and neighbors who may be vulnerable. Get educated and understand that abuse can happen to anyone. Speak up if you have concerns. Trust your instincts! Know what to look for. Keep reporting any suspicions you have of abuse to helping agencies. Spread the word. Share what you’ve learned to friends, family and people you work with.
Instructions to a caregiver:- If the caregiver overwhelmed by the demands of caring for an elder, instruct (he /she ) to do the following: Request help, from friends, relatives, or local respite care agencies, so you can take a break, if only for a couple of hours. Find an adult day care program. Stay healthy and get medical care for yourself when necessary. Adopt stress reduction practices. Seek counseling for depression, which can lead to elder abuse. Find a support group for caregivers of the elderly. If caregiver is having a problems with drug or alcohol abuse, get help.
• Despite your best efforts to identify elder abuse and offer assistance, the suspected victim may refuse help.• Whether abused or not, competent adults have the legal right to refuse medical and social services.