CHAPTER 50. Elder Abuse and Neglect
Nancy Stephens Donatelli
Elder abuse and neglect take different forms; however, the common denominator is harm or threatened harm to the health or welfare of the older adult. 6 Abuse and neglect have increased steadily as the number of older adults requiring dependent care has increased. The emergency nurse needs to cultivate a sensitivity and heightened consciousness of the scope of this problem and its risk factors, and approach the suspicion of elder abuse in the same manner that suspected child abuse is addressed.
DEFINING ELDER ABUSE AND NEGLECT
According to the American Medical Association, older adult abuse is defined as “actions or the omission of actions that result in harm or threatened harm to the health or welfare of the elderly.”7 Neglect is defined as the deliberate refusal to meet basic needs. Seven primary categories of elder mistreatment have been identified: physical abuse, neglect, self-neglect, psychologic or emotional abuse, abandonment, violation of personal rights, and financial abuse. 6
SCOPE OF THE PROBLEM
The life span of the average American is increasing, whereas the U.S. birth rate has declined. More people require care, but fewer people are available to provide care. Consequently, the literature suggests that the number of older adult abuse incidents will increase over the next 30 years because people are living longer, which increases the need for long-term care; the baby-boomer generation is entering the age-group of 60 plus; there is an increased demand on caregivers; and there is an increased legal obligation to report suspected abuse.
Obtaining a clear, accurate picture of demographics surrounding elder abuse is difficult. Significant shame and embarrassment are associated with this problem, so abused individuals may keep the problem hidden within the family to decrease further embarrassment. Study findings confirm commonly held theories that officially reported cases of abuse are only the “tip of a much larger iceberg.” For every case of abuse and neglect that is reported to authorities, experts estimate that there may be as many as five cases that have not been reported. 6
The best national data report that a total of 565,747 older adults, age 60 and over, experienced abuse, neglect, or self-neglect in domestic settings in 2004. 10 According to these estimates, between 1 and 2 million Americans age 65 or older have been mistreated by someone they depend upon for care or protection. 8 It occurs among men and women of all racial, ethnic, and socioeconomic groups. Most neglect is due to ignorance, lack of resources, or the frailty of the caregiver. Individuals age 80 and older are abused and neglected two to three times more often than those of other ages. This is attributed to the fact that they tend to have more health problems and are living longer, which increases stress on the caregiver.
Older women are far more likely than men to suffer from abuse or neglect, probably because they make up a larger proportion of the senior population. In 2003, two out of three (67.7%) elder abuse victims were women. 7 The more dependent the person, the more likely he or she is to be abused. In descending order of frequency, substantiated types of maltreatment were self-neglect (37.2%), caregiver neglect (20.4%), financial exploitation (14.7%), emotional/psychologic/verbal abuse (14.8%), physical abuse (10.7%), sexual abuse (1%), other (1.2%). 7 As for the perpetrator of the abuse, 62% of the time it is a family member; 52% are men, with spouses representing 30% of the total. Most often the abuser is 36 to 50 years of age; race is white about three fourths of the time, and less than one fifth of abusers were black. 6
An area of elder maltreatment that is quickly coming to the forefront is known as “gray murders.” The expectancy that an older adult will die is such a fact of life that details concerning the death are often not questioned. Homicide related to elder abuse has long been overlooked. Since 1960 the rate of homicide in those 65 years of age or older has increased. 3 According to police veteran, Joseph Soos, “Gray murders might be among the most overlooked violent crimes in America.”2
ORIGIN OF THE PROBLEM
Four main theories may explain elder abuse: role theory, transgenerational theory, psychopathology theory, and stressed-caregiver theory.
Role Theory
As the parent ages and becomes more childlike, the child must assume a parental role. The elder who once helped the child must now take orders from that child. The psychologic impact of this role reversal is significant for both generations. When role conflicts are present, the potential for abuse increases substantially. Many family caregivers find themselves “sandwiched” between the need to provide care for their own children while providing care for their older parent(s) or spouse’s parent(s), a situation creating additional stress and role conflicts.
Transgenerational Theory
The underlying philosophy of transgenerational theory is that violence is a learned behavior. If a child grows up in a family in which aggressive behavior is a part of life, the child exhibits similar behavior. If the parent abused the child, then the child, as the caregiver, abuses the parent in retribution.
Psychopathology Theory
Altered impulse control caused by psychologic problems such as mental illness or drug or alcohol dependence places the elder at greater risk for abuse. The typical abuser is a middle-age, white woman who lives with the victim, is an alcohol or drug addict, and has long-term financial problems and high stress levels. The abuser perceives the victim as the source of this stress.
Stressed-Caregiver Theory
This is one area in which the nurse providing long-term care for older adults can abuse their charge as easily as can the family caregiver. Caregivers under stress have limited amounts of internal resources. Stress associated with the health care environment and stress in the individual’s personal and family life may lead the caregiver to express stress through maltreatment of older adults.
PRIMARY CATEGORIES OF MALTREATMENT AND ASSOCIATED CLINICAL FINDINGS
Physical abuse is an act of violence that results in bodily harm or mental distress, including pain, injury, and physical confinement. Injuries result from slapping, shoving, hitting, beating, pushing, kicking, incorrect positioning, pinching, burning, biting, overmedicating or undermedicating, or improper use of restraints. Signs of physical abuse include bruises or grip marks around the arms or neck, lacerations, fractures, and rope marks or welts on the wrists and/or ankles.
The possibility of sexual abuse, unwanted sexual activity forced on a person by another through coercion or threats, must also be considered. Signs include unexplained genital or anal bleeding, bruised breasts, and sexually transmitted infections.
Neglect is the deliberate refusal to meet an individual’s basic needs, including activities such as withholding assistance vital to performance of activities of daily living, behavior that causes mental anguish, and lack of compliance with medication administration and treatment regimens. Signs of neglect include dehydration, malnutrition, decubitus ulcers, and poor personal hygiene.
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