Mistreatment Detection   13  

Billy A. Caceres and Terry Fulmer

OVERVIEW

In 2014, the U.S. Department of Justice consulted 750 stakeholders to enhance public and private response to elder mistreatment. Experts increasingly recognize the human, social, and economic impact of EM (U.S. Department of Justice, 2014). Most nurses in the acute care setting (and other settings) have likely provided care for an older adult suffering from EM without knowing it. By 2030, the population of Americans aged 65 years or older is expected to double and comprise 20% of the U.S. population (Centers for Disease Control and Prevention [CDC], 2013). Cases of EM are expected to become more prevalent given this expected surge of older adults. This drastic increase in the older adult population may exacerbate rates of EM. Technological advances of the past century have increased the life span of individuals with chronic diseases. However, older adults with chronic diseases require greater assistance in activities of daily living (ADL) and management of care (CDC, 2013). Also, the population of adults older than 90 years is expected to quadruple by 2050 (He & Muenchrath, 2011). The oldest old are at the greatest risk for EM because of increased disability and dependence on others to meet basic care needs (He & Muenchrath, 2011).

Furthermore, the impact of abuse, neglect, and exploitation has a serious fiscal cost. The direct medical costs associated with violent injuries to older adults are estimated by the National Center on Elder Abuse (NCEA) to add more than $5.3 billion to the nation’s annual health expenditures, and the annual financial loss by victims of elder financial exploitation was estimated to be $2.9 billion in 2009, a 12% increase from 2008 (Mouton et al., 2004; National Committee for the Prevention of Elder Abuse, Virginia Tech, MetLife Mature Market Institute, 2011). EM researchers agree that as the population continues to age, cases of EM will reach epidemic levels (National Research Council [NRC], 2003). Now, more than ever before, it is imperative for nurses to become better educated about EM and its complexities.

Nurses in the inpatient setting serve an important role in recognizing EM as they are often the first health care professional to perform a detailed medical history or physical assessment. Nursing’s presence at the bedside affords the opportunity to have direct contact with caregivers, observe caregiver–patient interactions, and identify red flags (Cohen, Halevi-Levin, Gagin, & Friedman, 2006). By virtue of the size of the workforce, which is the largest of any of the health professions, nurses are in a unique and optimal position to assess, identify, and intervene in cases of EM more often than other members of the interdisciplinary health care team.

The identification of EM should be a regular part of any geriatric assessment, and nursing curricula need to include the requisite content to ensure that all graduates have adequate knowledge and skills to assess and detect mistreatment. Many have suggested that mandatory EM training be a prerequisite for relicensure. EM is often multifactorial, so it is important to recognize it as the interplay among characteristics of the abused, the perpetrator, and environmental factors (Killick & Taylor, 2009). Physical markers of EM are often incorrectly attributed to physiological changes in the elderly or symptoms of chronic disease (Wiglesworth et al., 2009). Cases of EM may be challenging for nurses as they are often complicated by denial on the part of the perpetrator and older adult, refusal of services by victims, and fears that an accusation of EM may actually worsen EM. Significant ethical dilemmas may arise because nurses may struggle between their obligation to ensure patient well-being and uncertainty over the presence of EM (Beaulieu & Leclerc, 2006; Daly, Schmeidel Klein, & Jogerst, 2012). The development of EM protocols that are grounded in evidence-based research is crucial to ensure that EM cases are properly handled by nurses and other health care professionals.

BACKGROUND AND STATEMENT OF PROBLEM

Data from the NRC (2003) suggest that more than 2 million older adults suffer from at least one form of EM annually. The National Elder Abuse Incidence Study estimated that more than 500,000 new cases of EM occurred in 1996 (NCEA, 1998). A study by Acierno et al. (2010) estimated the prevalence of EM within a 1-year period to be approximately 11%. Although 44 states and the District of Columbia have legally required mandated reporting, EM is severely underreported. It should be noted that nurses, as mandatory reporters, have an obligation to report suspected cases of EM and all reports made in good faith are confidential. There is a lack of consistency across the United States regarding how cases of EM are reported and managed. Cases of EM are dealt with differently, with varying methods of investigation and intervention, state by state (Jogerst et al., 2003). NCEA (1998) estimates that only 16% of cases of EM are actually reported. In a systematic review, one third of health care professionals believe they detected a case of EM; however, only about 50% of that group actually reported the case (Cooper, Selwood, & Livingston, 2009). Similarly, another study found that despite 68% of emergency medical services staff stated they felt they had encountered a case of EM in the past year, only 27% of that group actually made a report (Jones, Walker, & Krohmer, 1995). Despite mandatory reporting on the part of health care professionals, it is believed that many are not reporting all cases of EM detected (Killick & Taylor, 2009). This, coupled with a lack of awareness of EM among older adults (Naughton, Drennan, & Lafferty, 2014), creates barriers for obtaining an accurate sense of the scope of EM and may have serious detrimental effects for victims of EM. In some instances, it may be that EM is addressed internally without reporting; for example, when a hospital administrator calls the police directly but there are no good data on internal processes that agencies use to independently handle EM cases.

Conflicting theories of causation and lack of uniform screening approaches may further impede EM detection. Understandably, it has been difficult for nurses to adequately respond to cases of EM when they are unclear about its manifestations, causes, appropriate screening techniques, and reporting laws. A lack of universally accepted definitions for different types of EM has hampered efforts to ascertain what constitutes EM. In an effort to establish a clear consensus, the NRC (2003) defined EM as either “intentional actions that cause harm or create serious risk of harm (whether harm is intended) to a vulnerable elder by a caregiver or other person who is in a trust relationship to the elder,” or “failure by a caregiver to satisfy the elder’s basic needs or to protect himself or herself from harm.”

Types of EM

Six types of mistreatments are generally included under the umbrella term of EM. Table 13.1 describes each form of EM as well as offers examples of each.

EM is the outcome of the actions of abuse, neglect, exploitation, or abandonment, and can be further classified as intentional or unintentional. For example, intentional neglect is a conscious disregard for caretaking duties that are inherent for the well-being of an older adult. Unintentional neglect might occur when caregivers lack the knowledge and resources to provide quality care (Cooper, Dow, Hay, Livingston, & Livingston, 2013; Jayawardena & Liao, 2006).

TABLE 13.1

Forms of Elder Mistreatment

EM, elder mistreatment.

Adapted from Fulmer and Greenberg (n.d.).

Neglect, whether intentional or unintentional, is recognized as the most common form of EM. NCEA (1998) revealed that neglect accounts for approximately half of all cases of EM reported to Adult Protective Services (APS). About 39.3% of these cases were classified as self-neglect and 21.6% attributed to caregiver neglect, including both intentional and unintentional. More than 70% of cases received by APS are attributed to cases of self-neglect with those older than 80 years thought to represent more than half of these cases (Lachs & Pillemer, 1995).

There is debate as to whether self-neglect should be included as a type of EM. Although other types of EM occur because of the action or inaction of a perpetrator, in self-neglect, the perpetrator and victim are one and the same (Anthony, Lehning, Austin, & Peck, 2009). Caregiver neglect is frequently identified as the most common and accepted form of EM internationally (Daskalopoulos & Borrelli, 2006; Mercurio & Nyborn, 2006; Oh, Kim, Martins, & Kim, 2006; Stathopoulou, 2004; Tareque, Ahmed, Tiedt, & Hoque, 2014; Yan & Tang, 2003). Most participants identified family members as the most likely perpetrators. Shockingly, neglect was seen as a “quasi-acceptable” form of abuse, whereas physical and emotional/psychological EM was viewed as extreme and harsh.

Theories of EM

The concept of vulnerability has been central to the discussion of EM. Fulmer et al. (2005) conducted a study of older adult patients recruited through emergency departments in two major cities. The purpose of this study was to identify factors within the older adult–caregiver relationship that may predispose some older adults to be victims of neglect over others. The theoretical framework used in this study was the risk-and-vulnerability model, which posits that neglect is caused by the interaction of factors within the older adult or in his or her environment. The risk and vulnerability model was adapted to EM by Frost and Willette (1994) and provides an appropriate lens through which to examine EM (Frost & Willette, 1994; Fulmer et al., 2005). Vulnerability is determined by characteristics within the older adult that may make him or her more likely to be a victim of EM such as poor health status, impaired cognition, and history of EM (Frost & Willette, 1994). Risks refer to factors in the environment that may predispose an older adult to EM and may include characteristics of caregivers such as health and functional status, as well as a lack of resources and social isolation (Fulmer et al., 2005). It is the interaction between risk and vulnerability that can predispose some older adults to EM (Killick & Taylor, 2009; Paveza, Vandeweerd, & Laumann, 2008).

The risk and vulnerability model and other models have been adapted from the health and social sciences literature in an effort to generate plausible theories of EM. However, there has been no clear consensus on one theory that explains EM (Fulmer, Guadagno, Bitondo Dyer, & Connolly, 2004). The development of interventions and strategies that cross multiple theoretical frameworks is likely to be the most clinically appropriate strategy (NRC, 2003).

Theories of EM, many of which emerged from the fields of family and interpersonal violence, include but are not limited to the following:

Dementia and EM

Older adults with dementia are particularly vulnerable to EM. As the population of older adults increases, it is expected that so will the number of older adults with dementia (Wiglesworth et al., 2010). The number of older adults with dementia is anticipated to increase threefold by 2050 (Hebert, Weuve, Scherr, & Evans, 2013). Because of the cognitive deficits associated with dementia, it is difficult to screen for EM in this population. The older adult with dementia may not be able to provide a reliable history, and signs of EM may be masked or mimicked by disease (Fulmer et al., 2005). Those providing care for older adults with dementia are at particular risk for caregiver strain and burnout. Disruptive behavior, such as screaming or wailing, physical aggression, or crying, can be exhausting for caregivers in any setting (Lachs, Becker, Siegal, Miller, & Tinetti, 1992).

As many as 47% of older adults with dementia are victims of some form of EM (Wiglesworth et al., 2010). Similarly, in a systematic review, one third of caregivers of older adults with dementia disclosed some form of EM, whereas 5% reported committing physical abuse (Cooper, Selwood, & Livingston, 2008). In a community-based study of caregivers of older adults with dementia, 51% of caregivers reported verbal abuse and 16% reported physical abuse (Cooney, Howard, & Lawlor, 2006). The implications of these data are sobering. However, these figures are likely underestimates of the true prevalence of EM as many cases are not reported.

Objective assessment alone cannot capture all cases of EM and, thus, policies are needed that combine objective measures and interviews with both the older adult and caregiver (Cooper et al., 2008). Some caregivers may be forthcoming with admission of EM and many may ask for help in developing coping strategies and plans of care to provide better care for care recipients (Wiglesworth et al., 2010).

EM in Racial/Ethnic Minorities

Research suggests that racial/ethnic differences might exist in the prevalence of EM; however, these differences are poorly understood (Laumann, Leitsch, & Waite, 2008). The CDC (2013) estimates that, by 2050, racial/ethnic minorities will account for 42% of all older adults. The health of racial/ethnic minority older adults continues to lag behind the health of non-Hispanic Whites as a result of language barriers, poverty, and differing cultural norms (CDC, 2013). DeLiema, Gassoumis, Homeier, and Wilber (2012) and Strasser, Smith, Weaver, Zheng, and Cao (2013) found high rates of EM in Latino older adults. The prevalence of sexual abuse was high at 9% (DeLiema et al., 2012). Risk factors for EM identified in this sample of Latino older adults included younger age, higher education level, and prior history of abuse, whereas years living in the United States were associated with higher risk of caregiver neglect (DeLiema et al., 2012). In addition, several studies indicate that EM may be higher in Blacks (Beach, Schulz, Castle, & Rosen, 2010; Dong, Simon, & Evans, 2013; Laumann et al., 2008). EM seems to be a problem among Asian older adults as well. Dong, Chang, Wong, Wong, and Simon (2011) conducted a qualitative study that revealed that Chinese older adults have limited knowledge of community resources for EM. The most common forms of EM experienced by Chinese and Korean older adults were caregiver neglect and emotional/psychological EM (Dong et al., 2011; Lai, 2011; Lee, Kaplan, & Perez-Stable, 2014). There is a need for more research on the prevalence of EM and culturally appropriate strategies for addressing EM among racial/ethnic minority older adults.

ASSESSMENT OF THE PROBLEM

The American Medical Association (AMA, 1992) released a set of guidelines and recommendations on the management of EM. The AMA urges providers to screen all older adults for EM. Many hospitals already include EM screening as part of the admission process for all patients older than 65 years. Assessment of EM is not easy as subtle signs of EM are hard to identify and may be difficult to substantiate (Anthony et al., 2009; Sandmoe & Kirkevold, 2011). Reporting of EM by health care professionals remains low because of a lack of education and training on the assessment, detection, and reporting of EM (Daly & Coffey, 2010; Thomson, Beavan, Lisk, McCracken, & Myint, 2010; Wagenaar, Rosenbaum, Page, & Herman, 2010). Unsubstantiated fears exist that increasing education on assessment of EM will lead to higher rates of false-positive cases and, therefore, expense and disruption in the system. However, a systematic review of 32 studies revealed that health care professionals educated about EM were not more likely to detect EM cases. However, these health care professionals were more inclined to report detected cases of EM than those who had little or no education (Cooper et al., 2009).

The complexity and variation within most cases of EM make it difficult to describe the profile of a perpetrator or victim. Some researchers suggest that victims of EM may be less likely to meet their own care needs because of cognitive and physical deficits (Cannell, Manini, Spence-Almaguer, Maldonado-Molina, & Andresen, 2014; Dong et al., 2013; Dong, Simon, & Evans, 2012; Dyer, Pavlik, Murphy, & Hyman, 2000). This supports findings on factors that impact mortality of victims of EM (Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998; Schofield, Powers, & Loxton, 2013). Others (Brozowski & Hall, 2010; Draper et al., 2008; Fulmer et al., 2005; McDonald & Thomas, 2013) identified a link between childhood abuse or abuse in young adulthood and physical and sexual EM later in life. Similarly, Brozowski and Hall (2010) found that individuals who were sexually abused before age 60 years were 294% more likely to be victims of physical and sexual abuse in late life. A lack of social support and social isolation increases the risk for EM in older adults (Acierno et al., 2010; Cannell et al., 2014; Dong, Beck, & Simon, 2010; Dong & Simon, 2008; Fulmer et al., 2005). Recent findings suggest that victims of EM report poor overall health (Cannell et al., 2014; Cisler, Amstadter, Begle, Hernandez, & Acierno, 2010). Overall, perpetrators are more likely to be family members, report greater caregiver strain, live with the victim, have a history of mental illness and/or depression, have a history of substance abuse, have lived with the victim for an extended time (approximately 9.5 years), have decreased social support, and report a long history of conflicts with the victim (Giurani & Hasan, 2000; Johannesen & LoGiudice, 2013; Wiglesworth et al., 2010).

While assessing for EM, it is recommended to separate the older adult from the caregiver to obtain a detailed history and physical assessment (Heath & Phair, 2009). Special attention should be paid to both physical and psychological signs of EM. Discrepancies between injury presentation or severity and the report of how the injury occurred as well as discrepancies between explanations from the caregiver and older adult should be paid close attention. Physically abused older adults are more likely to have significantly larger bruises and identify the cause of their injuries. Furthermore, Wiglesworth et al. (2009) assert that abused older adults are more likely to display bruising on the face, lateral aspect of the right arm, and the posterior torso (including back, chest, lumbar, and gluteal regions). Other possible indicators of physical abuse include bruises at various stages of healing, unexplained frequent falls, fractures, dislocations, burns, and human bite marks (Cowen & Cowen, 2002).

It is important to distinguish that signs and symptoms of EM may vary depending on the type of abuse. Table 13.2 provides strategies for assessment of each type of EM. Victims of sexual abuse are more likely to be female and exhibit “genital or urinary irritation or injury; sleep disturbance; extreme upset when changed, bathed, or examined; aggressive behaviors; depression; or intense fear reaction to an individual” (Chihowski & Hughes, 2008, p. 381). Ageist attitudes among health care professionals may limit the cases of sexual abuse that are identified as older adults are rarely thought of as the usual victims of sexual abuse (Vierthaler, 2008). Cannell et al. (2014) estimate that the prevalence of sexual abuse among older adults is low at approximately 0.9%. Victims of financial abuse are harder to identify; however, they share similar traits as victims of emotional/psychological abuse and neglect, including social isolation, physical dependency, and mental disorders (Peisah et al., 2009).

TABLE 13.2

Assessment of Elder Mistreatment

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