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Identifying and Intervening in Cases of Elder Abuse Part 1 of 3: Identifying Elder Abuse

Identifying and Intervening in Cases of Elder Abuse Part 1 of 3: Identifying Elder Abuse. Barbara A. Reilley, PhD and Carmel B. Dyer, M.D. The University of Texas Health Science Center at Houston. Learning Objectives. Successful students will be able to :

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Identifying and Intervening in Cases of Elder Abuse Part 1 of 3: Identifying Elder Abuse

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  1. Identifying and Intervening in Cases of Elder Abuse Part 1 of 3: Identifying Elder Abuse Barbara A. Reilley, PhD andCarmel B. Dyer, M.D. The University of Texas Health Science Center at Houston

  2. Learning Objectives Successful students will be able to : • Describe three types of elder abuse. • List five signs and symptoms that raise suspicion of elder abuse. • Identify three factors for elder abuse and neglect.

  3. Elder Abuse Definition The National Center on Elder Abuse defines elder abuse as: “intentional or neglectful acts by a caregiver or ‘trusted’ individual that lead to, or may lead to, harm of a vulnerable elder” The most common types are: X X X X X X • Physical abuse • Neglect, including self-neglect • Emotional or psychological abuse • Verbal abuse and threats • Financial abuse and exploitation • Sexual abuse • Abandonment • In many states, self‐neglect is also a reportable condition.

  4. Types of Elder Abuse(which is also known as Elder Mistreatment) • For more information:The National Center on Elder Abuse.

  5. What type of abuse is this? “Man Pleads Guilty to Biting Grandmother” And she told me she thought the beating would never stop. She yelled, begged, and it didn’t matter… Physical Abuse Caregiver Neglect Abandonment

  6. What type of abuse is this? “Man Pleads Guilty to Biting Grandmother” Correct, Physical abuse is the type of abuse that is demonstrated here. Continue »

  7. What type of abuse is this? “Man Pleads Guilty to Biting Grandmother” Obviously this is not self-neglect. Read ahead to find out more about self-neglect and how it differs from traditional physical abuse. Try again »

  8. What type of abuse is this? “Man Pleads Guilty to Biting Grandmother” This is not abandonment. Read ahead to find out more about abandonment and how it differs from traditional physical abuse. Try again »

  9. Physical Abuse Utah: “Man Pleads Guilty to Biting Grandmother” Definition: the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, and physical punishment of any kind also are examples of physical abuse. Learn more about this case »

  10. Outrage at Care Worker’s Rape Penalty Australia: “An aged-care worker who raped an 85-year-old woman will spend just six months behind bars, sparking outrage.” Learn more »

  11. Sexual Abuse Definition: non-consensual sexual contact of any kind with an elderly person. Includes, but is not limited to, unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity and sexually explicit photographing. • Example: sexual contact with any person incapable of giving consent. Learn more »

  12. Neglect Definition: the behavior of an elderly person that threatens his/her own health or safety. • Examples: refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder. • May include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care.

  13. Self-Neglect Definition: the refusal or failure to fulfill any part of a person's obligations or duties to an elder. A refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions. Excludes a situation in which a mentally competent older person, who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety as a matter of personal choice.

  14. Caregiver Neglect page 1 of 3 “Husband Let Wife Starve to Death” • England: • “A 71-year-old man has been jailed for allowing his mentally ill wife to starve to death while he went to the pub and visited the bookmakers. William Pottinger’s wife, Gillian, 61, died on a flea-ridden couch in June 2006 weighing four-and-a-half stone (Stone = a unit of weight equal to 14 pounds. This woman weighed 63 pounds.)” Learn more »

  15. Caregiver Neglect page 2 of 3 From Texas Elder Abuse and Mistreatment Institute Files • A Case of Caregiver Neglect • A woman reported to APS that she was being neglected by her daughter, who was the primary caretaker. The daughter frequently had to work out of town, and left the mother (post-stroke) alone for extended periods of time. The woman said that the daughter did not turn or change her. APS called the clinical elder mistreatment team. These were their findings (pictures taken after hospital admission (clean-up).

  16. Caregiver Neglect page 3 of 3

  17. Psychological or Emotional Abuse Definition: the infliction of anguish, pain, or distress through verbal or nonverbal acts. Examples are: verbal assaults, insults, threats, intimidation, humiliation, and harassment. In addition, treating an older person like an infant; isolating an elderly person from his/her family, friends, or regular activities; giving an older person the "silent treatment;" and enforced social isolation are examples of emotional/psychological abuse.

  18. Abandonment page 1 of 2 From Texas Elder Abuse and Mistreatment Institute Files • An elderly man was abandoned by his son in a motel. The incident was reported to APS, who referred the case to a team of clinicians knowledgeable about elder abuse. The elderly man was found severely malnourished • and dehydrated, with contractures • and decubitus ulcers. He was • placed in a safe environment. • What happened to the son • is unknown. Learn more »

  19. Abandonment page 2 of 2 The desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder. Learn more »

  20. Financial or Material Exploitation • Definition: the illegal or improper use of an elder's funds, property, or assets for monetary or personal benefit, profit or gain. Examples include, but are not limited to, cashing an elderly person's checks without authorization or permission; forging an older person's signature; misusing or stealing an older person's money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney. Financial Exploitation • It is estimated that one in 25 cases of elder abuse involves financial exploitation. • There may be at least 5 million cases of financial exploitation each year. • Wasik, John F. 2000. “The Fleecing of America’s Elderly,” Consumers Digest, March/April.

  21. Financial or Material Exploitation New York: • “Even those with great financial wealth become victims…” • In October 2009, Marshall was convicted on 15 counts of defrauding Mrs. Brooke Astor, his 105-year-old mother. Learn more »

  22. Undue Influence page 1 of 4 • Undue Influence is not always defined as a form of elder abuse, or as a crime. • Undue influence is recognized as a process or method used to commit financial or sexual exploitation. Financial exploitation may mean that an elder is under “undue influence”; this is described in varying ways by many states. Some states require substantiation that the elder is of diminished capacity. Treth, M. 2000. “Exposing Financial Exploitation of Impaired Elderly Persons. Spring 2000, Vol 8(2). P104-111. Hall RCW, Hall RCW, Chapman, MUJ. 2005. “Exploitation of the Elderly: Undue Influence as a Form of Elder Abuse”. Clinical Geriatrics

  23. Undue Influence page 2 of 4 • An example of undue influence is when reciprocity is used to exploit a victim. The suspect may perform caretaking duties for the victim, such as driving to doctors’ appointments, filling prescriptions, or cooking meals. The victim then feels that he or she “owes” the perpetrator something. • Influence becomes “undue” when the perpetrator exploits the victim’s dependency and trust and steals from the victim for personal financial gain. American Bar Association Commission on Law and Aging – American Psychological Association. 2008. “Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists.” http://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf, p 116.

  24. Undue Influence—Signs page 3 of 4 • Physicians with longstanding patient relationships may recognize some of the sign/symptoms suggesting undue influence: An elder’s actions are inconsistent with past values or beliefs. The elder makes sudden changes in their financial management, benefiting one person in particular. The caregiver dismisses any previous professionals and gets new ones for the elder. The elder is isolated from the community. A non-family caretaker moves into the elder’s home. Hall RCW, Hall RCW, Chapman, MUJ. 2005. “Exploitation of the Elderly: Undue Influence as a Form of Elder Abuse”. Clinical Geriatrics

  25. Undue Influence—Signs page 4 of 4 • Elder directs income flow to caregiver. • Wills, living wills and trusts are altered. • Elder develops mistrust of family members. • Older person gets new caregiver, who promises lifelong care in exchange for elder’s assets. • Power imbalance between elder and caregiver. • Caregiver attends financial transactions, and does not allow elder to speak during transactions. • Elder writes checks for cash in round numbers and provides cash to caregiver. • Elder becomes frightened or despondent. • Elder places caregiver in an exalted position. Hall RCW, Hall RCW, Chapman, MUJ. 2005. “Exploitation of the Elderly: Undue Influence as a Form of Elder Abuse”. Clinical Geriatrics

  26. The Epidemiology How Bad is the Problem of Elder Abuse? Epidemiology is the science that studies that studies the distribution and determinants of disease in populations over time. (1986 Green L, Lewis, F Measurement and Evaluation in Health Education and Health Promotion, p 362, Mayfield Publishing, Palo Alto, CA).

  27. National Prevalence of Elder Abuse page 1 of 2 • Millions of Americans age 65 or older have been injured, exploited, or otherwise mistreated by a caregiver or someone they trust. • Frequency of elder abuse estimates range from 2 to 10 percent based on various sampling and survey methods and case definitions. • Only 1 in 14 incidents of elder abuse in domestic settings, excluding self-neglect, are brought to the attention of authorities. • Self-neglect is the most commonly reported form of elder abuse (mistreatment) and is increasing. • Lachs, Mark S., and KarlyPillemer. October 2004. “Elder Abuse,” The Lancet, Vol.364: 1192-1263. • 2. Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America. 2003. Washington, DC: National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect. • Pillemer, Karl, and David Finkelhor. 1988. “The Prevalence of Elder Abuse: A Random Sample Survey, “ The Gerontologist, 28:51-57. • Teaster, P.B. A response to the abuse of vulnerable adults: the 2000 survey of statue adult protective services. 2000. http://www.nceas.aoa.gov/ncearoot/main_site/pdf/research/apsreport030703.pdf.

  28. National Prevalence of Elder Abuse page 2 of 2 • In a study of adults aged 60 years or older who are cognitively intact, the prevalence of elder abuse was: 4.6 % - psychological abuse 1.6% - physical abuse 0.6% - sexual abuse 5.1% - potential neglect 5.2% - financial abuse • 11% reported being abused in the past year. • There is a strong correlation between low social support and previous traumatic events and abuse. • This study excluded the prevalence of self-neglect. 4.6% 1.6% 0.6% 5.1% 5.2% Learn more » • Acierno, R., Hernandez, M.A., Amstadter, A.B., et al. 2010. Prevalence and correlates of emotional, physical, sexual and financial abuse and potential neglect n the United States: the National Elder Mistreatment Study. American Journal of Public Health, 100(2), pgs. 292-297.

  29. National Trends page 1 of 3 National Center on Elder Abuse (NCEA) Survey of Adult Protective Services (APS) reported an increase in elder abuse of 20% from 2000 to 2004. 2004 20% increase The NCEA surveyed 50 state APS offices, plus Guam and the District of Columbia. 2000

  30. National Trends 89.3% page 2 of 3 The 2004 NCEA Survey of APS also found: • 15.6 % increase in substantiated APS cases since 2000. • Most victims are female. (65.7 %) • 42.8 % of victims are 80 years or older. • The vast majority of elder abuse cases occurred in domestic settings (89.3%) 65.7% 42.8% 15.6% Learn more »

  31. National Trends page 3 of 3 • More accurate and consistent reporting of data; • More detailed age, gender, race and ethnicity-specific information; • Information on reporters of abuse such as municipal agents, postal service workers, or utility workers; • Outcome data on clients served; • Increased local, state, and national intervention and education efforts; • National data collection on perpetrators and the outcomes they experienced as a result of the investigation; and, • A national survey to be conducted no less than every four years. • Otto and Teaster. The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years of Age and Older. 2006. Accessed from www.elderabusecenter.org. • This survey demonstrated the need for:

  32. Mortality and Elder Abuse • Mortality: • The mortality of elders who are abused or neglected is about 30% higher in abused than non-abused elders as demonstrated in a landmark study by Lachs and colleagues in 1998. 30% 30% Lachs studied community dwelling elders and those from an APS data base and compared mortality rates over a period of years. He found that in the cases of validated self-neglect (N-180) there were 73 deaths or 40.3% of cases. The 78 elders who were validated as being mistreated demonstrated a 53.2% mortality rate. In those community dwelling elders where there was not elder abuse the mortality rate was 17.3%. Lachs, M. A., Williams, C. S., O’Brien, S., Pillemer, K. A., & Charlson, M. E. (1998). Mortality of elder mistreatment. Journal of the American Medical Association 280(5), 428−432.

  33. Mortality and Elder Abuse Status Number Deaths % Self-neglect 180 73 40.3% Elder mistreatment 78 31 53.2% No EAM 6649 1303 17.3% 53.2% 40.3% 17.3%

  34. Mortality from the study by Lachs et al. • The major cause of death in all three groups (self-neglect,elder abuse, no elder abuse) was circulatory disease. No elders died due to injury from abuse.“In today’s society, elder abuse is rarely or ever listed as a cause of elder death or even as a contributing factor.” • Elders who self-neglect have a higher rate of nursing home placement. • Some of the causes of nursing home placement were malnutrition, frailty and the existence of comorbidities. Lachs, M. A., Williams, C. S., O’Brien, S., Pillemer, K. A., & Charlson, M. E. (1998). Mortality of elder mistreatment. Journal of the American Medical Association 280(5), 428−432.

  35. Self-Neglect and Mortality Risk • In older adults who self-neglect, African-American older adults had a higher mortality rate compared to whites. • In a population-based cohort study of Chicago, Illinois residents aged 65 years or older, elder reported and confirmed self-neglect and abuse was associated with an increased risk in mortality. • Mortality risk after one year remained significant for confirmed elder self-neglect. • Increased mortality was not restricted to older adults with lowest levels of cognitive or physical function. Dong, X.Q., Simon, M.A., de Leon, C.M., et al. 2010. Elder self-neglect and mortality between black and white older adults. Journals of Gerontology: Series A, Biological Sciences & Medical Sciences. 66(6), pgs. 695-704. Dong, X.Q., Simon, M.A., de Leon, C.M., Fulmer, T., Beck, T., Hebert, L., Dyer, C., Paveza, G., & Evans, D. 2009. Elder self-neglect and abuse and mortality risk in a community-dwelling population. Journal of the American Medical Association, 302(5), pgs. 517-526.

  36. Elder Abuse Risk Factors page 1 of 2 • Age • Dependency • Functional decline • Personality disorders • Isolation • Excessive use of drugs or alcohol • Poverty • Cognitive impairment

  37. Elder Abuse Risk Factors page 2 of 2 The physician, especially one with a longstanding patient relationship, should be aware of changes in the older person that may indicate abuse or neglect. The more functionally impaired a person becomes, the more likely he/she is of being abused, neglected or exploited. • Abuse is more likely to occur if the victim is dependent on a caregiver. • Functional decline of the victim may create undue caregiver stress and lashing out. • Personality disorders, mental illness, and cognitive impairment of the elderly person are risk factors for abuse. • Isolation of both the abuser and the abused is a risk factor. • Alcohol or drug abuse history may be a contributing factor in elder abuse. • Poverty may create numerous coping difficulties. Lachs, M.S., Williams, C, O'Brien, S., Hurst, L., & Horwitz, R. 1997 Risk factors for reported elder abuse and neglect: a nine-year observational cohort study. Gerontologist. 37: 469-474.

  38. Perpetrator Risk Factors for Elder Abuse • Psychiatric disorders • Dependence of abuser on victim • External stressors • Lack of experience or education • Caregiver burnout • Note the similarity in risk factors in the abused and the abuser. Lachs, M.S., Williams, C, O'Brien, S., Hurst, L., & Horwitz, R. 1997. Risk factors for reported elder abuse and neglect: a nine-year observational cohort study. Gerontologist. 37: 469-474.

  39. The Interdisciplinary Approach Physicians may take an interdisciplinary team approach using formal and informal relationships with:

  40. Case Study – Mrs. F. page 1 of 4 Patient Presentation Mrs. F is an 89-year-old woman brought into the office by her niece for a periodic check up. Mrs. F lives alone, her niece takes her to run errands once a week. Mrs. F asks her niece to wait in the waiting room during her exam, and her niece readily agrees. Amishsteve on flickr.com

  41. Case Study – Mrs. F. page 2 of 4 Comprehensive Geriatric Assessment Mrs. F’s physical exam is unremarkable except for a blood pressure reading of 190/96 and for her feet. The dosage of her anti-hypertensives was increased six months ago. Upon questioning, she is not sure when she had her last dose. Her niece failed to obtain her prescription from the pharmacy.

  42. Case Study – Mrs. F. page 3 of 4 Questions to Consider What type of abuse would you consider that Mrs. F is experiencing? What are the risk factors that you would note for elder abuse in this case? What is her risk of dying in the next year?

  43. Case Study – Mrs. F. page 4 of 4 Physician Assessment—Outcome • Since Mrs. F’s niece is considered to be one of her caregivers, the physician may suspect caregiver neglect. • The risk factors of note for elder • abuse in this case include: Mrs. F lives alone; she relies on her niece for weekly errands; she takes anti-hypertensives; and her blood pressure is high and toenails have been neglected. • Her risk of dying in the next year is elevated. Mrs. F’s physician should begin work with an interdisciplinary team to prevent death from neglect.

  44. Conclusions • Elder abuse is common. Self-neglect is currently the most prevalent type of abuse. • Elder abuse is associated with an increased risk of mortality. • An interdisciplinary team approach to identifying and treating elder abuse will help to adequately address an elder abuse case. • Elder abuse is a growing public health problem.

  45. Learn More You have just completed part 1 : Identifying Elder Abuse. See more of this 3-part series … Identifying and Intervening in Cases of Elder Abuse • Part 2 of 3: Screening and Intervening • Part 3 of 3: Assessment of Mental Capacity

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