Elder Abuse and the Nursing Home… a Critical Interface

1. Elder Abuse and the Nursing Home… a Critical Interface Dr. Roger Butler Associate Professor of Family Medicine MUN

2. A war veteran / VP resident

3. Objectives Discuss current research on elder abuse demographics in relation to dementia care Discuss some theoretical models to explain WHY? Explore physician issues in elder abuse management Explore characteristics of caregivers,residents and the environment that predispose to elder abuse Update the audience on provincial law. What can physicians do?

6. Definition Elder abuse has been defined by the World Health Organization (WHO) as a single or repeated act ,or lack of appropriate action, occurring within any relationship where there is an expectation of trust and which causes harm or distress to an older person.

7. Elder Abuse and Neglect Elder abuse is any act or failure to act, within a relationship where there is an expectation of trust, that jeopardizes the health or well-being of an older person. Neglect is any inaction ,either intended or unintended , within a relationship where there is an expectation of trust, that causes harm to an older person.

8. Types of Abuse Physical – violent act or rough treatment causing injury or physical discomfort. Also includes sexual and medication abuse. Psychological or Emotional Abuse – an act that may diminish the sense of identity ,dignity , or self- worth of an individual. Financial or Material abuse- theft or misuse of a senior’s money or property

9. Neglect The failure to meet the needs of an older adult who cannot meet their needs on their own. It may have physical , financial or psychological components. Two Types; ACTIVE and PASSIVE ACTIVE: intentional withholding of basic necessities and /or care PASSIVE: non-intentional ,non-malicious withholding of basic necessities and /or care because of lack of experience, information ,or ability

10. Self Neglect The older person is living in an unsafe or unhealthy manner by choice or ignorance. What to do if you are worried?

12. Ageism Hughes and Mtezuka defined ageism as a “social process which negative images of and attitudes towards older people, based solely on the characteristics of old age itself;result in discrimination.”

13. Revera Report on Aging 8/10 Canadians agree that seniors (75+) less important than other members in our society Most tolerated social prejudice in Canada compared to gender or race-based discrimination 63% seniors report treated unfairly or differently because of their age Report based on survey of 1501 Canadians fall 2012.

14. Revera report continued 35% Canadians admit treating somebody different because of their age 56% age discrimination primarily from younger people 27% experienced it from Government 34% from health care professionals

15. Elder Abuse Demographics 2031, 25% Canadian population>65 (8 million) NL by 2026 27% of pop over 65 Elder abuse or neglect 7% In 1999 Canadian researchers found that: -7% respondents reported emotional abuse -1% reported financial exploitation -1% reported physical or sexual abuse At least 1/3 are family members It affects all demographic groups (Dept of Justice Canada)

17. LTC setting scenario You have just began your shift at the new LTC facility in St. John’s. The staff at the nursing station are having a discussion on how they are going to deal with a new resident with aggressive behaviour. One of the senior LPN’s says “ Once we get him into our routines everything will be just fine”. What is your immediate reaction?

18. Elder Abuse and Dementia 5-55% compared to 3.2-27.5% prevalence rates for nondemented ( Cooper et al US data) Elders with dementia have highest incidence of mistreatment and abuse in LTC...12% (9 year study 2003 Levine) Many cases unreported ½ nursing staff reported abuse towards resident in past year and 70% witnessed other staff commit act (Israel LTC study 2010) Mental abuse and neglect most common

19. Psycho-social factors affecting elders maltreatment in LTC facilities Study based on 22 nursing homes in Israel and published in 2010 (International Nursing Review) Random selection from 300 nursing homes in Israel 10 workers per site in various departments at various times of day Gov’t, site admin and ethics approval Staff confidentiality assured 85% staff response rate

20. Areas studied Details of the facility, demographic details and professional details Reporting incidents of violence, victim traits, attitudes towards and knowledge about maltreatment Burnout questionaire

21. Models for Abusive behaviour 1. Theoretical model for predicting causes of elder maltreatment in LTC facilities(Pillemer 1988) working model looking at institutional work environmental factors, staff traits and resident traits as interrelated causative factors. 2. The theory of reasoned action(Ajzen and Fishbein) 1980) Human behaviour depends on two components; behavioural attitude and subjective norms

22. Staff Traits Young female nursing aids (less training) more likely Longer working staff with positive attitude less likely Improper care associated with job pressures and staff burnout Worker burnout associated with physical and mental violence

23. Staff Traits continued Staff who perceive the following are at risk: - residents have to be constantly served -they are waiting to die -they behave like little children -they must be occasionally taught discipline

24. Patient Traits Elderly residents with dementia have the highest risk of abuse of all disabled people Aggressive resident behaviour is related to physical and verbal abuse by the caregiving nursing staff Women residents have the highest risk of abuse because they are probably most vulnerable Rate increases with age in the LTC and home environments Socially isolated are at greater risk

25. Facility features More prevalent in profit seeking facilities (Iowa 2006) Low staff ratio and high staff turnover leads to high risk compromise in quality care and subsequent high risk for elder maltreatment Lack of nursing staff leads to elder maltreatment (California/Scandinavia Non-profit facilities provide the best nursing and medical services

26. Results ½ staff report abusing residents in the previous year 2/3 of abuse involves physical and mental neglect Psychologically staff perceive neglect as an act of omission and therefore maybe seen as a systemic failure of the system rather than a personal one to provide basic needs. These do not involve personal motives or malicious intent hence easily reported

27. Results Continued Jewish moral custom of honouring seniors not perpetrated the nursing home culture Significant positive correlation between staff burnout and physical violence and mental abuse. Greater staff emotional fatigue and depersonalization greater maltreatment risk Less ambition in the workplace correlates with greater risk of maltreatment as well Burnout creats a neg attitude to job and elderly residents and lack of empathy and vise versa

28. Results Continued Nurses aids and practical nurses had more manifestations of elder maltreatment Surprising in this study more work experience correlated with a higher risk of abuse The more one witnesses abuse the more one is likely to perform abusive acts No correlation found with academic knowledge, clinical knowledge,seniority,attitudes to maltreatment ,gender and age of workers

29. Results Continued Elderly demented females higher risk of mental abuse Aggressive residents have 4x the risk of maltreatment

30. Bottom Line Need for periodic, structured and regular training of caregiving staff, mainly practical nurses and nursing aids unrelated to their professional seniority….highlighting difficulties with caring for demented residents, coping under pressure and managing feelings and attitudes towards residents. Staff support groups Establish enforcement systems within the facility Periodic exams with extrinsic government systems

31. Interprofessional Patient Care Team

35. What we must know about dementia care? We can change our behaviour towards a dementia resident but the dementia resident is usually not able to change how they react to us. Severely demented residents read body language and reflect body language behaviour. Distraction maneuvers which utilize resident procedural memory are highly effective in crisis management.

36. Aggressive Behaviour Management ABC… for the resident Antecedent, Behaviour and Consequences P.I.E.C.E.S …for the caregiver Assess caregiver physical health, intellectual health, emotional health, capabilities, environment ,and social supports. ( the secret of caring for the resident with dementia is caring for the caregiver… Alzheimer society)

37. Risk Factors for Elder Abuse Victim Advanced age Dependency for basic activities of daily living Dementia Combative behaviour Perpetrator 1.Depression/Mental illness 2.Alcohol or drug dependency 3.Financial dependence 4.Caregiver complaining about the patient

38. Home Based Abuse Estimated rates of abuse by caregivers is 5-14% in the dementia population as compared to 1-3% in the general population Financial exploitation was estimated to affect 20% of victims of elder mistreatment ( US 2003 National Aging Resource Centre on Elder Abuse)

39. Family Dementia Caregiver Study Hong Kong: Int J Geriatric Psychiatry Aug 2010 62% all forms in 1 month (122 family caregivers) Verbal>physical 62%vs 18% More coresiding days> violent episodes High level of agitated behaviour predicts verbal abuse Agitated behaviour may elicit abusive behaviours though it’s effect on caregiver burden

40. Why the lack of identification of elder abuse by family physicians? Elderly patients visit their family physician 5X per year Only 2% report cases of abuse or neglect Family physicians are champions of child abuse identification

41. Why? Failure of victim to corroborate the abuse. Fear of retaliation by a family member Unwillingness to become involved with adult protection services Discomfort with the problem Time /remuneration constraints Not knowing the signs and symptoms of elder neglect /abuse. Not a member of the community team

42. What can we do in the medical profession? Improve exposure in medical school to elder abuse. Increase geriatric education as mainstream in today’s medical environment Push for mandatory reporting of elder abuse. Instruct graduation physicians in the use of screening tools such as the EASI for identification of potential elder abuse victims. Be aware of the dementia syndrome, able to diagnose the common types and address the behavioural issues using evidence based approach. Work interprofessionally with the schools of Nursing,Pharmacy,and Social Work for common curriculum in Elder abuse.

43. EASI Within the past 12 months: 1.Have you relied on people for any of the following: bathing, dressing, shopping, banking , or meals? 2.Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with? 3.Have you been upset because someone talked to you in a way that made you feel shamed or threatened? Yaffe MJ et al Journal of Elder abuse and Neglect 2008 20(3) 276-300

44. EASI 4. Has anyone tried to force you to sign papers or to use money against your will? 5.Has anyone made you afraid ,touched you in ways that you did not want, or hurt you physically? 6.DOCTOR:Elder abuse may be associated with findings such as :poor eye contact, withdrawn nature ,malnourishment ,hygiene issues ,cuts ,bruises ,inappropriate clothing ,or medication compliance issues. Did you notice any of these to day or in the last 12 months. Yaffe MJ et al Journal of Elder Abuse and Neglect 2008:20(3)276-300

45. What Physicians can do in the home to help prevent elder abuse? Housecalls Work collaboratively with home care nurses, social workers and home support workers. Observe for signs of caregiver stress Anticipatory guidance to family and caregivers about the dementia syndrome . Suggest planned respite / caregiver support /community resources…family meeting Help address ETOH and drug abuse in the home. Be aware of polypharmacy issues and appropriate use of psychotropics for behavioural management.

46. What the physician can do in the LTC setting? Be proactive with staff re: dementia education and behavioural management techniques. Be available to listen and be supportive of approaches to reduce staff stressors. Address carefully aggressive behaviours in the LTC environment . Family meetings and distraction techniques and proper use of psychotropic medications.

47. Canadian Reporting Regulations Manitoba has mandatory reporting by “Key Health Care Professionals” PEI, NB, and BC have voluntary reporting NS and NL have general mandatory reporting This fall the Adult Protection Act will become law in NL which will make it law to report suspected elder abuse or neglect and failure to do so could be met with a $10,000 fine or 1 year max imprisonment

48. “ The soul is born old, but grows young... That is the comedy of life. The body is born young, but grows old..That is life’s tragedy” Oscar Wilde