Recognizing Elder Mistreatment Debra L. Bynum, MD Division of Geriatric Medicine With support from the Donald W. Reynolds Foundation
Learning Objectives o Describe the types of elder mistreatment o Relate the factors that put older adults at risk for mistreatment o Screen for elder mistreatment o Know how to report suspected elder mistreatment
Goals o Identify incidences of elder mistreatment o Protect older adults from mistreatment o Give healthcare providers information to deal more effectively with elder mistreatment
Outline o o o Cases Definition Prevalence and Risk Factors Screening Identifying Indicators of Mistreatment Focus Points from Cases n n n o o Financial Exploitation Caregiver Neglect Determination of Capacity Self Neglect Mistreatment in Institutions Reporting Resources
Case 1… 86 year old man with renal insufficiency, diabetes, vascular disease, peripheral neuropathy readmitted with recurrent nausea, vomiting, abdominal pain, dehydration and renal failure Son concerned that patient’s new wife, 35 years younger, is neglecting him and “in it for the money” At baseline, the patient was oriented, appropriate and felt to have capacity to make decisions regarding living situation and medical care o Could this be Arsenic Poisoning?
Case 1… The more pertinent questions: n n Is this Elder mistreatment? What would you do?
Case 2… o 83 year old woman admitted with DVT; she is disheveled and smells of urine and feces o The worried daughter calls. APS had previously been to the house and found it filthy, filled with cats and 20 years worth of magazines. She has had a long history of medical noncompliance and has “fired” multiple home health nurses and physicians o She has always been a quiet, secluded, and suspicious person o What would you do? How does the determination of her capacity influence the outcome of this case? o
Case 3… o 95 year old man admitted from a skilled nursing facility with dehydration, hypernatremia (Na 178), confusion, and a large decubitus ulcer o Family is concerned that he has had several weeks of declining intake and feel he is being neglected o What are some markers of neglect? Is this reportable? To whom? What resources are available to the family? o o
Case 4… o o 75 year old woman with severe dementia brought to the ED by police after being found in the street, wandering and confused She lives in HER house with her grandson. She previously had home health, but they refused to continue coming (? drug dealing at the house? ) The grandson often leaves her alone, and the house is in disrepair with recent discontinuation of electrical services Should the grandson continue to have Power of Attorney? Is this elder mistreatment?
Elder Mistreatment: Background o “Granny Battering” first described: BMJ 1975 o Increased awareness over last 20 years following interest in child and partner abuse o Differing definitions, poor detection, underreporting make exact extent unknown o Estimated that 5 -10% of elderly abused yearly (probably underestimated)
Definition Elder mistreatment refers to 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 persons who stand in a trust relationship to the elder or failure by a caregiver to satisfy the elder’s basic needs or protect the elder from harm. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2003). National Research Council
Elder Mistreatment o o Abuse n Physical n Emotional/psychological n Sexual n Isolation n Restraints n Financial n Violation of rights (personal liberty, personal property, privacy, voting, speech) Neglect n Inadequate provision of physical needs, hygeine, supervision, medical services Self-Neglect Domestic Violence
What are the numbers? No one knows… o Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America : "between one and two million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depend for care or protection. “ o Only 1 of every 5 to 14 cases is known Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2002) Committee on National Statistics (CNSTAT) - http: //www. nap. edu/openbook/0309084342/html/ National Incidence and Prevalence Study (NIPS) (1998) http: //www. aoa. gov/eldfam/Elder_Rights/Elder_Abuse. asp
The numbers… o Most Studies exclude financial and self neglect n o Self neglect accounts for majority of APS referrals! National Elder Abuse Incidence Study n n Noninstitutional Reports to APS Neglect most common (55% cases) Caregiver neglect: 13%
The numbers in North Carolina? o The best data available refer to disabled adults o NC’s Department of Health and Human Services reports data from counties’ Departments of Social Services: 2000 -2001. n n 9, 142 disabled adults were served 52% (4, 754) were between the ages of 60 -84 and 19% (1, 737) were 85 years old and older. Mistreatment was confirmed in 36% (3, 291). The need for protective services was substantiated for 23% (2, 103) http: //www. dhhs. state. nc. us/aging/adultsvcs/apsr 2002. pdf
Risk Factors o o o Older age Lack of access to resources Low income Social isolation Low level of education Functional debility Substance abuse (by older person or caregiver) Psychological disorders History of family violence Caregiver burnout and frustration Cognitive impairment
High Risk o Cognitive impairment with high physical needs o Difficult behavior with dementia o Social isolation
Who are the abusers? o Adult children are most often the abusers. Spouses and other family members also mistreat older adults. Almost 90% of abusers are family members. o Paid caregivers who come into the home are less likely to mistreat or be abusers than family members. o Older adults may be mistreated in assisted living facilities, rest homes, and skilled nursing facilities Elder Abuse Awareness Kit, http: //www. elderabusecenter. org/pdf/basics/speakers. pdf
Cycle of Abuse o Increasing recognition of cycle of domestic and family violence and abuse o Increasing partner/domestic abuse in older persons o Issues of Neglect of elders who were at one time the abusers of their current caretakers (adult children or spouses)
Barriers to reporting o Cognitive impairment o Fear of violence/retaliation o Embarrassment o Fear of placement worse than fear of abuse
Barriers to reporting o Friends/family may not be sure of what is happening or trained to know what is suspicious o “Not my business…” o Do not want to cause trouble o Fear retaliation o Believe that their actions will not make things better
What Questions to ask? o o o o Do you feel safe at home? How do you and _____ get along? Is ______ taking good care of you? Do you have frequent disagreements? What happens when you disagree? Are you yelled at? Has anyone ever scolded or threatened you? Are you afraid of anyone at home? Have you gone without food or medicine? Have you ever had you glasses or hearing aid taken from you? Has anyone ever hurt you? Slapped, punched or kicked you? Has anyone ever touched you without your permission? Has anyone every made you do things you did not want to do? Has anyone taken things away from you without asking? Are you made to stay in your room?
Screening Instruments o Team from Mc. Master University identified 90 articles that discussed risk factors. o 18 included screening tool, only six provided data on reliability and validity o First 3 done in the late 80 s. The last 3 carried out as part of one Canadian study of risk factors in the late 90 s. o Fulmer & O'Malley, 1987; Hamilton, 1989; Hwalek & Sengstock, 1986; Reis & Nahmiash, 1995 a; Reis & Nahmiash, 1995 b; and Reis & Nahmiash, 1998, Shott et al. , 1999
Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). o 6 questions discriminated effectively (Neale et. al. , 1991): n Has anyone close to you tried to hurt or harm you recently? n Do you feel uncomfortable with anyone in your family? n Does anyone tell you that you give them too much trouble? n Has anyone forced you to do things that you didn't want to do? n Do you feel that nobody wants you around? n Who makes decisions about your life. . . like how you should live or where you should live?
Women’s Health Survey o 15 -item H-S/EAST screening tool adjusted, reliability/validity analyzed in sample of older Australian women (n=12, 340) o 6 item scale: n n n Are you afraid of anyone in your family? Has anyone close to you tried to hurt or harm you ? Has anyone close to you called you names or put you down or made you feel bad recently? Does someone in your family make you stay in bed or tell you're sick when you know you aren't? Has anyone forced you to do things you didn't want to? Has anyone taken things that belong to you without your OK?
Should we screen? o Controversial Report from US Preventive Services Task Force o Insufficient evidence to recommend for or against routine screening o Lack of data does not mean lack of benefit o Does not address issue of asking questions in suspected cases…
Potential Indicators of Mistreatment…
Physical abuse or neglect… o o o Traumatic alopecia Poor oral hygiene Welts, bite marks, burns Decubitus ulcers Suspicious bruising (finger marks on arms or legs) Fractures Fecal impaction Weight loss Dehydration Hypernatremia Poor hygiene
Dehydration and hypernatremia o Hypernatremic dehydration in nursing home patients: an indicator of neglect
Sexual abuse o Physical signs, e. g. , bruises, pain, or itching on genital area or breasts o Sexually transmitted disease diagnosis o Change in older adult's behavior or mood that is unexplained o Fear of physical exam of genital area
Emotional or Psychological abuse… o Withdrawal o Unexplained change in mood o Refusal of caregiver to leave
Financial abuse… o o o Older adult unaware of income or financial matters Important papers and credit cards missing Bills not paid Funds not spent on older adult’s needs Unusual banking activity n n n o Adding caregiver’s name to account Older adult signing on caregiver’s loan Checks made to “cash” frequently Signature not that of older adult Activity older adult doesn’t understand or know about Frequent expensive gifts from older adult to caregiver New will
Financial Abuse o Elder has funds, property, house that are being used o Older adult may have fear of being “placed” in nursing home o Often most challenging to “prove”
Mistreatment in Institutions… o Great potential for abuse and neglect in assisted living and skilled nursing facilities o Study of 600 facilities: 40% surveyed reported committing at least one psychologically abusive act within the past year; 10% admitted to act of physical abuse o Markers of potential neglect: decubitus ulcers, wandering out of facility, dehydration, weight loss, poor oral care
Back to the Cases: Case 1 86 year old man with renal insufficiency, diabetes, vascular disease, peripheral neuropathy readmitted with recurrent nausea, vomiting, abdominal pain, dehydration and renal failure Son concerned that patient’s new wife, 35 years younger, is neglecting him and “in it for the money” At baseline, the patient was oriented, appropriate and felt to have capacity to make decisions regarding living situation and medical care
Case 1 n Difficult question of possible mistreatment n Potential neglect n Potential financial exploitation n Issue of Capacity on part of the patient o Protection vs autonomy
Case 2… o 83 year old woman admitted with DVT; she is disheveled and smells of urine and feces o The worried daughter calls. APS had previously been to the house and found it filthy, filled with cats and 20 years worth of magazines. She has had a long history of medical noncompliance and has “fired” multiple home health nurses and physicians o She has always been a quiet, secluded, and suspicious person
Case 2: Self Neglect o o Capacity vs Autonomy and Self Determination Capacity: n n n o o Specific to each decision Consistency Understanding consequences and ability to express this Express reasoning behind decision Does not have to match common values Cultural competency and understanding Competency: legal term Lack of competency necessitates assignment of guardian
Self Neglect o Diogenes Syndrome n n n Severe self neglect Normal cognition, normal MMSE Theories o o Extreme/continuation of lifelong “personality” trait or disorder? Frontal lobe process leading to poor judgment
More on Diogenes Syndrome o Characteristics: n n n Hoarding, collecting Social withdrawal and isolation Refusal of support Often judged to have “capacity” given normal orientation and cognitive testing Do they “lack of capacity to care for self? ” Most challenging cases for APS
Diogenes Syndrome and Self Neglect o Why do these fall through the crack? n APS relies on elder being “disabled”, meaning lacking capacity or competency, in order to get involved n If elder is not cognitively impaired, at what point can they be considered harmful to themselves
Case 3… o 95 year old man admitted from a skilled nursing facility with dehydration, hypernatremia (Na 178), confusion, and a large decubitus ulcer o Family is concerned that he has had several weeks of declining intake and feel he is being neglected
Case 3: The Nursing Home… o Increased awareness of neglect and abuse in skilled nursing facilities o Families can look up records of facilities o Things to look for: decubitus ulcers, dehydration, mouth care, use of restraints o Not all ulcers and cases of dehydration are due to neglect o Role of the ombudsman o Report to DFS
Case 4… o 75 year old woman with severe dementia brought to the ED by police after being found in the street, wandering and confused o She lives in HER house with her grandson. She previously had home health, but they refused to continue coming (? drug dealing at the house? ) The grandson often leaves her alone, and the house is in disrepair with recent discontinuation of electrical services
Case 4: Exploitation and Neglect o The most difficult to prove o If guardian is suspected to be abusing/neglecting elder, process to suspend their Power of Attorney n Physicians and caretakers must certify lack of capacity for competency hearing; then new guardian would be assigned (family member or person assigned by APS)
What to do…
If you suspect mistreatment… o Document what the older adult says. Use direct quotes. o Record any statements made by others to explain or support the older adult's statements. o Determine and record the older adult's cognitive status, mood, and capacity to make decisions o Photograph visual evidence after getting written permission to do so.
If suspect, report If you believe an older, disabled adult is being mistreated, report to the local county Department of Social Services (DSS) Adult Protective Services (APS). o Contact information is available online at http: //www. dhhs. state. nc. us/dss/local/index. htm A printed directory is available. o County DSS are required to evaluate reported allegations of the need for Adult Protective Services within 72 hours. o DSS must “confirm” and “substantiate” reports before protective services are given.
The law in North Carolina o State laws govern the mistreatment of adults; some states have specific statutes that address older adults. o DSS: Now Division of Aging and Adult Services: emphasizing need to also protect vulnerable eldelry o North Carolina Statute Article 6, 108 A-99 -111 is the Protection of the Abused, Neglected, or Exploited Disabled Adult Act. You can find this law at: http: //www. ncleg. net/Enacted. Legislation/Statutes/HTML/By. Article/Chap ter_108 A/Article_6. html
NC Law: current and future o o o NC: First State to enact elder abuse law in 1973 APS intervention directed toward “disabled adults”, not updated in 30 years! 2005 APS Task Force Report to NC Study Commission on Aging n n Develop Clearing House Model for APS Include ALL adults over the age of 60 as eligible for services
What to do… o Awareness o Screening in Nursing Assessment Form at UNC n “because so many people deal with fear and abuse in their relationships, we ask these questions of all our patients… does your partner/caregiver: have control over your decisions in your life? Threaten to harm you in any way? Shoved you in the past year? Ever failed to help you take care of yourself when you needed help?
Institutional Issues and Reporting o Division of Health Service Regulation DHSR (prior Division of Facility Services) n n o Hospitals, nursing homes, adult care homes, psychiatric hospitals, home health agencies, hospices, dialysis centers, surgical care centers, and other facilities www. dhhs. state. nc. us/dhsr/ Ombudsman Program
Other resources Resources for situations that do not meet the definition of cases served by DSS: o Interdisciplinary geriatrics care team o Local law enforcement o Caregiver support groups in senior centers, churches, adult day care and civic organizations o Family domestic violence support organizations
Resources o o Available through National Center on Elder Abuse (NCEA) Links to state resources, research, laws
Resources in NC N. C. Division of Aging and Adult Services - Promotes the independence and enhances the dignity of N. C. 's older and disabled persons and their families through a community-based system of opportunities, services, benefits, and protections. http: //www. dhhs. state. nc. us/aging/ Long Term Care Ombudsmen serve as advocates for residents in nursing homes and adult care homes (rest homes/assisted living) throughout N. C. - http: //www. dhhs. state. nc. us/aging/ombud. htm Area Agencies on Aging (AAAs) facilitate and support the development of programs to address the needs of older adults - http: //www. dhhs. state. nc. us/aging/aaa. htm N. C. Division of Social Services -works in cooperation with the Social Services Commission, the 100 local Department of Social Services and other public and private entities to protect children, strengthen families and help all North Carolinians to achieve maximum self-sufficiency - http: //www. dhhs. state. nc. us/dss/ N. C. Division of Facilities Services regulates medical, mental health and group care facilities, emergency medical services, and local jails. They ensure that people are safe and that the care in these facilities is adequate – http: //facility-services. state. nc. us/ N. C. Counties Departments of Social Services - Go to this website and select a county. It provides phone numbers, physical addresses, and mailing addresses for county offices of Departments of Social Services, Adult Protective Services - http: //www. dhhs. state. nc. us/dss/local/index. htm North Carolina Statute which addresses the Protection of the Abused, Neglected, or Exploited Disabled Adult - http: //www. ncleg. net/Enacted. Legislation/Statutes/HTML/By. Article/Chapter_108 A/Article_6. html
National Resources National Center on Elder Abuse - The NCEA, funded y the U. S. Administration on Aging, is a gateway to resources on elder abuse, neglect and exploitation - http: //www. elderabusecenter. org Elder Abuse Awareness Kit http: //www. elderabusecenter. org/pdf/basics/speakers. pdf National Committee for the Prevention of Elder Abuse - The NCPEA is an association of researchers, practitioners, educators, and advocates dedicated to protecting the safety, security, and dignity of America's most vulnerable citizens. The Committee is one of six partners that make up the National Center on Elder Abuse, which is funded by Congress to serve as the nation's clearinghouse on information and materials on abuse and neglect - http: //www. preventelderabuse. org/index. html Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2002) Committee on National Statistics (CNSTAT) - http: //www. nap. edu/openbook/0309084342/html/ Elder Abuse and Neglect: In Search of Solutions - pamphlet published by the American Psychological Association - http: //apa. org/pi/aging/eldabuse. html U. S. Administration on Aging's Elder Abuse Resource Page - http: //www. aoa. gov/eldfam/Elder_Rights/Elder_Abuse. asp
Acknowledgments… Funding: Donald W. Reynolds Foundation Carolina Geriatric Education Center, Bureau of Health Professions Author: Debra Bynum, MD and Margie Britnell, MPH Content: Diana Bass, MPH, and Diana Wells, RN, MSW, MPH, and Yvette Warren - Beacon Program, UNC Healthcare Debra Bynum, MD Florence Soltys, MSW, ACSW, CCSW Margaret Hudson, A/GNP Educational Development: Ellen Roberts, Ph. D, MPH William Ashley Davis, BA Program on Aging: Jan Busby-Whitehead, MD
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