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Elder Abuse and Dependent Adult Abuse
Recognition and Reporting for Nurses and Other Healthcare Professionals

Online Continuing Education Course

Course Description

This course covers recognizing and reporting elder abuse and dependent adult abuse and is applicable to nursing, occupational therapy, physical therapy, and EMS/paramedic providers. Define elder abuse and learn about elder/dependent adult abuse prevention in general and in nursing homes. State laws provide specific definitions relating to such abuse, and all healthcare professionals should familiarize themselves with the laws in their state.

Course Price: $18.00

Contact Hours: 2

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Elder Abuse and Dependent Adult Abuse
Recognition and Reporting for Nurses and Other Healthcare Professionals

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have the current, evidence-based information and tools you need to accurately identify and report suspected dependent adult and vulnerable elder abuse. Specific learning objectives to address potential knowledge gaps include:

  • Define “dependent adult abuse” and "vulnerable elder abuse."
  • Recognize the indicators of dependent adult and vulnerable elder abuse.
  • Discuss the risk factors for victims and perpetrators.
  • Explain the reporting process and barriers to reporting suspected abuse.
  • Summarize urgent and protective interventions that may be taken in cases of abuse.
  • Describe efforts to prevent abuse of persons at risk.

INTRODUCTION


The abuse and mistreatment of dependent adults and vulnerable elders is a hidden epidemic, with a massive number of invisible victims. Healthcare professionals are in a unique position to recognize and report this abuse in order to protect their patients, and in some states they are mandated by law to do so.

The abuse of dependent older adults by family members in particular dates back to ancient times. It often remained a private matter, hidden from public view. Mistreatment of the elderly and dependent older adults was first described in modern scientific literature under the term granny battering (Burston, 1975). Today, this sort of abuse is considered a social welfare issue as well as a public health and criminal justice concern.

The sadness that accompanies elder abuse and dependent adult abuse is incomprehensible and overwhelming at times. Disabled, dependent, and older adults are sometimes abused by the very people entrusted to help them, including professional caregivers (e.g., personal assistants, health technicians, home health aides, nursing assistants) and family members. These types of abuse are known to occur anywhere: at home, in healthcare facilities, and within the community at large.

When abuse does occur, the dependent or elder adult’s personal health, safety, and emotional well-being becomes eroded and at risk, along with their ability to engage in daily life activities.

DEFINITIONS

Following are general definitions of individuals who are involved in dependent adult and elder abuse (also called senior abuse). State laws provide specific definitions relating to such abuse, and all healthcare professionals should familiarize themselves with the laws in their state.

Dependent adult typically means a person 18 years of age or older who is unable to protect one’s own interests or unable to adequately perform or obtain services necessary to meet essential human needs, as a result of a physical or mental condition which requires assistance from another.

Vulnerable elder means an older adult, usually 60 or more years of age, who is unable to protect himself or herself from abuse as a result of age or a mental or physical condition.

Caretaker means a related or nonrelated person who has the responsibility for the protection, care, or custody of a dependent adult either voluntarily, through employment, or by order of the court. Caretaker also means a person who is a staff member of a facility or program who provides care, protection, or services to a dependent adult.

Disability means a physical or mental impairment that substantially limits an individual from carrying out one or more major life activities, including, but not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, working, and the operation of a major bodily function (LII, 2008). Having a disability does not in and of itself meet the criteria for being a dependent adult; many people with disabilities live independently.

EPIDEMIOLOGY

Dependent adult abuse and vulnerable elder abuse are two of the largest underrecognized and underreported problems within the United States. It is estimated that only 1 in 14 incidents of dependent adult abuse will come to the attention of law enforcement or human service agencies. Such abuse is far less reported than child abuse or domestic abuse due to lack of tracking, research, and public awareness (NCOA, 2017).

Most states did not establish protective services for adults to address dependent adult abuse until the mid-1980s. To compound the problem, medical and criminal justice communities have lacked comprehensive forensic guidelines for the identification of abuse of dependent older Americans, leading to problems with detection, conflicting definitions of the crime, and underreporting (NCOA, 2017). Certain data that has been collected by independent researchers illustrates a troubling reality:

  • Dependent adults who experience abuse had a 300% greater risk of death when compared to those who had not been abused.
  • In 60% of dependent adult abuse incidents, the perpetrator was a family member; two thirds of perpetrators are adult children or spouses of the victim.
  • An estimated 1 in 13 older adults in the state of New York were victims of at least one form of elder abuse in a single year, including 41 per 1,000 reporting major financial exploitation.
  • Financial abuse and fraud costs for older Americans are estimated at over $36.5 billion annually.
  • Roughly 50% of older individuals with dementia are abused or neglected by caregivers annually.
    (NCOA, 2017; Lifespan of Greater Rochester et al., 2011)

Care Facilities

Data on the extent of dependent adult abuse in institutions, nursing homes, and other care facilities are scarce, however, research and surveys suggest high rates of abuse in such facilities (see box).

ABUSE IN CARE FACILITIES
  • An estimated 50% of care facility staff admit to mistreating (i.e., physical violence, mental abuse, neglect) dependent older adults in America annually; two thirds of these incidents involve neglect.
  • Most dependent adult abuse in care facilities leads to preventable harm, including $2.8 billion annual Medicare hospital costs alone (excluding additional—and substantial—Medicaid costs caused by the same incidents).
  • Facility residents with cognitive incapacities (i.e., dementia, Alzheimer’s disease) suffer 100% greater economic losses in financial exploitation than those without such incapacities.
  • Dependent adult abuse in care facilities triples the risk of premature death.
  • Only 20% of abuse cases are estimated to ever get reported (believed due to residents’ cognitive or confidence level to report).
  • 44% of care facility residents state they have been abused.
  • 95% of care facility residents state they have been neglected or seen another resident neglected.
  • 17% of certified nursing assistants (CNAs) report pushing, grabbing, or shoving a care facility resident.
  • 23% of CNAs report yelling at a resident.
    (NCEA, 2012; Connolly et al., 2014)

Among Individuals with Disabilities

Individuals with disabilities are victimized by abuse at much higher rates than the rest of the population and are often targeted specifically because of their disability. As compared to the rest of the population, victims with disabilities experience higher rates of victimization by persons known to them and they report the crime far less frequently—often due to the nature of their disability (i.e., cognitive or physical disabilities or mental illness).

In the largest survey of its kind in the United States, the Disability and Abuse Project released a report in 2012–2013 entitled “Abuse of People with Disabilities: Victims and Their Families Speak Out.” The report was a rare look into the experiences of 7,200 survey participants (i.e., family members, advocates, service providers, and various types of professionals) who were asked about abuse and bullying by a personal assistant. The survey respondents represented all 50 states and the District of Columbia.

  • Over 70% of people with disabilities reported having been victims of abuse.
  • More than 50% of these experienced physical abuse.
  • Approximately 41% of these experienced sexual abuse.
  • Nearly 90% suffered verbal or emotional abuse.
  • Most experienced abuse on more than 20 occasions.
  • About 50% of abuse incidents were not reported to authorities.
  • When reports were filed, only 10% of alleged perpetrators were arrested.
  • Approximately one third of victims received therapy.
  • Fewer than 5% received benefits from victim compensation programs.
    (Baladerian et al., 2013)

CATEGORIES OF ABUSE

Dependent adult and elder abuse fall into several categories, all resulting from the willful, negligent acts or omissions, including misconduct, gross negligence, or reckless acts, of a caretaker:

  • Physical abuse
  • Sexual abuse
  • Emotional/psychological abuse
  • Material/financial exploitation
  • Neglect (also referred to as deprivation or denial of critical care)
  • Self-denial of critical care
  • Degradation

Following are general descriptions of these categories. Individual states provide specific descriptions for what constitutes dependent adult abuse and elder abuse in their jurisdiction, and healthcare professionals should familiarize themselves with the laws in their state.

What Constitutes Physical Abuse?

Physical abuse is defined as 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 (NCEA, n.d.-b).

What Constitutes Sexual Abuse?

Sexual abuse is defined as nonconsensual sexual contact of any kind with an elderly or dependent adult. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It 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 (NCEA, n.d.-b).

What Constitutes Emotional/Psychological Abuse?

Emotional or psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional/psychological abuse includes but is not limited to 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 (NCEA, n.d.-b).

What Constitutes Material/Financial Exploitation?

Exploitation of a dependent adult or vulnerable elder includes taking unfair advantage of that individual’s material or financial resources for one’s own personal or financial profit without the informed consent of the individual, including theft by the use of undue influence, harassment, duress, deception, false representation, or false pretenses.

Exploitation also includes acts by a caretaker to obtain, use, endeavor to obtain to use, or misappropriate a dependent adult’s funds, assets, medications, or property with the intent to temporarily or permanently deprive that individual of the use, benefit, or possession of those funds, assets, medications, or property for the benefit of someone other than the dependent adult.

What Constitutes Neglect?

Neglect, or denial of critical care, includes depriving the dependent adult or vulnerable elder of the minimum of:

  • Food
  • Shelter
  • Clothing
  • Supervision
  • Physical or mental healthcare
  • Other care necessary to maintain that individual’s life or health

What Constitutes Self-Neglect?

Self-neglect means situations in which the neglect is the result of the acts or omissions of the dependent adult themself. This may take the form of the individual refusing care or being unable to provide for their own care, resulting in a threat to their health or safety.

What Constitutes Personal Degradation?

Personal degradation means a willful act or statement by a caretaker—including the taking, transmission, or display of an electronic image—intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person.

PREVALENCE OF ELDER ABUSE, BY TYPE

In one study, researchers found that 1 in 10 respondents age 60 or over reported emotional, physical, or sexual mistreatment or potential neglect by a family member in the past year (NCOA, 2017). The one-year prevalence of abuse varied by type (see below), and the most consistent correlates of mistreatment across abuse types were low social support and previous traumatic event exposure.

  • Physical abuse, 1.6%
  • Sexual abuse, 0.6%
  • Psychological abuse, 4.6%
  • Financial abuse, 5.2%
  • Neglect, 5.1%
    (Acierno et al., 2010)

Circumstances Not Constituting Abuse

Certain situations encountered by caregivers are typically not considered to constitute abuse of the dependent adult or vulnerable elder. These include:

  • Circumstances in which the individual declines medical treatment if they hold a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment
  • Circumstances in which the individual’s caretaker, acting in accordance with the individual’s stated or implied consent, declines medical treatment or care
  • The withholding or withdrawing of healthcare from an individual who is terminally ill in the opinion of a licensed physician, when the withholding or withdrawing of healthcare is done at the request of the dependent adult or at the request of the individual’s next of kin, attorney in fact, or guardian pursuant to applicable laws
  • Good faith assistance by a family or household member or other person in managing the financial affairs of an individual at the request of the individual or at the request of a family member, guardian, or conservator of the individual
  • Touching which is part of a necessary examination, treatment, or care by a caretaker acting within the scope of practice or employment of the caretaker; the exchange of a brief touch or hug between the individual and a caretaker for the purpose of reassurance, comfort, or casual friendship; or touching between spouses or domestic partners in an intimate relationship
CASE
Neglect

Ellen is 85 years old and lives with her 50-year-old son, Jack. Since Ellen’s health is deteriorating, she needs assistance with activities of daily living, especially using the toilet and dressing. Jack has agreed to serve as his mother’s caretaker, but he is not consistent with assisting his mother when she indicates she needs help. Therefore, she sometimes remains lying in a urine-soaked bed for hours without clothing or blankets for warmth. Ellen has developed a urinary tract infection as well as pressure ulcers on her back due to Jack not responding to her elimination needs and not repositioning her in the bed.

Finally, Jack takes his mother to the local hospital’s emergency room when she becomes too sick to get out of bed. Ellen is admitted with a high temperature. The attending physician immediately suspects abuse, and she immediately acts to make a report. Investigators determine that Jack’s actions constitute neglect because he has not provided his dependent mother with the minimum care she requires.

CASE
Self-Neglect

Lester is 76 years old and lives in a dilapidated cabin along the river and about five miles from town. He is a chronic alcoholic, spending the majority of his monthly income on alcohol instead of groceries. Lester has type 2 diabetes, and he no longer remembers to take his insulin on time.

Lester’s water and electricity were cut off last week since he had not paid his bills for several months. He now uses only river water for cleansing and eats whatever old, canned foods he can find in the kitchen. Due to his poorly controlled diabetes, he has developed ulcers on his feet that have become infected.

When visiting from out of town, Lester’s adult son Charlie discovers his father’s poor living conditions, deteriorating personal hygiene, and ill health. He also notices that his father has become more mentally confused. Charlie tells his dad that he is worried about his health and safety, but Lester angrily insists that he is free to live his life the way he wants.

When Charlie leaves his father’s cabin, he immediately contacts the local county sheriff’s office for assistance and to make a “welfare check” to evaluate his father’s condition. Law enforcement visits Lester’s home. Suspecting self-neglect, they report the case to the state’s Department of Human Services, which investigates further and assists Lester to address his physical and mental health, hygiene, and safety issues.

RECOGNIZING ELDER ABUSE AND DEPENDENT ADULT ABUSE

Healthcare professionals should be aware of possible indicators of abuse when caring for adults who may be victims of elder abuse or dependent adult abuse. This abuse can be recognized by many indicators both among those adults who are victims of such abuse as well as among their abusers. It is important to be aware, however, that signs and symptoms of adult abuse are dependent on the type of abuse and that the indicators described below do not necessarily indicate abuse.

The complexity within and between cases of abuse make it difficult to establish assessment criteria to meet profiles of signs and symptoms of victims. There have been a succession of tools—such as the EASI (Elder Abuse Suspicion Index)—introduced and used with some success (Hoover & Polson, 2014). Common recommendations described within the literature for abuse assessment with dependent adults include:

  • Separate the dependent adult from the caregiver when carrying out an assessment.
  • Pay special attention to the physical and psychological aspects of the assessment.
  • Be aware that physically abused older adults are more likely to have significantly larger bruises and will readily identify the cause of that injury.
    • Bruises will¬† most likely occur on the face, lateral aspects of the right arm, and the posterior torso (i.e., back, chest, lumbar, and gluteal regions).
    • Bruises may be in various stages of healing from frequent falls, fractures, dislocations, burns, and human bite marks.
    (Boltz et al., 2016)

Victim Indicators

Possible victim indicators of dependent adult or elder abuse are described below, grouped into the categories of physical, behavioral/psychological, environmental, and financial (NCOA, 2017; NCEA, n.d.-b). This list is not all-inclusive.

POSSIBLE PHYSICAL INDICATORS

  • Lack of medical care
  • Lack of personal cleanliness and grooming, body odors
  • Swollen eyes or ankles
  • Decayed teeth or no teeth
  • Bites, fleas, sores, lesions, lacerations
  • Injuries incompatible with explanation
  • Bruises, broken bones, or burns
  • Untreated pressure sores
  • Signs of confinement (i.e., tied to furniture, locked in a room, etc.)
  • Obesity, malnourishment, or dehydration
  • Broken glasses (frames or lenses)
  • Drunk, overly medicated
  • Lying in urine, feces, old food
  • Petechiae (small, purplish, hemorrhagic spots on the skin) around the eye orbits from strangling
  • Dislocated joints (especially in shoulder from being grabbed)

POSSIBLE BEHAVIORAL AND PSYCHOLOGICAL INDICATORS

  • Not dressing appropriately for the weather conditions
  • Wearing all of one’s clothing at once
  • Living on the street (homeless)
  • Intentional physical self-abuse, suicidal statements
  • Refusing needed medical attention
  • Refusing to take medications
  • Not following medication directions
  • Threatening or attacking others physically or verbally
  • Refusing to open the door to a visitor
  • Spending the day in total darkness
  • Denying obvious problems (i.e., medical condition, etc.)
  • Exhibiting increased depression, anxiety, or hostility
  • Being withdrawn, reclusive, suspicious, timid, unresponsive
  • Refusing to discuss the situation
  • Expressing unjustified pride in self-sufficiency
  • Disoriented as to place and time
  • Exhibiting diminished mental capacity (i.e., dementia)
  • Longing for death with vague health complaints

POSSIBLE ENVIRONMENTAL INDICATORS

  • No food in the house or rotten, infested food
  • Lack of proper food storage
  • Clothes extremely dirty or uncared for
  • Utilities cut off or lack of heat in winter
  • Lack of water or contaminated water
  • Doors or windows made out of cardboard
  • Unvented gas heaters, chimney in poor repair
  • Gross accumulation of garbage, papers, and clutter
  • Large number of pets with no apparent means of care

POSSIBLE FINANCIAL INDICATORS

  • Sudden changes in bank account practices
  • Unexplained withdrawal of a great sum of money
  • Adding names on a bank signature card
  • Unapproved withdrawal of funds using an ATM
  • Sudden changes in a will or other financial documents
  • Unexplained missing funds or valuables
  • Unpaid bills despite having enough money
  • Forged signature for financial transactions or for the titles of property
  • Sudden appearance of previously uninvolved relatives claiming rights to a person’s affairs and possessions
  • Unexplained sudden transfer of assets
  • No knowledge of own finances
  • Caretaker overly interested in finances of the dependent adult
  • Isolation of the dependent adult
  • Caregiver refusing to allow visitors (socialization) to see the dependent adult alone
  • Loss of personal belongings such as art, silverware, jewelry, or other valuables

Perpetrator Indicators

Possible perpetrator indicators of abuse are described below. This list is not all-inclusive.

  • Not allowing the dependent adult to speak for himself/herself or to others without the presence of the caregiver
  • Obvious absence of assistance, attitudes of indifference, or anger toward the dependent individual
  • Blaming the dependent individual (e.g., accusation that incontinence is a deliberate act)
  • Failure to provide physical aids such as eyeglasses, hearing aids, or dentures
  • Withholding of food and water
  • Failure to help with personal hygiene
  • Aggressive behavior such as threats, insults, or other verbal harassment
  • Social isolation of the family or restriction of the older adult’s activity in a social unit
  • Conflicting accounts of incidents by family, supporters, caregiver, or victim
  • Unwillingness or reluctance to comply with service providers in planning for care of the dependent adult
  • Unauthorized withdrawal of the dependent adult’s funds using their ATM card or checks
    (Amstadter et al., 2011; NCEA, n.d.-b)
POSSIBLE INDICATORS OF ABUSE IN A FACILITY SETTING

Victim (Resident)

  • Signs of neglectful treatment: malnourishment, dehydration, pressure sores (could also be signs of naturally declining health)
  • Open wounds, bruising, bleeding
  • Ligature marks on neck, mouth, wrist, ankles
  • Burns and abrasions
  • Poor hygiene, urine and feces odor
  • Additional or more serious infections
  • Hair loss, skin tears
  • Torn or stained bedding or clothing
  • Listlessness or unresponsiveness
  • Infantile or other eccentric behaviors
  • Physical or emotional withdrawal
  • Disappearance of personal items
  • Sudden and unusual bank transactions
  • Unwillingness to open up and talk
  • States “I don’t want so-and-so to take care of me”
  • Family’s concern that “something just isn’t right”

Perpetrator (Care Provider)

  • Being mistreated by a dementia patient
  • Not perceiving certain behaviors as abusive
  • Treating patients like children
  • Being an unwilling or inexperienced caregiver
  • Displaying conflict in the relationship with the patient
  • Feeling job dissatisfaction, personal stress, burnout
  • Having negative attitudes toward dependent older adults
  • Working in a facility with staffing shortages or high staff turnovers
  • Behaving and acting neglectful toward a patient
  • Deflecting questions
  • History of sexual abuse (gerophiles who seek out elderly victims of the facility)

(ASA, 2016; AoA, 2016)

Caregivers may exhibit abusive behaviors with dependent adults and/or participate in neglectful behaviors toward the victim. The following table summarizes the types of dependent adult abuse, including examples of abusive actions and warning signs and symptoms of abuse.

SUMMARY OF ABUSE TYPES AND INDICATORS
Type of Abuse Abusive Act Signs and Symptoms
Source: Adapted by permission from Salsbury, 2011.
Physical
  • Violent behaviors including hitting, pushing, kicking, shaking, pinching, or burning
  • Inappropriate medication use, including over- or under-medicating
  • Physical restraint use
  • Force feeding
  • Physical punishment
  • Dependent adult’s report of physical abuse or mistreatment
  • Multiple and/or untreated injuries in various healing stages
  • Bruises, cuts, black eyes, open wounds or other marks on the skin
  • Broken bones, sprains, or dislocations
  • Broken personal care items (i.e., eyeglasses, dentures, hearing or ambulatory aids)
  • Lab findings of inappropriate medicine use
  • Changes in elder or caregiver behavior
Psychological or Emotional
  • Verbal assaults, insults, or harassment
  • Intimidation or threats
  • Humiliation
  • Social isolation from friends, family, or activities
  • “Silent treatment”
  • Treating dependent person as a baby or belittling
  • Dependent adult’s report of verbal or emotional abuse
  • Changes in the victim’s behavior or emotional responses
  • Tearfulness and/or agitation
  • Withdrawn behavior
  • Noncommunication
  • Caregiver answering for the dependent adult
Sexual Abuse or Exploitation
  • Unwanted touching
  • Coerced nudity
  • Sexually explicit photography or video recording
  • Sexual assault or rape
  • Dependent adult’s report of sexual abuse
  • Bruises or bleeding around breasts, genitals, or anus
  • Torn, bloody or stained underwear
  • Sexually transmitted disease or unexplained genitourinary infection
Financial or Physical Exploitation
  • Stealing or misusing money or possessions
  • Unauthorized check cashing, bank withdrawal, or credit card use
  • Signature forgery on legal documents
  • Improper use of power of attorney or trusteeship
  • Dependent adult’s report of exploitation
  • Unexplained money withdrawal or change in banking practices
  • Changes in legal documents such as a will or guardianship
  • Missing money or possessions
  • Provision of unneeded goods or services
Neglect
  • Lack of basic necessities including food, water, clothing, shelter, medicine, or utilities
  • Personal hygiene and discomfort not attended
  • Unsanitary living conditions
  • Dependent adult’s report of neglect by family member or other caregiver
  • Dehydration, malnutrition, weight loss
  • Untreated pain, falls, or medical conditions
  • Bedsores, lice, or other infections and injuries
  • Soiled or inadequate clothing or bedding
  • Spoiled food, fecal or urine odors
Self-Neglect
  • Lack of basic necessities including food, water, clothing, shelter, medicine, or utilities
  • Personal hygiene and discomfort not attended
  • Unsafe or unsanitary living conditions
  • Hoarding
  • Homelessness
  • Poor personal hygiene
  • Dehydration, weight loss, malnutrition
  • Untreated medical conditions, infections, or injuries
  • Spoiled food, fecal or urine odors, animal or pest infestations

Risk Factors

The dynamics of dependent adult abuse are context dependent. Risk factors for the abused (victims) and the abusers (perpetrators) differ according to the context. Most of the caregiving, and thus abuse, occurs within the family structure (i.e., community context). Common risk factors in the community context are described below.

POSSIBLE VICTIM RISK FACTORS

  • Married and white
  • Lower socio-educational level
  • Female 80 years of age or older
  • Lives with abuser but socially isolated
  • Aggressive toward self and others
  • Mental or physical impairment or disability
  • Dependence on abuser
  • Resides in unsafe or inadequate housing
  • Numerous serious illnesses
  • Increasing dependence for financial support
    (Jett, 2014)

POSSIBLE PERPETRATOR RISK FACTORS

  • Mental health or substance abuse issues
  • Financial dependence on abused/victim
  • Past or current health problems
  • History of abusing and being abused
  • Stress or frustration with caregiving role
  • Feelings of being unduly burdened
  • Poor coping mechanisms
  • Poor support system
  • Criminal background
  • Being an adult child, sibling, or spouse of a dependent adult
  • Living with a dependent adult
  • Social isolation
  • Lack of employment
  • Male between the ages of 30 and 59 years
    (Jett, 2014)
DYNAMICS OF ABUSERS

Abusers often act out of a desire to gain and maintain power and control over the victim. Their tactics may include setting the rules for living arrangements, professing to love the older person (i.e., “sweetheart scams”), or intimidating and manipulating victims to gain some type of benefit. The perpetrator’s “entitlement thinking” may lead them to believe that their wants and needs are greater than the victim’s.

Predatory individuals may seek out dependent older adults with the intention of exploiting them. This may include seeking employment as a personal care attendant or contacting recently widowed persons identified through newspaper death announcements. Recent research has indicated the most frequent underlying behavior of the abuser is entitlement thinking patterns and the desire to exert and maintain power over the victim (EALL, 2017).

REPORTING SUSPECTED ABUSE

All states have a mandatory reporting statute for elder abuse, but almost every state varies as to the following areas:

  • Who is required to report abuse or suspected abuse (the “mandated reporters”)
  • What activities constitute or require reporting
  • Whether or not the victim lacks capacity
  • Whether or not the victim resides at home or in an assisted living facility or nursing home

(For information on each state’s mandatory reporting statutes, see “Resources” at the end of this course.)

Dependent adult abuse and elder abuse laws provide for evaluations and assessments of alleged abused dependent adults and elders. These laws seek to provide services and make referrals to assist abused adults to acquire a safe living arrangement. Adult Protective Service agencies are available in most jurisdictions.

The primary purpose of the reporting process is to obtain available and pertinent information regarding the allegation of abuse. The ability of the reporter to gather this information is critical to the evaluation and assessment process and is often the first step taken to initiate safeguards for the dependent adult at risk. The intent of reporting laws is to accept and process valid reports while not infringing on an adult’s right to privacy.

A thorough intake will provide:

  • Protection for the dependent adult
  • Necessary information for the assigned Adult Protective Services worker
  • Information and referral

All allegations of abuse must be taken seriously whether they come from the patient, family, healthcare professional, neighbor, friend, or other service provider. Concerns must be reported to those responsible for assessment and followed up by inquiries about the nature and circumstances of the allegation.

Who Must Report?

MANDATED REPORTERS

All states have laws designating certain professionals as mandated reporters of dependent adult abuse (Schmeidel et al., 2012). By law, many organizations and individuals who are responsible for the care or custody of the elderly or dependent adults are required and mandated to report situations of abuse. Mandated reporters may include the following:

  • Health practitioners
  • Care custodians
  • Employees of Adult Protective Services agencies
  • Employees of financial institutions
  • Law enforcement
  • Clergy members

PERMISSIVE REPORTERS

Any person who believes a dependent adult has suffered some form of abuse may report the suspected abuse to the local Adult Protective Services (or equivalent governmental agency) or to law enforcement. This is referred to as permissive reporting. For example, a local shop owner may voluntarily report suspected financial exploitation of a dependent adult, or a neighbor may report suspected self-neglect of an older adult.

It is important to note that mandated reporters may also report suspected abuse outside the scope of their professional practice, as permissive reporters.

KEY CONCEPTS FOR NURSE MANDATED REPORTERS

The registered nurse is contextually involved in the dynamics of dependent adult abuse merely by the professional responsibility as a mandated reporter and an advocate for patients. Some of the key concepts involved within the profession of nursing include:

  • Nurses must maintain updated knowledge of signs and symptoms of suspected dependent adult abuse.
  • Nurses must maintain updated knowledge of laws pertaining to dependent adult abuse.
  • Nurses have a legal responsibility to report suspected abuse of dependent adults.
  • Nurses must be vigilant and sensitive to the potential for abuse in the frail and vulnerable adult.
  • Nurses must assess subtle signs of abuse.
  • Nurses must proceed with a full assessment, including determination of safety of the victim.
  • Nurses need to participate in the prevention and early recognition of potential abuse.
    (Touhy & Jett, 2016)

These same concepts can be applied by all mandated reporters.

CASE
Reporting Abuse

Jean is a 25-year-old with muscular dystrophy and moderate intellectual disabilities. She is dependent on her parents for all her activities of daily living and attends a special school to assist her with her disabilities. On a recent field trip with the school, Jean’s teacher left her alone and unsupervised in the school van with two male students for approximately ten minutes. While the teacher was gone, one of the young males removed Jean’s shirt and took a picture of the two of them while he fondled her breasts. Upon arriving back at the school, the two male students showed the picture to other students.

Back at home after school, Jean, distraught from the incident, tearfully told her mother what had happened. Jean’s mother, Barbara, who happens to be a nurse, immediately called the police and then the school administrator. Although Barbara is not considered a mandated reporter in this instance since she did not learn of the abuse while working in her professional capacity, she is well aware of the harmful effects of the abusive actions of the male students, and she felt that calling the police would be the correct intervention for her to take as a permissive reporter.

The police began an investigation for dependent adult abuse in the form of personal degradation and sexual exploitation. They also directed the complaint to the Department of Human Services for further assessment, and a social worker began to help Jean and her parents to find another school and to seek psychological/mental health services. An investigation was also begun of the school.

What Is the Reporting Process?

IMMEDIATE PROTECTION CONTEXT

If urgent protection is believed necessary for a dependent adult, a reporter should immediately call 911 or law enforcement. The law enforcement personnel receiving this information will then report to the designated state agency.

COMMUNITY CONTEXT

Mandated reporters who suspect elder abuse or dependent adult abuse within the community generally must immediately make an oral report via an Adult Protective Services or elder abuse hotline or an online reporting system. Reporters who are a staff member or employee of a care facility must generally also notify the person in charge at the facility.

A written report is usually required by the mandated reporter within a specified timeframe after the oral report.

(See also “Resources” at the end of this course for a sample report form.)

HEALTHCARE FACILITY CONTEXT

If abuse occurs in a facility, the reporter must immediately notify the person in charge, who must then notify the state’s Long-Term Care Ombudsman program within a designated timeframe (ACL, 2018). This program is established in all states under the Older Americans Act, which is administered by the Administration on Aging. Local ombudsmen work with and on behalf of residents in hundreds of communities throughout the country.

SELF-REPORTING ABUSE

Some victims of abuse may be able to self-report if they are provided with an opportunity to do so. Unfortunately, however, the rate of self-reporting abuse is low due to fear, futility, and/or embarrassment. Those who wish to self-report abuse may take any of the following actions:

  • Call 911 if you are in immediate danger.
  • Speak up; if unhappy with your care, tell someone you know and trust; ask that person to report the abuse, neglect, or substandard care to your state’s abuse hotline or Long-Term Care Ombudsman’s office; or make the call yourself. (See “Resources” at the end of this course for contact information.)
  • Report to the local Adult Protective Services agency.

The National Survey on Abuse of People with Disabilities examined disabled dependent adults and the frequency of self-reporting of abuse. Findings indicated:

  • Among individuals with disabilities who reported they had been victims of abuse, 37.3% said they had reported it to the authorities.
  • Among family members of these victims, the rate of reporting jumped to 51.7%.
  • The majority of these victims said they had experienced abuse on more than 20 occasions.

(Baladerian et al., 2013)

Report Contents

Reports of suspected dependent adult or elder abuse typically include:

  • Names and home addresses of the dependent adult or elder, relatives, caretakers, and other people believed to be responsible for the individual’s care
  • The dependent adult or elder’s present whereabouts, if not the same as the address given
  • The reason the adult is believed to be dependent or vulnerable
  • The dependent adult or elder’s age
  • The nature and extent of the abuse, including evidence of previous abuse
  • Information concerning the suspected adult abuse of any other dependent adults or elders in the same residence
  • Other information that may be helpful in establishing the cause of the abuse or the identity of the person(s) responsible for the abuse or helpful in assisting the dependent adult
  • Reporter’s name and address

Legal Issues for Reporters

An individual participating in good faith by reporting, cooperating, or assisting in evaluating a case of dependent adult of vulnerable elder abuse or participating in a judicial proceeding generally has immunity from liability, civil or criminal, which may have occurred due to the act of making the report or offering assistance. State laws generally prohibit a person or employer from discharging, suspending, or disciplining an individual required to report or who voluntarily reports suspected abuse.

A mandated reporter who is required to report a suspected case of dependent adult abuse and who knowingly and willfully fails to do so is considered to have commited a crime and is subject to prosecution according to applicable state laws. Likewise, a mandated reporter who knowingly interferes with or fails to make a report can be held civilly liable in some states for damages proximately caused by such acts or failures to act.

BARRIERS TO REPORTING

Researchers estimate that only 1 of every 14 incidents of dependent adult abuse actually come to the attention of law enforcement or human service agencies. Dependent adult abuse is one of the most underrecognized and underreported social problems in the United States. It is far less likely to be reported than child abuse because of the lack of public awareness (NCOA, 2017).

There are significant barriers to reporting the abuse of dependent elders.

Professional barriers may exist among those who hold the following beliefs:

  • Reporting abuse will hurt the relationship with the victim.
  • If found out, the abuser will retaliate with more abuse on the victim.
  • Fear of losing a job or position.
  • The reporter will lose work time due to court appearances associated with the case.
  • Nothing will change and everyone involved will get upset.
  • The reporter has not been able to get the state to accept a report before.
  • “I don’t want to get involved” or “It’s none of my business.”
  • Communication barriers (i.e., language or not following principles of good communication).

Victim barriers may cause an abused adult not to report:

  • Lack of confidence
  • Feels as if they somehow deserve the abuse
  • History of prior abuse
  • Fear of retaliation by the abuser
  • Fear of abandonment
  • Cultural beliefs (e.g., “What happens at home is nobody else’s business.”)
  • Embarrassment
  • Shame
  • Vowed to secrecy by the abuser
  • Threats from abuser (e.g., that they will send the victim to a nursing home or withhold food and other necessities)

(Schmeidel et al., 2012)

INTERVENTIONS

Urgent Interventions

If a law enforcement officer has reason to believe that criminal abuse has occurred, the officer will use all reasonable means to prevent further abuse. This may include:

  • Remaining on the scene as long as there is danger to the dependent adult
  • Assisting in obtaining medical treatment for the dependent adult
  • Providing a dependent adult with immediate and adequate notice of the dependent adult’s rights and understanding, such as:
    • “You have the right to ask the court for the following help on a temporary basis:
      • “Keeping the alleged perpetrator away from you, your home, your facility, and your place of work
      • “The right to stay at your home or facility without interference from the alleged perpetrator; and
      • “Professional counseling for you, your family, or household members, and the alleged perpetrator of the dependent adult abuse
    • “If you are in need of medical treatment, you have the right to request that the law enforcement officer present assist you in obtaining transportation to the nearest hospital or otherwise assist you.
    • “If you believe that police protection is needed for your physical safety, you have the right to request that the law enforcement officer present remain at the scene until you and other affected parties can leave or safety is otherwise ensured.”

If the designated state agency further determines that a dependent adult is suffering from abuse that represents an immediate danger to health or safety of the victim and may represent irreparable harm, then the courts may be petitioned to immediately:

  • Remove the dependent adult to safer surroundings
  • Order the provision of medical services
  • Order the provision of available services, including emergency services
  • Terminate a guardianship or conservatorship

Protective Interventions

When a determination has been made that abuse occurred, the appropriate governmental body will act to protect the dependent adult. When there is no way to protect a dependent adult adequately with voluntary services, the court may be petitioned to intervene on behalf of the dependent adult. Court interventions may include such actions as:

  • Authorizing the provision of protective services to a dependent adult suspected of being abused and who lacks the capacity to consent to receipt of such services
  • Prohibiting a caretaker from interfering with the provision of protective services to the victim
  • Ordering the provision of services to the victim who is in immediate threat to health and safety, such as: 1) removal of the dependent adult to safer surroundings; 2) provision of medical services to the dependent adult; and 3) provision of other needed services to the dependent adult
  • Restraining a caretaker from abusing the dependent adult

In some instances, the best interests of the dependent adult may require the court to appoint a guardian or conservator or to admit or commit the dependent adult to an appropriate institution or facility, pursuant to applicable laws and procedures:

  • Conservatorship: When one person is appointed by the court to assume responsibility for custody and control of the property of another (victim)
  • Guardianship: When one person is appointed by the court to make personal and healthcare decisions for another person (victim) who is incapacitated
  • Power of attorney: When one person (the principal) gives to another person (the attorney in fact) the authority to act on the principal’s behalf in one or more matters, including general powers (financial); limited or temporary powers; durable; and healthcare
  • Legal orders: Protective, restraining, and injunctive orders intended to protect the victim from further harm and prevent further abuse
  • Substance abuse/mental health commitment: When a person—either the perpetrator or the victim (from self-neglect)—is committed to a facility or hospital for care and treatment
  • Voluntary services: The provision of social services needed to protect the dependent adult and assist the adult toward independence
CASE
Protective Appointment

Harry Johnson is a 78-year-old retiree who has multiple chronic health problems and dementia. He is being considered for discharge from acute hospital care to home after experiencing complications with his diabetes. His caregiver is his wife of 45 years, Betty.

While the registered nurse, Anita, was doing the discharge planning for Harry, she discovered that Betty does not want Harry to return home because his dementia has caused Harry to have violent outrages targeted at her. Betty shared with Anita that at one point Harry had thrown her to the ground, breaking her ankle, and while she was on the ground, he punched her in the head and threatened to kill her. Betty stated she had not called the police or told anyone of Harry’s violent behavior, since he had threatened to kick her out of the house if she said anything. She was now afraid for her own well-being and life.

As a mandatory reporter, Anita promptly reported the incident to the Department of Human Services and also notified her supervisor and Harry’s doctor of the circumstances. In reviewing the information with Betty, the doctor concluded that Harry would be better off getting assistance with his violent behaviors and other care needs at a facility providing long-term dementia care, where he would receive more supervision. This would also provide Betty with the safety and consolation she needed. While Harry was at the care facility, the DHS would be able to continue with their investigation into the matter.

The doctor and interdisciplinary team made the coordinating arrangements with a facility close to the Johnson’s home so Betty could conveniently visit Harry. As a result of the DHS evaluation, the court determined that Harry should be committed to the care facility and not be returned to his home.

RIGHT TO SELF DETERMINATION

All adults have a right to self-determination. This means that the dependent adult can refuse services unless a court determines that the person is not competent to make decisions or is threatening his or her own life or that of others (EAPU, n.d.).

PREVENTION EFFORTS

Since so few incidents of abuse against dependent adults are ever reported, preventing dependent adult and elder abuse in the first place is particularly important. Appropriate prevention interventions must include legislation, education, respite, social support, perpetrator interventions, and money management programs (Daly, 2011).

  • Legislation. Statistics have shown that states requiring public education regarding dependent adult abuse correlate with higher abuse report rates, suggesting that heightened public awareness increases reporting of the abuse. Also, states that mandate reporting had a significantly higher investigation rate.
  • Education. Educating older adults, professionals, caregivers, and the public on abuse is critical to prevention.
  • Respite. Adult day care respite, in-home respite, and institutional respite ¬†programs can help reduce the stress and strain placed on those caring for dependent adults, thereby helping to prevent dependent adult abuse.
  • Social Support. Individual psychosocial interventions for long-term caretakers have been found helpful in alleviating caretaker stress.
  • Perpetrator Interventions. Programs with this focus include assisting the perpetrator to confront their attitudes about control, learn anger-management skills, engage in cognitive therapy, or a combination of these.
  • Money Management Programs. In order to prevent financial exploitation, these programs have been tried, with marginal success. If dementia or other cognitive issues are involved, medical intervention is suggested.
A MODEL PREVENTION PROGRAM

The Iowa Department on Aging administers the Elder Abuse Prevention and Awareness Program to address the problem of dependent adult abuse, neglect, and exploitation. Educating older adults, professionals, caregivers, and the public on elder abuse is critical to prevention. This program provides and develops education programs and policies that can assist in the prevention of elder abuse in Iowa (IA DoA, 2017a).

In order to meet its prevention goal, the Department on Aging distributes funds to Area Agencies on Aging in order to:

  • Employ elder rights specialists
  • Counsel families who are concerned about the safety or well-being of a loved one
  • Develop personalized intervention plans to reduce identified risks
  • Provide information about and referrals to appropriate protective service agencies.

Iowa produces a “Plan on Aging” on a three-year basis, with the FY 2018–2021 plan incorporating promoting healthy lifestyles, aging in place, abuse prevention of dependent adult Iowans, and protecting and preserving their rights (IA DoA, 2017b).

Older adults can also take preventive actions to help themselves stay safe from abuse. Recommendations include:

  • Take care of your health.
  • Seek professional help for drug, alcohol, and depression concerns and urge family members to get help for these problems.
  • Attend support groups for spouses and learn about domestic violence services.
  • Plan for your own future. With a power of attorney or a living will, you can address healthcare decisions now to avoid confusion and family problems later. Seek independent advice from someone you trust before signing any documents.
  • Stay active in the community and connected with friends and family. This will decrease social isolation, which has been connected to elder abuse.
  • Post and open your own mail.
  • Do not give personal information over the phone.
  • Use direct deposit for all checks.
  • Have your own phone.
  • Review your will periodically.
  • Know your rights. If you utilize the services of a paid or family caregiver, you have the right to voice your preferences and concerns.
    (IA DOJ, 2017)

CONCLUSION

Healthcare professionals have an ethical, moral, and legal responsibility to understand and address the complexities of dependent adult abuse. Community service agencies, care facilities, clinics, and other healthcare centers are ideal places to embed the frameworks presented here for assessing and identifying dependent adults who are at risk for abuse.

Nurses and other professionals serve as advocates for all those in their care, including the most vulnerable. It is through education and interdisciplinary teamwork that mandated reporters can provide a compassionate and quick response to suspected abuse in order to protect the safety and well-being of the dependent adults within our communities and facilities.

RESOURCES

Adult Abuse Hotline
800-222-8000

Adult protection statutes (by state)

Elder Locator Helpline (to self-report abuse)
800-677-1116

Mandatory reporting statutes (by state)

National Adult Protective Services Association

National Center on Elder Abuse

National Long-Term Care Ombudsman Resource Center

Suspected Dependent Adult Abuse Report (sample form) (Iowa Department of Human Services)

REFERENCES

NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.

Acierno R, Hernandez M, Amstadter A, Resnick H, Steve K, Muzzy W, & Kilpatrick D. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–7. Doi:10.2105/AJPH.2009.163089

Administration on Aging (AoA). (2016). Profile of older Americans: 2015. Retrieved from https://www.acl.gov

Administration for Community Living (ACL). (2018). Long-term care ombudsman program. Retrieved from https://acl.gov

American Society on Aging (ASA). (2016). Social media abuse in long-term care is just the tip of the iceberg. Retrieved from http://www.asaging.org

Amstadter A, Cisler J, McCauley J, Hernandez M, Muzzy W, & Acierno R. (2011). Do incident and perpetrator characteristics of elder mistreatment differ by gender of the victim? Results from the National Elder Mistreatment Study. Journal of Elder Abuse and Neglect, 23(1), 43–57. Doi:10.1080/08946566.2011.534707

Baladerian N, Coleman T, & Stream J. (2013). Abuse of people with disabilities: victims and their families speak out. Los Angeles: Spectrum Institute. Retrieved from http://disability-abuse.com/

Boltz M, Capezuti E, Fulmer T, & Zwicker D. (2016). Evidence-based geriatric nursing protocols for best practices (5th ed.). New York: Springer Publishing Co.

Burston G. (1975). Letter: granny-battering. British Medical Journal, 3, 592. Retrieved from https://www.ncbi.nlm.nih.gov

Connolly M, Brandl B, & Breckman R. (2014). The elder justice roadmap: a stakeholder initiative to respond to an emerging health, justice, financial, and social crisis. National Center on Elder Abuse. Retrieved from https://vawnet.org

Daly J. (2011). Evidence-based practice guideline: elder abuse prevention. Journal of Gerontological Nursing, 37(11), 11–7.

Elder Abuse Prevention Unit (EAPU). (n.d.). Rights of older people. Retrieved from http://www.eapu.com.au

End Abuse Late in Life (EALL). (2017). Dynamics of abuse later in life. Retrieved from https://www.eallsav.org

Hoover R & Polson M. (2014). Detecting elder abuse and neglect: assessment and intervention. American Family Physician, 89(6), 453–60. Retrieved from http://www.aafp.org

Iowa Department of Justice (IA DOJ). (2017). Preventing elder abuse. Retrieved from https://www.iowaattorneygeneral.gov

Iowa Department on Aging (IA DoA) (2017a). Elder abuse prevention & awareness. Retrieved from https://www.iowaaging.gov

Iowa Department on Aging (IA DoA) (2017b). Iowa state plan on aging: federal fiscal years 2018–2021. Retrieved from https://www.iowaaging.gov

Jett K. (2014). Economic and legal issues. In Ebersole & Hess, Gerontological nursing & healthy living, pp. 361–74, St. Louis: Elsevier and Mosby.

Legal Information Institute (LII). (2008). U.S. Code, title 42, chapter 26, 12102—definition of disability. Retrieved from https://www.law.cornell.edu

Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University, & New York City Department for the Aging. (2011). Under the radar: New York State elder abuse prevalence study. Retrieved from https://ocfs.ny.gov

National Center on Elder Abuse (NCEA). (2012). Abuse of residents of long-term care facilities. Retrieved from http://www.ncea.aoa.gov

National Center on Elder Abuse (NCEA). (n.d.-a). Research. Retrieved from https://ncea.acl.gov

National Center on Elder Abuse (NCEA). Types of abuse. (n.d.-b). Retrieved from https://ncea.acl.gov

National Council on Aging (NCOA). (2017). Elder abuse facts. Retrieved from https://www.ncoa.org

Salsbury SA. (2011). Clinical brief: recognizing, reporting and responding to dependent adult abuse. Integrative Health: International Journal, 2(3), 1–5. Retrieved from http://www.tihcij.com

Schmeidel A, Daly J, Rosenbaum M, Schmuch G, & Jogerst G. (2012). Healthcare professionals’ perspectives on barriers to elder abuse detection and reporting in primary care settings. Journal of Elder Abuse and Neglect, 24(1), 17–36. Retrieved from https://www.ncbi.nlm.nih.gov

Touhy T & Jett K. (2016). Common legal and ethical issues. Ch. 31 in Ebersole & Hess, Toward healthy aging: human needs and nursing response. St. Louis: Elsevier.

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