International Council of Nurses [Fact Sheet

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ELDER ABUSE
Elder abuse is a violation of human rights and a significant cause of injury, illness, lost productivity, isolation and despair.ⁱ

What is elder abuse?
Elder abuse is an act or omission that results in harm or threatened harm to the health or welfare of an older person.ⁱⁱ There are three common categories of elder abuse: domestic, institutional and self-neglect. The four common kinds of elder abuse are:

Physical abuse, the infliction of physical pain or injury, e.g. slapping, bruising, sexually molesting, restraining (approx. 20%).

Psychological abuse, the infliction of mental anguish, e.g. humiliating, intimidating, threatening (approx. 20%).

Financial abuse or exploitation, the misuse of someone's property and resources by another person (approx. 20%).

Neglect, failure to fulfil a care-taking obligation to provide goods or services, e.g. abandonment, denial of food or health-related services (approx. 40%). ⁱⁱⁱ This category may also include self-neglect.

Statistics

Because of differing definitions, poor detection and under-reporting (est. 4 out of 5 cases never reported), the extent of elder abuse is unknown. The prevalence rates presented in published studies range from 1-10%. Studies have shown that people of all socio-economic, ethnic, and religious backgrounds are vulnerable to abuse, including countries where the family's traditional systems of care exist, e.g. Asia, Africa.^ivWhere community violence is endemic, older people are often victims because of their greater vulnerability, e.g. Jamaica, South Africa. ^v Countries in transition often see an upsurge in levels of crime in some communities, and again vulnerable older people can easily become its victims.

Indicators of physical abuse: multiple injuries in various stages of healing, multiple fractures in various stages of healing, bruises clustered together and in regular patterns, bilateral bruises or parallel injuries, injuries in the "bathing suit" zone, injuries around the face, ears and neck, burns, rope burns, patterned injuries (e.g. belt buckle), sprains or dislocations, patchy hair loss, and frequent visits to the emergency department.

It is estimated that in the United States, 1.5 - 2-5 million older persons suffer from abuse each year (4-10%). ^vi Similarly, in Ontario (Canada), 4 - 10% of older persons have experienced or are experiencing abuse of some kind. ^vii During a two-year review ending in January 2001, more than 30% of the 5 283 nursing homes in the US investigated were cited for abuse violations, nearly 10% of the abuses resulting in serious injury or death.^viii Most cases of abuse are committed in domestic rather than institutional settings ^ix. In almost nine out of 10 incidents of domestic elder abuse and neglect, the perpetrator is a family member.^x The reported perpetrators are most likely to be children (50%), spouses (13%), siblings, relatives or paid caregivers.

The oldest elders (80 and over) are abused and neglected at two to three times their proportion of the elderly population. Female elders are abused at a higher rate than males while perpetrators tend to be male. Almost half of the abused and neglected older persons are not physically able to care for themselves. ^xi
Perpetrators

As mentioned, the most likely perpetrators of abuse are male and persons well acquainted with or in continual contact with the dependent individual. These could be family or non-family members who become caregivers, spouses or significant others, or professional caregivers. Abuse by a caregiver can be aggravated by "psychopatholgy (a pathologic need of the perpetrator to control another human being), trans-generational violence, dependency, or by more fundamental factors such as stress, ignorance, frustration or desperation, and an inability to provide adequate care. Other potential variables include the environment in which the older person lives and the financial relationship, if any, between caregiver and patient."^xii

Indicators of neglect: deterioration of health, dehydration/malnutrition, pressure ulcers or contractures, excessive dirt and odour on the body or clothing, missing or broken assistive devices (e.g. glasses, dentures), cachexia (severe wasting), inappropriate dress, presence of fleas or lice, urine burns, listlessness and fatigues, over/under medication (especially over-sedation) and any indication that the older person was left in an unsafe situation or alone for long periods.

Screening
Diagnosis of elder abuse depends on acquiring a detailed history from the patient and the caregiver. A thorough physical exam - including scrutiny of the musculoskeletal system and skin - and a detailed psychosocial assessment are the best tools for revealing signs of abuse. Neurologic and psychological testing should be used to help identify emotional abuse or caregiver/self-neglect, which may produce few obvious signs of mistreatment. The signs and symptoms of normal ageing, disease pathology, and functional limitations must be identified and differentiated from possible consequences of abuse.
Ironically, physicians and law enforcement professionals exhibit the lowest frequency of reporting abuse (2% by physicians). Reasons for this low rate include: 'victim denial', few accurate and reliable protocols for identifying abuse in the clinical setting, ignorance of mandatory reporting laws, vague and ambiguous reports by the patient, strong fear of offending patients, feelings of inadequacy in discussing interventions, and time constraints." ^xiii

Indicators of financial abuse: unexplained loss of pension checks, anxiety about personal finances, lack of knowledge about financial status, unpaid bills, checks being signed by another person without permission, pressure to endorse checks, failure to provide contracted services, lack of adequate food and medications, unanswered mail, and uncashed checks. ^xiv

Prevention
Addressing and reducing elder abuse requires a multisectoral, multidisciplinary approach involving justice officials, law enforcement officers, health and social service workers, labour leaders, spiritual leaders, religious institutions, advocacy organisations and older people themselves. Multidisciplinary teams have demonstrated their effectiveness. These teams typically include geriatricians, social workers, case management nurses, community nurses and representatives from legal, financial and adult protective services. Multidisciplinary teams are often more effective in problem-solving and provide a forum for discussion with participants involved in the care of the older adult and senior advocacy volunteer groups.^xv

Indicators of emotional abuse: confusion/disorientation, paranoia/depression/anger, fear of strangers, exhibiting fear in own environment, ambivalence toward caregiver, being quiet when caregiver is in the room, low self-esteem, and hunger for attention and socialisation.

One example presented in the literature, the State Elder Abuse Prevention Programme (US), focuses elder abuse prevention activities in four areas:

Professional training, e.g. workshops designed to introduce specific professional groups (e.g. law enforcement) to ageing and elder abuse issues; skill-building workshops for adult protective services personnel; conferences open to all service providers with an interest in elder abuse; and development of training manuals, videos, and other materials.

Coordination among state service systems and among service providers, e.g. creation of elder abuse hotlines for reporting; formation of state-wide coalitions and task forces; and creation of local multidisciplinary teams, coalitions, and task forces.

Technical assistance, e.g. development of policy manuals and protocols that outline the proper or preferred procedures.

Public education, e.g. development of elder abuse prevention curriculum for elementary and secondary students; development and delivery of elder abuse prevention public education campaigns, including radio and television public service announcements, posters, flyers and videos with training materials suitable for use with community groups. ^xvi

Other reported initiatives specifically addressing institutional care include: increased funding to nursing homes; mandatory nurse staffing levels; stricter sanctions on homes with below par standards; criminal background checks on employees; and increased Internet access to records of nursing home conditions. ^xvii In addition, approaches have focused on the empowerment of older persons, providing training for paralegals to advocate for the more vulnerable, respite services, support day-care services, intergenerational education campaigns, and finally an improved material security and well-being of the whole community.
Nurses' role in eliminating elder abuse
Nurses as professional health care providers and patient advocates have a role to play in safeguarding the health, dignity and security of older persons. Through direct service delivery, screening measures, and health promotion efforts, the nurse can identify victims and older persons at risk of abuse. While promoting health and providing medico-social support, the nurse (in partnership with others) can document cases of elder abuse, minimise the physical and mental consequences of elder abuse on the victims, and set in motion the process to reduce the incidence and prevalence of elder abuse.
ICN references: Position Statement Nursing Care of the Older Person
Fact sheet: ICN on Healthy Ageing: A Public Health and Nursing Challenge

For further information please contact
ICN at

Fact sheet/Elder Abuse

i WHO (2001) Health and Ageing - A Discussion Paper. WHO: Author

ii American Medical Association

iii Elder Abuse Prevention (2001) Administration on Aging - Elder Abuse Prevention. USA: National Aging Information Center

iv SAMHSA (2001) Violence Against the Elderly. The National Clearinghouse for Alcohol and Drug Information. July 26

v WHO (1999) Violence and Health. Kobe: Author

vi SAMHSA (2001) Violence Against the Elderly. The National Clearinghouse for Alcohol and Drug Information. July 26

vii CNW (2001) Province takes steps to end elder abuse. Government of Ontario Press Releases. Toronto. November 16

viii E. Trapps, T. (2001) Report : Nursing home abuse rising. Los Angeles Times. July 31

ix Marshall, Charles E. (2000) Elder abuse: Using clinical tools to identify clues of mistreatment. Geriatrics. February

x The National Elder Abuse Incidence Study (2001) Conclusions - Executive Summary

xi The National Elder Abuse Incidence Study (2001) Conclusions - Executive Summary

xii Marshall, Charles E. (2000) Elder abuse: Using clinical tools to identify clues of mistreatment. Geriatrics. February

xiii Marshall, Charles E. (2000) Elder abuse: Using clinical tools to identify clues of mistreatment. Geriatrics. February

xiv Gray-Vickrey, Peg (2000) Protecting the older adult. Nursing. July

xv Swagerty, Daniel L. (1999) American Family Physician. Elder Mistreatment. May 15

xvii Elder Abuse Prevention (2001) Administration on Aging - Elder Abuse Prevention. USA: National Aging Information Center

xviii E. Trapps, T. (2001) Report : Nursing home abuse rising. Los Angeles Times. July 31

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