Increase The Involvement of Caretakers in Geriatric Care
Who Are Caretaker
Enhance the involvement of members of the patient’s support system,
including family and friends identified by the patient, community based groups,
support groups, appropriate clergy, or organizational groups such as senior
centers.
Support the development of coping mechanisms, including
modifications in social, housing, and recreational environments, to minimize
associations with settings and groups in which substance use and abuse are
common (USDHHS, 2004a).
Counseling and Psychotherapy
Older persons tend to seek care from their primary care, medical
specialist, or nurse/ nurse practitioner provider even regarding assistance
with mental health and substance-related problems.
This practice derives from long-held beliefs that depression or
anxiety indicates weakness or lack of character.
Older people, more than others, stigmatize the excess use of
alcohol or use of an illicit drug and problems with prescription drugs.
Counseling done by the nurse using a brief intervention model or
supportive counseling is more readily acceptable to older patients than
referral to mental health or substance abuse clinics.
Optimally, short-term psychotherapy by a practitioner with
education about abuse and addiction is extremely helpful. The model of cognitive
behavioral therapy, in particular, has demonstrated good outcomes with
excessive drinking and marijuana use (Cooney, Babor, & Litt, 2001).
These approaches assist the older person to modify behavior and to
deal with negative feelings and/or chronic pain that often motivate use.
Treatment Outcomes
Health care providers and older persons may feel pessimistic about
the possibilities of changing their substance use behavior. Health providers
often do not intervene because they believe that older people do not change.
Treatment outcomes for older persons with substance use problems, however, have
been shown to be as good as or better than those for younger people (USDHHS,
2004b). Good treatment outcomes, however, can be compromised by inconsistency
of follow-up and limited access to aftercare for community dwelling older
adults physical assessment.
Their presence at the patient’s bedside affords
nurses the opportunity for direct contact with caregivers, firsthand
observations of caregivers’ interactions with patients, and identify red flags
(Cohen, Halevi-Levin, Gagin, & Friedman, 2006).
These factors place nurses
in the unique and difficult role to assess, identify, and act in cases of EM
more often than other members of interdisciplinary health care teams.
Nursing has had a long history in ensuring high standards of care
for older adults. The identification of EM should not be the exception. In
spite of this, nurses’ lack of training and knowledge of the extent of EM and
its presentation may hinder their ability to identify the signs of
mistreatment.
Abuse is often multifactorial; therefore, it is important to
recognize that it is an interplay between characteristics of the abused, the
perpetrator, and environmental factors (Killick & Taylor, 2009). Physical
markers of abuse are often incorrectly attributed to physiological changes in
the elderly rather than EM (Wiglesworth et al., 2009).
Cases of EM can prove to
be challenging for nurses as it is often complicated by denial on the part of
the perpetrator and older adult, refusal of services by victims, as well as
fears that an accusation of EM may actually worsen abuse.
Serious ethical
dilemmas may arise because a nurse may struggle between his or her obligation
to ensure the patient’s well-being and uncertainty over presence of EM
(Beaulieu & Leclerc, 2006).
The development of EM protocols that are
grounded in evidence-based research is crucial to ensure that EM cases are
properly handled by nurses and other health care professionals.
Background Of Problem
Recent data suggest that in the United States, more than 2 million
older adults suffer from at least one form of EM each year (National Research
Council (NRC), 2003). The National Elder Abuse Incidence Study estimated that
more than 500,000 new cases of EM occurred in 1996 (National Center on Elder
Abuse [NCEA), 1998).
A recent study by Acierno and colleagues (2010) estimated
the prevalence of MS within a 1-year period to be approximately 11%. Although
44 states and the District of Columbia have legally required mandated
reporting, EM is severely underreported. There is a lack of uniformity across
the United States on how cases of EM are handled.
Cases of EM are managed
differently state by state with varying methods of investigation and intervention
(Jogerst et al., 2003). NCEA (1998) estimates that only 16% of cases of abuse
are actually reported.
In a systematic review, one-third of health care
professionals included believe they had detected a case of EM; however, only
about 50% had actually reported the case (Cooper, Selwood & Livingston,
2009).
Similarly, another study found that despite 68% of emergency medical
services staff surveyed stating they felt they had encountered a case of EM in
the past year, only 27% had actually made a report (Jones, Walker, &
Krohmer, 1995).
Despite mandatory reporting on the part of health care
professionals, it is believed that many are not reporting all cases of EM that
they detect (Killick & Taylor, 2009).
This creates several issues in terms of obtaining an accurate sense
of the scope of EM in the country and may have serious detrimental effects for
the older adults suspected of being victims of EM.
Conflicting theories of causation and lack of uniform screening
approaches have further complicated EM detection. Understandably, it has been
difficult for nurses to adequately respond to cases of EM when they are unclear
about its manifestations, causes, and detection strategies.
EM researchers
agree that as the population continues to age exponentially, cases of EM will
reach epidemic levels. A lack of universally accepted definitions for different
types of EM has hampered efforts to ascertain what constitutes EM.
In an effort
to establish a clear consensus, the NRC (2003) defined elder mistreatment as
either “intentional actions that cause harm or create serious risk of harm
(whether harm is intended) to a vulnerable elder by a caregiver or other person
who is in a trust relationship to the elder,” or “failure by a caregiver to
satisfy the elder’s basic needs or to protect himself or herself from harm.”
Types of Elder Mistreatment
Six types of mistreatments are generally included under the term
EM. Table 27.1 describes each form of EM as well as examples of each.
The use of the term mistreatment rather than abuse further
underscores a crucial feature of EM; that EM is the outcome of the actions
abuse, neglect, exploitation, or abandonment.
Abuse and neglect can then be
further classified as intentional or unintentional. Intentional neglect might
be seen as a conscious disregard for caretaking duties that are inherent for
the well-being of the older adult.
Unintentional neglect might occur when
caregivers lack the knowledge and resources to provide quality care
(Jayawardena & Liao, 2006). Neglect, whether intentional or unintentional,
is recognized as the most commonly occurring form of EM, NCEA (1998) revealed
that neglect accounts for approximately half of all cases of EM reported to
Adult Protective Services (APS). About 39.3% of these cases were classified as self-neglect
and 21.6% attributed to caregiver neglect. including both intentional and
unintentional.
More than 70% of cases received by APS are attributed to cases
of self-neglect with those older than 80 years thought to represent more than
half of these cases (Lachs & Pillemer, 1995).
There is much debate as to whether self-neglect should be included
as a type of EM. Although other forms of EM occur because of the action or
inaction of an outside perpetrator, in self-neglect, the perpetrator and victim
are one and the same (Anthony, Lehning, Austin. & Peck, 2009).
Several
international studies studying perceptions of EM identified caregiver neglect
as the most common and accepted form of EM among participants (Daskalopoulos
& Borrelli, 2006; Mercurio & Nyborn, 2006; Oh, Kim. Martins, & Kim,
2006; Stathopoulou, 2004; Yan & Tang, 2003).
Subjects identified family
members as the caregivers more likely to be perpetrators. Shockingly, neglect
was seen as a “quasi-acceptable” form of abuse, whereas physical and emotional/psychological
abuses were viewed as extreme and harsh.
Theories of Elder Mistreatment
The concept of vulnerability has been central to the discussion of
EM. Fulmer and colleagues (2005) conducted a study of older adult patients
recruited through emergency departments in two major cities.
The goal was to
identify factors within the older adult-caregiver relationship that may
predispose some older adults to be victims of neglect over others. The
theoretical framework of the study is the risk-and-vulnerability model, which
posits that neglect is caused by the interaction of factors within the older
adult or in his or her environment.
The risk and vulnerability model adapted to
EM by Frost and Willette (1994) provides an appropriate model through which to
examine EM (Frost & Willette, 1994; Fulmer et al., 2005). Vulnerability is
determined by characteristics within the older adult that may make him or her
more likely to be victims of EM such as poor health status, impaired cognition,
history of abuse, and so forth.
Risks refer to factors in the external
environment that may predispose to EM. These may include characteristics of
caregivers such as health status and functional status, as well as a lack of
resources and social isolation (Fulmer et al., 2005).
It is the interaction
between risk and vulnerability that can predispose some older adults to MS
(Killick & Taylor, 2009; Paveza, Vanderweerd, & Laumann, 2008).
The risk and vulnerability model as well as other theories from the
literature on family violence have been adapted from the health and social
sciences literature in an effort to find probable theories for EM.
However,
there has been no clear consensus on one theory that explains EM (Fulmer,
Guadagno, Bitondo Dyer, & Connolly, 2004). The development of assessment
interventions and strategies that cross multiple theoretical frameworks is
likely to be the most clinically appropriate strategy (NRC, 2003).
Theories of EM Include but are not limited to the Following
1. Situational theory: Promotes the idea that EM is a result of
caregiver strain due to the overwhelming tasks of caring for a vulnerable or
frail older adult (Wolf, 2003).
2. Psychopathology of the abuser Abuse is
believed to stem from a perpetrator’s own battle with psychological illness
such as substance use, depression, and other mental disorders (Wolf, 2003).
3. Exchange theory: Speculates that the long-established dependencies present in
the victim-perpetrator relationship are part of the “tactics and response
developed in family life, which continue into adulthood” (Wolf, 2003).
4.
Social learning theory: Attributes EM to learned behavior on the part of the
perpetrator or victim from either their family life or the environment; abuse
is seen as the norm (Wolf, 2003).
5. Political economy theory. Focuses on how
older adults are often disenfranchised in society as their prior
responsibilities and even their self-care is shifted on to others (Wolf, 2003).
Dementia and Elder Mistreatment
Older adults with dementia are particularly vulnerable to EM. As
the population of older adults increases, it is expected that so will the
number of older adults with dementia (Wiglesworth et al., 2010).
It is
estimated that older adults with dementia will rise from 4.5 million in 2000 to
13 million by the year 2050 (Hebert, Scherr, Bienias, Bennett, & Evans,
2003).
Because of the cognitive deficits present in older adults with dementia,
it is particularly difficult to screen for EM. The older adult may not be able
to give a reliable history, and signs of EM may be masked or mimicked by
disease (Fulmer et al., 2005).
Those providing care for older adults with
dementia are at particular risk for caregiver strain and burnout.
Disruptive
behavior such as screaming or wailing, physical aggression, or crying can be
exhausting for caregivers in any setting (Lachs, Becker, Siegal, Miller, &
Tinetti, 1992).
One study reported that as many as 47% of older adults with
dementia were victims of some form of EM (Wiglesworth et al., 2010). The
researchers used a combination of two screening instruments as well as a
caregiver self-report.
Similarly, in a systematic review, one-third of
caregivers of older adults with dementia were willing to admit to some form of
EM, whereas 5% admitted to physical abuse (Cooper, Selwood, & Livingston,
2008).
In a community-based study of caregivers of older adults with dementia,
51% of caregivers admitted to verbal abuse and 16% to physical abuse. However,
only 4% admitted to neglect (Cooney, Howard, & Lawlor, 2006). The
ramifications of these data are sobering.
If 30% will admit to EM, there is
every reason to worry regarding EM in those who do not report. Objective
assessment alone cannot capture all cases of EM and, thus, a policy is needed
that incorporates both objective measures as well as a discussion with both the
older adult and caregiver (Cooper et al., 2008).
Most caregivers are
forthcoming with admission of EM and many of them ask for help in developing
coping strategies and plans of care to provide better care for care recipients
(Wiglesworth et al., 2010).
Assessment
The American Medical Association (AMA, 1992) released a set of
guidelines and recommendations in 1992 on the management of EM. The AMA urged
providers that all older adults should be screened for EM. Many hospitals
already include EM screening as part of the admission process for all patients
older than 65 years old. Assessment of EM is not an easy task.
Subtle signs of
EM are hard to identify and even harder to substantiate (Anthony et al., 2009).
Rates of reporting on the part of health care professionals are still low due
in large part to ageism in society and lack of education and training on the
assessment, detection, and reporting of EM.
Unsubstantiated fears exist that
increasing education on assessment of EM will lead to higher rates of false
positive cases and, therefore, expense and disruption in the system.
However, a
systematic review of 32 studies revealed that health care professionals
educated about EM were not more likely to detect EM cases but were more
inclined to report detected cases than those that had little or no education
related to EM (Cooper et al., 2009 ).
The complexity and variability of most cases of EM makes it hard to
describe what a typical perpetrator or a victim looks like. There is no
correlation found between age. gender, race, and any association with MS
(Krienert, Walsh, & Turner, 2009). Hence, it is difficult to describe who
is a “typical” victim or perpetrator of EM.
Some research suggests that victims
of MS are more likely to be unable to provide for self-care needs on their own
because of cognitive or physical deficits and have a history of depression
(Giurani & Hasan, 2000).
In a small scale, victims of EM had lower scores
on cognitive screens using the mini mental status exam (MMSE) and greater
functional deficits as scored with the Katz Index of Independence in ADL.
They
also had higher rates of depression when screened with the Geriatric Depression
Scale (GDS) scores (Dyer, Pavlik, Murphy, & Hyman, 2000). These studies
support carlier findings from a longitudinal study on factors influencing
mortality of victims of MS (Lachs, Williams, O’Brien, Pillemer, & Charlson,
1998).
Others (Draper et al., 2008; Fulmer et al., 2005) have also identified a
link between childhood abuse among victims and physical and sexual EM later in
life. A lack of social support and social isolation increase the risk for MS in
older adults (Acierno et al., 2010; Dong & Simon, 2008; Fulmer et al.,
2005).
Research suggests perpetrators are more likely to be family
members, report greater caregiver strain, live with the victim, have a history
of mental illness and/or depression, history of substance abuse, have lived
with the victim for an extended time (approximately 9.5 years ), have few
social supports, and have a long history of conflicts with the victim (Cowen
& Cowen, 2002; Giurani & Hasan, 2000; Wiglesworth et al., 2010).
In the clinical setting while conducting an EM screen, it is
recommended to separate the older adult from the caregiver and obtain a
detailed history and physical assessment ment (Heath & Phair, 2009).
Special attention should be paid to both physical and psychological signs of
EM.
Discrepancies between injury presentation or severity and the report of how
the injury occurred as well as discrepancies between explanations from the
caregiver and older adult should be paid close attention. Physically abused
older adults are more likely to have significantly larger bruises and to know
the cause of their bruise.
Furthermore, these abused older adults are more
likely to display bruising on the face, lateral aspect of the right arm and the
posterior torso (including back, chest, lumbar, and gluteal regions;
Wiglesworth et al., 2009).
Other possible indicators of physical abuse include
bruises at various stages of healing, unexplained frequent falls, fractures,
dislocations, burns, and human bite marks (Cowen & Cowen, 2002).
It is important to distinguish that signs and symptoms of EM may
vary depending on the type of abuse.Victims of sexual abuse are more likely to be
female and exhibit “genital or urinary irritation or injury; sleep disturbance;
extreme upset when changed, bathed, or examined; aggressive behaviors;
depression; or intense fear reaction to an individual” (Chihowski & Hughes,
2008, p. 381).
Ageist attitudes among health care professionals may limit the
number of cases of sexual abuse that are identified as older adults are rarely
thought of as the usual victims of abuse (Vierthaler, 2008). Victims of financial
abuse are harder to identify; however, they share similar traits such as social
isolation, physical dependency, and mental disorders as victims of emotional or
psychological abuse and neglect (Peisah et al., 2009).
Since the 1970s, a
myriad of screening instruments have been developed to detect cases of EM, but
few are appropriate for inpatient older adults. Most have had limited testing
in the acute care setting and focus on in-home assessments or extensive
questions that are better suited for primary care settings.
The Elder Assessment Instrument (EAI) developed by Fulmer and
colleagues (2004) is a 41-item screening instrument that requires training on
how to administer it but has been proven effective in busy hospital settings
(Perel-Levin, 2008).
The current EAI-R (revised in 2004) is considered more
appropriate for inpatient and outpatient clinics because it relies on objective
assessment by the clinician such as general appearance, assessment for
dehydration, physical and psychological markers, or pressure ulcers as well as
subjective information received from the patient.
The Hualek Sengock Elder
Abuse Screening Test (HS-EAST) is a 15-item instrument that relies on
self-report from older adults and is documented as appropriate for detecting
physical abuse, vulnerability, and high-risk situations. Some instruments focus
on the care giver, but an advantage of HS-EAST is the focus on the older adult
history.
It is regarded as appropriate for use in the hospital setting and can
be easily administered by nurses (Fulmer et al., 2004; Perel-Levin, 2008). If a
positive screen is noted, detailed physical assessment and medical history
should be completed to substantiate possible abuse. Referral to experts in
trauma or geriatrics, either on or off site, should take place for the best
available input.
In addition to these screening instruments for EM, there are a
number of other reliable and valid instruments that can aid nurses in
identifying those at risk for EM. As discussed previously, victims of EM tend
to have lower functional and cognitive abilities than their counterparts.
The
Katz Index of Independence in ADL and/or the Lawton instrumental activities of
daily living (IADL) scale may help in detecting older adults with functional
deficits (Graf, 2007: Wallace, 2007). Similarly, with higher rates of
depression in victims of EM, the GDS may be a useful instrument for nurses to
use in the hospital setting.
It is a 15-item screening instrument that is
effective at distinguishing depressed older adults (Kurlowicz & Greenberg,
2007). In the literature, perpetrators of EM often report higher caregiver
strain. The Modified Caregiver Strain Index (CSI) is a reliable and
self-administered instrument that can aid in assessing caregivers that may
benefit from intervention strategies to alleviate stress involved with
caregiving demands (Sullivan, 2007).
The process of identifying cases of self-neglect is often even more
daunting than other cases of EM. Assessing self-neglect is further complicated
by a lack of standardized screening instruments or markers for detection (Dyer
et al., 2006; Kelly, Dyer, Pavlik, Doody, & Jogerst, 2008; Mosqueda et al.,
2008). Several researchers are currently developing screening instruments for
self-neglect.
However, their use in the acute care setting is limited. Most
require in-depth assessments of home life and are based mostly on objective
findings from the health care professional. However, data suggests that
detection of self-neglect in the hospital setting is unfortunately made easier
because by the time these cases reach the hospital, they are often very severe
(Mosqueda et al., 2008).
Signs of self-neglect may include lack of adequate
nutrition such as dehydration: changes in weight: poor hygiene and appearance
such as soiled clothing, uncombed hair, debris in teeth; poor adherence to
medical treatments such as unfilled prescriptions; refusing to perform dressing
changes, poor glucose monitoring, and so forth (Cohen et al., 2006; Naik, Teal,
Pavlik, Dyer, & McCullough, 2008).
Objective measures as well as
questioning of the older adult about health patterns and activities of
self-care are also important factors in detecting self-neglect because it can
yield important information about attitudes and opinions of the older adult.
Interventions And Care Strategies
Detailed screening of older adults at risk for EM is the first step
in identifying cases of EM (Perel-Levin, 2008). There are various screening
instruments that can help in revealing older adults and caregivers at risk for
EM. Setting aside time to meet with the older patient and their caregiver
separately is an important aspect of the screening process.
This can highlight
any inconsistencies in depictions of how injuries occur, allow the nurse to
develop a closer relationship with each, as well as express his or her
willingness to help each party. Nurses should not work alone in detecting cases
of EM but, instead, should include professionals from other disciplines as much
as possible.
According to the literature when EM is suspected, the use of
interdisciplinary teams with professionals from both the acute care and
community settings is the best approach to managing such cases (Wiglesworth,
Mosqueda, Burnight, Younglove, & Jeske, 2006).
Institutions should develop
clear guidelines for practitioners to follow when cases of EM are identified
(Perel-Levin, 2008). Referral to appropriate community organizations is
paramount to ensure safe discharges for suspected victims of EM.
Interdisciplinary teams work best when they include team members with expertise
in various disciplines including nursing, social work, law, and so forth. It is
this diversity of skills that allows for innovative approaches to managing
cases of EM (Jayawardena & Liao, 2006).
Educating older adults, staff, and caregivers about the nature of
EM is key. It is crucial to educate older adults who have the cognitive
capacity to accept or refuse interventions about patterns of EM such that abuse
tends to increase in severity over time (Cowen & Cowen, 2002; Phillips, 2008).
For individuals who lack the cognitive capacity to consent for interventions,
it is important to report these cases to APS and develop a plan for safe
discharge. Older adults should receive emergency contact information as well as
community resources (Cowen & Cowen, 2002).
Interdisciplinary teams should also take into account the
difficulties caregivers may experience in caring for adults with diminished
functional and/or cognitive capacity and provide these caregivers with support
services and interventions of their own to assist them in providing the best
care they can (Lowenstein, 2009 ).
Services should be offered not only to
victims of EM but also to their suspected perpetrators. Helping caregivers gain
a better understanding of proper care techniques may help alleviate cases of
neglect in particular.
Because of the nature of hospital stays, most of the long-term
interventions currently occur in the community setting. A systematic review of
interventions for EM revealed that interventions tend to concentrate on the
situational theory of abuse by focusing on education, counselling, and social
support for perpetrators of EM to better cope with stressors of caregiving
(Ploeg et al., 2009).
However, even these community-based interventions have
shown mixed results in terms of effectiveness when studying factors such as
risk of recurrence of MS; levels of depression and self-esteem in older adults;
and levels of caregiver strain, stress, and depression in caregivers (Ploeg et
al., 2009).
In the acute care setting, patients are assumed to have the
autonomy to refuse medical treatments and participate in care management as
long as there are deemed to be able to give informed consent. However, what can
be done if the older adult is refusing to perform activities deemed essential
for their health and well-being?
The answer, at the moment, is very little
because there is currently no rigorously tested screening instrument to assess
cognitive capacity in this population (Naik et al., 2008). Naik et al. (2008)
discuss the ethical dilemma that is present when an older adult is suspected of
self-neglect.
If the older adult is deemed to have the cognitive capacity to
make decisions about their own self-care, there is very little that health care
professionals can do to intervene. Interdisciplinary health care teams are
thought to be the most effective way of identifying self-neglect.
Although it
may seem difficult and costly to implement interdisciplinary health care teams
to adequately treat this group of older adults, the costs of not connecting
these individuals to proper resources can be much greater as their health
conditions can go undiagnosed and untreated for longer time, therefore creating
greater health care costs (Lowenstein, 2009).
There is inherent difficulty in evaluating the success of
interventions implemented in acute care organizations. The nature of discharges
makes it difficult to learn about outcomes in cases of EM.
Not all suspected
victims of EM will return to the same institution for repeat visits, and
confidentiality issues can restrict information sharing among health care
professionals.