Elder Abuse and Neglect

Preventing, Recognizing & Reporting Abuse and Neglect

Objectives:

After finishing this course, you will be able to:

  1. Define mandated reporting, reasonable suspicion, and good faith immunity.

  2. Define elder abuse.

  3. List the types of elder abuse

  4. Define elder self-neglect

  5. List signs of elder abuse (elder, caregiver)

  6. Describe who is most at risk for elder abuse

  7. Discuss factors related to caregiver stress

  8. Describe steps in making a report

Elder Abuse (Case Vignette)

Dr. Peterson has been treating Louise, a 68-year-old widowed woman living with her adult daughter and son-in-law. Lately Louise has seemed more depressed than previously and is showing signs of forgetfulness. Last week Louise came to session with a large bruise on her arm. When asked how she got the bruise, Louise’s answer seemed evasive. She finally responded that she had probably bumped her arm on something.

Situations such as this are unfortunately all too common. Suspicions of abuse, lack of clarity whether it is occurring, and concerns about potentially violating confidentiality are ones that many mental health professionals face. Every person, old or young, should be treated with respect and with consideration and should be safe from harm.

Elder abuse, also referred to as elder mistreatment, is any abuse or neglect of a person aged 60 or older by a caregiver or another person in a relationship involving an expectation of trust that threatens his or her health or safety. Although elder abuse is likely underreported, prevalence data suggests that it is a significant problem. A 2003 National Research Council report estimated that there are between 1 million and 2 million cases of elder abuse and neglect in the United States every year. Those who are most affected are usually elderly people who are cognitively or physically frail, depressed, lonely, or lacking social support.

Although cases of institutional abuse have received significant media attention, most incidents of elder abuse do not occur in nursing homes. Most elder abuse and neglect takes place at home. Family, other household members, and paid caregivers are usually are the abusers. There is no single pattern of elder abuse in the home.

Elder abuse reporting laws vary from state to state, but all states have set up reporting systems. Most states work through Adult Protective Service agencies, to oversee, investigate and provide follow up services to those who suffer abuse, neglect or exploitation. As mandated reporters, it is important that mental health professionals be aware of state laws and requirements to report suspicious behavior.

Mandated Reporting

Mandated reporters are professionals who, in the course of their work with identified vulnerable populations (the elderly, children, and disabled persons) are required to report observed or suspected instances of abuse and neglect of these vulnerable individuals. Each state has its own laws governing elder abuse and neglect. Specific procedures are established for mandated reporters to make referrals to adult protective services.

Described in the mandated reporting rules are guidelines for when to report. Many states use the standard of “reasonable suspicion” of elder abuse, which means that if a mental health professional in his or her professional training and experience has a logical basis to think that an elder is being abused, a report should be filed. In addition, all states provide some form of immunity from liability for persons who in good faith report suspected instances of elder abuse or neglect. Good faith statutes protect reporters from civil or criminal liability for filing a report.

The term "good faith" refers to the assumption that the mandated reporter, to the best of his or her knowledge, has reason to believe that elder abuse had occurred. Even if allegations cannot be fully substantiated, the reporter is still provided with immunity.

 

Elder Abuse Defined (Case Vignette)

Regina, a 74-year-old widowed woman has been in treatment with Dr. Lee. She recently moved in with her son and his family, a move Dr. Lee supported. Recently, however, Dr. Lee has been concerned about Regina’s increasing depression. She has been reluctant to talk about the move. Finally, breaking down in session, Regina reveals that she is very lonely. Her daughter-in-law is forbidding her to see her friends, stating that now that she lives with the family her job is to watch her grandchildren. Regina feels isolated and overwhelmed.

There are many definitions of elder abuse. One commonly accepted definition is "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. This act or omission results in harm or potential harm to the health or welfare of the elder

The distinguishing feature of this definition is that it focuses on harm where there is "expectation of trust" of the older person toward their abuser. As such, it includes harm by people the elderly person knows or with whom they have a relationship, such as a spouse, or family member, a friend or neighbor, or a caretaker. Many forms of elder abuse are reflective of domestic or family violence.

Many state laws on elder abuse couples it with dependent adult abuse. A dependent adult is someone 18-64 who has physical or mental limitations that restrict his or her ability to carry out normal activities, or to protect his or her rights.

There are a number of different types of elder abuse. These include:

  1. Physical abuse: Non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. This includes physical assaults and the inappropriate use of drugs, restraints, or confinement.

  2. Emotional abuse: Verbal or psychological abuse that causes emotional pain or distress. This includes: intimidation through yelling or threats, humiliation and ridicule, ignoring the elder adult, isolating an elder from friends or activities.

  3. Sexual abuse: Sexual contact with an elderly person without the elder’s consent including physical sexual acts, showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to disrobe.

  4. Neglect or abandonment by caregivers: Failure to fulfill a caretaking obligation, either active or passive. This includes not providing the elder adult with proper food, medicine or medical care or ignorance or denial that an elder needs as much care as he or she does) This category of elder abuse constitutes more than half of all reported cases of elder abuse.

  5. Financial exploitation:  This involves unauthorized use of an elderly person’s funds or property, either by a caregiver or an outside con artist. Examples include: misuse an elder’s personal checks, credit cards, or accounts, stealing income checks, forging the elder’s signature.

  6. Healthcare fraud and abuse Fraud perpetuated by professional care providers, including: not providing healthcare, but charging for it, overcharging or double-billing for medical care or services, overmedicating or under medicating.

Self-Neglect

An emerging issue in elder abuse is that of self-neglect. Some states are requiring mandated reporters to report elder self-neglect as a form of abuse. If included statistically as a form of elder abuse, self-neglect represents the highest percentage of elder abuse. The Public Policy Institute of AARP estimates that self-neglect represents 40 to 50 percent of cases reported to states Adult Protective Services.

Elder self-neglect is a significant problem that can lead to illness, injury or death. Some commonly seen areas of elder self-neglect are:

  • Appropriate nutrition

  • Cleanliness (bathing/personal hygiene)

  • Adequate clothing for climate protection

  • Proper shelter

  • Clean and healthy surroundings

  • Medical attention for serious illness

  • Taking medications as prescribed

Self-neglect is often created by an elder's declining mental awareness or capability. In some cases neglect may result from poverty or other social condition. This is not considered "self neglect," but social services may be available to assist these elders.

Signs of Elder Abuse

There are signs of abuse, neglect or exploitation that might alert professionals to the possibility of problems. Although it is important not to take any of these signs as a “definite,” they should certainly be taken seriously. There is also the difficulty that some of these things may not be signs of abuse, but of client report skewed by declining mental state. Here are some common indicators of elder abuse:

  1. Sudden change in behavior such as decreased grooming, staring vacantly, fear, agitation or anxiety, unexplained crying, disorientation, depression, unusual behavior, such as biting or rocking , withdrawal or shame

  2. Discrepancies between a person's standard of living and his/her financial assets, or a depletion of assets without adequate explanation. Money or personal items that are missing without explanation, unpaid bills, reports of a new will or power of attorney.

  3. Withdrawn, apathetic, fearful, or anxious behavior, particularly around certain persons. The victim may suddenly and without explanation express a desire not to visit or receive visits from family or friends.

  4. Malnourishment, as evidenced by weight loss, including dehydration (cracked lips, sunken eyes), poor overall hygiene, over-sedation in session, inappropriate clothing, lack of healthcare appliances such as dentures or glasses.

  5. Physical injuries, bruises, especially when not over bony prominences, unexplained or implausible injuries, multiple emergency room or physician visits, broken glasses. 6. Reports of urinary tract infection, vaginal or anal bleeding 7. Medical needs not attended to.

  6. Sudden, unexplained changes in the victim's living arrangements, such as a younger person moving in to "care for" them shortly after meeting.

It is frequently very difficult to detect abuse. Typically, abusive behavior occurs in private and the victim may be unwilling or unable to describe the attacks. When reports are made, they are frequently not believed.

 

Signs of Elder Abuse (Caregiver)

The following may be red flags indicating possible elder abuse. It is important to assess each situation on a case-by-case basis.

  1. Caregiver not wanting elder to be seen on his/her own.

  2. Caregiver providing a different accounting of events (such as how elder received bruises, etc) than elder.

  3. Lack of cooperation by caregiver for recommended treatment plan.

  4. Caregiver attempts to isolate patient from family, friends or activities.

  5. Caregiver denying elder right to make decisions about care, living arrangements, etc.

  6. Observable behaviors, such as anger, substance use.

  7. Dependence of caregiver on elder for financial support. Who is Most At Risk for Elder

Who is Most at Risk for Elder Abuse?

There are certain risk factors that increase the likelihood that someone will be the victim of elder abuse. Awareness of these risk factors will allow the mental health professional to be more vigilant in his or her interactions with the elderly (New York State Office of Children & Family Services).

  1. Elders with Decreased Physical Health and Mobility. This may cause increased dependency on others for the necessities of daily living.

  2. Elders with Declining Mental Status. The elderly often suffer from declining mental status. This may be due to a number of factors including age-related dementia, Alzheimer’s, depression, bereavement and medical conditions. Some of these conditions may be reversible. Regardless, elders with decreased mental acuity are more likely to be the victims of abuse.

  3. Socially Isolated elders. Elders may find themselves to be more socially isolated due to lack of mobility or inability to drive. They may also have suffered the losses of contemporaries, spouses, siblings and friends. In many cases abusers try to keep an elder isolated. Isolation can hide the effects of many types of abuse including physical abuse, neglect and emotional abuse.

  4. Dependent Elders. Elders who are dependent on others for their care are more at risk.

  5. Impaired Elders. Physical impairment, mental illness, or mental retardation are also risk factors for abuse.

  6. Elders who Abuse Substances. Substance abuse among those 60 years and older (including misuse of prescription drugs) currently affects about 17 percent the elderly. These numbers are expected to double by 2020. Alcohol or drugs use among the elderly may result in increased confusion, absent mindedness or agitation. This in turn may make the elder less able to defend against abusers.

Caregiver Stress (Case Vignette)

Patricia is a 52-year-old married woman who works a demanding, full-time job. She has recently been called upon to help her mother with her medication. While at her mother’s house, she notices more and more things that are not getting done. There are dishes in the sink and her house is dirty. Patricia tries to help with all of these things. She has noticed that she is becoming irritable with her mother.

 

Caregiver stress is the most common cause of elder abuse. According to the American Society on Aging, one out of four U.S. households provides care to a relative or friend over 50, Forty percent of caregivers are also raising children, and 64 percent work either full- or part-time.

 

Caring for an older adult suffering from a mental or physical impairment is extremely stressful, and can lead to caregiver burnout, resulting in impatience, depression, anger and hostility. This may result in abuse. Other pressures, such as employment, dealing with other family needs, or financial issues can exacerbate caregiver stress.

 

Other symptoms of caregiver stress may include (Alzheimer’s Association):

  • Anger

  • Social withdrawal

  • Anxiety

  • Depression Exhaustion

  • Sleeplessness

  • Lack of concentration

  • Health problems

Mental health professionals who provide services to the elderly may also benefit from being aware of caregiver resources and stressing appropriate boundaries and self-care.

Reporting Elder Abuse

It is important to remember that if you do suspect abuse it is better to err on the side of caution. Abuse can continue and escalate without intervention.

 

There is some variability state by state on how to report suspected elder abuse. It is important to know the specific requirements of the state in which you practice. One resource is Eldercare Locator (1-800-677-1116). They can direct you towards the appropriate state resources. In most instances, suspected elder abuse is reported to Adult Protective Services. Each state generally has at least one elder abuse hotline.

 

When reporting suspected abuse the provider should be able to provide the following information:

  • elder’s name, gender and address;

  • caregiver name and address (if applicable);

  • nature abuse observed by reporter;

  • actions taken by the reporter;

  • where the act allegedly occurred; and

  • reporter’s name, location, and contact information

 

Summary

Elder abuse is a significant problem. Mental health professionals have a pivotal role in recognizing and reporting elder abuse. Knowing how and when to report abuse can help support efforts to reduce the incidence of elder abuse and maltreatment.

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© 2018 by An Answered Prayer, LLC