Violence Against the Older Adult
Cheryl A. Glass
Definition
Abuse of older individuals, defined as older than age 65, is associated with loss of functional capacity, depression, cognitive impairment, increased morbidity, and mortality. Perpetrators include partners, family members (of all ages), as well as strangers. There are several types of maltreatment in this population:
A.Physical abuse: Willful unnecessary restraint, the infliction of physical pain or injury.
B.Sexual abuse: Nonconsensual sexual contact.
C.Psychological abuse: Infliction of emotional harm, bullying, ridicule, verbal abuse, terrorizing, and threatening to place in a long-term facility until the elder submits.
D.Neglect: Failing to provide for needs and protection of a vulnerable adult.
E.Self-neglect (subset of neglect): Malnutrition, dehydration, lack of personal hygiene, listlessness, hoarding.
F.Abandonment: Desertion.
G.Financial exploitation: Misappropriation of resources, utilities turned off for nonpayment, essential purchases including food or medicine not made, discrepancies in personal bookkeeping including unexplained credit card activities, recent changes in property titles, deeds, and refinanced mortgages.
H.Healthcare fraud and abuse: Not providing care, but charging for services; overmedicating or undermedicating.
Incidence
A.In 2011 the population age 65 and older was estimated to be 41.4 million. It is estimated that 1 in every 10 people in the United States is an older person (60).
B.The exact incidence of elder abuse, neglect, exploitation, and self-neglect is unknown; however, it is believed to be common. The incidence is underreported because of the reluctance to report abuse, fear of implicating family members, and fear of being removed from the home.
C.Abuse is not uncommon in the institutional setting.
D.The highest rate of abuse is among elderly women older than age 80, with the abuser being the spouse or adult child. In the case of cognitive impairment, the victim may not remember or recognize abuse.
Pathogenesis
Maltreatment of vulnerable adults occurs by people who have an ongoing relationship with the older person when there is an expectation of responsibility: sons/daughters, spouses/intimate partners, other family members such as grandchildren, and others, including paid and unpaid caregivers. There are several identifying psychopathologies in the abuser:
A.Physical frailty and mental impairment of the victim plays an indirect role. The victim may have a decreased ability to defend or escape.
B.Caregiver stressors from caring for the elderly patient, including the patient’s physical and verbal demands. Psychosocial factors of the caregiver, mental illness, and alcohol or drug abuse contribute.
C.The child who was once abused may continue the cycle of violence transferred to the parent.
Predisposing Factors
A.Age: 60 years and older.
B.Institutionalized.
C.Cognitive impairment/diminished capacity.
D.Decreased capacity for performing activities of daily living (ADLs).
1.Feeding themselves.
2.Bathing and dressing themselves.
3.Going to the toilet and performing hygiene themselves.
E.Decreased capacity performing instrumental activities of daily living (IADLs):
1.Ability to prepare meals.
2.Ability to do household chores.
3.Ability to use the telephone.
4.Ability to manage personal finances.
F.Females suffer a higher incidence of physical/sexual abuse.
G.Male gender is associated with self-neglect associated with impaired ADLs and IADLs.
H.Family stressors involving the caretaker.
Common Complaints
A.Depression.
B.Falls.
C.History of hip fracture.
D.Pressure ulcers.
E.Bruises, lacerations, and burns.
Other Signs and Symptoms
A.Indications of healing spiral fractures on x-ray.
B.Poor nutrition: Lack of resources/transportation to obtain food; caregiver not providing adequate nutrition/withholding food and/or dehydration.
C.Multiple hospitalizations.
D.Recurrent urinary tract infections.
E.Noncompliance: May not be able to pay for medications; medications may be withheld or even given in excess by the caregiver.
F.Complaints of sexual abuse:
1.Pain or soreness in the genital area.
2.Bruises or lacerations on the perineum/rectum.
3.Vaginal or rectal bleeding.
4.Extremely upset when bathed, changed, or examined.
G.Traumatic tooth and/or hair loss.
H.Sedation from overmedicating.
I.Changes in personality.
J.Frequent unexplained injuries.
Subjective Data
A.The caregiver often refuses to leave the patient alone and may answer questions for the patient.
B.The caregiver has a different explanation of the injury.
C.Ask the patient directly about abuse, neglect, or exploitation:
1.Has anyone at home threatened or ever hurt you?
2.Are you afraid of anyone at home?
3.Are you left alone for long periods of time?
4.Who cooks your meals? How often and what amounts of food do you eat?
5.Who handles your financial business? Have you signed any documents that you didn’t understand?
D.Assess the patient’s living arrangements. Has the patient ever told family or friends, called hotlines, or attempted to leave the caregiver?
Physical Examination
A.Assessment:
1.Observation: If abuse is suspected, enforce the need to do the physical examination in private. Do a full body examination:
a.Forensic exams need thorough documentation of injuries:
i.Use color photographs before any treatment is started.
ii.Make at least one full body photograph and a facial photograph.
iii.Make close-up photographs of all injuries.
iv.Use a ruler to identify/document the size of the injuries.
v.Documentation on the back of the photographs should include the patient’s name, date, photographer’s name, as well as any witness to the examination. The photographer should also sign each photograph.
vi.Use direct quotes of the victim’s history.
2.Check blood pressure, pulse, respirations, and weight.
3.General observation: Observe for depression, withdrawn, flat affect, fearfulness, poor eye contact, inappropriate dress, and signs of malnutrition.
4.Observe for poor hygiene, presence of urine and feces, matted or lice-infected hair, odors, dirty nails and skin, and soiled clothing.
5.Assess cognitive abilities, depression, and functional ability of ADLs and IADLs.
B.Inspect:
1.Dermal examination for signs of burns, tears, lacerations, impression marks, and bruises in different stages of healing. Frequent areas of the body involved are the neck, arms, and/or legs. Evaluate for the presence of decubitus/pressure ulcers. Signs of dehydration include dry fragile skin, dry sore mouth, and mental confusion.
2.Oral examination for poor oral hygiene, absence of dentures, and dry mucus membranes.
3.Evaluate breasts and genitals for lacerations, and hematomas of the vagina or labia.
C.Auscultate:
1.Auscultate all lung fields.
2.Auscultate bowel sounds in all four quadrants of the abdomen.
D.Palpate:
1.Evaluate for dislocation, fractures, sprains, and contusions to the wrists, forearms, and shoulders.
E.Percuss:
1.Abdomen and chest (if indicated).
F.Genital/rectal examination:
1.Evaluate genitals/anal area for redness, swelling, bruising, hematomas, abrasions, or lacerations.
2.Evaluate for evidence of sperm.
3.Evaluate for the presence of foreign bodies.
Diagnostic Tests
A.Diagnostic tests and x-rays are ordered dependent on the type of presenting complaints.
B.Obtain a CT for evaluation of injuries to the head and assault to the face, neck, or head. A CT or Doppler may be ordered for abdominal injuries.
C.Order laboratory testing to evaluate dehydration, malnutrition, electrolyte imbalance, and medication/substance abuse:
1.Complete blood count (CBC).
2.Chemistry-7.
3.Urinalysis.
4.Calcium, magnesium, and phosphorus.
5.Drug/alcohol screen.
6.Serum levels for relevant medications.
D.Obtain DNA samples if sexual abuse is present.
Differential Diagnoses
A.Elder abuse.
B.Depression.
C.Abdominal trauma.
D.Sexual assault.
E.Gait disturbance/fall.
F.Pathologic fracture.
G.Epidural/subdural hematoma.
Plan
A.Provide a safe environment.
B.Clearly document the history, physical findings, and interventions.
C.Determine the perpetrator(s).
D.Evaluate the need for emergency room/hospital admission.
E.Determine and plan a safety plan. Include a safe place for the patient.
F.Discuss strategies to reduce harm and protect the patient from the potential abuse.
G.Provide emergency phone numbers of family, friends, community resources, police, and medication providers/emergency room.
H.Establish routine primary care and follow-up appointments to determine safety
Patient Teaching
A.Reinforce that abuse/neglect is not the victim’s fault. Elderly abuse is very common, and the aged do not deserve to be abused.
B.Help is available.
Pharmaceutical Therapy
A.Prescriptions are related to physical injuries.
B.Recommend treatment for sexually transmitted infections in the oral anal genital areas.
Follow-Up
The Department of Health and Human Services National Center on Elder Abuse Administration on Aging maintains a State-by-State Resource site that includes directories, helplines, hotlines, referral sources, state government agencies and laws, and regulations related to elder abuse; it is located at https://ncea.acl.gov/resources/state.html.
A.Develop a follow-up plan. All states have legislation protecting against abuse, neglect, and exploitation of the older population.
B.Know if your state has mandatory requirements to report any suspicion of elder mistreatment.
C.Abuse of a disabled person must be reported to the Disabled Person Protection Commission.
D.Know if your state has additional regulations related to self-neglect. Contact adult protective services or law enforcement agencies.
E.At the present time, there is no recommendation for universal screening of all older adult patients except in nursing facilities.
Consultation/Referral
A.Arrange a social work consultation to coordinate an inhome geriatric assessment visit.
B.Facilitate referrals to a shelter, counseling, and legal services.
C.Contact a sexual assault nurse examiner (SANE) qualified healthcare provider, if indicated.
D.Refer to the community area agency for assistance.
E.Refer for a psychiatric consultation, if indicated.
F.Refer for a neurologic or neurosurgical consultation for intracranial injuries or focal neurologic findings.
G.Refer for an orthopedic consultation for fractures.
Individual Considerations
A.Geriatrics:
1.This population is at high risk for mental and physical abuse. Careful evaluation and treatment for all patients is imperative.
2.Patients diagnosed with dementia also require careful assessment for mental and physical abuse.