Recognizing Elder Mistreatment

Debra L. Bynum, MDDivision of Geriatric MedicineUniversity of North Carolina at Chapel HillWith Support from the Donald W. Reynolds Foundation

May 2007

Learning Objectives

Describe the types of elder mistreatment.

Relate the factors that put older adults at risk for mistreatment.

Screen for elder mistreatment.

Know how to report suspected elder mistreatment.

Goals

Identify incidences of elder mistreatment.

Protect older adults from mistreatment.

Give health care providers information to deal more effectively with elder mistreatment.

Outline Cases Definition Prevalence and Risk

Factors Screening Identifying Indicators

of Mistreatment

Focus Points from Cases Financial Exploitation Caregiver Neglect Determination of

Capacity Self-Neglect Mistreatment in

Institutions Reporting Resources

Case 1

Could this be arsenic poisoning?

An 86-year-old man with renal insufficiency, diabetes, vascular disease, peripheral neuropathy was readmitted with recurrent nausea, vomiting, abdominal pain, dehydration and renal failure.

His son is concerned that patient’s new wife, 35 years younger, is neglecting her husband and is “in it for the money”

At baseline, the patient was oriented, appropriate and felt to have capacity to make decisions regarding living situation and medical care.

Case 1

The more pertinent questions: Is this elder mistreatment? What would you do?

Case 2 An 83-year-old woman is admitted with DVT; she is

disheveled and smells of urine and feces. The worried daughter calls. APS had previously

been to the house and found it filthy, filled with cats and 20 years worth of magazines. She has had a long history of medical noncompliance and has “fired” multiple home health nurses and physicians.

She has always been a quiet, secluded, and suspicious person.

What would you do? How does the determination of her capacity

influence the outcome of this case?

Case 3 A 95-year-old man is admitted from a skilled

nursing facility with dehydration, hypernatremia (Na 178), confusion, and a large decubitus ulcer.

His family is concerned that he has had several weeks of declining intake and feel he is being neglected

What are some markers of neglect? Is this reportable? To whom? What resources are available to the family?

Case 4 A 75-year-old woman with severe dementia is

brought to the ED by police after being found in the street, wandering and confused.

She lives in HER house with her grandson. She previously had home health, but they refused to continue coming (?drug dealing at the house?) The grandson often leaves her alone, and the house is in disrepair with recent discontinuation of electrical services.

Should the grandson continue to have power of attorney?

Is this elder mistreatment?

Elder Mistreatment: Background

“Granny Battering” was first described in BMJ 1975.

There has been increased awareness over last 20 years following interest in child and partner abuse.

Differing definitions, poor detection, under-reporting make exact extent unknown.

It is estimated that 5 - 10% of elderly are abused yearly (probably an underestimate).

Definition

Elder mistreatment refers to intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other persons who stand in a trust relationship to the elder or failure by a caregiver to satisfy the elder’s basic needs or protect the elder from harm.

Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2003). National Research Council

Elder Mistreatment Abuse

Physical Emotional/psychological Sexual Isolation Restraints Financial Violation of rights (personal

liberty, personal property, privacy, voting, speech)

Neglect Inadequate provision

of physical needs, hygiene, supervision, medical services

Self-Neglect Domestic Violence

What Are the Numbers?No one knows… Elder Mistreatment: Abuse, Neglect, and

Exploitation in an Aging America : “Between one and two million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depend for care or protection.”

Only 1 of every 5 to 14 cases is known.

Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2002) Committee on National Statistics (CNSTAT) - http://www.nap.edu/openbook/0309084342/html/National Incidence and Prevalence Study (NIPS) (1998) http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/Elder_Abuse.asp

The Numbers

Most studies exclude financial and self-neglect. Self-neglect accounts for majority of APS

referrals! National Elder Abuse Incidence Study

Noninstitutional Reports to APS Neglect most common (55% cases) Caregiver neglect: 13%

The Numbers in North Carolina? The best data available refer to disabled adults. NC’s Department of Health and Human Services

reports data from counties’ Departments of Social Services: 2000–2001. 9,142 disabled adults were served. 52% (4,754) were between the ages of 60–84 and

19% (1,737) were 85 years old and older. Mistreatment was confirmed in 36% (3,291). The need for protective services was

substantiated for 23% (2,103).

http://www.dhhs.state.nc.us/aging/adultsvcs/apsr2002.pdf

Risk Factors Older age Lack of access to resources Low income Social isolation Low level of education Functional debility Substance abuse (by older person or caregiver) Psychological disorders History of family violence Caregiver burnout and frustration Cognitive impairment

High Risk

Cognitive impairment with high physical needs Difficult behavior with dementia Social isolation

Who are the Abusers? Adult children are most often the abusers. Spouses

and other family members also mistreat older adults. Almost 90% of abusers are family members.

Paid caregivers who come into the home are less likely to mistreat or be abusers than family members.

Older adults may be mistreated in assisted living facilities, rest homes, and skilled nursing facilities

Elder Abuse Awareness Kit, http://www.elderabusecenter.org/pdf/basics/speakers.pdf

Cycle of Abuse

Increasing recognition of cycle of domestic and family violence and abuse

Increasing partner/domestic abuse in older persons Issues of neglect of elders who were at one time the

abusers of their current caretakers (adult children or spouses)

Barriers to Reporting

Cognitive impairment Fear of violence/retaliation Embarrassment Fear of placement worse than fear of abuse

Barriers to Reporting

Friends/family may not be sure of what is happening or trained to know what is suspicious

“Not my business…” Do not want to cause trouble Fear retaliation Believe that their actions will not make things better

What Questions to Ask? Do you feel safe at home? How do you and _____ get along? Is ______ taking good care of you? Do you have frequent disagreements? What happens when you disagree? Are you yelled at? Has anyone ever scolded or threatened you? Are you afraid of anyone at home? Have you gone without food or medicine? Have you ever had your glasses or hearing aid taken from you? Has anyone ever hurt you? Slapped, punched or kicked you? Has anyone ever touched you without your permission? Has anyone every made you do things you did not want to do? Has anyone taken things away from you without asking? Are you made to stay in your room?

Screening Instruments Team from McMaster University identified

90 articles that discussed risk factors. 18 included screening tool, only 6 provided

data on reliability and validity. First 3 done in the late 1980s. The last 3

carried out as part of one Canadian study of risk factors in the late 1990s.

Fulmer & O'Malley, 1987; Hamilton, 1989; Hwalek & Sengstock, 1986; Reis & Nahmiash, 1995a; Reis & Nahmiash, 1995b; and Reis & Nahmiash, 1998, Shott et al., 1999.

Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST)

6 questions discriminated effectively (Neale et al., 1991):

Has anyone close to you tried to hurt or harm you recently?

Do you feel uncomfortable with anyone in your family? Does anyone tell you that you give them too much

trouble? Has anyone forced you to do things that you didn't want

to do? Do you feel that nobody wants you around? Who makes decisions about your life... like how you

should live or where you should live?

Women’s Health Survey 15-item H-S/EAST screening tool adjusted,

reliability/validity analyzed in sample of older Australian women (n=12,340)

6-item scale: Are you afraid of anyone in your family? Has anyone close to you tried to hurt or harm you ? Has anyone close to you called you names or put you

down or made you feel bad recently? Does someone in your family make you stay in bed or tell

you you're sick when you know you aren't? Has anyone forced you to do things you didn't want to? Has anyone taken things that belong to you without your

OK?

Should We Screen?

Controversial Report from US Preventive Services Task Force

Insufficient evidence to recommend for or against routine screening

Lack of data does not mean lack of benefit. Does not address issue of asking questions in

suspected cases

Potential Indicators of Mistreatment

Physical Abuse or Neglect

Traumatic alopecia Poor oral hygiene Welts, bite marks,

burns Decubitus ulcers Suspicious bruising

(finger marks on arms or legs)

Fractures Fecal impaction Weight loss Dehydration Hypernatremia Poor hygiene

Dehydration and Hypernatremia

Hypernatremic dehydration in nursing home patients is an indicator of neglect.

Sexual Abuse

Physical signs, e.g., bruises, pain, or itching on genital area or breasts

Sexually transmitted disease diagnosis Change in older adult's behavior or mood that is

unexplained Fear of physical exam of genital area

Emotional or Psychological Abuse

Withdrawal Unexplained change in mood Refusal of caregiver to leave

Financial Abuse Older adult unaware of

income or financial matters

Important papers and credit cards missing

Bills not paid Funds not spent on older

adult’s needs New will

Unusual banking activity Adding caregiver’s name

to account Older adult signing on

caregiver’s loan Checks made to “cash”

frequently Signature not that of older

adult Activity older adult

doesn’t understand or know about

Frequent expensive gifts from older adult to caregiver

Financial Abuse

Elder has funds, property, house that are being used Older adult may have fear of being “placed” in

nursing home Often most challenging to “prove”

Mistreatment in Institutions Great potential for abuse and neglect in assisted

living and skilled nursing facilities. Study of 600 facilities: 40% surveyed reported

committing at least one psychologically abusive act within the past year; 10% admitted to act of physical abuse.

Markers of potential neglect: decubitus ulcers, wandering out of facility, dehydration, weight loss, poor oral care.

Back to the Cases: Case 1 An 86-year-old man with renal insufficiency,

diabetes, vascular disease, peripheral neuropathy was readmitted with recurrent nausea, vomiting, abdominal pain, dehydration and renal failure.

His son is concerned that patient’s new wife, 35 years younger, is neglecting her husband and is “in it for the money”

At baseline, the patient was oriented, appropriate and felt to have capacity to make decisions regarding living situation and medical care.

Case 1

Difficult question of possible mistreatment Potential neglect Potential financial exploitation Issue of capacity on part of the patient

Protection vs autonomy

Case 2 An 83-year-old woman is admitted with DVT; she is

disheveled and smells of urine and feces. The worried daughter calls. APS had previously

been to the house and found it filthy, filled with cats and 20 years worth of magazines. She has had a long history of medical noncompliance and has “fired” multiple home health nurses and physicians.

She has always been a quiet, secluded, and suspicious person.

Case 2: Self-Neglect Capacity vs autonomy and self-determination Capacity:

Specific to each decision Consistency Understanding consequences and ability to express this Express reasoning behind decision Does not have to match common values Cultural competency and understanding

Competency: legal term Lack of competency necessitates assignment of

guardian

Self-Neglect

Diogenes Syndrome Severe self-neglect Normal cognition, normal MMSE Theories

Extreme/continuation of lifelong “personality” trait or disorder?

Frontal lobe process leading to poor judgment

More on Diogenes Syndrome Characteristics:

Hoarding, collecting Social withdrawal and isolation Refusal of support Often judged to have “capacity” given normal

orientation and cognitive testing Do they “lack of capacity to care for self?” Most challenging cases for APS

Diogenes Syndrome and Self-Neglect

Why do these fall through the cracks? APS relies on elder being “disabled”, meaning

lacking capacity or competency, in order to get involved.

If elder is not cognitively impaired, at what point can they be considered harmful to themselves?

Case 3

A 95-year-old man is admitted from a skilled nursing facility with dehydration, hypernatremia (Na 178), confusion, and a large decubitus ulcer.

His family is concerned that he has had several weeks of declining intake and feel he is being neglected.

Case 3: The Nursing Home

Increased awareness of neglect and abuse in skilled nursing facilities.

Families can look up records of facilities. Things to look for: decubitus ulcers, dehydration,

mouth care, use of restraints. Not all ulcers and cases of dehydration are due to

neglect. Role of the ombudsman Report to DFS

Case 4… A 75-year-old woman with severe dementia is

brought to the ED by police after being found in the street, wandering and confused.

She lives in HER house with her grandson. She previously had home health, but they refused to continue coming (?drug dealing at the house?) The grandson often leaves her alone, and the house is in disrepair with recent discontinuation of electrical services.

Case 4: Exploitation and Neglect

The most difficult to prove If guardian is suspected to be abusing/neglecting

elder, process to suspend their power of attorney Physicians and caretakers must certify lack of

capacity for competency hearing; then new guardian would be assigned (family member or person assigned by APS).

What to Do…

If You Suspect Mistreatment

Document what the older adult says. Use direct quotes.

Record any statements made by others to explain or support the older adult's statements.

Determine and record the older adult's cognitive status, mood, and capacity to make decisions.

Photograph visual evidence after getting written permission to do so.

If You Suspect…ReportIf you believe an older, disabled adult is being

mistreated, report to the local county Department of Social Services (DSS) Adult Protective Services (APS).

Contact information is available online at http://www.dhhs.state.nc.us/dss/local/index.htm A printed directory is available.

County DSS are required to evaluate reported allegations of the need for Adult Protective Services within 72 hours.

DSS must “confirm” and “substantiate” reports before protective services are given.

The Law in North Carolina State laws govern the mistreatment of adults; some

states have specific statutes that address older adults. North Carolina's law does not specify protection to

“older” adults. It protects the “disabled adult.” North Carolina Statute Article 6, 108A-99-111 is the

Protection of the Abused, Neglected, or Exploited Disabled Adult Act. You can find this law at:

http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_108A/Article_6.html

NC Law: Current and Future APS intervention currently only for “disabled

adults” Archaic definition of “disabled”; Reliance upon lack of “capacity”, usually as a

result of dementia Work on changing law to ALL vulnerable elders

Recognition that elders who may be “competent” can still be vulnerable with reliance on caregiver

Pilot project summer 2007 for APS

What to Do

Awareness Screening in Nursing Assessment Form at UNC-CH

“Because so many people deal with fear and abuse in their relationships, we ask these questions of all our patients… does your partner/caregiver: have control over your decisions in your life? Threaten to harm you in any way? Shoved you in the past year? Ever failed to help you take care of yourself when you needed help?

Institutional Issues and Reporting Division of Facility Services

Centralized Complaint Intake Unit Hospitals, nursing homes, adult care homes,

psychiatric hospitals, home health agencies, hospices, dialysis centers, surgical care centers, and other facilities

http://facility-services.state.nc.us/complaintintake.html

1 - 800 - 624 - 3004 Ombudsman Program

Other Resources

Resources for situations that do not meet the definition of cases served by DSS:

Interdisciplinary geriatrics care team Local law enforcement Caregiver support groups in senior centers, churches,

adult day care and civic organizations Family domestic violence support organizations

Resources in North CarolinaN.C. Division of Aging and Adult Services - Promotes the independence and enhances the dignity of

N.C.'s older and disabled persons and their families through a community-based system of opportunities, services, benefits, and protections. http://www.dhhs.state.nc.us/aging/Long Term Care Ombudsmen serve as advocates for residents in nursing homes and adult care homes (rest homes/assisted living) throughout N.C.  - http://www.dhhs.state.nc.us/aging/ombud.htm

Area Agencies on Aging (AAAs) facilitate and support the development of programs to address the needs of older adults - http://www.dhhs.state.nc.us/aging/aaa.htm

N.C. Division of Social Services -works in cooperation with the Social Services Commission, the 100 local Department of Social Services and other public and private entities to protect children, strengthen families and help all North Carolinians to achieve maximum self-sufficiency - http://www.dhhs.state.nc.us/dss/

N.C. Division of Facilities Services regulates medical, mental health and group care facilities, emergency medical services, and local jails.  They ensure that people are safe and that the care in these facilities is adequate http://facility-services.state.nc.us/

N.C. Counties Departments of Social Services - Go to this website and select a county. It provides phone numbers, physical addresses, and mailing addresses for county offices of Departments of Social Services, Adult Protective Services - http://www.dhhs.state.nc.us/dss/local/index.htm

North Carolina Statute which addresses the Protection of the Abused, Neglected, or Exploited Disabled Adult - http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_108A/Article_6.html

National ResourcesNational Center on Elder Abuse - The NCEA, funded by the U.S. Administration on

Aging, is a gateway to resources on elder abuse, neglect and exploitation - http://www.elderabusecenter.org

Elder Abuse Awareness Kit http://www.elderabusecenter.org/pdf/basics/speakers.pdfNational Committee for the Prevention of Elder Abuse - The NCPEA is an

association of researchers, practitioners, educators, and advocates dedicated to protecting the safety, security, and dignity of America's most vulnerable citizens. The Committee is one of six partners that make up the National Center on Elder Abuse, which is funded by Congress to serve as the nation's clearinghouse on information and materials on abuse and neglect - http://www.preventelderabuse.org/index.html

Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2002) Committee on National Statistics (CNSTAT) - http://www.nap.edu/openbook/0309084342/html/

Elder Abuse and Neglect: In Search of Solutions - pamphlet published by the American Psychological Association - http://apa.org/pi/aging/eldabuse.html

U.S. Administration on Aging's Elder Abuse Resource Page http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/Elder_Abuse.asp

Acknowledgements

Funding: The Donald W. Reynolds Foundation, The Carolina Geriatric Education Center, and the Bureau of Health Professions

Authors: Debra Bynum, MD and Margie Britnell, MPH

Content: Diana Bass, MPH, Diana Wells, RN, MSW, MPH, and Yvette Warren, Beacon Program, UNC Health Care

Educational Development: Ellen Roberts, PhD, Ashley Davis, and Sarah Madry, MEd

UNC-CH Program on Aging: Jan Busby-Whitehead, MD

Last updated 2/13/2008.