Issues in Identification of Mistreated Elders

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Issues in Identification of Mistreated Elders

• Linda R. Phillips, PhD, RN
• Professor of Nursing and Medicine
• Co-Director Arizona Center on Aging Director,
  Arizona Geriatric Education Center
• University of Arizona

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Objectives

• Discuss why identification of elder mistreatment
  is so difficult
• Describe what the research tells us about
  clinical red flags for identifying elder
  mistreatment in family settings
• Describe what we know about the red flags for
  elder mistreatment in residential care facilities
  (nursing homes/ALFs)

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Why the Difficulty?

• Specification of the problem
• Nature of the identification process
• Lack of empirical data to guide our decisions

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Elder Mistreatment
DIMENSIONS Physical Psychosocial Medical Environm
ental Human Rights Financial
Elder Abuse
Elder Neglect
Exploitation
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Elder Mistreatment
DIMENSIONS Physical Psychosocial Medical Environm
ental Human Rights Financial
Elder Abuse
Criminal Justice Definition
Elder Neglect
Exploitation
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Elder Mistreatment
DIMENSIONS Physical Psychosocial Medical Environm
ental Human Rights Financial
Elder Abuse
Late Life Intimate Partner Violence
Criminal Justice Definition
Elder Neglect
Exploitation
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Elder Mistreatment
DIMENSIONS Physical Psychosocial Medical Environm
ental Human Rights Financial
Elder Abuse
Late Life Intimate Partner Violence
Criminal Justice Definition
Elder Neglect
Exploitation
Elder Neglect
Elder Neglect
Family Care
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Elder Mistreatment
DIMENSIONS Physical Psychosocial Medical Environm
ental Human Rights Financial
Elder Abuse
Late Life Intimate Partner Violence
Criminal Justice Definition
Elder Neglect
Exploitation
Elder Neglect
Elder Neglect
Mistreatment in Institutions
Family Care
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Summary Specification of the Problem

• The terms elder mistreatment and even elder
  abuse have multiple different meanings based on
• The nature of the acts
• The context (vulnerable or not)
• The identity of the perpetrator
• Signs, symptoms and risk factors for different
  types of mistreatment are to some different

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Nature of the Identification Process
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STAGE I Categories Considered
STAGE II Decision Outcomes
STAGE III Categories Considered
STAGE IV Decision Outcome
Caregivers Role Performance or Behavior
Diagnostic Decision
Relationship Factors
Intervention Options Available
Elder Factors
INDECISION CYCLE
STOP
Intervention Decision
Perceived Constraints
STOP
Caregiver Factors
Perceived Consequences
Situational Factors
Value Decision
Cultural Stereotypes
Personal Values
Professional Values
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Summary Nature of the Identification Process

• In many situations, the evidence is ambiguous
• Health professionals who suspect elder
  mistreatment invariably have a need to
  understand the situation
• Ultimately it is not hard to convince themselves
  that if mistreatment is occurring it is for very
  good reasons

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Lack of Empirical Data to Guide Decisions

• No nation-wide population-based study of the
  prevalence, but two small regional
  population-based studies
• One nation-wide study of incidence identify the
  base of the iceberg
• Multiple studies (large and small) of individuals
  served by APS which contains limited data
• Most studies have no comparison groups and most
  mix types of mistreatment include LLIPV

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What can we extract from the literature as guides
for identification?

• Summary of Key Findings from Studies (Brandl
  Cook-Daniels, 2003)
• Usually more than one type of abuse present
• Elders are reluctant to report or admit
• Neither stress of the caregiver, dependency of
  the elder, nor elders health problems have been
  shown to be causally related to abuse
• There are no verified risk factors for elders
• Risk factors are related to impairments of the
  abuser not the elder

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Caregiver-related Clinical Red Flags

• Problems with alcohol and/or drug abuse
• Mental or physical incapacity
• Life in disarray
• Lack of caregiving knowledge (just dont get
  it)
• Expressing great burden and stress
• Unrealistic caregiving expectations and a
  tendency to blame others

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Caregiver-related Clinical Red Flags

• Dependence, particularly financial dependence, on
  the elder
• Complaints of abuse from the elder
• Reports of past conflicts with the elder
• Expressions of negative attitudes
• Possessiveness and jealousy of the victim
• Denying or minimizing the seriousness of the
  violence (or elders needs)
• Denigrating comments about the elder

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Relationship/Family-related Red Flags

• Family history of abuse
• Family history of turbulence and conflict
• Concurrent presence of other forms of domestic
  violence
• Recent change (new marriage, role shift, physical
  or mental status)
• A woman is involved (most victims are women most
  perpetrators (except for neglect) are men)
• Social isolation

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Identifying Elder Mistreatment in RCFs

• Knowledge about incidence and prevalence is
  miniscule but numerous government reports say it
  is serious and widespread in both NHs and ALFs
• Includes all types of relationships
  resident-staff resident-resident
  resident-family (Burgess found 70 of sexual
  abuses were male relatives 30 husbands)
• And all types of mistreatment including physical,
  psychological and sexual abuse neglect and
  financial exploitation

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Why Mistreatment Occurs in Institutional Settings

• Staff related factors
• Status and devaluing of staff
• Staff shortages
• High staff turnover rates
• Staff attitudes and lack of understanding
• Inadequate training
• Lack of staff supervision
• Nursing Assistant Mental Models
• Golden Rule
• Mother Wit

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Why Mistreatment Occurs in Institutional Settings

• Institution-related factors
• Profit motive
• Nature of institutional settings
• Closed systems
• Monopoly on rewards
• Individuals have no alternative by to comply and
  keep quiet
• Resident-related factors
• Viewed as incompetent
• Cognitive and communication difficulties
• Trapped

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Red Flags

• Resident Manifestations
• Signs/symptoms out of proportion to current
  problem and elders history (e.g., bedsore in low
  risk client)
• Unexplained injuries or injuries from improbable
  causes (Bilateral bruises)
• Resident showing increasing withdrawal,
  increasing depression, progressive weight loss,
  combativeness and aggressive behavioraggression
  is getting worse
• Behavior escalates after the elder has visitors
  or a particular staff member is in the room

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Red Flags

• Staff Manifestations
• Life in disarray
• Lack of caregiving knowledge
• Expressing great burden, stress and frustration
• Expresses the view of residents as children
• Unrealistic caregiving expectations and a
  tendency to blame others
• Complaints of abuse from the resident
• Expressions of negative attitudes
• Power/control issues

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Summary

• Identification is sometimes difficult, but the
  key is beginning by believing the elder until
  absolutely proven otherwise