The Societal Challenges of Elder Mistreatment

1
The Societal Challenges of Elder Mistreatment

• The Aging Population, Alzheimers and Other
  Dementias Law Public Policy
• University of Iowa College of Law
• March 1, 2012
• Robert B. Wallace, MD, MSc
• University of Iowa College of Public Health

2
Why Mistreatment, Not Abuse?

• Abuse has the connotation of overt violence, but
  most mistreatment is not physical violence
• Complexity of social behavior in the home or
  institution is more likely to have bi-directional
  elements
• Abuse is more likely to be used in legal
  language not all mistreatment is a crime

3
Counting Cases Requires Definitions The
Phenomena of Elder Mistreatment

• Physical abuse
• Physical force that may result in bodily injury,
  pain or impairment (includes hitting, slapping,
  grabbing)
• Sexual abuse
• Non-consensual contact of any kind with an older
  person
• Emotional and psychological abuse
• Infliction of anguish, pain or distress
• Financial exploitation
• Illegal/improper use of funds, property or assets
• Neglect and Self--Neglect
• Refusal or failure to fulfill obligations or
  duties to an elder

4
Three Components of Elder Mistreatment

• Trust relationship
• Intent and motivation
• Harm in some form

5
Some Definitional Issues

• Assessing intent/ motivation of mistreatment and
  neglect
• The complexity of social behavior in trust
  relationships
• The (varying) role of legal and administrative
  definitions
• Is refusing to provide for someone else a
  personal crime or a social welfare issue?
• Iatrogenic events e.g., inadequate care
  restraint or psychotropic medication use adverse
  events of appropriate treatment

6
A Focus on the Self-Neglect Issue

• Have the capacities of the victim and caregivers
  been assessed?
• The role of disability, cognitive impairment and
  mental illness
• Economic means and resources
• Social access to information/ education
• Access to helping and clinical services

7
Some Larger Contexts of Elder Mistreatment

• All interpersonal violence
• Domestic violence
• Violence against disabled persons
• Management of abusive psychiatric behaviors
• Criminal behavior
• Social welfare and unmet needs in society
• Codes of professional conduct in health and
  social professionals
• Funding and fiscal accessibility in health care
• Retirement and pension policies

8
The Spectrum of Domestic Violence
9
Possible Examples of EMIn the Institutional
Setting?

• Forcing a resistant elder to wash her hair twice
  a week?
• Using chemical restraints (drugs) to improve
  patient safety?
• Not honoring holidays of all faiths in a
  long-term care facility?
• A capable family member who ignores an elder in a
  long-term care facility?
• Not providing a chapel in a long-term care
  facility?

10
An Example A Legal Issue Resulting from Elder
Abuse Law

• Under-treatment of pain in clinical setting
• Abuse or malpractice?
• Multiple settings (home care, hospice, nursing
  homes, hospitals)
• Circumventing usual litigation pathways
• Lack of training in pain medicine
• Reticence to use pain medicine to the fullest

11
The Complexities of Financial Exploitation(J
Elder Abuse Neglect 23304)
12
A Quarter Century of (Little) Epidemiology of
Elder Mistreatment 1975-2000

• Not clearly defined Suspected 1-10 annual
  prevalence
• Are rates incidence or prevalence?
• No national surveys of older persons
• Relative occurrence of abuse/ neglect/
  exploitation unclear
• Mode of data collection social service/
  protective agency gt clinical gt small populations

13
Data Sources for the Study of Elder Mistreatment

• Formal professional reports
• a. Justice system police (abuse, rape, murder)
• b. Forensic pathology reports
• c. Adult Protective Services
• d. Health professional screening and reporting
• e. Institutional reports (nursing homes assisted
  living)

14
Data Sources for the Epidemiological Study of
Elder Mistreatment

• 2. Screening in clinical (emergency departments,
  out-patient facilities)
• 3. Surveys of professionals/ professional
  records Emergency rooms ambulatory care
• hospitals long term care
• 4. Household surveys (1 or multi-stage)
• Potential victims
• Potential perpetrators
• Biomarkers without questionnaires
• 5. Citizen reporting

15
Staff Reports of Elder Mistreatment in
Iowa(JAMDA DOI 10.1016/j.jamda.2008.09.005)

• Work of McCool, Jogerst, et al.
• Two nursing homes Questionnaire to 335 staff
• About 50 participation rate
• Have you seen/suspected adult abuse?
• Type of abuse Nursing/admin Other staff
• Physical abuse 21.4 10.0
• Sexual abuse 0.0 0.0
• Emotional abuse 32.1 5.0
• Financial exploitation 28.6 0.0

16
Family Members Reports of Abuse in Michigan
Nursing Homes (J Elder Abuse Neglect 21105)
17
A Plea for Citizen Reporting and of Abuse and Its
Prevention

• Step 1 Evaluate the Situation
• Step 2 Report Abuse
• Step 3 Understand the Law
• Step 4 Help Prevent Abuse

18
A Plea for Citizen Reporting of Abuse and Its
Prevention -- American Humane Association

• Step 1 Evaluate the Situation
• Step 2 Report Animal Abuse
• Step 3 Understand the Law
• Step 4 Help Prevent Animal Abuse

19
National Social Health and Aging ProgramUS
National Survey of Mistreatment (JGSS 63BS248)

• Validated items In the past 12 months.
• Is there someone who insults you or puts you
  down? (verbal mistreatment)
• Is there anyone who has taken your money or your
  belongings without your okay, or prevented you
  from getting them even when you ask? (financial
  mistr.)
• Is there anyone who hits, kicks, slaps or throws
  things at you? (physical mistreatment)
• Then asked the relation of the perpetrator

20
National Social Health and Aging ProgramUS
National Survey of Mistreatment (JGSS 63BS248)
21
First UK Prevalence Survey of Mistreatment(J
Elder Abuse Neglect 211)
22
First UK Prevalence Survey of Mistreatment
Annual Prevalence (J Elder Abuse Neglect 211)
23
Consequences of Elder Abuse

• Physical Health
• Morbidity (skin wounds fractures, etc.)
• Death
• Dysfunction and disability
• Psychological Health
• Depression fear guilt shame distrust learned
  helplessness withdrawal post-traumatic stress
  syndrome
• Economic Status
• Loss of resources, possessions

24
Mortality Associated with APS-Identified EM in a
Defined Population Lachs, JAMA 280428
25
Risk Factors for Elder Abuse - I

• Victim dependency/ vulnerability
• Poor health disability/functional impairment
  poor personal defenses poverty possibly
  dementing illnesses (resp. to behav.)
• Gender--women
• Abuser dependency/deviance
• Alcohol and drug abuse mental illness poor
  employment record
• Social isolation
• Abuse undetected lack of social support to
  buffer stress
• Living arrangements
• Shared living arrangements greater opportunity
  for tension and conflict long term care
  facilities

26
Risk Factors for Elder Abuse IIThe Disturbing
Role of Childhood Experiences

• Childhood Sexual and Physical Abuse Risk for
  Victimization in Adulthood Lancet 358450
• -Unwanted sexual intercourse lt 16 years RR
  3.5
• -Rape lt 16 years RR 2.6
• -Severe beatings by parents or carers RR 3.6
• Childhood Abuse and Attempted Suicide JAMA
  2863089
• -Emotional abuse RR 5.0
• -Sexual abuse RR 2.8
• -Battered mother RR 2.6
• -Mentally ill household member RR 3.3
• -Parents separated/divorced RR 1.9

27
Risk/ Vulnerability Model of Self Neglect(J Am
Geriatr Soc 56S271)
28
A Gene Effect on Early Childhood Abuse and Adult
Behavior Science 297851
29
Indicators of Elder AbuseThe Gerontologist
38471-480

• Abusive Caregiver Characteristics
• Alcohol and substance abuse
• Mental health problems depression/ personality
  disorder behavioral problems care-giving
  reluctance, inexperience
• Generally poor interpersonal relationships poor
  pre-morbid relations current marital, family
  conflict lack of empathy, understanding of care
  needs and issues financially dependent on care

30
The Clinical Recognition of EMPossible Risk
Factors

• 1. Frequent primary care or ER visits
• 2. Frequent or unexplained falls
• 3. Injuries inconsistent with explanations given
• 4. Evidence of neglect malnutrition,
  dehydration, hypotherm.
• 5. Overmedication poisoning, stupor
• 6. Undue physical restraint
• 7. Inappropriate clothing
• 8. Inadequate aids and devices
• 9. Lack of money, possessions social isolation

31
The Role of Forensic ScienceA Midwestern
Program Ten-Year Experience

• Cases over 60 including homicide and neglect
• Homicide (avg age 72.1) Neglect (avg age 79.7)
• Gunshot 42 Pneumonia 50
• Beating 37 Sepsis 23
• Stabbing 19 Dehydration 9
• Asphyxia 10 Heart disease 9
• Fall 4
• Undetermined 4
• J. Forensic Sci. 49122

32
The Role of Forensic ScienceA Midwestern
Program Ten-Year Experience - II

• Homicide cases
• (N 52)
• Perpetrators
• Spouse 15
• Other family 10
• Acquaintance 10
• Undeterm. 73

• Neglect cases
• (N 22)
• Residence
• With family 32
• Non-fam. caretaker 14
• Alone non-fam.
• caretaker 9
• Nursing home 18
• Unknown 27

33
Findings from Autopsies of Patients Over 65 Years
with Antemortem EM Legal Medicine 57

• 15 Causes of Death in a Japanese Prefecture
• -Subdural hemorrhage(4) -Starvation
• -Hypothermia -Suffication (4)
• -Drowning -Arson
• -Strangulation -Traumatic brain inj.
• -Traumatic pneumothorax
• Perpetrators
• -Sons (7) -Grandson
• -Son-in-law -Son and Daugh.-in-law
• -Grandson (2) -Neighbor
• -Unk. -Others

34
Some Potential Biomarkers of Abuse/Neglect

• Blood biomarkers--examples for consideration
  myoglobin acute phase reactants
• Patterns of fractures morphology
• Morphology and distribution of bruising
• Quick tests of malnutrition and dehydration
• Forensic testingsimilar to assault and rape
  investigations

35
Items to Assess Elder Abuse in Epidemiological
Surveys J Appl Gerontol 5153 - I

• 1. Has anyone tried to hurt or harm you?
• 2. Have you been forced to do things you dont
  want to do? Please give an example.
• 3. Have you been threatened with being placed in
  a nursing home?
• 4. Has anyone stolen from you or taken your
  possessions without permission?
• 5. Has anyone sworn at you or threatened you?

36
Items to Assess Elder Abuse in Epidemiological
Surveys J Appl Gerontol 5153 - II

• 6. Has anyone confined you at home against your
  will?
• 7. Has anyone refused to provide you with food or
  with your medications
• 8. Has anyone beaten or assaulted you?
• 9. Have you ever signed any documents that you
  didnt understand?
• 10. Are you afraid of anyone in your home?

37
Brief Self-Report Screening InstrumentAustrali
an Longitudinal Study on Womens Health, 2000

• 1. Are you afraid of anyone in your family?
• 2. Has anyone close to you tried to hurt you or
  harm you recently?
• 3. Has anyone close to you called you names or
  put you down or made you feel bad recently?
• 4. Does someone in your family make you stay in
  bed or tell you youre sick when you arent?
• 5. Has anyone forced you to do things you dont
  want to do?
• 6. Has anyone taken things that belong to you
  without your okay?

38
Some Potential Problems with EM Screening and
Diagnostic Instruments in Surveys

• Items do not assess social/ family context of
  events
• Checklist response range excludes many real life
  situations
• Perpetrator information often incomplete
• Not responding to evidence-based practice
  guidelines

39
Legal, Administrative Challenges to Effective
Elder Mistreatment Services

• Divulging confidential information (e.g.,
  caregiver support session HIPAA)
• Different laws in various jurisdictions
• Inadequate responses/ resources by existing Adult
  Protective Services
• Disagreement on the fundamental mistreatment
  nature in various situations
• Remedies may make victims situation worse
• Fear of degrading existing elder services

40
(No Transcript)
41
An Approach to Management of Confirmed EM
Adapted from Lachs Pillemer Lancet 3641263
Confirmed Case
Patient Willing to Accept Services
Patient Unwilling or Unable to Accept Services
Context-specific Intervention -Educate -Implement
-Referral
Patient Lacks Capacity -Go to official
agency -Financial asst. -Conservatorship/
guardianship -Special committee -Courts
Patient has Capacity -Educate patient -Provide
emergency numbers -Develop safety
plan -Develop follow-up plan
42
Examples of Approaches to Managing EM Adapted
from Lachs Pillemer Lancet 3641263

• Potentially related to caregiver stress
• -Respite care -Adult day care
• -Carer education -Family carers recruit.
• -Carer psychother. -Reduce carer soc. isol.
• Longitudinal spousal violence
• -Marital counseling -Support groups
• -Shelters -Protection orders
• -Victim advocacy

43
Policy Approaches to Elder Mistreatment

• Mandatory Reporting Laws
• Improve Adult Protective Services
• Investigation, assessment, care planning, case
  monitoring
• Better Educate Other Care Providers
• Social service agencies hospitals long-term
  care insts.
• Law Enforcement-Criminal Justice System
• Victim assistance perpetrator prosecution
• Comprehensive Community Services
• Multidisciplinary teams community coalitions

44
Des Moines Register 26Feb12
45
Can Primary Elder Mistreatment Be Prevented?

• Depends on programs and political and
  administrative will
• Better educating professionals
• Increasing community awareness
• Educate all older people and the those at risk
• Isolate and punish offenders where possible
• Protect vulnerable elders better?
• Very few actual trials of prevention programs