ELDER AND VULNERABLE PERSON ABUSE, NEGLECT, AND …



3. Scope and Nature of Elder Mistreatment

Purpose

This module provides nurses with basic information on elder mistreatment, including prevalence and incidence, types of mistreatment, sign of possible mistreatment by type and distinguishing signs of possible mistreatment from common changes associated with aging, disease-related changes and medication-related changes. Family violence in later life, elder sexual abuse and institutional elder mistreatment are discussed in some detail.

Topics

• Scope (incidence and prevalence) and nature (types) of elder mistreatment.

• Signs of possible elder mistreatment.

• Common age-, disease-, chronic condition- and medication-related changes that may mimic possible elder mistreatment.

• Family violence in later life, elder sexual abuse and elder mistreatment in institutional settings.

Learning Objectives

By the end of this module, participants will be able to:

• Discuss the scope and nature of elder mistreatment;

• Discuss the incidence and prevalence of domestic and institutional elder mistreatment;

• Describe characteristics of victims and perpetrators of elder mistreatment;

• Describe signs of different types of possible elder mistreatment;

• Describe how common changes in aging, disease, chronic conditions and medications can mask or be misinterpreted as mistreatment; and

• Discuss family violence in later life, elder sexual abuse and elder mistreatment in institutional settings.

Instructor Preparation

Clarify roles of each instructor for this module. Ideally, a nurse educator and elder mistreatment expert should co-lead and a legal and/or adult protective services professional should be available to provide additional expertise. Consider including presenters from local/regional agencies that serve victims of family violence, sexual abuse and mistreatment in institutional settings (e.g., domestic violence or sexual assault programs or long-term care ombudsmen programs).

Preview activities, sequence and time allotments:

1. Small and large group discussions on a case study. (35 minutes) (Slides 2-6)

2. Small and large group discussions on prevalence of elder mistreatment and replacing misconceptions with facts. (35 minutes) (Slide 7-9)

3. Small and large group discussions on signs of possible elder mistreatment. (25 minutes) (Slides 10-11)

4. Large group discussion on distinguishing common age-related changes from signs of possible elder mistreatment. (40 minutes) (Slide 12)

5. Small and large group discussions using case studies on elder family violence, sexual abuse and institutional mistreatment. Optional viewing of film clips. (70 minutes/90 minutes with optional film clips) (Slides 13-29)

6. Closing assessment. (5 minutes) (Slide 30)

Note: This module may be presented in one, two or three presentations. For example, Activities 1-2 could be one class, 3-4 another class and 5 another class.

Preview materials for Module 3 in the Instructor’s Manual, Participant Materials and Slides. Note that information from the following key resources is interwoven into this module:

American Medical Association. (1992). Diagnostic and treatment guidelines of elder abuse and neglect. Chicago, IL: Author.

Aravanis, S.C., Adelman, R.D., Breckman, R., Fulmer, T.T., Holder, E., Lachs, M., O’Brien, J.G., & Sanders, A. (1993). Diagnostic and treatment guidelines on elder abuse and neglect. Archive of Family Medicine, 2, 371–388. Retrieved from .

Bonnie, R., & Wallace, R. (Eds.). (2003). Elder mistreatment, abuse, neglect and exploitation in an aging America. Washington, DC: The National Academies Press. Retrieved from .

Bitondo Dyer, C., Connolly, M., & McFeeley, P. (2003). The clinical and medical forensics of elder abuse and neglect. In R. Bonnie & R. Wallace (Eds.). Elder mistreatment, abuse, neglect and exploitation in an aging America (pp. 339-381).

Hawes, C. Elder abuse in residential long-term care settings: What is known and what information is needed? (2003). In R. Bonnie & R. Wallace (Eds.). Elder mistreatment, abuse, neglect and exploitation in an aging America (pp. 446-500).

Brandl, B., & Horan, D. (2002). Domestic violence in later life: An overview for health care providers. Women and Health, 35(2/3), 41-54. Retrieved from .

Collins, K. (2006). Elder maltreatment—A review. Northfield, IL: College of American Pathologists. Retrieved from .

Florida Council Against Sexual Violence. (2002). Elder sexual abuse: The hidden victim, a training for law enforcement (Module 1). Tallahassee, FL: author.

National Center on Elder Abuse. (2006). Abuse of adults aged 60+, 2004 survey of adult protective services (Fact sheet). Newark, DE: author. Retrieved from .

National Center on Elder Abuse. (2003). Elder abuse prevalence and incidence (Fact sheet). Newark, DE: author. Retrieved from .

National Center on Elder Abuse. (n.d.). Frequently asked questions and basics. Newark, DE: author. Retrieved from .

National Center on Elder Abuse. State. (n.d.). Resource directory on elder abuse prevention. Newark, DE: author. Retrieved from .

National Clearinghouse on Abuse in Later Life. (2006). Abuse in later life wheel. Madison, WI: Wisconsin Coalition Against Domestic Violence. Retrieved from .

National Clearinghouse on Abuse in Later Life. (2003). Interactive training exercises on domestic abuse in later life. Madison, WI: Wisconsin Coalition Against Domestic Violence. Retrieved from .

Phillips, L. (n.d.). Issues in identification of mistreated elders (Slide presentation). Tucson, AZ: Arizona Geriatric Education Center, Arizona Center on Aging, University of Arizona. Retrieved from .

Vierthaler, K. (2005). Addressing elder sexual abuse: Developing a community response (Module 3). Enola, PA: Pennsylvania Coalition Against Rape and Harrisburg, PA: Pennsylvania Department of Aging. Retrieved from and .

Preview videos/DVDs used in this module:

Optional Use: California District Attorneys Association. (2003). CDAA elder physical and sexual abuse: The medical piece, parts 1 and 2. Sacramento, CA: Author. This film is available for $25. To order, call 916-443-2017 and indicate your media preference (VHS/DVD). Shipping takes approximately seven to 10 days. For more information, see . The VHS/DVD helps nurses connect their roles in identifying and documenting signs and symptoms with investigation and prosecution of mistreatment. It offers concise information presented by well known experts in the field and images of various types of signs of possible mistreatment.

Identify relevant local, state and/or regional statistics on the prevalence of elder mistreatment in areas where participants work. A place to start is the National Center on Elder Abuse’s State Resource Directory on Elder Abuse Prevention, .

Lesson Plan

Activity 1: Case Study Introduction

This activity assesses what participants know and need to know to respond in elder mistreatment cases and introduces module topics.

Ask participants to review the case scenario and then discuss questions provided below in a small group setting. Participants should be prepared to report their answers to the large group. (15 minutes)

Mrs. Kennedy, an 87-year-old widow, arrived at the hospital emergency department (ED) by ambulance accompanied by her neighbor, Judy. Judy had noticed that her neighbor’s mail box was full and Mrs. Kennedy’s cat roaming outside the house for a couple days. Mrs. Kennedy did not answer Judy’s repeated phone calls. Judy did not remember seeing Mrs. Kennedy’s son around for the last week. While Mrs. Kennedy is mentally alert, she is physically frail and uses a walker to get around. She also has macular degeneration and suffers from emphysema. Mrs. K. depends on her son, who lives with her, to help with her daily activities—meal preparation, cleaning/home maintenance, bathing, dressing and administering her medications. Due to her concerns, Judy peered in Mrs. Kennedy’s window and saw her neighbor lying on the floor. She called 911.

Upon examination in the ED, Mrs. Kennedy was diagnosed with a broken hip, dehydration, malnutrition, hypertension and pneumonia complicated by emphysema. Her hygiene was poor; she had soiled herself and had not bathed in a couple days. There were purplish-colored bruises on her arms, legs and torso.

When the nurse asked Mrs. Kennedy about how she was caring for herself at home, Mrs. Kennedy reluctantly admitted that she had not seen or heard from her son for the last week; she had been trying to care for herself, but was unable to do so. Mrs. K. said that, while she was able to get herself to and from the bathroom, she had little energy for anything else. She reported that she fell on her way to the bathroom yesterday and could not get up to call for help. She also said that she had not been able to find her medications. When asked how long her son had been gone and how often these absences occurred, Mrs. Kennedy evasively replied that her son tries to do his best to help her, but that he needed a break from her and had his own problems. She mentioned that he was trying to kick a drug habit and had difficulty holding a job; that she writes him checks from time to time to help him financially. When asked about her bruises (especially the bruises on her torso), Mrs. Kennedy denied that her son ever deliberately hurt her.

Questions for the attending nurse to consider: (Slide 2)

? What are the patient issues in this case?

? What do you currently know that helps you address these issues?

? What do you still need to know to respond to these issues?

Facilitate a large group discussion on the questions, incorporating small group reports and the teaching points that follow. Note that italicized text in the teaching points indicates comments related to the case study. (20 minutes)

Teaching Points

In the course of their interactions with patients, nurses may suspect elder mistreatment in either domestic (community) or institutional setting. The term elder mistreatment describes intentional acts by a caregiver or “trusted other” that cause harm or serious risk of harm to a vulnerable older adult and/or omission of acts wherein a caregiver or trusted other fails to meet basic needs of a vulnerable older adult.[i] (Slide 3)

Vulnerable older adults—those who have a diminished capacity for self-care and self-protection—are often easy targets for perpetrators.[ii] (Slide 3)

Elder mistreatment may take place over a long period of time and only become apparent to others at certain times (e.g., when the patient is brought to the hospital with a severe injury). For some, origins of elder mistreatment may span earlier adulthood or even youth.[iii] (Slide 3)

In Mrs. Kennedy’s case: (Slide 4)

• Suspected types: (1) neglect and (2) abandonment of the patient by her son. Domestic/community setting. Possible (3) financial exploitation and (4) physical abuse. Need more data.

• Clues: Caretaker son has not provided daily assistance in a week (may have happened before, but with less dire consequences for Mrs. Kennedy). Patient’s injuries, medical problems and poor hygiene related to lack of assistance. She has bruises; it is not clear if they were intentionally or unintentionally inflicted by her son. Have medications been not purchased, hidden, stolen or put out of patient’s reach? How much money is the patient giving her son? Is there any financial exploitation going on?

It can be difficult to distinguish elder mistreatment from problems that occur due to progression of aging, disease, or chronic conditions. (Slide 5)

In Mrs. Kennedy’s case, for example:

• Broken hip: Common injury for physically frail older adult and those who have trouble seeing and walking. (Use of walker may suggest she is at increased risk for falling.)

• Poor vision may lead to problems in finding medications or confusion over which medication is in which container; and problems organizing and preparing meals.

• Bruising, particular those on the extremities, can occur in the process of moving around house.[iv]

• Is the patient dealing with any cognitive issues that could have influenced the events as described (e.g., could she have just forgotten the location of her medications)?

Nurses can combine previous experience with what they have learned in the first two modules of this course. For example, they may already know how to: assess for elder mistreatment; help patients feel more comfortable; avoid making age-related assumptions; notify law enforcement and/or adult protective services (APS) to make a mandatory report; and help patients with safety planning at the time of care transitions or discharge.

To respond in this case, the nurse and other health care providers need clarifying data to rule out elder mistreatment. Such information is gathered in the course of screening, physical assessment and discussions with others who accompany the patient.

In Mrs. Kennedy’s case, it would be helpful to know:

• What can Mrs. Kennedy do for herself in terms of daily activities and in which areas she needs help?

• What is the son’s role/duty (Is he her legal guardian/caregiver)?

• Is the son aware of his mother’s medical conditions and care needs? What is the agreement between mother and son regarding care and assistance?

• How did the bruising occur and what do the bruises look like (specific size, shape and coloring)?

• What financial assistance is she providing to her son? Is he exploiting her?

• What are the specifics about other occasions when her son has left her on her own?

• Has she presented to the health care system before with signs of possible elder mistreatment indicators?

When taking next steps in ruling out elder mistreatment, it is helpful for nurses to consider foundational information, as discussed in this module: (Slide 6)

• Risk factors for elder mistreatment:

How likely is it that a vulnerable older adult like Mrs. Kennedy will be mistreated by a trusted other? What factors place a vulnerable older adult at risk for mistreatment? How likely is it that a family member would intentionally harm and/or fail to help an older relative? Why would they mistreat this person? What risk factors increase the likelihood of elder mistreatment by a caregiver/trusted other? How likely is it that the vulnerable older adult being mistreated will/will not be able to seek help? What assumptions about elder mistreatment might keep health care providers from responding appropriately?

• Signs of different types of elder mistreatment. It is critical that nurses recognize all forms of elder mistreatment as serious.

• Differentiation between injuries/conditions that are related to age, disease, chronic conditions and/or medication effects versus injuries/conditions that occur in the course of mistreatment.

• Brief exploration of family violence in later life, institutional abuse and sexual abuse.

Activity 2: Data on Elder Mistreatment[v]

This activity presents basic data on prevalence and reporting of elder mistreatment and related risk factors, as well as victim/offender characteristics.

Pair participants and ask them to share with a partner how often they think elder mistreatment happens in domestic/institutional settings. Also ask them to consider: (10 minutes) (Slide 7)

? What misconceptions about the extent and nature of elder mistreatment have they seen held as truth in their work settings or in their communities?

? How do these misconceptions impact interactions between patients and health care providers and subsequent interventions?

Facilitate a large group discussion on the topic above. Interweave small group reports and teaching points from below, stressing the importance of replacing misconceptions with facts (25 minutes).

Teaching Points

No one knows precisely how many older adults are mistreated—surveillance is limited and the problem remains hidden. Three issues:[vi]

• Definitions of elder mistreatment vary (as previously discussed).

• State statistics vary widely due to lack of a uniform reporting system.

• No comprehensive national database of elder mistreatment cases exists.

Best available estimates of prevalence:[vii] (Slide 8)

• Between 1 and 2 million Americans age 65 or older have been injured, exploited or otherwise mistreated by someone on whom they depended for care or protection.[viii]

• Between 2 to 10 percent of older vulnerable adults aged 65+ are victims of some form of abuse or neglect.[ix]

Add local, state and regional statistics as available.

Reporting and Risk Factors[x] (Slide 9)

-Elder mistreatment is rarely reported. Some estimates include: one in 14 incidents of domestic elder mistreatment comes to the attention of authorities (1988);[xi] for every case of elder mistreatment reported, five cases go unreported (1996);[xii] and 8.3 cases of abuse are reported for every 1000 older Americans (2006).[xiii]

Add local, state and regional statistics as available.

• Many reasons why victims don’t report or seek help. For example, victims may want to protect perpetrators (who are often family members); fear retaliation and further mistreatment if they tell; blame themselves; feel shame and guilt; want to deny or hide the mistreatment; think they will not be believed; depend fully on perpetrators and fear losing their caregivers; fear nursing home placement; or may be limited in their capacity to report or seek help. Perpetrators may make it appear that victims’ claims of mistreatment are due to cognitive impairment (e.g., dementia) or a negative disposition. They may silence their victims (e.g., by isolating them, taking away their means of communicating with others or assuming power of attorney). Mistreatment may go unreported within residential facilities where older adults may be severely impaired, have little say in who cares for them and/or feel powerless to act when staff mistreats them.[xiv]

-Who are the victims? Abuse of Aged 60+, 2004 Survey of Adult Protective Services found two thirds of victims to be women (often 80+). Elder mistreatment occurs among people of all cultural and ethnic backgrounds and socioeconomic levels. Victims are usually socially isolated and live in close proximity to or with their perpetrators. Victims usually have personal relationships with their perpetrators (e.g., relative, neighbor, nurse/sitter/caregiver or family friend). Victims are often dependent on the perpetrators for assistance with daily activities. Just as important to note, however, is the fact that perpetrators may be dependent on their victims for housing, money, etc.

-Who are the perpetrators? They are usually family members, most likely an adult child or the victim's spouse or partner who serves in the caregiver role. Two-thirds of perpetrators fall into this category.[xv]

• One study showed that two-thirds of perpetrators were spouses and one-third were adult children.[xvi] Similarly, Abuse of Aged 60+, 2004 Survey of Adult Protective Services indicated that 33 percent of perpetrators were adult children.

• Common characteristics of perpetrators of elder mistreatment: a history of mental illness and/or substance abuse; excessive dependence on the older adult for financial support; and a history of violence within or outside of the family.[xvii]

-Risk Factors. Potential risk factors include the social context for the victim/perpetrator relationship (e.g., isolation); offender characteristics (see above); victim characteristics (e.g., dependence on others for care); living arrangements (e.g., shared) and relationship of perpetrator to victim (e.g., spouse or child); and power and control dynamics (level of dependence of victim/abuser, caregiver stress, guardianship/power of attorney, etc.).[xviii]

• Note on caregiver stress. “The concept that caregiver stress is a primary cause of elder abuse has been a prevailing theory for decades. The belief has been that stressed caregivers become overwhelmed and lash out at elders when care giving and life circumstances become too difficult…. There are cases where caregiver stress has caused an isolated incident of emotional or physical abuse…. However, too often abusers will describe being overwhelmed and stressed as an excuse so they will not be held accountable for their behavior. Often the abuse is not an isolated incident but part of a combination of emotional and physical abuse, isolation, threats, coercion and manipulation so the abuser gets his or her way. Professionals need to use caution and look for possible power and control dynamics in elder abuse cases rather than assuming stress or poor family dynamics are the cause. Unfortunately, elder abuse remedies that help with cases truly caused by stress can be dangerous for victims when power and control dynamics are present. Caregiver stress blames the victim, by implying that if the victim were not so hard to care for, the abuse would not occur. Too often remedies then focus on how to help the abuser feel less stressed rather than focusing on the safety needs of the victim. And finally social services remedies are often utilized without considering criminal justice interventions that hold the abuser accountable. In most cases, a stress-free abuser does not make the victim any safer.”[xix]

-Intentional versus unintentional injuries and neglect. Intentional mistreatment involves a conscious and deliberate attempt to inflict harm or injury. Unintentional mistreatment occurs when an action inadvertently results in harm to the person. Unintentional mistreatment is usually due to ignorance, inexperience and/or a lack of caregiver ability/desire to provide proper care.[xx]

Whether intentional or unintentional, however, mistreatment can have serious detrimental outcomes for older individuals and should be addressed. *It is not up to nurses/health care providers to determine whether mistreatment is intentional or unintentional.*

Activity 3: Signs of Possible Elder Mistreatment

Assessing older adults for signs of possible elder mistreatment will be discussed more fully in Modules 6 and 7.

In four small groups, ask participants to brainstorm signs for different types of elder mistreatment. One group can take physical and sexual abuse; another emotional/psychological abuse; another neglect and abandonment; and another financial exploitation and violation of rights. Ask groups to be prepared to report to the large group (10 minutes)

Facilitate a large group discussion, asking groups to report on signs they identified. Incorporate teaching points. (15 minutes)

Teaching Points

One sign does not necessarily indicate mistreatment. Patterns of physical, behavioral and environmental indicators point to a need to question whether mistreatment occurred.[xxi] (Slide 10)

In many cases, patients experience more than one type of mistreatment. For example, according to K. Quinn, then Chief of the Bureau of Elder Rights for the Illinois Department on Aging, more than half of the reports of elder abuse that her agency received involve financial exploitation. Financial exploitation often is tied to other abuse; securing the older person’s money is, in many instances, a motivating factor for other physical or mental abuse.[xxii]

Older victims are more likely to be injured and need medical attention than younger victims of abuse/neglect, due to age-related changes and impairments.

• Because age affects the body's ability to respond to injury and disruptions in physiologic balance, older adults recover from minor injuries at a slower rate than younger people. Older adults may have preexisting diseases, but several studies suggest that chronic disease does not adversely affect survival from trauma. The trauma itself creates morbidity and mortality. [xxiii]

Examples of signs for different types of elder mistreatment, in addition to reports by the patient:[xxiv] (Slide 11)

-Signs of possible emotional/psychological mistreatment

Note that these emotions and behaviors may be present with any type of mistreatment.

• Sudden agitation or confusion;

• Constant crying;

• Problems with sleep;

• Sudden changes in appetite or significant changes in weight;

• Unexplained withdrawal from activities;

• Depression, listlessness and/or non-responsiveness;

• Apathy/helplessness;

• Unusual behavior usually attributed to dementia (e.g., sucking, biting and rocking);

• Vague, chronic and/or non-specific complaints (e.g., victim may partially or vaguely disclose mistreatment to gauge reaction and the trustworthiness of the responder);

• New onset thoughts of suicide or self harm;

• New onset of fear or anxiety around caretaker or in general;

• New pattern in use/misuse of alcohol and drugs; and

• Implausible explanations of events.

-Signs of possible neglect by others:

• Dehydration (as evidenced by low urinary output, dry/fragile skin, dry/sore mouth, apathy, lack of energy and mental confusion)

• Malnutrition and weight loss

• Poor personal hygiene, inappropriate dress and unkempt appearance;

• Skin breakdown/pressure ulcers;

• Unattended/untreated health problems (e.g., as seen by exacerbation of chronic diseases despite a care plan);

• Missed health appointments or delays/lack of follow through with medical care;

• Medication mismanagement (e.g., as seen by empty or unmarked bottles or outdated prescriptions);

• Hazardous or unsafe living condition/arrangements (e.g., improper wiring, no heat or no running water);

• Absence of assistive devices, such as dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces or commodes;

• Unsanitary living conditions (e.g., dirt, fleas or lice on person, soiled bedding, fecal/urine smell, inadequate clothing);

• Implausible explanations of events and/or injuries; and

• Any of the above with emotional/psychological/behavioral signs.

-Signs of possible physical abuse

• Bruises in certain locations[xxv] (e.g., neck, ears, genitals, buttocks, soles of the feet or trunk) or pattern injuries (e.g., bruises or marks in the shape of fingers, wrap-around bruising on arms, legs and torso) not typically associated with accidental bruising in older adults;

• Welts, lacerations and abrasions;

• Open wounds, cuts, punctures, bite marks and other untreated injuries;

• Black eyes, broken eyeglasses/frames, bald spots where hair has been pulled out, rope marks and other physical signs of being subjected to punishment or being physically restrained;

• Bone fractures, broken bones and skull fractures;

• Sprains, dislocations and internal injuries/bleeding;

• Injuries not consistent with the history provided and significant unexplained injuries;

• Laboratory findings of medication overdose or under-utilization of prescribed drugs;

• Repeated accidental injuries and frequent trips to the hospital emergency department (or missed health appointments or delays/lack of follow through with medical care);

• Implausible explanations of events and/or injuries; and

• Any of the above emotional/psychological/behavioral signs.

-Signs of possible sexual abuse

• Bruises around the breasts or genitalia;

• Unexplained sexually transmitted diseases or genital infections;

• Unexplained vaginal or anal bleeding;

• Torn, stained or bloody underclothing;

• Implausible explanations of events and/or injuries; and

• Any of the above emotional/psychological/behavioral signs.

-Signs of possible abandonment

• Desertion of a vulnerable older adult at a hospital, a nursing facility or other similar institution;

• Desertion of a vulnerable older adult at a public location;

• Implausible explanations of events and/or injuries; and

• Any of the above emotional/psychological/behavioral signs.

-Signs of possible financial exploitation

• Older person signing financial documents she/he does not understand;

• Sudden changes in bank account or banking practice (e.g., unexplained withdrawal of money by a person accompanying the vulnerable older adult);

• Inclusion of additional names on an older person's bank signature card;

• Unauthorized withdrawal of a person's funds using ATM card;

• Abrupt changes in a will or other financial documents;

• Unexplained disappearance of funds or valuable possessions;

• Substandard care being provided or bills unpaid despite the availability of adequate financial resources;

• Discovery of an older person's signature being forged for financial transactions or for the titles of her/his possessions;

• Sudden appearance of previously uninvolved relatives claiming their rights to an older person's affairs and possessions;

• Unexplained sudden transfer of assets to a family member or someone outside the family;

• Provision of services that are not necessary;

• Implausible explanations of events; and

• Any of the above emotional/psychological/behavioral signs.

-Signs of possible violation of personal rights

• Forcible eviction or placement in a nursing home;

• Loss of decision-making power or new power of attorney or guardianship put in place;

• Loss of privacy;

• Implausible explanations of events and/or injuries; and

• Any of the above emotional/psychological/behavioral signs.

Behavioral signs of possible perpetrators: for example, minimize or deny abuse of the vulnerable older adult; blame the victim for being clumsy or difficult; are charming and helpful OR abusive to health care or other professionals (e.g., “I’ll call your supervisor” or “I’ll sue you.”); act loving to victim in professional’s presence; answer for the victim; say the victim is incompetent unhealthy or crazy; refuse to allow visitors to see/speak to the older person alone or for health care providers to complete care; agree to a health care plan but never follows through; use the system against the victim by threatening “their rights;” turn family members against the victim; threaten suicide or harm to loved ones or a family pet; take/do not let victim purchase or use/hides certain items (e.g., prayer book and medication); and talk about how good the victim has it or how ungrateful the victim is.[xxvi]

Activity 4: Distinguishing Between Mistreatment and Common Changes in Aging

Facilitate a large group discussion, asking participants to consider:

? What are markers of age-related changes—skin/physiologic changes, cardiovascular changes, gastrointestinal changes, muscle changes, neurological changes, sensory changes, genitourinary changes and hormonal changes?

? What has been your experience in distinguishing mistreatment from these changes as well as medication effects? What are the challenges?

Weave in teaching points below. (40 minutes)

To help facilitate the discussion, consider referring participants to the following on-line resource for an illustration of age-related changes: S. Squires and B. Maloney (Reporters) and T. Linderman (Graphic). How our Bodies Age (and What You Can Do About It). The Washington Post, 2006, on , .

Teaching Points

It can be difficult to distinguish between signs of age-related changes, disease/chronic conditions, medication effects and elder mistreatment. Also, normal age-related changes, disease/chronic conditions and medication effects may affect a vulnerable older adult’s capacity to distinguish abuse/neglect, seek help, give a history of it and/or make decisions about their care.

“The signs of [elder] abuse mimic those of chronic disease and accidental injury. Many common maladies among the elderly may be the result of elder abuse and mistreatment and may be overlooked. The key to interpreting these suspicious signs is not merely noting their presence, but also identifying the characteristics that will help further differentiate between a natural and an intentional occurrence.”[xxvii]

To help differentiate, here are some markers of age-related changes and disease/chronic conditions—[xxviii] (Slides 12 and 13)

• Age-related skin/physiologic changes include (1) loss of skin elasticity leading to wrinkles, folds, sagging and dryness; (2) atrophy of epidermal arterioles leading to poor circulation to the skin resulting in skin breakdown; and (3) decrease in subcutaneous fat on extremities. The functional effects of these changes include easy tearing of the skin, itching, cuts and hyperthermia/hypothermia.

• Age-related cardiovascular changes include: (1) vascular changes such as vessel wall thickening, narrowing lumens, loss of vessel elasticity, decreased valve efficiency and decrease in baroreceptor sensitively leading to orthostatic hypotension, stasis ulcers and dependent edema; and (2) cardiovascular changes including a decrease in muscle fibers and calcification and decreased elasticity of heart valves. The functional effects of these changes include low cardiac output, decreased peripheral circulation, dizziness in changing positions and changes in heart rhythm.

• Age-related gastrointestinal changes include periodontal disease and decrease in saliva, peristalsis and gastric secretions. The functional effects of these changes include loss of teeth, dry mouth and food intolerances.

• Age-related muscle changes include decrease in muscle mass, decalcification of bone and degenerative joint disease. The functional effects of these changes include diminished muscle strength, osteoporosis and limited mobility.

• Age-related neurological changes include degeneration and atrophy of nerve cells, decrease in the number of neurotransmitters and decrease in speed of nerve cell conduction. The functional effects of these changes include memory loss, slow learning and decreased reaction time.

• Age-related sensory changes include decrease in pupil size and yellowing of the lens leading to color distortion, glare, decreased accommodation, thickening of the tympanic membrane of the ear and sclerosis of the inner ear leading to impaired hearing; decrease in taste buds and diminished smell. The functional effects of these changes include reduction between taste and smell; decrease in the number of skin receptors causing a change in touch and sensation; and decreased awareness of body in space may affect balance.

• Age-related genitourinary changes include decreased renal blood flow, number of nephrons and urinary bladder capacity. The functional effects of these changes include decreased absorption of water and electrolytes, longer kidney filtration time and frequent urination.

• Age-related hormonal changes include decrease in thyroid hormone and an increase in cortisol level and pancreatic fibrosis. The functional effects of these changes include a decrease in the response to stress, temperature intolerance and decrease in cell- mediated immunity.

Medication Effects: There is a wide range of potential physical and cognitive side effects that may mask mistreatment or be interpreted as a flag of mistreatment. For example, medication effects may support or lead to the conclusion that the patient is demented.

Activity 5: Family Violence in Later Life, Elder Mistreatment in Institutional Settings and Elder Sexual Abuse

Ask participants to review the following examples of mistreatment[xxix] and then break into small groups and discuss the questions below: (20 minutes) (Slide 13)

1. Mrs. Kim, age 87, was bedridden as a result of severe arthritis. She needed help getting to her walker and getting around the house. She also needed meals prepared for her. Her husband provided care for her because he did not want to pay anyone to help them. He fed his wife only when he felt like it. Some days, he gave her medications and other days he did not in order to save money. When she complained too much, he would overmedicate her to “stop her nagging.” When overmedicated, he would “have sex” with her.

2. Mrs. and Mr. Jefferson lived together for 43 years. Two years ago, their youngest son moved in with them after his divorce. The son worked at the local casino, but drank and gambled away his salary. He threatened to hurt his mother and destroy his father’s reputation in the community (he was an elder on the tribal council) if they did not give him money.

3. APS was called because Mr. Felipe, age 63, was abandoned by his son at a local motel. The son did not pay his father’s motel bill, but continued to cash his father’s Social Security checks. Mr. Felipe was taken from the motel to the hospital for stabilization and treatment. He had uncontrolled hypertension and muscle weakness on his right side with contractures. He had mild dementia and severe depression. He also had a history of seizures and right-sided paralysis due to a stroke. He was completely unable to care for himself. He has a caring brother and sister-in-law, but his son denied him access to all other family members.

4. At age 96, Mr. Connell was living in a nursing home. He was in the last stage of Alzheimer’s disease, was totally bedridden and could not feed or toilet himself. When his daughter visited him, she often found him lying in his own excrement. He had advanced pressure ulcers on his tailbone and heels, as well as bruises around his mouth.

5. After a neighbor’s report, APS found Mrs. Stott, age 78, in her home. She was bedridden and sleeping on a urine-soaked cot. She was brought to the hospital by medics. While she was in the hospital, her adult son visited regularly. Staff described him as “creepy” and would cover their nametags when they saw him coming to avoid having to deal with him. A night nurse walked in to Mrs. Stott’s room and found her son with his head between his mother’s legs. He said he was “cleaning his mother” because staff members were not doing it properly.

Questions to consider: (Slide 14)

? For each case, what is the alleged perpetrator’s relationship with the victim? Where did the mistreatment occur (community or institution)? What types of mistreatment do you think occurred? How does the perpetrator use the victim’s vulnerabilities to control or exploit him/her? Is the victim able to reach out for help?

? What are challenges that nurses might face when presented with these different types of cases?

Comments on questions to help guide discussion:

1. Family violence (neglect and sexual abuse by husband)

2. Family violence (financial exploitation by son)

3. Family violence (abandonment by son)

4. Institutional mistreatment (neglect by staff)

5. Institutional mistreatment/ family violence (sexual abuse by son)

Note overlap; most are not one-time occurrences and emotional/psychological abuse is a factor in most instances.

Challenges nurses might face: For example, victim reluctance to speak out or inability to get help; feeling manipulated by the offender; seeing how offenders control victims; discomfort dealing with cases where health care providers may be offenders; ambiguity of signs and situations; feelings of helplessness to help victims stay safe; and lack of protocols.

Facilitate reporting back to large group for discussion on the questions. Integrate the teaching points below on each type of mistreatment. (50 minutes)

Optional: Prepare the VHS/DVD, CDAA Elder Physical and Sexual Abuse: The Medical Piece, Part 2 for presentation. Before you present on family violence and sexual abuse respectively, play that section of the VHS/DVD. The clips can help further the discussion about challenges posed for nurses in these cases. (This VHS/DVD is also used in an activity in Module 7.) (Add 20 minutes)

Teaching Points

Family Violence in Later Life [xxx]

[pic]

The Abuse in Later Life Wheel[xxxi] (created by the National Clearinghouse on Abuse in Later Life of the Wisconsin Coalition Against Domestic Violence, based on a variation of the Duluth Power and Control Wheel) illustrates the variety of tactics perpetrators use to gain and maintain power and control over their victims.[xxxii] Same goals as in domestic violence with younger people—just may involve different tactics. (Slide 15-16)

• The wheel’s outer rim defines violence or the threat of violence evident in the relationship. Violence may be frequent or limited, but threats and fear are present. Each pie piece represents different tactics that the perpetrator may use in a relationship. Note that the wheel distinguishes between emotional and psychological abuse. With emotional abuse, specific tactics, such as name-calling, put-downs, yelling and verbal attacks, are used to demean the victim. Psychological abuse is the ongoing, manipulative, “crazy making” behavior that becomes an overriding tactic in abusive relationships. The center of the wheel represents the goal/outcome of all of these behaviors for the perpetrator—power and control.[xxxiii]

• Perpetrators often use victims’ vulnerabilities to maintain control over them. For example, a perpetrator may place a walker where a victim could see but not reach it, not drive a victim to church, hurt a beloved pet or threaten to not let the victim see her/his grandkids or other family members. The perpetrator may ridicule the victim’s values and beliefs. These methods can systematically make it more and more difficult for a victim to reach out for help from the systems available to provide services.[xxxiv]

Continuum of family violence in later life: (Slide 17)

• Domestic violence grown old: situations in which abuse has occurred throughout a relationship or marriage. As the victim and abuser age, physical abuse may decrease, while emotional abuse might increase or abuse may have been increasing in recent months or years.

• A new life partnership or marriage that begins in later life is not necessarily immune to abuse. Abuse may occur while the couple is dating or may begin shortly after the couple has moved in together/got married or partnered.

• Late onset abuse: when someone who has not been abusive in the past becomes abusive. One explanation for this form of abuse may be physical or mental health issues now manifesting themselves in combative behavior. Getting a physical and/or mental health exam is an important first step in these cases. Another explanation might be that physical abuse did not occur in the past. But the victim may reveal that controlling behaviors have been present throughout the relationship.

• Adult child, grandchild or other family member: These individuals (who may or may not be caregivers) may become abusive and exploitive.

Health care providers sometimes see vulnerable older adults as frail and dependent on the perpetrator (even if they really are not) and may make decisions for victims rather than assist victims in making their own decisions. It is dangerous to believe perpetrators’ accounts of what happened, tell patients what to do or medicate patients rather than identify mistreatment. (Slides 18-19)

• Providers sometimes fail to understand that family violence at any stage of life may be a criminal act. They may not take it seriously or they may attribute abuse to caregiver stress and not report to APS and/or law enforcement.

• Providers should make safety/support options available to older victims of family violence (e.g., restraining orders and other legal remedies and services).

• Patients should understand a positive response (about whether mistreatment is occurring) could prompt mandatory reporting to law enforcement or APS. They may not want to disclose or may deny violence.

• Provide support/assurance regardless of victims’ decisions—listening with empathy; validating them; educating them about family violence and their options; and helping them plan for safety.

• Don’t blame victims or collude with batterers. Don’t minimize the potential danger to victims or health care providers.

o Recognize that a recommendation of couples/family counseling can imply that victims are at fault for the mistreatment rather than their perpetrators. Stress to victims they are not to blame for the mistreatment and give them the opportunity to decide if and what type of counseling is appropriate for their situation (e.g., individual counseling or counseling with nonoffending family members). If they chose to participate in counseling with their perpetrators, perpetrators should first participate in treatment for their abusive behavior so that counseling does not become another opportunity to manipulate and control their victims.

Strangulation and suffocation: These injuries are associated with domestic violence cases in general. There is a lack of studies on prevalence in older adults, but it is important to look for possible signs of strangulation/suffocation:[xxxv] (Slide 20)

• Strangulation: bruises or fingernail or ligature marks on the neck, bleeding in the throat area and fracture of the hyoid bone (on X-ray).

• Suffocation: petechial hemorrhages/red splotches in the eyes, face, lungs and neck area.

Homicide-suicide:[xxxvi] Among persons aged 55 and older, homicide-suicides do occur, although they are rare events.[xxxvii] A large number of spousal/intimate partner homicide-suicides in the older population involve male caregivers killing their ailing wives and then themselves.[xxxviii] A significant number of these perpetrators were depressed.[xxxix], [xl] For some (about 25 percent), the homicide-suicide is the final act of domestic violence/power and control.[xli] (Slide 20)

Institutional Elder Abuse[xlii]

Research suggests that vulnerable adults living in licensed nursing homes and other residential care facilities, on any given day, are at much higher risk for abuse and neglect than older persons who live at home. (Slide 21)

Factors linked with victimization. Many older adults who live in long-term care settings suffer from several chronic diseases that limit their physical and cognitive functioning and increase their dependence on others.[xliii] Many of these residents are either unable to report mistreatment or are fearful that reporting may lead to retaliation or otherwise negatively affect their lives.[xliv] Their families may share these opinions.

• Residents of long-term care facilities often feel trapped in a closed system, with no alternatives to compliance with perpetrators.[xlv]

• Atlanta Long-Term Care Ombudsman Program 2000.[xlvi] In this study, ombudsmen interviewed 80 residents in 23 nursing homes in Georgia. (Slide 22)

o 44 percent of the residents reported that they had been abused, while 48 percent reported that they had been treated roughly.

o 38 percent reported that they had seen other residents being abused, 44 percent said they had seen other residents being treated roughly.

o 95 percent report they had experienced neglect or witnessed other residents being neglected.

Forms of institutional elder mistreatment mirror those found in domestic settings. In addition, nursing home mistreatment includes institutionalized practices that can result in chronic neglect, substandard care, overcrowding, authoritarian practices and failure to protect residents against untrained, troubled or predatory workers or against abusive or predatory residents or visitors. Subtle forms can include ignoring resident “call button” requests for assistance; denying residents the right to exercise personal choice in such matters as when they want to eat or when they get up or go to bed; pressuring residents to participate in activities; and labeling individuals as troublesome, resulting in depersonalized treatment and exclusion.[xlvii]

Red Flags: Resident examples:[xlviii] (Slide 23)

• Signs/symptoms out of proportion to current problem/resident’s history (e.g., pressure ulcer in low risk client).

• Unexplained injuries or injuries from improbable causes (e.g., bilateral bruises or bruises on the torso).

• Behavioral changes after the resident has visitors or a particular staff member is in the room (e.g., crying, depression, rocking, unresponsiveness or changes in appetite).

• New onset of nightmares and/or sleep disturbances.

• Resident makes vague or indirect references to mistreatment to family/staff to see how they will react.

Who offends? Offenders can be staff, family of residents and/or visitors to the facility. Note that although aggression or violence among residents is not uncommon, it is not generally considered elder mistreatment for the purposes of this course.[xlix] If, for example, a resident had sexual contact with another resident without her/his consent, or if one party lacks the capacity to give legal consent, it would be considered sexual assault or abuse rather than elder mistreatment. However, there may be times when there is some overlap between other forms of interpersonal violence and elder mistreatment. For example, if a couple lives in the same assisted living/nursing facility and domestic violence occurs, it may or may not be elder mistreatment. (Slide 24)

• Factors linked with mistreatment by staff in residential long-term settings—stressful working situations, particularly staffing shortages; staff burnout, often a product of staffing shortages and mandatory overtime; and a combination of resident aggression and poor staff training on how to handle such challenging behaviors.[l] Examples of signs of possible abusive/neglectful staff: personal life is in disarray; lack of caregiving knowledge; verbalizations of great burden, stress and frustration; expressed view of residents as children; unrealistic caregiving expectations; tendency to blame others; complaints of abuse from residents; expressions of negative attitudes; and power and control issues.[li]

Under-reporting of institutional elder mistreatment. Health care professionals who are in a position to detect elder mistreatment rarely do so. They may be unfamiliar with mandatory reporting laws or lack protocols for identifying/addressing suspected cases. Residents and family members underreport because of a reluctance to complain, fear that a formal complaint might generate retaliation by facility against resident or belief that filing formal complaints is futile process. Ombudsmen may not file reports because they view their role as resolving complaints with the facility; they will file a complaint only if unable to resolve. They also may not be authorized to report (e.g., if they don’t have client consent and they didn’t witness the mistreatment). (Slide 25)

Elder Sexual Abuse[lii]

Sexual violence is sexual activity that occurs when an older person is forced, tricked, coerced or manipulated into unwanted sexual contact.[liii] The majority of sexual abuse victims are women, but men are sexually abused too.[liv] The continuum of sexual abuse can include rape, incest, ritual abuse, marital or partner rape, sexual exploitation, unwanted sexual contact, sexual harassment, exposure and voyeurism. For example: (Slide 26)

• The offender forces the victim to view pornography or to listen to explicit sexual accounts or comments;

• Coerced nudity and sexually explicit photographing;

• Sexualized kissing and fondling;

• Oral-genital contact/digital penetration;

• Vaginal rape/anal rape; and

• Rape by objects/attacking victim’s genitals with blows or weapons.

How do older persons react to/cope with being sexual abused, compared to younger persons? (Slide 27)

• They often lack a support system in the aftermath of sexual abuse;

• Their generational beliefs about sexual abuse (e.g., women were not supposed to have sex outside of marriage) and gender roles (e.g., a woman cannot sexually abuse another woman or a husband is entitled to sex from his wife) may increase their reluctance to seek help;

• They may be unwilling to talk about anything sexual in nature;

• Domestic or child sexual abuse that occurred in their lives may not have been recognized or addressed, so they may question the benefit of disclosing elder sexual abuse; and

• They may have longer recovery times emotionally and be more likely to internalize their feelings and not seek treatment.

How is sexual abuse physically different for older persons? (Slide 27)

• Increased chance of sustaining serious injury;

• Increased vaginal or anal tearing and bruising that may never fully heal;

• Brittle pelvis or hip bones can be broken by friction or weight;

• Increased risk of infections (due to risk of tearing/lack of medical attention);

• Exacerbation of existing illnesses; and

• Less likelihood that the sexual abuse will be reported, especially immediately after the abuse when treatment for injuries and sexually transmitted infections (STIs) is most important.

Who are the victims? Similar to elder abuse in general.

An overwhelming majority of older persons who are sexually abused have cognitive impairments and/or functional limitations.[lv]

Who are the offenders? Vast majority are male. (Slide 28)

• Intimate partner with domestic violence history (including sexual violence);

• Adult son or grandson;

• Caregiver in home; and

• Caregiver in the facility.

In addition to what we know about reluctance of older persons to reporting mistreatment, in general, other barriers to self-reporting elder sexual abuse may include: (Slide 29)

• Lack of education about sexual violence;

• Lack of language skills to explain sexual abuse;

• In long-term abusive relationship/unaware of marital rape laws; and

• Uncomfortable talking about sexual issues with much younger health care provider/officer/advocate/prosecutor.

Activity 6: Closing Assessment

Ask participants to write down one important thing they learned about (1) prevalence of elder mistreatment; (2) signs of possible elder mistreatment; and (3) health care challenges when responding to domestic violence in later life, mistreatment in institutional settings and sexual abuse. Also, write down one important thing that they will change in their practice based on what they learned. (Slide 30)

Then, in a large discussion, ask participants to share this information.

Also share suggestions for additional reading as listed in the Participant Materials.

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[i] R. Bonnie & R. Wallace (Eds.), Elder mistreatment, abuse, neglect and exploitation in an aging America (Washington, DC: National Academies Press, 2003), 39, .

[ii] Bonnie & Wallace, 10.

[iii] Paragraph from Bonnie & Wallace, 78.

[iv] See L. Mosqueda, K. Burnight & S. Liao, Bruising in the geriatric population (Orange, CA: University of California, Irvine College of Medicine, Program in Geriatrics, 2006), pdffiles1/nij/grants/214649.pdf. This study found, among other things, that most large bruises that are accidentally inflicted on older adults are on the extremities.

[v] “Prevalence” refers to the total number of people who have experienced elder mistreatment in a specified time period. National Center on Elder Abuse, Elder abuse prevalence and incidence (Fact sheet) (Newark, DE: Author, 2003), .

[vi] National Center on Elder Abuse.

[vii] For more statistics, see National Center on Elder Abuse, Elder abuse prevalence and incidence (Fact sheet) and National Center on Elder Abuse, Frequently asked questions, .

[viii] Bonnie & Wallace, Preface. This estimate is “based on figures extrapolated from local studies.”

[ix] M. Lachs & K. Pillemer, Elder abuse, Lancet, 364 (2004), 1192-1263.

[x] Statistics in this section, unless noted, are drawn from K. Collins, Elder maltreatment—A review, Archives of Pathology and Laboratory Medicine (September 2006), through bnet, (2010).

[xi] K. Pillemer & D. Finkelhor, The prevalence of elder abuse: A random sample survey, The Gerontologist, 28 (1988), 51-7. As cited in Collins.

[xii] National Center on Elder Abuse, National elder abuse incidence study (Washington, DC: Administration on Aging and Administration for Children and Families, U.S. Department of Health and Human Services, 1998), .

[xiii] National Center on Elder Abuse, Abuse of adults aged 60+, 2004 survey of adult protective services (Fact sheet) (Newark, DE: Author, 2006), .

[xiv] For a more extensive discussion on obstacles faced by older victims to getting help, see B. Brandl, C. Bitondo Dyer, C. Heisler, J. Marlatt Otto, L. Stiegel & R. Thomas, Elder abuse detection and intervention: A collaborative approach (New York: Springer Publishing Company, 2007), 52-57. Also see F. Kahan & B. Paris, Why elder abuse continues to elude the health care system, The Mount Sinai Journal of Medicine, 70(1) (2003), 66.

[xv] K. Kleinschmidt, Elder abuse: A review, Annals of Emergency Medicine, 30 (1997), 463- 472. As cited in Collins.

[xvi] Pillemer & Finkelhor.

[xvii] J. Lett, Abuse of the elderly, Journal of the Florida Medical Association, 82 (1995), 675-678; K. Collins, Elder abuse, in R. Froede (Ed.), Handbook of forensic pathology (2nd Ed.), (Northfield, Ill: College of American Pathologists, 2003), 257-264; J. Levine, Elder neglect and abuse: A primer for primary care physicians, Geriatrics, 58 (2003), 37-40 and 42-44; D. Swaggerty, P. Takahashi & J. Evans, Elderly mistreatment, American Family Physician, 59 (1999), 1-8; R. Steiner, K. Vansickle & S.B. Lippmann, Domestic violence: Do you know when and how to intervene? Postgraduate Medicine, 100 (1996), 103-116; M. Janz, Clues to elder abuse, Geriatric Nursing, 11 (1990), 220-222; M. Lachs & K. Pillemer, Abuse and neglect of elderly persons, New England Journal of Medicine, 332 (1995), 437-443; and M. Lach, C. Williams, S. O'Brien, K. Pillemer & M. Charlson, The mortality of elder mistreatment, Journal of the American Medical Association, 280 (1998), 428-432. As cited in Collins.

[xviii] Bonnie & Wallace, 91.

[xix] National Clearinghouse on Abuse in Later Life, Interactive training exercises on domestic abuse in later life (Madison, WI: Wisconsin Coalition Against Domestic Violence, 2003), 9-10, .

[xx] S. Aravanis, R. Adelman, R. Breckman, T. Fulmer, E. Holder, M. Lachs, J. O’Brien & A. Sanders, Diagnostic and treatment guidelines on elder abuse and neglect, Archive of Family Medicine, 2 (1993), 371-388, .

[xxi] See National Center on Elder Abuse, Frequently asked questions (Newark, DE: Author, last modified 2009), , and Center for Substance Abuse Prevention, Out of the shadows: Uncovering substance use and elder abuse (Online course module 4), (Washington, DC: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, last updated 2004), .

[xxii] Office of Justice Programs, Financial exploitation and consumer fraud: Innovative approaches to financial exploitation, Our aging population: Promoting empowerment, preventing victimization, and implementing coordinated interventions, a national symposium, a report of proceedings (Washington, DC: U.S. Department of Justice and U.S. Department of Health and Human Services, 2003), .

[xxiii] K. Brown, G. Streubert & A. Burgess, Effectively detect and manage elder (8), (2004), 22-31, . Also see Lach, Williams, Brien, Pillemer & Charlson, The mortality of elder mistreatment, and X. Dong, M. Simon, C. Mendes de Leon, T. Fulmer, T. Beck, L. Hebert, C. Dyer, G. Paveza & D. Evans, Elder self-neglect and abuse and mortality risk in a community dwelling population, Journal of the American Medical Association, 302(5) (2009), 517-26.

[xxiv] List of indicators adapted from the following sources: Health and Human Services, Office of Elder Services of Maine, ; Center for Substance Abuse Prevention; National Center on Elder Abuse, Major types of abuse (Newark, DE: Author, last modified 2007), ; and Shan-Wei Ko, Elder mistreatment, Healthcare , (2010).

[xxv] L. Mosqueda, K. Burnight & S. Liao, Bruising in the Geriatric Population (Orange, CA: University of California, Irvine College of Medicine, Program in Geriatrics, 2006), pdffiles1/nij/grants/214649.pdf. Results of this study suggest that accidental bruises occur in a predictable pattern in older adults. Nearly 90 percent of the bruises were on the extremities and in daily observation of 101 older adults, not a single accidental bruise was observed on the neck, ears, genitals, buttocks or soles of the feet. Most large bruises that are accidentally inflicted are on the extremities. Of the 20 large bruises (5 to 50 cm) in this study, only one was on the trunk. Moreover, older adults are significantly more likely to know how the bruise happened if the bruise is on the trunk. Also see A. Wigglesworth, R. Austin, M. Corona, D. Schneider, S. Liao, L. Gibbs & L. Mosqueda, Bruising as a marker of physical elder abuse, Journal of the American Geriatric Society, 57(7) (2009), 1191-1196.

[xxvi] B. Brandl, Assessing for abuse in later life (Madison, WI: National Clearinghouse on Abuse in Later Life, Wisconsin Coalition Against Domestic Violence, 2004), 8.

[xxvii] C. Pearsall, Forensic biomarkers of elder abuse: What clinicians need to know, Journal of Forensic Medicine, 1(4) (2005), 182-6.

[xxviii] This section was drawn primarily from material from the original draft of this curriculum. Also see Collins.

[xxix] Examples excerpted either directly or with slight adaptation from B. Brandl, C. Bitondo Dyer, C. Heisler, J. Marlatt Otto, L. Stiegel & R. Thomas, 64-71.

[xxx] Data (before bullet on Strangulation/Suffocation) gleaned, except where noted, from B. Brandl & D. Horan, Domestic violence in later life: An overview for health care providers, Women and Health, 35(2/3) (2002), 41-54, .

[xxxi] National Clearinghouse on Abuse in Later Life, Abuse in later life wheel (Madison, WI: Wisconsin Coalition Against Domestic Violence, 2006), .

[xxxii] National Clearinghouse on Abuse in Later Life, Interactive training exercises, 10.

[xxxiii] National Clearinghouse on Abuse in Later Life, Abuse in later life wheel, 2.

[xxxiv] First two paragraphs in this section from National Clearinghouse on Abuse in Later Life, Interactive training exercises, 9-10.

[xxxv] Also see K. Collins & S. Presnell, Elder homicide: A 20-year study, American Journal of Forensic Medicine and Pathology, 27(2) (2006), 183-187.

[xxxvi] Also see D. Cohen, Homicide-suicide in older people, Psychiatric Times, 17(1) (2000); D. Cohen, An update on homicide-suicide in older persons, Journal of Mental Health and Aging, 6(3) (2000), 195-197; D. Cohen & J. Malphurs, A newspaper surveillance study of homicide-suicide in the United States, American Journal of Forensic Medicine and Pathology, 23 (2002), 142–8; and J. Malphurs, C. Eisdorfer & D. Cohen, A comparison of older married men, American Journal of Geriatric Psychiatry, 9(1) (2001), 49-57.

[xxxvii] S. Eliason, Murder-suicide: A review of the recent literature, Journal of American Academy of Psychiatry and the Law, 37 (2009), 375.

[xxxviii] D. Cohen, M. Llorente & C. Eisdorfer, Homicide-suicide in older persons, American Journal of Psychiatry, 155 (1998), 390–6. This study found that 83 percent of homicide-suicides in the older age groups (over 55 years) were of the spousal/intimate partner type. The older couples were more likely to have medical illnesses, while the younger couples were more likely to have a history of verbal discord. Separation was also predominant among the younger couples, but not as frequent in the older couples. As cited in Eliason.

[xxxix] D. Cohen & J. Malphurs, A statewide case-control study of spousal

homicide-suicide in older persons, American Journal of Geriatric Psychiatry, 13 (2005), 211–17. This study of spousal homicide-suicide in older persons, found that 65 percent of homicide-suicide perpetrators were depressed. As cited in Eliason.

[xl] Cohen, Llorente & Eisdorfer’s study, Homicide-suicide in older persons, found that in the two groups of older persons studied, 37 and 19 percent had depression. As cited in Eliason.

[xli] In Cohen & Malphur’s statewide case-control study of spousal homicide-suicide in older persons, 25 percent of the homicide-suicide perpetrators studied had a history of domestic violence. As cited in Eliason.

[xlii] Except where noted, data for this section is gleaned primarily from C. Hawes, Elder abuse in residential long-term care settings: What Is known and what information Is needed?, in Bonnie & Wallace, 446-500.

[xliii] W. Spector, J. Fleishman, L. Pezzin & B. Spillma, Characteristics of long-term care users (Rockville, MD: Institute of Medicine, Committee on Improving Quality in Long-Term Care, Agency for Healthcare Research and Quality, 2001). As cited in Hawes.

[xliv] D. Hayley, C. Cassel, L. Synder & M. Rudberg, Ethical and legal issues in nursing home care, Archives of Internal Medicine, 156(3) (1996), 249-256. As cited in Hawes.

[xlv] L. Phillips, Issues in identification of mistreated elders (Tucson, AZ: Arizona Geriatric Education Center, Arizona Center on Aging, University of Arizona), .

[xlvi] Atlanta Long-Term Care Ombudsman Program. The silenced voice speaks out: A study of abuse and neglect of nursing home residents (Atlanta, GA: Atlanta Legal Aid Society and Washington, DC: National Citizens Coalition for Nursing Home Reform, 2002).

[xlvii] D. Meddaugh, Covert elder abuse in the nursing home, Journal of Elder Abuse & Neglect, 5 (3) (1993), 21-3. As cited in L. Nerenberg, Abuse in nursing homes, Newsletter of the National Center on Elder Abuse , 4(10) (2002), 10, .

[xlviii] Phillips.

[xlix] For more on this topic, see T. Rosen, K. Pillemer & M. Lachs, Resident-to-resident aggression in long-term care facilities: An understudied problem, Aggression and Violent Behavior, 13 (2008), 77-87. Note one high-risk population includes sex offenders who are residents in long-term care facilities—they do not necessarily stop being predators just because they are old and possibly impaired in their functioning. (See W. Bledsoe, Criminal offenders residing in long-term care facilities, Journal of Forensic Nursing, 2(3) (2006), 142-6).

[l] Phillips.

[li] Phillips.

[lii] Data for this section on sexual abuse gleaned, except where noted, from K. Vierthaler, Addressing elder sexual abuse: Developing a community response (Module 3) (Enola, PA: Pennsylvania Coalition Against Rape and Harrisburg, PA: Pennsylvania Department of Aging, 2004), ; and Florida Council Against Sexual Violence, Elder Sexual Abuse: The Hidden Victim, A Training for Law Enforcement (Module 1) (Tallahassee, FL: author, 2002).

[liii] Speaking the unspeakable: An interview about elder sexual assault

with H. Ramsey-Klawsnik, Nexus, A Publication for National

Committee for the Prevention of Elder Abuse Affiliates (1998),

. As cited in Vierthaler.

[liv] In a study of 284 cases of elder sexual abuse and assault, 93 percent of the victims were women. A. Burgess, Elderly victims of sexual abuse and their offenders (Chestnut Hill, MA: Boston College, Connell School of Nursing, 2006), 4, .

[lv] H. Ramsey-Klawsnik, Elder sexual abuse: Preliminary findings, Journal of Elder Abuse and Neglect, 3(3) (1991), 73-90; M. Holt, Elder sexual abuse in Britain: Preliminary findings, Journal of Elder Abuse and Neglect, 5(2) (1993), 63-71; and P. Teaster, K. Roberto, J. Duke & M. Kim, Sexual abuse of older adults: Preliminary finding of cases in Virginia, Journal of Elder Abuse and Neglect,12(3/4) (2001), 1-16. As cited in C. Bitondo Dyer, M. Connolly & P. McFeeley, The clinical and medical forensics of elder abuse and neglect, in Bonnie & Wallace, 358. Also see H. Ramsey-Klawsnik, Sexual abuse in the family, Journal of Elder Abuse and Neglect, 15(1) (2003), 43-58; P. Teaster & K. Roberto, Sexual abuse of older women living in nursing homes, Journal of Gerontological Social Work, 40 (2003), 105-119; and P. Teaster & K. Roberto, Sexual abuse of older adults: APS cases and outcomes, The Geronologist, 44(6) (2004), 788-796.

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Total Time

3.5 hours

4 hours with optional activity

35 minutes total

Slides 2-6

35 minutes total

Slides 7-9

25 minutes total

Slides 10-11

40 minutes total

Slide 12

70 minutes

Add 20 for optional activity.

Slides 13-29

5 minutes total

Slide 30

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