ELDER AND VULNERABLE PERSON ABUSE, NEGLECT, AND …



Participant Materials

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.

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.

Case Study Introduction

Case study

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:

? 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?

Key Points

In the course of their interactions with patients, nurses may suspect elder mistreatment in either domestic (community) or institutional settings. 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]

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

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).

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

To respond in these cases, nurses involved need clarifying data to further detect or rule out elder mistreatment (gathered in the course of screening, medical history taking, complete examination and discussions with others who present with the patient).

Data on Elder Mistreatment[iii]

Consider the following questions:

? What misconceptions about the extent and nature of elder mistreatment have you seen held as truth in your work setting or in your communities?

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

Key Points

No one knows precisely how many older adults are mistreated—surveillance is limited and the problem remains greatly hidden.

Best available estimates on prevalence:[iv]

• 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.[v] (2003)

• Between 2 and 10 percent of older adults 65+ are victims of some form of abuse or neglect.[vi] (2004)

Reporting and Risk Factors[vii]

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

-Who are the victims? Abuse of Aged 60+, 2004 Survey of Adult Protective Services found two thirds of victims were 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. Often, victims are dependent on their 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.[xi]

• One study showed that two-thirds of perpetrators were spouses and one-third were adult children.[xii] 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.[xiii]

-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.).[xiv]

- 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.”[xv]

-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.[xvi] Whether intentional or unintentional, however, mistreatment can have serious detrimental outcomes for older individuals and should be addressed. *It is not up to the nurse/healthcare provider to determine whether mistreatment is intentional or unintentional.*

Signs of Possible Elder Mistreatment

Key Points

Below are examples of signs of types of possible elder mistreatment, in addition to reports by the patient.[xvii] See Module 7 for more on indicators.

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[xviii] (e.g., neck, ears, genitals, buttocks, soles of the feet or trunk) or pattern injuries (i.e., 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; new power of attorney or guardianship 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; and, talk about how good the victim has it or how ungrateful the victim is.[xix]

Distinguishing Mistreatment from Changes in Aging

See 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, , .

Questions 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?

Key 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.

To help differentiate, here are some markers of health changes related to aging and disease/chronic conditions—[xx]

• 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.

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

Examples of family violence in later life, institutional elder mistreatment and elder sexual abuse.[xxi]

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 related to the above examples:

? 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?

Key Points

Family Violence[xxii]

[pic]

The Abuse in Later Life Wheel[xxiii] (created by 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 victims in a relationship.[xxiv] Note psychological abuse is an overriding factor in abusive relationships.

Perpetrators often use victims’ vulnerabilities to maintain control. For example, a perpetrator may place a walker where a victim could see but not reach it, not drive a victim to church or threaten to not let the victim see her/his grandkids or other family members or hurt a beloved pet.[xxv] The perpetrator may ridicule the victim’s values and beliefs.

Continuum of family violence in later life:

• Domestic violence grown old: those situations in which violence has occurred throughout a relationship or marriage.

• A new life partnership or marriage that begins in later life is not necessarily immune to violence. Violence may occur while the couple is dating or may begin shortly after they move in together/got married or partnered.

• Late onset abuse: when someone who has not been abusive in the past becomes abusive.

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

• 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).

• 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 healthcare providers.

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:[xxvi] (Slide 21)

• 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:[xxvii] Among persons aged 55 and older, homicide-suicides do occur, although they are rare events.[xxviii] A large number of spousal/intimate partner homicide-suicides in the older population involve male caregivers killing their ailing wives and then themselves.[xxix] A significant number of these perpetrators were depressed.[xxx],[xxxi] For some (about 25 percent), the homicide-suicide is the final act of domestic violence/power and control.[xxxii] (Slide 21)

Institutional Elder Abuse[xxxiii]

Research suggests that 2.5 million 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.

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.[xxxiv] 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.[xxxv] 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 abusers.[xxxvi]

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

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: 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” troublesome individuals, resulting in depersonalized treatment and exclusion.[xxxviii]

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.[xxxix] 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 or nursing facility and domestic violence occurs, it may or may not be elder mistreatment.

• 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.[xl] 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.[xli]

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; 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).

Elder Sexual Abuse[xlii]

Sexual violence is sexual activity that occurs when an older person is forced, tricked, coerced or manipulated into unwanted sexual contact.[xliii] The majority of sexual abuse victims are women, but men are sexually abused too.[xliv] 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:

• 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?

• 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?

• 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 victims of elder mistreatment in general.

Who are the offenders? Vast majority are male.

• 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 already know about elder abuse in general, added barriers to self-reporting elder sexual abuse:

• 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.

Suggested Additional Reading

Burgess, A. (2006). Elderly victims of sexual abuse and their offenders. Chestnut Hill, MA: Boston College Connell School of Nursing. Retrieved from . This exploratory study provided evidence that adults aged 60 and older may be victims of sexual abuse and assault in their own homes, in nursing homes and in the community and implies that age is no protection against sexual victimization. Recorded data from 284 cases were analyzed on elders referred to law enforcement or to adult protective services for investigation of suspected sexual abuse.

National Center on Elder Abuse. (n.d.). Reports and studies, nursing home abuse. Retrieved from . Through this site, access C. Hawes, Elder abuse in residential long-term care facilities: What is known about prevalence, causes and prevention, among other documents.

National Center on Elder Abuse. (Last modified 2007). Prevention of abuse and neglect in long term care settings. Newark, DE: author. Retrieved from .

National Clearinghouse on Abuse in Later Life. (2003). Interactive training exercises on domestic abuse in later life (pp. 8-10). Madison, WI: Wisconsin Coalition Against Domestic Violence. Retrieved from .

National Clearinghouse on Abuse in Later Life. (2006). Frequently asked questions. Madison, WI: Wisconsin Coalition Against Domestic Violence. Retrieved from

Payne, B. (2003). Preventing elder abuse requires an integrated approach. Quest: A Newsletter of Old Dominion University, 6(2). Retrieved from .

Squires, S., & Maloney, B. (Reporters), & Linderman, T. (Graphic artist). (December 5, 2006). How our bodies age (and what you can do about It). The Washington Post. Retrieved from .

Vierthaler, K. (2005). Addressing elder sexual abuse: Developing a community response (Module 3, pp. 15-7). Enola, PA: Project of Pennsylvania Coalition Against Rape and Harrisburg, PA: Pennsylvania Department of Aging. Retrieved from and . Limitations: Note this fact sheet summarizes statistics and information from six studies on elder sexual abuse. Most were conducted in the 1990s; two were conducted in 2000. Research on elder sexual assault was just beginning at that time, so studies were small and conducted under limiting circumstances. 129 was the largest sampling of victims—not a large enough sample to apply statistics to the general elder population. There was also no random sampling of the population. Each case study was gathered under specific circumstances—most used the memory of protective service workers (thus only using reported cases), while others used women from a nursing home sent to a forensic nurse for treatment or women seeking treatment from a medical doctor or rape crisis center. Some studies used only residential cases, others only nursing home cases. Although these studies can assist in identifying trends, no study used was a large sampling of the population of men and women age 60 or 65 and older. Thus, no study offered statistical information that could be applied to the general elder population.

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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] “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), .

[iv] 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, .

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

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

[vii] 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).

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

[ix] 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), .

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

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

[xii] K. Pillemer & D. Finkelhor, The prevalence of elder abuse: A random sample survey. The Gerontologist, 28 (1988), 51-57. As cited in Collins.

[xiii] 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.

[xiv] Bonnie & Wallace, 91.

[xv] 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, .

[xvi] 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, .

[xvii] 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).

[xviii]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.

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

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

[xxi] Examples excerpted either directly or with slight adaptation from B. Brandl, C. Bitondo Dyer, C.J. Heisler, J. Marlatt Otto, L. Stiegel & R. Thomas, Elder abuse detection and intervention: A collaborative approach (New York: Springer Publishing Company, 2007), 64-71.

[xxii] 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, .

[xxiii] National Clearinghouse on Abuse in Later Life, Abuse in Later Life Wheel (Madison, WI: Wisconsin Coalition Against Domestic Violence, 2006), .

[xxiv] National Clearinghouse on Abuse in Later Life, Interactive Training Exercises, 10.

[xxv] First two paragraphs in this section from National Clearinghouse on Abuse in Later Life, Interactive Training Exercises, 9-10.

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

[xxvii] 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..

[xxviii] S. Eliason, Murder-Suicide: A Review of the Recent Literature, J Am Acad Psychiatry Law, 37, 2009: 375.

[xxix] 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.

[xxx] 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.

[xxxi] 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.

[xxxii] D. Cohen and 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.

[xxxiii] 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.

[xxxiv] 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.

[xxxv] 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.

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

[xxxvii] 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).

[xxxviii] 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, .

[xxxix] 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).

[xl] Phillips.

[xli] Phillips.

[xlii] 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).

[xliii] 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.

[xliv] 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, .

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Source: National Clearinghouse on Abuse in Later Life of the Wisconsin Coalition Against Domestic Violence., 2006. Based on the Power and Control/Equality wheels developed by the Domestic Violence Intervention Project, Duluth, MN

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