Detection of Elder Mistreatment

 

OVERVIEW

With the projected increase in the population of older adults worldwide and the rise in medical and technological advances, it is anticipated that older adults will continue to live longer. Therefore, it is expected that cases of EM, although currently underreported, will rise. As patient advocates and providers of care, nurses serve an important function in the screening and treatment of cases of EM. However, current data show that nurses and other healthcare professionals do not report all cases of EM they encounter either due to lack of knowledge about the manifestations of EM or how reporting and investigation by state agencies function.

 

BACKGROUND/STATEMENT OF PROBLEM

A. Definitions

  1. EM: “Intentional actions that cause harm or create serious risk of harm (whether harm is intended) to a vulnerable elder by a caregiver or other person who is in a trust relationship to the elder,” or “failure by a caregiver to satisfy the elder’s basic needs or to protect himself or herself from harm” (National Research Council, 2003). There are conflicting causal theories of EM.
  2. Physical abuse: This refers to use of physical force that may result in bodily injury, physical pain, or impairment.
  3. Sexual abuse: This is any form of sexual activity or contact without consent, including with those unable to provide consent.
  4. Emotional/psychological abuse: This refers to infliction of anguish, pain, or distress through verbal or nonverbal acts.
  5. Financial abuse/exploitation: This refers to illegal or improper use of an elder’s funds, property, or assets.
  6. Caregiver neglect: This refers to refusal or failure to fulfill any part of a person’s obligations or duties to an older adult, including social stimulation.
  7. Self-neglect: This refers to the behavior of an older adult that threatens their own health or safety; disregard for one’s personal well-being and home environment.
  8. Risk and vulnerability model: This model posits that neglect is caused by the interaction of factors within the older adult and their environment. The risk and vulnerability model adapted to EM by Frost and Willette provides a good lens through which to examine EM. Vulnerability is determined by characteristics within the older adult that increase their risk of being abused by caregivers, such as poor health status, impaired cognition, and history of abuse. Risks refer to factors in the environment that may predispose an older adult to EM and may include characteristics of caregivers, such as health and functional status, as well as a lack of resources and social isolation.
  9. Situational theory: This theory was first used to explain the causes of child abuse. The situational theory promotes the idea that stressful family conditions contribute to mistreatment. Thus, EM may be viewed as a consequence of caregiver strain because of the overwhelming tasks of caring for a vulnerable or frail older adult.
  10. Psychopathology of the abuser: This posits that mistreatment stems from a perpetrator’s own battle with psychological illness, such as substance use, depression, and other mental disorders.
  11. Social exchange theory: This theory speculates that the long-established dependencies present in the victim–perpetrator relationship are responses developed within the family and then continue into adulthood.
  12. Social learning theory: This theory attributes mistreatment to learned behavior on the part of the perpetrator or victim from either family life or the environment.
  13. Political economy theory: This theory focuses on how older adults are often disenfranchised in society as their prior responsibilities and even their self-care are shifted onto others.

B. Characteristics of victims

  1. Decreased ability to complete ADL and more physically frail
  2. Cognitive deficits such as dementia
  3. History of trauma earlier in life
  4. Depression and other mental disorders, as well as an increased sense of hopelessness
  5. Social isolation and lack of support systems
  6. History of substance abuse

C. Characteristics of perpetrators

  1. Most commonly family members
  2. Long history of conflict with the victim
  3. Lived with victim for an extended time
  4. Higher rates of caregiver strain
  5. History of mental illness and substance abuse
  6. Depression and other mental disorders
  7. Social isolation and lack of support systems

D. Etiology and/or epidemiology

  1. Data from the National Research Council suggest that more than two million older adults suffer from at least one form of EM annually.
  2. The National Elder Abuse Incidence Study estimates that more than half a million new cases of EM occurred in 1996.
  3. Even though 44 states and the District of Columbia have legally required mandated reporting, EM is severely underreported. There is a lack of uniformity across the United States on how cases of EM are handled.
  4. The NCEA estimates that only 16% of cases of abuse are actually reported.
  5. More than 70% of cases received by APS are attributed to cases of self-neglect, with those older than 80 years thought to represent more than half of these cases.

PARAMETERS OF ASSESSMENT

A. See Table 15.2.

NURSING CARE STRATEGIES

A. Provide detailed screening to assess for risk factors for EM using a combination of physical assessment, subjective information, and data gathered from screening instruments.

B. Strive to develop a trusting relationship with the older adult as well as the caregiver. Set aside time to meet with each individually.

C. Use of interdisciplinary teams with a diversity of experience, knowledge, and skills can lead to improvements in the detection and management of cases of EM. Early intervention by interdisciplinary teams can help lower risk of worsening abuse and further deficits in health status.

D. Institutions should develop guidelines for responding to cases of EM.

E. Institutions should implement culturally appropriate strategies for identifying and addressing EM in racial/ethnic minority older adults.

F. Educate victims about patterns of EM such that EM tends to worsen in severity over time.

G. Provide older adults with emergency contact numbers and community resources.

H. Refer to appropriate regulatory agencies.

EVALUATION AND EXPECTED OUTCOMES

A. Reduction of harm through referrals, use of interdisciplinary interventions, and/or relocation to a safer situation and environment.

B. Victims of EM verbalize an understanding of how to access appropriate services.

C. Caregivers use services, such as respite care or treatment, for mental illness or substance use.

D. If possible, evaluate progress in relationships between the caregiver and the older adult through screening instruments, such as the Modified CSI and GDS, among other tools freely available at hign.org/consultgeri-resources/try-this-series.

E. Institutional establishment of clear and evidence-based guidelines for management of EM cases.

FOLLOW-UP MONITORING OF CONDITION

A. Follow-up monitoring in the acute care setting is limited compared with the follow-up that may be performed in the community or long-term care settings.

RELEVANT PRACTICE GUIDELINES

A. AMA, Diagnostic and treatment guidelines on elder abuse and neglect.

ABBREVIATIONS

AMA       American Medical Association

ADL        activities of daily living

APS        adult protective services

CSI         Caregiver Strain Index

EM         elder mistreatment

GDS       Geriatric Depression Scale

NCEA     National Center on Elder Abuse

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 15, Fulmer, T.T., Lees-Haggerty, K., Stoekle, R. & Ali, E. (2025) Elder Mistreatment Detection

 

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