Elder Mistreatment (EM)
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 because of lack of knowledge either about manifestations of EM or about how reporting and investigation by state agencies function.
BACKGROUND/STATEMENT OF PROBLEM
- Elder mistreatment: “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” (NRC, 2003, p. 1). There are conflicting casual theories of EM.
- Physical abuse: “The use of physical force that may result in bodily injury, physical pain, or impairment” (NCEA, 2008).
- Sexual abuse: Any form of sexual activity or contact without consent, including with those unable to provide consent (NCEA, 2008).
- Emotional/psychological abuse: “The infliction of anguish, pain, or distress through verbal or nonverbal acts” (NCEA, 2008).
- Financial abuse/exploitation: “The illegal or improper use of an elder’s funds, property, or assets” (Naik et al., 2008).
- Caregiver neglect: “The refusal or failure to fulfill any part of a person’s obligations or duties to an” older adult, including social stimulation (NCEA, 2008).
- Self-neglect: The behavior of an older adult that threatens his or her own health or safety. Disregard of one’s personal well-being and home environment (NCEA, 2008).
- Risk-vulnerability model: This model posits that neglect is caused by the interaction of factors within the older adult and his or her environment. The risk and vulnerability model adapted to EM by Frost and Willette (1994) provides a good lens through which to examine EM. Vulnerability is determined by characteristics within the older adult that increase his or her 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 (Fulmer et al., 2005).
- Situational theory: This theory was first used to explain 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 (Straus, 1971).
- 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 (Gelles & Straus, 1979).
- Social exchange theory: This theory speculates that the long-established dependencies present in the victim–perpetrator relationship are responses developed within the family that then continue into adulthood (Gelles, 1983).
- Social learning theory: This was developed by Bandura (1978), and this theory attributes mistreatment to learned behavior on the part of the perpetrator or victim from either family life or the environment.
- 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 (Walker, 1981).
B. Characteristics of victims
- Decreased ability to complete ADL and more physically frail (Dyer et al., 2000; Frost & Willette, 1994; Peisah et al., 2009)
- Cognitive deficits such as dementia (Dong et al., 2012; Fulmer et al., 2005; Gorbien & Eisenstein, 2005; Naik et al., 2008)
- History of trauma earlier in life (Brozowski & Hall, 2010; DeLiema et al., 2012; Draper et al., 2008; Fulmer et al., 2005)
- Depression and other mental disorders, as well as an increased sense of hopelessness (Dong et al., 2012; Dyer et al., 2000; Fulmer et al., 2005; Johannesen & LoGiudice, 2013)
- Social isolation and lack of support systems (Acierno et al., 2010; Cannell et al., 2014; Draper et al., 2008; Dyer et al., 2000; Peisah et al., 2009)
- History of substance abuse (Dyer et al., 2000; Peisah et al., 2009)
C. Characteristics of perpetrators
- Most commonly, family members
- Long history of conflict with the victim (Krienert, Walsh, & Turner, 2009)
- Lived with victim for an extended time (Rizzo et al., 2015; Wiglesworth et al., 2010)
- Higher rates of caregiver strain (Strasser, Smith, Weaver, Zheng, & Cao, 2013; Wiglesworth et al., 2010)
- History of mental illness and substance abuse (Jackson & Hafemeister, 2013; Wiglesworth et al., 2010)
- Depression and other mental disorders (Giurani & Hasan, 2000; Johannesen & LoGiudice, 2013; Wiglesworth et al., 2010)
- Social isolation and lack of support systems (Wiglesworth et al., 2010)
D. Etiology and/or epidemiology
- Data from the National Research Council (2003) suggest that more than two million older adults suffer from at least one form of EM annually.
- The National Elder Abuse Incidence Study estimates that more than half a million new cases of EM occurred in 1996 (NCEA, 1998).
- Even though 44 states and the District of Columbia have legally required mandated reporting, EM is severely underreported. There is a lack in uniformity across the United States on how cases of EM are handled (NCEA, 1998).
- NCEA (1998) estimates that only 16% of cases of abuse are actually reported.
- The National Council on Elder Abuse revealed that neglect accounts for approximately half of all cases of EM reported to APS. About 39.3% of these cases were classified as self-neglect, and 21.6% were attributed to caregiver neglect, including both intentional and unintentional (NRC, 2003).
- 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 (Burnes, Rizzo, Gorroochurn, Pollack, & Lachs, 2016).
NURSING CARE STRATEGIES
A. Detailed screening is important to assess for risk factors for EM using a combination of physical assessment, subjective information, and data gathered from screening instruments (Perel-Levin & World Health Organization, 2008).
B. Strive to develop a trusting relationship with the older adult as well as the caregiver. Set aside time to meet with each individually (Perel-Levin & World Health Organization, 2008).
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 the risk for worsening abuse and further deficits in health status (Jayawardena & Liao, 2006; Rizzo et al., 2015; Wiglesworth et al., 2010).
D. Institutions should develop guidelines for responding to cases of EM (De Donder, De Witte, Brosens, Dierckx, & Verté, 2015; Perel-Levin & World Health Organization, 2008; Sandmoe & Kirkevold, 2011; Wiglesworth et al., 2010).
E. Institutions should implement culturally appropriate strategies for identifying and addressing EM in racial/ethnic minority older adults (Horsford, Parra-Cardona, Schiamberg, & Post, 2011).
F. Educate victims about patterns of EM such that EM tends to worsen in severity over time (Phillips, 2008).
G. Provide older adults with emergency contact numbers and community resources (Lachs & Pillemer, 1995).
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 (Jackson & Hafemeister, 2013; Rizzo et al., 2015).
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 consultgerirn.org.
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 to the follow-up that may be performed in the community or long-term care settings.
RELEVANT PRACTICE GUIDELINES
A. American Medical Association (AMA). (1992). Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: Author.
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
NRC National Research Council
Updated: November 2020
Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description
Chapter 16: Caceres, B., Kurup, N., & Fulmer, T. (2021) Elder Mistreatment Detection. In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 223-257). New York: Springer.
Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–297. doi:10.2105/AJPH.2009.163089. Evidence Level IV.
American Medical Association. (1992). Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: Author. Evidence Level VI.
Bandura, A. (1978). Social learning theory of aggression. Journal of Communication, 28(3), 12–29. doi:10.1111/j.1460-2466.1978.tb01621.x. Evidence Level V.
Brozowski, K., & Hall, D. R. (2010). Aging and risk: Physical and sexual abuse of elders in Canada. Journal of Interpersonal Violence, 25(7), 1183–1199. doi:10.1177/0886260509340546. Evidence Level V.
Burnes, D., Rizzo, V. M., Gorroochurn, P., Pollack, M. H. & Lachs, M. S. (2016). Understanding service utilizations in cases of elder abuse to inform best practice. Journal of Applied -Gerontology, 35(10), 1036–1057. doi:10.1177/0733464814563609
Cannell, M. B., Manini, T., Spence-Almaguer, E., Maldonado--Molina, M., & Andresen, E. M. (2014). US population estimates and correlates of sexual abuse of community-dwelling older adults. Journal of Elder Abuse & Neglect, 26(4), 398–413. doi:10.1080/08946566.2013.879845. Evidence Level IV.
De Donder, L., De Witte, N., Brosens, D., Dierckx, E., & Verté, D. (2015). Learning to detect and prevent elder abuse: the need for a valid risk assessment instrument. Procedia-Social and Behavioral Sciences, 191, 1483–1488.
DeLiema, M., Gassoumis, Z. D., Homeier, D. C., & Wilber, K. H. (2012). Determining prevalence and correlates of elder abuse using promotores: Low-income immigrant Latinos report high rates of abuse and neglect. Journal of the American Geriatrics Society, 60(7), 1333–1339. doi:10.1111/j.1532-5415.2012.04025.x. Evidence Level IV.
Dong, X., Simon, M., & Evans, D. (2012). Decline in physical function and risk of elder abuse reported to social services in a community-dwelling population of older adults. Journal of the American Geriatrics Society, 60(10), 1922–1928. doi:10.1111/j.1532-5415.2012.04147.x. Evidence Level IV.
Draper, B., Pfaff, J. J., Pirkis, J., Snowdon, J., Lautenschlager, N. T., Wilson, I., ... Depression and Early Prevention of Suicide in General Practice Study Group. (2008). Long-term effects of childhood abuse on the quality of life and health of older people: Results from the Depression and Early Prevention of Suicide in General Practice Project. Journal of the American Geriatrics Society, 56(2), 262–271.
Dyer, C. B., & Goins, A. M. (2000). The role of the interdisciplinary geriatric assessment in addressing self-neglect of the elderly. Generations, 24(2), 23–27.
Frost, M. H., & Willette, K. (1994). Risk for abuse/neglect: Documentation of assessment data and diagnoses. Journal of Gerontological Nursing, 20(8), 37–45. doi:10.3928/0098-9134-19940801-08. Evidence Level V.
Fulmer, T., Paveza, G., VandeWeerd, C., Fairchild, S., Guadagno, L., Bolton-Blatt, M., & Norman, R. (2005). Dyadic vulnerability and risk profiling for elder neglect. The Gerontologist, 45(4), 525–534. doi:10.1093/geront/45.4.525. Evidence Level IV.
Gelles, R. J. (1983). An exchange/social control theory. In D. -Finkelhor, R. J. Gelles, G. T. Hotaling, & M. A. Straus (Eds.), The dark side of families: Current family violence research (pp. 151–165). Beverly Hills, CA: Sage Publications. Evidence Level V.
Gelles, R. J., & Straus, M. A. (1979). Determinants of violence in the family: Toward a theoretical integration. In W. R. Burr, R. Hill, F. I. Nye, & I. L. Reiss (Eds.), Contemporary theories about the family (pp. 550–581). New York, NY: Free Press. Evidence Level V.
Giurani, F., & Hasan, M. (2000). Abuse in elderly people: The Granny Battering revisited. Archives of Gerontology & -Geriatrics, 31, 215–220. doi:10.1016/S0167-4943(00)00080-7
Gorbien, M. J., & Eisenstein, A. R. (2005). Elder abuse and neglect: an overview. Clinics in Geriatric Medicine, 21(2), 279–292.
Horsford, S. R., Parra-Cardona, J. R., Schiamberg, L., & Post, L. A. (2011). Elder abuse and neglect in African American families: Informing practice based on ecological and cultural frameworks. Journal of Elder Abuse & Neglect, 23(1), 75–88. doi:10.1080/08946566.2011.534709
Jackson, S. L., & Hafemeister, T. L. (2013). Enhancing the safety of elderly victims after the close of an APS investigation. Journal of Interpersonal Violence, 28(6), 1223–1239. doi:10.1177/0886260512468241. Evidence Level IV.
Jayawardena, K. M., & Liao, S. (2006). Elder abuse at end of life. Journal of Palliative Medicine, 9(1), 127–136.
Johansen, M., & LoGiudice, D. (2013). Elder abuse: A systematic review of risk factors in community-dwelling elders. Age & Ageing, 42(3), 292–289. doi:10.1093/ageing/afs195
Krienert, J. L., Walsh, J. A., & Turner, M. (2009). Elderly in America: A descriptive study of elder abuse examining National Incident-Based Reporting System (NIBRS) data, 2000-2005. Journal of Elder Abuse & Neglect, 21(4), 325–345. doi:10.1080/08946560903005042
Lachs, M. S., & Pillemer, K. A. (2015). Elder abuse. New England Journal of Medicine, 373(20), 1947–1956. doi:10.1056/NEJMra1404688. Evidence Level VI.
Naik, A. D., Teal, C. R., Pavlik, V. N., Dyer, C. B., & McCullough, L. B. (2008). Conceptual challenges and practical approaches to screening capacity for self-care and protection in vulnerable older adults. Journal of the American Geriatrics Society, 56, S266–S270. doi:10.1111/j.1532-5415.2008.01979.x. Evidence Level V.
National Center on Elder Abuse. (1998). The National Elder Abuse Incidence Study. Retrieved from https://acl.gov/sites/default/files/programs/2016-09/ABuseReport_Full.pdf
National Research Council. (2003). Elder mistreatment: Abuse, neglect, and exploitation in an aging America. Washington, DC: National Academies Press. Evidence Level V.
Peisah, C., S. Finkel, K. Shulman, P. Melding, J. Luxenberg, J. Heinik, R., . . . Bennett,, H. I. (2009). The wills of older people: risk factors for undue influence. International -Psychogeriatrics, 21(1), 7–15.
Perel-Levin, S., & World Health Organization. (2008). Discussing screening for elder abuse at primary health care level. Retrieved from https://www.who.int/ageing/publications/Discussing_Elder_Abuseweb.pdf. Evidence Level V.
Phillips, L. R. (2008). Abuse of aging caregivers: Test of a nursing intervention. Advances in Nursing Science, 31(2), 164–181.
Rizzo, V. M., Burnes, D., & Chalfy, A. (2015). A systematic evaluation of a multidisciplinary social work–lawyer elder mistreatment intervention model. Journal of Elder Abuse & Neglect, 27(1), 1–18. doi:10.1080/08946566.2013.792104. Evidence Level III.
Sandmoe, A., & Kirkevold, M. (2011). Nurses’ clinical assessments of older clients who are suspected victims of abuse: An exploratory study in community care in Norway. Journal of Clinical Nursing, 20(1–2), 94–102. doi:10.1111/j.1365-2702.2010.03483.x. Evidence Level IV.
Strasser, S. M., Smith, M., Weaver, S., Zheng, S., & Cao, Y. (2013). Screening for elder mistreatment among older adults seeking legal assistance services. Western Journal of Emergency Medicine, 14(4), 309–315. doi:10.5811/westjem.2013.2.15640
Straus, M. A. (1971). Some social antecedents of physical punishment: A linkage theory interpretation. Journal of Marriage and the Family, 33(4), 658–663. doi:10.2307/349438. Evidence Level IV.
Walker, A. (1981). Towards a political economy of old age. Ageing & Society, 1(1), 73–94. doi:10.1017/S0144686X81000056. Evidence Level VI.
Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W. (2010). Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society, 58(3), 493–500. doi:10.1111/j.1532-5415.2010.02737.x. Evidence Level IV.