Every year hundreds of thousands of adults over the age of 65 are neglected, abused, and/or exploited by family members and others. The Centers for Disease Control and Prevention (CDC) recognizes elder abuse as an epidemic and a major public health issue because of associated pain, suffering, and diminished quality of life. The personal costs of elder abuse are catastrophic and include loss of independence, health, security, and dignity. Unfortunately, the problem of elder abuse is likely to get worse as the percentage of older adults increases.

As many as 5 million older adults are abused in the United States annually and approximately 85% of these cases are never reported. Most elder abuse victims are female and about 40% are over the age of 80. Although the vast majority of elder abuse occurs in the home, it also takes place in extended care facilities and assisted living facilities.

What is elder abuse?

Elder abuse is an umbrella term that refers to any “intentional or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult”. Several different types of abuse fall under this heading: physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, neglect, and self-neglect.

Physical abuse is the use of physical force that results in bodily injury, pain, or impairment. This could include striking, beating, pushing, shaking, slapping, or burning an elder. The inappropriate use of drugs, physical restraints, force-feeding, or physical punishment is also considered physical abuse.

Sexual abuse is any nonconsensual sexual contact and could include unwanted touching and all types of sexual assault or battery.

Emotional or psychological abuse is the infliction of distress through verbal or nonverbal acts. Examples of this include verbal assaults, insults, intimidation, humiliation, harassment, social isolation, and treating an older adult like an infant.

Financial exploitation is the misuse of older adult’s resources and assets. This could include taking Social Security checks, abusing a joint checking account or taking property and other resources for personal financial gain.

Neglect is defined as “the refusal or failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder”. Self-neglect is “characterized as the behavior of an elderly person that threatens his/her own health or safety”. Self-neglect is the most reported of all elder abuse cases. Below is the breakdown of the types of elder abuse.

Often the perpetrators of elder abuse are under the age of 60. According to 2004 APS reports adult children were responsible for the abuse 34% of the time and other family members 22% of the time. The perpetrators are often financially dependent on the elder’s and may have issues related to drugs and alcohol. Below is the breakdown of perpetrators of elder abuse.

Who is at risk?

You should be aware of the risk factors listed below during your interactions with, and assessments of, the elderly. These risk factors can’t explain all types of elder abuse.

How can elder abuse be detected?

The trust and respect that patients often have for their nurses place us in a position to identify elder abuse. Unfortunately, unless there are obvious signs of injury, elder abuse may be difficult to detect. In addition, elders often don’t report abuse because of factors such as:

• Fear of retaliation from the abuser
• Fear of losing contact with family members
• Fear of admittance to a nursing home
• Shame over the abuse
• Guilt over naming a family member or friend as an abuser

Below are some signs of elder abuse.

When abuse is suspected, it’s important to be nonjudgmental and allow plenty of time to interact with the elder. Interview and assess the victim in a private setting to make the elder more comfortable with discussing his or her situation. Consider using a screening tool such as the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) (see http://www.uihealthcare.com/depts/med/familymedicine/research/eldermistreatment/screeninginstruments/hwalek.pdf). According to the authors of this tool, “a response of “no” to items 1, 6, 12, and 14; a response of “someone else” to item 4; and a response of “yes” to all others is scored in the “abused” direction”.

What should you do if you believe there is elder abuse?

Nurses are obligated to report suspected abuse of any kind. Report immediately to a supervisor and to Adult Protective Services (APS). Currently, there is no federal law regarding elder abuse in the United States, but individual states do have laws for reporting, investigating, and prosecuting abuse. All reporting is confidential. It is important to remember that all adults have the right to refuse services offered by APS.

Documentation is crucial in cases of abuse. Here are some recommendations from the National Institute of Justice:

• Take photographs of injuries known or suspected to have resulted from abuse.
• Make a written statement that includes what you observed, when you observed the incident, who was present, and any other information that may be useful.
• Describe the victim’s injuries in detail, including type, location, size, color, and age. Body charts are helpful in accurate documentation.
• Set off the patient’s own words in quotation marks or use such phrases as “patient states” or “patient reports” to indicate that the information recorded reflects the patient’s words.

An opportunity and an obligation

Nurses have the opportunity and obligation to detect and report elder abuse. As a nurse, you can make a tremendous impact to prevent and identify abuse.

Several resources are available to assist you. Support programs can help caregivers connect with others who are in similar positions and provide mechanisms for coping with the stress of being a caregiver. These programs can be found through resources such as The Alzheimer’s Association (http://www.alz.org/), Family Caregiver Alliance (www.caregiver.org), and the National Family Caregivers Association (http://www.nfcacares.org). Elder abuse helplines and hotlines can be found on the National Center on Elder Abuse website (http://www.ncea.aoa.gov).

As nurses, we must protect the rights, safety, and health of the elderly. Consider sharing this information with your colleagues to help increase the awareness of elder abuse.

Elizabeth Richards is a clinical associate professor at Purdue University School of Nursing in West Lafayette, Indiana.

References

Administration on Aging. Elder rights & resources. http://www.eldercare.gov/ELDERCARE.NET/Public/Resources/Helpful_Links/Elder_Rights.aspx. Accessed July 7, 2011.

Centers for Disease Control & Prevention. The State of Aging and Health in America 2007. http://www.cdc.gov/aging/data/stateofaging.htm. Accessed July 7, 2011.

National Center on Elder Abuse. Abuse of adults age 60+: The 2004 survey of the Adult Protective Services. 2006.

National Committee on the Prevention of Elder Abuse. Major types of elder abuse. http://www.cdc.gov/aging/data/stateofaging.htm. Accessed July 7, 2011.

National Committee on the Prevention of Elder Abuse. What is elder abuse? http://preventelderabuse.org/elderabuse/. Accessed July 7, 2011.

Isaac NE, Enos VP. Documenting domestic violence: How health care providers can help victims. National Institute of Justice Research Brief. September 2001; 1-6.

Neale AV, Hwalek MA, Scott RO, Stahl C. Validation of the Hwalek-Sengstock elder abuse screening test. J Applied Gerontol. 1991;10(4), 406-415.