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Elder abuse and neglect
Elder Abuse and Neglect BY MARSHELLE THOBABEN, RN,C, PHN, FNP
ome care providers have a professional and legal obligation to help prevent their elderly patients from being abused and neglected by family members and other home care providers. The elderly are often in a vulnerable situation because they depend on family members or others to help with personal care, housekeeping chores, and money management. A recent article in a major newspaper illustrates the problem.1 It reported that Mr. X, who was 84 years old, had been without food or water while he lay curled in the trunk of his car for 2 days before he was found by the police. When found, he reported that he saw daylight only when his housekeeper lifted the car trunk lid to ask him if her forgery of his check looked authentic. After he was rescued, he acknowledged that he was confused about why his housekeeper, who had befriended him, had turned on him. He expressed concern for her and hoped she would get a break in her sentencing. “She didn’t kill me,” he said. 1 This situation is not that unusual. Elder abuse and neglect is a major public health problem in the United States, with most cases hidden from public scrutiny. The National Center on Elder Abuse reports that cases of domestic abuse against the elderly increased from 117,000 in 1986 to 24 1,000 in 1994, and that represented only a fraction of older Americans who were abused and neglected in their homes. The Center estimates that 8 18,000 elderly Americans were victims of various types of domestic abuse in 1994. They believe the rise in reported cases illustrates a growing pattern of violence and neglect among the nation’s expanding elderly population.2 ADDRESS FOR CORRESPONDENCE: MarrhelleThobaben,RN,C 432 Shirley Blvd. Arcata. CA 95521
SEPTEMBER/OCTOBER
1996,
VOL.
1 NO. 5
HOME
CARE PROVIDER
267
BEYOND
PHYSICAL
CARE
Abuse and/or neglect may be intentional or the result of the caregiver’s lack of knowledge or capacity to care for an elderly patient. Abuse also can be reflective of a stressed employee or family member. Families may have financial problems or marital conflict, be unemployed, or feel caught between caring for a parent and their children. Most families do not have the knowledge or training to provide adequate care. They have not been taught how to make a bed with a person in it, give medications, or change dressings. Others are not physically able to care for their family member because of their own physical limitations. Some family members and home care providers have their own psychopathology that impairs their ability to care for the patient. They may have severe mental or emotional problems, or they may abuse alcohol or other drugs. This can lead to neglect of the patient, with development of decubitus ulcers, malnourished state, over sedation, under medication, or death.
For other care providers, violence is a way of life. They have learned that physically abusing a family member or a person under their care is an acceptable way to control behavior. For example, children who are caring for their parents may have been abused by their parents when they were young, and they are now retaliating for the way they were treated. A wife who has been abused by her husband may be retaliating against her husband for the years of abuse she endured. The first priority of professional home health care providers to patients who are being abused and neglected is t,o ensure their safety. Providers will need to act as detectives because abusive situations often are hidden. Patients rarely divulge that they are abused because they are too humiliated to admit it; they fear social stigma, retaliation from the abuser, or removal from their home; or they lack other resources. A caregiver’s behavior can provide clues that indicate abuse of the patient. The patient may not be allowed to speak for himself or herself or may not be allowed to speak without the presence of the caregiver. The caregiver’s attitude toward the patient might be one of indifference, anger, or aggression. He or she may be flirtatious or coy or may give other indications of an inappropriate sexual relation268
HOME
CARE PROVIDER
THOBABEN
ship. The caregiver may give conflicting accounts of the patient’s injury. The box herein gives a brief list of indicators of elder abuse or neglect. These indicators alone do not necessarily signify abuse or neglect but may be clues, and thus they may be helpful in an assessment of the potential for abuse and neglect.3 The second priority for home health care professionals after the patient has been abused or neglected is to determine whether legal interventions are appropriate and necessary. Nearly every state has a law that requires health and social service professionals to report suspected abusive situations and states under what conditions that abuse is to be reported. Each state has its own definition of elder abuse and neglect, including definitions of what constitutes physical, sexual, fiduciary, and psychological abuse and neglect. For example, California defines physical abuse as any physical pain or injury that is willfully inflicted on an elderly victim by a person who has care or custody of an elderly person or who stands in a position of trust with that elderly person. Financial abuse is any theft or misuse of an elder’s money or property by a person in a position of trust with an elderly person. The failure of any person having the care or custody of an elderly person to provide the degree of care that a reasonable person in a like position would provide constitutes neglect. Psychological or emotional abuse is the willful infliction of mental suffering by a person in a position of trust with an elderly person.4 Most state laws require that professional home health care providers report abuse cases to a specific agency, such as the county adult protective service agency. The professional care provider will not bear any civil or criminal liability for reporting suspected abuse unless the report is false. Home health care professionals have been reluctant to report cases of abuse or neglect for many reasons, some of which follow: (1) They think that such a report will destroy their relationships with their patients. (2) They may be in denial that their patients are being abused. (3) They do not want to become involved in family matters or possibly have to testify in a court hearing. (4) They feel uncomfortable dealing with abusive situations and do not understand the dynamics of abuse, including that it is a recurring and escalating situation. (5) Abusive situations may be frustrating to professionals because competent patients have a legal right to remain in an abusive or neglectful situation, even when it is in their best interest to leave. What can home health care providers do to prevent domestic abuse and neglect? Agencies should have protocols in place to help personnel routinely screen their patients for potential abuse and neglect. Cases may not be obvious or may resemble other problems; therefore new employees should have inSEPTEMBER/OCTOBER
1996,
VOL. 1 NO.5
THOBABEN
BEYOND
PHYSICAL
CARE
service training to help them detect potential cases. Suspected abusive cases should be discussed in case conferences. Some agencies have specific teams for follow-up home visits when field nurses have identified potential abusive situations. They often work with other health and social service agencies to develop and implement a comprehensive plan to eliminate the abuse or to prevent an elder from being severely neglected. Home health care providers need to empower patients to do as much for themselves as possible. They need to teach patients how to care for themselves, and they need to teach caregivers how to provide adequate care. The health care provider will need to have a keen understanding of community services available for patients (e.g., adult day health care and case management) or services that might alleviate stress for family members (e.g., respite care and support groups). In summary, home health care providers are in a key position to prevent elder abuse and neglect or to minimize its devastating effects. Home health care providers need to be alert for potential cases and comply with their state law on elder abuse. A patient’s life could be saved.
REFERENCES I. Housekeeper kept frail man in car trunk. San Francisco Chronicle 1996 Mar 8; Sect A:8. 2. http://cyrerv.cyber.nl/ageingresearch/dutch/pub2.html. Report: elder abuse rising. July 7, 1996. 3. http://users.aimnet.com/-oaktree/elder/define.html. Definitions of abuse. July 7, 1996. 4. Thobaben M. Elder and dependent adult abuse. In: Humboldt County guidelines for mandated reporters. 199l:ll-5. Area I Agency on Aging, Eureka, CA.
Marshelle
Thobaben,
fessor
State
California.
She is licensed
public sively issues
affecting expert
health
Humboldt nurse
abuse
RN,C,
of community
home on the
University
and nurse health
nurse.
and presented care
practitioner
clients
Phil Donahue
PHN,
FNF: is pro-
nursing
as a psychiatric and is a certified
She has published nationally
and staff.
at
in Arcata,
exten-
on psychosocial She was
an elder
show.
Reprint no. 69/l/16764
SEPTEMBER/OCTOBER
1996,
VOL.
1
NO.
5
HOME
CARE PROVIDER
269
ome care providers have a professional and legal obligation to help prevent their elderly patients from being abused and neglected by family members and other home care providers. The elderly are often in a vulnerable situation because they depend on family members or others to help with personal care, housekeeping chores, and money management. A recent article in a major newspaper illustrates the problem.1 It reported that Mr. X, who was 84 years old, had been without food or water while he lay curled in the trunk of his car for 2 days before he was found by the police. When found, he reported that he saw daylight only when his housekeeper lifted the car trunk lid to ask him if her forgery of his check looked authentic. After he was rescued, he acknowledged that he was confused about why his housekeeper, who had befriended him, had turned on him. He expressed concern for her and hoped she would get a break in her sentencing. “She didn’t kill me,” he said. 1 This situation is not that unusual. Elder abuse and neglect is a major public health problem in the United States, with most cases hidden from public scrutiny. The National Center on Elder Abuse reports that cases of domestic abuse against the elderly increased from 117,000 in 1986 to 24 1,000 in 1994, and that represented only a fraction of older Americans who were abused and neglected in their homes. The Center estimates that 8 18,000 elderly Americans were victims of various types of domestic abuse in 1994. They believe the rise in reported cases illustrates a growing pattern of violence and neglect among the nation’s expanding elderly population.2 ADDRESS FOR CORRESPONDENCE: MarrhelleThobaben,RN,C 432 Shirley Blvd. Arcata. CA 95521
SEPTEMBER/OCTOBER
1996,
VOL.
1 NO. 5
HOME
CARE PROVIDER
267
BEYOND
PHYSICAL
CARE
Abuse and/or neglect may be intentional or the result of the caregiver’s lack of knowledge or capacity to care for an elderly patient. Abuse also can be reflective of a stressed employee or family member. Families may have financial problems or marital conflict, be unemployed, or feel caught between caring for a parent and their children. Most families do not have the knowledge or training to provide adequate care. They have not been taught how to make a bed with a person in it, give medications, or change dressings. Others are not physically able to care for their family member because of their own physical limitations. Some family members and home care providers have their own psychopathology that impairs their ability to care for the patient. They may have severe mental or emotional problems, or they may abuse alcohol or other drugs. This can lead to neglect of the patient, with development of decubitus ulcers, malnourished state, over sedation, under medication, or death.
For other care providers, violence is a way of life. They have learned that physically abusing a family member or a person under their care is an acceptable way to control behavior. For example, children who are caring for their parents may have been abused by their parents when they were young, and they are now retaliating for the way they were treated. A wife who has been abused by her husband may be retaliating against her husband for the years of abuse she endured. The first priority of professional home health care providers to patients who are being abused and neglected is t,o ensure their safety. Providers will need to act as detectives because abusive situations often are hidden. Patients rarely divulge that they are abused because they are too humiliated to admit it; they fear social stigma, retaliation from the abuser, or removal from their home; or they lack other resources. A caregiver’s behavior can provide clues that indicate abuse of the patient. The patient may not be allowed to speak for himself or herself or may not be allowed to speak without the presence of the caregiver. The caregiver’s attitude toward the patient might be one of indifference, anger, or aggression. He or she may be flirtatious or coy or may give other indications of an inappropriate sexual relation268
HOME
CARE PROVIDER
THOBABEN
ship. The caregiver may give conflicting accounts of the patient’s injury. The box herein gives a brief list of indicators of elder abuse or neglect. These indicators alone do not necessarily signify abuse or neglect but may be clues, and thus they may be helpful in an assessment of the potential for abuse and neglect.3 The second priority for home health care professionals after the patient has been abused or neglected is to determine whether legal interventions are appropriate and necessary. Nearly every state has a law that requires health and social service professionals to report suspected abusive situations and states under what conditions that abuse is to be reported. Each state has its own definition of elder abuse and neglect, including definitions of what constitutes physical, sexual, fiduciary, and psychological abuse and neglect. For example, California defines physical abuse as any physical pain or injury that is willfully inflicted on an elderly victim by a person who has care or custody of an elderly person or who stands in a position of trust with that elderly person. Financial abuse is any theft or misuse of an elder’s money or property by a person in a position of trust with an elderly person. The failure of any person having the care or custody of an elderly person to provide the degree of care that a reasonable person in a like position would provide constitutes neglect. Psychological or emotional abuse is the willful infliction of mental suffering by a person in a position of trust with an elderly person.4 Most state laws require that professional home health care providers report abuse cases to a specific agency, such as the county adult protective service agency. The professional care provider will not bear any civil or criminal liability for reporting suspected abuse unless the report is false. Home health care professionals have been reluctant to report cases of abuse or neglect for many reasons, some of which follow: (1) They think that such a report will destroy their relationships with their patients. (2) They may be in denial that their patients are being abused. (3) They do not want to become involved in family matters or possibly have to testify in a court hearing. (4) They feel uncomfortable dealing with abusive situations and do not understand the dynamics of abuse, including that it is a recurring and escalating situation. (5) Abusive situations may be frustrating to professionals because competent patients have a legal right to remain in an abusive or neglectful situation, even when it is in their best interest to leave. What can home health care providers do to prevent domestic abuse and neglect? Agencies should have protocols in place to help personnel routinely screen their patients for potential abuse and neglect. Cases may not be obvious or may resemble other problems; therefore new employees should have inSEPTEMBER/OCTOBER
1996,
VOL. 1 NO.5
THOBABEN
BEYOND
PHYSICAL
CARE
service training to help them detect potential cases. Suspected abusive cases should be discussed in case conferences. Some agencies have specific teams for follow-up home visits when field nurses have identified potential abusive situations. They often work with other health and social service agencies to develop and implement a comprehensive plan to eliminate the abuse or to prevent an elder from being severely neglected. Home health care providers need to empower patients to do as much for themselves as possible. They need to teach patients how to care for themselves, and they need to teach caregivers how to provide adequate care. The health care provider will need to have a keen understanding of community services available for patients (e.g., adult day health care and case management) or services that might alleviate stress for family members (e.g., respite care and support groups). In summary, home health care providers are in a key position to prevent elder abuse and neglect or to minimize its devastating effects. Home health care providers need to be alert for potential cases and comply with their state law on elder abuse. A patient’s life could be saved.
REFERENCES I. Housekeeper kept frail man in car trunk. San Francisco Chronicle 1996 Mar 8; Sect A:8. 2. http://cyrerv.cyber.nl/ageingresearch/dutch/pub2.html. Report: elder abuse rising. July 7, 1996. 3. http://users.aimnet.com/-oaktree/elder/define.html. Definitions of abuse. July 7, 1996. 4. Thobaben M. Elder and dependent adult abuse. In: Humboldt County guidelines for mandated reporters. 199l:ll-5. Area I Agency on Aging, Eureka, CA.
Marshelle
Thobaben,
fessor
State
California.
She is licensed
public sively issues
affecting expert
health
Humboldt nurse
abuse
RN,C,
of community
home on the
University
and nurse health
nurse.
and presented care
practitioner
clients
Phil Donahue
PHN,
FNF: is pro-
nursing
as a psychiatric and is a certified
She has published nationally
and staff.
at
in Arcata,
exten-
on psychosocial She was
an elder
show.
Reprint no. 69/l/16764
SEPTEMBER/OCTOBER
1996,
VOL.
1
NO.
5
HOME
CARE PROVIDER
269