Abuse, Neglect, and Exploitation of Older Persons Strategies for Assessment and Intervention Edited by Lorin A. Baumhover, Ph.D., & S. Colleen Beall, Dr.P.H.

Excerpted from the Introduction of Abuse, Neglect, and Exploitation of Older Persons: Strategies for Assessment and Intervention, edited by Lorin A. Baumhover, Ph.D., & S. Colleen Beall, Dr.P.H.

Copyright © 1996 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Introduction

The medical community is becoming increasingly aware that general health and overall well-being are influenced by many factors outside the health care delivery setting. Pediatricians are realizing the overall impact of malnutrition, drugs, and interpersonal violence on their patient population. Emergency room physicians and nurses have been victimized by the violence that has followed their patients in from the streets (increasingly, visitors and family members must pass through a metal detector to enter emergency rooms). The white coats of home health nurses, which once afforded them safety in violence-prone neighborhoods, now provide notice that drugs and needles may be at hand. Health care providers are becoming aware that their patients bring a variety of related problems into the examining room. Numerous environmental, ecological, and community variables affect how health care is delivered in the United States. These variables also affect elder abuse.

Although physicians were in the forefront in the detection, diagnosis, and treatment of child abuse cases, this does not appear to be true of elder mistreatment. This is particularly ironic when the indicators for the detection of abuse and neglect are perhaps most readily visible to physicians and nurses, and particularly home health care providers. Considerable support is found in the literature for the fact that the individuals most likely to report and act on cases of elder abuse are health care professionals involved in primary care. Clark-Daniels, Daniels, and Baumhover (1989) found that the individuals who are most likely to report cases of elder mistreatment are home health care nurses, more so than other family members, the victims themselves, clergy, social workers, or other health care providers. It is also becoming apparent that insufficient attention is being paid to domestic violence and elder abuse issues in medical education, in clinical rotations, and in real-life work settings.

The United States is undergoing a convergence of aging and individual mistreatment. Although an awareness exists that the American population is aging, it has only been since 1994 that researchers have found that aging family members are victimized at a much higher rate than anticipated (Tatara, 1994). The population group that is most likely to be victimized, people over age 75, is growing more rapidly than any other subset of the older adult population. Individuals who are the most frail and have the greatest number of chronic conditions, and people who are widowed or otherwise alone, are more likely to be targeted for abuse and neglect.

Elder abuse is seen frequently only as physical abuse. If no lacerations, burn marks, punctures, or bruises can be found on the body, it is too often assumed that no abuse or neglect has occurred. Neglect, the type of mistreatment most frequently found among the older adult population, often leaves no outward signs nor reveals any particular symptoms. Psychological abuse also leaves no external wounds. This book attempts to sensitize health care practitioners to the full range and types of abuse and neglect, including physical abuse, neglect (passive or active), psychological abuse, financial exploitation, and violation of civil rights.

This book also emphasizes that elder mistreatment is more covert than spouse or child abuse. Victims of elder abuse frequently deny the occurrence of abuse, neglect, or both out of fear, guilt, shame, or passivity, and elder abusers attempt to justify and rationalize their actions. Elder mistreatment is more easily hidden from public view in both the home and the long-term care setting. Older people are more isolated than are people in other age groups, have fewer social engagements and role obligations, and are more likely to be either physically or mentally impaired.

This book is the culmination of more than a decade of research, education, and training in elder mistreatment. It offers a comprehensive set of guidelines that can be used by health care personnel in assessing whether elder abuse and neglect has occurred. The chapters include some theoretical and conceptual elements, but are largely geared toward the practical application of the art and science of diagnosing and managing elder abuse cases. The book is intended to serve as a practical guide for practitioners, and as a stimulus for developing new protocols in health care settings in which these instruments do not exist and for possible new research and training. The text focuses on both acute and long-term care issues.

The volume is organized into four parts. Part I, "Understanding the Problem," opens with a chapter by Edward Ansello, who reviews the primary causes of elder abuse and some possible explanations as to why elder mistreatment continues to occur.

Chapter 2, by Jordan Kosberg and Daphne Nahmiash, presents a detailed outline of characteristics that may be associated with elder abuse. These characteristics are related not only to the victims and perpetrators of abuse but also to the social and cultural context in which abuse incidents occur. The authors are careful to point out the limitations of current data related to individual characteristics.

In Chapter 3 James O'Brien focuses on the identification of abuse within the context of a clinical interview and physical examination. O'Brien points out that opportunities to screen for abuse are within the purview of primary care physicians. He calls upon physicians to become aware of the type of information that is useful in assessing abuse and of the necessity for careful documentation whenever abuse is suspected.

The focus in Part II, "Assessment," is a detailed description of the case-finding process. Holly Ramsey-Klawsnik opens this section by examining the roles of health care providers in the assessment of possible elder physical and sexual abuse. Symptoms and dynamics of physical and sexual abuse are presented, as are specific guidelines for assessment in such cases. Requirements and professional limits of responsibility also are addressed.

In Chapter 5 Terry Fulmer and Elaine Gould discuss the assessment of neglect within a framework that recognizes the contribution of aging processes, disease, and neglect to the older person's condition; distinguishes self-neglect from caregiver neglect; and acknowledges the role of intent and competence in determining whether neglect is active or passive. Fulmer and Gould present an assessment instrument, the Elder Abuse Assessment Form, to assist practitioners in assessing and documenting neglected older people.

Mary C. Sengstock and Sally Steiner extend the assessment framework to include psychological mistreatment and exploitation in Chapter 6. The signs and symptoms with which victims of such mistreatment present are not generally physical and, therefore, are easy to overlook in a clinical setting where the focus is on physical illness and injury. Service providers are challenged to notice psychological affect, subtle behaviors, and interpersonal interactions in order to identify nonphysical mistreatment and to institute measures to safeguard the welfare of victims.

The final chapter in Part II is coauthored by Melanie Hwalek, Carolyn Stahl Goodrich, and Kathleen Quinn. In it, the authors act as facilitators, explaining the "black box" of Adult Protective Services (APS) to health care providers. They call attention to the different meanings of risk assessment within APS and health care settings and to the role of a standardized APS risk assessment to guide investigations, interventions, and evaluations. Roles for health care professionals within the investigation and intervention processes are defined.

The emphasis in Part III, "Intervention," is on clinical activities with victims of elder mistreatment. The continued importance of the documentation that was inaugurated during the initial assessment is the focus of Dorrie Rosenblatt's chapter. Although it serves many functions, such as supporting legal interventions or funding requests, the primary reason for careful documentation is that it provides the basis for good patient care. Documentation is the first step in developing a care plan that is specific to the patient's or client's needs and resources, obtaining services to carry out the plan, and facilitating communications among service providers.

A promising model for intervention within hospitals is the multidisciplinary team. In Chapter 9 Sue Parkins describes the events that led to the formation of a multidisciplinary team in one setting (St. Vincent's Medical Center, Toledo, Ohio), describes the composition of the team, and provides examples of how multidisciplinary involvement facilitates a coordinated approach to developing effective intervention strategies.

A key component of intervention for many victims and their caregivers is psychological therapy, addressed in Chapter 10 by Bridget Booth, Audrei Bruno, and Robert Marin. To be effective, psychological treatment must be guided by the clinician's knowledge of the causes and consequences of mistreatment as they coexist in a particular case. Suggestions are offered for primary, secondary, and tertiary interventions.

Part IV, "Some Solutions to the Problem," addresses victim follow-up, abuse in institutions, and the outlook for elder abuse. The final step of clinical care for the victim of mistreatment often is discharge planning. In Chapter 11 Lisa Nerenberg and Susan Haikalis discuss some of the pressures and obstacles that may hinder effective discharge planning. By serving as the interface between in-hospital and in-home services, discharge planners can contribute to overcoming and removing these barriers. This is accomplished by engaging in planning and advocacy efforts in the community and by educating care providers that aggressive, proactive approaches to abuse can be cost effective.

Chapter 12, by Beth Hudson Keller, examines the typical kinds of mistreatment, often subtle and largely unnoticed, that may occur in a long-term care setting. She outlines a training program designed to sensitize care providers to their own possibly abusive behaviors and to replace such behaviors with actions that are more adaptive for care providers and contribute to a better quality of life for older adults. Although the focus of Hudson Keller's chapter is on nursing facility care, similar approaches are advocated for care providers in the home health and board and care home industries.

The editors conclude the volume with a chapter that summarizes and reexamines common barriers that are likely to continue to frustrate health care providers as they attempt to identify and manage a growing number of elder abuse victims. Drawing from recommendations by contributors to the volume, as well as their own experience in the field, the editors offer prescriptions for overcoming these barriers.

References

Clark-Daniels, C.L., Daniels, R.S., & Baumhover, L.A. (1989). Physicians and nurses' responses to abuse of the elderly: A comparative study of two surveys in Alabama. Journal of Elder Abuse & Neglect, 1(4), 57-72.

Tatara, T. (1994). Elder abuse: An information guide for professionals and concerned citizens (4th ed.). Washington, DC: National Center on Elder Abuse.