Educate staff about elder abuse
Educate staff about elder abuse
Home care workers may not recognize the problem
Anywhere from 500,000 to 2 million elderly people are abused each year, and home care staff may see many of them without realizing there’s a problem. A recent study concludes that only 16% of abuse cases involving people over age 60 are reported to local Adult Protective Services agencies. The National Elder Abuse Incidence Study found that the exact number of abused seniors is difficult to determine because health care workers and others have missed the signs of abuse.1 (A report on the study has been published on the World Wide Web. See Internet Connect, p. 15, for details.)
The study, which ran from October 1994 to December 1997, was conducted by the National Center on Elder Abuse at the American Public Human Services Association in Washington, DC, and Baltimore-based Westat, a social science and survey research firm. The study showed that the greatest percentage of cases of elder abuse occurred among victims age 80 or older. More than half the cases of neglect involved people in the 80+ age group, and about 44% of physical abuse involved people in that age group.
Every state has laws addressing elder abuse. Most states require health care workers to report any suspected or known abuse. So perhaps it’s time for your agency to hold an inservice on domestic violence and elder abuse to make sure your staff understand what to look for and what their responsibilities are if they suspect the presence of elder abuse.
Comprehensive Home Healthcare Services in Middlesboro, KY, recently held a half-day workshop on family violence as part of a Kentucky requirement for licensed nurses. Other staff were invited to attend as well. The workshop provided information that could be useful to aides and other home care employees, says Deborah Hembree, RN, staff development coordinator for the freestanding agency, which has offices in Kentucky, Tennessee, and Virginia. The agency is managed by Health Management Association of Chicago, and it serves a 150-mile radius in the three-state area.
Hembree invited domestic violence experts to speak at the workshop, which was divided into four modules of about one hour each. Those modules were:
1. Dynamics of family violence.
Hembree asked two social workers to present this portion of the workshop. "They talked about how women often are in situations where they feel trapped," Hembree says. "They showed a video about the elderly, showing how women who had been married 40 to 50 years were still being abused."
The five types of abuse involving the elderly typically are described as physical, emotional, financial, neglect, and abandonment. The National Elder Abuse Incidence Study found that the greatest percentage of elderly who suffered from any one of those five types of abuse had household incomes of $5,000 to $9,999. Here is a guideline to the different types of abuse:
o Physical abuse.
"The easiest type of abuse to identify is physical abuse," says Jimmy Middleton, a family service worker clinician with the Community Based Services Protection and Permanency of the Department of the Kentucky Cabinet for Families and Children in Barbourville, KY. Middleton, who spoke at the home care workshop.
He says cigarette and other types of burns are quite common, and health care workers should be alert to signs of bruising, specifically looking at colors of bruises. "The color is an indication of how old the bruise is. So if there are several bruises of different colors on a person, then there’s an indication the bruises were made at different times." This type of bruising could mean a person is being battered, he adds.
Another indicator is the location of the bruises. Bruises on the upper arm might be caused by someone grabbing and shaking the person. Health care professionals sometimes can see indications of a fingertip in a bruise or thumb marks on opposite sides of finger marks. This type of pattern could be evident on a person’s neck if he or she was choked.
"Also, if they used an instrument, quite frequently you can see the print of that instrument," Middleton says. "For example, I’ve seen on children a fly swatter grid, or you can see belt marks."
o Emotional/verbal abuse.
When home care workers visit patients, they should pay attention to how the patient’s family talks to the patient. In cases of emotional or verbal abuse, the perpetrator might have trouble sounding civil even when other people are present.
When the verbal exchanges between patient and family members offer no clues, home care professionals should be alert to odd behaviors by the patient. Victims of emotional abuse might behave as though they are afraid, even when there is no apparent reason. They also might appear to be withdrawn and unwilling to trust their health care workers. "They might act like a pet that’s been mistreated," Middleton says.
o Financial abuse.
This could manifest in the elderly person being defrauded or exploited financially. Home care professionals might see signs of financial abuse if the patient appears unable to afford medication or other important medical items when an admission assessment indicated the patient had adequate income.
Other forms of financial abuse include running up bills the victim is responsible for paying, including long-distance phone calls; withholding money or access to money; and forcing the victim to commit welfare fraud. A victim’s family member also may refuses to buy the supplies the person needs for comfort and recovery. For example, suppose a home care patient needs a special lotion for his or her skin, but the patient’s spouse is unwilling to buy the product although the money is available, Middleton says.
Home care professionals also should check to see if the patient’s food and nutritional needs are being met, he notes.
o Neglect.
Neglect concerns the environmental conditions of the home. Home care professionals should note whether the home is in poor repair or whether it is adequate to meet the patient’s needs. Neglect also might involve a family member preventing the patient from keeping medical appointments and receiving follow-up care, Middleton suggests.
In terms of basic caregiving, bedridden or very sick patients need help with personal care, and it might be evident they are not receiving such help. The patient might have bed sores, for example. "The home health aide might go into the home and find that the patient has had a bowel movement that was not removed or cleaned up."
o Abandonment.
Some patients may be homebound and left to fend for themselves, even though they had family members living in their homes before their illness.
2. Characteristics of victims of domestic family violence.
A police officer speaking at the workshop described domestic violence he had seen in homes, including victims of child abuse and women who wanted to leave their abusive husbands but were afraid to do so. Health care workers might recognize in their patients some of these common characteristics of an abused adult:
• admits to being a victim of maltreatment;
• has a history of prior abuse or neglect;
• is physically and mentally frail;
• is fearful of partner or caregiver;
• appears anxious or fearful;
• complains of chronic pain and other physical problems;
• is overly aggressive or passive;
• has sleeping or eating disorders;
• makes comments about suicide;
• has injuries to genitalia, breasts, or rectum;
• has an injury that is inconsistent with the cause named.
Other major characteristics of abused elderly persons include an inability to care for themselves, mental confusion, and moderate to severe depres sion. Also, while more elderly women than men are victims, there is a higher percentage of men who are abandoned. About 62% of the victims of abandonment, according to The National Elder Abuse Incidence Study, were men, while about 38% were women. Women (76%) were more likely than men (24%) to be victims of emotional abuse.
3. Prevention and intervention strategies.
The National Elder Abuse Incidence Study recommends that health care workers be trained to detect instances of abuse and neglect. Elderly abuse victims often are more isolated than other abuse victims, so health care workers may be their first line of defense. Home care agencies should have a list of organizations that assist the elderly and handle elder abuse reports. All staff should know where to find the list. In Kentucky, for instance, the Community Based Services Protection and Permanency Department has information for anyone who wants to learn more about abuse and neglect, Hembree says.
If a home care worker suspects abuse when visiting a patient’s home, the workers should report the suspicion to an agency director, and the agency may send a social worker to the home to assess the situation, she says. Any suspected abuse should be reported to the state. However, adult victims who are mentally competent are entitled to refuse services, Middleton says.
Home care workers should keep in mind that elder abuse doesn’t follow the same pattern as domestic violence. Whereas domestic violence among adults under age 60 typically involve a male perpetrator and a female victim, elder abuse perpetrators may as likely be women. The study showed that 52.5% of the incidents involved male perpetrators, and 47.5% involved female perpetrators. If the abuse is neglect, which is the most frequent type of maltreatment, it’s more likely to involve a female perpetrator. The other forms of abuse are more likely to be caused by men.
Also, most abusers are children of their elderly victims. Abusers also might be friends, neighbors, or other relatives. Grandchildren account for a far smaller percentage of abusers, and the victim’s spouse is even less likely to be an abuser.
Some abusers may act out of ignorance or because they feel overwhelmed with caring for a homebound patient. Home care nurses could prevent these types of neglect by carefully educating caregivers or making referrals to agencies that could provide respite care.
4. Legal and social mandates.
Hembree invited legal experts to speak with Comprehensive Home HealthCare’s staff about Kentucky’s legal requirements for health care professionals."They said that if we suspected abuse and didn’t report it, we could be held liable," she says.
Kentucky and many other states require health care workers to report suspected physical abuse and neglect. "If they suspected abuse and didn’t report it, they could be sued by the victim’s family members at a later date," says Mike Pace, who spoke at the home care workshop. Pace is domestic violence attorney advocate for the Appalachian Research and Defense Fund of Kentucky in Barbourville.
He suggests health care workers include a question on their admission forms, asking patients if they have ever been involved in a domestic violence situation. "Each organization or company or hospital could word it however they felt it would best suit their needs."
Reporting suspected abuse
Some states also carry statutes requiring health care workers to report emotional or verbal abuse of the elderly. In Kentucky, this type of abuse should be reported only if it involves a direct or indirect threat to harm the victim. "Arguing or name-calling is not covered," Pace says. "There has to be an actual threat of violence."
In addition to reporting suspected abuse to state officials, home care workers should document these incidences in agency files, so these notes could be used in a court proceeding, he adds. Finally, home care workers should call 911 if they enter a home and witness a violent situation.
Reference
1. National Center on Elder Abuse of the the American Public Human Services Association, Westat. The National Elder Abuse Incidence Study. Washington, DC; Baltimore; 1998.
sources
• Deborah Hembree, RN, Staff Development Coordi nator, Comprehensive Home Healthcare Services, P.O. Box 236, Middlesboro, KY 40965-0236. Phone: (423) 626-8661.
• Jimmy Middleton, Family Service Worker Clinician, Community Based Services Protection and Perm anency, Department of the Kentucky Cabinet for Families and Children, P.O. Box 1420, Barbourville, KY 40906. Phone: (606) 546-5154.
• Mike Pace, Domestic Violence Attorney Advocate, Appalachian Research and Defense Fund of Kentucky, 460 Court Square, Barbourville, KY 40906.
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