Transcript An Introduction to the Issues of Elder Abuse

The Societal Challenges of
Elder Mistreatment
The Aging Population, Alzheimer’s and Other Dementias:
Law & Public Policy
University of Iowa College of Law
March 1, 2012
Robert B. Wallace, MD, MSc
University of Iowa College of Public
Health
Why “Mistreatment,” Not “Abuse?”
• Abuse has the connotation of overt violence, but
most mistreatment is not physical violence
• Complexity of social behavior in the home or
institution is more likely to have bi-directional
elements
• “Abuse” is more likely to be used in legal
language; not all mistreatment is a crime
Counting “Cases” Requires Definitions: The
Phenomena of Elder Mistreatment
Physical abuse
– Physical force that may result in bodily injury, pain or impairment
(includes: hitting, slapping, grabbing)
Sexual abuse
– Non-consensual contact of any kind with an older person
Emotional and psychological abuse
– Infliction of anguish, pain or distress
Financial exploitation
– Illegal/improper use of funds, property or assets
Neglect and Self--Neglect
– Refusal or failure to fulfill obligations or duties to an elder
Three Components of Elder
Mistreatment
Trust relationship
Intent and motivation
Harm in some form
Some Definitional Issues
Assessing intent/ motivation of mistreatment and
neglect
The complexity of social behavior in trust
relationships
The (varying) role of legal and administrative
definitions
Is refusing to provide for someone else a
personal crime or a social welfare issue?
Iatrogenic events: e.g., inadequate care;
restraint or psychotropic medication use;
adverse events of appropriate treatment
A Focus on the “Self-Neglect” Issue
Have the capacities of the victim and caregivers
been assessed?
The role of disability, cognitive impairment and
mental illness
Economic means and resources
Social access to information/ education
Access to helping and clinical services
Some Larger Contexts of Elder Mistreatment
• All interpersonal violence
• Domestic violence
• Violence against disabled persons
• Management of abusive psychiatric behaviors
• Criminal behavior
• Social welfare and unmet needs in society
• Codes of professional conduct in health and social
professionals
• Funding and fiscal accessibility in health care
• Retirement and pension policies
The Spectrum of Domestic Violence
Possible Examples of EM
In the Institutional Setting?
Forcing a resistant elder to wash her hair twice a
week?
Using chemical restraints (drugs) to improve
patient safety?
Not honoring holidays of all faiths in a long-term
care facility?
A capable family member who ignores an elder
in a long-term care facility?
Not providing a chapel in a long-term care
facility?
An Example:
A Legal Issue Resulting from Elder
Abuse Law
Under-treatment of pain in clinical setting
Abuse or malpractice?
– Multiple settings (home care, hospice, nursing
homes, hospitals)
– Circumventing usual litigation pathways
– Lack of training in pain medicine
– Reticence to use pain medicine to the fullest
The Complexities of Financial Exploitation
(J Elder Abuse Neglect 23:304)
A Quarter Century of (Little) Epidemiology of
Elder Mistreatment: 1975-2000
Not clearly defined: Suspected 1-10% annual
prevalence
Are rates incidence or prevalence?
No national surveys of older persons
Relative occurrence of: abuse/ neglect/
exploitation unclear
Mode of data collection: social service/
protective agency > clinical > small populations
Data Sources for the Study of Elder
Mistreatment
1. Formal professional reports:
a. Justice system & police (abuse, rape,
murder)
b. Forensic pathology reports
c. Adult Protective Services
d. Health professional screening and reporting
e. Institutional reports (nursing homes; assisted
living)
Data Sources for the Epidemiological
Study of Elder Mistreatment
2. Screening in clinical (emergency departments,
out-patient facilities)
3. Surveys of professionals/ professional records;
Emergency rooms; ambulatory care;
hospitals; long term care
4. Household surveys (1 or multi-stage):
a. Potential victims
b. Potential perpetrators
c. Biomarkers without questionnaires
5. Citizen reporting
Staff Reports of Elder Mistreatment in Iowa
(JAMDA DOI: 10.1016/j.jamda.2008.09.005)
Work of McCool, Jogerst, et al.
Two nursing homes: Questionnaire to 335 staff
About 50% participation rate
Have you seen/suspected adult abuse?
Type of abuse
Nursing/admin %
Physical abuse
21.4
Sexual abuse
0.0
Emotional abuse
32.1
Financial exploitation
28.6
Other staff %
10.0
0.0
5.0
0.0
Family Members’ Reports of Abuse in
Michigan Nursing Homes (J Elder Abuse & Neglect 21:105)
A Plea for Citizen Reporting and of Abuse
and Its Prevention
Step 1: Evaluate the Situation
Step 2: Report Abuse
Step 3: Understand the Law
Step 4: Help Prevent Abuse
A Plea for Citizen Reporting of Abuse and
Its Prevention -- American Humane
Association
Step 1: Evaluate the Situation
Step 2: Report Animal Abuse
Step 3: Understand the Law
Step 4: Help Prevent Animal Abuse
National Social Health and Aging Program:
US National Survey of Mistreatment (JGSS
63B:S248)
Validated items: In the past 12 months….
1. Is there someone who insults you or puts you down?
(verbal mistreatment)
2. Is there anyone who has taken your money or your
belongings without your okay, or prevented you from
getting them even when you ask? (financial mistr.)
3. Is there anyone who hits, kicks, slaps or throws
things at you? (physical mistreatment)
……Then asked the relation of the perpetrator
National Social Health and Aging Program:
US National Survey of Mistreatment (JGSS
63B:S248)
First UK Prevalence Survey of Mistreatment
(J Elder Abuse & Neglect 21:1)
First UK Prevalence Survey of Mistreatment:
Annual Prevalence (J Elder Abuse & Neglect 21:1)
Consequences of Elder Abuse
Physical Health
Morbidity (skin wounds; fractures, etc.)
Death
Dysfunction and disability
Psychological Health
Depression; fear; guilt; shame; distrust; learned
helplessness; withdrawal; post-traumatic stress
syndrome
Economic Status
Loss of resources, possessions
Mortality Associated with APS-Identified EM
in a Defined Population [Lachs, JAMA 280:428]
Risk Factors for Elder Abuse - I
Victim dependency/ vulnerability
– Poor health; disability/functional impairment; poor personal
defenses; poverty; possibly dementing illnesses (resp. to behav.)
Gender--women
Abuser dependency/deviance
– Alcohol and drug abuse; mental illness; poor employment record
Social isolation
– Abuse undetected; lack of social support to buffer stress
Living arrangements
– Shared living arrangements; greater opportunity for tension and
conflict; long term care facilities
Risk Factors for Elder Abuse – II
The Disturbing Role of Childhood Experiences
Childhood Sexual and Physical Abuse: Risk for Victimization in
Adulthood [Lancet 358:450]
-Unwanted sexual intercourse < 16 years:
-Rape < 16 years
-Severe beatings by parents or carers:
RR = 3.5
RR = 2.6
RR = 3.6
Childhood Abuse and Attempted Suicide [JAMA 286:3089]
-Emotional abuse
-Sexual abuse
-Battered mother
-Mentally ill household member
-Parents separated/divorced
RR = 5.0
RR = 2.8
RR = 2.6
RR = 3.3
RR = 1.9
Risk/ Vulnerability Model of Self Neglect
(J Am Geriatr Soc 56:S271)
A Gene Effect on Early Childhood Abuse
and Adult Behavior [Science 297:851]
“Indicators” of Elder Abuse
[The Gerontologist 38:471-480]
Abusive Caregiver Characteristics:
Alcohol and substance abuse;
Mental health problems: depression/ personality
disorder; behavioral problems; care-giving reluctance,
inexperience
Generally poor interpersonal relationships; poor premorbid relations; current marital, family conflict; lack
of empathy, understanding of care needs and issues;
financially dependent on care
The Clinical Recognition of EM:
Possible Risk Factors
1. Frequent primary care or ER visits
2. Frequent or unexplained falls
3. Injuries inconsistent with explanations given
4. Evidence of neglect: malnutrition, dehydration,
hypotherm.
5. Overmedication: poisoning, stupor
6. Undue physical restraint
7. Inappropriate clothing
8. Inadequate aids and devices
9. Lack of money, possessions; social isolation
The Role of Forensic Science:
A Midwestern Program Ten-Year Experience
Cases over 60 including homicide and neglect
Homicide (avg age 72.1) Neglect (avg age 79.7)
Gunshot
Beating
Stabbing
Asphyxia
42%
37
19
10
[J. Forensic Sci. 49:122]
Pneumonia
Sepsis
Dehydration
Heart disease
Fall
Undetermined
50%
23
9
9
4
4
The Role of Forensic Science:
A Midwestern Program Ten-Year Experience - II
“Homicide” cases
(N =52)
“Neglect” cases
(N = 22)
Perpetrators
Residence
Spouse
Other family
Acquaintance
Undeterm.
15%
10
10
73
With family
Non-fam. caretaker
Alone; non-fam.
caretaker
Nursing home
Unknown
32%
14
9
18
27
Findings from Autopsies of Patients Over 65
Years with Antemortem EM [Legal Medicine 5:7]
15 Causes of Death in a Japanese Prefecture
-Subdural hemorrhage(4)
-Starvation
-Hypothermia
-Suffication (4)
-Drowning
-Arson
-Strangulation
-Traumatic brain inj.
-Traumatic pneumothorax
Perpetrators
-Sons (7)
-Grandson
-Son-in-law
-Son and Daugh.-in-law
-Grandson (2)
-Neighbor
-Unk.
-Others
Some Potential “Biomarkers” of
Abuse/Neglect
Blood biomarkers--examples for
consideration: myoglobin; acute phase
reactants
Patterns of fractures; morphology
Morphology and distribution of bruising
Quick tests of malnutrition and dehydration
Forensic testing—similar to assault and
rape investigations
Items to Assess Elder Abuse in
Epidemiological Surveys [J Appl Gerontol 5:153] - I
1. Has anyone tried to hurt or harm you?
2. Have you been forced to do things you don’t
want to do? Please give an example.
3. Have you been threatened with being placed in
a nursing home?
4. Has anyone stolen from you or taken your
possessions without permission?
5. Has anyone sworn at you or threatened you?
Items to Assess Elder Abuse in
Epidemiological Surveys [J Appl Gerontol 5:153] - II
6. Has anyone confined you at home against your
will?
7. Has anyone refused to provide you with food or
with your medications
8. Has anyone beaten or assaulted you?
9. Have you ever signed any documents that you
didn’t understand?
10. Are you afraid of anyone in your home?
“Brief Self-Report Screening Instrument”
[Australian Longitudinal Study on Women’s Health, 2000]
1. Are you afraid of anyone in your family?
2. Has anyone close to you tried to hurt you or harm you
recently?
3. Has anyone close to you called you names or put you
down or made you feel bad recently?
4. Does someone in your family make you stay in bed or
tell you you’re sick when you aren’t?
5. Has anyone forced you to do things you don’t want to
do?
6. Has anyone taken things that belong to you without your
okay?
Some Potential Problems with EM Screening
and Diagnostic Instruments in Surveys
Items do not assess social/ family context of
events
Checklist response range excludes many real
life situations
Perpetrator information often incomplete
Not responding to evidence-based practice
guidelines
Legal, Administrative Challenges to
Effective Elder Mistreatment Services
Divulging confidential information (e.g.,
caregiver support session; HIPAA)
Different laws in various jurisdictions
Inadequate responses/ resources by existing
Adult Protective Services
Disagreement on the fundamental mistreatment
nature in various situations
Remedies may make victim’s situation worse
Fear of degrading existing elder services
An Approach to Management of
Confirmed EM [Adapted from Lachs & Pillemer Lancet
364:1263]
Confirmed Case
Patient Unwilling or
Unable to Accept Services
Patient Willing to
Accept Services
Context-specific
Intervention
-Educate
-Implement
-Referral
Patient Lacks Capacity
-Go to official agency
-Financial asst.
-Conservatorship/
guardianship
-Special committee
-Courts
Patient has Capacity
-Educate patient
-Provide emergency
numbers
-Develop safety plan
-Develop follow-up
plan
Examples of Approaches to Managing
EM [Adapted from Lachs & Pillemer Lancet 364:1263]
Potentially related to caregiver stress:
-Respite care
-Adult day care
-Carer education
-Family carers recruit.
-Carer psychother. -Reduce carer soc. isol.
Longitudinal spousal violence
-Marital counseling -Support groups
-Shelters
-Protection orders
-Victim advocacy
Policy Approaches to Elder Mistreatment
Mandatory Reporting Laws
Improve Adult Protective Services:
Investigation, assessment, care planning, case
monitoring
Better Educate Other Care Providers:
Social service agencies; hospitals; long-term care insts.
Law Enforcement-Criminal Justice System
Victim assistance; perpetrator prosecution
Comprehensive Community Services
Multidisciplinary teams; community coalitions
Des Moines Register 26Feb12
Can Primary Elder Mistreatment Be
Prevented?
Depends on programs and political and administrative will:
• Better educating professionals
• Increasing community awareness
• Educate all older people and the those at risk
• Isolate and punish offenders where possible
• Protect vulnerable elders better?
Very few actual trials of prevention programs