Elder Abuse: Identifying and Assisting the Victim
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Elder abuse is related to the development of concern about family violence, as well as to a dramatic increase in the number of elderly in the population. This article describes typologies of abuse, factors related to elder abuse, and strategies for identifying elders at risk. Suggestions are offered for working with abuse victims and their families.
Key Words: elder abuse, gerontology, assessment, intervention
This paper is taken from materials developed for Sengstock, et al., 1990, "Elder Abuse Assessment and Management for the Primary Care Physician," a training program on elder abuse developed especially for physicians, but adaptable for other health and social service professionals. The program was developed under a grant from the Administration on Aging, and can be obtained from the Office of Medical Education, Research, and Development, Michigan State University, College of Human Medicine, East Lansing, Michigan, 48824.
Development of this material was funded by grant #05AM9045/01, "Statewide Short-Term Training and Continuing Education for Physicians on Elder Abuse," from the Administration on Aging, Office of Human Development Services, Department of Health and Human Services, Washington, D.C., 20201. Points of view or opinions do not necessarily represent official Administration on Aging policy.
Researchers and service providers first began to express concern over the abuse of the elderly in the late 1970s (Block & Sinnott, 1979; Chen et al., 1981; Krasnow & Flesher, 1979; Lau & Kosberg, 1979; Sengstock & Liang, 1983). Recognition of the problem was largely related to the development of concern for family violence in general, as well as to a dramatic increase in the number of elderly in the population, increasing the visibility of any problems related to aging. Concern with elder abuse increased with a report of the House of Representatives Select Committee on Aging (1981) and the foundation of a National Aging Resource Center on Elder Abuse (NARCEA) in 1988 (U.S. Dept. of Health and Human Services, 1992). A survey to estimate the frequency of elder abuse was conducted in the Boston area in 1985; this study found that 32 elders per 1,000 (3%) were victimized (Pillemer & Finkelhor, 1988). Since a limited definition of elder abuse was used, this rate should be considered a minimum.
Elder abuse has generally included a wider variety of actions than those originally included in child and spouse abuse (Humphreys & Ramsey, 1993; Sengstock & Barrett, 1993). Thus elder abuse laws usually include "abuse, neglect, and exploitation" (Sengstock & Hwalek, 1986a). In describing elder abuse to physicians and other health and social service professionals, the following typology has been found to be useful:
- Psychological neglect involves isolation of the elderly, not providing them with social stimulation and/or preventing others from associating with them.
- Psychological abuse is more overt, involving direct verbal assaults against the elderly—insulting or ridiculing them or making threats to withhold care or to place them in a nursing facility.
- Violation of personal rights prevents an elderly person from making decisions for him/herself, such as where to live, whether or not to marry or divorce, to change a deed or will, and so on.
- Material or financial abuse involves the theft or misuse of an elder's money or property. It may include such things as taking an elder's Social Security check or other funds or tricking an elder into deeding property over to another. Violation of personal rights and material abuse are often categorized together in the law as exploitation.
- Physical neglect is the failure to provide a dependent elder with the necessities of life, such as food, clothing, shelter, medical care, or such items as hearing aids or eyeglasses.
- Physical abuse is the direct assault of an elderly person, such as hitting, punching, pushing, and so on. This type also includes sexual assaults which probably occur with the elderly more frequently than is usually observed.
Several other typologies have been developed to describe elder abuse (Hudson, 1991). The above typology has the advantage of focusing on observable behavior. Other typologies include special categories focusing on the identity or motivations of the abuser, or other factors. Thus there may be a special category for self neglect by competent elderly who fail to provide themselves with the necessities of life. Others make a distinction between passive neglect, in which the caregiver is unaware of the harmful effects of his/her behavior, and active neglect, in which the caregiver is deliberately neglectful. Severe isolation of an elder is sometimes defined as confinement, and sexual abuse may also be a separate category (Hwalek, 1987; Hwalek et al., 1989).
Research has shown that the various types of abuse often occur together. Rarely is an elder a victim of only one type (Sengstock & Liang, 1983). As has been found with spouse abuse, the types of maltreatment may progress from the less to the more serious types (Walker, 1984). Consequently, psychological abuse or neglect or material abuse may be precursors of physical neglect or direct physical abuse. The problems of aging may place elders and their families in difficult positions at times, forcing family members to choose between one type of abuse or another (Sengstock & Liang, 1983). For example, a frail elderly parent may be incapable of managing an independent home but does not wish to move. The family must choose between forcing the parent to move (which constitutes a violation of the elder's personal rights), or allowing the elder to remain in the home, but risk being accused of neglect at a later point if the elder cannot manage or is injured.
Factors Related to Elder Abuse
Professionals who deal with the elderly should be aware of the characteristics that have been found to be related to elder abuse. Perhaps most importantly, they should be aware that elder abuse can occur in all income levels, races, religious, and ethnic groups (Sengstock & Liang, 1983; Wolf, 1986; Wolf & Pillemer, 1984; 1989). No professional can safely say that such behavior would not occur in his/her practice, no matter how affluent or "respectable" the clients may appear. Research has shown that most elder abuse victims are women, largely because the elderly population is predominantly female (Sengstock, 1991). However, it has also been found that risk of elder abuse may be greater among men (Pillemer & Finkelhor, 1988), as well as among those elderly who are mentally or physically incapacitated (Wolf, 1986; Wolf & Pillemer, 1984; 1989). It has also been found that some abusive relatives are financially dependent on their victims; the elder's Social Security or pension check may be the only steady income in the family (Wolf, 1986; Wolf & Pillemer, 1984; 1989).
Elder abuse may be perpetrated by persons in a variety of relationships to the elderly. While it is often presumed that the elderly are abused primarily by their children, the abusers may also be unrelated caregivers, neighbors, landlords, grandchildren, or spouses (Sengstock & Liang, 1983; Sengstock & Barrett, 1993). Some instances of elderly spouse abuse may represent the continuation of a pattern which has continued for many years, while others may be new patterns which develop with the stresses that develop in old age, such as life changes in retirement or one spouse's need for extensive care. With some couples, a long term abusive pattern may be altered, as a formerly abusive husband becomes more frail and his wife, now dominant, takes revenge for years of abuse (Sengstock, 1991).
While elder abuse is not a new problem, numerous factors in modern society may favor its development. The growth of the aged population is clearly a factor. Even if the rate of elder abuse remained the same, the number of cases would increase due to the sheer number of elderly. This has also placed great stress on families who are pressed to provide care for more elderly members for a longer period of time. In recent generations families are also smaller, requiring fewer children to provide the care for a larger number of elderly members. In earlier years, a family might have one frail parent who needed care for two or three years. Today, a married couple might be caring for both sets of parents. With modern medical advancements, these care needs may continue for twenty or more years.
These care problems are exacerbated by changes have occurred in family structure. In the past, families tended to remain in the same geographic area; hence several children might be available to help with care. Today's mobile society sees families spread over several states, with only one or no children nearby to assist an aged parent. The greater presence of women in the work force also plays a role, with few women staying at home to provide care for an aged parent. While some women are pressed to leave the work force to provide elder care, for many, employment is a financial necessity and not an option (Sengstock, 1991).
The need to care for an elderly relative is, in itself, a stress producing situation which can bring about abusive or neglectful behavior. Many caregivers are themselves elderly or nearly so (Pillemer & Finkelhor, 1988; Sengstock & Liang, 1983; Wolf, 1986; Wolf & Pillemer, 1984; 1989). A 90-year-old elder may be cared for by an 85-year-old spouse or a 65-year-old son or daughter who is incapable of the persistent, often strenuous responsibilities of caregiving. Professionals often fail to recognize that elder care is more stressful than child care: While children are increasingly able to manage their own care and become more self-sufficient, with the elderly, the reverse is true. Elderly persons require increasingly more assistance as the years go on. An elder who requires only assistance with shopping or yard work this year may require assistance with cooking next year and help with dressing or eating the year after that. Consequently, families are faced with ever-increasing care responsibilities as time passes. Unlike professionals, family caregivers do not have limited hours. Most are on duty all day, everyday, year in and year out. Respite care is available only on a limited basis (Sengstock et al., 1990). The result of this pattern is a high level of caregiver burnout in many families. It should also be recognized that some families are more prone to elder abuse than others. The likelihood is particularly high in families in which substance abuse or mental illness are present. While families without these problems may still exhibit abuse, the most serious abuse often occurs when these problems are present (Sengstock et al., 1990). Families with a long history of family violence or other strained relationships are likely to turn their wrath against the weakest members, who may be an elderly parent. The need to provide care for an aged member may also regenerate old antagonisms between siblings or between parents and their children, adding to the likelihood of abuse or neglect. Finally, it should be noted that even the most cordial family relationships can be stressed to the breaking point by the requirements of providing care for an aged relative. Three generations living in a household can strain the best of relationships. The home becomes more crowded and privacy is at a premium; children may be boisterous while their grandparents are seeking peace and quiet. These situations strain everyone's nerves.
The need to provide care to an aged spouse or parent also disturbs long-standing status and power relationships in the family. Parents are used to being in control; they now find their children making important decisions, such as the scheduling of meals, shopping, or other appointments. Marital relationships may also be disrupted; a wife who has always planned and cooked the meals may now be dependent upon her husband or child; or a husband who formerly made all family decisions may have to submit to the will of wife or children. Such changes in status or decision-making power are never taken lightly. These changes are particularly stressful if the elder requires direct personal care, such as assistance with bathing, dressing, or toileting. These tasks require that children invade their parents' most private territory and observe their parents naked, violating some of western society's most stringent sexual taboos (Sengstock et al., 1990). Professionals should be sensitive to these concerns and be aware that situations which involve these factors may produce inadvertent abuse or neglect. That is, family members may often be neglectful not because of lack of concern but because they are trying to avoid these unpleasant situations.
Identifying Elder Abuse and Neglect
Professionals who work with the elderly should be aware that there are serious consequences which can occur as a result of elder abuse—even those types, such as psychological neglect, that appear on the surface to be somewhat benign (Sengstock et al., 1990). As persons age, their bodies are less able to recover from trauma which may be inflicted as a result of abusive actions. If elders are dependent upon others for their care, the lack of such care may result in the absence of food or medicine which are necessary for their health. Financial abuse can deprive elders of the funds necessary to provide for their health and welfare. Also, all of the various forms of abuse and neglect can cause elders to become depressed; this depression may result in loss of appetite and a loss of will to carry out normal daily activities. This may result in a pattern similar to the "failure to thrive" phenomenon seen in infants (Humphreys & Ramsey, 1993). For these reasons, the identification of elder abuse victims, and provision for their care, is a critical concern for professionals in the gerontology field. A two-level process is involved in identifying abused or neglected elders: (a) identifying those elders at risk and (b) focusing on elders actually suspected of being victims.
IDENTIFYING ELDERS AT RISK
Initially, health and social service workers should focus on those persons at greatest risk of abuse or neglect (Johnson, 1991). As indicated above, certain types of persons tend to be at greater risk. The most dependent elderly are at particularly high risk since their care places considerable stress on the family and caregivers. Mentally incompetent elderly, such as those suffering from Alzheimer or related disorders, are at particularly high risk because of the difficulties involved in their care. In view of the high risk in such cases, professionals should take special care to observe characteristics of these patients and their caregivers. In effect, elders who are mentally and/or physically impaired should always be considered to be at risk of abuse.
Abuse is not solely confined to persons who are impaired in some way (Sengstock & Liang, 1983; Wolf, 1986; Wolf & Pillemer, 1984; 1989). Hence elders who are fully competent and capable of caring for themselves should also be screened. Special attention should be paid to certain categories. For example, elders whose family members are mentally ill or substance abusers are at greater risk, as are persons who share a household with someone else (Sengstock et al., 1990). Easily observable risk factors are not found in all victims however; hence it is important that professionals take special care to locate victims who may not fit into the most common categories.
The use of a screening tool, such as the Elder Abuse Screening Test (EAST) can be of value in this regard (Hwalek & Sengstock, 1987; Neale, et al., 1991). Such tools are short series of questions designed for use with mentally competent elders to determine whether they may be in an abusive or threatening situation. For example, the EAST is made up of 15 questions such as: "Do you feel uncomfortable with anyone in your family?" "Has anyone taken things that belong to you without your O.K.?" "Does someone in your family make you stay in bed or tell you you're sick when you know you're not?" "Has anyone close to you tried to hurt you or harm you recently?" (Neale et al., 1991).
The responses to such questions have been found to be effective in identifying elderly victims of abuse (Neale et al., 1991). However, they are not foolproof and should not be the only mechanism used. It should be noted that these tools are designed primarily for use with fully competent elders, and their value cannot be guaranteed with the mentally impaired. However, direct questioning should not be dismissed out of hand as a method for use with the impaired elderly. Most mentally impaired persons have some level of competence in observing and reporting their experiences. Any reports they make about persons attacking or attempting to injure them should be taken seriously.
OBSERVING AND RECORDING SYMPTOMS EXHIBITED BY SUSPECTED VICTIMS
The second level of identification involves the observation and substantiation of symptoms of abuse or neglect in elders who are suspected of being victims. Once an elder has been identified as being at risk of abuse, it is necessary to determine whether abuse or neglect is actually occurring, and, if so, the nature and seriousness of the abuse. Various measures have been developed to assist in this process by indicating cues which can signal the presence of elder abuse or neglect (Sengstock & Hwalek, 1986a). These cues require the observation of the physical characteristics of the elder, as well as the elder's manner of behavior, characteristics and demeanor of the elder's caregiver or other family members, and characteristics of the elder's health care patterns. Since these cues tend to be specific to certain types of abuse or neglect, they will be discussed in that context.
Physical abuse can be identified by observing physical characteristics of the suspected victims. Examples of important symptoms include bruises which take the form of common objects, such as the hand or fingers, a coat hanger, an electric cord or rope (Sengstock & Hwalek, 1986a). Injuries in or around the genital area or the breast may be signs of sexual abuse. Medical personnel should also compare the injuries observed with the explanation provided. If these do not correspond, this could be a sign of abuse. For example, some injuries, such as spiral fractures or bruises on the inner planes of the body (the inner thigh or arm, for example) are unlikely to occur as a result of accidental falls or bumping (Sengstock et al., 1990). If the explanation focuses on such unlikely possibilities, this could be a danger sign.
Clues can also be found in the elder's medical care pattern. When injuries occur accidentally, immediate medical attention is usually sought. When injuries are the result of abuse or neglect, caregivers often delay seeking medical care, in the hope that the injuries will heal and need not be observed by others. Hence the presence of scars from old, untreated injuries can be a sign of abuse, as can the presence of injuries at several different stages of healing. Bruises, for example, exhibit different patterns as they heal. Initially they tend to be bright red, blue, or purple; after five days they tend to fade to green; during subsequent weeks they may turn yellow or brown (Sengstock et al., 1990). If "old" bruises are alleged to result from a recent fall, this claim could be a danger sign.
Observing the interaction of the elder and caregiver or other family members can also provide clues as to the presence of abuse or neglect. If a caregiver is evasive about the manner in which the injuries occurred, this could be a sign of abuse (Sengstock & Hwalek, 1986a). Similarly, elders who are abused may also exhibit signs of fear when around the abuser. Family members who refuse to allow an elder to talk privately with professional workers may be trying to hide abusive behavior.
Physical neglect can also be identified by observing physical signs, such as loss of weight without a medical reason, the presence of body odor, rashes, or insect bites (Sengstock & Hwalek, 1986a). Neglect can be observed most easily by workers, such as home care aids or visiting nurses, who have access to the elder's home environment. Such workers can observe whether the elder's environment is dirty or unsafe. Neglected elders may have untreated bed sores, be found tied to a bed or chair, or lying in feces or urine-soaked beds. Prescribed medications or needed aids, such as eyeglasses, hearing aids, or dentures, may be absent. Neglect may be active, in that the caregiver is aware of the elder's needs but fails to provide for them. However, in many instances, persons responsible for an elder's care may be unaware of proper methods of providing care. For example, many caregivers are unaware of the conditions under which a frail elder can or should be restrained to a bed or chair, or how to impose such restraints safely (Sengstock et al., 1987).
Material or financial abuse can be observed by noting an elder's financial situation. Even in medical or social settings, workers may have the opportunity to observe whether or not elders indicate that they are out of money early in the month or exhibit hunger or malnutrition. These circumstances may indicate that someone is stealing a Social Security or pension check. A patient who has no funds to pay for medical care—particularly if this represents a change in behavior—may also be a victim of material abuse. Particularly risky situations are those in which an elder has someone else handle financial matters; examples are having a representative payee for Social Security, or placing someone else's name on a deed or bank account (Sengstock & Hwalek, 1986a).
Violation of personal rights occurs when mentally competent elders are prevented from making decisions about their own lives. If an elder moves into or out of a hospital or nursing facility or refuses medical treatment, workers should take care to note who is making this decision. If the elder is unaware of the plans or seems reluctant to carry them out, it could indicate that he/she is being forced into the action. Special concern should be shown if an elder reports visits to a bank or attorney and does not understand the reason for the visit. This situation may indicate that he or she is being forced to make unwanted changes in a will or bank account.
Health care professionals themselves often violate elders' personal rights by asking family members to provide information or make decisions for their mentally alert elderly members. For example, hospital clerks—in the interest of bureaucratic efficiency—may ask a family member to find an elder's Medicare card or respond to health history questions for an elderly relative. Such requests constitute an intrusion into the elder's privacy and may result in release of an elder's confidential health or financial information to family members against the elder's wishes.
Psychological abuse and neglect should be taken seriously by health and social service workers because they may accompany or be precursers of more life-threatening forms of abuse (Sengstock et al., 1990). Workers should note the demeanor of the elder and family members, particularly their interaction with each other. When elders exhibit signs of depression, such as downcast eyes or speaking in a monotone, this can be an indicator of psychological abuse or neglect (Blazer et al., 1987). If elders appear anxious around a caregiver or other family members, or state that they do not want someone around, their concern could be a sign of psychological abuse or neglect. Professionals should note the way in which caregivers and family members interact with their elderly members. Using a harsh tone of voice, making humiliating or insulting statements, or threatening an elder with guardianship, abandonment, or institutionalization are signs of psychological abuse. Professionals should be aware that any one of the signs listed here is rarely significant; but if several are noted, this observation represents an important signal than an elder may be in danger.
Working with Abuse Victims and their Families
The management of cases of abuse or neglect is a skill to which many professionals in practice today have not been introduced. It requires, for example, special techniques of interviewing in order to increase the likelihood of learning the presence of abuse (Sengstock & Hwalek, 1986b). Interviewing suspected victims of abuse requires the separation of the suspected victim from the caregiver or other family members during the interview process. Elders who are victimized will not feel free to speak in front of those who are victimizing them (Sengstock et al., 1990). If possible, one worker should interview the elder while another speaks with the caregiver. Both can provide valuable insight into problems with the elder's care and the family situation.
It is important that both respondents be made to feel comfortable and at ease and confidentiality be maintained. Workers should never reveal to either respondent what the other has said. For example, do not say to a caregiver, "Mrs. X. said you pushed her." Professionals should also become comfortable with asking direct questions, for example: "Has anyone hurt you?" or "Did someone hit you?" If necessary, they should practice asking such questions on neutral parties until they feel comfortable with the process.
Professionals should also become knowledgeable about the legal requirements of the state in which they practice. State laws differ in the manner in which they handle the problem of elder abuse. Many states, such as Michigan, have mandatory reporting laws, which require that professionals who work with the elderly report suspected elder abuse to a state agency, usually the state's department of social services or aging affairs (Faulkner, 1982; Salend et al., 1984; Traxler, 1986). Other states may not have mandatory reporting but may require that special services be provided to elder abuse victims (Hwalek, 1987; Hwalek et al., 1989). Because elders are adults, most states also provide for their involvement in any service plans, including the right to refuse services if they choose (Faulkner, 1982; Hwalek, 1987). Often elders may refuse services because they believe there are no alternatives to their present situation; the abusive relative with whom they live may be their only living relative or may have convinced them that there are no alternatives to the existing situation. Hence workers should make certain that clients who choose to refuse services are making an informed decision and are aware of the possible alternatives.
If abuse or neglect is suspected, it is important that a thorough physical exam be performed on the alleged victim. Any such exam should involve the removal of clothing, since many injuries may be hidden. Inadequate foot care, for example, is often missed in medical exams and can be extremely serious, especially for elders with conditions such as diabetes (Sengstock et al., 1990). Both elder and family members should be made aware of what is likely to take place. That is, if laws require reporting the case to a state agency, it is best to inform the elder and family that this is the case. This can be done without confrontation or threats. Thus the professional can indicate that incidents involving certain types of injuries must be reported, without suggesting that there is any "fault" involved. Professionals reporting abuse or neglect should remember that they are only observers, not judges or prosecutors, nor even investigators. This process can be left to others more familiar with elder abuse and the laws governing it.
Families in which elder abuse is a problem usually require extensive services in order to deal with the problem (Sengstock et al., 1990). As with other types of domestic abuse, it is critical that workers make an initial assessment of the dangerousness in the situation (Milner & Campbell, 1995). If the elderly victim's life or safety is in question, then an immediate separation of victim and abuser may be warranted. If health or safety are not immediate problems, then the professional has greater leisure to determine the proper care management.
Appropriate services in these cases depend on the nature of the abuse as well as the characteristics of the elder and his/her family situation (Bergeron, 1989). For example, physical abuse may involve criminal sanctions and material abuse may require the services of an attorney; psychological forms of abuse, however, are more likely to require family counseling. Elders who require a lot of care may be placing considerable strain on the family; in such cases, respite care or other assistance for the family may be required. Many abusive situations may be resolved by providing assistance for other problems which may exist in the elder's family, such as unemployment, child care needs, or marital stress. Workers should become aware of any such issues which may impact on an elder's care situation.
Services required by abuse and neglect victims are also more complex than those involved with other types of gerontological problems (Kinney et al., 1986). Unfortunately, many of the services which can assist elderly victims are available only on a limited basis. Furthermore, existing agency organization and funding patterns may not be conducive to providing the types of assistance required in these cases. For example, agencies serving the elderly are often prohibited by funding requirements from providing assistance to younger clients; but such assistance may be necessary in order to alleviate elder abuse. Professionals must often become inventive and agencies may need to be more flexible in their requirements in order to serve these clients effectively (Sengstock et al., 1991).
While the number of abused and neglected elders may be small relative to the total number of elders, these are critical and often life-threatening situations. They deserve serious attention from the health and social service professions. Professionals must be alert to the signs of abuse, neglect, and exploitation in their elderly clients. They must also develop techniques for finding the assistance need by these clients and their families in order to alleviate existing abuse and prevent its occurrence in the future.
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