Overview

Most nurses in the acute care setting have likely provided care for an older adult suffering from elder mistreatment (EM) without knowing it.  In a report published by the United Nations (2007), it is estimated that the number of older adults worldwide is expected to triple by the year 2050.  Cases of EM are expected to become more prevalent given the expected surge of older adults.  In 2000, older adults comprised 13% of the U.S. population.  By 2030, it is predicted that adults older than 65 will increase to 20% of the American population.  By 2030, it is predicted that adults older than 65 will increase to 20% of the American population (Ebersole & Touhy, 2006).  With a 274% increase since1960, adults 85 years or older, commonly referred to as the "oldest old," are the fastest growing sector of the American population (Cowen & Cowen, 2002).  The oldest old are at the greatest risk of EM because of increased vulnerability and dependence on caregivers for many aspects of care.  This drastic increase in older adults may only serve to exacerbate the issue of EM.  Technological advances of the past century have made it possible for those with chronic diseases to live longer; however, they require greater assistance in activities of daily living (ADL) and management of care.  Now, more than ever before, it is imperative for nurses to become better educated about EM and its complexities (Ploeg, Fear, Hutchinson, MacMillan, & Bolan, 2009).  

Nursing has had a long history in ensuring high standards of care for older adults.  The identification of EM should not be the exception.  In spite of this, nurses' lack of training and knowledge of the extent of EM and its presentation may hinder their ability to identify the signs of mistreatment.  Abuse is often multifactorial; therefore, it is important to recognize that it is an interplay between characteristics of the abused, the prepetrator, and environmental factors (Killick & Taylor, 2009).  Physical markers of abuse are often incorrectly attributed to physiological changes in the elderly rather than EM (Wiglesworth et al., 2009).  Cases of EM can prove to be challenging for nurses as it is often complicated by denial on the part of the perpetrator and older adult, refusal of services by victims, as well as fears that an accusation of EM may actually worsen abuse.  Serious ethical dilemmas may arise because a nurse may struggle between his or her obligation to ensure the patient's well-being and uncertainty over presence of EM (Beaulieu & Leclerc, 2006).  The development of EM protocols that are grounded in evidence-based research is crucial to ensure that EM cases are properly handled by nurses and other health care professionals.  

Nursing Standard of Practice Protocol: Detection of Elder Mistreatment

Terry Fulmer, PhD, RN, FAAN , Billy A. Caceres, RN, BSN, BA

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.

Evidence-Based Content - Updated August 2012

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Goal
Overview
Background/Statement of Problem
Parameters of Assessment
Nursing Care Strategies
Evaluation and Expected Outcomes
Follow-Up Monitoring of Condition
Relevant Practice Guidelines
References

Goal

Identify best practices in identifying and responding to cases of EM

Overview

With the projected increase in the population of older adults world-wide and the rise in medical and technological advances, it is anticipated that older adults will be living longer. Therefore, it is expected that cases of EM, although currently underreported, will be on the rise. As patient advocates and providers of care, nurses serve an important function in the screening and treatment of cases of EM. However, current data shows that nurses and other health care professionals are not reporting all cases of EM they encounter either because of lack of knowledge about manifestations of EM or how reporting and investigation by state agencies functions.

Background/Statement of Problem

A. Definitions:

1. Elder mistreatment: “Intentional actions that cause harm or create serious risk of harm (whether harm is intended) to a vulnerable elder by a caregiver or other person who is in a trust relationship to the elder,” or “failure by a caregiver to satisfy the elder’s basic needs or to protect himself or herself from harm (Ref 1).” Conflicting casual theories of EM:
2. Physical abuse: The use of physical force that may result in bodily injury, physical pain, or impairment (Ref 2).
3. Sexual abuse: Any form of sexual activity or contact without consent, including with those unable to provide consent (Ref 2).
4. Emotional/psychological abuse: The infliction of anguish, pain, or distress through verbal or nonverbal acts (Ref 2).
5. Financial abuse/exploitation: The illegal or improper use of an elder’s funds, property, or assets (Ref 3).
6. Caregiver neglect: The refusal or failure to fulfill any part of a person’s obligations or duties to an older adult, including social stimulation (Ref 2).
7. Self-neglect: The behavior of an older adult that threatens his or her own health or safety. Disregard of one’s personal well-being and home environment (Ref 2).
8. Risk-vulnerability model: Posits that neglect is caused by the interaction of factors within the older adult and his or her environment. The risk and vulnerability model adapted to EM by Frost and Willette (1994) provides a good lens through which to examine EM. Vulnerability is determined by characteristics within the older adult that may make him or her more likely to be abused by caregivers such as poor health status, impaired cognition, history of abuse, and so forth. Risks refer to factors in the external environment that may contribute to EM (Ref 4; 5).
9. Psychopathology of the abuser: Abuse is believed to stem from a perpetrator’s own battle with psychological illness such as substance use, depression, and other mental disorders (Ref 6).
10. Exchange theory: Speculates that the long-established dependencies present in the victim–perpetrator relationship are part of the “tactics and response developed in family life, which continue into adulthood” (Ref 6).
11. Social learning theory: Attributes EM to learned behavior on the part of the perpetrator or victim from either their family life or the environment; abuse is seen as the norm (Ref 6).
12. Political economy theory: Focuses on how older adults are often disenfranchised in society as their prior responsibilities and even their self-care are shifted on to others.

B. Characteristics of Victims:

1. Decreased ability to complete ADLs and more physically frail (Ref 4; 7; 8).
2. Cognitive deficits such as dementia (Ref 5; 9; 3).
3. History of childhood trauma (Ref 5; 10).
4. Depression and other mental disorders, as well as an increased sense of hopelessness (Ref 5; 8).
5. Social isolation and lack of support systems (Ref 7; 8; 11).
6. History of substance abuse (Ref 7; 8).

C. Characteristics of Perpetrators

1. Family member in 80% or more of cases (Ref 12).
2. Long history of conflict with the victim (Ref 13).
3. Live with victim for an extended time (Ref 14).
4. Higher rates of caregiver strain (Ref 14).
5. History of mental illness (Ref 14).
6. Depression and other mental disorders (Ref 14).
7. Social isolation and lack of support systems (Ref 14).

D. Etiology and/or Epidemiology

1. Recent data suggests that in the United States, more than 2 million older adults suffer from at least one form of EM each year(Ref 1).
2. The National Elder Abuse Incidence Study estimates that more than half a million new cases of EM occurred in 1996 (Ref 15).
3. Even though 44 states and the District of Columbia have legally required mandated reporting, EM is severely underreported. There is a lack in uniformity across the United States on how cases of EM are handled (Ref 15).
4. NCEA, (1998) estimates that only 16% of cases of abuse are actually reported.
5. The National Council on Elder Abuse revealed that neglect accounts for approximately half of all cases of EM reported to APS. About 39.3% of these cases were classified as self-neglect and 21.6% attributed to caregiver neglect, including both intentional and unintentional (Ref 1).
6. Over 70% of cases received by APS are attributed to cases of self-neglect with those older than 80 years thought to represent more than half of these cases (Ref 16).

Parameters of Assessment
Assessment  of Elder Mistreatment
Type of Mistreatment Questions to Assess Type of Mistreatment Physical Assessment and Signs and Symptoms
Physical abuse Has anyone ever tried to hurt you in any way?
Have you had any recent injuries?
Are you afraid of anyone?
Has anyone ever touched you or tried to touch you without permission?
Have you ever been tied down?


Suspected evidence of physical abuse (i.e., black eye) ask:
-How did that get there?
-When did it occur?
-Did someone do this to you?
-Are there other areas on your body like this?
-Has this ever occurred before?
Assess for:
Bruises (more commonly bilaterally to suggest grabbing), black eyes, welts, lacerations, rope marks, fractures, untreated injuries, bleeding, broken eyeglasses, use of physical restraints, sudden change in behavior.

Note if a caregiver refuses an assessment of the older adult alone.

Review any laboratory tests. Note any low or high serum prescribed drug levels.

Note any reports of being physically mistreated in any way.
Emotional/Psychological abuse Are you afraid of anyone?
Has anyone ever yelled at you or threatened you?
Has anyone been insulting you and using degrading language?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?
Assess cognition, mood, affect, and behavior.
Assess for:
Agitation, unusual behavior, level of responsiveness, and willingness to communicate.

Delirium

Dementia

Depression

Note any reports of being verbally or emotionally mistreated.
Sexual abuse Are you afraid of anyone?
Has anyone ever touched you or tried to touch you without permission?
Have you ever been tied down?
Has anyone ever made you do things you didn't want to do?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?
Assess for:
Bruises around breasts or genital area; sexually transmitted diseases; vaginal and/or anal bleeding; or discharge, torn, stained, or bloody clothing/ undergarments.

Note any reports of being sexually assaulted or raped.
Financial abuse/exploitation Who pays your bills? Do you ever go to the bank with him/her? Does this person have access to your account(s)? Does this person have power of attorney?

Have you ever signed documents you didn’t understand?
Are any of your family members exhibiting a great interest in your assets?
Has anyone ever taken anything that was yours without asking? Has anyone ever talked with you before about this?
Assess for:
Changes in money handling or banking practice, unexplained withdrawals or transfers from patient's bank accounts, unauthorized withdrawals using the patient's bank card, addition of names on bank accounts/cards, sudden changes to any financial document/will, unpaid bills, forging of the patient's signature, appearance of previously uninvolved family members. 

Note any reports of financial exploitation.
Caregiver neglect Are you alone a lot?
Has anyone ever failed you when you needed help?
Has anyone ever made you do things you didn’t want to do?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?
Assess for: Dehydration, malnutrition, untreated pressure ulcers, poor hygiene, inappropriate or inadequate clothing, unaddressed health problems, non-adherence to medication regimen, unsafe and/or unclean living conditions, animal/insect infestation, presence of lice and/or fecal/urine smell, soiled bedding. 

Note any reports of feeling mistreated.
Self-neglect How often to you bathe?
Have you ever refused to take prescribed medications?
Have you ever failed to provide yourself with adequate food, water, or clothing?
Assess for:
Dehydration, malnutrition, poor personal hygiene, unsafe living conditions, animal/insect infestation, fecal/urine smell, inappropriate clothing, non-adherence to medication regimen.

SourceFulmer, T., & Greenbery, S. (n.d.). Elder mistreatment & abuse. Retrieved from http://consultgerirn.org/resources

Nursing Care Strategies

A. Detailed screening to assess for risk factors for EM using a combination of physical assessment, subjective information, and data gathered from screening instruments (Ref 17).
B. Strive to develop a trusting relationship with the older adult as well as the caregiver. Set aside time to meet with each individually (Ref 17).
C. The use of interdisciplinary teams with a diversity of experience, knowledge, and skills can lead to improvements in the detection and management of cases of EM. Early intervention by interdisciplinary teams can help lower risk for worsening abuse and further deficits in health status (Ref 14; 18).
D. Institutions should develop guidelines for responding to cases of EM (Ref 14; 17).
E. Educate victims about patterns of EM such that EM tends to worsen in severity overtime (Ref 12; 19).
F. Provide older adults with emergency contact numbers and community resources (Ref 12).
G. Referral to appropriate regulatory agencies.

Evaluation and Expected Outcomes

A. Reduction of harm through referrals, use of interdisciplinary interventions and/or relocation to a safer situation and environment.
B. Victims of EM express an understanding how to access appropriate services.
C. Caregivers take advantage of services such as respite care or treatment for mental illness or substance use.
D. If possible, evaluate progress in relationships between caregiver and older adult through screening instruments such as The Modified CSI and GDS.
E. Institutions establish clear and evidence-based guidelines for management of EM cases.

Follow-Up Monitoring of Condition

A. Follow-up monitoring in the acute care setting is limited compared to the follow-up that may be performed in the community or long-term care settings.

Relevant Practice Guidelines

A. American Medical Association. Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: Auhtor.
B. Aravanis, S. C., Adelman, R. D., Breckman, R., Fulmer, T. T., Holder, E., Lachs, M., . . . Sanders, A. B. (1993). Diagnostic and treatment guidelines on elder abuse and neglect. Archives of Family Medicine, 2, 371–388.
C. Jones, J., Dougherty, J., Schelble, D., & Cunningham, W. (1988). Emergency department protocol for the diagnosis and evaluation of geriatric abuse. Annals of Emergency Medicine, 17(10), 1006–1015.
D. Neale, A., Hwalek, M., Scott, R., Sengstock, M., & Stahl, C. (1991). Validation of the Hwalek-Sengstock elder abuse screening test. Journal of Applied Gerontology, 10, 406–418.
E. Phillips, L. R., & Rempusheski, V. F. (1985). A decision-making model for diagnosing and intervening in elder abuse and neglect. Nursing Research, 34(3), 134–139.

References

1. National Research Council. (2003). Elder mistreatment: Abuse, neglect, and exploitation in an aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect. In R.J. Bonnie & R.B. Wallace (Eds.), Committee on National Statistics and Committee on Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academics Press.

2. National Center on Elder Abuse. (2008). Information about laws related to elder abuse. Retrieved from http://www.ncea.aoa.gov/NCEAroot/Main_Site/Library/Laws/InfoAboutLaws_08...

3. Naik, A.D., Teal, C.R., Pavlik, V.N., Dyer, C.B., & McCullough, L.B (2008). Conceptual challenges and practical approaches to screening capacity for self-care and protection in vulnerable older adults. Journal of the American Geriatrics Society, 56(Suppl. 2), S266-S270.

4. Frost, M.H., & Willette, K. (1994). Risk for abuse/neglect: Documentation of assessment data and diagnoses. Journal of Gerontological Nursing, 20(8), 37-45.

5. Fulmer, T., Paves, G., VandeWeerd, C., Fairchild, S., Guadagno, L., Bolton-Blatt, M., & Norman, R. (2005). Dyadic vulnerability and risk profiling in elder neglect. The Gerontologist, 45(4), 525-534. Evidence Level IV.

6. Wolf, R. (2003). Elder abuse and neglect: History and concepts. In R.J. Bonnie, & R.B. Wallace (Eds.), Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect (pp. 238-248). Committee on National Statistics and Committee of Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academics Press.

7. Peisah, C., Finkel, S., Shulman, K., Melding, P., Luxenburg, J., Heinik, J.,...Bennett, H. (2009). The wills of older people: Risk factors for undue influence. International Psychogeriatrics/IPA, 21(1), 7-15. Evidence Level V.

8. Dyer, C.B., Pavlik, V.N., Murphy, K.P., & Hyman, D.J. (2000). The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatrics Society, 48(2), 205-208. Evidence Level IV.

9. Gorbien, M.J., & Eisenstein, A.R. (2005). Elder abuse and neglect: An overview. Clinics in Geriatric Medicine, 21(2), 279-292. Evidence Level V.

10. Lachs, M.S., Williams, C.S., O'Brian, S., Pillemer, K.A., & Charlson, M.E. (1998). The mortality of elder mistreatment. Journal of the American Medical Association, 280(5), 428-432. Evidence Level II.

11. Draper, B., Pfaff, J.J., Pirkis, J., Snowdon, J., Lautenschlager, N.T., Wilson, I., & Almeida, O.P.(2008). Long-term effects of childhood abuse on the quality of life and health of older paople: Results fromt he depression and early prevention of suicide in general practice project. Journal of the American Geriatrics Society, 56(2), 262-271. Evidence Level II.

12. Cowen, H.J., & Cowen, P.S. (2002). Elder mistreatment: Dental assessment and intervention. Special Care in Dentistry, 22(1), 23-32.

13. Krienert, J.L., Walsh, J.A., & Turner, M. (2009). Elderly in America: A descriptive study of elder abuse examining National Incident-Based Reporting System (NIBRS) data, 2000-2005. Journal of Elder Abuse & Neglect, 21(4), 325-345. Evidence Level V.

14. Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W. (2010). Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society, 58(3), 493-500. Evidence Level IV.

15. National Center on Elder Abuse. (1998). The national elder abuse incidence study: Final report. Retrieved from http://aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Elder_Abuse/docs/AbuseR...

16. Lachs, M.S., & Pillemer, K. (1995). Abuse and neglect of elderly persons. The New England Journal of Medicine, 332(7), 437-443.

17. Perel-Levin, S. (2008). Discussing screening for elder abuse at the primary health care level. Retrieved from World Health Organization http://www.who.int/ageing/publications/Discussing_Elder_Abuseweb.pdf

18. Jayawardena, K.M., & Liao, S. (2006). Elder abuse at end of life. Journal of Palliative Medicine, 9(1), 127-136. Evidence Level V.

19. Phillips, L.R. (2008). Abuse of aging caregivers: Test of a nursing intervention. Advances in Nursing Science, 31(2), 164-181. Evidence Level II.

Journal Articles

Abrams, R. C., Lachs, M., McAvay, G., Keohane, D. J., & Bruce, M. L. (2002). Predictors of self-neglect in community-dwelling elders. American Journal of Psychiatry, 159(10), 1724-1730.

Anetzberger, G. J. (2001). Elder abuse identification and referral: The importance of screening tools and referral protocols. Journal of Elder Abuse & Neglect, 13(2), 3-22.

Capezuti. E., Brush, B. L., & Lawson, W. T. III. (1997). Reporting elder mistreatment. Journal of Gerontological Nursing, 23(7), 24-32.

Daly, J. M., Jogerst, G. J., Brinig, M., & Dawson, J. (2004). Mandatory reporting: Relationship of APS statue language on state reported elder abuse. Journal of Elder Abuse and Neglect, 15(2), 1-21.

Dyer, C. B. (2000). The role of the interdisciplinary geriatric assessment in addressing self-neglect of the elderly. Generations, 24(2), 23-27.

Dyer, C. B., Pavlik, V. N., Murphy, K. P., & Hyman, D. J. (2000). The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatrics Society, 48(2), 205-208.

Erlingsson, C. L., Carlson, S. L., & Saveman, B. (2003). Elder abuse risk indicators and screening questions: Results from a literature search and a panel of experts from developed and developing countries. Journal of Elder Abuse & Neglect, 15(3/4), 185-203.

Fulmer, T. (2003). Elder abuse and neglect assessment. Journal of Gerontological Nursing, 29(1), 8-9.

Fulmer, T. (2003). Elder abuse and neglect assessment. Journal of Gerontological Nursing, 29(6), 4-5.

Fulmer, T., Guadagno, L., Bitondo-Dyer, C., & Connolly, M. T. (2004). Progress in elder abuse screening and assessment instruments. Journal of the American Geriatrics Society, 52(2), 297-304.

Fulmer, T., Paveza, G., Abraham, I., & Fairchild, S. (2000). Elder neglect assessment in the emergency department. Journal of Emergency Nursing, 26(5), 436-443.

Fulmer, T., Paveza, G., Vandeweerd, C., Fairchild, S., Guadagno, L., Bolton-Blatt, M., & Norman, R. (2005). Dyadic vulnerability and risk profiling for elder neglect.The Gerontologist, 45(4), 525-534.

Fulmer, T., Paveza, G., Vandeweerd, C., Guadagno, L., Fairchild, S., Norman, R., Abraham, I., & Bolton-Blatt, M. (2005). Neglect assessment in urban emergency departments and confirmation by an expert clinical team. Journal of Gerontology: Medical Sciences, 60A(8), 1002-1006.

Lachs, M. S., Williams, C. S., O'Brien, S., & Pillemer, K. A. (2002). Adult protective service use and nursing home placement. Gerontologist, 42(6), 734-739.

Malks, B., Buckmaster, J., & Cunningham, L. (2003). Combating elder financial abuse -- a multi-disciplinary approach to a growing problem. Journal of Elder Abuse & Neglect, 15(3/4), 55-70.

Last updated - May 2006