Title of Course: Abuse & Neglect of the Elderly CE Credit: 4 Hours Instruction Level: Introductory Author: Marilyn Weese, BA & Laura More, MSW, LCSW

Transcription

1 Title of Course: Abuse & Neglect of the Elderly CE Credit: 4 Hours Instruction Level: Introductory Author: Marilyn Weese, BA & Laura More, MSW, LCSW Abstract: Elder abuse is a disturbing reality in today's society. The risk of being abused, neglected, or exploited is real for many older people. Family members or other caregivers are most often the abusers. The problem crosses all geographic, socioeconomic, racial, and ethnic barriers. According to the National Center on Elder Abuse (NCEA), elder abuse in domestic settings is a widespread problem, possibly affecting hundreds of thousands of elderly people across the country. However, because it is still largely hidden under the shroud of family secrecy, this type of abuse is grossly underreported. It is estimated that only one out of fourteen domestic elder abuse cases is reported to the authorities. This course will familiarize readers with the various types of elder abuse, offer recommended identification techniques, list the rights of residents of care facilities, and discuss proven prevention strategies Learner Objectives: 1. Define elder abuse as it is described in the course 2. Distinguish among physical, sexual, and emotional abuse 3. Name the various types of neglect and exploitation 4. Identify effective prevention methods 5. List the rights of residents of nursing facilities 6. Identify ways in which elder abuse is being confronted at federal, state, and local levels 7. List prevention strategies and resources for staff training 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 1 of 38

2 Abuse and Neglect of the Elderly Introduction Lesson Goal: In this section, the student will be introduced to the issues relating to the abuse and neglect of the elderly. Lesson Keynote: Elder abuse is most often defined as an action by a person in a position of trust that causes harm to an elderly person. Harmful actions by strangers are usually not considered elder abuse. Elder abuse is a disturbing reality in today's society. The risk of being abused, neglected, or exploited is real for many older people. Family members or other caregivers are most often the abusers. The problem crosses all geographic, socioeconomic, racial, and ethnic barriers. According to the National Center on Elder Abuse (NCEA), elder abuse in domestic settings is a widespread problem, possibly affecting hundreds of thousands of elderly people across the country. However, because it is still largely hidden under the shroud of family secrecy, this type of abuse is grossly underreported. It is estimated that only one out of fourteen domestic elder abuse cases is reported to the authorities. Elder abuse can take a number of forms and may be defined in various ways. It is most often defined as an action by a person in a position of trust that causes harm to an elderly person. Harmful actions by strangers are usually not considered elder abuse. The exact incidence of elder abuse is unknown. The NCEA estimates that in the United States the number of seniors abused or mistreated is between 1 and 2 million per year. The figure may be much higher, since elder abuse is often not reported. In any event, with a rapidly growing elderly population, the numbers can be expected to rise. Although elders who have mental or physical disabilities are at the greatest risk, elder abuse can happen to anyone. More women than men live to be elders, but both sexes are equally at risk for abuse. Some older adults are abused by their spouses or by their children, others by caregivers in institutions. As with other types of abuse, those who abuse elders usually keep the victim socially isolated. It is estimated that for every one case of abuse, exploitation and neglect that is reported to authorities, about five more go unreported. Data on Elder abuse, specifically in domestic settings, suggest that one in 14 incidents, excluding incidence of self-neglect, come to the attention of authorities. This statistic highlights the difference between care giving in an institutional setting and the potential for abuse in the home setting. Types of Abuse There are two categories of elder abuse: 1) Domestic, which is maltreatment of an older person by someone who has a special relationship with the elder (spouse, sibling, child, friend, caregiver); and 2) Institutional, which is maltreatment of an older person that occurs in residential facilities for older persons (nursing homes, group homes, and board and care facilities) Care2Learn #40-15 Abuse & Neglect of the Elderly Page 2 of 38

3 According to the dictionary, to abuse means to use someone in an improper or wrong way, or to mistreat someone, especially physically. Abuse is defined as the improper treatment, injury, or damage resulting from mistreatment. Types of elder abuse may include the following categories: Physical Abuse: Using physical force that results in physical pain or injury. This can be the refusal or failure to fulfill any part of a person's obligations or duties to an elderly person; failure to provide necessary care by withholding food or medical attention; or leaving a senior in an unsafe or isolated place. Physical abuse can also include the use of physical force that may result in bodily injury, physical pain or impairment by hitting or pushing, forcing confinement in a room, bed or chair, or overmedication. Sexual Abuse: Non-consensual sexual contact with an older person includes sexual molestation, unwanted touching, and rape. Aside from being abusive, many of these actions are also crimes. Emotional Abuse: Verbal assaults, humiliation, threats, harassment, intimidation, or other abusive behavior. Neglect: Failure or refusal to fulfill any part of a person's obligations and duties to an elderly person. Self-Neglect: Behavior of an elderly person that threatens the elder s health or safety, such as refusal to provide himself with adequate food, water, clothing, or shelter, or refusing medication. Financial or Material Exploitation: The misuse or withholding of an older adult's resources by another, to the older adult's disadvantage. This exploitation includes the following: The illegal or improper use of an elderly person's funds, property or assets Withholding money Cashing an elderly person's check without authorization Forcing an elderly person to sell personal property Stealing an older person s money or possessions Misusing Power of Attorney Abandonment: Desertion of an elderly person by an individual who has physical custody of the elder or by a person who has assumed responsibility for providing care to the elder. Combinations: It is possible that more than one type of abuse may be suspected in any given case. Financial exploitation and emotional abuse are the most commonly reported combination. Example: Mrs. Lewis is eighty years old. She has some health problems and recently has been having problems getting around. A year ago her daughter Susan, fifty-four, came to live with her. Things were going well until Susan lost her job. She has been unable to find another and has become increasingly dependent on her mother. She started drinking excessively and now spends hours watching television. This angers Mrs. Lewis and has led to arguments between the two women. Recently, the arguments have been getting physical, with Susan pushing and hitting Mrs. Lewis. Then Mrs. Lewis discovered that Susan has been taking large sums of money out of her bank account, which is in both names so that Susan can pay bills. Mrs. Lewis is upset and frightened that confronting Susan will make her angrier Care2Learn #40-15 Abuse & Neglect of the Elderly Page 3 of 38

4 Parties in Abuse The Victim Research suggests that certain groups of elders are more vulnerable to abuse than others, and that certain groups are more vulnerable to specific types of abuse. Those in poor health, socially isolated, or having little social support are much more vulnerable to all types of abuse. For example, victims of physical and psychological abuse are most likely to be married or living with a child. Victims of financial abuse are more often widowed and living alone. Elders who are neglected also tend to be widowed. The typical victim of elder abuse is a widowed, white female in her mid-seventies or older, living on a limited income. The older person usually lives with the perpetrator, who is often a spouse or adult child. Elder victims often do not report being abused. Fearing retaliation by the abuser, being ashamed of the situation, or worrying about having to leave one's home are some of the reasons older adults do not report abuse. The Abuser There are no characteristics that can reliably identify abusers. However, family members who have mental, emotional, or substance abuse problems may be more likely to abuse an elder. Relatives or caregivers who are emotionally or financially dependent on the victim are at increased risk of abusing. The stress of caring for an elderly person can sometimes lead to neglect or abuse, especially if other contributing factors are present. In addition, a history of domestic violence can result in the abuse of elderly family members. For example, in some cases, adults who were mistreated as children end up abusing their aging parents. However, it is not always adult children who abuse. Sometimes elder abuse is a continuation of an ongoing pattern of spouse abuse. Although the incidence of spouse abuse drops with age, spouses who batter do not necessarily stop just because they turn sixty. Many of the risk factors associated with spouse abuse in younger couples can also be seen in older couples. These include the following factors: Poverty Unemployment Alcohol abuse Drug abuse Attitudes that support the use of violence to solve problems The typical abuser is most often the adult child or spouse of the victim, although older family members and nonrelatives may be perpetrators. The abuser may depend on the older person for housing, financial assistance, or emotional support. Research indicates that caregiver stress, alcohol or substance abuse, and emotional or financial problems are factors in many instances of abuse. Warning Signs Just as there are many types of abuse, there are also numerous signs or symptoms that abuse may be taking place. The following signs do not always indicate an abusive situation but can be important clues to possible abuse or neglect. Symptoms of an abused older person include the following: Unusual or unexplained injuries (cuts, bruises, burns) Unkempt appearance Pressure sores or bedsores 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 4 of 38

5 Confinement against her will (tied to furniture or locked in room) Dehydration or malnutrition without a medical cause Fear Withdrawal Depression Anxiety Visits to many doctors or hospitals Unable to follow through on treatment plans for medical care. Misses appointments Strange and inconsistent explanations for injuries Helplessness History of alcohol or drug abuse, including prescription drug use Hesitation to talk openly if caregiver is present Signs of an abuser include the following: Verbally assaulting, threatening, or insulting the older person Concerned only with the older person's financial situation and not his or her health or well-being Problems with alcohol or drug abuse Not allowing the older person to speak for himself Blaming the older person Attitudes of indifference or anger toward the older person Socially isolating the older person from others Attempting to convince others that the older person is incompetent Depersonalizes the older person when talking to others about him The American Medical Association estimates a five to 6% prevalence of elder abuse, which equals 1.8 million individuals. Unfortunately, the recognition rate by physicians in a variety of settings has shown to have been as low as 5%; in other words, the physician only recognizes abuse in one case out of 20 that presents for care. Like domestic abuse in general, abuse of older people is often hidden if not invisible and, to complicate matters, may take many different forms. The abuse may arise from mere thoughtlessness, such as failing to turn a bedridden person frequently in order to avoid bedsores. It may also take the form of outright physical abuse, verbal abuse, psychological manipulation, intentional neglect, fraud, theft, or exploitation of a frail person's vulnerability. Physical abuse and theft, for example, are obviously against the law; but victims may be unable to testify in court or may be fearful of testifying. As with other kinds of domestic violence and abuse, law enforcement is not always successful when it attempts to intervene in a family dispute. In other cases the laws may mask abuse. For instance, the guardianship laws in some states may limit the rights of older people to make decisions about their own well-being. All the states have adopted some form of adult protective services law, enabling state agencies to offer remedies to victims of abuse; but fewer than half the state laws provide civil or criminal penalties for elder abuse. The National Center on Elder Abuse reports that, in domestic settings, the most common form of elder abuse reported is neglect/abandonment (55%) followed by physical abuse (15%), emotional abuse (8%) financial abuse (12%) and sexual abuse (0.3%). In Long-Term Care settings, abuse mirrors that found in domestic settings, including physical and sexual abuse, neglect, inappropriate restraints, financial abuse, isolation, verbal threats, and intimidation. In addition, nursing home abuse can include institutionalized practices that result in chronic neglect, substandard care, or failure to protect residents against untrained, troubled or predatory workers, or against abusive residents and/or visitors Care2Learn #40-15 Abuse & Neglect of the Elderly Page 5 of 38

6 Abuse can be subtle or covert, including harassing elderly residents or controlling them with drugs or restraints. Restricting the personal choices of residents in regard to bathing or feeding times or what to wear can also be abusive. Sometimes residents are placed in isolation, especially if they are aggressive or hard to care for. Prevention Experts seem to agree that the most effective way to prevent abuse and to stop it once it has started is through services provided in the home by outsiders, like Meals-on-Wheels and home health care. They can help prevent the deterioration of health that makes older people dependent on those who abuse them. Additionally, the presence of an outside observer can also have a deterrent effect. The hidden problem needs to be seen in the light of day. Only then is it possible to offer remedies, assistance, counseling, and referrals. We need more protective services in and from the community, such as help with simple household chores, offering money management, and providing guardianship. Investigation and Enforcement The primary federal law relating to elder abuse is the Older Americans Act. It provides definitions of elder abuse and authorizes the use of federal funds for the National Center on Elder Abuse as well as for elder abuse awareness, training, and coordination activities in state and local communities. All 50 states, as well as the District of Columbia have enacted legislation authorizing the provision of adult protective services in cases of elder abuse. This establishes systems for reporting an investigation of elder abuse, as well as the provision of social services to help the victim and ameliorate the abuse. The statutes, definitions of abuse, eligibility for social services, and the classification of abuse as a criminal or civil pact vary widely by state. Reporting requirements also vary from state to state. All states do have laws authorizing the Long-Term Care Ombudsman Program, which is responsible for advocating on behalf of long-term care facility residents who experience abuse, violations of the rights, or other problems. Ombudsman programs are mandated in every state as a condition of receiving federal funds under the Older Americans Act. Ombudsman programs generally except reports of potential abuse, investigate, and, in some states, fulfill the role of adult protective services. Elements of Physical Abuse Lesson Goal: When the student has completed this section, he will understand what physical abuse is and why it happens. Lesson Keynote: Physical abuse is the most prevalent form of elder abuse that is reported. Family violence is a pervasive problem in the United States. Because most family violence occurs in the home behind closed doors, it is difficult to collect data on the extent and patterns of such violence. Estimates are based on information from several sources: Clinical observations and case reports Community surveys Crime reports Psychological evaluations Interviews with victims and perpetrators 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 6 of 38

7 Intimate and Spousal Abuse Nearly one in every three adult women experiences at least one physical assault by a partner during adulthood. Approximately four million American women experience a serious assault by an intimate partner every year. Women are six times more likely to experience violence by an intimate partner than by a stranger, but they often fail to report the crime. Several types of violence and abuse usually occur within the family. Men who batter their intimate partners are more likely to also abuse their children. Perpetrators of violence usually have problems with power and control and a history of physical or sexual abuse or threats of abuse. Battered women and their abusers come from all demographic groups. There is no single psychological profile of either, and the only risk factor they both share is exposure to violence between parents. Both victims and perpetrators of domestic violence have a tendency to abuse alcohol. Excessive alcohol use is more than 50 percent for male batterers and around 20 percent for women victims. The highest risk for serious injury or death from violence in an intimate relationship is at the point of separation, or at the time when the decision to separate is made. Elder Abuse Physical abuse is defined as any physical pain or injury that is willfully inflicted upon an elder by a person who has care or custody of, or who stands in a position of trust with that elder. This includes, but is not limited to, direct beatings, sexual assault, unreasonable physical restraint, or prolonged deprivation of food or water. Data on reported cases of institutional elder abuse are poor, because they are often incomplete or are combined with other adult abuse statistics. Data collection is also difficult, because several of the following agencies may be responsible for investigation of more than one service: Adult protective services Long-term care ombudsman offices State Medicaid fraud-control units Health departments Law enforcement agencies Reports of elder abuse have increased from 147,000 in 1999 to 192,000 in 2004, according to the Administration on Aging, 2004 National Ombudsman Reporting System Data Tables. As you might expect, the highest number of abuse complaints are in states with high aging populations: California, New York, and Texas. Interestingly, Florida and Ohio had a fraction of the complaints of the other high-elderly states. For example, California had 44,701 complaints in 2004, while Ohio had 9,395 and Florida had 7,555. Activity 1: Take 10 minutes to review the complaints for your state, using the following three links: Complaints for your state: Top complaints in skilled nursing facilities: Assisted living/boarding care complaints: Care2Learn #40-15 Abuse & Neglect of the Elderly Page 7 of 38

8 Victims of murder over age 64 were two times more likely than victims aged 12 thru 64 to have been killed by relatives or intimates, according to the Bureau of Justice statistics. Because most caregivers for the elderly are women, they commit most of the cases of neglect, whereas male family members are the most frequent perpetrators of physical abuse. Abusers usually have a history of personal problems or pathology and/or may be financially or emotionally dependent on the older person. Men who abuse their elderly partners may be continuing a pattern of abuse that has been going on throughout the life cycle, or they may start abuse because of an emotional disorder or organic brain deterioration. Physical abuse is when a person touches an elderly person in a hurtful way such as hitting, pinching, kicking, punching, hair pulling, biting, burning with cigarettes, withholding food, and over- or under-medicating. Many of these types of physical abuse will go unnoticed by others because it is often assumed the older person has bumped himself and bruises easily. Family, friends, and healthcare professionals should be alert for possible signs of abuse regardless of who the caregiver is or where the elder stays. Example: Mr. Jones is an 85-year-old resident of a nursing home. None of his relatives visit him. He is forgetful, easily confused and is often resistant to the regular routines around bathing, dressing, and feeding. He will yell, hit, and kick the staff when they try to dress him, and becomes especially agitated in the shower. This behavior frustrates the staff. One worker in particular became very angry with Mr. Jones when he kicked at her during the shower routine, and she slapped him. Signs of Physical Abuse Malnutrition or dehydration: Withholding food or water as a punishment or act of cruelty is a form of abuse. Sudden weight loss, cracked lips, dry mucus membranes, or the inability to produce tears can all be indicators of this type of abuse. Open wounds or sores: These can indicate lack of proper care in cases of bedridden elderly. They can also indicate the results of abusive behavior by a caregiver that has used cigarettes to burn the elder, stabs using pencils or some other small, sharp object, or intentional cutting with sharp objects. Bruises or welt marks: These could be the result of brushes, belts, extension cords, or other such objects being used to beat the elderly person. Bruises, welts, or actual rope burns near the wrists or ankles would indicate the use of restraints. Sudden hair loss in patches: This could be a sign of someone grabbing, pulling, or actually yanking the hair out. Fractures of bones: Fractures that can t be explained, as well as fractures that caregivers and/or the elderly person may avoid discussing are indications of abuse. Differing accounts of an injury can also be an indicator of abuse. Healthcare professionals may wish to ask questions about an injury separately, gathering information from both the caregiver and the elderly person. Discrepancies can be a warning signal of an abusive situation. Inescapable signs: These include bite or burn marks, fingerprints, scratches, black eyes, and broken noses and/or fingernails. Sprains, dislocations, and untreated injuries in various stages of healing are also possible signs of abuse. Caregivers who frequently take the elder to the emergency room may be guilty of physical abuse. Many times the need will be justified, but the caregiver can use his or her apparent concern as a cover-up for abuse. Medications: Indications that the elderly person is being over-medicated are warning signs. Many medications make a patient drowsy or cause him to fall asleep. People in this condition make easy patients to care for, with no complaints or needs. Under-medicating a person is also a type of physical abuse. Withholding medications can be used as a threat, a form of punishment, or even a type of blackmail. Example: Caregiver to elder: If you tell the doctor that I hit you, I won t give you your heart medicine Care2Learn #40-15 Abuse & Neglect of the Elderly Page 8 of 38

9 Reporting the Abuse For state by state toll free numbers to report elder abuse, go to the Helplines and Hotlines page on the NCEA website and click on your state: Statistics from the National Center on Elder Abuse (NCEA) show only ten percent of elderly people who need assistance or care live in a long-term care facility such as a nursing home. The remaining 90 percent either live alone or with loved ones. It is hard to imagine a son, daughter, or grandchild abusing an elder; but the truth is that they make up over one-third of the reported incidents of elder abuse. Anyone on whom the elderly person depends or with whom he comes into contact can be an abuser. This can include family, neighbors, professional caregivers, friends, or landlords. Abuse is often a silent crime, because the abused person is reticent to discuss the abuse. There are an infinite number of reasons why an elderly person may not say anything to other family members or healthcare workers about abuse. A few of the more common reasons are as follows: They may be embarrassed or ashamed of the abuse. They deny what is happening to them. They worry about how their report may affect the lives of loved ones. They feel guilty and have come to believe they are the cause of the abuse. The abuser has made them believe they deserve the punishment. They were abused earlier in life, so the present situation is just a continuation of a long history of abuse. They do not want to appear weak or vulnerable. The abuser has apologized and given assurance it won t ever happen again, and the victim desperately wants to believe him. They are afraid no one will believe them. They are afraid of the unknown future if they are removed from the care of the abuser. The known danger is not nearly as scary to them as the unknown. They are concerned that they will be placed in a nursing home, and they believe that would be the only course open to them if the abuse is reported. They minimize the abuse after the fact and convince themselves that it wasn t really that bad. Regardless of the reasons an elderly person chooses not to tell of abuse, never assume that they are to blame for the abuse, that they deserve or enjoy it, or that they are at fault for not reporting it. Perhaps they have tried and no one has believed them. As in child or spousal abuse, the abusers are all too often such experts at putting on a front that neighbors, friends, and church members refuse to believe they could possibly act in such a way. Elder abuse may be happening more frequently due to the increasing number of elders needing care and the greater stress on caregivers due to financial, emotional, or physical problems; or because the public has been made more aware of the problem, and/or due to the changing aging demographic in this country. The fact is that complaints of abuse of the elderly are rising. If you know or are related to an elderly person who is dependent upon others for their care, take the time to visit them. If the elderly person is living with family members, give the caregiver time to take a break and get away for a little while. For those in nursing homes, you should check in with them at different times of the day. Ask questions, make observations, and write them down. If at any time you suspect abuse is occurring, report it immediately to the proper authorities. In most counties there is a division of Adult Protective Services that will investigate the allegations and take action if necessary. To know of abuse and not take action against it is the same as condoning the act. Later in the course you will have an opportunity to note the contact information for the abuse reporting agency in your area Care2Learn #40-15 Abuse & Neglect of the Elderly Page 9 of 38

10 Elements of Sexual Abuse Examples: Lesson Goal: After studying this section the student will understand the responsibility of those who are caring for the elderly to protect them from sexual abuse. Lesson Keynote: If sexual abuse is a function of power and control, frail older persons, who often have little power and may be dependent upon others, can be extremely vulnerable to sexual mistreatment. One of the most disturbing offenses perpetrated against the elderly is one of a sexual nature. However, it is very rarely reported by itself. Sexual abuse against the elderly is usually discovered while investigators research other forms of mistreatment, such as physical abuse, financial abuse, or neglect. Medically fragile older women have little power and are often dependent upon others for their personal care, putting them at risk. An elderly disabled woman lives with her adult son, who forces her to watch pornography. A nursing home resident with Alzheimer s disease attempts sexual contact with a female resident he believes to be his wife, becoming forceful when she resists. A care giving spouse makes demeaning remarks about his dependent wife s intimate body parts, and is rough when bathing her. Recognizing the Abuse Recognition of sexual abuse is important for healthcare professionals who work with the elderly. Some of the signs are as follows: Physical signs of sexually transmitted diseases Evidence of injury to genital areas Difficulty in sitting or walking Fear of being alone with caretakers Reports of sexual abuse Although other forms of violence within the family have received increasing attention from professionals and the media over recent years, including the physical abuse and neglect of children, child sexual abuse, and domestic violence, elder abuse remains relatively hidden. This is especially true of sexual abuse. While there are some references to stranger rapes of older women, the topic of elder sexual abuse within the family is rarely addressed in the professional literature and seldom confronted by social workers, medical personnel, or advocates. This is partly true because sexuality is generally associated with younger people. Since sexual abuse is a function of power and control, frail older persons, who often have little power and may be dependent, can be extremely vulnerable to sexual mistreatment. Elder sexual abuse is defined as coercing an older person, through force, trickery, threats, or other means, into sexual contact against her will. It often begins with covert activities such as inappropriate remarks and threats and escalates to more severe types of mistreatment, including the following: Forcing the victim to view pornography or listen to explicit sexual accounts Sexual kissing and fondling Oral-genital contact Digital penetration 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 10 of 38

11 Vaginal rape Anal rape Rape by objects Exploitation Sadistic acts Ritualistic abuse Studying Abuse The prevalence of elder sexual abuse is not known, because no systematic study has been done to determine how widespread the problem is. It is usually uncovered by adult protective services workers who are called to intervene in other types of mistreatment of older persons, such as physical abuse, neglect or financial exploitation. A study was conducted several years ago of twenty-eight cases in which sexual abuse was identified by elder abuse caseworkers. It reported the following statistics: All the victims resided in the community, not in nursing homes or other institutional facilities. All were female, ranging in age from 65 to 101. All but one of the offenders was male. Eighty percent of the offenders were caregivers to the victims, the vast majority of whom had significant impairments that made them totally dependent on others for daily assistance. The offenders were usually relatives of the victim. In 39 percent of the cases an adult son was the abuser; in 29 percent it was the victim's husband. Over one-third of the abusers were elderly themselves, and were the victim's spouse, male friend, or brother. The most frequent form of abuse suffered by the victims in the study was repeated vaginal rape. In a similar study in Great Britain professionals identified ninety elder sexual abuse cases and reported the following statistics: Eighty-six percent were women, and fourteen percent were men. Almost all the victims of both sexes were over eighty-five years old and functioned at a poor or very poor level, rendering them totally dependent on others for care. Ninety-eight percent of the abusers of both sexes were male. Over half of the abusers of the women in the study were their adult sons, while fourteen percent were their husbands. Almost two-thirds of the abusers of the men were "friends," and one-third were housekeepers. Most of the women were vaginally raped, and over three-quarters of the men were anally raped. In the cases of marital rape, it is not known if the assaults began late in life or were present throughout the marriage. It is likely that at least some of the victims were sexually mistreated for most of their adult years. Older women, who may have been socialized to believe that a wife must always submit to her husband s wishes, may continue to suffer sexual mistreatment silently. At least since the seventeenth century, rape law has included a formal marital rape exemption. This exemption meant that men could not be charged with raping their wives and, if they were, marriage provided them with a complete defense. Beginning in the 1970s, reformers targeted this doctrine and worked to eliminate it from the law. According to Michelle Anderson, Villanova law professor, The good news is that twenty-four states and the District of Columbia have abolished marital immunity for sexual offenses. The bad news is that twenty-six states retain marital immunity in one form or another. Although in some of these twenty-six states marital immunity for the specific crime of forcible rape is dead, immunity for other sexual offenses thrives. For example, twenty states grant marital immunity for sex with a wife who is incapacitated or unconscious and cannot consent. (Italics added) 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 11 of 38

12 Studies show that sexual abuse is the least frequent type of report received. In one survey only 209 cases (4%) of over 5,000 total reports alleged sexual abuse. While these figures could mean that elder sexual abuse is a rare occurrence, it should be noted that other forms of family violence were also considered rare until they were identified and researched. Sexual abuse reports to the Elder Abuse Center also had the highest rate of "not verified" of all the types of mistreatment reported, meaning that after an investigation not enough credible evidence existed to substantiate sexual abuse. Most reports of elder abuse allege more than one type of mistreatment, so that the program may have served the victims for other types of abuse. This points, however, to the need for more education of caseworkers on how to identify such abuse and how to work with victims once it is discovered. Conditions for Sexual Abuse Experts believe that it is not the physical attributes of the victim but rather vulnerability that attracts the sexual offender. If this is true, elders are especially susceptible to such abuse. The victims in the two studies cited here were unable to function independently and had no choice but to rely on others, usually family members, for daily care and assistance. In addition, speech and language problems may be present among older persons with physical problems, such as victims of stroke. Such problems may make it virtually impossible for the victim to disclose the abuse to outsiders. Many older persons also suffer from dementia and other mental impairments. Cognitive impairments may mean that victims will have little credibility if they report sexual abuse. According to one expert, females are predisposed to victimization due to the greater physical, social, political, and financial power generally held by males. Old age and impairment decrease personal power and thereby increase the risk of abuse. Persons working with older sexual abuse victims should recognize that, as with many victims of family violence, the victim may have ambivalent feelings toward the abuser, including love and loyalty as well as fear and revulsion. Protection of the Victim Older sexual assault victims need many of the same services and interventions younger victims need: Non-judgmental emotional support Medical care Protection from unsupervised access by the abuser Legal interventions where appropriate and desired There are additional considerations in sexual abuse of the elderly: The elderly have an increased chance of sustaining a serious injury during abusive acts. Generational beliefs about sexual abuse may increase feelings of shame and guilt. There is a longer recovery time in dealing with the physical effects of abuse. Brittle pelvis or hip bones can be broken by friction or weight There is in an increased risk of infection Abuse may exacerbate an existing illness It is essential that anyone working with elder abuse victims recognize that competent older persons have the right to refuse any and all interventions, even those that are "for their own good." Persons with cognitive impairments, however, may need others to take steps to protect them and provide needed services Care2Learn #40-15 Abuse & Neglect of the Elderly Page 12 of 38

13 The primary community response point for any sexual abuse is the hospital emergency room. Most communities have well-organized, multidisciplinary teams that include medical, police, and legal resources to ensure that sexual abuse victims receive appropriate assistance and services. However, the services begin at the entry point, which is the emergency department. Elder victims are not served by this model, because most do not report sexual abuse, nor go to the emergency department for treatment. The healthcare professional, (whether home health aide, therapist, nurse, dietitian, or social worker) is likely to be the first responder. It is important that all healthcare professionals who work with the elderly be knowledgeable about the indicators of abuse, and the services available to the elderly. Adult protective services (APS) programs should consult with rape crisis center staff to learn more about the dynamics of sexual abuse and how to intervene effectively with victims. In return, APS supervisors can educate the sexual assault network about working with vulnerable adults and about the assistance available through APS programs. Any suspected or confirmed victim of elder sexual abuse should be referred to an Adult Protective Services Program, even if the person is also being served by a rape crisis center. The referral means that the older person can be linked up to a wide array of services available through the aging network. These services could include in-home services such as cleaning, meal preparation or delivery, and home health care. These services will reduce the victim's dependence on the abuser and will also reduce his isolation, both of which contribute significantly to vulnerability to abuse. The rape crisis center and local adult protective services programs should cooperate on other interventions such as legal remedies in order to avoid duplication of effort and to reduce the confusion to the client. Older persons need and deserve the skilled attention of all those with whom they come into contact in order to reduce their vulnerability to sexual abuse. Tips for responding: Do not display alarm or disbelief to the victim. Protect the victim's privacy. Assess injuries. Express concern and validate the victim's feelings. Ask the victim if s/he would like to speak to a sexual violence advocate Arrange for medical attention. Refer to adult protective services Elements of Emotional Abuse Lesson Goal: After completing this section, the student will understand that a caregiver may emotionally abuse an elderly person because he is overburdened or resentful of the demands of care giving. Lesson Keynote: Psychological or emotional abuse is the infliction of mental suffering by a person in a position of trust. Verbal assaults, intimidation, threats, instilling fear, humiliation, or isolation are examples of emotional abuse. Some experts use a frequency to define emotional abuse: those who had experienced it at least ten times in the last year were considered victims of psychological abuse Care2Learn #40-15 Abuse & Neglect of the Elderly Page 13 of 38

14 Identifying the Abuse Usually in situations of emotional abuse the caregiver has become overburdened and resentful of all the demands placed upon him. His abusive reactions are not aimed at the elderly person specifically, but at the situation. Primary healthcare providers should look for signs in elderly patients such as helplessness, hesitation to talk openly, falsifying stories, confusion or disorientation, anger, fear, depression, denial, and agitation. Healthcare providers who work by appointment at long-term care centers, assisted living facilities and home settings, such as nurse practitioners, home health aides, and therapists should pay close attention to certain indicators of emotional abuse: Is the elderly patient not allowed to talk for herself? Must the caregiver (possibly the abuser) accompany the patient when seeing the healthcare professional? There are a number of questions that should be asked to verify abuse: Do you ever feel alone? Have you ever been threatened with punishment, deprivation, or institutionalization? Have you received "the silent treatment"? Have you been force-fed? Do you receive routine news or information? What happens when you and your caregiver disagree? Can you have visitors whenever you would like? Do you get to make decisions about your care? Can you arrange a visit from your priest or rabbi? Some psychological abuse is subtle, arising from insensitivity and is usually unintentional. Examples of subtle psychological abuse include not taking the elderly person s statements about problems at face value; treating the elder like a child; ignoring calls or placing call bells out of reach; and blocking constructive criticism from the elder about care. Most emotional or psychological abuse is not subtle at all. Humiliation, demeaning and ridiculing are easily identified as an abuse of this type. Insulting and name-calling are also quickly labeled in this category. The Wisconsin Coalition against Domestic Violence also identifies the type of emotional abuse that they call "engages in crazy -making behavior." This is an easily remembered label for the type of behavior toward an elder, which is not easily categorized but easy to identify by its consequences -- it is disturbing to the elder who is being cared for. Ridiculing of values, beliefs or spirituality is another form of emotional abuse. The elder may be denied access to clergy visits. The abuser may scoff at the elder's personal values and beliefs. A caregiver may ignore or even ridicule an elder s stated religious or cultural tradition. This is another area where cultural diversity training can be helpful in prevention of abuse. The use of silence and/or the withdrawal of affection from a caregiver can have a devastating effect on a dependent person, especially when the caregiver is their primary social contact. Do not be misled by the fact that this is not an active form of abuse such as physical abuse. Isolation and the denial of the warmth of care giving is a definite form of abuse. The abuser may also limit or deny the person access to family and other visitors. Some abusers do not allow the person to receive or send letters, or to use the telephone. Note that these examples all contain the elements of power and control. The Wisconsin Coalition Against Domestic Violence has created the Abuse In Later Life Power and Control Wheel as a teaching tool, to emphasize the role of power and control in family violence in later life Care2Learn #40-15 Abuse & Neglect of the Elderly Page 14 of 38

15 Example: Mr. and Mrs. Partridge used their savings to buy a duplex ten years ago, with an apartment for them and one for their married daughter, Sarah, and her family. Relations were amicable until Mr. Partridge died about two years ago. Mrs. Partridge is now seventy-five years old and has a heart condition. Since Mr. Partridge s death Sarah has been going out a great deal and leaving the care of the children and the housework to Mrs. Partridge. She also insisted that Mrs. Partridge begin paying rent for her apartment and that Mrs. Partridge buy expensive gifts for the children with her pension money. When Mrs. Partridge objected, Sarah instructed the children not to speak to her, and Mrs. Partridge was ignored for a week. Mrs. Partridge is unhappy with her treatment but fears rejection and abandonment if she does not comply. Although clinical records and case studies have documented the severe emotional distress experienced by older persons as a result of mistreatment, relatively few studies have dealt with the consequences of elder abuse on the victim. "Consequences" in this context refers to the psychosocial impact of the mistreatment on the victim rather than the physical effects such as bruises, fractures, malnutrition, and bedsores. As with any assessment of the elderly, the cultural background of the elderly person must be taken into account when assessing for emotional abuse. An extremely loud conversation between family members that appears to an outsider to be arguing, may be the cultural norm for that family. In this case, content should be evaluated more than volume. In other cultures, a raised voice is the equivalent of a verbal slap. Cultural diversity programs for staff of all levels that have contact with elderly persons, is an excellent way to assure adequate communication, as well as appropriate assessment of the communication between the elderly person and family or visitors. Consequences of Abuse Several studies comparing abused and non-abused elders receiving care found a larger proportion of the abused elders suffered from depression than did the non-abused elders. One investigator showed that persons reporting violence in their marital relationship had higher levels and frequency of depression than those in nonviolent relationships. The topic of emotional distress was addressed in a recent study. Researchers in the Netherlands examined data from a survey of elders living in Amsterdam to determine risk indicators for elder mistreatment in the community. Depressive symptoms emerged as a risk indicator for physical aggression and financial mistreatment. A year later they reinterviewed the victims and found seventy-seven who had been victimized in the intervening year. The seventy-seven made up the sample for a second analysis along with a comparison group of non-victims. The main research questions were as follows: Do elderly victims of mistreatment suffer from more psychological distress than non-victims? Do certain aspects of social support, self-confidence, and self-esteem directly or indirectly influence psychological distress in elderly victims of mistreatment? Compared to non-victims the elderly victims of mistreatment had significantly higher levels of psychological distress and lower scores on social support, self-confidence, and self-esteem. Victims who received more social support showed less psychological distress. Social supports had a positive effect on the level of psychological distress in victims but not in non-victims, indicating that victims benefit more from the social support they receive than do non-victims. Low selfconfidence and self-esteem were directly related to psychological distress in both the victim and non-victim. A more negative perception of the ability to cope is associated with psychological distress in general. This study demonstrated that mistreatment of the elderly does affect the psychological health of the victims and that social supports and feelings of being in control of one s life are beneficial to emotional well-being. Therefore, if it is not possible to mitigate the cause of mistreatment, then social supports should be provided to the victim at home, or support groups should be organized so that victims may be helped to become more competent or self-efficacious in dealing with the mistreatment Care2Learn #40-15 Abuse & Neglect of the Elderly Page 15 of 38

16 Neglect of the Elderly Lesson Goal: In this section the student will learn the signs of neglect in elderly. Lesson Keynote: Neglect is the failure of a caretaker to provide goods or services necessary to the care of an elder. Physical Neglect Neglect is a serious form of abuse that can go unnoticed or unreported for long periods of time. Indicators of neglect include obvious malnutrition or dehydration, lack of personal cleanliness, unsanitary conditions, and health and safety hazards in the environment. A patient who may be neglected is one that is inadequately clothed, poorly fed, is in need of medical or dental care, or is left unattended for long periods of time. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care. Signs and symptoms of neglect include but are not limited to: dehydration, malnutrition, untreated bed sores, and poor personal hygiene unattended or untreated health problems hazardous or unsafe living condition/arrangements (e.g., improper wiring, no heat, or no running water) unsanitary and unclean living conditions (e.g. dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing) an elder's report of being mistreated Neglect can be seen in a caregiver who creates long waits for food, changes in temperature for comfort, or medication. The caregiver may neglect to put reading glasses, a wheelchair, dentures, or walker within reach, then be out of earshot and unavailable to bring the items to the elderly person. Neglect is also seen in the caregiver who neglects to note symptoms of an impending illness such as fever, redness from an infection, incipient skin breakdown, shortness of breath, et cetera. Neglect also encompasses a caregiver's failure to follow medical, therapy or safety recommendations from a medical professional for the elderly person. The abusing caregiver may cause the elderly person to miss medical appointments, not call for transportation in time for appointments, or fail to make follow-up appointments. Neglect can even extend to financial matters; i.e. a caregiver who does not actually embezzle the elderly person's money, but simply mismanages their funds by neglecting to pay important bills. For an elderly person living alone and needing help with her finances, this can lead to termination of electrical services and loss of heat in the winter, which can have serious health consequences. Emotional and Psychological Neglect Emotional or psychological neglect is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. This type of neglect or abuse is not limited to verbal insults, threats, intimidation, humiliation, or harassment. It can also include infantilization, which is treating an older person like an infant, or isolating an elderly person from his family, friends or regular activities. This type of neglect can be assessed by examining the elder's physical appearance, the quality of the physical environment, and whether nutritional and dietary needs are being met. A common indicator of the abuser is that he has become overburdened and resentful of the demands placed upon him for care giving for the elder Care2Learn #40-15 Abuse & Neglect of the Elderly Page 16 of 38

17 One study (Meddaugh, 1993) looked at what the authors termed covert elder abuse." This is a category of subtle abuse that falls within the emotional or psychological abuse category. It would include loss of personal choice, with caregivers ignoring requests of choice of clothing, food, etc., or the elder being left alone for long periods of time, derogatory labeling of the elder, or thoughtless practices, such as hurrying through a task with little regard for the elder as an individual person. Indicators to watch for emotional/psychological abuse or neglect include: Emotional withdrawal or non-responsiveness Agitation or emotional upset Unusual behavior that is generally attributed to dementia, for example, biting, rocking, or sucking An elder s report of being verbally or emotionally mistreated Suggested interventions include the following: Enriching the environment: For example, playing music of the resident s choice Increase areas of choice and control over the environment whenever possible choice of food, choice of clothing, choice of activities. Limitation on individual choice is psychological abuse. (Payne, 1995) Reducing infantilization: Be aware of the subtle ways that you may talk down to elders, or arrange for activities that are below their cognitive skills. Activities should be enjoyable, but mildly challenging. Residential care facilities should assure that a variety of activities at different cognitive levels are offered to meet the needs of residents with different skill levels. Additionally, staff training should emphasize respectful address of every individual, avoiding terms such as "Honey", and "Dear". In the home setting, family should, when at all possible, include the disabled family member in family discussions about running the household, finances, etc. in order to maintain participation in household management. Educating and training staff in residential care settings: It is important that staff, especially direct care staff and those who come in contact with residents on a daily basis, be aware of the impact that their demeanor and communications with residents have in maintaining their psychological health. Orientation and ongoing training should emphasize not only resident s rights, but maintenance of good psychological health for residents. Increasing community involvement in nursing homes: This has the effect of enriching the environment, and affords an opportunity for people in the community to become aware of, and participate in, the care of disabled elderly. Abandonment Abandonment is the willful neglect of responsibility for an older adult by one tasked with caring for that person, or by one who usually is in a care giving position. Abandonment must be suspected if any of the following events occur: The caregiver of a dependent older adult leaves for a period of time without arranging for substitute care An employed home care aide does not show up for work and does not call in her absence. An older adult's care deteriorates markedly even with the presence of a caregiver in the home. Self-Neglect Self-neglect is characterized as the behavior of an elderly person that threatens his/her own health or safety. Assessing for competency is important when identifying the potential for self-neglect. In general, self-neglect indicators are similar to those of physical abuse or neglect. The difference is that the elder is neglectful of himself instead of a caregiver being neglectful of the older person. These are some possible indicators of self-neglect: 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 17 of 38

18 The inability to manage personal finances as manifest by the inability to pay bills even with sufficient funds available or exhibiting poor judgment in spending or gift giving A danger to self, including suicidal tendencies, wandering outside at unsafe times or in unsafe areas, refusal of medical care when needed, substance abuse, and/or self-medication Lack of ability to manage basic activities of daily living, including bathing and personal care, meal preparation, and taking medications Living in unsanitary conditions, including living with neglected pets; inability to ensure that foods are kept fresh and dishes cleaned; and incontinence, with accompanying inability to keep themselves and their surroundings clean. Rashes, sores, fecal/urine smell, unclean clothing, malnourishment, dehydration, etc. Changes in intellectual functioning, such as confusion, withdrawal, dementia, or paranoia. Any of these factors indicate a lack of ability to care for oneself, and further professional assessment, including a competency evaluation, is indicated. Financial Exploitation of the Elderly Lesson Goal: The student will learn in this section the various ways in which an elderly person can be abused financially. Lesson Keynote: When elderly or dependent adults lose the ability to manage their financial affairs, they are at risk of financial exploitation. Age Discrimination in the Workplace In the last decade increased use of part-time and contract employees, greater reliance on automation, and less job security have created what some researchers call a "corporate culture of expendability." In such a climate it is the older worker who is at particular risk of losing a job. There has also been a marked decline in the number of companies offering retirement benefits such as pension plans. Some older employees reach the age when retirement presumably could occur, only to discover that their financial resources would not sustain them without continued revenue from employment. Stressful conditions in the workplace are projected to continue during a time when the number of workers 55 and older will jump from 16 million in 1996 to 22 million in 2005, and rise even higher with the aging of the baby boomers. One survey of 400 companies found that only 1 in 8 companies surveyed sees an urgent need to respond to the aging of the work force, just 1 in 3 offers older workers the chance to transfer to jobs with less responsibility, and only 1 in 5 offers phased retirement. According to another report, personnel directors and company executives rate older workers very highly but believe younger managers do not really want older employees, no matter how good their skills. These attitudes were undoubtedly at work at the Monsanto Company, based in St. Louis, Missouri, in 1993, when some young executives fired sixty-six sales managers, fifty-nine of whom were forty or older. Forty-three of the men that were fired sued Monsanto and in June 1996 won the second largest per-person settlement in age discrimination case history, receiving $125,000 to $500,000 each. These and other court cases and the damages being awarded to victims are likely to make companies think twice about downsizing strategies that target older workers, who may be reliant on their work income for basic living expenses Care2Learn #40-15 Abuse & Neglect of the Elderly Page 18 of 38

19 The United States Administration on Aging (AoA), in an effort to assist older individuals to become better educated about their pension rights and remain independent in their own homes and communities, have sponsored and funded grants for pension information and counseling projects across the country. These projects are designed to reach out, educate, and promote pension awareness and protection for older adults. A side effect of this program has been education around many areas that impact individuals as they grow older: the documentation needed to establish financial claims for Social Security as well as pensions, the legal loopholes created by divorce and widowhood, the advantages and disadvantages of lump-sum payments versus annuities, and other issues important to the retirement security of older Americans. Exploitation When elderly or dependent adults lose the ability to manage their financial affairs, they are at risk for financial exploitation. Acts of financial or material abuse are sometimes referred to as exploitation. Exploitation is defined as the unauthorized use of an older person's money, property, or other resources for personal gain. In an institutional setting, it may exist in the form of material or monetary theft by staff or mismanagement of resident funds by administrators or owners of the facilities. Examples of such exploitation include the following: Collecting money from Medicare or Medicaid for deceased or discharged residents Charging for therapy or medication that was not provided Embezzling from a resident's funds A person in a position of trust and confidence may gain access to the older person's funds, assets, or property through deceit, treachery, coercion, or intimidation. The elderly person may voluntarily give financial authority to an untrustworthy individual, or may even be coerced or manipulated into signing away property and home ownership. Family members may attempt to persuade the elderly, disabled relative to transfer assets to them in order to speed the Medicaid qualification for skilled nursing facility care. The elderly relative may not understand the legal implications of this action, and may genuinely wish to protect assets that otherwise would be willed to relatives upon their death. Financial exploitation also includes a variety of scams perpetrated by sales people for health-related services, mortgage companies, and financial managers. The elderly person living alone, who has very little social contact, is vulnerable to the telemarketer who calls with a warm and friendly offer of a service or product. The product or service may actually be legitimate, but the elderly person may not need what is being offered. The purchase may occur due to confusion about what is being purchased or simply by the desire to please the friendly voice at the other end of the phone. Healthcare providers should be aware of some key indications of financial exploitation. Some general indications include the following: Disparity between income and lifestyle Excessive payments for services Unexplained withdrawals from bank accounts Unusual interest of others in the older person's assets Missing personal belongings Recent changes in a will, or creation of a will Unusual or inappropriate activity in bank accounts Signatures on checks, etc., that do not resemble the older person's signature, or signed when older person cannot write Power of attorney given when the person is incapable of making such decisions Unusual concern by caregiver that an excessive amount of money is being expended on the care of the older person Numerous unpaid bills or overdue rent when someone is supposed to be paying the bills for a dependent elder 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 19 of 38

20 Placement in a nursing home or residential-care facility which is not commensurate with size of estate Lack of amenities, such as television, personal grooming items, or appropriate clothing that the estate can well afford Missing household belongings such as art, silverware, or jewelry Recurring credit card charges for items or services that the elderly person cannot remember or explain Discharge planners can assist in locating financial management services for older persons who are incapable of managing their own finances. An appointed individual or agency may simply help the resident pay bills or do transactions. With the changing demographics in our country, many companies have begun to offer bill paying services. For a small monthly fee, the company will gather bills monthly, pay them out of the person's account, and provide a record of such payments for review. An alternative is to have lawyers set up legal transfers of authority such as powers of attorney, representative payeeships, or guardianships. Example: A nurse frequently changes jobs in the long term care setting in order to have access to disabled residents, whom she befriends, offers to manage their financial affairs, and then skims sums of money from their accounts. Rights of Nursing Home Residents Lesson Goal: The student will learn in this section that a resident of a nursing facility has a number of rights related to his medical and personal treatment, and that state and federal laws protect these rights. Lesson Keynote: Those working in long-term care are responsible to insure that the rights of the elderly in nursing homes are protected. Protection of resident rights has been linked to prevention of elder abuse. A resident of a nursing facility has a number of rights related to his medical and personal treatment. These rights are protected by rules established by both the state and federal government. One s rights as a Medicaid recipient guarantee him the same quality of medical care as other nursing facility residents. He has the right to be informed about his medical care and the operation of the nursing facility. Residents also have a right to be fully informed, in understandable language, of their rights and all rules and regulations governing their conduct and responsibilities during their stay in the nursing facility. Civil Rights The resident has a right to receive adequate and appropriate care, regardless of one s race, color, religion, national origin, sex, age, handicap, marital status, sexual preference, or source of payment for care. The resident or her legal representative may exercise any or all of the following rights: Upon oral or written request, to have access, make copies, and approve the release of personal and medical records To make complaints and be free of coercion or reprisal from the nursing facility in exercising rights To handle personal mail To talk with a physician, attorney, or other persons regarding personal decisions To participate in planning treatment and be informed of medical condition and care plan To assist in managing personal financial affairs 2008 Care2Learn #40-15 Abuse & Neglect of the Elderly Page 20 of 38

21 Right to Information The resident has a right to receive information on how to apply for Medicaid coverage and how to get refunds for previous payments made for services covered by Medicaid. The nursing facility and local county department of social services are available to assist in this. The nursing facility cannot restrict one s right to apply for Medicaid or set an arbitrary beginning date for accepting one s Medicaid eligibility. The resident must be informed orally and in writing about guaranteed rights upon admission, whenever information is requested, and periodically during the stay in a nursing facility. Residents have the right to inspect the most recent survey of the nursing facility conducted by the Department of Health or federal surveyors and any plan of correction in place for the nursing facility. The resident has a right to receive written notice of all services available in the nursing facility and their cost. This includes services covered by Medicare and Medicaid as well as services not covered by these programs for which there is an extra charge, as well as any changes in such services or their costs. Advance Directives The resident has a right to make medical care decisions, including giving advance directives, which are written instructions concerning one s wishes about medical treatment. These instructions are used in the event that the resident becomes unable to make healthcare decisions for herself. The nursing facility must give the individual information on advance directives such as living wills, medical durable power of attorney, cardiopulmonary resuscitation (CPR) directives, substitute decision makers (medical proxies), and guardians. The resident is not required to have or make advance directives in order to receive care or treatment, but he must be informed about them. Residents should talk to physicians about any medical condition that might make advance directives useful. Copies of advance directives should be included in medical records. It is the resident s responsibility to provide copies to the nursing facility, the physician, the family, and any agents acting on the patient s behalf. Residents should discuss whether such directives will be honored and be sure they are readily available at all times. Records and Resident Trust Fund Residents must receive a copy of the nursing facility s rules concerning resident care and conduct and have access to current and past nursing facility records. The nursing facility may charge a reasonable fee for copies. The nursing facility must make records available no later than two business days after receiving the written request. The resident s medical records may not be released without written permission, except as required because of a transfer to another healthcare facility or as required by law or third-party payment contracts. Residents have a right to receive a copy and an explanation of all bills, no matter who paid them. At admission residents are entitled to a copy of the nursing facility s policy regarding patient trust fund accounts. They may manage their own money, appoint a responsible party, or require the nursing facility to manage it. Any amount of more than $50 handled by the nursing facility must be kept in an interest-bearing account. If a resident appoints a nursing facility to manage her money, the facility must provide a quarterly report. They must also inform a resident when the balance is within $200 of the amount that would make one ineligible for Medicaid. Residents should receive receipts for any withdrawals or deposits and may request a statement listing all services received and paid Care2Learn #40-15 Abuse & Neglect of the Elderly Page 21 of 38

22 Right to Self-Determination, Dignity, Choice, and Privacy Residents have a right to reside in a nursing facility and receive services in a reasonable manner in order to accommodate individual needs and preferences, except where their own or other residents health or safety is endangered. The resident has the right to confidentiality. Treatment and personal needs must be met with privacy and dignity. The resident has the right to choose the personal attending physician. The resident has the right to be free from physical or drug-induced restraints. The resident must be informed of the nursing facility s complaint procedures and be free to present all complaints, including those relating to other residents, abuse, neglect, or misappropriation of property without fear of harassment, retaliation, or being evicted. The resident has the right to a telephone that allows privacy. The resident retains all civil and constitutional rights. The resident may meet at any time with immediate family members, other relatives, or visitors. However, the nursing facility may place reasonable restrictions upon this right. The nursing facility may require that non-family visits not take place in a resident s room while a roommate is asleep or receiving care. The Long-term Care Ombudsman is not subject to visiting-hour limitations. Residents have the right to deny or withdraw consent for visitation of immediate family members, other relatives, and non-family visitors at any time. The resident has the right to privacy in written communications, including the right to send and promptly receive mail unopened. Nursing facility staff may open the resident s mail only with permission. The nursing facility must provide access to stationery, postage, and writing implements, but may charge the resident for these items. The resident may participate in any social, religious, or community group that she chooses. She has the right to share a room in a nursing facility with a spouse if both spouses consent to the arrangement. They also have the right to meet with other residents and residents families in the nursing facility to discuss nursing facility issues. The resident may keep and use personal clothing and possessions as long as space permits and they are not harmful to the patient or others and do not infringe on others rights. Right to Appropriate Care The resident has the right to complete information about his medical condition and care plan. He has the right to refuse treatment and must be told of the possible consequences of refusing treatment. He must be informed of his physician s name, type of practice, and how to contact her. The resident is protected from mental and physical abuse and from corporal punishment, involuntary seclusion, and misappropriation of property. The resident does not have to take part in any experimental procedures. The resident does not have to perform any work or services for the nursing facility that are not part of his care plan. If he does choose to work, it must be permitted within his care plan. The care plan must specify if the work is voluntary or paid. If one is paid, the wage must be at or above prevailing rates Care2Learn #40-15 Abuse & Neglect of the Elderly Page 22 of 38

23 The resident may handle and administer his own medications unless the nursing facility staff determines it would not be safe. Transfer and Discharge Rights The resident must be given advance notice before his room or roommate is changed. The notice is to allow him to prepare for the change. The nursing facility staff must notify him promptly when they are aware that a change is necessary. He may discharge himself from the nursing facility at any time, unless his guardian requires him to stay. He cannot be discharged or transferred from the nursing facility against his will except under the following circumstances: The transfer is required for medical reasons and his needs cannot be met in the nursing facility His health or welfare or that of other residents or staff is in danger He does not pay his bills His health has improved so that he no longer needs nursing facility services The nursing facility closes or is no longer approved by the Medicaid program The resident and a family member or legal representative must be given a thirty-day written notice before an involuntary transfer or discharge. The notice must include the following information: Reason for transfer or discharge Effective date Location to which one is being transferred or discharged Resident s right to protest or appeal a transfer The name, address and telephone number of the long-term care ombudsman If appropriate, the mailing address and telephone number of the agency responsible for the protection and advocacy for persons with developmental disabilities or mental illness A thirty-day written notice would not have to be given for a transfer or discharge when it is a healthcare emergency, residents or staff are in danger, or resident has been in the nursing facility less than thirty days or has agreed to transfer. In these cases the notice must be given as soon as practical. Legislation and Elder Abuse Lesson Goal: The student will learn in this section that elder abuse is being addressed at the federal as well as state and local levels of government. Lesson Keynote: The elderly need advocacy on their behalf, because their physical or mental disabilities, social isolation, limited educational attainment, or limited financial resources prevent them from being able to protect or advocate for themselves. Most states have statutes or adult protective service laws addressing the issue of elder abuse. National Research Congress, under the Family Violence Prevention and Services Act of 1992, required that a study of the national incidence of abuse, neglect, and exploitation of elderly persons be conducted. The Administration for Children and Families (ACF) has responsibility for administering the provisions of this legislation. The ACF combined resources and expertise with the Administration on Aging (AoA) and jointly funded the study as a research activity of the AoA-supported National Center on Elder Abuse (NCEA) Care2Learn #40-15 Abuse & Neglect of the Elderly Page 23 of 38

24 Because the legislative mandate primarily was concerned with the prevention of violence in domestic settings, the study focused only on the maltreatment of non-institutionalized elderly persons. Elders living in hospitals, nursing homes, assisted living facilities, or other institutional or group facilities were not included in the report. The National Elder Abuse Incidence Study (NEAIS) utilized a sentinel research design. This methodology for collecting data from nationally representative samples was new to the field of elder abuse, but it had been used for federally-supported national incidence studies of child abuse and neglect. State Legislation Most previous attempts to generate national data on domestic elder abuse in the United States relied on statistics of suspected elder abuse compiled by states. Over the past twenty years states have become increasingly concerned with the problem of elder abuse, both domestic and institutional, and have enacted laws to prevent and treat the problem. As a result all states now have statutes addressing elder abuse. In most states, elder abuse laws mandate that certain professionals report all suspected incidents of elder maltreatment to officially designated report-receiving agencies. Some states administer domestic elder abuse laws but make elder abuse reporting voluntary. In some states the elder for whom a report of suspected abuse has been made may refuse an investigation. Both the states with laws on mandatory reporting and those where reporting is voluntary regularly gather statistics on reports of elder abuse, although the comprehensiveness of elder abuse information systems varies considerably from state to state. The National Center on Elder Abuse has documented laws in the fifty states, the District of Columbia, Puerto Rico, Guam, and the Virgin Islands that address abuse, neglect, and exploitation of elders. Across these seventy-one state laws, the five most common information elements are the type of person covered by the law, definitions of elder abuse, reporter immunity, the age of persons covered by the law, and the agency designated to receive reports. Other elements include the timing and method of reporting, mandatory reporting requirements, mandatory reporters, involvement of law enforcement, and confidentiality of client information. Following the intake of a report of alleged abuse in an agency designated to receive these reports, such as Adult Protective Services (APS), the case is assigned to a protective service worker for investigation. The length of time that elapses prior to the investigation varies both by state and by the nature of the abuse. Once an investigation of an alleged elder abuse incident has begun, a case still may be referred to another agency for intervention or services. A case may be found substantiated, unsubstantiated, or in some states, "indicated but not confirmed." The requirements for case disposition vary by state. State Programs While conditions for older Americans have improved markedly since the passage of the Older Americans Act of 1965 (OAA), some elders still suffer abusive situations ranging from financial exploitation to severe neglect. They may need advocacy on their behalf, because their physical or mental disabilities, social isolation, limited educational attainment, or limited financial resources prevent them from being able to protect or advocate for themselves. Title VII, the Vulnerable Elder Rights Protection Program, was created by Congress in the 1992 Amendments to the OAA to protect and enhance the basic rights and benefits of vulnerable older people. The Administration on Aging, which administers Title VII at the federal level, encourages its nationwide network of 57 State and Territorial Units on Aging (SUAs), their 655 Area Agencies on Aging, and 221 Tribal Organizations to focus their efforts on issues affecting those elderly persons who are the most socially and economically vulnerable Care2Learn #40-15 Abuse & Neglect of the Elderly Page 24 of 38

25 Title VII has a dual focus: (1) it brings together and strengthens four advocacy programs: The Long-Term Care Ombudsman Program, Programs for the Prevention of Abuse, Neglect and Exploitation, State Elder Rights and Legal Assistance Development Programs, and Insurance/Benefits Outreach, Counseling and Assistance Programs and calls for their coordination and linkage in each state; and (2) it calls on the state and territorial agencies to coordinate the Title VII programs and to work with other legal services programs and advocates in each state to address those issues of highest priority for the most vulnerable elderly. Combining state advocacy programs under a single title has fostered increased collaboration among advocates within a state and between states to assist older people, their families, and representatives, while strengthening the mission of each program. The Ombudsman Program assists residents of long-term care facilities and their families and friends to voice concerns and correct conditions that affect the quality of their care. The program also promotes policies and practices that improve the quality of life in nursing and board-and-care homes and other adult-care facilities. The AoA provides leadership and support to state long-term-care ombudsman programs and funds the National Ombudsman Resource Center to provide training and technical assistance to ombudsmen. Working through hundreds of grassroots programs, ombudsmen and ombudsman volunteers monitor private and publicly subsidized long-term care facilities and educate consumers and providers about residents' rights and good care practices. The ombudsmen's role in preventing neglect and even abuse of residents is one of their most important functions. State activities strengthen both prevention and treatment programs through statewide and local professional training and public education initiatives. Following passage of the 1992 OAA amendments states increased the use of funds to support statewide and local coordination among elder abuse prevention programs and strengthen coordination with other state and local programs and services to protect vulnerable adults, particularly older individuals. The AoA provides leadership for state activities and is emphasizing increased coordination among service systems and disciplines to prevent elder abuse and combat crimes against the elderly. They emphasize informing professionals serving the elderly about elder abuse, increasing public awareness of elder abuse and the seriousness of crimes against the elderly, and public education of the elderly to enable them to avoid being victimized, abused, or exploited. The AoA has participated in the development of the American Medical Association's (AMA) "Diagnostic and Treatment Guidelines on Elder Abuse and Neglect." The AMA distributed the guidelines to physicians across the country so that they could identify victims of abuse more readily. The AoA worked with the American Bar Association s Commission on Legal Problems in its development of recommendations for state courts handling elder abuse cases. The AoA also joined with the Police Executive Research Forum, the Justice Department, and the American Association of Retired Persons (AARP) to improve the law enforcement community's response to crimes against the elderly and elder abuse. Under the State Elder Rights and Legal Assistance Development Program, the state and territorial agencies have established programs to provide leadership in improving the quality and availability of legal and advocacy assistance to ensure a comprehensive system of elder rights. States have designated a legal assistance program developer and established a focal point for conducting policy review, analysis, and advocacy on issues including guardianship, age discrimination, pensions and health benefits, consumer protection, protective services, public benefits and dispute resolution. States have implemented the State Outreach, Counseling, and Assistance Program for Insurance and Public Benefits in a variety of ways to respond to needs in their states, and have coordinated activities with related counseling and outreach programs. States emphasized areas such as pensions, outreach to those eligible for Supplemental Security Income and Food Stamps, and expansion of health insurance, counseling, and assistance efforts Care2Learn #40-15 Abuse & Neglect of the Elderly Page 25 of 38