Elder Abuse in the US; Current Developments and Trends Daniel J. Sheridan, PhD, RN, FNE-A, FAAN Associate Professor, Johns Hopkins University School of Nursing Visiting Scholar, Flinders University School of Nursing & Midwifery sher0126@flinders.edu.au Recognizing Elder Abuse Early 1970s - Granny Bashing, England Mid 1970s - US Senate Special Committee on Agency, Nursing Home Abuse Late 1970s - Case histories of elder abuse in the home reported in US medical literature 1981 - US House of Representatives Select Committee on Aging hearings with victims 1986 - Institute of Medicine Elder Mistreatment in Institutions Recognizing Elder Abuse 1990 - Elder Abuse Task Force, Sec. of US Dept. of Health and Human Services 1991 - National Institute on Elder Abuse, Aging s Elder Care Campaign 1992 The Joint Commission first called for improved identification, documentation, and management of elder abuse (family violence) in ED s, hospital s and ambulatory care sites Still not being routinely enforced 1
Elder Justice Act - 2010 After almost ten years of lobbying, it finally was passed into law in 2010 Tens of millions of dollars earmarked for improving investigations, services and prevention Monies for new national prevalence studies Several million earmarked for medical forensic training NEVER received $1 of funding - YET Prevalence No one knows precisely how many older adults are mistreated in USA. Definitions of elder abuse vary. State statistics vary widely because there is no uniform reporting system. There is no comprehensive national database of elder abuse cases. Prevalence 1996 - US Administration on Aging Last National Study 500,000 per year 3% to 5% of all elders (Krummel, 1996) Just as pervasive as child abuse Family caregiver stress versus older domestic violence versus non-family caregiver assaults Wisconsin study 1997 linked to DV grown older AARP (American Association of Retired Persons) found 50% of their members reported DV grown older (1995) 2
Lundy & Grossman - 2004 N = 1,057 > 65 seeking help at DV Programs Illinois Coalition Against Domestic Violence five-year period in the late 1990s Represented <1% of people who sought DV services in Illinois Most older victims seek other resources Other relatives, church, senior services Female 90% Male 10% White 75% Relationship of client to abuser Current or Ex-husband 38% Male relative 34% Female relative 12% Current or former male friend 7% Unknown 9% (79% of perpetrators were male) 3
Source of referrals Police 35% Social service agency 15% State s Attorney 11% Hospital/MD/RN 6% Friend 5% Relative 5% (N = 1,057) Types of abuse experienced Emotional abuse 96% Physical abuse 71% Sexual abuse 5% Five Types of Abuse 1. Physical Abuse Sexual abuse 2. Psychological Abuse Verbal abuse 3. Financial Abuse 4. Active Neglect 5. Passive/Unintentional Neglect 4
Flags of Abuse Physical Bruises in various stages of healing Fractures in various stages of healing Injuries not consistent with the history being provided Significant unexplained injuries of a vulnerable person Patterned injuries Bilateral bruising to arm especially in finger-tip pattern Wrap around bruises to wrist and ankle - grabbed Ligature/restrain abrasions to the wrist or ankle Injuries to genitalia Bite marks anywhere to the body Positive culture for sexually transmitted infection Emotional/Verbal Abuse Very Common Emotional verbal abuse usually precedes physical abuse. Scars take longer if ever to heal. Flags of Neglect Behavioral Depression/Dementia place person at risk Anxiety or fear around caretaker Unexplained withdrawal from normal activities New onset thoughts of suicide or self harm New onset of fear or anxiety around person 5
Flags of Neglect Neglect Poor hygiene Unkempt hair and nails Dehydration or malnutrition Over/Under medicated Many missed medical appointments Skin breakdown/pressure ulcers Untreated wounds Insect infestation Compulsory Reporting Mandatory reporting in all states? It is NOT mandatory in the following States: Colorado, New Jersey, New York, North Dakota, South Dakota, and Wisconsin Maryland Vulnerable Person Abuse/Neglect www.elderabusecenter.org Reasonable cause to suspect Do not have to prove Primary providers cannot order other mandatory reporters to not report Lack of Uniform Definitions Elder abuse/neglect v. Elder maltreatment v. Abuse/Neglect of Vulnerable Persons Acts of commission and/or omission that result in harm or threatened harm to the health or welfare of an older adult (>60 years old or >65 years old) physical financial psychological/verbal sexual 6
Investigations Vary Based on Patient/Victim Location Abuse and neglect in one s home Adult protective services Until recently rarely had a forensic nurse as a part of the investigation team Abuse and neglect in aged care or group home facility State Survey (regulatory inspection division) Must follow federal guidelines set by Centers for Medicaid and Medicare Services Most surveyors are nurses but with limited forensic training US National Resource - FREE Center for Medicare and Medicaid Services (CMS) Elder Abuse and Neglect Investigation Course This CMS course covers topics such Signs and Symptoms of Abuse and Neglect; The Normal Aging Process and Abuse and Neglect; 4. Screening Techniques for Identifying Abuse and Neglect; 5. Written and Photographic Documentation; 6. Legal Considerations in Abuse and Neglect; 7. Cultural Considerations in Abuse and Neglect. http://cmstraining.info/pubs/abuseandneglect.aspx Abuse & Neglect in Nursing Homes CMS has detailed regulations and guidelines about investigation/prevention of abuse & neglect in nursing homes and regulated group homes BUT Has no authority over abuse in personal homes 7
Receiving Reports of Abuse or Neglect Can be discovered during routine CMS surveys. Most often surveyors told about possible abuse directly by the facility, or from family members, or from ombudsmen or from emergency room staff. Sometimes when a facility promptly reports abuse or neglect to the survey agency, surveyors may not be able to conduct an immediate site visit. Did the Facility Conduct a Competent/Thorough Abuse or Neglect Investigation? Prior to the surveyor conducting a site visit, the facility has an obligation to conduct an internal investigation of known or suspected abuse or neglect. The following slides discuss the principles of competent/thorough investigations of abuse or neglect. Was the Internal Investigation Competent A facility needs to demonstrate it has conducted a competent internal review of unexplained injuries and/or suspected abuse or neglect. As such, it has to provide an investigator sufficient documentation to support its findings or conclusions. 8
Timely Investigations All reasonable efforts need to be made to conduct a prompt investigation for the following reasons: Memories of events can fade. Evidence can get lost and/or destroyed There can be collusion among staff to cover up the facts of an event Perpetrators of abuse are more likely to confess if questioned within 24 hours of an event, than when questioned days later Competent Investigations All reasonable efforts need to be made to conduct a competent, fact-based investigation. Aspects of competence include: Asking non-leading, open ended questions of residents and staff in a neutral tone of voice starting with general issues then becoming more specific as the interview progresses. Interviewing all reasonable witnesses or persons of interest Using a standardized protocol to conduct and write up the interview, especially when interviewing cognitively impaired persons Avoiding trick questions and adversarial questioning Reviewing records that may explain what happened Unbiased Investigations All reasonable efforts need to be made to conduct an investigation free of bias. Was there an actual or perceived conflict of interest by the investigator? Has there been a prior or is there a current relationship between the investigator and the people being interviewed. Common conflicts of interest occur when the investigator is connected to the people being interviewed by such things as related by blood or marriage, former or current friends, ex-lovers, and being a co-workers. Were all theories of causation thoroughly explored. 9
Securing Resident Records Promptly Time delays from between days to weeks can occur when abuse or neglect is suspected or reported and when an investigator can be on site. Once notified of a possible abuse or neglect incident, one of the first things to do is secure and photocopy all facility records. This will minimize the potential for record tampering. Barriers to Discloser of Abuse Fear of being placed in a nursing home Fear of having to leave one s own home Difficulty of detecting signs and symptoms of abuse or neglect. Denial and not wanting to admit abuse. Wanting to protect abuser. Feelings of shame and guilt. Fear of retaliation/punishment/more abuse/death. Fear of being accused of lying. (Siegel, 2004) Barriers to Discloser of Abuse Caregiver, family or visitor is in the room when assessment questions are asked Location of assessment must be a place where the patient feels safe to answer questions. Patient s privacy must be respected. Need to post a policy statement in the waiting room that ALL patients are interviewed alone every visit. 10
References Acierno, R. (2003). Elder mistreatment: Epidemiological assessment methodology. In R. J. Bonnie & R. B. Wallace (Eds.), Elder mistreatment: Abuse, neglect and exploitation in an aging America, (pp. 261-302). Washington, DC: National Research Council of the National Academies. Aravanis, S. C., Adelman, R. D., Breckman, R., et al. (1992). Diagnostic and treatment t t guidelines on elder abuse. Chicago: American Medical Association. Brandl, B., & Horan, D. L. (2002). Domestic violence in later life: Overview for Health Care Professionals. Women & Health, 35(2/3), 41-53. Dyer, C. B., Connelly, M. T., & McFeeley, P. (2003). The clinical and medical forensics of elder abuse and neglect. In R. J. Bonnie & R. B. Wallace (Eds.), Elder mistreatment: Abuse, neglect and exploitation in an aging America, pp. 339-381. Washington, DC: National Research Council of the National Academies. References Geroff, A. J. & Olshaker, J. S. (2007). Elder abuse. In J. S. Olshaker, M.C. Jackson, & W. S. Smock (Eds.), Forensic emergency medicine (2 nd ed.), (pp.174-201). Philadelphia, Lippincott, Williams, & Wilkins. Krummel, S. (1996). Abuse of the elderly. In D. M. Burby (Ed.) The Impact of violence on the family. Boston: Allyn & Bacon. Lundy, M., & Grossman, S. F. (2005). Elder Abuse: Spouse/Intimate Partner Abuse and Family Violence Among Elders. Journal of Elder Abuse & Neglect, 16(1), 85-102. Merriam-Webster s Medical Desk Dictionary, Revised Edition. (2005). Springfield, MA: Merriam-Webster Incorporated. References Mosqueda L, Burnight K, Liao S (2205). The life cycle of bruises in older adults. Journal of the American Geriatric Society, 53(8, 1339-1343. National Elder Abuse Incidence Study (1998). http://www.aoa.gov/abuse/report/default.htm Nash, K. R., & Sheridan, D. J. (2009). Can one accurately date a bruise? State of the science. Journal of Forensic Nursing, 5, 31-37. Poulos, C., & Sheridan, D. J. (2008). Genital injuries in postmenopausal women after sexual assault. Journal of Elder Abuse and Neglect, 20(4), 323-335. 11
References Sheridan, D, J., Nash, K. R., Poulos, C. A., Watt, S., & Fauerbach, L. (2009). Soft tissue and cutaneous injury patterns. In C. Mitchell& D. Anglin (Eds.). Intimate partner violence: A health based perspective (pp. 237-252). New York: Oxford University Press. Sheridan, D. J. (2007). Treating survivors of intimate partner abuse. In J. S. Olshaker, M.C. Jackson, & W. S. Smock (Eds.), Forensic emergency medicine (2 nd ed.), (pp. 202-222). Philadelphia, Lippincott, Williams, & Wilkins. Sheridan, D. J., Fernandes, L., Van Pelt, D., Alden, A., & Campbell, J. C. (2006). Intimate partner violence and sexual assault. In K. D. Schuiling & F. Likis (Eds.). Women s gynecologic health. (pp. 293-320). Boston, MA: Jones & Bartlett Publishers. References Sheridan, D. J., Nash, K., Hawkins, S., Makely, J., Campbell, J. C. (2006). Forensic implications of intimate partner violence. In R. Hammer, B. Moynihan, & E. M. Pagliaro (Eds.) Forensic nursing: A handbook for practice. (pp. 255-277). Boston, MA: Jones & Bartlett Publishers. Sheridan D J (2003 March) Forensic identification and documentation of Sheridan, D. J. (2003, March). Forensic identification and documentation of patients experiencing intimate partner violence. Clinics in Family Practice, 5(1), 113-143. 12