The elder population of the world, as well as that of the United States, is growing at an unprecedented rate. According to the recent reports from the U.S. Census Bureau, “in 2050, the population aged 65 and over is projected to be 83.7 million, almost double its estimated population of 43.1 million in 2012” (U.S. Census Bureau, 2014). As the population ages, the risk of elder mistreatment is increasing as well. Older adults are especially vulnerable to abuse. Estimates suggest that “500,000 to 2 million cases of elder abuse and neglect occur annually in the United States” (Ricci, Kyle, & Carman, 2017). Although, older people may experience violence in a variety of settings, “elder abuse by a family member is the most common type of abuse (65.5%), with an adult child being the most common perpetrator, followed by other family members” (Lawson, 2013). Therefore, it is important for healthcare providers, including nurses, to have solid knowledge of signs and symptoms of abuse as well as great attention to detail in order to recognize at-risk patients, to screen and to assess elder abuse victims, to document violence acts properly, and to respond to such acts in a nonjudgmental, sensitive, and legally adequate way. Since “nurses have frequent contact with older victims of abuse, they play a significant role in detecting, reporting, and intervening in such cases” (Ricci et al., 2017).
Elder abuse can take many forms. The five recognized categories include physical, financial, psychological, sexual abuse, and neglect. Although neglect is the most prevalent form of abuse, it is not uncommon for elder people to become victims of two or more types of mistreatment at the same time (Bewley, & Welch, 2014). Older adults make themselves vulnerable “by trusting the abuser, who is someone you would normally expect to trust, like a family member” (Andrews, 2017). According to Lawson (2013), “elder abuse can affect people of all ethnic backgrounds, social status, and both men and women, although research indicates that certain groups of people are at higher risks than others” (p.246). Thus, “among older adults, a younger age has been consistently associated with a greater risk of abuse”, and “one possible reason for this finding is that the ‘young old’ more often live with a spouse or with adult children, the two groups that are the most likely abusers” (Lachs, & Pillemer, 2015). Typically, elder mistreatment often takes place in “the context of poor long-term family relationships”, and “it may be associated with the carer’s inability to cope or consistently provide the care needed” or due to “ignorance or a lack of skills and available external support or supervision” (Bewley, & Welch, 2014). Besides, the factors associated with a greater risk for elder abuse include cognitive impairment, social isolation, physical disability, lower household income, and previous traumatic events (Lawson, 2013). As research indicates, “perpetrators are most likely to be adult children or spouses, to have a history of past or current substance abuse, mental or physical health problems, to have a history of trouble with police, to be socially isolated, unemployed or have financial problems, and to be experiencing major stress” (Lachs, & Pillemer, 2015).
Elder maltreatment has devastating, far-reaching health repercussions. Besides the obvious traumatic injury and pain, it has been well-documented that the victims of abuse experience a range of psychological effects, including an increased rate of depression, anxiety, guilt, shame, learned helplessness, and other negative outcomes. Moreover, as studies show, “elder abuse greatly increases the likelihood of placement in a nursing home and of hospitalization (Lachs, & Pillemer, 2015). Older adult maltreatment is preventable, not inevitable. Therefore, early identification of at-risk patients and prompt interventions are crucial in the prevention of the elder abuse and in safeguarding the health and wellbeing of the patients.
Unfortunately, many elder victims do not report abuse or seek professional help due to fear or embarrassment. Others may consider mistreatment by a family member to be a personal matter and often do not want to get the perpetrator in trouble. Besides, some older adults may have limited ability to disclose situations of abuse due to cognitive impairment or a language barrier. As a result, “underreporting by elderly is a major hurdle to appropriate action” (Lawson, 2013). Thus, routine screening of elder abuse should be a part of each visit. Although it takes only a few minutes, it can have an enormously positive effect on the outcome for the victim (Ricci et al., 2017). Nurses are in an ideal position to recognize abuse and to provide timely interventions for the elder who suffer from maltreatment. This requires an acute awareness of the signs of possible abuse or neglect as well as attention to detail (Hinkle, & Cheever, 2018). Among situations that might raise suspicion or concern are physical signs of abuse such as bruises, burns, abrasions, or unexplained injuries, frequent attendance for minor traumas, or injuries that are in various stages of healing (Hunt, 2014). In addition, the “possibility of neglect should be investigated whenever a person who is dependent shows evidence of inattention to hygiene, to nutrition, or to medical needs” such as inappropriate clothing, unkempt appearance, losing weight, “unfilled medication prescriptions or missed appointments with health care providers” (Hinkle, & Cheever, 2018). It is essential for nurses to be vigilant even for subtle cues of abuse such as apathy, drowsiness, anxiety, a recent change in behavior, or recurrent genital or urinary tract infections (Hunt, 2014).
Healthcare professionals, including nurses, are required to report suspected elder mistreatment or neglect to the appropriate agencies, usually Adult Protective Services. As Dong points out in his article (2015), “almost all states have mandatory reporting legislation requiring health professionals to report reasonable suspicions of elder abuse” (p.1234). Additionally, whenever abuse is suspected, thorough evaluation along with careful documentation of events and injuries are important since “medical record may be used as part of a legal proceeding” (Hinkle, & Cheever, 2018). A nurse should gather and document a detailed history, especially the psychosocial and cultural aspects, “observations of patient behavior, reactions to questions, and family dynamics and conflicts” (Dong, 2015). The suspected victim “should be interviewed separately and alone, both because a relative or caregiver may be the abuser and because victims may be hesitant to reveal mistreatment when others are present because of embarrassment or shame” (Lachs, & Pillemer, 2015). In order to elicit accurate information, nurses need to be able to communicate effectively and to be skilled in interviewing techniques (Hinkle, & Cheever, 2018). Furthermore, it is important to build rapport with the victim by creating an atmosphere of openness, communicating support and understanding, and showing interest and concern (Ricci et al., 2017). Listening to the patient with calmness and care, avoiding using leading or probing questions, demonstrating nonjudgmental attitude makes him/her feel safer and more willing to open up and to talk about the traumatic event.
Once abuse is detected, the victim’s safety becomes the primary concern. For that reason, if the older adult is in immediate danger, he/she should be separated from the abuser as soon as possible. Additionally, providing sensitive care, support, and reassurance for the abuse victim is essential. A nurse can provide appropriate interventions by encouraging the elder to express feelings and concerns, teaching coping strategies, helping to set realistic goals, and educating about available help and resources. Empowerment is another integral aspect of care. In order to help the abuse victim to regain control over his/her life, a nurse should offer step-by-step explanations of all procedures, pace the nursing interventions, allow the patient to take the lead and to actively participate in care (Ricci et al., 2017). Therefore, “the person suffering abuse must be absolutely central to the decision-making process” and have control over all health care decisions (Hunt, 2014).
Several interventions can be implemented to prevent further abuse. Nurses need to work in collaboration with other healthcare team members since “successful interventions in cases of elder abuse are typically interprofessional, ongoing, community-based, and resource-intensive” (Lachs, & Pillemer, 2015). If elder maltreatment or neglect is the result of the burdens of caregiving, respite services or additional home care may be provided for the impaired family member (Lachs, & Pillemer, 2015). Respite services are crucial in reducing caregiver stress, which is one of the major contributing factors in elder abuse. When mental illness of the caregiver is responsible for the situation, the abuser “may require mandated mental health treatment” (Lachs, & Pillemer, 2015). Besides, educating older adults and “providing them with accurate information about their rights, self-protection measures, and solution-oriented behaviors greatly contributes to their sense of self-efficacy” and helps to prevent further abuse (Lawson, 2013). Furthermore, support activities are another promising prevention tool that further empowers elderly people. Abuse victims attend individual or group meetings that allow the participants to share their experiences, reduce social isolation, provide them with a sense of hope and a chance to identify with other people who have similar problems (Lawson, 2013).
Elder abuse is a serious public health issue that needs close attention. This problem is greater than most people realize. In today’s aging society, more and more older adults become victims of maltreatment or neglect and, sadly, the perpetrator is most often a family member. Elder abuse in all its forms is ugly, immoral, and traumatic. Safeguarding health and wellbeing of vulnerable elderly people, recognizing abuse in a timely manner, being attentive even to subtle cues of abuse, and providing appropriate interventions are an important part of a nursing practice. Nurses play a vital role in identifying at-risk patients. They need to be proficient and confident in their skills to assess, interview, and provide competent, compassionate care to patients who found themselves in this distressing situation.
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