Evidence-Based Practice Guideline

Elder Abuse Prevention

lder abuse is a problem that cally and psychologically vulnerable & Finkelhor, 1988; Podnieks, 1992). occurs across all settings than in other settings. (p. 88) From the most recent prevalence Eand is encountered by all Estimates of elder abuse preva- study of individuals 60 and older, 1 in health care providers and others lence are available from a variety 10 respondents reported emotional, not in the health care field. Elder of sources, such as adult protective physical, or sexual abuse, or potential abuse is “a single, or repeated act, neglect in the past year. or lack of appropriate action, oc- curring within any relationship PURPOSE where there is an expectation of The purpose of this evidence-based trust which causes harm or dis- practice guideline is to facilitate health tress to an older person” (World care professionals’ assessment of old- Health Organization, n.d., para. 1). er adults in domestic and institutional Elder abuse has many forms, such settings who are at risk for elder as abandonment, emotional or psy- abuse, and to recommend interven- chological abuse, financial or mate- tions to reduce the incidence of mis- rial exploitation, neglect, physical treatment. The guideline is intended abuse, and sexual abuse (Daly & for frontline staff (e.g., RNs, licensed Jogerst, 2001, 2006). In addition, practical nurses, nursing assistants) resident-to-resident abuse can oc- who provide care for older adults and cur in institutional settings. their families in domestic or institu- In institutional settings, elder service agencies, probability sam- tional settings. This protocol helps abuse can take on a different mean- ples of older adults in communities, nursing caregivers assess older adults ing. According to Wierucka and health care personnel working with for potential or actual abuse, develop Goodridge (1996): older individuals, and medical re- a care plan, and implement strategies The collective nature of institu- cord review. Nine epidemiological for prevention of elder abuse. It is also tions means there is greater potential community-based prevalence stud- intended for managers and adminis- for abuse/neglect to occur as there ies have been conducted (Acierno et trators who develop policy and pro- are more people and more interac- al., 2010; Chokkanathan & Lee, 2005; cedures and conduct investigations of tions than in community settings. The Comijs, Pot, Smit, Bouter, & Jonker, abuse. The full text of Elder Abuse nature of the interactions may create 1998; Keskinoglu et al., 2007; Kivelä, Prevention (Daly, 2010) is available very strong tensions among adminis- Köngäs-Saviaro, Kesti, Pahkala, & for purchase from The University of trators, staff, and residents. The client Ijas, 1992; Ogg & Bennett, 1992; Oh, Iowa Hartford Center of Geriatric and his/her family are more physi- Kim, Martins, & Kim, 2006; Pillemer Nursing Excellence at http://www.

Jeanette M. Daly, PhD, RN Edited by Deborah Perry Schoenfelder, PhD, RN

Journal of Gerontological Nursing • Vol. 37, No. 11, 2011 11 nursing.uiowa.edu/Hartford/nurse/ hen, 2008), and are non-White are at Lachs et al., 1994, 1997; National Re- ebp.htm. higher risk for elder abuse (Lachs et search Council, 2003; Shugarman et al., 1994; Lachs, Williams, O’Brien, al., 2003; Vida, Monks, & Des Ros- DEFINITIONS OF KEY TERMS Hurst, & Horwitz, 1997; Shugar- iers, 2002): The following definitions of types man, Fries, Wolf, & Morris, 2003). l Physical, functional, or cogni- of elder abuse are from the National Older adults in a shared living tive impairment. Center on Elder Abuse (NCEA, situation are more likely at risk for l Mental illness, alcoholism, or 2011): abuse than those living alone (Bur- drug abuse problems. l Abandonment is the desertion gess, Brown, Bell, Ledray & Poarch, l Socially isolated, have a poor of an older person by an individual 2005; Lachs et al., 1997; Pillemer & social network, or low social who has assumed responsibility for Finkelhor, 1988; Pillemer & Suitor, support. providing care for the older adult, or 1992). Risk of abuse is also evident l Dependent on others. by a person with physical custody. for adults who are socially isolated, l Past history of abusive relation- l Emotional or psychological have poor social networks, or have ships. abuse is the infliction of anguish, low social support (Acierno et al., l Financial problems or other pain, or distress through verbal or 2010; Lachs et al., 1996). In addition, family problems. nonverbal acts. alcohol abuse (Anetzberger, Korbin, l Reside in inadequate housing or l Financial or material exploita- & Austin, 1994) and exposure to a unsafe conditions. tion is the illegal or improper use of previous traumatic event (Acierno et l Depression. an older adult’s funds, property, or al., 2010) place older adults at risk for l Delusions. assets. abuse. l Previous traumatic exposure. l Neglect is the refusal or failure l Poor health. to fulfill any part of a person’s obli- CONSEQUENCES OF ELDER l Caregiver is stressed/frustrated gations or duties to an older adult. ABUSE with the difficult task of caring l Physical abuse is the use of Elder abuse is associated with a for an older person. physical force that may result in range of adverse health outcomes. l Caregiver has mental illness, bodily injury, physical pain, or im- There is evidence of greater mortal- alcoholism, or drug abuse prob- pairment. ity risk (Baker et al., 2009; Lachs, lems. l Sexual abuse is nonconsensual Williams, O’Brien, Pillemer, & l Caregiver has inadequate finan- sexual contact of any kind with an Charlson, 1998); higher dependence cial resources. older adult. in performance of activities of daily l Caregiver has health problems. In addition, according to Rosen living (Cohen, 2008); and increased et al. (2008), resident-to-resident ag- dementia, delusions, and depres- ASSESSMENT TOOLS AND gression is “negative and aggressive sion (Cooper et al., 2006; Cooper, FORMS physical, sexual, or verbal interac- Manela, Katona, & Livingston, 2008; Several tools are available to as- tions between long-term care resi- Coyne, Reichman, & Berbig, 1993; sess adults at risk for abuse or actual dents that in a community setting Dyer, Pavlik, Murphy, & Hyman, victims of abuse. The tools may be would likely be construed as un- 2000; Pillemer & Suitor, 1992). Oth- short screening questions or in- welcome and have high potential to er findings indicate that older wom- depth assessments depending on the cause physical or psychological dis- en who experience abuse are likely to individual being assessed and prac- tress to the recipient” (p. 1398). consult practitioners with conditions tice setting. The following tools are such as physical injuries, gynecologi- available in the complete guideline INDIVIDUALS AT RISK FOR cal issues, gastrointestinal disorders, (Daly, 2010): ELDER ABUSE fatigue, headache, myalgias, depres- l Actual Abuse Tool (Bass, Various factors are associated sion, and anxiety (Mouton & Espi- Anetzberger, Ejaz, & Nagpaul, with individuals who are victims no, 1999). 2001). of abuse or at risk for abuse. Those l Elder Abuse Suspicion Index© who are older (Cohen, 2008; Lachs, ASSESSMENT CRITERIA (Yaffe, Wolfson, Lithwick, & Berkman, Fulmer, & Horwitz, 1994; The following assessment criteria Weiss, 2008). Lachs, Williams, O’Brien, Hurst, indicate those older adults who are l Elder Assessment Instru- & Horwitz, 1996; Pillemer & Fin- likely to benefit the most from use of ments (Fulmer, 2003; Fulmer & kelhor, 1988), married (Pillemer & this elder abuse prevention guideline Cahill, 1984; Fulmer & Wetle, Finkelhor, 1988; Podnieks, 1992), (Acierno et al., 2010; American Med- 1986). have a low educational level and low ical Association, 1992; Cohen, 2008; l Health, Attitudes Toward Ag- income level (Baker et al., 2009; Co- Cooper et al., 2006; Dyer et al., 2000; ing, Living Arrangements, and

12 Finances (HALF) Assessment givers (Daly, Merchant, & Jogerst, in l The higher the number of (Ferguson & Beck, 1983). press; Ploeg, Fear, Hutchison, Mac- abuse definitions in the regulations, l Hwalek-Sengstock Elder Abuse Millan, & Bolan, 2009). Other in- the higher the substantiation rates Screening Test (Neale, Hwalek, terventions attempted were support and ratios of substantiation/inves- Scott, Sengstock, & Stahl, 1991). groups for caregivers, which did not tigations, as some states have one l Index of Spouse Abuse (Hudson alleviate stress (Hsieh, Wang, Yen, & generic definition covering multiple & McIntosh, 1981). Liu, 2009), and daily money manage- types of abuse, and other states l Indicators of Abuse Screen (Reis ment for the older adults to hinder define each type of abuse (i.e., aban- & Nahmiash, 1998). financial exploitation, which did not donment, emotional abuse, exploita- l Mini-Mental State Examination lessen financial exploitation (Wilber, tion, neglect, physical abuse, sexual (Folstein, Folstein, & McHugh, 1991). Appropriate interventions for abuse). 1975). preventing elder abuse could include l Caseworkers who only in- l Partner Violence Screen (Feld- legislation, education, respite, social vestigated elder abuse reports had haus et al., 1997). support, batterer interventions, and a higher substantiation ratio than l Questions to Elicit Elder Abuse money management programs. caseworkers assigned to both child (Carney, Kahan, & Paris, 2003). and elder abuse work. l Risk of Abuse Tool (Bass et al., Legislation l A state’s administrative deci- 2001). Limited research has been con- sion to track reports of abuse led l Screen for Various Types of ducted on adult protective servic- to significantly higher investigation Abuse or Neglect (American es-related legislation and its re- and substantiation rates as well as Medical Association, 1992). lationship to elder abuse reports, substantiation ratios. l Suspected Abuse Tool (Bass et investigations, and substantiations. l A higher proportion of total al., 2001). In a landmark study, Jogerst, Daly, population categorized as “elderly” l Two-Question Abuse Screen Brinig, et al. (2003) reviewed all 50 was associated with lower substan- (McFarlane, Greenberg, Weltge, states and the District of Colum- tiation rates. & Watson, 1995). bia’s adult protective service-related Research pertinent to manda- l Vulnerability to Abuse Screen- statutes and regulations to evaluate tory reporters and the reporting of ing Scale (Schofield, Reynolds, the impact of state adult protective elder mistreatment is recommended Mishra, Powers, & Dobson, service legislation on the rates of (National Research Council, 2003). 2002). investigated and substantiated do- Forty-four states and the District of mestic elder abuse. The following is Columbia have laws providing that DESCRIPTION OF THE a list of significant findings: individuals who assume the care or PRACTICE l States that require public custody of older people are consid- Prevention of elder abuse requires education regarding elder abuse ered mandatory reporters, and 38 the involvement of multiple sec- correlated with higher abuse report statutes specify a penalty for man- tors of society. Education and dis- rates, suggesting that heightened datory reporters who do not report semination of information are vital public awareness increases reporting abuse or suspected abuse. Higher for health care professionals and for of elder abuse. abuse investigations rates are associ- the general public. Interventions for l States that require mandatory ated with a mandatory reporting re- prevention of elder abuse have been reporters had a significantly higher quirement in the law (Daly, Jogerst, suggested but have not been tested. investigation rate. Brinig, & Dawson, 2003). According to the National Research l The substance of how the Council (2003): mandatory reporting requirement Education No efforts have yet been made was written in the statute was not Iowa is the only state that requires to develop, implement, and evalu- important (i.e., listing all the manda- education for mandatory reporters. ate interventions based on scientifi- tory reporters or just saying “any A person required to report allega- cally grounded hypotheses about the person”). tions of dependent adult abuse must causes of elder mistreatment, and no l Thirty-three states had a provi- complete 2 hours of training within systematic research has been conduct- sion for penalties for failure to report 6 months of initial employment and ed to measure and evaluate the effects abuse, which was significantly associ- every 5 years thereafter (Iowa State of existing interventions. (p. 121) ated with higher investigation rates. Code, 2001). Comparing the inves- Unfortunately, only 14 elder l Investigation rates were almost tigation and substantiation rates for abuse intervention studies have been identical between states with or with- elder abuse allegations before and af- conducted, with the majority focused out a specific definition/criterion of ter July 1988, when Iowa statute was on education interventions for care- adult dependence or vulnerability. revised to ensure training of manda-

Journal of Gerontological Nursing • Vol. 37, No. 11, 2011 13 tory reporters, elder abuse investi- included a screening tool package, al., 2003). Another study identified gation and substantiation rates did teams to design and execute inter- factors related to client satisfaction not change (Jogerst, Daly, Dawson, vention strategies, advice on prob- and found that those caregivers who Brinig, & Schmuch, 2003). lems, volunteer buddies, a victim’s were able to dress and transport the It is evident that legislation and empowerment group, and education. dependent person to adult day care public policy have an impact on elder However, no outcomes were tested services were significantly more abuse rates, but other interventions, to determine the impact of the inter- satisfied than those caregivers who specific to the type of abuse, are also vention model. were unable to do so (Montgom- beneficial. Approximately eight edu- Other interventions that have ery, Marquis, Schaefer, & Kosloski, cational interventions focusing on been suggested in the literature in- 2002; Townsend & Kosloski, 2002). caregivers have demonstrated utility clude home visitation programs, During a pilot of a weekend re- in preventing or reducing elder abuse respite for caregivers, development spite program, it was found that (Désy & Prohaska, 2008; Goodridge, of pro-social skills for caregivers, caregivers need to be reassured their Johnston, & Thomson, 1997; Hsieh intensive multicomponent support loved ones are safe in a respite pro- et al., 2009; Pillemer & Hudson, 1993; services for caregivers, counseling gram and that both the caregiver Richardson, Kitchen, & Livingston, for caregivers, and shelter stays for and dependent person benefit from 2002, 2004; Uva & Guttman, 1996; care recipients (Nicoll, Ashworth, the experience (Perry & Bontinen, Vinton, 1993). Educational interven- McNally, & Newman, 2002; Rhodes 2001). In addition, social support is tions range from 1 to 8 hours and are & Levinson, 2003; Townsend & Ko- an important factor in a caregiver’s taught by many different methods, sloski, 2002; Wathen & MacMillan, satisfaction with respite care (Nicoll such as one-on-one instruction, in 2003). et al., 2002). Polarity therapy, a a classroom or at a conference, or touch therapy that uses gentle pres- with group support. Improvements Respite sure on energy points and biofields after educational interventions were Respite is a potential intervention to help clients achieve physiological noted by increased knowledge (Désy to prevent elder abuse. Three types relaxation, was tested as an alterna- & Prohaska, 2008), use of assessment of respite care are available: adult tive to respite (Korn et al., 2009). tools (Désy & Prohaska, 2008), im- day care, in home, and institution- Caregiver stress, depression, vital- proved job performance (Goodridge al (Townsend & Kosloski, 2002). ity, and general health improved in et al., 1997), and declines in reports Among families and service provid- the polarity therapy group when of abusive actions of staff (Pillemer ers, respite services are desired and compared to the enhanced respite & Hudson, 1993). needed by individuals caring for group. Pillemer and Hudson (1993) de- those who are dependent. Accord- A meta-analysis of respite inter- veloped and implemented a model ing to Nicoll et al. (2002), “respite vention studies was conducted to abuse prevention curriculum for is one way that the strain of caring determine its effect on caregivers nursing assistants employed in nurs- may be relieved” (p. 479). This relief (McNally, Ben-Shlomo, & New- ing facilities. The eight-module cur- might reduce the caregiver’s level of man, 1999). Twenty-nine studies riculum included video, lecture, stress and burden, which could en- were usable for analysis but because problem solving, role-playing, and hance the quality of interactions be- of the variety of respite interven- group support (Hudson, 1992). Fol- tween the caregiver and dependent tions offered, a true meta-analysis lowing the intervention, the num- person, which may in turn alleviate was not possible. It was determined ber of conflicts with residents de- some abuse. that “although caregivers often ex- clined and a reduction in resident Ten in-depth qualitative inter- hibit improvements in well-being aggression was reported. Another views of caregivers identified the during respite periods, these gains educational intervention consisting need to support the caregiver’s role are short-lived,” suggesting the re- of a video, booklet, and interactive (Lane, McKenna, Ryan, & Flem- spite does not provide a long-term workshop was conducted with nurs- ing, 2003). The stress of caring for social support system (McNally et ing assistants in nursing facilities in someone 24 hours per day affects al., 1999, p. 13). Hawaii. The pre-/posttest design the caregiver’s psychological well- indicated improved job satisfaction being. In-home respite was sug- Social Support (Braun, Suzuki, Cusick, & Howard- gested as a means to relieve the Caregivers have identified a need Carhart, 1997). burden without causing additional for social support, which varies with Reis and Nahmiash (1995) imple- problems for the dependent per- an individual’s stage of life, length of mented an intervention model to son related to relocation. Family time as a caregiver, and acuity and combat abuse/neglect of older adults support was another suggestion to intensity of the caregiving situation living in the community. The model relieve caregiver burden (Lane et (Norbeck, Chaftez, Skodol-Wilson,

14 & Weiss, 1991). A meta-analysis of Money Management Programs efit from use of the evidence-based 18 studies providing interventions Intervention trials to prevent ex- practice guideline Elder Abuse Pre- for caregiver distress demonstrated ploitation have not been complet- vention (Daly, 2010), which offers that respite services and individual ed, but daily money management suggestions for nursing diagnoses, psychosocial interventions were (DMM) programs have emerged as interventions, and outcomes. moderately effective, and group a result of professionals in diverse Unfortunately, few interven- psychosocial interventions were settings observing their clients hav- tions have been tested to prevent slightly effective (Knight, Lutsky, ing exploitation problems. DMM abuse, and those suggested for use & Macofsky-Urban, 1993). In a lit- programs assist people who have are from health care providers in erature review of the effectiveness of difficulty managing their personal various practice settings. Despite mental health interventions for long- financial affairs and include prepar- this lack of evidence, we have sev- term caregivers of highly dependent ing checks, making bank deposits, eral recommendations. Consistent individuals, the authors concluded dispensing cash, negotiating with use by health care providers of that psychosocial interventions pro- creditors, maintaining home pay- well-established assessment tools moting support and coping help re- roll for attendants, and calculating to identify abuse or risk of abuse duce caregiver stress (Sowden et al., federal and state taxes. The roles of is critical and should not be seen as 1997). In summary, research litera- daily money managers are educators, optional. Education and awareness- ture provides a wealth of informa- client advocates, debt managers, bill raising efforts should be ongoing tion on social support and its mea- payers, paying agents, representative wherever care and services are pro- surement, but it has not been tested payees, attorneys-in-fact, trustees, vided for older adults. Once risk as an intervention to prevent elder and guardians (Nerenberg, 2003). for abuse or actual abuse has been abuse. Wilber (1991) examined whether identified, individualizing plans of DMM services would divert vul- care and service seems logical to Batterer Interventions nerable older adults from conser- decrease the risk for abuse or stop Vinton (1991) noted that abuse vatorship (legal arrangement under the abuse. Focusing both on older of women is evident across the life which an individual is appointed by adults and caregivers is an essential span, with the prevalence of spousal the court to manage the affairs of part of intervening so that the fam- abuse decreasing with age. Batterer an adult). Sixty-three community- ily dynamics are addressed and ap- intervention programs to prevent dwelling adults ages 60 to 96 were as- propriate support is rendered. further violence are available after signed to usual customary screening Another important aspect of el- the fact for individuals who stay with or to money management groups. der abuse prevention, detection, the perpetrator. However, a U.S. De- After 12 months of intervention, and treatment is the need for an partment of Justice (2003) report no significant differences in rates of interdisciplinary team approach. summarizing the research literature conservatorship were found between Positive outcomes are more apt indicates batterer intervention pro- the groups, suggesting the individu- to happen with the entire team on grams have positive results. als who require conservatorship may board to assist older adults and Batterer intervention programs be different from those who need their loved ones. As stated earlier, are established and implemented DMM services. caseworkers who only investigated based on different theories, includ- elder abuse reports had a higher ing: men control their partners, the CONCLUSION AND substantiation ratio than casework- batterer has errors in thinking, and IMPLICATIONS FOR ers assigned to both child and elder battering has multiple causes. Thus, GERONTOLOGICAL NURSING abuse work. Having caseworkers programs vary in their focus and PRACTICE for age-specific abuse or types of include helping batterers confront All health care providers should abuse, such as child, domestic, and their attitudes about control, learn be aware of the risk factors for po- elder may be warranted. anger management skills, use cogni- tential elder abuse and the various Safety is a basic human need and tive therapy, use couples therapy, or types of abuse. Many instruments is an especially important consid- a combination of these approaches. are available for determining wheth- eration for older adults who are at In 88% of the 34 programs offer- er a person is at risk for abuse or is risk for abuse. Nurses can lead the ing cognitive-behavioral therapy, the a victim of abuse. Differentiating the way in addressing elder abuse by re-offense rates were significantly types of elder abuse and knowing using the evidence-based practice lower in the treatment groups when the prevalence of each type may pro- guideline Elder Abuse Prevention compared with groups receiving no vide impetus for identification and (Daly, 2010), helping older adults treatment (U.S. Department of Jus- development of specific interven- achieve the quality of life they de- tice, 2003). tions. Health care providers can ben- serve.

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