Sexual Abuse of Elders

•Kathleen Brown •Associate Professor •University of Pennsylvania •School of Nursing

Kearsley Home

 Retirement home for elderly women  Located in West Philadelphia  Gothic stone home over 200 years old  60 residents, ages 60-94  Security force on grounds  Small in-patient unit;  Highly trained staff

1. Margaret Eckard

 Popular, bubbly 92 year old resident  One of longest residents at Kearsley  January 23, 1983: missed at breakfast  Nurse went to investigate; door ajar  Body lying on floor next to rumpled bed  Clad in nightgown; curled in fetal position  Signs of rigor mortis starting to appear

1 Examination

 MD concerned over bruises on face; smears of blood around nose and mouth

 Streaks of blood in vagina and anus  Decided not sufficiently disturbing to make an issue; decided natural death due to her age

 Funeral held

2. Katherine A. Maxwell

 85 year old resident  February 12, 1983: 21 inch snow storm  Katherine failed to show for breakfast  Door ajar; body lying on bed  Pajamas spotted with blood  Storm kept Dr. Webster from the Home

Katherine Maxwell

 Body taken to hospital; no autopsy  Blood believed to have occurred by natural causes at her death

2 3. Elizabeth Monroe  Celebrated her 86th birthday with a party  Next morning, failed to appear at breakfast  Nurse found door ajar and her body in bed  Face discolored; vaginal bleeding  Dr. Webster away; substitute MD  Sent body to undertaker

Dr. Webster’s Concern  Webster called the undertaker; suspicious over the 3 deaths

 ME’s office were not concerned over the 3 elderly victims’ deaths

 Webster insistent and ME accepted it for investigation but embalming made it difficult

 Ruled natural cause death

4. Lillie T. Amlie

 89 year old resident described as flamboyant, colorful, offbeat

 Continued to attract men despite age; had boyfriend whom she saw regularly

 Never locked apartment door  Failed to appear for dinner  Last seen in afternoon going for nap

3 Lillie Amlie

 Body discovered immersed facedown in a few inches of lukewarm water

 Traces of blood around nose, mouth, vagina and rectum

 Wearing hose and jewelry

5. Eugenia Borda

 In June 1983 Miss Borda moved to Kearsley House  Never married; found dead in bed  Blood around mouth, nose, vagina, rectum  Dr. Webster refused to sign death certificate to force ME to investigate as suspicious death

6. Mildred Alston

 72 year old resident found dead same day as Miss Borda

 Lived across the hall

4 Autopsy

 Borda died of strangulation  Alston was suffocated  Alston was robbed: wedding rings; purse missing

Investigation

 Detectives believed suspect was worker at home or known to the residents

 Killer possibly a night worker  Kearsley employed over 40 staff  Anthony Joyner became a focus

Anthony Joyner

 Polite, young black man; age 22  Hired to kitchen staff as assistant diet tech  Administrator impressed with his manners and apparent affection for older women

 Described by friends as “cool dude”  Slight build; neighborhood made jokes: weird

5 Acquaintance of Joyner’s  Said Joyner bragged about raping an elderly woman and stealing her jewelry

 Police found unsolved case of 68 year old woman in West Phila and arrested Joyner

 Confessed, “Okay, okay. I killed them all.”

Confessed Motive

 Wanted to prove he was a man  Murder after fighting with girlfriend  Said sex was not a motive

 MO: slip into the victim’s room, press pillow over face to keep her from screaming and from recognizing him

 Then rape

Planning

 Teased by friend at bar; drinking beer; go to Kearsley; enter building through cellar

 Selected victims at random  Targeted Ms. Amlie because she accused him of stealing (which he had)

 Tried to smother her; she got up; he drowned her

6 Post Mortem Behavior

 When victim stopped struggling, “thought she went back to sleep.”

 Joyner attended Alston’s wake and funeral  With legal representation, recanted his confession; said he was tricked

 Claimed he didn’t hear the judge charge him with murder

Investigation of Kearsley

 Were there more victims?

 17 women died at Kearsley during Joyner’s employment

 More than 25% of resident population

Prosecution Witnesses

 23 year old girl friend

 Bragged 2 days before arrest: “I’m going to be famous. Watch the news.”

 Told police he was angry that friends teased him; called him a faggot

 Convicted and sentenced to life: happy he had “beaten the death penalty”

7 8 Concept of Vulnerability

 Elderly patients in a health care system

Sexual Abuse (available: http://www.elderabusecenter.org)  Non-consensual sexual contact of any kind  Sexual contact with any person incapable of giving consent

 Includes: unwanted touching, all types of sexual assault or battery (e.g. rape, sodomy, coerced nudity, sexually explicit photographing)

Barriers To Preventing & Identifying Sexual Abuse  Social and health care system  Myths about aging  Myths about factors contributing to abuse  Staffing  Physiologic barriers due to aging  Multiple medical problems complicate assessment  Markers of abuse mimic changes of aging  Increased prevalence of depression, isolation  Cognitive and sensory impairment  Research barriers  Epidemiology, instruments

9 Some age-related changes:

 Atrophy of skin tissues  Increased vascular fragility  Loss of muscle mass  Decreased estrogen  Pubic area loses fatty deposits (labia majora and minora thinner; clitoris not as protected)

The brain is our interpreter of conscious experience - Hippocrates

Model of Multifaceted Assessment

Person with Dementia Cognitive losses Remaining abilities

Inability to Respond Reduction in to Verbal Need: Self-Report Assessment Tool

Multifaceted -Under-Recognition Assessment -Under-Treatment

Adverse Consequences

Adapted from: Feldt, Warne, & Ryden, 1998, J. Geron. Nsg, 24 (11), p.17

10 An alternative view of behavior

BACKGROUND PROXIMAL Behavior FACTORS FACTORS • Resistiveness •Neurological •Personal to Care •Cognitive •Physical • Agitation •Health Environment -Verbal •Psychosocial •Social -Physical Environment • Aggression • Others

Based on: Algase, D.L., et al., (1996) Amer. J. of Alzheimer’s Disease

MILD MODERATE SEVERE TERMINAL

I MEMORY RESISTIVENESS N PERSONALITY INCONTINENCE SPATIAL EATING D DISORIENTATION DIFFICULTIES MOTOR E APHASIA IMPAIRMENT P APRAXIA BEDFAST E CONFUSION AGITATION MUTE N INSOMNIA DYSPHAGIA D INTERCURRENT INFECTIONS E N C E

TIME

“People do not consist of memory alone. They have feeling, will, sensibilities, moral being . . . It is here that you may find ways to touch them” Luria

11 Elder Sexual Abuse

Elder Sexual Abuse

 1976 NIMH report: no information on topic  Nat’l Coalition for Nursing Home Reform: 600+ cases and increasing. NIMH realized, in the 90’s, that this was the only place reporting sexual abuse of elders

Concerns  Elderly, especially Alzheimer patients can’t remember. Do they experience trauma from sexual abuse?

 Who would want to rape an elderly person?  Elderly with decreased cognition? Is rape a fantasy?  Elders: consensual sex versus non-consensual sex

12 Ground Breaking Work: Nursing Home Study

 Burgess, Dowdell & Prentky in Journal Psychosocial Nursing, 38 (6):June 2000  20 cases derived from civil litigation. All founded cases  Sample: One 16 and one 33 year old year old gun shot head trauma; 53 year old ALS  Remainder 70-94 year old  Multiple medical problems and many with cognitive deficits

Victims Reporting the Assault  Inform a family member (7) or staff (3)  Abuse witnessed or suspected (7)  Clues (4), e.g., bruising, pain

Perpetrator Identification

 Some gave full descriptions  Many confused some details  Some staff disbelieve and think it a “delusion”  Out of 20, 18 perpetrators were identified by the victim

 Not identified by the victim: 2 cases of HPV

13 Style of Attack  Confidence style: “let’s go for a walk”  Blitz style: one case of extensive injury  Deception style: most cases where no physical force used

 Threats in 2 cases

Physical and Forensic Evidence  Difficulty in collecting evidence  Resistance to pelvic exam  Difficulty visualizing area (eg. leg contractures)  Communication problems  Difficulty obtaining accurate report from victim and staff

Signs and Symptoms  Sign: visible or witnessed  Trauma to genitals, rectum, breasts including bleeding, bruises, skin tears; bite marks; burns; scarring, redness; finger imprints; forcible restraint  Infection; sexually transmitted diseases  Eyewitness observes sexually abusive behavior

14 Symptoms of Sexual Abuse  Symptoms: suggestive of sexual abuse  Sexually-oriented statements  Expression of fear of male staff  Avoidant behaviors with male staff  Withdrawn behavior; fetal position  Staying near nurses station  Reenactment behaviors

Behavioral Symptoms

 Protest behaviors  Appears to be in shock  Crying spells  Sleep and appetite changes  Immune system compromised  Deterioration of health

Gerophiles  Study of 18 sexual predators  Burgess, Prentky & Dowdell in Journal Psychosocial Nursing 38(8) 2000

 15 were employees of nursing home  3 were male residents

15 Dynamics of Offense  Victims were all highly vulnerable due to decreased cognition, physical fragility, helplessness

 16 assaults in victim’s bed; 3 victims were taken off unit; one was assaulted in wheelchair (multiple assaults)

 Usually evening or night shift

Style of Attack  Confidence style: “let’s go for a walk”  Blitz style: one case of extensive injury  Deception style: most cases where no physical force used

 Threats in 2 cases

Control of Victim  Mere presence  One threatened with knife  One had wrists secured  Victim resistance in 2 cases  Victim screamed in 3 cases but not one came

16 Type of Sexual Acts (perpetrators)  5 cases had evidence of preexisting sexual fantasy  One said victim moaned and turned him on  Several had sadistic motive and caused pain

Classifying the Offenders  Multiple motives  Classified with low social competence  Exploited victims who were frail and defenseless

Legal Outcomes of 18 cases  Criminal cases: 2 plea bargains and 4 convictions  One acquittal who later arrested for child sexual abuse  Few with prior sexual charges; more with non-sexual arrests

17 Recommendation: Multi-Team Approach  Immediate report to supervisor of suspicious bruising, remarks, behavior  Review all charts at least bimonthly for all types of elder abuse and neglect  Have protocol and policy for the review  Invite law enforcement, geriatrician, ombudsman, social work, psychology, nursing to review

Documenting Abuse and Treatment  Resident’s record: include resident’s own words  Document signs and symptoms of trauma  Document treatment intervention and resident response  Change treatment procedure if indicated

Case of Mary  86 year old nursing home resident  Outgoing, chatty  18-year-old CNA caught in sexual act  Told co-worker not to report  Told police was thinking of sex  Mary said he was doing the test again

18 Investigation of Mary’s nursing home  Victim- sleep problems for months  Repetitive nightmare  CNA told daughter she had bad dream  “Couldn’t put pieces together”  “ the tests”

Additional Victims  Roommate of primary victim  Residents with history of falling when CNA on duty  Multiple bruises  Protested males bathing them

Family Member Response  Couldn’t keep mother in the NH  Should I move my mother?  Roommate of primary victim?  Is the nursing home liable?

19 Outcome

 Pled guilty; sentenced to 10 years  Sexually oriented offender  Mary: trauma therapy; lifelong nursing care  Civil suit against nursing home

Ground Breaking Work: In the Community

 Ramsey- Klawsnik (1990’s)

Types of Sexual Assault

1. Stranger or acquaintance sexual assault  Perpetrated by someone unknown or casually known to the victim.

2. Caregiver sexual assault  Perpetrated by a professional, paraprofessional or volunteer providing services to the victim under a contractual or formal agreement.

20 Types of Sexual Assault

3. Incestuous abuse  Perpetrated by a family member (non-spouse) such as a child, niece, nephew.

4. Partner sexual assault  Perpetrated by a spouse, intimate partner, or person involved in a dating relationship with the victim.

Types of Sexual Assault

5. Peer sexual assault  Involves an individual forcibly, or in the absence of informed consent, engaging in sexual contact with a peer, such as a room-mate. This may occur in nursing homes and other elder care settings.

Conditions Under Which Sexual Contact is Abusive

 Sexual contact is physically forced on an individual  An individual is pressured or manipulated into sexual contact

 An individual is unable to grant informed consent to sexual activity

 A service provider engages in sexual contact with a service recipient

21 Range of Behaviors Involved in Sexual Assault

1. “Hands-off” offenses  Exhibitionism  Voyeuristic activity  Forcing to view pornographic material  Sexual harassment and threats

Range of Behaviors Involved in Sexual Assault

2. “Hands-on” offenses  Kissing  Touching/molesting breasts genitals, buttocks  Oral/genital contact  Penetration of vagina or rectum with penis, fingers, or objects

Range of Behaviors Involved in Sexual Assault

3. “Harmful genital practices” Unwarranted, intrusive and/or painful procedures in caring for genitals or rectal area  Application or insertion of creams, ointments, thermometers, enemas, catheters, fingers, soap, washcloths, or other objects not medically prescribed / unnecessary for health or well-being  Meets needs of offender, not health or hygiene needs of victim

22 Range of Behaviors Involved in Sexual Assault

3. “Harmful genital practices” Unwarranted, intrusive and/or painful procedures in caring for genitals or rectal area

Perpetrators may: Appear obsessed with the behavior Claim the harmful practices are required for health or hygiene Be reluctant to stop when so instructed

Range of Behaviors Involved in Sexual Assault

3. “Harmful genital practices” Unwarranted, intrusive and/or painful procedures in caring for genitals or rectal area

Practices may co-occur with offenses listed in 1 or 2 above Particularly vulnerable: Individuals unable to independently bathe, use the toilet, and attend to personal needs

Signs and Symptoms of Sexual Assault

1. Statements made suggesting sexual assault  May be clear and direct -or- less clear but hint at possible sexual abuse.

2. Eyewitness observes sexually abusive behavior toward individual.

3. Trauma to genitals, rectum, mouth, breasts (bleeding, bruising, injury, infection, scarring, redness, pain, irritation).

23 Signs and Symptoms of Sexual Assault

4. Sexually transmitted disease (person uninvolved in consenting sexual relations).

5. Evidence of forcible restraint (rope marks, finger imprints, etc.).

6. Evidence of severe physical abuse (human bite marks, burns, etc.).

Signs and Symptoms of Sexual Assault

7. Shame or guarded response displayed when asked about physical signs.

8. Display of fear or strong ambivalent feelings toward caregiver, family member, or other person.

9. Extreme upset displayed during provision of personal care.

Signs and Symptoms of Sexual Assault

10. Inappropriate boundaries between individual and staff member.

11. Care provider overly intrusive re: provision of personal care.

24 Types of Offenders

1. Well-Intended, Normally Competent Individuals  Overwhelmed, lashing out  High stress, low resources  Maltreatment

2. Well-Intended, Impaired Individuals  May have chronic or cyclical impairments  Impairment  Maltreatment

Types of Offenders

3. Narcissistic Individuals  Self-centered, exclusive interest in own needs  Meet own needs by using others  User mentality  Maltreatment

4. Abusive Individuals  Chronically angry, unhappy, critical  Feel justified in attacking vulnerable others  Abusive personality  Maltreatment

Types of Offenders

5. Sadistic Individuals  Derive a sense of power from controlling others  Enjoy inflicting pain and suffering on others  Sadistic personality  Maltreatment

25 Key concept: Patterns

NIJ Funded Research: Dr. Burgess  Statistician: Tim Baker

INVESTIGATIVE DATA

 Convenience Sample  Providers  Attorneys  Investigators  Sample Size: 125

 Founded and Unfounded cases

26 SAMPLE  Cases from 22 Different States

 Sex: All female

 AGE  Mean 78  Median 78  Oldest 98

 RACE  Caucasian 83%  Black 12%  Asian 2%  Hispanic 3%

 Marital Status: 66% widowed

DISABILITIES N%  PHYSICAL 56 49%  Bed Bound 10 10%  W/C Bound 114 13%  Speech Impaired 8 8%  Assist Eat/Dress 21 20%  Other 19 18%  MENTAL 52 45%  Dementia 36 34%

LIVING SITUATION

N%

 Alone 51 43%  W/spouse/family 11 10%  Nursing Home 46 38%  Assisted Living 7 6%  Other 4 3%

27 OFFENSE N%

 Multiple Victims (94) 42 45%  Time:  One third of incidents occurred between 1 and 7 a.m.  31% incidents occurred between 7 p.m. and 1 a.m.  Day of the week  Sunday had the greatest number of incidents

LOCATION

N%  Residence (106) 90 85%  Bed 62 62%  Shower 6 6%  Living Area 23 24%  Outside (98) 2 2%  Unknown (91) 5 6%

 Sexual Acts: Vaginal sex occurred 66% of the time  Victim Characteristics:  Average height: 5’2”  Average weight: 130 lbs  60% were hypertensive  25% had low pulse rates  Evidence Destruction: 33% of the cases, the victim either urinated, changed clothes or showered before the exam

28 Physical Exam of the Victim  Method of exam:  86% exams were direct visualization  50% exams used a speculum  33% colposcopic exam  25% bimanual exam  60% photos take  75% evidence kit was collected

 Exam results:  In most cases, no pharyngeal or anal tests were done  Vaginal tests done in only a quarter of cases  VD and HIV tests done in only a quarter of cases  Sperm found in 35% of the cases  DNA done in about 50% of cases

Physical Trauma of the Victim  60% genital trauma  46% vaginal trauma  33% labia minora, posterior fourchette and labia majora

 50% of cases had physical trauma to other body parts  38% head  31% arms  24% legs  22% chest

OFFENDER CHARACTERISTICS

N%  Sex (105)  Male 97 92%  Female 8 8%  Race (93)  Black 38 41%  Caucasian 47 51%  Hispanic 6 7%  Other 2 2%

29 THE CRIME

 Weapon present 16%  Items of value were taken 37%  Personal items taken 27%  Phone Disabled 17%  Evidence removed from the scene 18%

 Blitz Attack 75%

 Control by presence 71%

 Battery/beatings 46%

 Threats 41%

 Weapon 18%

 Gags 14%

 Bindings 10%

 Clothing removed 77%

 Use of alcohol or drugs 46%

 Physical Force used 75%  minimal: 42%  brutal: 14%

 Victim resisted force in 2/3 of cases  Offenders reaction to victim resistance with increased force in 2/3 of cases

 Offended noted with sexual dysfunction 30% of the time.

30 LEGAL SERVICES N%  Police Notified (120) 116 97%  Offender Identified (117) 88 75%  Offender Arrested (116) 65 56%  Offender Charged (116) 64 55%  Offender Tried (113) 57 55%  Plea Bargain (96) 33 34%

CHARGES N = 113

N%

 NOT GUILTY 55 49%  GUILTY 26 23%  PLEA BARGAIN 32 28%

CHARGES N = 71

N%

 No Sex Offense charged 19 27%  Lesser Sex charge 19 27%  Rape charge 33 47%  Murder Charge 15 22%

 PTSD Assessment done in 24% of the cases

31 Genital Photos

Pictures of body injury

Sample cases from Burgess’s Study

32 Velma

 Admitted to NH in Feb. with husband  Husband died 11 months later in Jan.  Velma sexually assaulted April 22

The Sexual Assault  Matt, nursing aide (NA), enters Mrs. B’s room  Observes Mrs. B. lying across bed , no clothing on bottom half, legs over side, moaning, Travis, NA, making humping motions

 Yells: What are you doing? You’re sick.  Tells RN: Travis having sex with Mrs. B.  RN examines Mrs. B: no observable mental or physical distress; no bruises or bleeding

Nursing Home Exam

 Resident is calm  Note: several tiny red areas of petechiae at lower vag opening

 Note erythemic rash areas in right groin  Note excessive powder  Sent to University Hospital for exam

33 SANE Exam  Emotional status: confused; Alzheimer’s  Posterior fourchette red abrasion at 0600; vulva redness bilaterally to inner labia; inside vaginal walls very red; consistent with friction

 History consistent with forceful manipulation of genital area

 Fought exam; legs bent, contractures

Serology/DNA Report

 Swabs failed to give chemical indications for presence of sperm

 Vaginal swabs indicated possible presence of blood

Post-Assault Symptoms  Daughter could not keep mother awake  Very deep sleep; mumbling; refusing food

 Like looking at a zombie; “traumatized”  No smiling; difficult to get to respond  Lean over in chair; hand touching floor  4 days later develops serious UTI

 Staff agreed “she is not the same”

34 Moved to Daughter’s Home  8 days later moved to live with daughter  Began eating; responding to visitors;  Reaching for things; tissues; bright again  Examined by psychologist

 By August talking more; ‘I don’t want him rubbing me. Don’t let him hurt me. I don’t want to face him.

 UTI returned; deteriorates; died in Nov.

Juvenile Offender Age 15; mother worked at nursing home

 Childhood problems; special ed student; ADHD;  Many complaints re: work; always talking about sex; bragged about having sex in laundry;

 Absent from work; came to work drunk; three warnings in folder; terminated after assault

Criminal Case

 Taken to Justice of Peace; father told him to tell truth  Gave confession  Convicted as juvenile; case appealed

35 Civil Suit: Defense

 Nursing home said it wasn’t a sexual assault  RN testified and demonstrated how peri-care was done using a humping motion

 Psychiatrist testified Mrs. B. had no memory of the incident; no need for any $

Plaintiff

 Many warnings to juvenile; mother worked at nursing home

 Damage to victim?  Impact to immune system?

Jury Outcome

 Jury verdict: 1.75 M in actual damages  4 M in punitive damages

36 EVA: NURSING HOME RESIDENT

 89-year old widow  Dementia, Alzheimer’s Type  Cerebral Atrophy  Prior fracture of left hip  Opens eyes; Does not speak  Last room on corridor and furthest from nurses’ station

Nursing Home Observation

 Patient has separation of symphysis pubis  Lying in fetal position  In pain  Physician looking for metastatic disease or fracture or abuse

37 BRUISING  Swelling and dark bruising to abdomen  Patient in pain  Bruising between thighs extending back to rectum  Treated for bladder infection  No kit done  Hematoma in inguinal area  Triangular shaped 20 cm X 10 cm X 10 cm width base toward umbilicus

Emergency Department Record

38 ER: 11/29/97

 X-Ray compared to 2/4/97  4.4 cm diastasis of symphysis pubis  Hematoma in inguinal area  Ecchymosis few days old  Resists movement of legs  Purulent discharge

BRUISING

 Records indicate at 5 A.M. on 11/27/97 pain prior to bruising when right thigh touched  Was it due to stretching leg muscles?  Nurse did not do range of motion exercises

BRUISING HISTORY  Abdominal bruising not noted until 8:20 P.M. on 11/27/97  X-Rays negative for fractures  Widening of symphysis pubis noted  Had been wearing “posey belt”  Dark bruising noted on both sides of vagina and labia

39 LAB FINDINGS

 Urine sample of positive skin flora  Lack of trichomonas, yeast, or clue cells  Kit done after 72 hours  Inconclusive for chlamydia

DEFENSE STRATEGY

 Pelvic and labial bruising due to seatbelt-type restraint  Bruising due to “posey hugger”  Crotch injuries due to perineal care or due to stretching leg contractures injuring muscle

PLAINTIFF STRATEGY  Pattern of bruising  Migrating blood into tissue from trauma  Males had access to Eva  Maintenance supervisor had keys to facility  Supervisor known to make sexual advances to residents

40 SUSPECT Maintenance Supervisor  Hired after being fired for having sex with a mentally ill patient

 Son had been fired from an agency for sex with a resident at another nursing facility

Civil Case Results

 Facility deficient in reporting incident to officials  Deficient in performing hourly checks of Eva’s position  Deficient in doing background checks on employees  Rape complaint not verified

Nursing Home Case: Eleanor

 Born in 1910  4th child of 6  Educated as RN  Worked in ER during marriage  One daughter  Moved to Florida; worked as office nurse  Husband died; moved near daughter

41 Living Arrangements

 6 months in assisted living  Then home with daughter  Increasing dementia  Admitted to nursing home for total care  Nursing notes indicate occasional combative behavior around meds/meals

Cognitive and Health Status

 Oriented to name  Hearing and vision poor  Difficult to communicate; use yes/no questions  December through January increased combative behavior

 Feb. 2000 skin tear on right forearm

February 2000 Timeline

 Feb: listless, cold, clammy

 Glassy eyed; wouldn’t eat; liquid ooze out of side of mouth

 Clearly tells daughter: “I need to see the doctor”  Daughter tells nursing staff

42 Friday, February 10th

 Daughter feeds mother at noon  Less symptoms  MD orders lab tests and urinalysis  Daughter notified at 9:44 p.m. mother is being transported to emergency room

 ER resuscitates patient; IV inserted; foley catheter ordered

February 11, 2000

 Catheter inserted easily  Blood clots and tears noted  Y shaped tear on labia majora; tear on posterior fourchette

 Bruising and contusions; bleeding continues  Contusion noted on left forearm

Family Decisions

 Patient without neurological survival  Taken off life support  Autopsy report  Pulmonary emboli with arteriosclerosis of 25% occlusion of coronary arteries

 Genital trauma from attempted catheterization

43 Autopsy Sketch

 Note bruising to forearms  Right arm with contusion  Left arm with ecchyosis  Note photos taken in ICU and position of bruises  Note genital trauma

Criminal Investigation

 Nursing director reported no catheter done  LPN unable to complete on 2/10

 Recommended “hat” to catch urine  No catheter kits missing from supply closet  No male caretakers reported that day  Autopsy report considered  Case closed

44 Civil Suit

 Daughter uneasy with finding: “Mother would want to prevent others from this.”

 Had viewed her mother’s injuries  Issues: sudden death  Pulmonary emboli; genital trauma  Staff fail to report injuries; detected at ER

Defense Witnesses

 Aide testified she did catheterization and failed to document the procedure

 Expert testified to a “botched catheterization”  Medical examiner testified he sees many such findings

Theresa

 Age 82; in nursing home for 2 years

 Dx: Parkinson’s Disease; colon resection  Oriented to name not place or time  Poor short and long term memory  Three children; visited fairly regularly

45 Disclosure of Rape

 10:45pm RN giving medications  On bed stand notes condom wrapper  Summons charge RN  Visually examines Theresa - no injury  Observes used condom in toilet  Back in patient room; male attendant flushes toilet

Forensic Exam

 Taken to hospital ER  Exam shows fingerprint bruises on thighs  Abrasions to perineal area  Test results negative for semen

Victim Responses: PTSD

 Intrusive thoughts: “He came here a week ago; then came back; was mentioning sex”

 “I’m a God-fearing woman. I had no choice. I feel bad”

 Told daughter: “I’m a prostitute. Man said it was OK to do because he knew her”

 Talked to deceased husband: He was mad.

46 PTSD (cont.)

 Reexperiencing symptoms: crying spells; refuses to take shower or go to bed;

 Avoidant behaviors: swears at staff when removing clothes; covers groin with hand

 Feelings of humiliation: “Whole hospital looking at me.”  Wouldn’t talk with male crisis therapist

Post Trauma Feelings

 Guilt: I should have screamed. Maybe he would have stopped

 Suicidal: Want to kill myself

 Anger: Told staff they didn’t know how she felt; didn’t happen to them

Gerophile: Aaron

 18 year old; confessed  Showered her; putting on clothes. Just put on a condom; stopped after 10 seconds

 Knew he was wrong  Denied being sexually aroused; had erection from the cold (shower) or being nervous

47 Precipitant Stress

 Kicked out of family  Parents controlled his money; had turned off electricity in trailer (they owned it)

 Dropped out of high school in 10th grade  Finished his GED; Had no money

 Hated his job; only “guy” there  No time card; angry; took it out on old lady

Self-Description

 Goatee; sideburns; long hair  Earrings; many necklaces;  Tongue ring  Tattoos  Mother was schizophrenic; moved to foster home age 2 months. Adopted age 5

 ADHD; emotional neglect

Pennsylvania  96 year old woman lived alone in the Victorian house she resided in since her marriage  Offender asked her if he could help around her house  She said no, but invited him in for a snack  He returned later and entered her home (using a key?)

48  The elderly woman wore glasses and a hearing aide  She did not hear him enter  He robbed the house  He raped the elderly lady

 Arrested weeks later – robbery in progress  DNA tied this 15 year old boy to the rape of a 40 year old woman and the 96 year old woman

 Search warrant connected him to many robberies and burglaries

 Confession tied him to more crimes – assaults  Crimes occurred over a period of more than two years

 15 year old worked alone  All crimes committed in his neighborhood  Victims - vulnerable  Mentally competent to stand trial  Tried as an adult  Life in prison

49 Current Research

Sexual Abuse of Older Adults: APS Cases and Outcomes

 Teaster, Roberto, The Gerontologist, 2004  Examined records for five years of Adult Protective Services in Virginia

 N = 82  Sexual Abuse 1% of cases reported and substantiated

Analysis

 95% women  Ages 60-79  17% living with family  50% could not ambulate without assistance  86 % needed help with orientation to time and  81% to place  15% not ambulatory

50  Most common type of sexual abuse involved sexualized kissing and fondling: 73%

 Isolated incidence 79%  Ongoing 16%  Perpetrators 60 or older (88%)

 Two thirds lived in nursing homes  70% of perpetrators were residents residing in a facility

Message from this data

 Protect vulnerable victims who might have orientation problems

 Low prosecution rate (resolution by other avenues)

51 Substantiations, and Risk Factors

 Phillips and Guo, The Gerontologist 2011  Sample 454 facilities  Substantiated sexual abuse was less frequent in small ALFs

 For profit homes more cases  Implications: evaluate unlicensed assistive personnel, increased oversight of care by professional nurses

Perception of Elder Abuse in the Courtroom

 Hodell & Golding , Violence Against Women, 2009  Elder sexual misconduct. 118 participants read a fictional criminal trial summary of a 76 year old woman abused by either a son or a neighbor

 Conviction rate was very low (25% and 33%)  More women than men voted guilty

Appropriate Responses for Health and Human Services

 Teitelman, Journal of Health and Human Services, 2006

 Further evaluation of the Virginia data  Consequences of sexual abuse observed in an older client are attributed to client’s age, disability, self injurious behavior

 Substantiated incidences of sexual abuse

52  60% were “confused”  31% very confused  28% somewhat confused

 Poorly screened and poorly supervised staff  Inadequately defined roles and boundaries of professional behavior

 Family members unaware of problems with staffing

 Dependency – real or perceived of the victim on the perpetrator

 Physical, cognitive or functional capacity victims is important

 Vast majority females with male perpetrators

53 Advancing the Field of Elder Abuse

 Duong, Journal American Geriatric Soc., 2012  March 2011 Senate Subcommittee on Aging held at hearing on “Justice for All: Ending Elder Abuse”

 Based on a Government Accountability Office report, victims and experts talked about lack of research, education, training and prevention of elder abuse

 NIH 1.1 million  CDC 50,000  5.9 million by the administration on community living  1.2 million NIJ  OVC 520,000

Suggestion

 Need to develop a comprehensive coordinated cost effective system of home, and community based services that help elder individuals maintain their health and independence in their homes and communities

54 Conclusion

 Great lack of knowledge about evidence based prevention and intervention strategies to assist victims of elder abuse

Forensic Aspect of Elder Abuse

 Ghodous, Maghsoodloo, Hosein Journal of Research in Medical Sciences, 2011

 68 aged people who were intentionally abused were studied

 Abused people were illiterate or had low education  Abusers mostly male  Residents were in cities

Conclusions from Research

55 Elders and Sexuality

 Elders may not provide good histories  In the elderly, expression of sexuality, even in the presence of dementia may be viewed as problematic

 Finding a balance between protecting rights and preventing sexual abuse is complicated

 Hypersexuality can be a feature of disinhibition associated with dementia

Reasons for Prosecutor Inaction

 Lack of detecting, documenting & reporting of appropriate cases

 Lack of expert testimony to support such prosecutions  Lack of training of law enforcement staff in order to successfully prosecute

Summary

 Poorly trained carers  Vulnerable Victims  Elder patients with behavioral disorders; unexplained injuries

 Histories taken at face value  Routine Screening for sexual abuse  Multidiscipline teams in ALF, Nursing Homes and Communities

 Standardized, regulated protocols and procedures

56