Elder Abuse

Introduction: What Is Known About Elder Abuse
Elder abuse occurs at an alarming rate: around one million incidences a year and perhaps more due to under-reporting and inconsistencies in defining what constitutes elder abuse (Falk, Baigis, Kopac, et al., 2012). Roberto (2016) estimates as many as one in every ten American elders experience some kind of abuse. Unfortunately, “there is no uniform term or agreed-upon definition used among state governments, researchers, health care and service providers, and advocates,” (Roberto, 2016, p. 302). Cultural and religious diversity further impedes the evolution of a comprehensive and universally applicable definition of elder abuse, in spite of the fact that some forms of abuse and certain instances can be considered unequivocal (Saghafi, Bahramnezhad, Poormollamirza, et al., 2019).
Some types of abuse may go undetected, such as financial abuse or identity theft, which could go unnoticed for years. Healthcare workers often feel powerless to intervene in instances of financial abuse perpetrated by family members because of the fact that the family members are also primary caregivers, and there may also be little if any legal resources to investigate the problem (Falk, Baigis & Kopac, 2012). Other than the fact that it is “highly prevalent,” perpetrated by healthcare workers, caregivers, and other elders in assisted living/nursing home communities, not much is known about elder abuse because there are no established means of reporting it or assessing for risk factors (Lachs, Teresi, Ramirez, et al., 2016, p. 229). Elder abuse consists of various forms and degrees of physical, sexual, psychological, and financial abuse. It is also important to include self-neglect and general neglect as forms of elder abuse. Furthermore, both men and women can be victims and perpetrators but research shows that men are by far more likely to be the perpetrators of the sexual abuse of elders (Malmedal, Iversen & Kilvik, 2015).
Ethical Dimensions
Why Is Elder Abuse An Ethical Issue?
On the surface, elder abuse appears to be a cut-and-dry ethical issue. However, the different phenomena comprising elder abuse are far more complex than it would seem. Not all cases of elder abuse involve physical or sexual assault, or overt instances of verbal abuse and aggression. Financial abuse and psychological abuse vary in their severity; moreover, cultural differences may impact perceptions of abuse. Competency creates ethical dilemmas, particularly when it comes to the decision-making capacity of elders due to cognitive decline and the legal role that family members play in healthcare decisions (Forum on Global Violence Prevention; Board on Global Health, 2014).
Healthcare workers and caregivers are also not always the perpetrators of elder abuse. The fact that other residents of senior care facilities can be perpetrators in verbal, emotional, physical, and sexual abuse makes it even more challenging to respond to and identify elder abuse (Lachs, Teresi, Ramirez, et al., 2016). Nurses have a responsibility to protect their patients from abuse, but may encounter conflicts when they suspect family members, other residents, or other healthcare workers are perpetrating some form of elder abuse. Misreading cues, misunderstanding cultural communication or elder care styles, and being overly intrusive into the affairs of residents could also become major challenges to preventing or mitigating elder abuse in healthcare institutions.
Sexual abuse is a surprisingly common form of elder abuse. In a review of literature by Malmedal, Iversen & Kilvik (2015), findings “show that sexual abuse occurs in nursing homes and that both older women and men are victims of sexual abuse. Perpetrators appear mainly to be staff and other residents and mainly to be men, but also women abuse both older men and older women,” (p. 7). However, even sexual abuse is not always easy to define, and matters related to mental competency will be mediating factors.
Relevance to Nursing and Health Professionals
Elder abuse is of extreme importance to all healthcare professionals, including those whose work does not otherwise focus on the geriatric population. An aging population and the growing numbers of seniors in healthcare institutions ensures that almost all health professionals will in some way encounter elder abuse issues in their careers. Elder abuse issues are of special concern to healthcare administrators and those working directly in elder care. For example, administrators and care providers in nursing homes, assisted living facilities, or in home health care can be considered primary stakeholders.
Nurses and other care providers need a supportive workplace environment and organizational culture within which to effectively report elder abuse. Healthcare providers and administrators need improved reporting systems, offering staff the means by which to offer anonymous tips or suggestions for internal investigations. The organizational culture and environmental factors can be designed in ways that can minimize some forms of elder abuse. For instance, mandating that patients have greater access to information and the outside world, creating better means by which to monitor patients and observe patient interactions with other residents or healthcare workers are some ways administrators can reduce the instances of elder abuse in their facilities.
Protocols may also allow healthcare workers to confront possible perpetrators—including perpetrators who are staff members, residents of the care facility, or caregivers like family members. Wangmo, Nordstrom & Kressig (2017) also recommend that healthcare institutions provide “proper education and training, better management nursing care provider's responsibilities and timely intervention to address abuse and neglect, as well as rotating care provider,” (Wangmo, Nordstrom & Kressig, 2017, p. 385). Information booklets and workshops may also help residents, caregivers, and family members understand better how their actions could adversely impact elders—as some forms of abuse might be more unconscious or due to ignorance than to actual malice. Due to situational variables and the cultural complexities of elder abuse definitions, it would be impossible to create a set of standardized protocols for identification and response to reported incidents. At the same time, all suspected incidents should be taken seriously, given the fact that elder abuse can lead to fatalities, litigation, and other dramatically deleterious outcomes.
When it comes to financial abuse, competency can be assessed using established and evidence-based means. One researcher developed a system for evaluating financial competency along four main domains: basic monetary skills, cash transaction competency, banking competency, and financial judgment (Forum on Global Violence Prevention; Board on Global Health, 2014). The capacity to live independently likewise presents care providers with the opportunity to develop checklists that allow for maximum independence and autonomy without enabling self-neglect. Elder abuse that takes place within care facilities can be easier to identify and address than elder abuse that takes place in the home. Nurses and healthcare professionals—particularly home health aides—should be trained on how to recognize the signs and symptoms of various types of abuse including psychological, physical, financial, and sexual abuse. Similarly, caregivers should be given information about how to identify signs and symptoms of abuse.
Ethical Analysis
The various ethical principles involved in elder abuse include autonomy (right to self-determination), fairness, social justice, nonmaleficence, and beneficence (Forum on Global Violence Prevention; Board on Global Health, 2014). Ethical theories that can be applied to an analysis of the phenomena of elder abuse include utilitarianism, universalism/deontology, and character/virtue ethics. There are some laws that do protect both healthcare workers and the elders in their care. Falk, Baigis & Kopac (2012) point out that awareness of elder abuse began in the 1960s with the Medicare, Medicaid, and the Older Americans Act legislation. Similarly, the Public Welfare Amendments to the Social Security Act “authorized funding to states for the establishment of protective services for those elderly with physical and/or mental challenges who were neglected, exploited, or unable to manage personal matters,” (Falk, Baigis & Kopac, 2012, p. 1).
The most directly relevant legislation pertaining to elder abuse arrived in 2010 with the Elder Justice Act, part of the Patient Protection and Affordability Act (Falk, Baigis & Kopac, 2012, p. 1). The Act calls for the creation of an Elder Justice Coordinating Council, which provides recommendations to the Secretary of the Department of Health and Human Services on issues of abuse, neglect, and exploitation of the elderly (Falk, Baigis & Kopac, 2012, p. 1). The Act also assures federal funding specifically for long-term care, to improve service quality and accessibility.
Issues related to patient autonomy can be particularly vexing for healthcare workers. It can be difficult to ascertain a patient’s level of cognitive control, and therefore hard to know how to determine legal or ethical competency. Nurses and caregivers need to work together, collaborating on strategies for allowing maximum autonomy without enabling neglect. Perhaps regular assessments by experts in cognitive decline can provide insight into the individual’s capacity for decision-making, thereby reducing conflicts between autonomy and the need to intervene so that the patient takes all required medications or engages in appropriate self-care. It is more challenging for healthcare workers to mediate between family members engaged in conflicts over the placement of elders in care facilities. Some family members are genuinely not equipped to be caregivers, while others are perceived as abandoning their elders to healthcare institutions—a conflict that cannot be easily resolved.
The ethical principle of fairness also factors into healthcare administration. Treating some patients better than others would adversely impact quality of care and could be considered a form of psychological abuse. The principle of beneficence obligates healthcare professionals to provide the best possible healthcare services and interventions according to the patient’s needs, in conjunction with family support. Nonmaleficence obligates healthcare providers to avoid doing harm of any type—which means avoiding verbal abuse even when a patient becomes upset. Conflicts can arise when patients become verbally or physically abusive, requiring conscientious and compassionate interventions on the part of the healthcare team or administration.
Professional and Personal Response to the Issue
After researching elder abuse, the situation is far more complex than anticipated. Nurses and administrators also need to be more aware of the problem of financial abuse. One related concern is that many elders who suffer from cognitive decline lose the ability to make sensible financial decisions. Their caregivers and family members may have a legitimate interest in releasing the elder’s control over his or her finances, which then raises questions about patient autonomy. Then there is the issue of cultural differences. Some elders—particularly women—have tolerated behaviors that could be considered abusive by some cultural frames of reference. Nurses have to make difficult decisions about when to intervene in situations where verbal or psychological abuse is considered normative in other cultures, perhaps by speaking directly with the patients themselves.
From a professional point of view, nurses need to continually review the professional literature and stay abreast of changes to eldercare legislation, policy, and protocol. Concerns should be raised immediately to administrators, who may need to be reminded of their responsibilities and obligations under federal or state laws. Nurses also need to become more sensitive to what constitutes elder abuse, as many of their actions could be misconstrued as abusive when really they are trying to help patients avoid self-injurious behavior or self-neglect. For example, elders who are prone to wandering aimlessly could get lost. Some patients are quick to lose their tempers at nurses, and it should also be noted that many healthcare providers experience abuse at the hands of their patients. There may also be cases in which patients will abuse the system or manipulate healthcare providers by feigning abuse. Nurses need to learn the means by which to physically guide irascible patients and address challenging scenarios and situations.
Conclusion and Reflection
All healthcare workers need to become more aware of and concerned about elder abuse. Elder abuse is commonplace, but it frequently goes ignored or undetected. Some nurses or healthcare providers might worry that their concern about elder abuse constitutes an infringement on the rights of the patient or caregivers, while others may fear losing their jobs by whistleblowing on a colleague. To reduce the severity and prevalence of elder abuse, all nurses can arm themselves with information about the laws that protect them and their patients. Likewise, nurses can empower patients with information about how to recognize abuse, helping patients understand and exercise their legal rights if necessary. Creating a supportive and safe environment in eldercare facilities, training personnel and caregivers, and being more mindful of the various types of abuse including financial abuse, will all be key components in reducing instances of elder abuse.
References
Falk, N. L., Baigis, J., Kopac, C., (August 14, 2012) "Elder Mistreatment and the Elder Justice Act" OJIN: The Online Journal of Issues in Nursing 17(3).
Forum on Global Violence Prevention; Board on Global Health; Institute of Medicine; National Research Council (2014). Ethical considerations. Washington (DC): National Academies Press (US); 2014 Mar 18.
Lacher, S., Wettstein, A., Senn, O., et al. (2016). Types of abuse and risk factors associated with elder abuse. Swiss Medical Weekly 2016(146): 1-10.
Lachs, M.S., Teresi, J.A., Ramirez, M., et al. (2016). The prevalence of ersident-to-resident elder mistreatment in nursing homes. Annals of Internal Medicine 165(4):229-236.
Malmedal, W., Iversen, M.H. & Kilvik, A. (2014). Sexual abuse of older nursing home residents: A literature review. Nursing Research and Practice 2015(Article 902515): http://dx.doi.org/10.1155/2015/902515
Roberto, K.A. (2016). The complexities of elder abuse. American Psychologist 71(4): 302-311.
Saghafi, A., Bahramnezhad, F., Poormollamirza, A., et al. (2019). Examining the ethical challenges in managing elder abuse: a systematic review. Journal of Medical Ethics and History of Medicine 2019(12): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6642445/
Wangmo, T., Nordstrom, K. & Kressig, R.W. (2017). Preventing elder abuse and neglect in geriatric institutions: Solutions from nursing care providers. Geriatric Nursing 38(5): 385-392.