Elder abuse: prevalence, types, and intervention strategies

Elder Abuse

It is a sad fact of reality that the elderly in the United States and indeed across the world are or have been abused by those they depend upon for their care. According to the National Center on Elder Abuse (2005), 1 to 2 million Americans who have reached the age of 65 and beyond have been abused in some way.

The problem has increased with the improvement of medical science, which ensures a longer lifespan for Americans and other Western countries. The increase in number of individuals who can be classified as "elderly" in the country has brought about more than simply a longer life. It has also resulted in a number of difficulties for those who are living these lives. In addition to challenges such as the rising costs of living, which can simply not be covered by increasingly meagre pension amounts, the elderly are also suffering social isolation and stigmatization. Furthermore, those who care for the elderly are under increasing pressure not only to provide excellent care, but also to provide such care to an increasing number of individuals. The level of stress often suffered by care givers is then often cited as one of the major factors contributing to the phenomenon of elder abuse.

Elder abuse is nonetheless a complex issue that cannot be reduced to a singular cause. It is a complex problem that needs to be investigated thoroughly in order to find appropriate solutions that will ensure the best outcome for all involved parties.

In order to find solutions for the increasing occurrence of elder abuse, society as a whole needs to involve itself in both the awareness of the problem and its likely solutions. Family members, caregivers, and psychology professionals need to form a network of information in order to not only curb the problem, but also to prevent it in the first place. However, as professionals correctly estimate, it is in no way a simple problem with simple solutions.

THE ROOT of the PROBLEM

The specific reasons for elder abuse, like the issue itself, are many and complex. These relate not only to the rigors of caregiving itself, but also to other factors, including the relationship of the caregiver to the elderly person being cared for, the nature of the care provided, and the personality of the persons involved in the caregiving and care receiving relationship.

Woolf (1998) substantiates the fact that elder abuse is a problem of growing concern in the United States. One main factor in this phenomenon is the lack of public awareness. One of the reasons for this is the sensitive nature of the topic. No person, elderly or otherwise, readily admits to being abused. This is also a common phenomenon in spousal abuse, where the problem often remains hidden for years, and sometimes, tragically, only comes to light once it is too late to provide help. Even worse, those who abuse often feel isolated and unable to obtain help as a result of social as well as professional perception. Hence the problem escalates beyond control, often with tragic or even fatal results. Sadly, this is particularly the case with the elderly.

There are many possible causes for elder abuse, of which one of the most prominent is caregiver stress. Caregiver stress may be the result of a lack of information or necessary skills to care for an adult who is not well or suffering from mental or physical impairment. Nerenberg (2002, p.5) gives an extensive overview of the various factors involved in caregiver stress.

Because finances are usually a constraint upon the nature of the care being provided. Indeed, the author cites studies to suggest that primary care is generally provided by one of the family members, where others serve the role of so-called "secondary caregivers." Nerenberg furthermore states that primary care is generally provided by the spouse, in the absence of which the first choice for care falls to the eldest daughter, or in the absence of a daughter, to the son.

In order to become more aware of the factors involved in elder abuse, it is also necessary to understand the cultural factors involved in caregiving activities. Blacks and Hispanics for example are most likely to engage adult children in caregiving, as the women from these groups are generally more likely to be single than those from Caucasian groups. Hence, adult daughters from minority families are more likely to be engaged in caregiving, as they do not have their own families to care and be responsible for.

Another factor is the progression of the disease. According to Nerenberg (2002, p.6), the progression of diseases that result in dementia demands an increasing level of care. The initial stages of the disease for example would require care only for the higher level functions such as shopping and financial management, whereas an increasingly basic level of care would be required in the future, including dressing and eating.

Particularly in the family context, it must be understood that caregivers have particular needs in terms of the level of care they should provide, and the likelihood that they will continue providing care. Nerenberg (2002, p.6) provides seven markers to indicate the needs and stress trajectories that familial caregivers may be subject to. The first marker is the beginning, when the caregiver first engages in caregiving activities. The second is the self-perception of the person as caregiver. The third marker is reached when the caregiver begins to provide personal care. At the fourth level, the caregiver begins to actively search for formal support. At the fifth level, the familial caregiver begins to consider placing the elder in a nursing home, while acting upon these considerations at the sixth level. Finally, the familial caregiver terminates his or her role as caregiver.

A further factor is the influence of the type or illness or disability in the elderly care receiver. Those who care for elders with cognitive dementing illnesses for example tend to be more prone to depression and other stress-related conditions than those who care for elders with other types of disability (Nerenberg, 2002, p.6). Depression and anxiety for example are found in 43-46% of caregivers whose elders are cognitively disabled as opposed to 35.2% for caregivers whose elders suffer from other types of disability.

Depression and anxiety then also manifest themselves in problems such as lack of sleep, inadequate nutrition, and a lack of exercise. Compounding such problems is the fact that patients with disabilities generally are in need of constant supervision and care. All these factors contribute significantly to familial caregiver stress.

On the other hand, it is also important to acknowledge the growing problem of elder abuse in caregiving institutions such as old age homes, hospitals, and other caregiving facilities. Hence, while their basic lack of expertise and knowledge may result in elder abuse, those with the necessary skills and education could also fall victim to stress that may cause them to become abusive towards their charges. These persons are who Nerenberg (2002, p.1) refers to as "formal" caregivers.

The National Center on Elder Abuse (NCEA, 2005) notes that, while it is difficult to quantify the issues and factors that lead to abuse, certain institutional problems can be isolated in terms of the likelihood of the problem. The risk of abuse is for example higher in an institution where the ratio dementia residents are high, with a low staff ratio. This problem also relates to poor training for aides in charge of residents who have behavioral problem such as hitting or kicking. A low staff ratio would mean long hours for existing staff. The addition of poor training increases the risk of high stress and concomitant abuse.

As mentioned above, a further complicating factor is the fact that abuse is not always readily visible. With a high resident and low personnel ratio, monitoring each caregiving situation is not easy, particularly where abuse is neither suspected nor visible. According to the NCEA (2005), there are three categories of risk factors that should be taken into account when abuse is suspected. The first is facility risk factors, the second resident risk factors, and the third relationship risk factors.

In terms of facility risk factors, poor staffing and training are supplemented by institutional difference in terms of increasing the risk of elder abuse at facilities. Various factors in this regard need attention, including adequate training for staff, monitoring staff stress and burnout, as well as staff ratio and turnover.

Category 2: resident risk factors focus on certain types of residents in nursing homes, who could be more vulnerable to abuse than others. Risk factors in this regard include a high degree of dementia, needs that are not being met, and extreme dependence, which is associated with social isolation.

The third category focuses on relationship risk factors. Such relationships include residents' relationships with their family members and caregivers. If the relationship with family members is distant, for example, residents may be at a higher risk, as nobody from the world beyond the facility is available to regularly check on their well-being. A lack of good relationships with staff can also result in a high risk factor for abuse from caregivers at these facilities.

According to Woolf (1998), other factors that can contribute to the abuse of elderly persons, either in care facilities or in the home environment include external stress and intra-individual dynamics or personal problems. In terms of the former, a family members financial problems, job stress, or other issues may impact upon their ability to properly care for their elders in need. In terms of intra-individual dynamics, caregiving professionals could be the victims of their own circumstances, which may put them at risk of becoming abusive towards elders. The NCEA (2005) cites alcoholism, drug addiction, or emotional disorders as high-risk factors in this regard.

THE NATURE of ELDER ABUSE

According to the NCEA (2005), elder abuse in nursing homes can manifest itself in various ways, of which physical abuse is only one category. One of the problems related to abuse is the general public conception that it usually manifests only in terms of physical abuse, where elders are being physically harmed in some way. It is therefore critical to raise public awareness of the problem in terms of other forms of abuse, including verbal, emotional, or sexual abuse, as well as neglect and exploitation. Neglect can take the form of either physical or medical neglect, whereas exploitation generally involves the elder's personal property.

McNamee and Murphy (2006) emphasize that there are various complicating factors in detecting abuse. The reason for this is not only a basic lack of awareness among the public or concern within caregiving facilities. An additional reason is the nature of the various conditions that could lead to injury or death for elders. The authors for example note that caregivers, Adult Protective Services agencies and doctors must rely on forensic markers to detect abuse. The problem is however that these professionals are not trained to distinguish between neglect and injury as a result of illness or the aging process.

Indeed, some abuse symptoms may be mirrored in the effects of these diseases and conditions. This means that, should abuse be present, this is not necessarily detectable. A further problem is that police officers also often lack the necessary training to investigate and prosecute cases of elder abuse. The issue is therefore surrounded not only by direct problems, but also by a number of more distantly related factors that make it difficult to either detect, prosecute, or prevent abuse.

McNamee and Murphy (2006) cite research to suggest that bruising tends to be one of the most common and obvious indicators for abuse. The authors state that, while research on patterns of bruising related to child abuse is plentiful, the lack of similar data for the elderly population is significant. Perhaps this is indicative of the nature of the problem in terms of society and its concern for the elderly.

According to the authors, a futher body of research focusing on elderly deaths in caregiving institutions, revealed some markers that professionals could use in investigating possible abuse cases. These markers relate closely to the risk factors for abuse in institutions, as mentioned above, and include 1) the physical condition/quality of care; 2) facility characteristics; 3) inconsistencies, and 4) staff behaviors.

Physical markers for abuse may for example include untreated injuries, fractures, sores, lack of oral care, poor hygiene, and lack of cleanliness. Unusual bruising and family statements regarding the lack of physical care can also be used as markers. Facility characteristics may include unchanged linen, strong odors, unemptied trash cans, or other general forms of unhygienic conditions. Inconsistencies may include discrepancies between medical records, staff statements, and investigator observations. Staff behaviors that could raise suspicion include lack of knowledge or concern about residents, evasiveness, and an unwillingness to release medical records.

In addition to the basic lack of knowledge, expertise, and concern for elder abuse in the United States, is the general attitude towards deaths in nursing homes. According to McNamee and Murphy (2006), the general belief even among professionals who work with the elderly on a daily basis is that deaths as a result of elder abuse are rare. Hence, many cases where such abuse might have been suspected, are simply ignored. In addition, there tends to be an attitude of ageism among medical examiners and coroners. This results in a belief among these professionals that nursing home deaths is a waste of time and resources, as the elderly are already on the verge of dying. Hence there is a lack of concern with determining the true cause of death in elderly patients.

According to the American Psychological Association (APA, 2010), elder abuse in many cases is also related to cultural issues, such as the level of respect -- or lack thereof -- for the elderly in society. Some causes of abuse are also attributed to cultural differences or differing definitions of abuse, and therefore remain unchecked and uninvestigated.

In Western society today, there is also a general disregard for the elderly as disposable. They are therefore either intentionally or unintentionally, considered to be undeserving of dignity or support. If an elderly person is abused within the home environment, persons outside the home who suspect this often feel that it is a private family matter and that it is not appropriate to intervene.

Finally, religious and ethical belief systems in some cultures could result in the mistreatment of female family members, particularly if such family members are older. The strength of these beliefs is such that often not only the abuser, but also the victim, believe that no harm is being done. This keeps the victim lock in the situation without realizing it.

Another limiting factor in detecting abuse is the stereotypical profile of the abuser and the abused. According to the University of Illinois Extension (2010), and several other authors, the typical victim of elder abuse tends to be white female in her mid-70s or older, widowed, and living on a limited income. Generally, the abuser lives with the abused persons and in family situations is generally the spouse or adult child. For a variety of reasons, elderly victims tend to not report abuse. These reasons include fear of retaliation, shame resulting from the situation, or fear of leaving the home for the purpose of submitting a report. Abusers usually depend upon the elder for housing, financial or emotional support.

The problem with such typifying reports is that, once a typical pattern is broken, it tends to be disregarded. Less attention is for example given to situations where elder abuse takes place when neither abuser nor abused follow the typical profile of either.

It must however also be stated that there is no single excuse that might be forwarded for any type of abuse. Because it is usually the vulnerable and defenceless who suffer, abuse is one of the most tragic crimes. Compounding the tragedy is the situation of the abuser, who is often driven to such actions by personal circumstances and problems. In civilized society, however, a respect for all life should be promoted. Elder abuse can therefore not be allowed to continue; society should be required to restore the respect and high regard it once held for its aged population.

In addition to providing reasons for and the descriptions of the nature of elder abuse, many authors therefore also provide suggestions for possible solutions.

ELDER ABUSE: THE REMEDY

To prevent elder abuse, various sectors of society can play a significant role. Indeed, individuals, professionals and institutions can work together towards the aim of preventing elder abuse and stopping it where it is occurring. The NCEA (2005, Jul.) is for example raising awareness by means of publication. Some documents focus on risk factors that could lead to elder abuse, and mitigating these factors in order to prevent abuse before it occurs.

The NCEA's reports focus on preventing abuse in caregiving facilities. The culture and management of a facility may for example be a risk factor, where certain behaviors and attitudes are for example considered to be acceptable within the culture of the workplace. This could typically occur where the staff is generally homogeneous in terms of culture or commonly held beliefs. In this light, the authors suggest a collaborative effort in order to prevent abuse. According to the NCEA (2005, Jul), it is vitally important to construct a team of representatives who will collaborate to prevent abuse. The team's actions and collaboration should furthermore be fully transparent to the rest of the staff in order to provide every individual with the power of prevention.

The authors also suggest collaboration on a wider scale. Nursing facilities for example have the responsibility of quality care and life for those residing with them. As such, all staff members at such facilities should take responsibility to report abuse should this happen. Staff members should also be aware of this responsibility as a deterrent for crimes of this nature.

Facilities should then also work in collaboration with licensing and certification agencies. These agencies enforce state and federal laws on a formal level. Evaluators have the task of regularly inspecting care homes in order to ensure that facilities are adequate to meet the needs of residents.

The adult protective service program, an entity that conducts investigations in many states, also makes regular inspections of caregiving facilities. Ideally, the program should function together with nursing homes and licensing agencies in order to prevent the likelihood of abuse.

From the victim's perspective, the long-term care (LTC) ombudsman program acts in response to complaints by or on behalf of nursing home residents. These facilities ensure that the elderly are safe within their care environment, while also maintaining regular visits to facilities to ensure that all is well. In terms of personal property or financial abuse, recourse is provided by the Medicaid fraud control unit, which investigates Medicaid fraud and patient abuse.

McNamee and Murphy (2006) add to these the role of the medical examiner. The authors note that the role of these professionals is the investigation of deaths to determine whether elder abuse played a role. This is to be done with sufficient thoroughness and care to ensure that it serves not only as justice for the demised, but also as a deterrent for any future perpetrators of such crimes.

The authors also emphasize that many elderly persons, and particularly those with cognitive disabilities, cannot take responsibility for their own well-being. It is therefore important that medical and care facilities collaborate to provide them with as much protection as possible against abuse.