Elder Abuse

1. Elder Abuse Nancy V. Karp, Ed.D., P.T. nvkarp@gmail.com

2. Abuse Module This presentation will: • Examine the demographics of elder abuse. • Define elder abuse and list the types of abuse. • Outline the screening procedures a PT should use for detecting elder abuse. • Describe correct PT documentation procedures for elder abuse. • Explain the ways that a PT can intervene for a patient when elder abuse is suspected.

3. Elder Abuse and Neglect Categories • Physical abuse • Sexual abuse • Emotion/psychological abuse • Neglect • Abandonment • Financial/material exploitation • Self-neglect

4. Family Violence Prevention and Services Act • Passed in 1992 • Mandated national study of abuse • Provided insight into the characteristics of the abused, self-abused, and abusers.

5. National Elder Abuse Incidence Study • Published September, 1998 • Found that 5.3 times more abuse than is reported. • Abuse in domestic settings • 50% neglect • 35% emotional/psychological abuse • 30% financial exploitation • 25% physical abuse • 4% abandonment • <1% sexual abuse Note: totals >100% because of the possibility of multiple abuses.

6. Elder Victim Characteristics • Abuse increases with age; >50% over age 80. • Average income of victims $5000-$9000/yr (1996 dollars) • 60% female • Victim demographics • 50% unable to care for themselves • 30% somewhat able to care for themselves • 60% exhibit confusion • 45% exhibit signs of depression

7. Self-Neglecting Elders Characteristics • 65% women • Self-neglect increases with age; 45% > 80 years old • 75% demonstrate confusion • 50% demonstrate depression

8. State Statutes on Elder Abuse • All states have elder abuse statutes. • GA requires that PT’s must report suspected abuse to specific, designated agencies. • PT’s are in a critical position to identify elder abuse and intervene because patients view PT’s as advisors, educators and confidantes.

9. Elder Abuse and Neglect Categories

10. Physical Abuse • Definition – The use of physical force which may result in bodily injury, physical pain or impairment. • Mechanisms • Chemical and physical restraints • Incorrect positioning • Force feeding • Improper medication use • Physical punishment of any type • Providing physical therapy which is unwanted or at an inappropriate intensity level to maximize reimbursement

11. Physical Abuse Lesser-known manifestations • Wound locations inconsistent with patient’s explanation • Evidence of unused prescribed medicines • Unwillingness to communicate • Changes in demeanor or activity level • Caregiver’s refusal to allow visitors to see an elder alone

12. Sexual Abuse • Definition – Nonconsensual sexual contact of any kind with an elder person. Includes sexual contact with any individual incapable of giving consent. • Manifestations • Bruises around breasts, genitals, or inner thighs • Unexplained venereal disease or genital infections • Unexplained anal bleeding • Torn, stained, or bloody underclothing • Difficulty in walking or sitting without evidence of musculoskeletal disease • Reports of being sexually assaulted or raped

13. Sexual Abuse • Many elders were raised in a time when sexual matters were not discussed openly. • Many elders view sexual abuse as the worst form of lost dignity.

14. Emotional/Psychological Abuse • Definition – The infliction of anguish, emotional pain, and distress through verbal or non-verbal acts. • Manifestations • Emotional upset or agitation • Depression • Anxiety • Passivity • Evasiveness • Fear

15. Neglect • Definition – The refusal or willful failure to fulfill any part of a person’s obligations or duties to an elderly person. • Mechanism • Active neglect The refusal or willful failure to provide for food, water, shelter, clothing, personal hygiene, medicine, comfort, personal safety, and other essentials included as a responsibility or an agreement. • Passive neglect The non-willful failure of a caregiver to fulfill fiduciary functions and responsibilities due to inadequate knowledge or understanding of the need for prescribed services. Includes lack of compliance with clinical regimens and failure to provide safety precautions.

16. Neglect Manifestations Dehydration Malnutrition Hypo/hyperthermia Decubitus ulcers Poor personal hygiene Misuse of meds General deterioration of health Unattended or untreated health problems Misuse of medications Failure to provide prosthetics, glasses, dentures, etc. Hazardous or unsafe living conditions Unsanitary or unclean living conditions Reports of being neglected

17. Abandonment • Definition – The desertion of an elderly person by an individual who has physical custody of the elder or a person who has assumed responsibility for providing care for the elder. • Manifestations • Desertion of an elder at a hospital, nursing facility or other similar institution • Desertion of an elder at a shopping center or other public location • Reports of abandonment

18. Financial/Material Exploitation • Definition – The illegal or improper use of an elder’s funds, property, or assets. • Mechanism • Cashing checks without authorization or permission • Forging signatures • Misusing or stealing an elder’s money or possessions • Coercing or deceiving an elder into signing a document • Providing and billing for PT services without informed consent of the patient or power of attorney.

19. Financial/Material Exploitation Manifestations • Inclusion of additional names on an elder’s bank signature card • Unexplained, sudden transfer of assets to a family member or someone outside the family • Sudden appearance of previously uninvolved relatives claiming rights to the elder’s affairs and possessions • Provision of services that are not necessary

20. Self-Neglect Definition Behaviors by an elderly person that threaten the elder’s healthy or safety. Does not include situations in which mentally competent elders make conscious and voluntary decisions to engage in acts that threaten their health or safety.

21. Self-Neglect Mechanism The inability, due to physical or mental impairments, to perform tasks essential to caring for oneself, including obtaining essential food, water, clothing, shelter, personal safety, personal hygiene, medical care, and goods and services necessary to maintain physical health, emotion well-being, and general safety, and to manage financial affairs.

22. Screening

23. ScreeningPart of PT Assessment Physical therapists who suspect elder abuse should incorporate questions and examinations related to elder abuse into their daily practice to assist in further investigation by the appropriate authorities.

24. ScreeningPart of PT Assessment • Environment - the environment selected to screen elders when abuse is suspected should facilitate open communication. • Examples • Keep instructions short and simple • Keep voice and mannerism calm • Asking clear questions • Allow ample time for hearing, understanding, answering • Assess non-verbal cues

25. ScreeningPart of PT Assessment Evaluating decision-making capacity • Is the patient able to make and express choices regarding an intervention? • Is the person able to provide reasons for choices? • Do the person’s reasons make sense? • Is the person able to understand potential harm from choices? • Is there a need for psychological assessment?

26. ScreeningPart of PT Assessment Interviewing Technique Every clinician should have an interview protocol for the detection and assessment of elder abuse.

27. Direct Questions for Interview • What sort of difficulties have you experienced recently, either at home or somewhere you go regularly? • Has anyone made you do anything or sign anything you didn’t want to? • How are you eating at home? • Do you take any medications? • Do you depend on anyone to help you? • Does that person give you the help you need?

28. Indirect Questions for Interview • Tell me what you think the problem is here? • What type of care does the elder require? • Do you have any emotional support? • Does the elder manage his/her own finances?

29. Validating Many elders who have been abused have stated that the most helpful thing anyone can do is listen to them, believe them, and take them seriously.

30. PT Validating Points Express the following: • You are concerned about the elder’s safety and well-being. • You understand how difficult it is for the elder to make the necessary changes. • The elder is not alone. • The violence the elder is experiencing is not the elder’s fault, and only the abuser can stop the abusive behavior. • No one deserves to be abused, there is no excuse for abusive behavior, and the elder deserves better. • There are options and resources available.

31. The Right to Refuse Help Despite your best efforts to identify elder abuse and offer assistance, the suspected victim may refuse help. Whether abused or not, adults have the legal right to refuse medical and social services.

32. Documentation

33. Documentation • It is the PT’s responsibility to carefully document any injuries that are suspected or known to have resulted from elder abuse. • Treatment records may provide important evidence in legal proceedings.

34. Clinical Examples of Elder Abuse- Review of Systems - • Cardiovascular/Pulmonary system • Edema in extremities • Dehydration (reduces blood volume and bp) • Integumentary system • Patient’s hygiene • Skin turgor as a sign of dehydration • Skin lesions • Bruises, burns, pressure ulcers • Scalp abnormalities

35. Clinical Examples of Elder Abuse- Review of Systems - • Musculoskeletal system • Abused patients show pain or fear of movement • Contractures • Muscle weakness; patient is unable to perform ADL • Fractures not consistent with reported injury • Neuromuscular system • Slow response to commands without a pathological condition • Fear or apprehension • Unexplained communication problems • Somulence or slurred speech • Incoordination

36. Note A patient may exhibit some of the signs of abuse but these may be related, instead, to depression, dementia, medication reactions, or undiagnosed medical conditions. It may not be abuse.

37. Interventions

38. PT Responsibilities If elder abuse is suspected, the PT should: • Document the elder abuse • Report suspected elder abuse • Prevent elder abuse via patient and caregiver education • Develop a plan-of-care to promote functional independence

39. Promoting Functional Independence • As independence in ADL increases, abuse of geriatric patients decreases. • Functional activities should be taught to every geriatric patient or client.

40. PT Documentation Highlights • Record the abuse in the patient’s own words. • Record the caregiver’s explanations in the caregiver’s own words. • Use a body template or body map to record abuse. • Provide detailed descriptions and measurements of injuries in objective terms. Do not use judgmental or emotional terminology.

42. PT Documentation Highlights • With patient’s permission, take photographs to document abuse. • Document place photo taken • Document date, time, name of photographer • Document name of witness to photographic session • Facilities may have a protocol for taking photographs. This may be done by medical records personnel, nurses, or others.

43. Reporting Abuse • It is the therapist’s responsibility to know the applicable state laws and appropriate state agencies for reporting abuse. • Elder abuse is usually reported to Adult Protective Services. Look up the number for your county or local area. In Georgia, the listing is usually under: Georgia State GovernmentFamily and Children Services, Adult Protective Services • Report suspected abuse immediately.

44. Adult Protective Services Georgia State GovernmentDepartment of Family and Children Services Augusta, GA 30901 Phone: (706) 790-2400  After Hours, Columbia County 115 Davis RdAugusta, GA 30907-2383 Phone: (706) 541-2880 

45. In A Facility… The protocol in a specific facility may require that you contact social services, first, rather than reporting the abuse directly to Adult Protective Services. However, it is your responsibility to insure that there is a follow-up.

46. References This information in this powerpoint presentation is taken from two sources: American Physical Therapy Association, Guidelines for Recognizing and Providing Care for Victims of Elder Abuse, APTA, Alexandria, VA, 2000. Little, CD, What every physical therapist should know about elder abuse, Gerinotes,9 (4), p 5-9, July, 2002.

47. Questions If you have additional questions once you have gone through this module, feel free to speak to me either before or after class or email me. nvkarp@gmail.com

48. Elder Abuse The End