Elder Mistreatment

"Elder mistreatment (EM) is a serious, unreported, under-detected phenomenon that afflicts thousands of elderly annually" (Pillener and Finkelhor 1998).

Critically discuss such a statement identifying the role of the nurse towards the prevention and management of abuse.

Introduction

In today's ageing society, the elderly population is increasing with estimates of those aged over 65 years of age expected to double in number between the years 2000 and 2025 (United Nations, 2000; Nelson, 2002). An increasing frequency of young adults is therefore required to care for their elderly parents or grandparents. In our country we can also notice the presence of elderly residences and nursing homes, some of which have been established for quite some time and others new in the field. What is for sure is that they are on the increase. This means that we are having an increase in our elderly population, just like the entire world. Lately, increased attention has been addressed towards the mistreatment of the elderly with assessment and management tools being proposed and action being taken in various countries. The problems which unfortunately hinder this kind of mistreatment from being reported or documented and action being taken are various and include ageism, fear of the abuser, embarrassment, shame and concern about family privacy, and avoidance of public exposure amongst others (Edlin, Golanty, and McCormack Brown, 1999).

Elder mistreatment and identified risk factors

Elder mistreatment (EM) or abuse is defined as a reportable offense (Anderson, 2002) of physical, sexual, or emotional maltreatment or financial exploitation of an older adult, 60 or older (Edlin et al, 1999). EM also involves violation of the individual's rights (Burrell, Gerlach, and Pless, 1997) and inhibits a healthy ageing process. Roper, Logan, and Tierney (2001) state that EM causes harm to the older person either temporarily or over a period of time and it may be intentional or unintentional. EM is quite a complex issue and contributing factors to such abuse are various. These include economic situations, interpersonal conflicts, poor health status, age and physical dependency/frailty, impairment of activities of daily living (ADLs), alcohol or drug dependence, psychosocial status and psychological condition of the elder (dementia), physical and psychological demands on/of the carer (Edlin et al, 1999; Coyne, 2001; Levine, 2003). All these, in a way or another may affect either the abused or the abuser and so trigger mistreatment.

Having mentioned Dementia (Senile Dementia of the Alzheimer's type), one should note that these patients may have impaired decision making and executive functioning and therefore not able to advocate for their own needs. Coyne (2001) found that behavioral disturbances, violent behavior (including hitting, kicking, biting, punching and making threats) and a lack of understanding on the part of caregivers and health care professionals as to how best to manage aggressivity (either behaviorally or pharmacologically) in patients may provoke the likelihood of abuse.

Who, where and why?

Abusers may include family members (a spouse, child or relative), friends or other caregivers who are not related to the victim. What is mostly worrying about these situations is that the elderly person often denies being abused or feels helpless and resigns to this behaviour (Anderson, 2002), therefore living in a culture of silence. This culture, besides due to fear, may also be induced due to the fact that the elderly would notice that their "carers" are at the end of their tethers and so decide to refrain from reporting. Abuse has been found to be two to three times more prevalent in those over 80 than in those in the 60-80 age group (Grey-Vickrey, 2004). Besides, Grey-Vickrey also found that those women over 80 years of age who need total or partial care are the likeliest to be mistreated. This could be attributed to the fact that women either report abuse at higher rates or because the severity of injury is higher than in men (Krouse, 2004; Fulmer, Guadagno, and Bolton, 2004). Grey-Vickrey (2004) also states that between 1999 and 2001, "30% of nursing homes in the United States were cited for abuse."

Various factors are implicated in the under-detection of EM. Levine (2003) explains that financial and time constraints, lacking recourses, and limited availability of human resources make detection quite difficult. To these one can safely add the fear of retaliation and learned helplessness to which the health carer should ideally address most of his/her attention. The elder should be empowered to move out of this culture of silence. In most cases, detection would just mean the tip of the iceberg. Once detected, a case would have to be followed further and action taken upon it, which would again involve a lot of the above mentioned resources.

Many a times the victim is dependent on the abuser and therefore reluctant to report abuse. In other instances, victims may be unable to communicate (being demented or bed ridden, socially isolated persons) or any bruises attributed to their age/health status. A good example is when a 4 year old is admitted to an emergency department with a broken arm. A differential diagnosis will also consider battering but how many times one attributes a broken hip to osteoporosis with no further investigation? This may lead the inexperienced or untrained "investigator" (who could be the nurse) to improperly examine an alleged victim or not to believe him/her (Brown, Streubert, and Burgess 2004).

What is also important to consider is that while abuse refers to acts which have been committed, neglect refers to omissions. These again can be intentional or unintentional. Neglectful behaviour includes failure to meet nutritional and hygienic needs which could lead to suicide or accuses of manslaughter (Humphreys Lynch, 1997). Humphreys Lynch also states that these omissions could be involuntary, such as when the required care exceeds the capabilities of the caregiver. It is quite understandable that a 75 year old who needs help herself with her functioning would not be able to care for her bed ridden spouse. This would be a good example of involuntary neglect.

The role of the nurse

The nurse is a key professional in the prevention, detection, and management of EM but it has also been argued that elder abuse (which has been compared to familial violence) cannot be dealt with successfully by one profession, since it includes such a complex range of issues (Kingston and Penhale, 1997). Therefore, one