Health Care Providers Understanding of Elder Abuse. Michele Owens, MSN, FNP-BC. June 28, 2010

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1 Running head: HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE Health Care Providers Understanding of Elder Abuse Michele Owens, MSN, FNP-BC June 28, 2010 SUBMITTED IN PARTIAL FULFILLMENT OF NURS 6903: FAMILY VIOLENCE ACROSS THE LIFE SPAN Texas Woman s University Denton, Texas

2 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 2 Review of Literature Does understanding of community-dwelling elder abuse differ among various health care providers? If this is true, understanding what leads to this difference may help all providers in understanding what constitutes abuse, assessing, recognizing, diagnosing, and managing elder abuse cases. In health care various providers have contact with elderly patients, including paramedics, nurses, technicians, students, and doctors. Elder Abuse Defined Several definitions were uncovered during the literature review. The Department of Health and Children (United Kingdom) in 2002 defined elderly abuse as a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person, or violates their human and civil rights (Daly & Coffey, 2010, p. 33).The National Center on Elder Abuse defines elder abuse as an act referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult (Dong et al., 2009, p. 517). The American Medical Association defines elderly abuse as any act of either omission or commission that results in harm to the health or welfare of an elderly person (Kennedy, 2005, p. 482). Elderly who depend on others for their care can be at risk for elderly abuse. Between 1 and 2 million elderly Americans 65 years and older have been harmed and/or exploited by someone they depended on for their care (Halphen, Varas, & Sadowsky, 2009). In 2005, it was reported 40% of community-dwelling elderly had difficulties with performing their activities of daily living. Of these, a considerable amount do not received the necessary assistance they should have or are actually mistreated and neglected. The frequency of abuse from various sources in this population ranges from 2 to 10% (Halphen, Varas, & Sadowsky, 2009).

3 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 3 The abuse of elderly is a problem our society is learning needs more attention. Assessing the dynamics of living situations where the elderly are dependent on others for their care is especially important when attempting to prevent or stop abuse. Daly and Coffey (2010) discuss the need to study elder abuse. An approach they take is researching what staff members of long term care residences feel represents abuse. Understanding what elder abuse is, what can increase its occurrence, how to assess for it and barriers to reporting it, we as health care professionals can become more adept at recognizing it and acting appropriately. Prevalence of Elderly Abuse Daly and Coffey (2010) state the World Health Organization reports 80% of elder abuse is unreported. The National Elder Abuse Study was conducted in the United States in It was the first major study of mistreatment in elderly in the U.S. This study did not randomly study older adults rather it looked at cases reported to APS. It indicated only 1 in 14 cases of elder abuse was actually referred to authorities (Tatara, 1997). In 2010, Acierno et al. using a randomly selected national sample conducted 589 telephone interviews with older adults to assess for potential abuse and neglect. Their study titled National Elder Mistreatment Study reported prevalence of emotional abuse (4.6%), physical mistreatment (1.6%), neglect (5%), and financial (5%) by the older adults within the past year. There is significant mortality and morbidity associated with elder abuse. In a cohort study of elderly cases reported to Adult Protective Services (APS), there was reduced survival over a 13 year period. Of those elderly found to be abused or neglected by a caregiver 9% survived, of those reported but not referred for investigation 40% survived (Lachs, Williams, O Brien, Pillemer, & Charlson, 1998). Dong, et al. (2009) studied mortality risk and elderly abuse. They also found that cases of suspected abuse and confirmed abuse reported to social service agencies

4 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 4 increased the mortality risk of the elderly. They found this risk was not limited by the person s cognitive or physical status. Signs of Elderly Abuse Halphen, Varas, and Sadowsky (2009) reviewed and listed specific risk factors and warning signs of elder abuse: Advanced age especially 80 years and older; Being female; Having a self-care disability; Cognitive dysfunction; Depression; Social Isolation; Caregiver or victim stress including: health, financial, and situational; Poor caretaker characteristics including: mental illness, lack of finances, substance abuse, and history of violence; Signs of financial misuse; Staff shortages; Unusual physical exam findings that do not correlate with reported cause; and Signs of malnutrition, dehydration, wounds, medication misuse or abuse, presence of STD s. Barriers to Underreporting by Health Care Provider Daly and Colley s (2010) review found that a lack of awareness and different perceptions of elder abuse have lead to difficulties with identification of elder abuse in general for health care providers and a lack confidence in reporting abuse. Similar findings have been found by Thompson-McCormick, Jones, Cooper, & Livingston (2009); Taylor, Bachuwa, Evans, & Jackson-Johnson (2006); Kennedy (2005); and McCreadie, Bennett, Gilthorpe, Houghton, & Tinker (2000). All researchers recommended more education on awareness of abuse, risk factors, and managing abuse. Acierno et al. (2010) found in their study slightly more than 1% of their communitydwelling cognitively intact older adults experience some type of abuse, mistreatment, or neglect.

5 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 5 They reported very few of these incidences had been reported to authorities. Lack of knowledge of risk factors and situations of elderly abuse has been found to be an important element aiding general practitioners in diagnosing elder abuse. McCreadie, Bennett, Gilthorpe, Houghton, and Tinker (2000), reported a diagnosis of elder abuse was 4 times more likely to be recognized by practitioners who reported reading articles on elder abuse. Primary care providers are required by law to report suspected elder abuse, however only a small percentage (2%) of cases are reported by physicians (Halphen, Varas, & Sadowsky, 2009). An excuse that has been used in the past is not recognizing what is a normal part of aging and what is not. For a lay person this might be a plausible excuse, however a physician may be one of the most qualified persons to make this distinction. Halphen, Varas, and Sadowsky (2009) point out the only other person other than the caregiver that an elder person may see would be his/her physician. They discussed barriers to clinician identification and intervention. Particular barriers they found on review included: Lack of an easy to use assessment screening tool; Time to screen and get involved; Lack of knowledge of risk factors and warning signs; Difficulty knowing by visit alone if the patient has the ability to care and protect themselves; Lack of knowledge on how to report abuse; Belief that reporting the suspension will lead to disciplinary action; Wanting to honor the victims or caregivers wishes; Unaware that reporting is required by law; and Fears of being sued or revenged. Studies Assessing Providers Understanding of Elder Abuse Study Subjects N Instruments Design Conclusion Dally & Coffey (2010) 66 nurses; 48 care assistants Quantitative, descriptive co-relational Long-term care nurses and assistants Elder abuse questionnaire by Kottwitz and Bowling (2003) High level of uncertainty about what constituted elder abuse

6 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 6 Crosssectional cohort selfreport McCreadie, Bennett, Gilthorpe, Houghton, & Tinker (2000) Thompson- McCormick, Jones, Cooper, & Livingston (2009) Kennedy (2005) Rinker (2009) Taylor, Bachuwa, Evans, & Jackson- Johnson (2006) General practitioners in Birmingham Fourth year medical students in London and Birmingham Primary care physicians in Ohio Pre-hospital and Hospitalbased care providers Family practice and internal medicine physicians in Michigan 291 Selfcompletion questionnaire 202 Caregiving Scenario Questionnaire; Demographic and education questionnaire 216 family physicians; 176 internists 272 Prehospital; 127 Hospital based 8 page questionnaire mailed to a random sample 20-question survey at several EMSs conferences in Maryland 95 Attitude and knowledge questionnaires Crosssectional cohort selfreport Crosssectional cohort selfreport Crosssectional cohort selfreport Stratified crosssectional cohort selfreport Overall inadequately prepared to recognize abuse and risk factors Not able to recognize elder abuse; Difficulty recognizing neglect as abuse; Education on subject not as effective as real-life care experiences More education on elder mistreatment needed. Family physicians were more aware of problem, willing to report and manage. Perception of abuse outweighed actual reported abuse. Many aware of legal requirement to report. Majority unable to recognize risk factors; Many expressed lack of understanding on how to report; Recommended more education. Daly and Coffey (2010) studied nurses and care assistants perceptions of elder abuse in long-term care settings in Ireland. Of those few who reported having some knowledge of elder abuse were found to be more likely to voice concern about identifying elderly abuse. They found there was high uncertainty on what constituted elder abuse. They found there was a need to

7 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 7 encourage the education of health care workers on elder abuse. They felt the need to promote awareness and understanding of the multifaceted aspects of elder abuse. Having a plan in place prior to finding a case of abuse is especially important. This will reduce the anxiety of when, where, why, and how to report a suspected case of abuse. Halphen, Varas, and Sadowsky (2009) reiterated that reporting is legally and ethically required, they suggested that reporting is the most beneficial intervention. In most cases Adult Protective Services is the place to start, the authors suggest that APS will help direct the clinician to the appropriate services if they deem it necessary. McCreadie, Bennett, Gilthorpe, Houghton, and Tinker (2000) studied general practitioners to determine whether they reported diagnoses of abuse, could they adequately identify elders at risk, and how ready they were to manage suspected abuse. A majority, 55%, of participants denied diagnosing a case of abuse in the previous year. Due to the lack of prevalence data this percentage is difficult to relate to lack of abuse or lack of knowledge of risk factors. GP s who reported reading on the topic and those having more than 500 patients were more likely to have diagnosed elderly abuse. Researchers suggest research-based education would aid in identification and management of elder abuse. Thompson-McCormick, Jones, Cooper, & Livingston (2009) were the first to study elder abuse awareness among medical students. They chose fourth year students due to having had some clinical experience and familiarity with dementia. They found the students had difficulty recognizing elder abuse. Many did not recall receiving education on elder abuse and those who did were still less likely to recognize elder abuse than those with no recollection of education. They found in this particular study those students having experience working as a professional caretaker of elderly were more likely to recognize elderly abuse. The researchers recommended

8 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 8 hands-on, problem-solving in real-life situations may provide better understanding of the topic than teaching alone. Kennedy s (2005) study was a response to the lack of detection guidelines, awareness, reluctance to report, and the medical community s general inconsistencies toward responding to elderly abuse. He compared differences between family and internist physicians. Family physicians reported identifying more elder abuse cases and perceived the magnitude of the problem to be higher than the internists. Astonishingly 94% of those who had suspected a case of elderly abuse did not report it, giving excuses such as questionable signs, victim denial, unsure of reporting procedures, and unsure of legal requirement. The researchers recommended further education in increasing awareness of elder abuse and improve competence in managing elder abuse. Rinker (2009) chose to study health professionals who had contact with elderly prior to arrival to hospital and those who cared for them in the emergency rooms. These health care professionals represent some of the first medical personnel who abused elderly may come in contact with. These occupations include EMT s, paramedics, licensed practical nurses, registered nurses, hospital-based technicians, and medical doctors. Approximately 40% reported having been associated with a case of elder abuse in the last year, however 65% reported they had suspected cases of elder endangerment. The majority of participants did report their legal obligation to report suspected cases. Rinker (2009) recommended these providers become more adept at assessing for abuse just as they would assess for a cardiac problem, and suggested a comprehensive training program. Taylor, Bachuwa, Evans, & Jackson-Johnson (2006) aimed to assess barriers to identifying and managing elder abuse by primary care providers. They chose to assess

9 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 9 knowledge and attitudes of elderly abuse. They found the majority of participants did not have an accurate perception of the prevalence or risk of elderly abuse. The also falsely identified primary care providers being the highest reporters of cases to adult protective services, when in actuality these providers only report 2% of the cases APS receives. The attitude expressed by providers revealed they did believe providers failed to routinely screen for elder abuse. Overlooking abuse was partially blamed on lack of knowledge regarding signs of family violence and appropriate reporting procedures. The providers recognized the need for further education and the goal of the researchers was to use the information to develop multiple educational programs. Conclusion In the past several years several studies and reviews have been completed on the understanding of elder abuse by various health care providers. These reviews typically end with a common conclusion: further education is needed to better prepare the providers to recognize and assess for elder abuse. Research demonstrated repeatedly providers had difficulty assessing, recognizing, and managing elder abuse. While more experienced providers did seem to be more likely to recognize elder abuse even they demonstrated difficulty reporting the abuse. Routine continuing education with visual reenactments of actual elder abuse may be more beneficial to learning than just teaching alone.

10 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 10 References Acierno, R., Hernandex, M.A., Amstadter, A.B., Resnick, H.S., Steve, K., Muzzy, W., et al. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public Health, 100(2), Daly, J. & Coffey, A. (2010). Staff perceptions of elder abuse. Nursing Older People, 22(4), Dong, X., Simon, M., Mendes de Leon, C., Fulmer, T., Beck, T., Hebert, L., et al. (2009). Elder self-neglect and abuse and mortality risk in a community-dwelling population. Journal of the American Medical Association, 302(5), Halphen, J.M., Varas, G.M., & Sadowsky, J.M. (2009). Recognizing and reporting elder abuse and neglect. Geriatrics, 64(7), Kennedy, R.D. (2005). Elder abuse and neglect: The experience, knowledge, and attitudes of primary care physicans. Family Medicine, 37(7), Kottwitz, D., & Bowling, S. (2003). A pilot study of the elder abuse questionnaire. Kansas Nurse, 78(7), 4-6. Lachs, M.S., Williams, C.S., O Brien, S., Pillemer, K.A. & Charlson, M.E. (1998). The mortality of elder mistreatment. Journal of the American Medical Association, 280(5), McCreadie, C., Bennett, G., Gilthorpe, M., Houghton, G., & Tinker, A. (2000). Elder abuse: do general practitioners' know or care? Journal of the Royal Society of Medicine, 93(2), Rinker, A.G., Jr. (2009). Recognition and perception of elder abuse by prehospital and hospitalbased care providers. Archives of Gerontology and Geriatrics, 48,

11 HEALTH CARE PROVIDERS UNDERSTANDING OF ELDER ABUSE 11 Tatara, T. (1997). The national elder abuse incidence study: Executive summary. New York: Human Press. Taylor, D.K., Bachuwa, G., Evans, J., & Jackson-Johnson, V. (2006). Assessing barriers to the identification of elder abuse and neglect: A communitywide survey of primary care physicians. Journal of the National Medical Association, 98(3), Thompson-McCormick, J., Jones, L., Cooper, C., & Livingston, G. (2009). Medical students recognition of elder abuse. International Journal of Geriatric Psychiatry, 24,

Alice Coffey PhD Joan Daly MSc.

Alice Coffey PhD Joan Daly MSc. Background and Context Study Methodology Results Recomendations A single or repeated act or lack of appropriate action occurring within any relationship where there is an