Written by Kathleen
Thimsen & Diana Faugno
ELDER ABUSE is an under-reported
crime that is estimated to occur in 14-15% of the population over 65 years of
age. Data shows that the crime is witnessed in most cases, but not reported.
The reasons for under-identification and under-reporting include the concept of
ageism or bias against the elderly, time constraints and prioritization of care
in the emergency department, age related changes, cognitive impairment,
co-morbidities, and the lack of validated instruments for screening.
Cases of elder abuse that are
reported are those that have blatant, overt signs and conditions that compel
health-care professionals to respond and report to adult protective services.
Most of the cases reported are of a catastrophic nature, with severe signs,
symptoms, or with grossly evident injuries. Despite the severity of the abuse,
prosecution rates decline as the age of the victim increases.
Vulnerable populations do not
routinely receive screening for abuse (Administration on Aging 1998). The actual
prevalence of elder abuse cases is unknown for a variety of reasons.
Self-reporting, discussing what occurs in the privacy of one’s home, and
any reporting of historic and persistent maltreatment usually fails to happen
due to embarrassment, fear of punishment, or loss of freedom and independence.
The health-care profession is among
other disciplines that play a role in the under-reporting of elder abuse. Lack
of knowledge and inadequate training of health-care providers and first
responders through professional education potentiates the under-identification
of abuse. Additionally, there is a generalized acceptance of certain forms of
abusive behaviors presenting in health-care access encounters (Laumann, Leitsch & Waite
2008). The need to advance education and skills development for
professionals working in the adult-abuse environment is imperative given the
fact that 10,000 Baby Boomers turn 65 years of age each day.
Chism (2013) discussed the fact that,
given the political activism and advocacy of the Baby Boomer generation, the
face of aging will be changed with renewed beliefs and expectations for a more
proactive stance on how aging is perceived. Likewise, consumerism may shift
toward a healthier approach to living and lifestyles. Considering this, the
issue of elder abuse will become a challenged occurrence with much more avid
attention to cases, reporting, investigations, and prosecutions. Gone are the
days that ageism will be the lens that society casts upon those over 50 years of age (Butler 1969 & 1975).
The term ageism—that is, bias
against the elderly—was coined in 1969 by Dr. Robert Butler, the first Director
of the National Institute of Aging. The social condition still exists today.
Ageism takes on many forms and most of us have a degree of ageism that taints
our perspective on older people. This bias, as it relates to elder abuse and
neglect, serves as an explanation and an excuse to downplay observations of—and, perhaps, participation in—maltreatment. This bias is not intentional in our
conduct; rather, it is embedded in our perspectives and expectations of what
aging involves that is limited to a small percentage of the aged population. Most
persons over the age of 50 are healthy, active, vibrant, and contribute to
society in viable and productive ways. The small percentage of the aged that
are frail, sick, and debilitated live in nursing facilities or assisted living
and are dependent on others for routine care. Cases of elder maltreatment are
reported to occur 78% of the time in care facilities.
To identify elder maltreatment
case reports, investigations, and follow up, a retrospective review was
performed to recognize patterns and trends in the life, personal care, medical treatment,
and safety planning of the persons involved in the cases. The secondary aim of
the study was to interpret the findings and create opportunities and care strategies
to prevent abuse and neglect of the elderly (K. Thimsen, pers. comm.).
MethodsA retrospective review of 612
cases of suspected elder abuse was conducted to identify if abuse or neglect
played a role in the deterioration of the elder. Data that was used in the
review included medical records, state investigations, crime reports, and death
Ageism and elder abuse have been shown
to impact health-care access and delivery. Studies show significant health
disparities in the population (Dong & Simon 2014; Acierno 2009, Brozowski & Hall 2010). Data shows that victims of elder abuse
present to emergency departments four times more often than other seniors of
the same age that are not victims of abuse and maltreatment (H-Cup Data). Elders
presenting to emergency departments for care are at increased risk due to the
complexities of the screenings and the examinations that are indicated to be
carried out related to the primary presenting complaint and associated
Assessment and differentiation of
elder abuse from co-morbidities and age-related changes creates the obstacles
to specific diagnosis and response to a victim of abuse given the time required
for thorough workup and the time-sensitive nature of emergency-department
treatment. This is also a huge obstacle for first responders to home
environments or assisted, long-term care homes. Differentiating illness and
disease-related conditions from abuse symptoms is difficult.
The prevalence of chronic disease and
comorbidities also contributes to polypharmacy. According to economic data, numerous
medications prescribed to people over 50 carry with them high costs, as well as
drug interactions. This is compounded by the use of self-prescribed herbal,
over-the-counter (OTC) remedies, as well as alcohol and street drugs. This
polypharmacy creates difficulty in the appropriate discernment of the actual underlying
condition of abuse.
Many OTC medications have a
significant impact on the mental status of older adults. Some medications that
are self-prescribed have a benzodiazepine effect on neural transmission that
often causes cloudy, confused, and impaired thinking and behaviors. Medication
effects and dehydration-related altered mental status are often not
differentiated from dementia and delirium. This can result in misdiagnosed
mental-status changes and the mislabeling of dementia or Alzheimer’s Disease.
A retrospective study of 612 persons
reported to have been victims of elder maltreatment (abuse and neglect) was
carried out by analysis of the
clinical records. Of the 612 cases, only 10% of the cases were found to be
abuse cases by adult protective services. The remaining cases that had not been
formally noted to be abuse cases, were in fact significant for signs, symptoms,
injury, or death attributable to neglect and abuse. The severity of decline and
worsening of physical capacity and performance was shown to be so significant
that once emergent care was sought, it was too late in the decline; the result
was amputation or death.
The themes of abuse
and neglect were specific and significant for showing patterns and trends with
resulting amputation or death. Earlier identification and intervention would
have mitigated injury and harm and ultimately pain, suffering, and death. In
the cases reviewed, 100% involved hydration (or dehydration) as a major
perpetration of the abuse. Further, 87% of the cases involved a minimum of two
of the following themes: nutrition and hydration; medication management and
administration; falls; and skin alterations.
loss greater than 5% in a 30-day period is considered starvation, and places the
individual in a catabolic state with high potential for malnutrition. Diagnostic
laboratory findings of an albumin screen (3.5–5.0 g/dL) is a measure of protein
stores. Albumin levels are indicative of the preceding 20–27 days. A prealbumin
screen (15–36 mg/dL) is a more definitive evaluation of nutritional status as
the half-life is 2–4 days as compared to albumin that is 20–27 days.
Albumin levels are
also sensitive to hydration status. In the presence of dehydration or altered
kidney function, an albumin screen may be falsely inflated and appear normal.
In many patients with malnutrition, sub-therapeutic prealbumin or albumin
levels may be used to gauge prognosis, as nutritional status may not be
responsive to aggressive nutritional support when values reach a specific level
and are untreated at an early point in time.
In the patient series
studied, the trajectory of the elders’ decline was evident (on average) at 10
months prior to onset of acute illness, catastrophic injury, or death. The
severity of the malnutrition, as evidenced by albumin levels below 2.2 and
pre-albumins below 10, made the patients’ prognosis poor, with resulting death
within 7 months of the initial decline. Aggressive nutritional interventions
were not successful at reversing the condition.
Medication Management and Administration
Patients in the
series that had medication administration maltreatment were shown to have
hypo-therapeutic levels or hyper-therapeutic levels of medications. In some
cases, there was no medication found on laboratory evaluation, despite reports
and medical record documentation of medications being administered. Most common
medications found to have altered or absent levels included anticoagulants,
anti-seizure, pain/analgesia, diuretics, and dementia medications.
The medical records
of the patients in the series were often found with unexplained injuries or deformities
to extremities when being evaluated for other complaints or in routine health
encounters. Persons presenting with complaints of pain receiving diagnostic x-rays
found old, untreated fractures.
In the cases of
altered mental status, changed in vision, and with and without history of a
fall, head trauma and subdural hematoma were consistent findings incident to
other workups or on autopsy. Most falls with head trauma received no imaging
studies, even in those patients at highest risk for brain bleeds related to
concurrent anti-coagulant or aspirin therapy.
Many of the cases
were brought to medical attention due to the visual observation of burns, extensive
bruising, and numerous lacerations. Most cases presenting to an emergency
department involved severe, chronic, and infected, catastrophic wounding that
was odorous or so extensive that family initiated the transfer for emergent
Pressure injuries (such
as bed sores or pressure ulcers) were of a severity of Stage 3 and greater.
Stage 3 pressure injuries involve tissue destruction that extends to the
subcutaneous tissue and deeper into tendon, muscle, and bone involvement. This
type of wound results from unrelieved pressure, immobility, and malnutrition.
Wounds of this type and severity are very painful. Wounds that were gangrenous,
covered with necrosis, or that resulted in amputation represented 79% of the
wounds in the series.
The science of aging is in a novel
position as advancements have been made that have introduced and
made available many tools, instruments, and technology to differentiate abuse
and maltreatment from age-related changes and comorbidities. Accurate
identification and response depends on the use of these resources, and being
aware of bias that creates disparities in the treatment and safe discharge of this
valuable and yet vulnerable portion of our society. This will affect evidence-collection
potential for your cases.
Given the graying of society, it is
critically important to better identify, report, investigate, and prosecute
cases of adult and elder maltreatment. All professionals and disciplines
involved in working with or caring for the elderly must recognize their
professional responsibility and heed the call for improving the ethical
response to victims of maltreatment by implementing innovative strategies to
present abuse and neglect while ensuring improvements in screening,
identification, and appropriate response to elder abuse (Ash & Miller 2014).
People who witness or who are
complicit with observing abuse must be held accountable for reporting abuse. The
issue of elder abuse must become a priority for mandated reporters, as we aim
to aid an unseen population of victims of crimes who have a limited voice. Look
for education on this topic to increase your understanding of potential
evidence collection in this area.
female takes a bus to the emergency room and states to the nurse that someone
entered her apartment and sexually assaulted her. The nurse notifies law
enforcement, as the nurse knows that reporting of sexual assault is mandatory. The emergency room also calls the forensic nurse in sexual assault
care to see this patient for a medical forensic examination. The patient
discloses that someone who she does not know came through her garden wall to
steal food out of her refrigerator. She reports that she is diabetic but has
not taken her medicine for some time because she ran out. She is also
complaining of burning and pain in the genital area. This morning she put cold cream
on it, “but it still burns down there.” There are no relatives to call or notify.
The forensic nurse notifies the emergency social worker for assistance in
comprehensive notification of adult protective services and community
organizations who will help to locate family members in the area. Law enforcement
is dispatched to the apartment building to locate any evidence there. The head-to-toe
examination reveals a blue bruise on her left inner thigh area. She complains
of pain and pulls away when this area is touched. She cannot remember how that
happened. The genital examination discovers a white “cold cream-like” substance
in the genital area. The yeast odor and the presentation of the area reveals
that she has a very large area affected by yeast, extending out beyond the
genital area into the folded-skin spaces at the top the legs. She pulls away in
pain when touched. No acute lacerations or abrasions are observed by the
forensic nurse. Blind vaginal swabs are obtained in lieu of a speculum
examination after discussion about the method with the patient. The evidence
collection kit is completed and signed over to law enforcement, maintaining the
chain of custody. The emergency room nurse practitioner orders standard lab
tests, revealing a blood glucose of 460 and urine dipstick showing 4+ ketones.
Other lab work is pending so the patient is admitted to the hospital for
observation and continued medical evaluation. Social services will follow her
while in the hospital and after discharge.
This case was
complex for many reasons. The investigation and evidence collection did go
forward, but it was determined that no one had entered her apartment and she
needed a higher level of care at this time in her life. The case was closed and
upon discharge the patient was admitted to assisted living.
Thimsen (DNP, RN), an assistant professor at Goldfarb School of Nursing at
Barnes Jewish College, always had an interest in vulnerable populations and
action-focused research. As a young nurse, Thimsen pursued interests in an
evolving specialty of nursing, Enterostomal Therapy (now known as Wound, Ostomy
Continence) that started her trajectory into evidence-based research that focused
on gaps in care and medical practices, resulting in numerous publications and
four patents aimed at quality and safety in patient care. Further pursuit of
her interest put her on track to address violence and personal-violence
intervention research to improve care, nursing practice, and, ultimately, to
advance person-centered care for those impacted by violence. Thimsen’s current
work involves community-based participatory research and evidence-based
practices across the specialty of forensic nursing—specifically elder abuse and
Diana K. Faugno (MSN, RN,
CPN, SANE-A, SANE-P, FAAFS, DF-IAFN, DF-AFN) is a Founding Board Director for
End Violence Against Women International (EVAWI), is the current president of
the Academy of Forensic Nurses, as well as a retired-fellow in the American
Academy of Forensic Science and a Distinguished Fellow in the Academy of Forensic
Nursing. She now works for Life Safe as a forensic nurse in Marietta, Georgia.
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