Dr. Kay Foland Introduces Section 4 Concepts The problem of elder abuse is expected to get worse as our population becomes older and sicker and financial pressures strain personal relationships.

To intervene effectively when you care for an elderly victim of abuse, you need to be able to recognize the problem and act when it appears. 

You must also be familiar with your legal obligations and the various service agencies that can provide support for abused elders. 

Evaluation for elder abuse needs to be done in all settings and should include:

• a careful history

• a thorough physical exam

• and use of an assessment tool specific to elder abuse. 

If you suspect abuse, the caregiver should always be interviewed separately. Keep your questions simple, direct, nonthreatening, and nonjudgmental. This will help you gain confidence with the elder and caregiver. Rarely will the elder or the caregiver readily admit that abuse is taking place. Therefore, questions about abuse, injury, and harm do need to be asked directly.

As Dr. Craig related in Module 2 of this series, during a physical assessment, you need to remain aware of normal age-related changes.

But also, you must always be alert for the following possible signs.

When assessing for physical abuse look for signs of fractures, dislocations, and bruises (especially at different stages of healing) or bruises that may be weapon shaped. 

By carefully questioning the elder, nurses can usually distinguish a bruise that has been caused by falling down from one that is caused by being struck. 

Look at the size of the bruise to see if it could have come from a fall as described and check to see if a person can logically fall on that bruised spot. 

When a person falls, the hands usually go out to shield the rest of the body therefore, bruising of the upper part of the body is more difficult to get from a fall.

When assessing for physical abuse, also look for burns (especially cigarette burns or those from hot appliances), check for genital pain, injury, or sexually transmitted infections.

In addition, look for indications that medications have been misused, head and facial injuries (such as orbital fractures, black eyes, and broken teeth), welts that may show up in a rope-like pattern, or physical findings that are inconsistent with the explanation of the injury.

Signs of physical neglect may include decubiti at any site, poor hygiene (which includes dirty clothes, decayed teeth, or dirty nails), unexplained contractures or broken or missing devices (such as dentures, hearing aids, glasses, or a walker), malnourishment (which might show as weight loss, a lack of energy or being sleepy), dehydration or malnutrition (which is not explained by an illness) which can be evident by sunken eyes or cheeks and fecal impaction or diarrhea.

And also among the signs of physical neglect, I’d like to mention are untreated old injuries, a noticeable delay in seeking treatment with an exacerbation of illness or living conditions which are unsafe (for example:  inadequate heat for the elder).

It may be difficult to detect psychological abuse in an elder during a clinic visit or even a home visit because the visit may focus on other issues. 

The shame, embarrassment, or fear associated with this issue may cause elders to deny that the abuse is occurring. 

As was discussed in the last module, psychological abuse can occur along with other forms of abuse. It is hard to imagine physical abuse occurring without emotional consequences.

When elderly persons are abused or mistreated by a caregiver they often become fearful of others providing their care. You may notice guardedness or wariness as a first reaction. 

An elder may be suspicious or paranoid of a health care provider that’s trying to help them. Driven by fear, elders may also have erratic or changing explanations for their injuries. Therefore, it is important that you watch for conflicting accounts between the caregiver and the elder.

The following signs may indicate psychological abuse:

• Depression and anxiety

• Anger or rage

• Fear of strangers

• Fear in their own environment

• Doctor shopping

• Threats used by the caregiver

• Caregiver’s refusal to leave the elder alone with you.

• the elder withdrawing…

• showing a hunger for attention and socialization…

• confusion or disorientation…

• or the caregiver feels a need to consistently speak for the elderly person.

Asking questions regarding financial affairs is a delicate matter but this information is very important and can be used to help screen elders at risk for abuse. 

The nurse should be looking for:

• checks that have been signed by another person…

• expensive purchases of goods, supplies, or services that are not for the elder (or needed by the elder)…

• poor yard work, or no work on the house when the work has already been paid for…

• or utilities turned off because of lack of payment when someone other than the elder was responsible.

The first step in detecting elder abuse is to recognize that the problem exists. Because any elderly person is a potential victim of abuse, all elders should be screened during an interview with an open-ended question, such as:

“Are you afraid of anyone who takes care of you?”… 

or “Does anyone you know strike you or shout at you?”

The elder’s answer or reaction to such a question could raise suspicions and prompt more in-depth questions. 

Screening is also important when an elder needs to be hospitalized or when their health declines. To aid in detecting abuse, there are some useful assessment tools available. 

For example, the Gerontologist Journal in 1998 published an article by Reis and Nahmiash that described a wonderful screening tool that they had developed called the Indicators of Abuse.

This tool is a short survey designed for you to use when interviewing an elder but it can be used as a checklist in the clinic or hospital as well. 

It includes questions that are directed at the characteristics and substance use of both the elder and the caregiver. A tool like this is helpful so that when you assess for elder abuse, you follow a routine pattern. Of course, careful documentation is essential in all cases of suspected elder neglect or abuse. Make sure your documentation of the interview is accurate, detailed, and objective. Whenever possible, write down the exact words the elder and his or her family members used with quotation marks. 

Remember that documentation is also important since it may be needed for any legal proceedings.

Thorough written records include the description of the event (in the client’s own words) and detailed descriptions of all injuries. The written narrative should be accompanied by diagrams and photographs when possible. Be aware, though, that the elder’s consent is required prior to any pictures being taken. It is a good idea to use a simple drawing of a body to record the size and position of any visible injuries.

Don’t worry about creating great art just be sure that someone else could determine the extent of any injuries from your drawing.

Now, the last part of this module will address Interventions for abused elders and possible referrals.

The most important initial consideration should be is the elder in immediate danger or do they have serious medical problems that are not receiving attention. 

An elder who is in potential danger should not be permitted to return to his or her home until the issue of abuse or neglect has been addressed. 

Hospitalization may be necessary or perhaps referral to a shelter.

As a health care provider, you need to work with your State Department of Adult Protective Services when any case of suspected elder abuse is present. 

This is the primary service agency with legal responsibility and authority to investigate reports of abuse and neglect and to provide services to elderly victims. 

For more information, surf to National Center on Elder Abuse and read about how to go about reporting elder abuse:  Reporting Elder Abuse

Most states require health care professionals to report suspected cases of abuse to adult protective services. Many states have instituted a 24-hour toll-free number for receiving reports of abuse and neglect. The calls are almost always confidential. The state agency’s responsibility is to ensure that the legal rights of elders are protected.

If the elder is willing to receive assistance voluntarily, there are a number of things the nurse should do.

• First of all, the nurse can help to educate the elder about abuse including the fact that abuse tends to increase in frequency and severity over time.

• Next, the nurse can help to implement a safety plan. This may include a protective order, change of residence, or hospital admission. The safety plan needs to help the elder decide what he or she does if there is danger.

• The nurse should also provide phone numbers of local resources that can help such as hospitals, police and social service agencies.

• The nurse will also need to work with the family (or whoever is providing care) to alleviate the causes of neglect or abuse. 

• This can include a number of things. Among them setting up home health care services, such as a nurse, bath aide, physical therapist, or housekeeper or contacting programs like Meals on Wheels. 

• Also, increasing socialization through church activities or pastoral visitation, or even attending a senior center might be helpful.

• Contact support groups for caregivers, and for specific health care problems refer them to agencies (such as Alzheimer’s Disease Association).

• Be sure to refer the patient and family to appropriate services for counseling or legal help.

• Also, help the family obtain necessary equipment: like a hospital bed, grab bars, a bedside commode, walker or wheelchair.

• And finally: consider moving the elder to a higher level of care, such as assisted living or perhaps even to a skilled nursing facility if circumstances demand it.

This may include continuing to educate the elder and providing written phone numbers for appropriate referrals. A follow-up plan must be developed. 

As mentioned earlier, the most important initial consideration is whether the elder is in imminent danger or has health issues that are serious. 

To completely evaluate this may actually require several patient visits, as well as contact with different agencies. 

Elders at risk who refuse needed help are of great concern to nurses. 

Making the tough decision of when to intervene against an elder’s will or when to respect that person’s right to self-determination presents practical 
and ethical challenges.

With increased sensitivity to the risk factors for physical and psychological abuse you are often the best person to help prevent elder abuse in the Native American population.

As a nurse, you are also in the ideal position to detect and help treat it at an early stage so that there may be no further harm.

Thank you for participating in Section 4 of Module 3. This ends the entire series about the Care of Native American Elders and how as nurses we can best care for them.

By discussing our cultural differences as well as the specific problems that are indigenous to Indian people, we hope that we have helped you to provide improved health care access and delivery to the clients you serve. 

To review, we have defined and elaborated on the following concepts.
 

Thank you for your time and attention.  Please be sure
to take the Post-Test for Section 4.

Please complete the Evaluation Form and submit with tests.