As a caregiver, you spend more time than anyone else caring for elders – this makes you the backbone of our team, and the one who is more likely to spot if something is wrong with patients. Your observations are particularly important for identifying abuse and neglect.

Abuse can be physical (hitting, pinching, force-feeding), psychological (threatening, humiliating), material (stealing), or sexual.
Neglect is failing to provide for someone’s basic needs. Both can be perpetrated by staff, other patients if in a facility, or even family members.

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DOMESTIC VIOLENCE
Domestic violence is abuse from someone in a household against a family member or another household member. It can be physical force, intimidation, neglect, verbal abuse and threats, isolation, economic control, destruction of personal property, stalking, and so on.

When domestic violence happens to an older person, it is elder abuse. And elder abuse is a serious problem in this society. Elder abuse is grossly under-reported because of family secrecy and because victims are reluctant to report anything to authorities. This is because, too-often, family members, neighbors and others treat suspected abuse as a private affair and don’t want to do anything publicly about it. And, often, the abused elder is either afraid to report the abuse, or has a condition such as Alzheimer’s, and doesn’t even know that the abuse is occurring, or what they can do about it.
 

Unfortunately, it’s a very big problem: It’s estimated that 1-2 million elders every year are mistreated by someone they depend on for care and protection. Fines and judgments can be in the hundreds of thousands of dollars, and long prison terms can be handed out by the courts. In fact, in some cases of pressure ulcer development due to neglect, judgments can be in the millions of dollars against caregivers and facilities involved in this type of abuse.
 

In most cases, pressure ulcers are preventable by regular, attentive, caregiving measures. And when they develop in an elder, it can be considered a serious form of elder abuse.

 

ELDER ABUSE FACTS
 

• Ninety percent of elder abuse and neglect is caused by adult children, spouses or other family members. This is a type of domestic violence, for which all caregivers need to be aware, as they may have patients who are, or have been, the victims of domestic violence. 

• Less than 10 percent of abuse is by paid caregivers.

• Neglect is the most common form of elder abuse followed by physical abuse.

• Most elder abuse occurs in the elder’s home and not in institutional settings.

• Women are abused more frequently than men.

• Caregivers need to be aware of elder abuse – why it happens, what it is, what are the warning signs, and what can be done about it. All new clients should be screened for abuse and actions of family members and visitors observed.

• Elder abuse sometimes does not stop when the elder is admitted to a facility.
   

All of this means that frontline caregivers are often in a position to spot signs of abuse of their elders and can do something about it.

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TYPES OF ELDER ABUSE
The National Center on Elder Abuse defines several different types of elder abuse:

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1. Physical abuse. The use of physical force that may result in injury, physical pain or some type of impairment. Examples of physical abuse include slapping, shoving, hitting, pushing, kicking, pinching, burning, biting, beating, restraining with rope or chain, over or under-medicating, depriving of food, exposing to severe weather, or depriving of any basic need. Note: Many elders will not say anything about abuse – they remain silent due to “family” or out of fear.

2. Sexual abuse. Non-consensual contact of any kind with an elderly person. This can be anything from sexual exhibition to actual rape, and includes inappropriate touching, forcing to pose for suggestive photography, forcing to watch pornography, forcing sexual contact with someone else, forcing nudity, forcing conversations of a sexual nature, or any unwanted sexual behavior.

3. Emotional/psychological abuse. Infliction of anguish, pain or distress through verbal or non-verbal acts. The acts are demeaning and cause fear and withdrawal. These include name-calling, making threats, giving insults, shouting, swearing, frightening, blaming, ridiculing, constantly criticizing, ignoring, humiliating and isolating from others. A common theme with emotional abuse is that the abuser will find something of importance to the elder and then use it to force the elder to something the abuser wants. One method is to threaten harm to a beloved pet. Isolation is a strategy for keeping the abuse secret or it can result from the stress related to caring for an elderly family member.

4. Financial/material exploitation. The illegal or improper use of an elder’s funds, assets or property. This abuse is growing rapidly and the abusers are not always family members or caregivers. Outside sources use many different measures to get to money and valuables they think the elderly have. Embezzlement, fraud, forgery and scams are some ways the elderly are bilked out of their financial resources.

5. Neglect. When someone refuses to, or fails to, provide for the health and well-being of an elder he or she is obligated to care for. Neglect is withholding attention and failing to meet physical, emotional and social needs. These needs include food, water, clothing, healthcare, safety and protection, medications, help with activities of daily living, companionship and general comfort. Neglect is the most common form of abuse.

6. Abandonment. The desertion of an elderly person by someone who has physical custody of the elder, or by someone who has assumed responsibility for providing care to the elder.

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RECOGNIZING ABUSE
Besides knowing the types of abuse that threaten your elders, it is important to know what to look for in recognizing elder abuse in general. Some of the signs and symptoms listed below could result from disease conditions or certain medications. They could also result from abuse:

Physical abuse – bruises or grip marks around the arms or neck, pressure marks, abrasions, burns, broken bones. Rope marks or welts on the wrists and ankles. Hair loss from someone pulling hair, black eyes, broken fingernails. Repeated unexplained injuries. Dismissive attitude about injuries. Refusal to go to the same emergency room for repeated injuries, doctor shopping.
 

Sexual abuse – flinching at movements, frightened of opposite gender, unexplained vaginal or anal bleeding, torn or bloody underwear, bruised breasts or genital area, venereal disease or vaginal infections. Note: Men are also victims of sexual abuse.
 

Emotional/psychological abuse – uncommunicative and unresponsive to questions or statements. Hesitation to talk openly. Strained or tense relationships, with frequent arguments. Fearful or suspicious, lack of interest in social contacts, evasiveness, nervous behavior such as rocking, sucking, biting.
 

Financial/material exploitation – personal belongings begin to disappear, money is withheld from the elder, life circumstances don’t match with the size of the estate, signatures on checks don’t match the elder’s, large withdrawals from bank accounts, credit cards disappear, checks made out to cash, checks written out of order, unusual ATM activity, and numerous unpaid bills. Someone may live with the elder and refuse to leave.
 

Neglect – dirty bed linens and clothes, poor hygiene, unattended medical needs, bedsores, extreme thirst, sunken eyes or loss of weight.
 

Abandonment – easy to spot – left somewhere without any possessions or information. Confusion may make the situation more difficult. May be reluctant to talk to anyone.

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EVIDENCE-BASED STRATEGIES THAT WORK
As a caregiver in close contact with elders, you play an important role in helping reduce the tragedy of elder abuse.
It all comes down to following a few key evidence-based strategies:

• Be observant for signs of abuse in your elders:

  • Bruises or other injuries

  • Shrinking back in fear, when someone goes near them

  • Withdrawal from activities

  • Appetite loss

  • Sad mood

  • Medical problems that are not being addressed

  • Poor hygiene, such as being left in soiled diapers

  • Malnutrition and/or dehydration.

• Ask! Asking the person directly can often provide useful information, even when the older adult has cognitive impairment. Examples of questions include:

  • How is everything going?

  • Is there anything that concerns you?

  • I see you have bruises on your arm. What happened? 

• Take all complaints of abuse seriously. This includes complaints from residents or patients with dementia. Research has shown that those in the mild and moderate stages of the disease can remember if they have been mistreated. 

• Report any suspicions. Don’t just assume that someone else will report it. It is your obligation to report anything that may suggest abuse or neglect. 

• Follow up. Once you have reported your concerns, it’s not your responsibility to investigate what happened, but it’s good to ensure the problem is being addressed. Check on the elder often to make sure they are okay. 

 

REPORTING ABUSE
Keep in mind that elder abuse is a crime that needs to be investigated by authorities. In many states, there are laws that require home care agencies to report elder abuse to local law enforcement or health department officials, if it is suspected by a caregiver. 
 

Importance of Screening. As a major step forward in stopping elder abuse, caregiver associations recommend that every type of healthcare institution serving the elderly should adopt a program of routinely screening for elder abuse. 
 

And when you suspect it: Report it immediately.
 

As a frontline caregiver who gets to know your elders better than almost anyone, you may be one of the first to suspect elder abuse.
If you do, it’s your duty to immediately report your suspicions to your supervisor.
 

Abuse hotlines. Every state has a service designated to receive and investigate allegations of abuse. To find yours go to www.ncea.aoa.gov. This is the federal government’s National Center for Elder Abuse website, and it has valuable information on this topic that may be helpful to you in your caregiving job.
 

Investigating cases of elder abuse is not your job. It’s the job of law enforcement agencies, trained social service workers, and other experts, who will take over the investigation after the report to them is made. You do not need to investigate your suspicions yourself, gather evidence, and so on. You do not need absolute proof that the abuse is occurring in order to report it.
 

Confirming the abuse, getting evidence and so on, is the job of trained experts in law enforcement and social service agencies.
Your job is to immediately report your suspicions to your supervisor. 

 

CARING FOR THOSE WHO HAVE BEEN ABUSED
You occasionally may provide care for an elder who has been abused, and who may show some of these behavioral problems.
Depending upon the type of abuse and for how long it went on, the behaviors may be mild or severe. In cases of long-term abuse, the impact on the elder may be devastating. The National Center on Elder Abuse lists the following as common behavioral problems of those elders who have been abused:
 

• Fear

• Anxiety, agitation

• Anger

• Isolation, withdrawal

• Depression

• Non-responsiveness, resignation, ambivalence

• Contradictory statements, implausible stories

• Hesitation to talk openly

• Confusion or disorientation

What can you do for these elders? This answer is not simple, as these situations can be very complex, and much depends on the extent of the elder’s problems. You can help considerably by showing them kindness, compassion and understanding.
 

If they’ve been abused a long time, they may initially be very fearful of caregivers, and even angry at them. So you’ll need to be patient to show them that you really do care for them. Also, in general, for elders who are depressed and isolated, simple exercise programs have been shown to significantly help. Programs to help them socialize with others can be beneficial as well. 
 

Regardless of the extent of their problems, your loving, attentive and watchful care may well be the best thing that can be done to help them recover, and help get them on their way to a much-improved, much happier, quality of life.
 

And here is another important point to remember.
 

Stress and burnout make you more likely to become an abuser or to ignore acts of abuse you witness, according to new research in the journal International Psychogeriatrics. So, if you start to find that you’re getting stressed or burned out in your caregiving job, you need to take steps to remedy the situation.
You can do this by learning how to destress by regularly engaging in relaxation, leisure, socializing and exercise activities.
 

Another effective way to prevent stress and burnout, according to findings in the Journal of Clinical Nursing, is to develop “emotional intelligence.” Emotional intelligence is essentially a set of qualities:
 

• The ability to develop good relationships with co-workers,

• Knowing how to control anger and other negative emotions,

• Being motivated to perform at your best, and

• Showing understanding for other people’s feelings.

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In a recent study of 122 nurses working in hospital wards, higher emotional intelligence was associated with lower risk of stress and burnout.

 

Remember, it’s your elders’ right to be free from abuse and neglect. And it’s your responsibility to ensure this right is protected – at all times.