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The following course content

Introduction

The term “advocate” refers to an individual that supports and promotes the interests of another person (1). As nurse advocates, we protect our patients against incompetency while safeguarding their wellbeing (2). As a nurse advocate in a suspected elder abuse situation, we are obligated, by law, to identify, report, and protect individuals experiencing elder abuse. As trusted members of the healthcare team, we are often the first interaction with a patient (and their family). Therefore, we are in a pivotal position to assess a situation for suspected abuse and neglect, while assuring patient safety, appropriate treatment, and improved outcomes.

Statistically, it is believed that approximately one in 10 Americans over the age of 60 years has experienced some type of elder abuse (3). As our aging population continues to grow, the likelihood of increased rates of elder abuse is a national concern. Nurse professionals often interact with the aging community and must be educated on the many aspects of caring for a person in a suspected abuse situation.

Statistics 

The aging population is facing many challenges related to finances, health and well-being, and safe secure housing options. In 2023, Senior List, a site dedicated to researching senior related products and services, reported some alarming statistics regarding the occurrence of elder abuse on a worldwide scale.

From financial fraud to nonfatal assaults and exploitation, it is estimated that “one in 10 older adults will experience some form of elder abuse, and many endure multiple types of abuse simultaneously” (4). The World Health Organization estimates that “320 million seniors will suffer from some form of elder abuse by the year 2050” (4).

According to a 2019 report by the Office of Inspector General, “1 in 5 emergency room visits among nursing home residents was attributed to abuse or neglect” (5). As the world population of elder persons continues to grow, the occurrence of elder abuse may also continue to grow, due to mental and physical decline, challenges with limited incomes, growing healthcare costs, and lack of appropriate age-related resources and support systems.

Types of Elder Abuse 

According to the World Health Organization, there are many types of elder abuse. In 2022, it was estimated that approximately one out of every six adults over the age of 60 had been subjected to some form of abuse in the prior calendar year (6). While rates are higher in institutions such as nursing homes and related long term care facilities, many forms of elder abuse occur in the home setting (6). The following list highlights various types of elder abuse. Any intentional act (or lack of appropriate action) that results in harm or distress to an older person is considered abuse.  

Psychological Abuse
Psychological abuse is any action (or even the threat of action) that causes fear of violence or humiliation, a feeling of hopelessness, or isolation. This abuse may manifest itself as threats, verbal abuse, and intimidation tactics. 

Physical Abuse 

Physical abuse is any action that causes physical harm or injury to an elder person. This abuse may present itself as unexplained cuts, bruises, and broken bones. 

Financial Abuse / Financial Exploitation 

Financial abuse/exploitation is any action taken against an elder person’s money, belongings, or financial related documents. Financial exploitation can include unauthorized removal of money from bank accounts, fraudulent transfer of funds, unauthorized use of one’s savings and property, and internet scamming. 

Sexual Abuse 

Sexual abuse is any kind of sexual contact that occurs without the person’s consent. This abuse may present as unexplained sexually transmitted infections, torn or bloodied undergarments, difficulty walking, bruising on genitalia or inner thighs, and possible internal injuries. 

Neglect 

Neglect is a unique form of elder abuse, in that the abuse occurs from the lack of doing something (omitting care) versus the actual infliction of injury. Forms of neglect may include withholding medications and necessary medical treatment, withholding basic food and fluid requirements, and not seeking appropriate medical care for the elderly person when indicated. Victims of neglect may often present with dehydration, in under medicated (subtherapeutic) states, and often lacking basic hygiene care (dirty, soiled diapers or undergarments, disheveled appearance, malnourished). 

Other Abuse Signs/Symptoms 

Other signs and symptoms that may indicate elder abuse can include unintentional weight loss, a noted withdrawal from family and friends, unusual financial transactions, and a lack of basic medical needs such as routine medications and assistive devices (glasses, hearing aids, dentures). Further explanation is needed in these situations, as (the perception of) abuse and neglect may actually be the result of extenuating circumstances unrelated to actual abuse.

Risk Factors and Protective Factors 

There are certain individual characteristics that put an elder person at risk for abuse. Persons with poor physical and mental health often do not have the ability to seek appropriate care within their community. Additionally, those who suffer from forms of cognitive impairment or physical disability may inadvertently place themselves in vulnerable situations.

Finally, those with low income and lack of a support system, especially those living alone, are at higher risk of becoming victims. Protective factors place an elder person at a lower risk for abuse. These include good health, financial stability, appropriate physical activity/physical ability, and a strong social support system. The important thing to remember is that elder abuse can occur across all cultures, races/ethnicities, and socioeconomic levels. There are no single identifiers that confirm or exclude an elder person from possible abuse. 

Conversely, alleged perpetrators of elder abuse may suffer from issues that increase the risk of abuse to an elder person. Untreated medical and mental health issues such as mental illness, illegal substance abuse, and financial instability may all heighten the risk of abuse. Alleged abusers may be male or female, and in “almost  60% of elder abuse and neglect incidents,” the perpetrator is a family member” (7). “Two thirds of perpetrators are adult children or spouses,” who thus have had the opportunity to be well versed in knowing the victims physical and/or mental vulnerabilities (7).  

Additionally, alleged perpetrators of elder abuse often have no other means of support, aside from the victim’s social security checks, personal savings, and housing (8). Many have a prior criminal record, suffer from mental illness or disabilities themselves, and frequently have a history of drug and alcohol abuse (8).

Prevention 

The prevention of elder abuse is multifaceted. There is no single answer/action that prevents abuse in this vulnerable population. However, there are guidelines in place to maximize an elder person’s safety and well-being. The overall goal of elder abuse prevention is to lower the risk factors associated with heightening the occurrence of abuse. As nurses, we are in a pivotal position to advocate for the elder patient, as well as identify potential resources to benefit both patient and family (9).  

The “accusation” of suspected abuse will most likely be ill-received. Caregivers, family members and others close to the elder person may feel threatened, defensive, and angry when a healthcare professional discusses their concerns over what appears to be suspected elder abuse.

The suspected victim may also feel humiliated, embarrassed, and fearful of law enforcement involvement. The suspected victim has most likely been abused by someone who has violated their trust and taken advantage of them. Therefore, it is possible that many victims of abuse are fearful of further retaliation, especially if the alleged perpetrator is an immediate family member. 

When possible, the members of the healthcare team should interview caregivers and all suspected abusers separately from the alleged victim. Sometimes, subtle discrepancies between the suspected abuser and the victim interview may give unique insights worthy of further investigation.  

Consider the following scenario. An elderly patient arrives via ambulance, from her private home, and appears malnourished, incontinent, and confused. As you document your findings, a team member voices concerns over suspected abuse. You are told the patient lives with an immediate family member. Initial calls are made to alert authorities of a possible elder abuse situation. The family member arrives, and states they are the patient’s primary caregiver. 

1. The primary caregiver is the 19-year-old granddaughter. What are your initial concerns over what appears to be neglect? 
2. The primary caregiver is the 78-year-old husband, appearing frail, walking with a cane, obviously undernourished. Do your concerns change?  
3. The primary caregiver is a 45-year-old son, unemployed, avoiding eye contact, appearing disheveled. Any additional concerns? 

The nurse advocate must remain objective, nonjudgmental, and empathetic while investigating the situation. What initially appears as intentional abuse and neglect may also be due to the fact that many caregivers are also overwhelmed by the complexity of the situation, whether it be lack of knowledge, financial insecurity or mental/physical disabilities themselves.

The goal of nurse advocacy in these challenging situations is to fully assess not only the health and well-being of the elder, but that of the caregiver. All related documentation on a suspected abuse case must remain objective, reflecting only actual statements made by the patient and accompanying caregiver/ family member, as well as physical examination findings.  

For guidance on medical record documentation when elder abuse is suspected, visit Documenting in the Medical Record by Stanford Medicine. ***Always check with your current worksite for site specific protocols/guidelines regarding approved documentation standards. 

The current elder population is growing rapidly. By 2030, one in six people in the world will be aged 60 years or over. At this time the share of the population aged 60 years and over will increase from one billion in 2020 to 1.4 billion.

Common age-related health conditions occur often leading to complex medical issues at a time when finances, family/community support, safe housing options, and available resources may be in limited supply (10). Over time, the once healthy vibrant elder person can become frail, malnourished, depressed and isolated. This is the pivotal point in which many nurses first cross paths with the elder person.  

A multidisciplinary team approach may be needed to address the various physical, mental and emotional needs of a vulnerable elder, dependent on the current health status, physical needs, and financial means. Team goals should include efforts to return the elder person to an environment best suited to support healthy eating, physical activity, a safe and affordable living environment, accessible transportation, and a supportive community.

Depending on the health status of the individual, the goal can vary the spectrum, from independent living to nursing home placement. Again, these efforts are best addressed by a multidisciplinary team approach.  

In the acute phase, when elder abuse is suspected (or confirmed), the safety of the victim is the highest priority. As nurses, we are mandated to report all suspected abuse, including that of vulnerable adults. Your specific workplace should have written protocols regarding the reporting of suspected abuse, as well as guidelines of documentation of the suspected abuse.

Failure to do so may result in a variety of penalties, including but not limited to fines as well as criminal charges (ranging from misdemeanor to felony charges). It is imperative that you, as a licensed professional, become familiar with your state’s mandatory reporting laws (11).  

Reporting 

As stated previously, a nurse’s workplace should have written protocols in place to report suspected elder abuse. The majority of states also have written guidelines in place for reporting suspected abuse. The United States Department of Health and Human Services also offers guidelines for all persons in the reporting of such abuse.

If the person is in immediate or life-threatening danger, the local authorities should be notified through 9-1-1. In the event that abuse is suspected, but there is no immediate threat to life or limb, the recommendation is to notify the local adult protective services (APS) or police department (12).

End of Life Considerations

According to the position statement on end of life care from the American Nurses’ Association, nurses “are often ideally positioned to contribute to conversations about end of life care and decisions, including maintaining a focus on patients’ preferences, and to establish mechanisms to respect the patient’s autonomy” (13). Similarly, a statement entitled “The Right to Self Determination” from the Code of Ethics for Nurses with Interpretive Statements also emphasizes the nurse’s role in end of life planning and care: 

“The importance of carefully considered decisions regarding resuscitation status, withholding and with-drawing life-sustaining therapies, forgoing nutrition and hydration, palliative care, and advance directives is widely recognized. Nurses assist patients as necessary with these decisions. Nurses should promote advance care planning conversations and must be knowledgeable about the benefits and limits of various advance directive documents. The nurse should provide interventions to relieve pain and other symptoms in the dying process consistent with palliative care standards and may not act with the sole intent of ending a patient’s life” (13). 

What these statements say is that nurses have ethical roles and responsibilities that are fundamental to nursing practice. Nurses should ensure that both patients and family members understand the options and treatments that have been presented to them, and should ensure that the patient’s autonomy is being respected throughout all aspects of their care. Nurses are first and foremost patient advocates, and this is especially crucial during the end of life stage. Nurse advocacy during this time can encompass anything from symptom and pain management, culturally sensitive care provision, and ethical decision making (14).

Talking to Patients and Families

Talking to a patient and their family about end of life care can be a huge challenge for nurses. In addition to managing patients’ and families’ emotions, nurses must manage their own emotions and approach the subject with professionalism as well as empathy.

Often, during the end of life planning phase, patients will go through the five stages of grief, as outlined in the book “On Death and Dying” by Elizabeth Kubler-Ross. The five stages of grief include (14):

Denial: Usually a temporary defense, patients may say that they’re fine, or that this is some mistake.
Anger: Once the patient is no longer in denial, anger is often the next stage. It may be difficult to care for the patient during this stage, as they may misplace their angry feelings on their caregivers.
Bargaining: At this stage, the patient seeks ways to postpone death – often in the form of promising to reform a lifestyle in exchange for more life.
Depression: This stage may involve the refusal of treatments or visitors, and the disconnection from people, love, and affection.
Acceptance: The final stage, which is not reached by all patients. In this stage, the patient has come to terms with their mortality and has accepted that death will happen.

It is important for the nurse to understand these five stages, as most patients will be experiencing one or more of the stages during the end of life process.

Here are some helpful techniques for nurses to use when talking to patients about hospice or end of life planning, according to the American Academy of Family Physicians (15):

Make sure you have time.

While this may seem impossible while on a shift when you have other patients, it’s imperative that a nurse allow enough time to have this difficult conversation. This is not a conversation that can be rushed – rushing through the conversation may make a nurse miss important details that the patient has shared.

Turn off your phone.

Minimizing distractions during these difficult conversations will ensure that the nurse can get ample information from this patient and family interaction.

Listen to the patient.

Above all, listen to what the patient is saying. Begin the conversation by asking what the patient and their doctor have already discussed. Be sure that the plan of care has been reviewed with the doctor prior to this conversation, then have the patient repeat their plan of care as they understand it. If there are major differences in the plan of care and what the patient says, this may warrant further conversation with the health care team to clarify and identify knowledge gaps.

Learn what the patient’s goals are.

Active listening is crucial during the conversation phase of end of life care planning. Once the nurse has determined that the patient understands the options that have been presented, it is vital to ask them what their goals are for palliative and comfort care. Understanding a patient’s goals can help identify what resources will be best suited for their individual needs.

Conversations surrounding end of life care should happen as soon as possible. Do not wait until the patient is no longer able to participate in the discussion. Encourage the presence of family members, but be sure to respect the patient’s wishes regarding who is involved in the planning process. Other members of the healthcare team that should be included in the planning process include social workers, patient navigators (if applicable in that setting), and any primary and specialist physicians involved in the patient’s care.

Additional Resources 

The Elder Abuse Guide for Law Enforcement (EAGLE) 

 Use this website to review state-specific elder justice laws.  

https://eagle.usc.edu/state-specific-laws/  

National Adult Protective Services Association 

Use this website to find specific contact information for your state location 

https://www.napsa-now.org/help-in-your-area  

ElderCare Locator/ United States Administration on Aging  

Use this website to connect with services for older adults and families. 

https://eldercare.acl.gov/Public/Index.aspx  

World Elder Abuse Awareness Day 

June 15th has been declared World Elder Abuse Awareness Day (WEAAD). For more information, visit https://eldermistreatment.usc.edu/weaad-home/. The website offers multi-language downloads on elder abuse facts, as well as social media guides, awareness campaigns, elder justice groups, and associated tool kits.  

Conclusion

As the elder population continues to grow, so does the risk of elder abuse. As nurse professionals, we must continue to advocate for the safety and well-being of our aging population. We must continue to stay informed and educated on identifying abuse throughout the age spectrum.

Lastly, we must be knowledgeable of our own available resources to best assist the elder population and their basic needs, including food and shelter, access to healthcare, and transportation, as well as community wide support services.

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