Abuse and Neglect of Elderly Persons - Dissertation Example

1. Literature Review – Elder Abuse 1 Introduction “Elder Abuse is a single or repeated act or lack of appropriate action occurring in any relationship where there is an expectation of trust, which causes harm or distress to an older person” (adopted by the International Network for the Prevention of Elder Abuse as a universal definition, cited by HFMS, 2004). Elder abuse can be physical, psychological, financial, sexual and neglect. According to a report by WHO, elder abuse can range from outright physical assault of old people in modernized cultures to systematic ostracisation of tribal elders in the less developed countries (Lachs & Pillemer, 2004). Elder abuse can take place in the individual’s home, the carer’s home, at the day centre, at the nursing home (institutional abuse) or in the hospital. This paper will review existing literature on elder abuse with emphasis on Ireland. Credible and strong medical evidence indicates that increasing age leads to mental decline (Burns, 2002). Elders become more vulnerable to diseases which may directly or indirectly affect brain function. They also suffer from various medical and psychological conditions, which even if it does not completely incapacitate them, it may cause temporary impairment. This reduces their ability to distinguish what is in their best interests. Despite legislative measures elders are at a high risk of mistreatment and abuse. 1.2 Definition of abuse Abuse has been defined as “the willful infliction of physical pain, injury, or mental anguish, or willful deprivation by a caretaker of services necessary for physical and/or mental well being” (Lachs & Lippemer, 1995). According to Buka and Sookhoo (2006) the increase in longevity and the higher ratio of elderly people needing care affects the quality of care. Elder abuse is an under-researched area as the awareness in UK has been created recently. For the elders the issue of trust in a caregiver is central to the relationship. Breach of trust results in abuse while McCormack (2006) states that abuse of all kinds eats away at this trust. Erosion of trust can at best lead to care omissions and at worst it can lead to systematic abuse of elders. In UK cognitive impairment was the leading indicator of abuse among elders. Although social recognition of elder abuse and legal, health and public concerns about abuse of older people is a recent phenomenon, the mistreatment of the elderly has occurred over the course of history. ‘Granny battering’ was used in a British Medical Journal and an article in Modern Geriatrics to discuss the inadequate care provided to the elderly (Ayres & Woodtli, 2001). Elder abuse in England was primarily framed within the context of medicalization and institutionalization. Definitions of elder abuse have differed according to research and practice. Since the quality of care giving is the central issue in elder abuse, researchers contend that there should be a shift to care giving paradigm for clinical practice. Elder abuse is not a new phenomenon but the combination of an ageing population and the new definitions of abuse have created a greater level of awareness in the society and in the medical profession particularly. Awareness has led to increased research on the prevalence of abuse, its predisposing factors and the efficacy of interventions (Coyne, Reichman, & Berbig, 1993). Elder abuse remains largely unreported and the healthcare professionals do not realize the potential risks that the elders are associated with. McCormack (2006) contends that abuse is under-reported due to the psychosocial factors associated with it. At the same time, Fletcher and Buka (1999) contend that the sign of abuse may not always be obvious and may be uncovered secondary to other issues. Abuse may be ‘discovered’ by a healthcare professional on admission assessments during Accidents & Emergencies (cited by Buka & Sookhoo). Clinical manifestations and diagnosis of elder abuse can be difficult to confirm, agree Lachs and Pillemer (2004). Patients with symptoms of elder abuse may not have really been subjected to it and vice versa as several signs and symptoms of many illnesses of late life can be attributed to abuse. 1.3 Types of abuse Abuse of older adults includes physical violence, which means acts carried out with the intention of causing physical pain or injury. The most common violent acts towards elders are slapping, hitting and striking with objects. These result in bruises, sprains and abrasions, sometimes even skeletal fractures, burns and other wounds. Psychological abuse accompanies physical abuse like habitual verbal aggression in the form of threats and insults. Even threat of abandonment falls under this category of abuse. The failure of a designated caregiver to meet the needs of a dependent elderly person is a form of abuse (Lachs & Pillemer, 1995). Sexual abuse includes sexual rape or assault without the consent of the older adult while financial abuse includes theft, fraud, exploitation, pressure in connection wills, or the misuse or property, possession or benefits (POF, 2002). Neglect may be intentional or unintentional and may stem from ignorance of a genuine inability to provide care, say Lachs and Pillemer (1995). Research demonstrates that psychological abuse was the highest at 38.9% while sexual and societal types at the lowest level at 1.9% and 1.5% respectively (Buka & Sookhoo). According to Buka and Sookhoo (2006) elder abuse may be categorized under three broad areas – neglect, violation of human, legal and medical rights and deprivation of choices and decisions. It is essential for healthcare professionals to understand the classification of abuse in order to explore the range of issues related to different types of elder abuse. The DoH introduces another category known as discriminatory abuse sometimes even known as institutional abuse. This results from inadequate provision for the elders. Elder abuse arises from inadequacy of care, as a result of lack of resources, reports POF (2002). Discriminatory abuse also includes racism and sexism based on a person’s disability and other forms of harassment, slurs or similar treatment. Institutional abuse arises when care standards are poor, when there is lack of positive responses to complex needs, under rigid routine and inadequate staffing, or when there is insufficient knowledge base within the service. Some instances of abuse like sexual assault and rape, theft and fraud also constitute a criminal offence when the older adults are entitled to protection under law. Apart from physical, sexual and neglect, abuse can also take the form of over-medication (Newton). The elders were frightened, embarrassed or unable to report abuse due to which it often went unnoticed. The report identified that training was essential to identify abuse. The caregivers often were not even aware of the reporting procedures. To combat the shortages of staff, the elders were often prescribed anti-psychotic drugs to sedate the people. 1.4 Government Policies related to elder abuse Two important policy documents in relation to older people are the NSF for Older People (2001) and the other No Secrets (DoH, 2000). The NSF for Older People (DoH 2001) is a comprehensive strategy to ensure ‘high quality, integrated health and social care services for older people’. No Secrets aims to ensure health and social services have appropriate policies and procedures in place to protect vulnerable adults from abuse. Another document released in Northern Ireland deals with the issues of content when working with older people (De Laine C et al., 2002). By monitoring the standards the DoH hopes to ensure that everyone will receive the same standard of service, irrespective of their age and place of residence. 1.5 Diseases most likely related to abuse Elder abuse is now accepted as a problem and research suggests that people with dementia may be particularly vulnerable to it. Abuse depends to a large extent on the institutional setting. Mistreatment of older people by staff can be termed sadistic or reactionary, which occurs due to lack or proper training or overwork (Richardson, Kitchen & Livingston, 2002). Emotional exhaustion results in negative attitude towards the patients. The staff was high on burn-out and experienced high conflict with patients. Lachs and Pillemer (2004) confirm that studies report higher incidence of elder abuse in patients with dementia and the major cause of retaliation by staff is the stress and distress that they are subjected to. Grasel (1995) however states that subjective factors like the stress that the caregiver is exposed to is more strongly associated with elder abuse that objective factor like dementia. The care givers who have low social support are at high risk for psychological distress and depression. The goals of treatment hence should be to improve the quality of life of the demented person and minimize burdens on the caregiver. Apart from the roles of stress, dependence, physical health, alcohol and other drug abuse, dementing illness like Alzheimer’s disease place an individual in the high-risk group for abuse (Lachs & Pillemer, 1995). Results indicate that the caregivers who abused patients were providing care for more years and had been providing care for more hours per day. They cared for patients functioning at a lower level and displayed higher levels of burden. After the onset of dementia, the patients also abused the caregivers and those that had been dealing with such patients for more number of years were more likely to be abused by elder patients. Interventions to reduce the level of stress and depression in caregivers include psychopharmacological treatment, supportive psychotherapy, support and education groups, and services that reduce the number of hours per day spent providing direct patient care. In fact the caregivers use more of antidepressants, anti-anxiety and hypnotic medications than the general older adult population. Group psychotherapy interventions are initiated by physicians, which help in the psychological consequences of the caregivers’ losses and recently required responsibilities. Effective techniques to reduce stress do positively impact the burden on the therapists. Pressure ulcer prevention and management is high on the agenda in Ireland. The Health Strategy of Department of Health and Children (DoHC) clearly states that the provision of care should be timely, appropriate and evidence based (Moore & Price, 2004). The ultimate objective should be to improve the health and quality of life of users of the Irish healthcare system. A report of 2002 of The Working Group on Elder Abuse puts the responsibility for providing adequate preventive measures for pressure ulcer prevention and management firmly in the hands of care providers. The failure to provide such care is a form of abuse and is intolerable. Hence, in Ireland elder abuse does not merely pertain to physical, sexual or financial abuse but even lack of care is considered abuse. Research demonstrates that staff nurses have a positive attitude towards ulcer prevention and management but lack of time and shortage of staff prevent this positive attitude from being reflected in clinical practice (Moore & Price). The positive attitude of nurses was not influenced by the length of service, the clinical areas that the nurses were qualified in, or whether they had received any formal training in pressure ulcer prevention and management. Certain areas of pressure ulcer prevention like repositioning cannot be carried out unaided and hence shortage of staff contributed to lack in treatment. Even though the positive attitude was not dependent on whether they had received any formal training but research suggests that nurses with sounder knowledge base made better clinical decisions thus highlighting the importance of training and education. Hence to reduce elder abuse nurses must seek required education to maintain competency in this aspect of clinical practice. Positive attitude is not enough to ensure behavioral change. Study also revealed that while a positive attitude to people with dementia was highly correlated with baseline knowledge, learning was not associated with change in attitude. Most staff has an initial positive attitude and hence there is not much improvement as they learnt. Qualified staff has a more positive attitude than the unqualified staff but length of experience did not change the staff attitude (HFMS). Another important area where abuse is likely to occur is continence among the older people. Abuse can occur in any setting and in any circumstances but the case of older people requiring continence care provides illustration of pertinent issues. Continence care requires strong lead from nurses and the quality of care rests with this professional group. Continence ahs to be person-centered care as it means putting the older person at the center of his or her treatment. This ensures that the services are need led and not service-led. This requires the staff to have adequate knowledge of continence care and they should eliminate any discrimination. The word ‘abuse’ has many negative connotations. In the field of nursing older people ‘routinised geriatric style care’ was the norm for many years. They concentrated on meeting the physical needs and getting through the work. This depersonalized the client and in this process abusive care might have occurred. Continence care is an example where continence care could be manifested. Old attitudes are not easy to eliminate and hence the policies aim to raise awareness of what constitutes abuse. Exclusion of clients because of incontinence or not being able to identify or recognize incontinence as a problem is a form of abuse. 1.6 Role of nursing staff in elder abuse Very little research is available evaluating the effect of educating staff to increase their skills in dealing with abuse. Research demonstrated that there was lack of good management in dealing with elder abuse and educational seminars were superior to printed material in increasing knowledge and good management in this field. The courses have to be tailored according to the initial knowledge of the participants. It is extremely important that staff is able to identify abusive situations and have confidence in their management. At the baseline the staff does not often recognize, records, and report abuse, contend Richardson, Kitchen and Livingston. According to study by HFMS also one of the major problems in dealing with elder abuse is the difficulty in identifying it. Recognizing the signs of abuse depends upon the healthcare professional’s training and experience (Buka & Sookhoo). It is essential that the nursing home staff are able to recognize the signs of abuse before it is too late. Nurses are expected to apply policy to practice. A study revealed that the concerns of nurses appeared to be invisible to everyone except nurses (De Laine C et al., 2002). Nursing is viewed as unimportant as compared to medicine, especially by the government. Failure to apply policy to practice or failure to engage with groups that influence policy may result in their not being included when decisions are being made about the direction of care. This ultimately means that the level and the type of nursing care offered to patients may be inappropriate. There is a general tendency to treat all old people in the same way irrespective of their clinical need. This is not a person-centered approach to care. 1.7 Abuse in Ireland A random sample survey of nursing home staff members found that forty percent of the nurses’ aides reported committing at least one act of physical abuse (Lachs & Pillemer, 1995). Survey revealed that 88% of District Nurses had ‘encountered elder abuse during the course of their work’ (Community and District Nursing Association [The Community and District Nursing Association (CDNA), 2004 p. 1, cited by Buka & Sookhoo]. Another survey on telephone by Action on Elder Abuse demonstrated that nurses may themselves have been implicated in abuse with 10% in care homes and 6.5% in residential homes. Twenty-five percent of all calls made to Action on Elder Abuse raised concerns about abuse in institutional settings (McCormack). Abuse manifested itself through ‘old-fashioned’ and ‘regimented nursing care’ in a mental health unit in Manchester as reported by the Commission for Health Improvement. Nurses and doctors turn a blind eye especially when the abuse is systematic. According to the World Health Organization 5% of all older people 65 years and above may be the victims of one form of abuse. Ireland, in 2001, had approximately 430,000 people over 65 years and above, which would mean an approximate 21500 people subject to elder abuse (HFMS, 2004). About 10-20% of older people 65 years and above suffers from serious mental health problems including Alzheimer’s, dementia and depression. Depression in the people in this age group ranges from 15% in the general community to 30% of those in residential homes, according to Northern Health and Social Service Board (EHR, n.d). Research by NHSSB suggests that when people with dementia were admitted to hospital, acute staff did not know how to cope with people with learning disabilities. It is further estimated that in Ireland between 12000 and 20000 people living in the community may be suffering from abuse, neglect and maltreatment ((O’Loughlin and Duggan, 1998 cited by POF, 2002). These figures may be underestimated because figures of abuse in institutions are not available. Since the Irish population aged 65 and above and aged 85 and above is growing, the number of people at risk of and suffering from abuse will inevitably increase. Since the status of older people is devalued, the identification and prevention of elder abuse is likely to be hindered. Informal care for people in their own homes to support the services of the health care seems to be on the rise in Ireland especially for elders. West of Ireland has a higher proportion of older people than the rest of Ireland - 14% as opposed to 11% aged over 65 years and 3% compared with 2% aged over 80 years (McCann & Evans, 2002). This trend is likely to continue and it is expected that 17% of the population of the region will be aged over 65 years and 5% will be aged over 80 years by 2011. According to a recent report to the UK Parliament around 500,000 elderly people may be being abused out of which two-thirds of the cases appear in their own homes. About 12% abusing occurs in nursing homes, 10% in residential care, 5% in hospitals, 4% in sheltered housing and 2% in other locations (Newton, 2005). A study in UK found that ‘…residential and nursing home as well as hospital setting accounted for 26.7% of calls’ received by Action on Elder Abuse helpline (Buka and Sookhoo). As of 2002 the number of people over 60 years form one-fifth of the UK population and demographic trends indicate that the number aged over 80 will almost double by 2030 (DoH 2001, cited by De Laine C et al., 2002). As reported by a clinician in Ireland elder abuse is often unintentional and the structures of health and social care are responsible for it (POF). The elders are treated and cared for by over-worked, stressed, burnt-out staff that is too small in number to cater for their needs properly. POF suggests that a holistic approach, with integrated services and staff equipped with the skills and knowledge to respond to both the protection and wider health and social care needs of older people in Ireland. There are ten health boards in Ireland and each of these should develop a strategy to integrate the cause of elder abuse in to the framework for health and social care services for people. Ayres and Woodtli discuss that the abuse of ageing caregivers is equally important. Caregivers in any setting whether it is domestic or hospital setting, face the same consequences. All of them describe of a personal or psychological conflict associated with the care giving relationship but these have not been termed as abuse. It should be rather termed as ‘mistreatment’. Buka and Sookhoo however state that the carers are themselves vulnerable elders and they often express feelings of frustration, despair and worry of not being cared for. They feel the situation is beyond their control. 1.8 Recommendations to eliminate elder abuse The Nursing & Midwifery Council (2004) Code of Conduct para 3 requires the nurses to have the patient’s informed consent to treatment. Paragraph 4 requires the nurses to identify and minimize any risks to patients (Buka & Sookhoo). Control, dependency and imbalance of power have to be evaluated in the patient/carer relationship. The Mental Capacity Act of 2005 now grants new powers of advocacy for person who are lacking in mental capacity. The healthcare professional is expected to be aware of the ethical principles and values necessary to respect the patient’s values and right to choice. Failure to take into account these factors can result in breach of human rights. In institutional settings, to minimize elder abuse it is essential that legislation and regulations are in place, the policies and procedures are meant for best practice, the skills of carers are as required, the right level of support, training and supervision is available to carers, and the resources are available in plenty (POF). Support system for the care staff should be in place to help them deal with and alleviate stress. The older people also must be cautioned that certain types of conduct are unacceptable. Studies demonstrate that attention has to be paid to ensure that care services are more rigorously monitored, clinical governance framework has to prevent and monitor abuse, and the leadership has to be strengthened. Regulate standards of care has to be in place, says McCormack. Education intervention has only a limited impact in preventing elder abuse. What are required are identification, documentation, and reporting of abuse. Cultures that harbor abuse have deeply ingrained characteristics that are inconsistent with clinical effectiveness and education is insufficient to change these. The approach has to be systematic where everyone concerned is allowed to voice his/her opinion. Adequate support and provision of services should be made available to all carers and not merely those with dementia. Public awareness programs can help to generate awareness of elder abuse among the general public in Ireland. This would also make the service providers conscious of responding to the cause of elder abuse in a positive manner. The senior staff in health boards and the service providers should undergo induction and training. As far as the other staff is concerned, training should be designed to meet the specific needs of the staff. POF does not recommend the mandatory reporting of elder abuse. At the same time, it also suggests that whistle blowing should be encouraged in all organizations involved in health and social care so that those who report abuse are not victimized. All reporting or suspicion of reporting has to be taken seriously. The written guidelines should clearly state what action will be taken if allegations of abuse are made against an employee. It is essential to recognize people who are unable to make their own decisions and ensure adequate protection for them. 1.9 Conclusion Services for older people have until recently been given low priority and it is essential that are nurses are involved in the implementation of the policies. Elder abuse has always existed perhaps under different names like mistreatment. Elder abuse can take many forms – some with fatal consequences and others may be subtle and more difficult to detect. Abuse ranges from physical, mental, financial, and sexual to those related to neglect and maltreatment. Institutional abuse is by far the largest. Literature suggests that it is lack of training of the staff that is largely responsible for abuse. Overwork is another important factor contributing to abuse as the outcome. Lack of awareness and lack of readiness to accept the existence of abuse are the reasons why elder abuse has not been recognized as a problem which needs attention. Reporting is also not absolute due to which the statistics on abuse may not be right. Training of not just the staff but senior health care professionals is equally important. The elders themselves need to be trained to recognize abuse as many may not be in a position to take decisions for themselves. Caregivers are always stressed due to work overload which increases elder abuse. Shortage of staff contributes indirectly to abuse as the work load on the existing staff increases. While government policies do exist, very often nurses are not aware of them or do not have access to them. They need to apply the policies to practice to impart better patient care and thereby reduce elder abuse. Elder abuse is now well recognized problem and the government has taken steps to correct the standards of care although much still needs to be done especially in terms of increasing the number of staff. References: Ayres, M. A., & Woodtli, A., (2001), Concept analysis: abuse of ageing caregivers by elderly care recipients, Journal of Advanced Nursing, 35(3), 326-334 Buka, P., & Sookhoo, D., (2006), Current legal responses to elder abuse, Journal Compilation, Blackwell Publishing, 28 Jan 2007 Burns, F. R., (2002), The elderly and undue influence inter vivos, EWCA Civ 885, 28 Jan 2007 Coyne, A. C., Reichman, W. E., & Berbig, L. J., (1993), The Relationship Between Dementia and Elder Abuse, Am J Psychiatry 1993; 150:643-646 De Laine C et al (2002) Continence care and policy initiatives. Nursing Standard. 17, 7, 45-51. 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P., (2005), Abuse in the elderly – a perennial problem, Gerodontology 2005; 22: 1–2 POF (2002), Protecting our Future, Report of the Working Group on Elder Abuse, 27 Jan 2007 Richardson, B., Kitchen, G., & Livingston, G., (2002), The effect of education on knowledge and management of elder abuse: a randomized controlled trial, Age and Ageing 2002; 31: 335–341 Read More