Elder Abuse: Assessment and Intervention.
Elder Abuse: Assessment and Intervention. Kris Fredrickson, MSW, LICSW Clinical Social Worker Geriatric Research, Education and Clinical Center- PSHCS 9/28/09 Stats and Facts "Every year an estimated 2.1 million older Americans are victims of physical, psychological, or other forms of abuse and neglect. For every case of elder abuse and neglect reported to authorities, experts estimate that there may be as many as 5 cases not reported. American's over the age of 50 years represent 30% of the population, 12% of murder victims and 7% of other serious and violent crime victims. 90% of elder abuse and neglect incidents are by known perpetrators, usually family members; 2/3 are adult children or spouses. 42% of murder victims over 60 were killed by their own children. Spouses were the perpetrators in 24% of family murders of persons over 60. The eldest of our seniors, 80 years and older, are abused and neglected at 2-3 times the proportion of all other senior citizens. -- Bureau of Justice Statistics 21.6% of all domestic elder abuse reports came from physicians or health care professionals 9.4% from service providers, 14.9% from family members. Types of abuses and frequency: Neglect 58.5% Physical abuse 15.7% Financial exploitation 12.3% Emotional abuse 7.3% Sexual abuse .04% All other types 5.1% Unknown .06% National Center on Elder Abuse, 1994 The National Elder Abuse Incidence Study: Final Report Washington, DC: Administration for Children and Families & Administration on Aging, US Department of Health and Human Services King County http://www.metrokc.gov/proatty/ELDER/index.htm for questions: Page Ulrey, Senior Deputy Prosecuting Attorney 206-296-9000. Elder Abuse Project “As the elderly population in King County grows, so do the incidents of abuse against it. Currently, about 29% (roughly 24,540 citizens) of Washington's 85 and over population reside in King County. This community is expected to increase 53% by the year 2025. In2002, there were 2,637 reports of adult abuse in King County, a number that has increased 6% since 2001 and exceeds the reports of any other Washington county by 105%.” Elder Abuse Project goals are three-fold: to prosecute cases of neglect of the elderly and disabled; to work collaboratively with police, social service agencies, and medical professionals to improve the referral, investigation, and, ultimately, prosecution of cases of abuse and neglect of vulnerable adults; and, to provide training to first responders so that they can better recognize and respond to such cases. DANIEL T. SATTERBERG King County Prosecuting Attorney W554 King County Courthouse 516 Third Avenue Seattle, WA 98104 Phone: 206-296-9000 FAX: 206-296-9013 TDD: 206-296-0100 ** Coordinated Quality Response Workgroup (through Elder Abuse Council): City, HSD, Criminal Justice Types of Abuse Neglect: *Active neglect: the CG fails to meet their obligation to care for the Pt’s physical, • social, and/or emotional needs. Can also be abandonment by leaving Pt without the • means or ability to obtain necessary food, clothing, shelter, health care. • *Passive neglect: the failure is unintentional. Often the result of CG overload or lack of information concerning appropriate care giving strategies. *Self neglect: failure of Pt to meet their own physical, psychological, and/or social needs. Physical Abuse: intentional infliction of physical harm upon a Pt. Psychological Abuse: intentional infliction of mental harm and/or psychological distress upon the Pt. Sexual Abuse: any sexual activity for which the Pt does not or can not give consent. Financial Exploitation: misuse, misappropriation, and/or exploitation of a Pt’s possessions, property and/or monetary assets. Violations of Basic Rights: depriving the Pt of the basic rights that are protected under state and federal law, such as the right of privacy, to participate in politics and to freedom of religion. Is often concomitant with psychological abuse. . Who is at Higher Risk? (and more easily/ often victimized.) Women “Older” adults (over 80) Diagnosed with dementia and MH issues Socially isolated Have a caregiver in the home _____________________________________________________________ ____ Per Adult Protective Services: A vulnerable adult is defined by law as: a person 60 years of age or older who lacks the functional, physical, or mental ability to care for him or herself; an adult with a developmental disability per 71A.10.020; an adult with a legal guardian per 11.88 RCW; an adult living in a long-term care facility (an adult family home, boarding home or nursing home); an adult living in their own or family’s home and receiving services from an agency or contracted individual provider; or an adult “self-directing” their care per law (74.39.050 RCW) by directing and supervising a paid personal aide to perform daily tasks. Potential Indicators and Symptoms of Abuse Neglect Pt symptoms/indicators: Lack of personal care, hygiene Malnourishment (e.g. sunken eyes, loss of weight), dehydration (extreme thirst) Chronic physical and/or psychiatric problems Pressure sores/ decubitus wounds CG Behavior: Leaving Pt in bed/chair all day, abandonment at ER or a public place, leaving Pt at home without means to meet daily needs, withholding food/H2O, failure to give Pt meds Emotional/Psychological Pt Symptoms/indicators: Uncommunicative/ unresponsive Unreasonable and excessive fearful, exaggerated startle/cowering, trembling, clinging, hypervigilant Evasive, passive, lack of eye contact Avoidant of social contact Anxious, agitation Ambivalence, deference, shame Depression, hopelessness, helplessness, suicidal ideation Confusion, disorientation CG Behavior: Caregiver withholds or reads the Pt’s mail, obstructs the Pt’s religious observances (e.g. dietary restrictions, holiday participation, visits by minister/priest/rabbi etc.) , Removal of doors from the Pt’s rooms. Allowing Pt to speak only when CG present, Overmedication or over sedation, Threats to harm Pt’s pet or send Pt to nursing home. Potential Indicators and Symptoms of Abuse continued... Physical/Sexual Abuse Pt symptoms/indicators: Signs of physical or restraint trauma such as scratches, bruises, cuts, burns, welts, punctures, choke/gag marks, rope burns, sexually transmitted diseases, pain, itching, bleeding or bruising in the genital area Repeated or “unexplained” injury such as sprains, fractures, dislocations, detached retina, paralysis.CG failure to disclose an injury, occurrence of time lags between the time of the injury and medical treatment Hypothermia, abnormal chemistry values, pain upon being touched A history of doctor/emergency room "shopping," refusal to go to the same MD/ER CG Behavior: Refusal to take Pt to MD when injured, MD shopping Material or Financial Abuse Pt symptoms/indicators: Living below means (e.g. lack of new clothing or amenities, unpaid bills) Personal belongings/ money going missing Never having access to their money for incidentals CG Behavior: Unclear documents for the Pt to sign, excessive care giver concern regarding the Pt’s financial status, forged signatures on checks/ documents , unusual banking activity (such as large withdrawals during a brief period of time, switching of accounts from one bank to another, ATM activity by a homebound Pt, bank statements mailed to someone else), making promises/ financial deals with Pt and others, alienating Pt from family. Self Neglect Self Neglect : Q: If an individual is legally competent but chooses to neglect their personal health or safety or refuse appropriate care is this abuse or self neglect and does it warrant intervention? A: Per APS-”Failure of a vulnerable adult, who is not living in a facility, to provide for himself the goods or services necessary for their physical or mental health, and the absence of which impairs or threatens their wellbeing. (May include vulnerable adult, or individual who is receiving services through home health, hospice, or home care agency, or an individual provider when the neglect is not the result of inaction by that agency or individual provider.)” Must demonstrate: Failure to manage or seek assistance with bathing, dressing, toileting/incontinence care, transferring, eating, AND Failure to take medications, attend appointments, manage home sanitation, financial affairs appropriately (bills unpaid, exploitation by others…) OR Engaging in unsafe activities (smoking in bed, leaving burners on, outside w/o appropriate clothing, driving recklessly…) OR Isolation, not answering door, correspondence or phone Potential Causes of and Contributors to Elder Abuse Caregiver stress: Inadequate coping skills, resources Dependency or impairment of the older person: As a Pt’s dependency increases so can the resentment and stress of the CG. Individuals in poor health are more likely to be abused CGs who are dependent on the Pt financially are more likely to perpetrate abuse. External stress: Financial problems Job stress Relationship problems Social isolation: Limited choices for help, costs prohibitive Intergenerational transmission of violence: Individuals who are abused as children are hypothesized to become part of a cycle of violence. Violence is learned as a form of acceptable behavior in childhood as a response to conflict, anger, or tension. If the Pt previously abused their CG, the CG may feel they are returning the abuse they suffered. Individual dynamics or personal problems of the abuser: Alcoholism Drug addiction Psychiatric issues, mental disorder Culture and Abuse Societal attitudes that make it easier for abuse to occur and continue without detection or intervention: The devaluation and lack of respect for older adults Older people are regarded as disposable, or a drain on resources Society’s belief that what goes on in the home is a private, "family matter." Shame and embarrassment often make it difficult for older persons to reveal abuse. Language barriers effect ability to investigate, assess and intervene Definition of what is considered "abuse" varies across diverse cultural and ethnic communities Religious or ethical belief systems and those who participate in these behaviors do not consider them abusive. Women’s basic rights are not honored, and older women in these cultures may not realize they are being abused. How To Prevent Elder Abuse Provide the Pt: Education: Promote the social attitude that no one should be subjected to violent, abusive, humiliating, or neglectful behavior. Educate about the special needs and problems of older adults and about the risk factors for abuse. Provide resources accessible for geographic areas and on-going and emergent support. Respite care: Temporary rest and “time off” is essential in reducing caregiver stress, a major contributing factor in elder abuse. Can be offered in SNF, ADHC, home health, or with family /friends. Social contact and support: Encourage being part of a social circle or support group. Having other people to talk to is an important part of relieving tensions. Many times, families/ friends can share solutions and provide informal respite for each other. Abuse is less likely to go unnoticed when there is a larger social circle, “more eyes” on the Pt. Counseling: Encourage changing lifelong patterns of behavior and finding solutions to problems emerging from current stressors. If there is a substance abuse, behavior problem in the family, treatment is the first step in preventing violence against the older family member. Address mental illness issues. Professionals and Community should: Keep a watchful eye out for family, friends, and neighbors who may be vulnerable. Get educated and understand that abuse can happen to anyone. Speak up if you have concerns. Trust your instincts! Know what to look for. Keep reporting any suspicions you have of abuse to helping agencies. Spread the word. Share what you’ve learned to friends, family and people you work with. “Must we report?” Yes! “Why?” It’s VA Policy and WA state law http://center.pugetsound.med.va.gov/sites/policies/Lists/Policies%20Upda ted%20in%20Last%2030%20Days/DispForm.aspx?ID=169 VHA Directive 2006-068 : “A state cannot ordinarily compel a VA facility or its employees, while acting within the scope of their employment, to comply with state law. But as a matter of policy, all VA medical centers, VA OPCs and Vet Centers must comply with state law in reporting abuse and neglect. Relevant state statutes must be followed for the identification, evaluation, treatment, referral and/or reporting of possible victims of physical assault, rape or sexual molestation, and domestic abuse of elders, spouses, partners, and children. “ Reports of abuse will be made pursuant to Washington State law, i.e. Revised Code of Washington (R.C.W.) Chapter 26.44, regarding the abuse of children, adult dependent and developmentally disabled persons, and R.C. W. Chapter 74.34 regarding abuse of vulnerable adults. These state statutes will be followed for identification, evaluation, treatment, and referral and/or reporting of victims of “abuse and neglect” as defined in the law. http://apps.leg.wa.gov/RCW/default.aspx?cite=74.34.020 RCW 74.34.020 (10) "Mandated reporter" is an employee of the department; law enforcement officer; social worker; professional school personnel; individual provider; an employee of a facility; an operator of a facility; an employee of a social service, welfare, mental health, adult day health, adult day care, home health, home care, or hospice agency; county coroner or medical examiner; Christian Science practitioner; or health care provider subject to chapter 18.130 RCW. First steps to report abuse or neglect 1) Make referral to VA Social Worker for assistance with the reporting process, resources and so follow up on APS report and continued monitoring is done. (Every Pt has an accessible VA SW) - Main SW office 206.764.2646 -GRECC SW-Kris Fredrickson, LICSW 206.764.2188, pager 206.570.0241 2) Call Adult Protective Services (DSHS ) in the county the Pt lives in: -1.866.End Harm (1.866.363.4276) -King County 206. 341.7660 http://www.adsa.dshs.wa.gov/APS/ -Snohomish County 1.800.487.0416 -Pierce County 1.800.442.5129 3) Complete a note in CPRS including the “Report of Abuse or Neglect” data limited to as follows: Date Name, address and age of abused child/dependent adult Nature and extent of the injuries, neglect or sexual abuse Any information of previous abuse/neglect/exploitation/abandonment Identity of alleged perpetrator “The clinician who determines that a report needs to be made MUST document in CPRS.” 4) Sign on Kristen Jensen, ROI Legal Technician 277-5081 (x65081) to the note to inform mineof the situation and the need for disclosure. For further review or in depth discussion about reporting contact: Sean Longosky Alternate Privacy Officer 206-764-2885 Who Else to Contact? Police if there is imminent danger to Pt or criminal activity: 911 Domestic Violence resources: -National Domestic Violence Hotline at 1.800.799.SAFE (7233) or TTY 1.800.787.3224. -Domestic Abuse Women’s Network (DAWN) 24-Hour Crisis Hotline: 425.656.7234 -New Beginnings 24-hour Help Line: 206.522.9472 Area Agency on Aging: Aging and Disability Services-Seattle/King County Help for older adults to plan and find long term care. 700 5th Ave. Suite 5100 Seattle WA 98104 Mailing address: PO BOX 34215 Seattle WA 98124-4215 Phone: 206.684.0660 or toll Free: 888.435.3377 Long Term Care Ombudsman Advocates for people living in care facilities. Vicki Elting 1501 N. 45th St. Seattle, WA 98103-6708 Phone: 206-623-0816 Fax: 206-675-8093 Email: [email protected] More resources to call… Senior Services of Seattle-King County: Senior Information and Assistance Information and referral service for adults age 60+ OR Family Caregiver Support Program Assistance locating care resources, respite 2208 2nd Ave. Seattle, WA 98121 206-448-3110 or 1-888-435-3377 or 1-888-4-ELDERS Website: http://www.seniorservices.org Dept of Social and Health Services: Home and Community Services (DSHS) Help for adults who may need Medicaid to help pay for supervised care. 1737 Airport Way S, Suite 130 (King Co Office) Seattle, WA 98134 P. O. Box 24847 (Mail) Seattle, WA 98124-0847 206-341-7750 or 1-800-346-9257 TTY: 1-800-833-6384 Resources/References The National Elder Abuse Incidence Study. (1998). U.S. Department of Health and Human Services, Administration on Aging (www.aoa.dhhs.gov/abuse/report/default.htm). Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. American Medical Association. A Profile of Older Americans. (1998). American Association of Retired Persons (AARP) and the Administration on Aging, (www.aoa.gov/aoa/stats/profile/default.htm). Understanding and Combating Elder Abuse in Minority Communities. (1998). Archstone Foundation and the National Center on Elder Abuse. Domestic Mistreatment of the Elderly: Toward Prevention. AARP.
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