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
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"Every year an estimated 2.1 million older Americans are victims of physical, psychological, or
other forms of abuse and neglect.
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For every case of elder abuse and neglect reported to authorities, experts estimate that there
may be as many as 5 cases not reported.
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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.
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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.
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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
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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.
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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
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for questions: Page Ulrey, Senior Deputy Prosecuting Attorney 206-296-9000.
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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%.”
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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
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“Older” adults (over 80)
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Diagnosed with dementia and MH issues
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Socially isolated
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Have a caregiver in the home
_____________________________________________________________
____
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Per Adult Protective Services:
A vulnerable adult is defined by law as:
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a person 60 years of age or older who lacks the functional, physical, or mental
ability to care for him or herself;
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an adult with a developmental disability per 71A.10.020;
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an adult with a legal guardian per 11.88 RCW;
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an adult living in a long-term care facility (an adult family home, boarding home or
nursing home);
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an adult living in their own or family’s home and receiving services from an agency
or contracted individual provider; or
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an adult “self-directing” their care per law (74.39.050 RCW) by directing and
supervising a paid personal aide to perform daily tasks.
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Potential Indicators and Symptoms of Abuse
Neglect
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Pt symptoms/indicators:
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Lack of personal care, hygiene
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Malnourishment (e.g. sunken eyes, loss of weight), dehydration (extreme thirst)
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Chronic physical and/or psychiatric problems
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Pressure sores/ decubitus wounds
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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
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Pt Symptoms/indicators:
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Uncommunicative/ unresponsive
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Unreasonable and excessive fearful, exaggerated startle/cowering, trembling, clinging,
hypervigilant
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Evasive, passive, lack of eye contact
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Avoidant of social contact
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Anxious, agitation
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Ambivalence, deference, shame
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Depression, hopelessness, helplessness, suicidal ideation
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Confusion, disorientation
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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
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Pt symptoms/indicators:
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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
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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
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Hypothermia, abnormal chemistry values, pain upon being touched
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A history of doctor/emergency room "shopping," refusal to go to the same MD/ER
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CG Behavior: Refusal to take Pt to MD when injured, MD shopping
Material or Financial Abuse
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Pt symptoms/indicators:
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Living below means (e.g. lack of new clothing or amenities, unpaid bills)
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Personal belongings/ money going missing
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Never having access to their money for incidentals
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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:
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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:
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As a Pt’s dependency increases so can the resentment and stress of the CG.
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Individuals in poor health are more likely to be abused
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CGs who are dependent on the Pt financially are more likely to perpetrate
abuse.
External stress:
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Financial problems
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Job stress
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Relationship problems
Social isolation:
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Limited choices for help, costs prohibitive
Intergenerational transmission of violence:
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Individuals who are abused as children are hypothesized to become part of a
cycle of violence.
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Violence is learned as a form of acceptable behavior in childhood as a
response to conflict, anger, or tension.
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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:
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Alcoholism
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Drug addiction
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Psychiatric issues, mental disorder
Culture and Abuse
Societal attitudes that make it easier for abuse to occur and
continue without detection or intervention:
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The devaluation and lack of respect for older adults
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Older people are regarded as disposable, or a drain on resources
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Society’s belief that what goes on in the home is a private, "family
matter."
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Shame and embarrassment often make it difficult for older persons to
reveal abuse.
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Language barriers effect ability to investigate, assess and intervene
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Definition of what is considered "abuse" varies across diverse cultural
and ethnic communities
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Religious or ethical belief systems and those who participate in these
behaviors do not consider them abusive.
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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
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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
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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. “
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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
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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:
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Date
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Name, address and age of abused child/dependent adult
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Nature and extent of the injuries, neglect or sexual abuse
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Any information of previous abuse/neglect/exploitation/abandonment
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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?
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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
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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
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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.