Written by T.G. Mieure & Pam Kaufman, Mieure is comm supervisor with Mundelein Ill. PD and Kaufman is EMD program mgr for APCO Institute
One busy afternoon, a call comes into the 911 line. The caller says she's not sure it's really an emergency and she doesn't really know whether or not she should even be calling 911. Through careful questioning, you encourage her to explain why she felt compelled to call:
"Well, I was walking down the street when I saw an elderly neighbor I've known for years. She was coming out to get her mail. I stopped to say hi. She said hello but was acting weird. She kept looking around like she was afraid of something, and she acted like she didn't know me. Then I saw a really nasty bruise on her forearm. When I asked how it happened, she said it was just an accident. The car door closed on it. The she said goodbye really quickly and headed back to her house. Her behavior was just odd. Something just doesn't seem to be right with her. At first I dismissed my concerns. After all, she is getting old, so maybe she was just confused. But I kept thinking about that bruise and her skittish behavior. I couldn't shake the feeling that there's something else. Something just isn't right."
You thank the caller, telling her that she did the right thing by calling. But did she? What do you do? Do you send an EMS response to take care of what could be a simple bruise and a confused old woman? Do you send police out to determine if someone is hurting her?
Public safety calltakers and dispatchers need to know when to suspect elder abuse and act accordingly.
Definitions & Incidence
According to the National Center on Elder Abuse in Washington D.C., elder abuse refers to any knowing, intentional or negligent act by a care-giver or other person that causes harm or a serious risk of harm to a vulnerable adult. So elder abuse can be active or passive, doing something or failing to do something that results in harm to an elderly person or puts a helpless older person at risk of harm.
It's generally recognized that elder abuse is vastly underreported, so the true national incidence or prevalence of elder abuse is not known, although various studies have attempted to quantify the problem. The National Elder Abuse Incidence Study found that approximately 450,000 elderly persons in domestic settings were abused and/or neglected during 1996. When elderly persons who experienced self-neglect are added, the number increases to approximately 551,000. A report issued by the National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect states, "According to the best available estimates, between one and two million Americans age 65 or older have been injured, exploited or otherwise mistreated by someone on whom they depended for care or protection." As the older population increases, it is likely that the incidence will also increase.
Most researchers agree that abuse of the elderly falls within the following broad categories: physical abuse, sexual abuse, psychological or emotional abuse, exploitation or financial abuse, and neglect or abandonment.
Physical abuse includes any kind of physical assault, such as slapping, pushing, kicking, punching or injuring the elder with an object or weapon with the intention of causing pain or injury. It also includes deliberate exposure to severe weather, inappropriate use of medication and unnecessary physical restraint.
Signs (i.e., physical manifestations) and symptoms (i.e., subjective descriptions) of physical abuse include unexplained signs of injury, such as bruises, welts or scars, especially if they appear symmetrically; broken bones, sprains or dislocations; human bite marks; broken eyeglasses/frames; physical signs of being subjected to punishment and signs of being restrained; laboratory findings of medication overdose or under utilization of prescribed drugs; an elder's report of being hit, slapped, kicked or mistreated; an elder's sudden change in behavior; a caregiver's refusal to allow visitors to see an elder alone.
Burns are another possible indication of physical abuse. Red burn or scald marks could be caused by a hot tub of water, a cigarette, iron, curling iron or other hot instrument. Cuts, punctures or scratches could indicate the elder was jabbed with a sharp instrument, such as a pencil, or scratched by fingernails. Broken bones may occur when an elder victim has osteoporosis and is handled roughly by someone. Internal injuries may be hard to detect but could be caused by a caregiver purposely giving an elder alcohol or drugs that result in making the elderly person sick. Scars may indicate repeated or past abuses of the victim.
Sexual abuse involves any non-consensual sexual contact, such as inappropriate touching, rape or pornographic photography. Signs and symptoms of sexual abuse include bruises around the breasts or genitals; unexplained venereal disease or genital infections; unexplained vaginal or anal bleeding; torn, stained or bloody undergarments; and an elder's report of being sexually assaulted or raped. Someone calling to report sexual abuse may say they:
- Noticed a caregiver offering affectionate gestures that were too lingering and seductive or were centered on the sex organs, anus and breasts;
- Observed an injury to a victim's genitals, anus, breasts or mouth;
- Overheard a caregiver or another person openly making sexual remarks to or about a victim;
- Observed a caregiver expose the genitals of an elderly person;
- Learned of a caregiver taking nude photographs of a victim; or
- Observed severe changes in the victim's behavior related to hygiene, such as constant and vigorous washing of the hands or brushing of the teeth.
Psychological or emotional abuse is the use of such tactics as humiliation, isolation, intimidation, threats and inappropriate control of activities that cause mental or emotional anguish or isolation. Removal of decision-making power when a person is still competent to make their own decisions also qualifies as psychological abuse.
An elder who is being psychologically or emotionally abused may show signs of being emotionally upset or agitated, or being extremely withdrawn and non-communicative or non-responsive. A victim may exhibit unusual behavior frequently attributed to dementia, such as sucking, biting or rocking. Other indications include witnessed threatening, belittling or controlling behavior by a caregiver, or an elder's report of being verbally and emotionally mistreated.
Exploitation or financial abuse includes the misuse of the elderly person's funds or property through fraud, trickery or force for the benefit of another person. Inappropriate use of financial power of attorney is also considered financial abuse. Indicators of exploitations or financial abuse include:
- Sudden changes in bank account or banking practice, including significant withdrawals from the elder's account;
- Sudden changes in the elder's financial condition;
- The addition of names on an elder's bank signature card;
- Suspicious changes in a will, power of attorney, titles or other financial documents;
- Items of cash missing from the senior's household;
- Unpaid bills or lack of medical care, although the elder has money to pay for it;
- Discovery of an elder's signature being forged for financial transactions;
- Sudden appearance of previously uninvolved relatives claiming their rights to an elder's affairs and possessions;
- Unexplained sudden transfer of assets to a family member or someone outside the family;
- The delivery of unnecessary services, goods or subscriptions; and
- An elder's report of financial exploitation.
Neglect is any lack of actioin required to meet the needs of an elderly person. It includes inadequate provision of food, clothing, shelter, required medication or other kinds of health and personal care, as well as the denial of social companionship.
Abandonment is the desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person. Signs and symptoms of neglect or abandonment include:
- Unusual weight loss, dehydration, malnutrition;
- Untreated physical problems, such as bed sores;
- Unattended or untreated health problems;
- Hazardous of unsafe living conditions/arrangements, such as improper wiring and no heat or running water;
- Unsanitary and unclean living conditions, such as dirt, bugs, soiled bedding and clothes;
- Unsuitable clothing or covering for the weather;
- An elder's report of being mistreated;
- The desertion of an elder at a public place; and
- An elder's own report of being abandoned.
There are basically four types of abusers: well intentioned and over stressed; well intentioned and incapable; abusive and tries to control others; and sadistic and enjoys hurting others. Abusers of elders are both women and men, and family members are more often the abusers than any other group.
For several years, statistics had shown that adult children were the most common abusers of family members. However, when data about elders and vulnerable adults are combined, recent information indicates that spouses are the most common perpetrators of elder abuse. The fact to remember: Elder abuse is typically a family issue.
Domestic Elder Abuse
Elder abuse tends to take place where a senior lives, most often in the home, where the abusers are apt to be adult children, other family members (e.g., grandchildren) or spouses/partners of elders. Institutional settings, especially long-term care facilities, can also be locations where elder abuse occurs.
More than two-thirds of those who mistreat the elderly are members of the victim's own family. Interfamily abuse may by physical, psychological or economic. It ranges from criminal assault to neglect, and may result from the frustration and stress of the caregiver. Some studies cite the abuser's resentment, which may stem from past events or the present situation, as one of the causes of mistreatment.
Crimes against the elderly include cases of domestic violence, and many of the same dynamics that exist in domestic violence cases involving younger victims apply with even more force in the elder abuse situation. This is especially true when the abuser is a spouse. Older victims in situations of long-standing abuse are even more immobilized than other victims from taking action in their own defense, including reporting abuse. Third parties who are aware of the abuse may be reluctant to act for fear of breaking up a marriage of many years.
In fact, an abusive situation within a family can be quite difficult for outsiders to detect. Some of the abused may feel that such situations are family matters and should not be dealt with by outsiders. Shame and lack of alternatives tend to play roles in ongoing unreported abuse.
Techniques and methods used when dealing with other ages may not necessarily be effective with the elderly. Characteristics of aging may demand special attention. It's difficult to take care of an elder when he or she has many different needs, and it's difficult to be elderly when age brings with it infirmities and dependence. Both the demands of caregiving and the needs of the elder can create situations in which abuse is more likely to occur.
Caregiver Risk Factors
Many nonprofessional caregivers--spouses, adult children, relatives and friends--find taking care of an elder to be satisfying and enriching. But as the elder's condition deteriorates, the responsibilities and demands of elder caregiving can become extremely stressful. The stress of caring for an elder can lead to mental and physical health problems for the caregiver, including burnout, impatience and the inability to keep from lashing out against the elder in their care.
Among those giving care to the elderly, significant risk factors for elder abuse are:
- A lack of resilience and inability to cope with stress;
- Depression (common among caregivers);
- Lack of support from other potential caregivers;
- The perception that caring for the elder is burdensome and lacks psychological reward; and
- Substance abuse.
Condition & History of the Elder
Several factors concerning elders themselves may influence whether they are at greater risk for abuse, including the intensity of their illness or dementia, social isolation (the elder and caregiver are alone together almost all of the time), an elder's role at an earlier time as an abusive parent or spouse, a history of domestic violence in the home and an elder's own tendency toward verbal and physical aggression.
In many cases, even though it is real, elder abuse is unintentional. Caregivers are pushed beyond their capabilities or psychological resources and may not mean to yell at, strike or ignore the needs of the elders in their care.
Long-Term Care Facilities & Elder Abuse
More than two out of every five Americans will need long-term care at some point in their lives. Long-term care encompasses a wide variety of settings and services designed to meet the special needs of elders. The same types of elder abuse discussed above can occur in a long-term care facility.
The existence of indicators and warning signs doesn't necessarily mean that abuse has occurred. Instead, they should be treated as signs that diligent attention or investigation is needed. Physical warning signs specific to long-term care facility abuse may include a call light that isn't functioning or is beyond the reach of the resident, development or worsening of bed sores, signs of excessive drugging, as well as the other indicators listed earlier. Behavioral warning signs include being withdrawn, confusion or forgetfulness, depression, helplessness or anger, hesitation to talk freely, fright and being secretive.
Residents of skilled nursing facilities are guaranteed certain rights and protections under federal and state laws. Facilities are required to provide a copy of these rights to individuals upon admittance to a facility. To report abuse that has occurred in a long-term care facility, calling the local Long-Term Care Ombudsman is an option. Under the federal Older Americans Act, every state is required to have an ombudsman program that addresses complaints and advocates for improvements in the long-term care system. An ombudsman is an advocate for residents of nursing homes, board and care homes, and assisted living. Ombudsmen provide information about how to find a facility and what to do to get quality care. They are trained to resolve problems. The ombudsman can also assist people with complaints. Unless permission is given to the ombudsman to share your concerns with the facility, these matters are kept confidential.
A Serious Problem
Each year, hundreds of thousands of older persons are abused, neglected and exploited by family members and others. Many victims are people who are older, frail and vulnerable, cannot help themselves and depend on others to meet their most basic needs.
Legislatures in all 50 states have passed some form of elder abuse prevention laws. Laws and definitions vary considerably from one state to another, but all states have set up reporting systems. Generally, adult protective services (APS) agencies receive and investigate reports of suspected elder abuse. The APS agency screens calls for potential seriousness and keeps the received information confidential.
If the agency decides the situation possibly violates state elder abuse laws, a caseworker is assigned to conduct an investigation. Cases of emergency are usually assigned within 24 hours. If a victim requires crisis intervention, services are made available. If elder abuse is not substantiated, most APS agencies will work as necessary with community agencies to obtain the health and social services the elder person requires. However, the elder person does have the right to refuse services offered by APS. Services by APS is provided only if the elder agrees or has been declared incapacitated by the court and a guardian has been appointed. APS takes this action only as a last resort.
Abuse or Self-Neglect?
Sometimes elders neglect their own care, which can lead to illness or injury. Self-neglect behaviors include hoarding, failing to take essential medications, refusing to seek medical treatment for serious illness, poor hygiene, not wearing clothing suitable for the weather, confusion, inability to attend to housekeeping and dehydration.
Self-neglect accounts for the majority of cases reported to authorities. Often, the problem is paired with declining health, isolation, Alzheimer's disease or dementia, or drug and alcohol dependency.
In some cases, elders will be connected to support systems in the community that can allow them to continue living on their own. Some conditions, such as depression and malnutrition, may be successfully treated through medical interventions. If the problems are serious enough, a guardian may need to be appointed.
Elder Abuse Reports to the Telecommunicator
Everyone has a responsibility to keep vulnerable elders safe from harm. The laws in most states require health-care professionals to report suspected abuse or neglect. These professionals are called mandated reporters. They are instructed and have been trained to call the police or 911 immediately if someone is known to be in immediate, life-threatening danger.
Telecommunicators receiving calls of suspected elder abuse should follow local policies and procedures in regard to obtaining needed information. In general, if there is the possibility of elder abuse, the telecommunicator should ask questions in such a way to determine if any of the following conditions exist:
- A discrepancy between a person's standard of living and his or her financial assets, or a depletion of assets, without adequate explanation;
- Malnourishment and inadequate physical care;
- Physical injuries, such as bruises, burn marks, welts, rope burns, tufts of hair missing or broken bones, none of which can be adequately explained;
- Withdrawn, apathetic or fearful behavior, particularly around certain people; and
- Medical needs that have not been attended to.
If the telecommunicator is receiving the call from a third party, ask this person if it's possible to talk to the victim to determine the extent of the abuse. If the third party feels that the abused person is in imminent danger, law enforcement officers should be sent without delay. If the abused does not wish to leave the situation, the telecommunicator should provide the individual with contact information for agencies that may aid the victim and improve their situation.
The proper authorities and agencies should be dispatched to begin the investigation. Try not to automatically discount abuse reports from residents of managed care facilities. Numerous calls may be received from the same elderly person stating the nurses are stealing from that individual. Three or four previous unfounded calls may cause doubt as to the validity of the current complaint. Follow your local policies and procedures when handling this type of report.
In the event a call is received in which EMS is needed to treat a patient, the telecommunicator should follow the agency's emergency medical dispatch procedures and assist the caller with the care for the patient using the appropriate chief complaint, as well as the appropriate pre-arrival instructions to the signs and symptoms being relayed by the caller.
Preventing Abuse & Neglect
The prevalence of elder abuse can be reduced, but it will take effort on everyone's part. Listen to seniors and their caregivers, intervene when elder abuse is suspected, and educate others on how to recognize and report elder abuse.
If caregivers are overwhelmed by the demands of caring for an elder, they can:
- Ask for help from friends, relatives or local care agencies;
- Find an adult day care program;
- Stay healthy and get medical care for themselves when necessary;
- Adopt stress reduction practices;
- Seek counseling for depression;
- Find a support group; and
- Get help if experiencing problems with alcohol or drug abuse.
Remember, elder abuse help lines offer help to caregivers as well as elders. Advise the caregiver to seek help if they think there's a possibility they might cross the line into elder abuse.
Concerned friends or family members can:
- Watch for warning signs that might indicate elder abuse. If suspected, report it.
- Look at the elder's medications. Does the amount match up with the date?
- Watch for financial abuse. Ask to scan their bank and credit card account for unauthorized transactions.
- Call and visit as often as possible. Help to build the trust to be considered a confidante.
- Offer to stay with the elder to give the caregiver a break, on a regular basis, if possible.
If/when you are an elder, you can protect yourself by:
- Making sure your financial and legal affairs are in order. Enlist professional help to get them in order if they aren't already.
- Keep in touch with family and friends, and avoid being isolated. Isolation increases your vulnerability to elder abuse.
- If you're unhappy with the care you're receiving--whether it's your home or in a care facility--speak up. Talk to someone you trust and ask that person to report the abuse, neglect or substandard care or make the call yourself.
Finally, if you aren't in a position to help an elder personally, you can volunteer or donate money to educate people about elder abuse. You can also lobby to strengthen state laws and policing so elder abuse can be investigated and prosecuted more readily.