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Elder Mistreatment in the Long-Term Care Setting
There are approximately 1.6 million elderly individuals residing in nursing homes (NHs), of whom approximately 50% are ≥85 years of age.1 NH residents typically have impaired activities of daily living (ADLs) and instrumental ADLs, severe cognitive decline (ie, Alzheimer’s disease and other dementias), or both, making them dependent on others for their care. Many very ill and vulnerable elders reside in our nation’s long-term care (LTC) facilities. Twenty-five percent of long-stay NH residents die each year,2 and the death rate for those in assisted living facilities (ALFs) is approximately 20%.3
Elder mistreatment (EM) is a common problem in LTC facilities. A survey conducted in 1987 found that 36% of NH staff members observed elders being physically abused during a 12-month period.4 The true incidence of EM is probably considerably higher. It is likely that many EM cases go unreported due to resident disability, fear, or other factors. The purpose of this review article is to provide an overview of EM in NHs and other LTC settings. In this article, we define the types of EM, discuss the obligation of healthcare providers to report EM, and review intervention and prevention strategies. We also provide information on the epidemiology, risk factors, common perpetrators, morbidity and mortality, signs and symptoms, and screening and assessment of EM.
Types of Elder Mistreatment
EM refers to one or more of the following incidents occurring in vulnerable older adults (usually considered to be >65 years of age), who may also be disabled: (1) physical abuse; (2) sexual abuse; (3) caregiver neglect; (4) self-neglect; (5) exploitation; (6) emotional abuse; and (7) abandonment (Table).5,6 According to National Ombudsman Reporting System (NORS) data from 2008, physical abuse was the most common allegation reported by NH and board-and-care residents.7 This estimate was based on 20,673 complaints investigated by Long-Term Care Ombudsman (LTCO) programs in the United States. LTCO programs were established under the Older Americans Act of 1965, a federal statute that mandates that each US jurisdiction establish such a program at the state level to identify, investigate, and resolve complaints relating to seniors in NHs and ALFs.
Epidemiology
There are few data on the national incidence of EM in LTC facilities. In 2008, NORS recorded approximately 269,000 incidents of EM involving LTC residents in the United States, and roughly 25% of these cases specifically alleged EM.7 Although NORS collects reports made to various state LTCO programs, the numbers likely are not accurate because reports may be made to agencies that NORS does not capture data from and many other incidents may go unreported altogether.8,9
Outcomes
Community-dwelling elders who are victims of EM have a higher risk of death than those who are not victims.10-12 The same is likely true for LTC residents. Unaddressed EM has a severe impact on the vulnerable elder who may have diminished functional reserves and limited financial and social resources. EM in LTC facilities may result in health problems, such as malnutrition, dehydration, pressure sores, and untreated medical conditions, and it may negatively affect the victim’s ability to pay for his or her care at the LTC facility.13
Risk Factors
Studies regarding EM in LTC facilities are limited, but it has been suggested that risk factors for abuse in LTC residents are similar to those for abuse in community-dwelling elders. Reported risk factors include advanced age, cognitive impairments, behavioral symptoms (eg, physical aggression), confusion, communication impairments, and functional impairments.14-16 These risk factors are also common characteristics observed in NH residents, as demonstrated by a 1996 report by the Agency for Healthcare Research and Quality.17 The report assessed the characteristics of 1,563,900 NH residents and found that 771,200 (49.3%) were ≥85 years of age; 218,100 (13.9%) needed assistance with one to two ADLs; 1,302,200 (83.3%) needed assistance with more than three ADLs; 746,100 (47.7%) had dementia; 817,500 (52.9%) had long- and short-term memory problems; 465,900 (30.2%) had behavior problems; and 685,800 (44.3%) had impaired communication.17 Because risk factors for EM are similar to the demographic characteristics of NH residents, these individuals may be especially vulnerable to abuse.
Signs and Symptoms
Although recognizing the signs and symptoms of EM is essential to prevent further episodes of abuse and possible medical deterioration of the abused NH resident, it is also important to differentiate EM from normal signs of aging. Suspicious findings relating to physical abuse include bruises, skin tears, and multiple fractures or long-bone fractures that are inadequately explained. A female resident’s reluctance to undergo a pelvic examination can raise suspicion of sexual abuse. Other suspicious findings of sexual abuse for female and male residents include bruising of the breasts, chest, or genital area; a newly diagnosed or unexplained sexually transmitted disease; vaginal or rectal discharge that is bloody or purulent; and unusually stained undergarments.18 The signs and symptoms of possible physical or medical neglect include unintentional weight loss, poor hygiene (including oral), dehydration, and social fear or withdrawal.18 Additional “red flags” include suspicious wounds, inappropriate or unmonitored medications, and poorly managed medical conditions. Misappropriation of a resident’s personal property (eg, money, jewelry, other valuable items) should lead the healthcare provider to suspect financial exploitation. When any of the aforementioned signs and symptoms are discovered, it is imperative not to assume EM is occurring before conducting an adequate investigation.
Common Perpetrators
In NH facilities, the most common perpetrators of EM may be other residents. Resident-to-resident verbal and physical aggression are likely more prevalent than resident abuse by NH staff. Approximately 80% of NH residents have cognitive impairment, which can manifest as behavioral disturbances, including aggression.19 In one study that included 747 LTC residents, 42 (5.6%) experienced at least one resident-to-resident assault that involved a police investigation.20 It is likely that only the most serious cases were reported; thus, the actual number of assaults may have been higher.
A focus group study including NH staff members and residents who could reliably self-report identified calling out or noisemaking by residents with dementia as the most common trigger for resident-to-resident aggression.19 Calling-out vocalizations are common, seen in about 11% to 30% of NH residents. Other triggers of aggression included wandering behaviors, territoriality, impatience, and resident behavioral disinhibition.19
Although NH facilities still predominantly care for elderly individuals, the demographic is shifting to include an increasing number of younger residents, such as those with psychiatric problems. Because these patients are younger, they tend to be stronger and are able to inflict more harm on the elderly. In addition, some LTC residents may have criminal histories as sex offenders or perpetrators of other violent crimes.21 Although there are federal requirements for states to maintain databases of registered sex offenders, there is no requirement that LTC facilities be notified of an individual’s sexual or other criminal history. Neither the federal government nor most states require LTC facilities to investigate residents for prior criminal activity. In a study conducted by the federal government in 2006, only two of 29 LTC facilities surveyed used information regarding prior criminal activity to require special supervision or segregation of residents.22 Most facilities relied on resident behavior after admission to guide special supervision or segregation.
Although other residents are likely the most common perpetrators of EM, staff members are not exempt. In a survey that included responses from 510 NH employees in
Israel, approximately 50% of respondents admitted to having mistreated elderly residents over the previous year.23 Two-thirds of these EM incidents involved staff failing to respond to residents’ physical or emotional needs, usually without malicious intent. Systemic problems at the institution, such as not having enough time, were thought to be reasons for mistreatment. The following characteristics are considered to place staff at risk for abusing residents: (1) emotional fatigue; (2) feeling depersonalized; (3) under excessive work pressure; (4) possessing negative attitudes toward the elderly; (5) possessing negative attitudes toward their jobs; (6) limited professional training (ie, nurse’s aides); (7) a history of domestic violence; (8) a history of mental illness; (9) a history of drug or alcohol dependence; and (10) a criminal record.18,23,24
When staff members view resident mistreatment as normal behavior in the institution, they are more inclined to mistreat residents.23 In addition, some institutions have practices that are convenient for NH staff but may be difficult on residents, such as changing bedding materials at night or giving baths early in the morning. Practices such as these may be manifestations of an institutional culture that is more likely to foster the mistreatment of residents.23 Another facility characteristic that increases the number of resident mistreatment complaints is a lower staff-to-resident ratio.25
Screening and Assessment
Screening and assessment for EM is designed to discover whether the elderly person is being abused, exploited, or neglected by someone or if he or she is unable to provide self-care. While self-neglect is not usually found in LTC residents, it may be seen in individuals residing in ALFs. Such cases occur when an elder does not allow others to help with tasks that he or she can no longer handle, such as managing medications and finances. Some elders reside in ALFs because they realize that they need help with meal preparation and mobility, but they do not think they have other needs.
The American Medical Association states that clinicians should screen for EM when they encounter elders in any clinical setting,26 whereas the Medicare program requires nursing facilities to screen and monitor elders for signs and symptoms associated with EM.27 Clinicians have a moral and ethical obligation to screen for EM because of its potentially serious consequences.28 They are also in the best position to distinguish the signs and symptoms of EM from those of normal aging.28,29 If a clinician has any suspicion of EM, the suspected victim should be interviewed alone.26,30 Many suspected victims may be cognitively impaired and unable to accurately recount their abuse. If the potential perpetrator is present, he or she may be motivated to take advantage of the resident’s impairments or fears and misrepresent the events or circumstances. Even without the perpetrator present, the victim may be afraid to discuss his or her abuse. Therefore, it is important for clinicians to use an approach that does not heavily rely on the report of the suspected victim or his or her caregivers.31
A useful tool for identifying EM cases is the comprehensive geriatric assessment (CGA), which involves taking the suspected victim’s history, including a thorough social, medical, and functional history, and conducting a physical examination, including cognitive screening and assessing for mental conditions, such as depression.29,32 The history-taking process may require gathering information from
individuals who have had contact with the suspected victim. Because the CGA is so involved, it is best performed by a multidisciplinary team. The CGA typically enables a clinician to discern whether EM is plausible, and subsequent investigation by the appropriate government agency should result in EM being identified.
Reporting
State statutes typically mandate that LTC facility healthcare providers, owners, and employees report reasonably suspected resident mistreatment to a government agency. Some states require all persons to report such suspicions. Despite these mandates, there is significant underreporting of EM, even by mandatory reporters.
Although every state has an LTCO program, which generally advocates for residents in their dealings with facilities, government agencies, and others, states vary as to which agency receives and investigates EM reports. Depending on the jurisdiction, issues of EM may be dealt with by the LTCO or referred to other governmental agencies, including those at the federal level.25,33 In some cases, multiple governmental agencies will investigate one incident simultaneously, but information may not be shared between them. For example, an LTCO program involved in investigating an EM complaint may not be allowed to report identifying resident information to other persons or agencies if the resident or resident’s representative does not consent to its release.34
When EM is identified, a facility found to be at fault is typically disciplined by the agency that licenses it, whereas any healthcare provider found to be at fault is disciplined by his or her licensing agency.33 Cases of more severe EM may be investigated and prosecuted as criminal matters by a local district attorney’s office or state attorney general’s office.33
Intervention and Prevention
Because facility staff are unlikely to receive notice of a resident’s prior criminal record or behavior problems before he or she enters the facility, resident-to-resident aggression may be most effectively prevented by diligent staff surveillance for inappropriate sexual or aggressive behaviors directed at other residents.22 In an effort to anticipate potential resident-to-resident aggression, facility staff should be educated about common risk factors for EM. Resident factors that can lead to victimization include wandering, cognitive impairment, and behavioral disturbances, such as vocalization (hollering). Risk factors for a resident becoming a perpetrator may include cognitive impairment, depression, constipation, delusions, and hallucinations. Besides vigilant surveillance, interventions such as separating the victim and the perpetrator may be needed.35 Training should also be given to the staff to help them deal with disruptive resident behaviors, acquire appropriate attitudes toward the elderly, manage staff stress levels, and manage negative feelings (eg, poor job satisfaction, low wages, feelings of no control).23,36
Institutional factors that may reduce the incidence of EM include improving staff-to-resident ratios, using volunteers, and conducting criminal background checks on prospective employees.16 In cases where there is a suspicion of potential financial exploitation, the facility may try to limit access of the suspected perpetrator to the resident.37 To prevent neglect, the facility should establish protocols for monitoring and reporting changes in resident condition and function.38 Protocols for addressing suspected sexual abuse, including prompt preservation of evidence, also need to be established.39
The most effective intervention may be reporting EM to the appropriate governmental agency. Multiple regulatory and licensing agencies in each jurisdiction work to suppress and prevent EM by enforcing minimum quality of care standards and penalizing harmful practices.34
Long-Term Care Residents Receiving End-of-Life Care
In 2002, approximately 22% of people in the United States died in an NH. Of these individuals, 43% were ≥85 years of age.40 It is also estimated that approximately 33% of ALF residents die in these facilities annually.41 These data make clear that many people die in LTC facilities, and it is projected that the proportion will increase because more people will be residing in NHs in the future.42
LTC residents receiving end-of-life care are especially vulnerable to EM. They often have cognitive impairments, require help with ADLs, and may be relatively isolated, having few close family members or friends who are able to visit them. It may be hard to distinguish normal dying from EM in these individuals. Dehydration, poor nutritional status, and pressure sores often accompany the end of life outside the setting of EM.43 Since this population is expected to die, autopsies or other investigations are unlikely to be undertaken, unless evidence of EM is readily apparent.
End-of-Life Scenarios
Established patterns of family interaction tend to remain even when a family member becomes terminally ill. A resident who is subjected to EM before his or her terminal illness may still be at risk of mistreatment from a family perpetrator. There may also be a family history that includes abuse by the resident, and the roles may reverse so that the prior victim becomes the caregiver or decision-maker for the prior abuser.44 If the resident lacks the capacity to make his or her own decisions and there has been a long, poor relationship between the substitute decision-maker and the dying resident, decisions may not be made properly on behalf of the resident. For example, decisions to withdraw life-sustaining treatments may be motivated by a desire to punish the patient or to inherit sooner.
Occasionally, a facility owner may unofficially make decisions for a resident who is no longer competent and has no proper surrogate decision-maker. The owner may have a financial incentive to keep the resident in the facility despite the inability of the facility to meet the resident’s needs. This amounts to exploitation and neglect of the resident. Even when a resident has a proper surrogate, and the resident is receiving hospice services in an LTC facility, if the dying resident needs more care and attention than the facility and the hospice are willing or able to deliver, the result may be a death that is unnecessarily uncomfortable.
Another end-of-life scenario that may be encountered is of a caretaker who diverts the resident’s medications because the caretaker has a substance abuse problem or wants to sell the medication for money. Narcotic medications or benzodiazepines are the most likely medications to be stolen by caretakers. Stealing these medications is abusive, causing the resident unnecessary discomfort at the end of life.45
A variety of factors may prevent hospice and palliative care staff from reporting suspected EM, including concern that reporting may be unethical, fear of legal consequences, concern about keeping their employment, and reluctance to believe the victim.47 Educating staff about their legal and ethical obligations to report suspected EM, including neglect, exploitation, and abuse, is important to prevent EM in residents at the end of life.
Conclusion
As the population of older adults continues to increase, demand for LTC services will increase. Educating healthcare professionals, facility staff, family members, and the general public on EM can prevent vulnerable elders from being abused. With their medical expertise, clinicians play an especially vital role in minimizing and preventing EM; however, to have the greatest impact, they need to be able to distinguish EM from common signs of aging, know how to conduct a CGA assessment, and recognize that they have an ethical and legal obligation to report EM. NHs and other dependent-care facilities also need to do more to prevent EM. Protocols for preventing and identifying EM, including sexual abuse, should be implemented in and mandated for every LTC facility.
The authors report no relevant financial relationships.
Ms. Pickens is clinical coordinator, Texas Elder Abuse & Mistreatment Institute, University of Texas Health Science Center (UTHSC)-Houston School of Medicine, Harris County Hospital District; Dr. Halphen is associate program director, Geriatric Medicine Fellowship, UTHSC-Houston School of Medicine Harris County Hospital District; and Dr. Dyer is director, Division of Geriatric and Palliative Medicine, UTHSC-Houston School of Medicine, and interim chief, Lyndon B. Johnson Hospital, Harris County Hospital District, Houston, TX.
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