Elder Abuse and the Nursing
Home… a Critical Interface
DR. ROGER BUTLER
ASSOCIATE PROFESSOR OF FAMILY
MEDICINE MUN
A war veteran / VP resident
Objectives
 Discuss current research on elder abuse
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demographics in relation to dementia care
Discuss some theoretical models to explain WHY?
Explore physician issues in elder abuse management
Explore characteristics of caregivers,residents and
the environment that predispose to elder abuse
Update the audience on provincial law.
What can physicians do?
Definition
 Elder abuse has been defined by the World Health
Organization (WHO) as a single or repeated act ,or
lack of appropriate action, occurring within any
relationship where there is an expectation of trust
and which causes harm or distress to an older
person.
Elder Abuse and Neglect
 Elder abuse is any act or failure to act, within a
relationship where there is an expectation of trust,
that jeopardizes the health or well-being of an older
person.
 Neglect is any inaction ,either intended or
unintended , within a relationship where there is an
expectation of trust, that causes harm to an older
person.
Types of Abuse
 Physical – violent act or rough treatment causing
injury or physical discomfort. Also includes sexual
and medication abuse.
 Psychological or Emotional Abuse – an act that may
diminish the sense of identity ,dignity , or self- worth
of an individual.
 Financial or Material abuse- theft or misuse of a
senior’s money or property
Neglect
 The failure to meet the needs of an older adult who
cannot meet their needs on their own. It may have
physical , financial or psychological components.
Two Types; ACTIVE and PASSIVE
ACTIVE: intentional withholding of basic necessities
and /or care
PASSIVE: non-intentional ,non-malicious withholding
of basic necessities and /or care because of lack of
experience, information ,or ability
Self Neglect
 The older person is living in an unsafe or unhealthy
manner by choice or ignorance.
 What to do if you are worried?
Ageism
 Hughes and Mtezuka defined ageism as a “social
process which negative images of and attitudes
towards older people, based solely on the
characteristics of old age itself;result in
discrimination.”
Revera Report on Aging
 8/10 Canadians agree that seniors (75+) less
important than other members in our society
 Most tolerated social prejudice in Canada compared
to gender or race-based discrimination
 63% seniors report treated unfairly or differently
because of their age
Report based on survey of 1501 Canadians fall 2012.
Revera report continued
 35% Canadians admit treating somebody different
because of their age
 56% age discrimination primarily from younger
people
 27% experienced it from Government
 34% from health care professionals
Elder Abuse Demographics
 2031, 25% Canadian population>65 (8 million)
 NL by 2026 27% of pop over 65
 Elder abuse or neglect 7%
 In 1999 Canadian researchers found that:
-7% respondents reported emotional abuse
-1% reported financial exploitation
-1% reported physical or sexual abuse
At least 1/3 are family members
It affects all demographic groups (Dept of Justice
Canada)
LTC setting scenario
 You have just began your shift at the new LTC facility
in St. John’s. The staff at the nursing station are
having a discussion on how they are going to deal
with a new resident with aggressive behaviour. One
of the senior LPN’s says “ Once we get him into our
routines everything will be just fine”. What is your
immediate reaction?
Elder Abuse and Dementia
 5-55% compared to 3.2-27.5% prevalence rates for
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nondemented ( Cooper et al US data)
Elders with dementia have highest incidence of
mistreatment and abuse in LTC...12% (9 year study
2003 Levine)
Many cases unreported
½ nursing staff reported abuse towards resident in
past year and 70% witnessed other staff commit act
(Israel LTC study 2010)
Mental abuse and neglect most common
Psycho-social factors affecting elders
maltreatment in LTC facilities
 Study based on 22 nursing homes in Israel and
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published in 2010 (International Nursing Review)
Random selection from 300 nursing homes in Israel
10 workers per site in various departments at various
times of day
Gov’t, site admin and ethics approval
Staff confidentiality assured
85% staff response rate
Areas studied
 Details of the facility, demographic details and
professional details
 Reporting incidents of violence, victim traits,
attitudes towards and knowledge about
maltreatment
 Burnout questionaire
Models for Abusive behaviour
 1. Theoretical model for predicting causes of elder
maltreatment in LTC facilities(Pillemer 1988)
working model looking at institutional work
environmental factors, staff traits and resident traits
as interrelated causative factors.
 2. The theory of reasoned action(Ajzen and Fishbein)
 1980) Human behaviour depends on two
components; behavioural attitude and subjective
norms
Staff Traits
 Young female nursing aids (less training) more likely
 Longer working staff with positive attitude less likely
 Improper care associated with job pressures and
staff burnout
 Worker burnout associated with physical and mental
violence
Staff Traits continued
 Staff who perceive the following are at risk:
- residents have to be constantly served
-they are waiting to die
-they behave like little children
-they must be occasionally taught discipline
Patient Traits
 Elderly residents with dementia have the highest risk
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of abuse of all disabled people
Aggressive resident behaviour is related to physical
and verbal abuse by the caregiving nursing staff
Women residents have the highest risk of abuse
because they are probably most vulnerable
Rate increases with age in the LTC and home
environments
Socially isolated are at greater risk
Facility features
 More prevalent in profit seeking facilities (Iowa
2006)
 Low staff ratio and high staff turnover leads to high
risk compromise in quality care and subsequent high
risk for elder maltreatment
 Lack of nursing staff leads to elder maltreatment
(California/Scandinavia
 Non-profit facilities provide the best nursing and
medical services
Results
 ½ staff report abusing residents in the previous year
 2/3 of abuse involves physical and mental neglect
 Psychologically staff perceive neglect as an act of
omission and therefore maybe seen as a systemic
failure of the system rather than a personal one to
provide basic needs.
 These do not involve personal motives or malicious
intent hence easily reported
Results Continued
 Jewish moral custom of honouring seniors not
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perpetrated the nursing home culture
Significant positive correlation between staff burnout
and physical violence and mental abuse.
Greater staff emotional fatigue and
depersonalization greater maltreatment risk
Less ambition in the workplace correlates with
greater risk of maltreatment as well
Burnout creats a neg attitude to job and elderly
residents and lack of empathy and vise versa
Results Continued
 Nurses aids and practical nurses had more
manifestations of elder maltreatment
 Surprising in this study more work experience
correlated with a higher risk of abuse
 The more one witnesses abuse the more one is likely
to perform abusive acts
 No correlation found with academic knowledge,
clinical knowledge,seniority,attitudes to
maltreatment ,gender and age of workers
Results Continued
 Elderly demented females higher risk of mental
abuse
 Aggressive residents have 4x the risk of
maltreatment
Bottom Line
Need for periodic, structured and regular training of
caregiving staff, mainly practical nurses and nursing
aids unrelated to their professional
seniority….highlighting difficulties with caring for
demented residents, coping under pressure and
managing feelings and attitudes towards residents.
Staff support groups
Establish enforcement systems within the facility
Periodic exams with extrinsic government systems
Interprofessional Patient Care Team
What we must know about dementia care?
 We can change our behaviour towards a dementia
resident but the dementia resident is usually not able
to change how they react to us.
 Severely demented residents read body language and
reflect body language behaviour.
 Distraction maneuvers which utilize resident
procedural memory are highly effective in crisis
management.
Aggressive Behaviour Management
ABC… for the resident
Antecedent, Behaviour and Consequences
P.I.E.C.E.S …for the caregiver
Assess caregiver physical health, intellectual health,
emotional health, capabilities, environment ,and social
supports.
( the secret of caring for the resident with dementia is
caring for the caregiver… Alzheimer society)
Risk Factors for Elder Abuse
Victim
1. Advanced age
2. Dependency for basic
activities of daily living
3. Dementia
4. Combative behaviour
Perpetrator
1.Depression/Mental
illness
2.Alcohol or drug
dependency
3.Financial dependence
4.Caregiver complaining
about the patient
Home Based Abuse
 Estimated rates of abuse by caregivers is 5-14% in
the dementia population as compared to 1-3% in the
general population
 Financial exploitation was estimated to affect 20% of
victims of elder mistreatment ( US 2003 National
Aging Resource Centre on Elder Abuse)
Family Dementia Caregiver Study Hong Kong: Int
J Geriatric Psychiatry Aug 2010
 62% all forms in 1 month (122 family caregivers)
 Verbal>physical 62%vs 18%
 More coresiding days> violent episodes
 High level of agitated behaviour predicts verbal
abuse
 Agitated behaviour may elicit abusive behaviours
though it’s effect on caregiver burden
Why the lack of identification of elder abuse by
family physicians?
 Elderly patients visit their family physician 5X per
year
 Only 2% report cases of abuse or neglect
 Family physicians are champions of child abuse
identification
Why?
 Failure of victim to corroborate the abuse.
 Fear of retaliation by a family member
 Unwillingness to become involved with adult
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protection services
Discomfort with the problem
Time /remuneration constraints
Not knowing the signs and symptoms of elder
neglect /abuse.
Not a member of the community team
What can we do in the medical profession?
 Improve exposure in medical school to elder abuse.
 Increase geriatric education as mainstream in today’s
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medical environment
Push for mandatory reporting of elder abuse.
Instruct graduation physicians in the use of screening
tools such as the EASI for identification of potential elder
abuse victims.
Be aware of the dementia syndrome, able to diagnose the
common types and address the behavioural issues using
evidence based approach.
Work interprofessionally with the schools of
Nursing,Pharmacy,and Social Work for common
curriculum in Elder abuse.
EASI
 Within the past 12 months:
 1.Have you relied on people for any of the following:
bathing, dressing, shopping, banking , or meals?
 2.Has anyone prevented you from getting food, clothes,
medication, glasses, hearing aids or medical care, or from
being with people you wanted to be with?
 3.Have you been upset because someone talked to you in a
way that made you feel shamed or threatened?
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Yaffe MJ et al Journal of Elder abuse and Neglect 2008 20(3) 276-300
EASI
 4. Has anyone tried to force you to sign papers or to use
money against your will?
 5.Has anyone made you afraid ,touched you in ways that
you did not want, or hurt you physically?
 6.DOCTOR:Elder abuse may be associated with findings
such as :poor eye contact, withdrawn nature
,malnourishment ,hygiene issues ,cuts ,bruises
,inappropriate clothing ,or medication compliance issues.
Did you notice any of these to
 day or in the last 12 months.
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Yaffe MJ et al Journal of Elder Abuse and Neglect 2008:20(3)276-300
What Physicians can do in the home to help
prevent elder abuse?
 Housecalls
 Work collaboratively with home care nurses, social
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workers and home support workers.
Observe for signs of caregiver stress
Anticipatory guidance to family and caregivers about the
dementia syndrome .
Suggest planned respite / caregiver support /community
resources…family meeting
Help address ETOH and drug abuse in the home.
Be aware of polypharmacy issues and appropriate use of
psychotropics for behavioural management.
What the physician can do in the LTC setting?
 Be proactive with staff re: dementia education and
behavioural management techniques.
 Be available to listen and be supportive of
approaches to reduce staff stressors.
 Address carefully aggressive behaviours in the LTC
environment . Family meetings and distraction
techniques and proper use of psychotropic
medications.
Canadian Reporting Regulations
 Manitoba has mandatory reporting by “Key Health Care
Professionals”
 PEI, NB, and BC have voluntary reporting
 NS and NL have general mandatory reporting
 This fall the Adult Protection Act will become law in NL
which will make it law to report suspected elder abuse or
neglect and failure to do so could be met with a $10,000
fine or 1 year max imprisonment
“ The soul is born old, but grows young... That is the comedy of life.
The body is born young, but grows old..That is life’s tragedy” Oscar
Wilde