Dementia and Elder Abuse

Elder Abuse; a Family
Physician’s Perspective,
Community and LTC
Dr.Roger Butler
A war veteran / VP resident
Discuss current research on elder abuse
demographics in relation to dementia care
Discuss some theoretical models to explain
Explore challenges in dementia care both in
the community and LTC sectors
Explore barriers physicians face in elder
Explore characteristics of caregivers,residents
and the environment that predispose to elder
What can physicians do?
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 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.
Elder Abuse and Neglect
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
Types of Abuse
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.
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
The older person is living in an unsafe or
unhealthy manner by choice or ignorance.
What to do if you are worried?
Self Neglect
2031, 25% Canadian population>65 (8
 Elder abuse or neglect 7%
 In 1999 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)
Elder Abuse Demographics
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?
LTC setting scenario
5-55% compared to 3.2-27.5% prevalence
rates for nondemented ( Cooper et al US
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
Mental abuse and neglect most common
Elder Abuse and Dementia
Study based on 22 nursing homes in Israel
and published in 2010 (International Nursing
Random selection from 300 nursing homes in
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
Psycho-social factors affecting
elders maltreatment in LTC
Details of the facility, demographic details
and professional details
 Reporting incidents of violence, victim
traits, attitudes towards and knowledge
about maltreatment
 Burnout questionaire
Areas studied
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
2. The theory of reasoned action(Ajzen and
1980) Human behaviour depends on two
components; behavioural attitude and
subjective norms
Models for Abusive behaviour
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
Staff who perceive the following are at
- residents have to be constantly served
-they are waiting to die
-they behave like little children
-they must be occasionally taught discipline
Staff Traits continued
Elderly residents with dementia have the
highest risk 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
Rate increases with age in the LTC and home
Socially isolated are at greater risk
Patient Traits
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
 Lack of nursing staff leads to elder
maltreatment (California/Scandinavia
 Non-profit facilities provide the best
nursing and medical services
Facility features
½ staff report abusing residents in the
previous year
2/3 of abuse involves physical and mental
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
Jewish moral custom of honouring seniors
not perpetrated the nursing home culture
Significant positive correlation between staff
burnout and physical violence and mental
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
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
Results Continued
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
Periodic exams with extrinsic government
Bottom Line
Interprofessional Patient Care Team
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
 Distraction maneuvers which utilize
resident procedural memory are highly
effective in crisis management.
What we must know about
dementia care?
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
( the secret of caring for the resident with
dementia is caring for the caregiver…
Alzheimer society)
Aggressive Behaviour
Age 86 with Alzheimer’s
type dementia who has
his daughter and her
family living with him
because they were
unemployed and he
needed help. He has
been agitated recently
and requires some
assistance with
dressing. He tends to
pace and follow his
daughter around the
house repeatedly
asking her questions.
Mr. Duddleberry
His daughter Shirley
brings him in for his
appointment .It is clear
she is unhappy and
resentful. You ask your
nursing assistant to
bring him into your
exam room and you
take his daughter
 You acknowledge she
looks depressed and
ask “How are things
Shirley relates how her
father was never
around when she was
growing up and now he
needs help he has
come back into her life
and is ruining it. She
finds she can’t spend
time with her kids , her
husband is annoyed
and you smell a faint
smell of alcohol on her
Duddleberry Case
The family physician is
in an ideal situation to
recognize that this is a
potentially abusive
situation. It will require
listening time,
supportive counselling
or referral, linking with
the Alzheimer’s society,
and looking at respite,
day care options to
prevent burnout in this
1. Advanced age
2. Dependency for
basic activities of
daily living
3. Dementia
4. Combative
2.Alcohol or drug
complaining about
the patient
Risk Factors for Elder Abuse
Estimated rates of abuse by caregivers is
5-14% in the dementia population as
compared to 1-3% in the general
 Financial exploitation was estimated to
affect 20% of victims of elder
mistreatment ( US 2003 National Aging
Resource Centre on Elder Abuse)
Home Based Abuse
62% all forms in 1 month (122 family
 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
Family Dementia Caregiver Study
Hong Kong: Int J Geriatric Psychiatry
Aug 2010
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 the lack of identification of elder
abuse by family physicians?
Failure of victim to corroborate the abuse.
Fear of retaliation by a family member
Unwillingness to become involved with
adult 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
Improve exposure in medical school to elder abuse.
Increase geriatric education as mainstream in today’s
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.
What can we do in the medical
Work collaboratively with home care nurses,
social 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
What Physicians can do in the
home to help prevent elder abuse?
Be proactive with staff re: dementia
education and behavioural management
 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.
What the physician can do in the
LTC setting?
“ 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
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