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The Hidden Problem
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Abuse: physical, emotional, and sexual
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Neglect: self and other
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Exploitation: financial and sexual
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Abandonment
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No one knows for certain how big the problem is because
relatively few cases are identified.
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It is estimated that 2 million older adults are mistreated
each year in the U.S.
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5 of 6 cases are NOT reported
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Hospice and palliative care patients have multiple risk
factors
o Dependent on others for care
o Cognitive impairment
o Caregiver stress
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Elder abuse can occur anywhere – in the home, nursing
home, or other institutions
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It can affect the elderly across all socio-economic groups,
cultures, and races
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Women and “older” elders are more likely to be victims
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Dementia is a significant risk factor
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Mental health and substance abuse issues are risk factors
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Isolation can also be a risk factor
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A Victim May…
Have injuries that do not
match the explanation of
how they occurred and
have repeated “accidental
injuries”
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Appear to be isolated
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Say or hint feeling afraid,
coded messages about
what is occurring
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An Abuser May…
Minimize or deny the
victim’s injuries, attempt to
convince others that the
victim is incompetent or
crazy, blame the victim for
being clumsy or difficult
Physically assault or
threaten violence, prevent
or forbid victim contact
with others
Act overly attentive towards
the victim, especially in the
presence of others
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A Victim May…
Consider or attempt
suicide
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An Abuser May…
Consider or attempt
suicide
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Have a history of
substance abuse
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Have a history of
substance abuse
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Be “difficult” or hard to get
along with
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Refuse to allow an
interview with the victim
without being present,
speak on behalf of the
victim
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A Victim May…
Be emotionally and/or
financially dependent on
the abuser
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Show signs of depression,
stress, or trauma
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Have vague, chronic, nonspecific complaints
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An Abuser May…
Be emotionally and/or
financially dependent on
the victim
Turn family members
against the victim, talk
about the victim as though
they are not there or not a
person
Say the victim is
incompetent, unhealthy or
crazy
Why is this a bit tricky at end of life?
Physical, behavioral, and emotional changes
that happen at end of life may also be signs of
possible abuse, neglect, or exploitation.
Physical: slap marks, unexplained bruises, pressure
marks, burns, blisters
 Neglect: pressure ulcers, filth, lack of medical care,
malnutrition or dehydration
 Emotional: withdrawal from normal activities,
unexplained changes in alertness or other unusual
behavioral changes
 Sexual: bruises around the breasts or genital area and
unexplained STDs
 Exploitation: sudden change in finances and accounts,
altered wills and trusts, unusual band withdrawals,
checks written as “loans” or “gifts”, loss of property
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Hospice Patient
Increasing frailty
Cognitive impairment
Increased assist with ADLs
Display of abusive behavior
Unstable/poor social
supports
Conflicted relationships
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Caregiver
Perception of stress
Dependency on patient
Poor relationship prior to
illness
Substance abuse
Mental illness
Burnout/frustrations
Lack of skills
Depletion of resources
 Educate
ourselves and our team
 Increase
communication among the hospice team
to include each member’s observations and
awareness when you suspect a situation.
 Our
policy requires that our staff immediately
report any suspected case of abuse, neglect, or
exploitation to his/her immediate clinical
supervisor or to the Clinical Counseling Officer.
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Remember that you don’t need proof of abuse, neglect, or
exploitation to make a report – reasonable suspicion is all
that is required
Involving adult protective services does not mean your team
failed
Don’t assume that someone has already reported a
suspicious situation. Most cases go unreported.
Any individual who is legally mandated to report suspected
abuse, neglect or exploitation and who intentionally fails to
report such is guilty of a misdemeanor and liable for
damages cause by failure. KRS Chapter 209
 Lack
of awareness of problem
 Insufficient understanding
 Loyalty to patient/family
 Legal and practical consequences
 Feeling of failure
 Assumptions about adult protective service
response
 Denial of mistreatment
 Lack of recognition of warning signs
 Potential effect on rapport with patient and family
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Get management support
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Include team members and supervisors from the very
beginning of seeing any of the warning signs
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Keep focus on enhancing quality patient care