Elder Mistreatment As An Syndrome And Nursing Management

Mistreatment In Elders and Nursing Management

Prevalence and Risk Factors of Mistreatment ,Types of Mistreatment ,Reporting of Mistreatment ,Theories of Mistreatment ,Mistreatment and Nursing Care.

Whats is Elder Mistreatment

    Elder mistreatment (EM) is a complex syndrome that can lead to morbid or even fatal outcomes for those afflicted. Mistreatment is the term used to describe outcomes from such actions as abuse, neglect, exploitation, and abandonment of the elderly, and it affects all socioeconomic, cultural, ethnic, and religious groups. 

    The prevalence of EM is estimated between 700,000 and 1.2 million cases annually in this country (Pillemer & Finkelhor , 1988). The National Elder Abuse Incidence Study documented over 500,000 new cases. annually ( Tatara , 1993).

Prevalence and Risk Factors of Mistreatment 

    The National Research Council (NRC). (2003) agreed an expert panel to review prevalence and risk for elder abuse and neglect and concluded that EM is an intentional action that causes harm or creates a serious risk of harm (whether or not harm is intended) to an at risk elder by a caregiver or other person who stands in a trusting relationship to the elder, or is the failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm. 

Types of Mistreatment 

    There are several types of MS described in the NRC report. Abuse is generally understood as physical assault inflicted on an older adult resulting in harmful effects. Abusive behavior may include hitting, kicking, punching, and other physical contact. Neglect is the refusal or failure to fulfill any part of a caregiver's obligations or duties to an older adult. 

    Neglect may be intentional or unintentional. Self-neglect occurs when an older adult, either knowingly or unknowingly, lives in such a manner that is deleterious to his or her health. Exploitation is fraudulent activity in connection with an older adult's property or assets, and abandonment is defined as the deliberate and abrupt withdrawal of services in caring for an older adult. 

    Restriction as a form of EM has recently been examined in an investigation of caregiver behaviors that have fewer social sanctions but may be equally deleterious to the older person (Fulmer & Gurland , 1996). 

Reporting of Mistreatment 

    Evidence suggests that only 1 in 14 EM cases is reported to some public agency. Nurses can do much to help in the screening and detection process of EM by doing a careful history and physical assessment with attention to the subjective complaint of EM, along with any signs or symptoms of the same. 

    Under reporting of EM is a serious concern because older adults may have disease symptoms or age-related changes that mimic or conceal mistreatment symptoms, making the assessment process complex. Few clinicians have been trained in EM assessment and intervention, which has also led to underreporting. 

    With an unprecedented number of individuals living beyond the age of 65 and even beyond the age of 85, nurses must be sensitive to the possibility of EM (Bergeron & Gray, 2003; Capezuti , Brush, & Lawson, 1997; Fulmer et al., 2003; Fulmer, Guadagno, Bitondo Dyer, & Connolly , 2004; Harrell et al., 2002; Heath, Dyer, Kerzner, Mosqueda , & Murphy, 2002).

Theories of Mistreatment 

    Theories for EM causality have been posited. The dependency theory refers to the amount of care an elderly person requires and is related to stressed caregiver research, which describes overwhelmed caregivers who lose their control or stop providing reasonable care. 

    Conversely, there are data that reflect the caregiver's dependency on the elder (for shelter, money, etc.), which puts the elder at risk. Trans generational violence theory refers to children who learn violent behavior as normal and then become violent and abusive as they grow older. 

    This might be viewed from a learning theory perspective, although some have looked at it as a retribution act: an adult child may strike back at a parent or caregiver who was once abusive. The psychopathology of the abuser theory refers to any non normal caregiver, such as substance abusers (alcohol, drugs), psychiatrically impaired individuals, or mentally retarded caregivers. 

    The number of mentally retarded elders over 65 years of age has grown substantially over the past decade, creating situations where mentally retarded or disabled offspring become care givers for very elderly parents (National Research Council, 2003).

Mistreatment and Nursing Care

    Early studies looked at the prevalence of MS from a variety of perspectives: acute care, community nursing care, and the nursing home setting. Differences in operational definitions, methodological approaches, and the lack of national prevalence studies have made it difficult to understand the conditions under which EM is likely to occur. 

    Although EM education and training has improved, there is still a great need for more systematic nursing assessment, care planning, and follow-up with the older adult. The need for researchers who can contribute to this area of inquiry is great.

    There is no Denver Developmental screen for older adults that enables the clinician to understand what an 80-year-old looks like and what conditions are likely to represent EM. 

    Signs and symptoms of EM might include unexplained bruises, fractures, burns, poor hydration, reports of hitting or any other violent behavior against the older adult, sexually transmitted disease in institutionalized older adults, unexplained loss of money or goods, evidence of fearfulness around a caregiver, or the subjective report of abuse. 

    It is especially difficult to evaluate the demented older adult for EM; A careful and thorough interdisciplinary team approach is required. The American Medical Association's Diagnostic and Treatment Guidelines on Elder Abuse and Neglect (American Medical Association , 1992 ; Aravanis et al ., 1993), although over 10 years old, provides excellent guidelines for the assessment of EM, along with flowcharts for assessing and intervening in cases. 

    A summary of EM instruments for screening and assessment is available ( Fulmer, Hyex , et al., 2004). Special attention must be given to an older adult who has diminished or absent decision making capacity. 

    Dementia has been documented as a risk factor for EM and should automatically trigger EM assessment (Lachs, Williams, O'Brien, Hurst, & Horwitz, 1997; Coyne, AG, Reichman, & Berbig , 1993). 

    Cognitive status can only be determined by rigorous clinical testing and use of validated instruments. Overzealous protection of a competent elder is a form of ageism that infantilizes the older individual and takes away their autonomy. 

    Each state has elder mistreatment reporting laws or requirements that professionals should be familiar with. Interdisciplinary care teams are especially important in the EM assessment process. Each team member is able to use their own expertise to the benefit of older adults (Fulmer et al., 2003). 

    A key practice implication for EM is the inclusion of family violence questions in every history with attention to and documentation of any signs or symptoms of EM.