Enhance the Involvement of Care Taker of Patient

Afza.Malik GDA

Increase The Involvement of Caretakers in Geriatric Care

Enhance the Involvement of Care Taker of Patient

Who Are Caretaker,Types of Elder Mistreatment,Theories of Elder Mistreatment,Dementia Elder Mistreatment,Assessment,Interventions And Care Strategies.

Who Are Caretaker

    Enhance the involvement of members of the patient's support system, including family and friends identified by the patient, community based groups, support groups, appropriate clergy, or organizational groups such as senior centers.

    Support the development of coping mechanisms, including modifications in social, housing, and recreational environments, to minimize associations with settings and groups in which substance use and abuse are common (USDHHS, 2004a).

Counseling and Psychotherapy

    Older persons tend to seek care from their primary care, medical specialist, or nurse/ nurse practitioner provider even regarding assistance with mental health and substance-related problems.

    This practice derives from long-held beliefs that depression or anxiety indicates weakness or lack of character.

    Older people, more than others, stigmatize the excess use of alcohol or use of an illicit drug and problems with prescription drugs.

    Counseling done by the nurse using a brief intervention model or supportive counseling is more readily acceptable to older patients than referral to mental health or substance abuse clinics.

    Optimally, short-term psychotherapy by a practitioner with education about abuse and addiction is extremely helpful. The model of cognitive behavioral therapy, in particular, has demonstrated good outcomes with excessive drinking and marijuana use (Cooney, Babor, & Litt, 2001).

    These approaches assist the older person to modify behavior and to deal with negative feelings and/or chronic pain that often motivate use.

Treatment Outcomes

    Health care providers and older persons may feel pessimistic about the possibilities of changing their substance use behavior. Health providers often do not intervene because they believe that older people do not change. 

    Treatment outcomes for older persons with substance use problems, however, have been shown to be as good as or better than those for younger people (USDHHS, 2004b). Good treatment outcomes, however, can be compromised by inconsistency of follow-up and limited access to aftercare for community dwelling older adults physical assessment. 

    Their presence at the patient's bedside affords nurses the opportunity for direct contact with caregivers, firsthand observations of caregivers' interactions with patients, and identify red flags (Cohen, Halevi-Levin, Gagin, & Friedman, 2006). 

    These factors place nurses in the unique and difficult role to assess, identify, and act in cases of EM more often than other members of interdisciplinary health care teams.

    Nursing has had a long history in ensuring high standards of care for older adults. The identification of EM should not be the exception. In spite of this, nurses' lack of training and knowledge of the extent of EM and its presentation may hinder their ability to identify the signs of mistreatment. 

    Abuse is often multifactorial; therefore, it is important to recognize that it is an interplay between characteristics of the abused, the perpetrator, and environmental factors (Killick & Taylor, 2009). Physical markers of abuse are often incorrectly attributed to physiological changes in the elderly rather than EM (Wiglesworth et al., 2009). 

    Cases of EM can prove to be challenging for nurses as it is often complicated by denial on the part of the perpetrator and older adult, refusal of services by victims, as well as fears that an accusation of EM may actually worsen abuse. 

    Serious ethical dilemmas may arise because a nurse may struggle between his or her obligation to ensure the patient's well-being and uncertainty over presence of EM (Beaulieu & Leclerc, 2006). 

    The development of EM protocols that are grounded in evidence-based research is crucial to ensure that EM cases are properly handled by nurses and other health care professionals.

Background Of Problem

    Recent data suggest that in the United States, more than 2 million older adults suffer from at least one form of EM each year (National Research Council (NRC), 2003). The National Elder Abuse Incidence Study estimated that more than 500,000 new cases of EM occurred in 1996 (National Center on Elder Abuse [NCEA), 1998). 

    A recent study by Acierno and colleagues (2010) estimated the prevalence of MS within a 1-year period to be approximately 11%. Although 44 states and the District of Columbia have legally required mandated reporting, EM is severely underreported. There is a lack of uniformity across the United States on how cases of EM are handled. 

    Cases of EM are managed differently state by state with varying methods of investigation and intervention (Jogerst et al., 2003). NCEA (1998) estimates that only 16% of cases of abuse are actually reported. 

    In a systematic review, one-third of health care professionals included believe they had detected a case of EM; however, only about 50% had actually reported the case (Cooper, Selwood & Livingston, 2009). 

    Similarly, another study found that despite 68% of emergency medical services staff surveyed stating they felt they had encountered a case of EM in the past year, only 27% had actually made a report (Jones, Walker, & Krohmer, 1995). 

    Despite mandatory reporting on the part of health care professionals, it is believed that many are not reporting all cases of EM that they detect (Killick & Taylor, 2009).

    This creates several issues in terms of obtaining an accurate sense of the scope of EM in the country and may have serious detrimental effects for the older adults suspected of being victims of EM.

    Conflicting theories of causation and lack of uniform screening approaches have further complicated EM detection. Understandably, it has been difficult for nurses to adequately respond to cases of EM when they are unclear about its manifestations, causes, and detection strategies. 

    EM researchers agree that as the population continues to age exponentially, cases of EM will reach epidemic levels. A lack of universally accepted definitions for different types of EM has hampered efforts to ascertain what constitutes EM. 

    In an effort to establish a clear consensus, the NRC (2003) defined elder mistreatment as either “intentional actions that cause harm or create serious risk of harm (whether harm is intended) to a vulnerable elder by a caregiver or other person who is in a trust relationship to the elder,” or “failure by a caregiver to satisfy the elder's basic needs or to protect himself or herself from harm.” 

Types of Elder Mistreatment

    Six types of mistreatments are generally included under the term EM. Table 27.1 describes each form of EM as well as examples of each.

    The use of the term mistreatment rather than abuse further underscores a crucial feature of EM; that EM is the outcome of the actions abuse, neglect, exploitation, or abandonment. 

    Abuse and neglect can then be further classified as intentional or unintentional. Intentional neglect might be seen as a conscious disregard for caretaking duties that are inherent for the well-being of the older adult. 

    Unintentional neglect might occur when caregivers lack the knowledge and resources to provide quality care (Jayawardena & Liao, 2006). Neglect, whether intentional or unintentional, is recognized as the most commonly occurring form of EM, NCEA (1998) revealed that neglect accounts for approximately half of all cases of EM reported to 

    Adult Protective Services (APS). About 39.3% of these cases were classified as self-neglect and 21.6% attributed to caregiver neglect. including both intentional and unintentional. 

    More than 70% of cases received by APS are attributed to cases of self-neglect with those older than 80 years thought to represent more than half of these cases (Lachs & Pillemer, 1995).

    There is much debate as to whether self-neglect should be included as a type of EM. Although other forms of EM occur because of the action or inaction of an outside perpetrator, in self-neglect, the perpetrator and victim are one and the same (Anthony, Lehning, Austin. & Peck, 2009). 

    Several international studies studying perceptions of EM identified caregiver neglect as the most common and accepted form of EM among participants (Daskalopoulos & Borrelli, 2006; Mercurio & Nyborn, 2006; Oh, Kim. Martins, & Kim, 2006; Stathopoulou, 2004; Yan & Tang, 2003). 

    Subjects identified family members as the caregivers more likely to be perpetrators. Shockingly, neglect was seen as a “quasi-acceptable” form of abuse, whereas physical and emotional/psychological abuses were viewed as extreme and harsh.

Theories of Elder Mistreatment

    The concept of vulnerability has been central to the discussion of EM. Fulmer and colleagues (2005) conducted a study of older adult patients recruited through emergency departments in two major cities. 

    The goal was to identify factors within the older adult-caregiver relationship that may predispose some older adults to be victims of neglect over others. The theoretical framework of the study is the risk-and-vulnerability model, which posits that neglect is caused by the interaction of factors within the older adult or in his or her environment. 

    The risk and vulnerability model adapted to EM by Frost and Willette (1994) provides an appropriate model through which to examine EM (Frost & Willette, 1994; Fulmer et al., 2005). Vulnerability is determined by characteristics within the older adult that may make him or her more likely to be victims of EM such as poor health status, impaired cognition, history of abuse, and so forth. 

    Risks refer to factors in the external environment that may predispose to EM. These may include characteristics of caregivers such as health status and functional status, as well as a lack of resources and social isolation (Fulmer et al., 2005). 

    It is the interaction between risk and vulnerability that can predispose some older adults to MS (Killick & Taylor, 2009; Paveza, Vanderweerd, & Laumann, 2008).

    The risk and vulnerability model as well as other theories from the literature on family violence have been adapted from the health and social sciences literature in an effort to find probable theories for EM. 

    However, there has been no clear consensus on one theory that explains EM (Fulmer, Guadagno, Bitondo Dyer, & Connolly, 2004). The development of assessment interventions and strategies that cross multiple theoretical frameworks is likely to be the most clinically appropriate strategy (NRC, 2003).

Theories of EM Include but are not limited to the Following

1. Situational theory: Promotes the idea that EM is a result of caregiver strain due to the overwhelming tasks of caring for a vulnerable or frail older adult (Wolf, 2003). 

2. Psychopathology of the abuser Abuse is believed to stem from a perpetrator's own battle with psychological illness such as substance use, depression, and other mental disorders (Wolf, 2003). 

3. Exchange theory: Speculates that the long-established dependencies present in the victim-perpetrator relationship are part of the “tactics and response developed in family life, which continue into adulthood” (Wolf, 2003). 

4. Social learning theory: Attributes EM to learned behavior on the part of the perpetrator or victim from either their family life or the environment; abuse is seen as the norm (Wolf, 2003). 

5. Political economy theory. Focuses on how older adults are often disenfranchised in society as their prior responsibilities and even their self-care is shifted on to others (Wolf, 2003).

Dementia and Elder Mistreatment

    Older adults with dementia are particularly vulnerable to EM. As the population of older adults increases, it is expected that so will the number of older adults with dementia (Wiglesworth et al., 2010). 

    It is estimated that older adults with dementia will rise from 4.5 million in 2000 to 13 million by the year 2050 (Hebert, Scherr, Bienias, Bennett, & Evans, 2003). 

    Because of the cognitive deficits present in older adults with dementia, it is particularly difficult to screen for EM. The older adult may not be able to give a reliable history, and signs of EM may be masked or mimicked by disease (Fulmer et al., 2005). 

    Those providing care for older adults with dementia are at particular risk for caregiver strain and burnout. 

    Disruptive behavior such as screaming or wailing, physical aggression, or crying can be exhausting for caregivers in any setting (Lachs, Becker, Siegal, Miller, & Tinetti, 1992).

    One study reported that as many as 47% of older adults with dementia were victims of some form of EM (Wiglesworth et al., 2010). The researchers used a combination of two screening instruments as well as a caregiver self-report. 

    Similarly, in a systematic review, one-third of caregivers of older adults with dementia were willing to admit to some form of EM, whereas 5% admitted to physical abuse (Cooper, Selwood, & Livingston, 2008). 

    In a community-based study of caregivers of older adults with dementia, 51% of caregivers admitted to verbal abuse and 16% to physical abuse. However, only 4% admitted to neglect (Cooney, Howard, & Lawlor, 2006). The ramifications of these data are sobering. 

    If 30% will admit to EM, there is every reason to worry regarding EM in those who do not report. Objective assessment alone cannot capture all cases of EM and, thus, a policy is needed that incorporates both objective measures as well as a discussion with both the older adult and caregiver (Cooper et al., 2008). 

    Most caregivers are forthcoming with admission of EM and many of them ask for help in developing coping strategies and plans of care to provide better care for care recipients (Wiglesworth et al., 2010).


    The American Medical Association (AMA, 1992) released a set of guidelines and recommendations in 1992 on the management of EM. The AMA urged providers that all older adults should be screened for EM. Many hospitals already include EM screening as part of the admission process for all patients older than 65 years old. Assessment of EM is not an easy task. 

    Subtle signs of EM are hard to identify and even harder to substantiate (Anthony et al., 2009). Rates of reporting on the part of health care professionals are still low due in large part to ageism in society and lack of education and training on the assessment, detection, and reporting of EM. 

    Unsubstantiated fears exist that increasing education on assessment of EM will lead to higher rates of false positive cases and, therefore, expense and disruption in the system. 

    However, a systematic review of 32 studies revealed that health care professionals educated about EM were not more likely to detect EM cases but were more inclined to report detected cases than those that had little or no education related to EM (Cooper et al., 2009 ).

    The complexity and variability of most cases of EM makes it hard to describe what a typical perpetrator or a victim looks like. There is no correlation found between age. gender, race, and any association with MS (Krienert, Walsh, & Turner, 2009). Hence, it is difficult to describe who is a “typical” victim or perpetrator of EM. 

    Some research suggests that victims of MS are more likely to be unable to provide for self-care needs on their own because of cognitive or physical deficits and have a history of depression (Giurani & Hasan, 2000).

     In a small scale, victims of EM had lower scores on cognitive screens using the mini mental status exam (MMSE) and greater functional deficits as scored with the Katz Index of Independence in ADL. 

    They also had higher rates of depression when screened with the Geriatric Depression Scale (GDS) scores (Dyer, Pavlik, Murphy, & Hyman, 2000). These studies support carlier findings from a longitudinal study on factors influencing mortality of victims of MS (Lachs, Williams, O'Brien, Pillemer, & Charlson, 1998). 

    Others (Draper et al., 2008; Fulmer et al., 2005) have also identified a link between childhood abuse among victims and physical and sexual EM later in life. A lack of social support and social isolation increase the risk for MS in older adults (Acierno et al., 2010; Dong & Simon, 2008; Fulmer et al., 2005).

    Research suggests perpetrators are more likely to be family members, report greater caregiver strain, live with the victim, have a history of mental illness and/or depression, history of substance abuse, have lived with the victim for an extended time (approximately 9.5 years ), have few social supports, and have a long history of conflicts with the victim (Cowen & Cowen, 2002; Giurani & Hasan, 2000; Wiglesworth et al., 2010).

    In the clinical setting while conducting an EM screen, it is recommended to separate the older adult from the caregiver and obtain a detailed history and physical assessment ment (Heath & Phair, 2009). Special attention should be paid to both physical and psychological signs of EM. 

    Discrepancies between injury presentation or severity and the report of how the injury occurred as well as discrepancies between explanations from the caregiver and older adult should be paid close attention. Physically abused older adults are more likely to have significantly larger bruises and to know the cause of their bruise. 

    Furthermore, these abused older adults are more likely to display bruising on the face, lateral aspect of the right arm and the posterior torso (including back, chest, lumbar, and gluteal regions; Wiglesworth et al., 2009). 

    Other possible indicators of physical abuse include bruises at various stages of healing, unexplained frequent falls, fractures, dislocations, burns, and human bite marks (Cowen & Cowen, 2002).

    It is important to distinguish that signs and symptoms of EM may vary depending on the type of abuse.Victims of sexual abuse are more likely to be female and exhibit “genital or urinary irritation or injury; sleep disturbance; extreme upset when changed, bathed, or examined; aggressive behaviors; depression; or intense fear reaction to an individual” (Chihowski & Hughes, 2008, p. 381). 

    Ageist attitudes among health care professionals may limit the number of cases of sexual abuse that are identified as older adults are rarely thought of as the usual victims of abuse (Vierthaler, 2008). Victims of financial abuse are harder to identify; however, they share similar traits such as social isolation, physical dependency, and mental disorders as victims of emotional or psychological abuse and neglect (Peisah et al., 2009). 

    Since the 1970s, a myriad of screening instruments have been developed to detect cases of EM, but few are appropriate for inpatient older adults. Most have had limited testing in the acute care setting and focus on in-home assessments or extensive questions that are better suited for primary care settings.

    The Elder Assessment Instrument (EAI) developed by Fulmer and colleagues (2004) is a 41-item screening instrument that requires training on how to administer it but has been proven effective in busy hospital settings (Perel-Levin, 2008). 

    The current EAI-R (revised in 2004) is considered more appropriate for inpatient and outpatient clinics because it relies on objective assessment by the clinician such as general appearance, assessment for dehydration, physical and psychological markers, or pressure ulcers as well as subjective information received from the patient. 

    The Hualek Sengock Elder Abuse Screening Test (HS-EAST) is a 15-item instrument that relies on self-report from older adults and is documented as appropriate for detecting physical abuse, vulnerability, and high-risk situations. Some instruments focus on the care giver, but an advantage of HS-EAST is the focus on the older adult history. 

    It is regarded as appropriate for use in the hospital setting and can be easily administered by nurses (Fulmer et al., 2004; Perel-Levin, 2008). If a positive screen is noted, detailed physical assessment and medical history should be completed to substantiate possible abuse. Referral to experts in trauma or geriatrics, either on or off site, should take place for the best available input.

    In addition to these screening instruments for EM, there are a number of other reliable and valid instruments that can aid nurses in identifying those at risk for EM. As discussed previously, victims of EM tend to have lower functional and cognitive abilities than their counterparts. 

    The Katz Index of Independence in ADL and/or the Lawton instrumental activities of daily living (IADL) scale may help in detecting older adults with functional deficits (Graf, 2007: Wallace, 2007). Similarly, with higher rates of depression in victims of EM, the GDS may be a useful instrument for nurses to use in the hospital setting. 

    It is a 15-item screening instrument that is effective at distinguishing depressed older adults (Kurlowicz & Greenberg, 2007). In the literature, perpetrators of EM often report higher caregiver strain. The Modified Caregiver Strain Index (CSI) is a reliable and self-administered instrument that can aid in assessing caregivers that may benefit from intervention strategies to alleviate stress involved with caregiving demands (Sullivan, 2007).

    The process of identifying cases of self-neglect is often even more daunting than other cases of EM. Assessing self-neglect is further complicated by a lack of standardized screening instruments or markers for detection (Dyer et al., 2006; Kelly, Dyer, Pavlik, Doody, & Jogerst, 2008; Mosqueda et al., 2008). Several researchers are currently developing screening instruments for self-neglect. 

    However, their use in the acute care setting is limited. Most require in-depth assessments of home life and are based mostly on objective findings from the health care professional. However, data suggests that detection of self-neglect in the hospital setting is unfortunately made easier because by the time these cases reach the hospital, they are often very severe (Mosqueda et al., 2008). 

    Signs of self-neglect may include lack of adequate nutrition such as dehydration: changes in weight: poor hygiene and appearance such as soiled clothing, uncombed hair, debris in teeth; poor adherence to medical treatments such as unfilled prescriptions; refusing to perform dressing changes, poor glucose monitoring, and so forth (Cohen et al., 2006; Naik, Teal, Pavlik, Dyer, & McCullough, 2008). 

    Objective measures as well as questioning of the older adult about health patterns and activities of self-care are also important factors in detecting self-neglect because it can yield important information about attitudes and opinions of the older adult.

Interventions And Care Strategies

    Detailed screening of older adults at risk for EM is the first step in identifying cases of EM (Perel-Levin, 2008). There are various screening instruments that can help in revealing older adults and caregivers at risk for EM. Setting aside time to meet with the older patient and their caregiver separately is an important aspect of the screening process. 

    This can highlight any inconsistencies in depictions of how injuries occur, allow the nurse to develop a closer relationship with each, as well as express his or her willingness to help each party. Nurses should not work alone in detecting cases of EM but, instead, should include professionals from other disciplines as much as possible. 

    According to the literature when EM is suspected, the use of interdisciplinary teams with professionals from both the acute care and community settings is the best approach to managing such cases (Wiglesworth, Mosqueda, Burnight, Younglove, & Jeske, 2006). 

    Institutions should develop clear guidelines for practitioners to follow when cases of EM are identified (Perel-Levin, 2008). Referral to appropriate community organizations is paramount to ensure safe discharges for suspected victims of EM. 

    Interdisciplinary teams work best when they include team members with expertise in various disciplines including nursing, social work, law, and so forth. It is this diversity of skills that allows for innovative approaches to managing cases of EM (Jayawardena & Liao, 2006).

    Educating older adults, staff, and caregivers about the nature of EM is key. It is crucial to educate older adults who have the cognitive capacity to accept or refuse interventions about patterns of EM such that abuse tends to increase in severity over time (Cowen & Cowen, 2002; Phillips, 2008). 

    For individuals who lack the cognitive capacity to consent for interventions, it is important to report these cases to APS and develop a plan for safe discharge. Older adults should receive emergency contact information as well as community resources (Cowen & Cowen, 2002). 

    Interdisciplinary teams should also take into account the difficulties caregivers may experience in caring for adults with diminished functional and/or cognitive capacity and provide these caregivers with support services and interventions of their own to assist them in providing the best care they can (Lowenstein, 2009 ). 

    Services should be offered not only to victims of EM but also to their suspected perpetrators. Helping caregivers gain a better understanding of proper care techniques may help alleviate cases of neglect in particular.

    Because of the nature of hospital stays, most of the long-term interventions currently occur in the community setting. A systematic review of interventions for EM revealed that interventions tend to concentrate on the situational theory of abuse by focusing on education, counselling, and social support for perpetrators of EM to better cope with stressors of caregiving (Ploeg et al., 2009). 

    However, even these community-based interventions have shown mixed results in terms of effectiveness when studying factors such as risk of recurrence of MS; levels of depression and self-esteem in older adults; and levels of caregiver strain, stress, and depression in caregivers (Ploeg et al., 2009). 

    In the acute care setting, patients are assumed to have the autonomy to refuse medical treatments and participate in care management as long as there are deemed to be able to give informed consent. However, what can be done if the older adult is refusing to perform activities deemed essential for their health and well-being? 

    The answer, at the moment, is very little because there is currently no rigorously tested screening instrument to assess cognitive capacity in this population (Naik et al., 2008). Naik et al. (2008) discuss the ethical dilemma that is present when an older adult is suspected of self-neglect. 

    If the older adult is deemed to have the cognitive capacity to make decisions about their own self-care, there is very little that health care professionals can do to intervene. Interdisciplinary health care teams are thought to be the most effective way of identifying self-neglect. 

    Although it may seem difficult and costly to implement interdisciplinary health care teams to adequately treat this group of older adults, the costs of not connecting these individuals to proper resources can be much greater as their health conditions can go undiagnosed and untreated for longer time, therefore creating greater health care costs (Lowenstein, 2009). 

    There is inherent difficulty in evaluating the success of interventions implemented in acute care organizations. The nature of discharges makes it difficult to learn about outcomes in cases of EM. 

    Not all suspected victims of EM will return to the same institution for repeat visits, and confidentiality issues can restrict information sharing among health care professionals.

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