Elder Abuse in End-of-Life-Care

        Elder Abuse is defined as “acts  of commission or omission that result in harm or threatened harm to the health or welfare of an older adult….Mistreatment of the elderly person may include physical, psychological, or financial abuse or neglect, and it may be intentional or unintentional.” (AMA, 1987). There are seven types of elder care abuse: physical, emotional, sexual abuse, financial exploitation, neglect, self- neglect, and miscellaneous. Neglect can be in the form of withholding necessary food, clothing and medical care, or any denial of basic necessities that meets the physical and mental needs of the elderly person. The individual can also neglect him or herself by engaging in behavioral patterns that endangers his or herself health or safety.

        Neglect can be intentional as a result of ignorance or inability to care for self. Intentional neglect is when the caregiver fails to carry the duties imposed on her for caring for the elderly resulting in injury or harm. Physical abuse occurs when pushing, striking, or causing bodily injury, forced feeding, or improper use of restraints is used on the elderly person. Sometimes, withholding of medication can lead to infliction of pain, and constitutes an abuse ethically and legally. Financial abuse includes theft, misuse of funds, coercion, or manipulation of the elderly with monetary transactions; this can also include changing wills or deeds. Psychological or emotional abuse can be verbal or nonverbal insults, humiliation, abandonment, and threats. Sexual abuse is the nonconsensual intimate contact, and this includes individuals who do not have the capacity to give consent.

      The incidence of elder abuse is on the rise in the United States with an estimate of about two million cases each year. It is estimated that about 84% of abused cases are not reported making it difficult to address the problem. Neglect seems to be the most common type of abuse constituting about 49% of elder abuse. Self–Neglect is as more common than neglect from others resulting to an increase in mortality in the elderly. According to a study conducted by Pillemer et al, 58% of abuse cases come from the spouse, which is more than half of reported cases. The National Elderly Abuse study revealed that 47% of abusers are children of the elderly victims and when compared to the 50,000 cases of abuse cases reported in the nursing homes, 236,000 cases were reported occurring at home.

     It is important to identify the risk factors for palliative caregivers in order to recognize possible victims, and seek an early intervention. The best approach is to identify the needs of the patient and family and address the problem proactively. The victim, perpetrator, and the social/cultural factor are related to the type of abuse. It is worthy to note that all individuals with social, physical or emotional problems become abusers, and not all abusers can be easily identified. The caregiver’s stress can be a risk factor for abuse, a thorough assessment should be done during the initial assessment by the palliative care professional.

   Individuals with cognitive impairment and the need for assistance with activities of daily living is another important risk factor in elder care abuse. Elders that have abusive tendencies of provocative behaviors themselves are also at risk for abuse. Patients with poor social support system in place and are always having conflict with family members are more prone to being abused. Dependency of the abuser on the elder, commonly seen in adult children of the elderly can be more significant than the elder’s dependence on the abuser. Caregivers with substance abuse especially abuse of alcohol increases the rate of abuse.

     Health Professionals should do a detailed history and physical examination, and are encouraged to find out about domestic relationship that exists between the patient and the caregiver routinely. The palliative care team should evaluate patient and caregiver’s cognitive, physical, and functional capacity, and interview should be done separately between the caregiver and the patient.  Physical findings are concrete clue that an actual abusive is taking place. A caregiver who refuses to leave the room during an examination may be concerned that patient will complain. If the patients exhibits fear, tentative, or rehearsed in her story, or seems too careful in presenting the information, suspicion of an on-going abuse should be raised.

   Financial abuse manifests in signing of legal documents (wills, trusts, deeds) by cognitively impaired person,  missing financial records, or any signs of undue influence (coercion or threats), and should be evaluated by the physician. Another “red flag” in a financial abuse case is romantic involvement of a new person (especially of a younger age) following a bereaved spouse’s life. Failure to fill prescriptions, inability to provide adequate basic care, can be financially motivated. The abuser and the victim have a codependency due to the financial relationship. If a family member knowingly neglects an elder at home, and still would not want the elder to be placed at a facility, there could be some financial dependency in the relationship.

Every health care provider is a mandatory reporter of elder abuse. Allied professionals who are involved in the care of the elder, neighbors or friends should also report all cases of abuse. Health care professionals sometimes get frustrated at what can be termed no action by the adult protective services (APS), due to lack of understanding on how the APS operates. The confidentiality limitation that APS can give to the reporting party, in this case the palliative care team, making it hard to find the results of the investigation.  Hospice care providers are often frustrated with the one-way flow of information.


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