Combating elder abuse: It's not easy to recognize
Obstacles: Learning signs, reporting instances
With large senior caseloads, private duty providers inevitably face elder abuse, neglect, and exploitation among patients. Despite companies' best efforts, however, field staff - particularly home health aides - struggle with recognizing and acting on suspected abuse. Ensuring that your organization properly responds in such situations requires significant education, oversight, and intervention, sources say.
There is no national elder abuse definition or intervention standard. Governed by state law, definitions vary but are similar. (See commonwealth of Virginia's definition, p. 100.) "Abuse" is sometimes used generically to describe situations that by definition involve neglect or exploitation.
Abuse, neglect, and exploitation involving one person (or more) not meeting responsibilities for another usually takes five forms:
· Best efforts used to be good enough.
"These are people who are doing the best they can. They were once good caregivers, but they've reached a breaking point. With intervention they are redeemable," says Joy Duke, MSW, adult protective services consultant for the Virginia Department of Social Services in Richmond.
This is the most common scenario among Livonia, MI-based United Home Care Services' abuse reports, says Michelle Kalous, RN, clinical coordinator. "Family members don't know what else to do. They become overwhelmed. They feel ignored, and don't have time, energy, or financial resources to get outside services," she adds. As a result, for example, they may leave a loved one alone for long hours during the day without addressing their nutrition, hydration, or hygiene needs.
· Best efforts are not good enough.
Sometimes caregivers neglect others through well-intentioned, but misinformed efforts, says Duke. She cites an elderly husband caring for his bedridden wife. He mistakenly thought it best not to disturb her, and she developed severe decubiti.
· Financial motivation.
"These people have neither the skills nor interest to do a good job. Their goal is to preserve resources," Duke notes. Children may take on an ailing parent's care to avoid nursing home placement and financial asset use. In such situations, the most dysfunctional family member often becomes the caregiver, Duke adds.
· Mentally ill caregiver.
Abuse and neglect sometimes results when caregivers themselves are mentally incapacitated and not able to serve their own or others' best interests, says Duke.
· Willful abuse and neglect.
These are just bad people intent on hurting others, says Duke. Fortunately, only a few adult abuse cases fall into this category, which can result in criminal prosecution. Duke estimates less than 5% of all reported cases in Virginia end up in the court system.
Self-neglect as common as inflicted abuse
While much elder abuse involves one person's inappropriate care of another, many reported cases - up to 60% - are self-neglect. Adult protective service actions with self-negligent patients is "extremely controversial," says Duke. "Most people are considered competent until they are proven otherwise," so agencies' intervention hands are sometimes tied, she adds.
If the person is capable of caring for himself but chooses to live in an unhealthy environment, the adult protective services division may be unable to force changes. The person who made the initial neglect report may believe the agency did nothing, "but we don't close the case," says Duke. Agencies often continue to monitor reported neglect for changes that warrant their intervention. The dividing line is often the client's inability to care for himself in an emergent situation. At such a juncture, the protective services division may petition the courts to provide involuntary services to the client.
Recognizing elder abuse is the most important, and can be the most difficult, step for private duty providers. Patients' duplicity in masking a situation and field staff fear and guilt about reporting it compound sometimes already subtle changes in patient behavior, physical appearance, and surroundings.
Pinpointing the cause of slight changes is more art than science. For example, a patient who cries and expresses fears about her safety and asks for the home care worker's secrecy may be in an abusive situation. However, she may also be acting out the paranoia that accompanies her dementia, notes Kalous. In such a situation, field staff members would also look for physical signs of neglect or abuse, she adds. (See list of neglect and financial exploitation indicators, inserted in this issue.)
Denial also plays a role. "The elderly person does not want to think their own child can [mistreat them]," so they participate in covering up the abuse, says Sharon Newton, RN, BA, CDMS, assistant director of state programs at Outreach Health Services, in Forney, TX.
If you don't report abuse, who will?
Once home care workers suspect abuse, they may be loathe to report it, partially because they are not certain of their suspicion. "Sometimes you know something isn't right, but you can't put your finger on it," says Kalous.
"Anything out of the ordinary should raise your consciousness, but home care workers don't have to have all the evidence. They don't have to prove it. And if they don't report it, they will place the person in more jeopardy," says Ron Lyons, MSW, supervisor with Adult Protective Services for the city of Alexandria, VA.
Those who remain silent and work in states that require adult abuse reporting also risk prosecution themselves, Lyons adds.
"We know abuse is so under-reported. We may not satisfy those who make the report [because of clients' competency and decision to live a certain way], but we can do nothing on those not reported," says Duke. "There is an African proverb that I use in my training sessions: 'If you don't call out, who will open the door?' Report, report, report," she adds.
Education is crucial to make staff aware of abuse signs and their reporting responsibilities. Most states' adult protective service divisions provide various abuse-related materials and training.
Close field supervision is also important, says Newton. Supervisors offer another set of eyes and ears, particularly when field staff members are uncertain about whether their client is being abused, she adds.
Appropriate intervention depends on the circumstances, says Newton. Visible signs of abuse, such as bruises, scratches, or burns, warrant an immediate report. However, if staff encounter a client who has suddenly become depressed, fearful, and has poor skin turgor (possibly indicating dehydration), but shows no outward signs of abuse, Outreach first counsels the family.
"It may be happening due to some circumstances [that the family is going through at the time], or a misunderstanding of the family. For example, they may not have been offering Grandma anything to drink at night to keep her from wetting the bed, but they may not understand that it can cause dehydration," Newton adds.
If a United home health aide suspects abuse, a supervisor meets with the family. If the supervisor subsequently makes an adult protective services referral, United informs the family, even though it is not required to do so, says Kalous. Depending on the circumstances, the home health aide may or may not return to the home.
United often works with adult protective services and the family to develop a plan and correction timeline. "We try to collaborate and maintain a relationship with the family, if possible. We become an extended caseworker. Usually the family is OK and doesn't see us as an adversary," she adds.
Sometimes, however, their private duty provider or the family choose to discontinue services. "I would encourage home care workers, to the extent they can, to hang in there," says Duke.
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