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OTE Volume 16 Number 1 - Spring 2010 Overlooking Elder Abuse
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Overlooking Psychological Elder Abuse: A Case Study       

 
By Karen Livornese, RN-BC, CCRC, CFN, LT USPHS
On The Edge - Spring 2010
 
 
Introduction
Elder abuse has long been a hidden problem in our society that has just started to break through as a collaborating healthcare and legal issue. Several forms of elder abuse such as physical, sexual and financial exploitation leave evidence that can be measured or traced (Wang, Lin and Lee, 2006). However, psychological elder abuse usually leaves no tangible evidence (Wang et al. 2006).  To recognize the signs and symptoms of this type of elder abuse, one needs training in both assessing for actual or potential abuse, and understanding the legal responsibilities of reporting. Using the nursing process and having some legal knowledge together may lead to more cases of psychological abuse being reported, not overlooked.

The fictitious case study below presents a potential psychological elder abuse case of a male adult living at home in Virginia. The purpose of presenting this case study is to demonstrate the subtlety of this type of abuse.  Signs and symptoms of psychological abuse will be presented as well as new assessment tools for screening psychological abuse cases. Unfortunately there are barriers to reporting this type of abuse and this may lead to a larger number of domestic cases of psychological elder abuse to be overlooked by healthcare providers (Wang, Tseng, & Chen, 2007).

Case Study
Frank calls his daughter on his cell phone stating that his wife gets upset when she sees phone numbers from his children on the landline caller ID. Frank is an 81-year-old widower who remarried 12 years ago. In the sixth year of marriage, Frank needed open-heart and bypass surgery, was diagnosed with spinal stenosis, peripheral neuropathy, and has pain that is difficult to manage. During this time, Frank’s personality changed insidiously from a lively conversationalist with many interests, to a somewhat solemn recluse with limited direct contact with his children and friends. Was this due to his change in health or due to the change in the dynamic of his marriage from husband and wife to elder patient and caregiver? Frank’s daughter is extremely upset by this phone call. Frank makes excuses for his wife’s behavior, such as, “She is cranky because she doesn’t eat breakfast” or “I’m such a burden.” The daughter realizes that immediate action needs to be taken before the situation gets worse.

Frank’s daughter finds herself in a difficult situation.  She does not want to call Adult Protective Services (APS) as she feels that action will permanently damage her relationship with her father. She decides to call one of Frank’s specialists to explain that there is a lot of stress in the home and that Frank’s wife is reacting by isolating him and making him feel like a burden. After listening to the daughter’s concerns, the specialist states that this is an issue that needs to be brought up with Frank’s primary care provider. The specialist does not want to get involved with something that appears to be a family matter. Frank’s daughter and his specialist find themselves not wanting to report a suspected abuse for fear of possible repercussions in their personal and professional relationship respectively.

Significance of the Problem
As the life span of our society increases, so does the probability of legal issues and healthcare issues crossing paths (Ciccarello, 2007). Having nurses trained in these legal issues, or forensics, may help increase the number of elder abuse cases reported. In the above case study, there was neither a bridge nor guidance on how to intervene; only the fear of negative consequences of reporting for both the family member and healthcare provider. There are resources for elder adults, but how can they be successfully accessed? Forensic nursing may be used as conduit from healthcare to legal rights for an elder abuse victim. Knowing the signs of psychological elder abuse, being trained to assess for it, understanding the laws for reporting the abuse, and seeing the barriers to and ethical dilemmas of reporting will assist this vulnerable population in receiving the justice they deserve. Unfortunately, without physical evidence, healthcare providers may find themselves in difficult situations of second-guessing and leaving a victim without help.

Signs and Symptoms of Psychological Elder Abuse
Psychological elder abuse occurs when a person speaks or treats the elder in a way that causes emotional distress. In most cases, the abuser is a person close to the victim such as a spouse, child or known caregiver.  Verbal forms of psychological elder abuse are humiliation, ridicule, blaming or intimidation through yelling or threats. Nonverbal forms of psychological elder abuse are isolating an elder from friends or activities, ignoring (silent treatment) or terrorizing the elder (Elder Abuse: type,signs, n.d.).

Psychological abuse usually leaves no physical evidence such as bruises, cuts or bedsores. Knowing the signs and symptoms of this type of abuse and knowing the elder adult’s environment, may help the healthcare provider make an informed decision to report a suspected, psychological abuse case (Wei and Herbers, 2004) 

Symptoms of psychological elder abuse may be seen in certain behaviors of the victim.  The elder adult may act emotionally upset or agitated, become withdrawn and non-responsive, and may display behaviors attributed to dementia such as rocking, sucking or biting (The City of San Diego, n.d.).  Being fearful, angry and anxious, especially around the abuser is a key symptom as well. Self-deprecating remarks such as being a burden to the caregiver or feeling worthless are also symptoms. More directly, the elder adult may report being psychologically mistreated to the healthcare provider (Elder abuse information, n.d.).

In the above case study, Frank is being isolated from his children by being intimidated by his wife’s anger when she finds out about the communication. Frank makes self-deprecating remarks and makes excuses for her behavior. His personality has changed to a withdrawn recluse and he reported to his daughter the fear of his wife’s anger when he calls his family. All these symptoms lead to suspected psychological abuse, yet there seems to be a gap or barrier to reporting this suspicion, especially in primary care physicians’ and specialists’ offices.

Screening for Psychological Elder Abuse
In the case of emergency room visits and home visits, the nurse is usually the first healthcare provider to interact with the elder adult victim. Elder adults who do not utilize these services, may not be adequately screened for abuse. This leaves the office physician and office nurse to screen for symptoms of elder abuse, including psychological abuse (Ciccarello, 2007).

Lynch (2006) suggests interviewing both the elder adult and the caretaker in suspected abuse cases. There are some recently developed evaluation tools specifically designed for a nurse to use while screening for psychological elder abuse. These screening tools are given to both the elder adult and the caregiver. To date, there are no standard measurements or scales to screen exclusively for psychological elder abuse (Wang, et al., 2007). However, research over the last few years has developed validated and efficacious measures that a nurse can utilize in suspected cases of psychological elder abuse.

Before these tools are used, a trained healthcare provider must interview the caretaker and the elder adult separately. It is important for the nurse to perform a mini- mental status exam on the elder adult to ensure a comprehensive assessment (Lynch, 2006, p.273). For psychological abuse, questions for the elder adult may be, “Has anyone been having difficulties at home?” or “Have you felt like a burden to your family” or “Has anyone made you feel guilty when you ask for help?”  Questions posed to the caregiver or suspected abuser in these cases may be, “How much of this person’s care is your responsibility?” or “How difficult is it for you to provide this care? Or, “Do you have any support?” (Lynch, 2006, p. 274). With this approach, the nurse may be able to understand the home environment and provide avenues for assistance such as a visiting home nurse or a home health aid to ease the stress between the caregiver and elder adult.

Wang et al. (2006) developed the Caregiver Psychological Elder Abuse Behavior Scale (CPEAB). This is a Likert-type scale that contains twenty items to determine the degree of the caregivers’ psychologically abusive behavior towards the elder adult. The CPEAB is to be administered to the caregiver.  Examples of questions on this scale include “Sneer at him or her (the elder)” and “Threaten him or her verbally.” (Wang et al., 2006).  This scale usually takes under ten minutes to complete (Wang et al., 2006) and can easily be completed in a doctor’s office or health clinic.

In 2007 Wang and colleagues developed the Elders’ Psychological Abuse Scale (EPAS). This scale is a 32-item measurement given to the elder adult. The creators of this scale recommend that this be used as a preliminary screening to identify psychological abuse in all settings including nursing homes, day care facilities and homes (Wang et al., 2007). This scale can also be easily administered at a doctor’s or health clinic.  Using these scales gives the nurse tangible evidence that there is a strong probability elder abuse of a psychological nature is occurring in the domestic setting.

Reporting someone for a legal injustice leaves a lot of responsibility in the hands of the healthcare provider. Although interviewing and recording patients’ responses on questions about abuse may lead to reporting, there may be a hindrance to do so with the lack of tangible evidence. Forensic nursing may be the conduit to introduce the CPEAB and EPAS as a basic screening tool for all healthcare sites, including primary care and specialist’s offices.  If these tools were utilized in the case study, reporting the suspected abuse may be less of a dilemma as they would have measurable evidence to accompany the report.

Mandatory Reporting Requirements of Elder Abuse
All 50 states, including the District of Columbia, have elder abuse laws. However, there are six states where reporting is not mandatory.  New York, New Jersey, Colorado, North Dakota, South Dakota and Wisconsin only have voluntary reporting (Elder law newsletter, 2008). Since this case study takes place in Virginia, the focus will be on mandatory reporting requirements for Virginia, including who is required to report, where to report and what happens after the report is made.

According the Virginia Department of Social Services, providers that are mandated to report elder abuse hold health licenses under Code of Virginia  §54.1-2503, except for veterinary medicine and any mental health services provider as defined in Code §54.1-2400.1 (Virginia Department of Social Services, 2008). This includes audiologists, certified massage therapists, certified nursing aides, guardians and conservators, counselors, dentists, doctors, emergency medical services personnel, interns and residents, law enforcement, nurses, nursing home administrators, optometrists, pharmacists, physical therapists, psychologist, radiological technologists and social workers. These licensed professionals are required by Virginia law to report elder abuse situations immediately if they suspect an adult is being abused, neglected, or exploited, or is at risk of being abused, neglected, or exploited.

For the state of Virginia, and all other states, elder abuse is reported to the state’s Adult Protective Services (APS). The reporter is to identify the suspected abused elder, give the age and the location of the abused and well as any information regarding the suspected abuse. Once APS receives the report, an investigation is started.  APS determines if services are needed for the elder and provides those services and makes arrangements to commence those services for the victim. Finally, APS notifies the mandated reporter (the person who made the initial report) that their report has been investigated. There are certain things that APS cannot do for reported elder abuse. Services cannot be forced upon a competent adult who refuses them. An endangered adult cannot be taken into custody and no investigation will commence when the said victim is no longer at risk (Virginia Department of Social Services, 2008).

According to all APS laws, those who report abuse, whether mandatory or voluntary, are immune from liability for reports made in good faith (Virginia Department of Social Services, 2008). Calls to APS can be made anonymously.  According to Virginia APS statistics, the majority of abuse reports were made by a family member (35%). Significantly less reports were made by mandated professionals: Physicians (8%), Social Workers (6%), Nursing home staff (6%), nurses (6%), law enforcement (3%) and licensed programming staff (1%) (Virginia Department of Social Services, 2008). Given these low reporting rates, there are some challenges healthcare providers must overcome in order to report elder abuse cases.

Barriers to Reporting
According to the National Center on Elder Abuse (NCEA) in 2005, it is estimated that only 2% - 10% of all elder abuse cases are reported (Elder Abuse Prevalence and Incidence, 2005). Given the mandatory reporting requirements for healthcare professionals, there must be reasons why healthcare providers are not reporting elder abuse or suspected elder abuse. Although the NCEA did not specifically report statistics on psychological elder abuse, the statistics for domestic elder abuse are reported that for one case reported there are 14 other cases not reported. According to APS statistics for Virginia, in fiscal year 2007, there were 13,515 reports and 11,802 reports were investigated. Seven thousand six hundred and fifteen were substantiated or 65% of the reports. Of these substantiated reports, 501 (6.5%) were substantiated for mental/psychological abuse. (Virginia Department of Social Services, 2008).

There are several perceived barriers to reporting elder abuse that leaves many without needed services. Healthcare-patient rapport, stereotyping and lack of knowledge may contribute to the reluctance to question and/or report psychological elder abuse (Rodriguez, Wallace, Woolf and Mangione, 2006).

Risking the rapport and trust built with a patient is a quandary healthcare providers find themselves in when confronted with elder abuse. When confronted with suspecting abuse, the physician or nurse may be reluctant to report because they may feel the risk is too great to lose the trust in the elder adult. If the patient abuse is reported, that patient may not return for other much needed treatment.  Rodriguez, et al (2006) studied physicians and their likelihood of reporting elder abuse. Fifty percent of these physicians were concerned with the contradictory effects the reporting would bring, such as losing total communication with the patient.

Another barrier to reporting is healthcare stereotyping. Healthcare providers may mistakenly take a sign or symptom of elder abuse and attribute it to age-related disabilities. In the example, symptoms related to dementia such as rocking and being withdrawn may be dismissed as a sign of abuse. Gender may also play a role in stereotyping. Yaffe, Weiss, Wolfson and Lithwick (2007) reveal that heterosexual males have been neglected by social services and have been underreported for elder abuse. For the fiscal year 2007, Virginia APS reports that 37% of all reported cases were male. Studies have shown that women consult with doctors and healthcare professionals more often than men and with this pattern, may give the impression that elder abuse is predominately a women’s problem (Yaffe et al., 2007).  Gender issues may also extend to the healthcare provider as well. Henderson & Weisman (2001), as cited in Yaffe et al, 2007, conducted a cross sectional study and found that female physicians gave more general screening than male physicians and that female patients reported receiving more gender specific screening from female doctors.  According to this study, males tend not to interface with the healthcare system as often as women, and when they do, if their physician is a male, there may be less screening for abuse.

Lack of knowledge of reporting requirements may be the biggest barrier to get help for these victims. Each state has an APS, but all states have different laws. In Virginia, there are mandatory reporting laws for all healthcare providers to report suspected abuse. There are also penalties, including fines up to $1000 for not reporting (Virginia Department of Social Services, 2008).  Unfortunately, most healthcare providers are not living up to their potential of reporting and protecting this vulnerable population (Wei & Herbers, 2004).

Forensic Implications
What can forensic nursing do to help these underreported cases of psychological elder abuse that are presented daily in our healthcare system?  First, it is imperative to educate fellow healthcare providers that they have an obligation (mandatory or voluntary) to report a suspected abuse. Forensic nurses also need to educate fellow healthcare providers that they will be immune to retaliation of a report of abuse made in good faith. Second, the forensic nurse can educate fellow healthcare providers on the subtle signs and symptoms of less reported abuse such as psychological abuse and not assume that certain behaviors are signs of dementia. This may help reveal that this issue is much more prevalent than the current statistics show.  Lastly, having a forensic nurse train staff on interviewing techniques and administering measurements for psychological abuse will give healthcare providers a resource if they question or need follow-up on their suspicions. Taking these steps to educate healthcare colleagues will bring more visibility to this mostly hidden and growing problem.

LT Livornese received her Bachelor’s of Science in Nursing from the University of Rochester and is currently pursuing her Master’s in Nursing Administration at George Mason University. She is a Certified Clinical Research Coordinator through the ACRP, a Board Certified Mental Health Nurse through the ANCC and a Certified Forensic Nurse through the ACFEI. LT Livornese is a Commissioned Corps Officer for the United States Public Health Service. She serves as a Clinical Research Nurse for the Clinical Center at the National Institutes of Health in Bethesda, MD. In addition to her nursing degree, LT Livornese also holds a BA from Georgetown University and an MA from Virginia Tech.

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