Crit Care Nurs Q Vol. 38, No. 3, pp. 293–297 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Indicators of Abuse in the Elderly ICU Patient Amy Carney, NP, PhD, FAAFS Elder abuse is a growing problem in the United States. Incidents of physical and sexual abuse, as well as neglect, continue to rise as the population ages. Maltreatment of the elderly is associated with increased morbidity and mortality rate, as well as increased health care costs. Fear, shame, and lack of knowledge contribute to underreporting of elder abuse and put the safety of elders at risk. This paper describes indicators of physical and sexual abuse and neglect in the elderly intensive care unit patient and presents how abuse can be identified in the critical care setting. Key words: critical care, elder abuse, indicators, patient safety, risk management
W
HEN THE ELDER JUSTICE ACT was signed in to law by President Barack Obama on March 23, 2010, as part of the Patient Protection and Affordable Care Act, it provided federal resources for addressing and preventing elder abuse, neglect, and exploitation. Although the literature supports that about 10% of the American population suffers some form of abuse or neglect every year, many more cases go unreported. Because of fear, shame, and lack of understanding, physical and emotional abuse, neglect, and financial exploitation usually go undetected. Elder abuse negatively affects quality of life and violates elders’ rights. It is correlated not only with increased morbidity and mortality rate, but also with an increase in the number of emergency department (ED) visits.1 The Elder Justice Act
Author Affiliation: School of Nursing, California State University San Marcos, San Marcos, California. The author thanks Kayla Hood and Grace Tran for their research excellence. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Amy Carney, NP, PhD, FAAFS, School of Nursing, California State University San Marcos, 333 S. Twin Oaks Valley Rd, San Marcos, CA 92096 (acarney @csusm.edu). DOI: 10.1097/CNQ.0000000000000069
provided for the establishment of the Elder Justice Coordinating Council to propose federal action, the Advisory Board on Elder Abuse, Neglect, and Exploitation, and research protections relating to human subjects.2 Nurses interact with patients in all clinical settings and with more than 3 million registered nurses in the United States, engaging nurses in the effort to identify, assess, and report elder abuse serves to protect a vulnerable population.1 Lack of agreement on the definition of elder abuse, as well as what constitutes elder abuse, has made it difficult to assess incidence and prevalence. According to the World Health Organization, elder abuse is a single or repeated act, or lack of an appropriate action, that occurs in any relationship where there is an expectation of trust and causes distress or harm to the older person. This definition excludes random acts of criminal behavior or violence, and it puts the trusting relationship at the center of the issue.3 It is this trusting relationship that often puts any resulting injuries into question, when physical signs of abuse are taken for the expected signs of aging, such as ulcers or bruising or accidents such as a fall.4 Injuries may be mistaken for result of disease or medication, and the possibility of abuse usually is not considered. In the 30 years since elder abuse was first identified as “granny battering,”5 the medical and legal communities have come together 293
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
294
CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2015
to investigate elder abuse and add to the scientific knowledge in identification and intervention. Medical costs associated with violent injuries to elders in the United States are estimated at $5.3 billion dollars annually. This cost, as well as the morbidity and mortality associated with elder abuse, is expected to rise with the growth of the geriatric population.6 The ability to identify abuse is the first step in assisting the elderly to safety. Barriers to the identification of mistreatment range from lack of awareness of abuse to fear of retaliation. In the setting of the intensive care unit (ICU), patients are treated for severe illness, usually for brief amounts of time. This short period of concentrated care may not include time for exploration of potential abuse.7 This paper provides an overview of indicators of abuse and how mistreatment can be identified in the ICU setting. IDENTIFYING ELDER ABUSE IN THE ICU Physical indicators Many elderly patients are admitted to ICU through the ED. Evaluation of injuries, as well as state of cognitive awareness and functioning, takes place in this milieu. Injury presentation is the pattern of injury incurred by individuals, noting the type of injury and its location on the body. Cognitive evaluation of the elder patient assesses the ability of the patient to recount a history of the injury, as well as the ability to advocate on their own behalf.8 If an elderly patient is unable to do this, the story of how the injury occurred comes from those with the patient. This history is often obtained in part from first responders at the scene, also referred to as prehospital care providers, which include emergency medical technicians, paramedics, and law enforcement. Interaction with first responders may be the first time a neglected or abused elder has had contact with someone who is able to assist them. Prehospital providers can alert ED personnel not only to physical injury but also to the surroundings in which the elder was located, such as a living situation, which shows the patient is in danger of neglect.9,10
The inclusion of this information in the patient’s medical record is of particular importance to ICU personnel, who were not present in the patient’s living environment and may not have been present in the ED. This documentation can serve to heighten the awareness of the ICU nurse during the patient’s evaluation. Dehydration and undernourishment, poor hygiene, fear, and withdrawal may be the first indicators of patient abuse or neglect.11 Critical care nurses can utilize dermatologic evaluation of the skin for more than the presence or absence of decubiti. While aging, fragile skin and the common use of medications such as aspirin and anticoagulants contribute to bleeding and bruising, the patient’s history of the event is valuable in distinguishing accident from inflicted injury.12 Physical location on the body may distinguish abuse from agerelated changes that mimic or mask abuse. Accidental bruises are found on the extremities, not the ears, neck, soles of the feet, genitalia, or buttocks; injuries in these locations are consistent with indicators of abuse. Bruises 5 cm or greater in width on the head, lateral right arm, and posterior torso should also raise the nurse’s index of suspicion. The patient’s mobility status should also be considered; bruises consistent with gait instability or falls will not be present in an immobile patient. Elders who take medications, which interfere with coagulation pathways, are more likely to have multiple bruises; however, color of a bruise has not been shown to be a reliable indicator of how long a bruise has been present, as bleeding and coagulation can be influenced by those medications as well.13,14 Injuries other than bruises are also found in the elder ICU patient. More severe mechanisms of abuse include burns by hot water, lacerations, strangulation, and being pushed or thrown. These victims of abuse are often female and have a history of dementia or depression; the perpetrator is often the partner, spouse, or child.15 Inflicted injuries to the periocular region and eyelid are common in abused elders. Injuries to the skull and brain, comprising the most serious inflicted wounds, are often found only on autopsy.16
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Indicators of Abuse in the Elderly ICU Patient In the setting of the ICU, care must be given to the assessment of the relationship of the potentially abused elder and those who care for them. This is particularly true of the elderly patient who cannot speak, such as in aphasia or mechanical ventilation, or has a history of dementia. Certain characteristics of the relationship between the caregiver and elder victim are correlated with increased risk of abuse—caregivers who are financially dependent on an elder are at high risk for perpetrating instances of abuse, whereas a disabled elder may be more vulnerable due to disturbances of vision or balance. Socially isolated, with a poor social support system, the elder may not have been able to previously seek care.17 Sexual abuse Sexual mistreatment of an elder is a separate and distinct type of elder abuse, legally and clinically.16 Sexual abuse often occurs in the frail or incompetent elder, usually in a home setting, more often than in a care facility. Indications may be genital tenderness, dysuria, or the presence of a sexually transmitted infection. The ICU patient may exhibit fear of a visiting caregiver or signs of depression.18 Sexual abuse is defined as any nonconsensual sexual contact, of any kind, with an elderly person or sexual contact with a person who is incapable of giving consent. It includes unwanted touching and all forms of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photography. In addition to physical injuries such as welts or rope marks, or in more highly visible locations, such as a black eye, critical care nurses must observe for bruises on the breasts or genitalia, vaginal or anal bleeding, and torn or stained underclothing. If a rape examination has been done, this will be noted in the chart. Intensive care unit nurses can monitor and describe the course of healing wounds and injuries, as well as provide clear written descriptions in the documentation.19 Obtaining an oral history of sexual assault from an elderly ICU patient may be difficult for various reasons. Trauma and shock may
295
keep the patient from being able to process information in a predictable manner. Cognitive decline may inhibit giving an accurate history, and the elderly with a diagnosed cognitive impairment prior to the sexual assault may experience accelerated dementia afterward.20 Fear and embarrassment, by both the victim and the family, may prevent obtaining an accurate history; however, any suspicion of sexual assault warrants further investigation by the ICU nurse. Neglect Neglect is defined as failure to provide basic necessities and care to a person by someone who has accepted caregiving responsibilities. This includes failure to provide the basic needs of daily living, such as water and food, failure to provide a safe and clean living environment, and failure to provide medications. Although some neglect is found to be from the elder victim on their own, such as selfneglect, intentional neglect by another is the knowing failure to provide necessary care. Indicators of intentional neglect include malnutrition, dehydration, and poor hygiene, all of which can contribute to the development of pressure sores. Assistive devices may be missing or withheld, such as dentures or glasses. A sudden decline in the patient’s health, often seen as “normal” in the elderly, may also be a sign of neglect. The ICU nurse may notice that the caregiver is reluctant to leave the patient alone or to allow the patient to speak for themselves.21 Multiple theories on causation of neglect exist in the literature. Changes in family structure and relationships have taken place, leading to multigenerational families sharing a home. Changes in marital status and income lead adult children to move home with their parents, eventually becoming caregivers. Caregiver stress is cited frequently, but is often noted to be associated with the use of medication, alcohol, or drugs.22 As in the cases of physical and sexual abuse, the ICU nurse should be prepared to asses for, and document, findings of neglect to reduce morbidity and mortality for the patient and bring
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
296
CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2015
them to the attention of the team of professionals who will respond to the abuse. INTERVENTION IN THE ABUSE OF THE ELDERLY ICU PATIENT When a case of elder abuse, either suspected or confirmed, has been identified by the critical care nurse, the safety of the patient must be assured. This could take the form of separating the suspected abuser from the elderly patient to prevent further harm, notifying the admitting physician of findings, or calling hospital security staff. The protocol of both the facility and local laws should be followed. In most states, Adult Protective Services and law enforcement agencies are notified.23 Social work and geriatric care teams may be called for assistance, and a multidisciplinary approach applied. In preparation for the potential recognition of elder abuse in the ICU setting, barriers to identification and intervention must be determined. These may include lack of time to
screen and assess; lack of knowledge of warning signs and risk factors; fear of retaliation by a family member, such as being involved in a lawsuit; and the desire of the family not to report.24 Once identified, these barriers form a basis for education for both the ICU nurse and the larger elder abuse response team. CONCLUSIONS Elder abuse is a widespread and common problem. As the population ages, reporting of incidents of elder abuse is increasing. The critical care nurse must have the knowledge and tools to identify and intervene in elder abuse. Understanding of the processes of what constitutes “normal” aging and being able to differentiate these from signs of abuse is essential.25 The ability to be able to intervene in elder physical abuse, sexual abuse, and neglect in the ICU will lead to decreased morbidity and mortality rate, increased quality of life for patients, and provide a basis for research and practice in the ICU setting.
REFERENCES 1. Kleba PA, Falk NL. The Elder Justice Act: what nurses need to know. Am J Nurs. 2014;114(9): 65-68. 2. Colello K. The elder justice act: background and issues for Congress. Congressional Research Service. www.fas.org/sgp/crs/misc/R43707.pdf. Published September 3, 2014. Accessed December 1, 2014. 3. Mysyuk Y, Westendorp RG, Lindenberg J. Added value of elder abuse definitions: a review. Ageing Res Rev. 2013;12(1):50-57. 4. Gibbs LM. Understanding the medical markers of elder abuse and neglect: physical examination findings. Clin Geriatr Med. 2014;30(4):687-712. 5. Phelan A. Elder abuse and neglect: the nurse’s responsibility in care of the older person. Int J Older People Nurs. 2009;4(2):115-119. 6. Lofaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):713-728. 7. Daly J, Klein A, Jogerst G. Critical care nurses’ perspectives on elder abuse. Nurs Crit Care. 2012;17(4):172-179. 8. Ziminski C, Phillips L, Woods D. Raising the index of suspicion for elder abuse: cognitive impairment,
9.
10.
11. 12.
13.
14.
15.
falls, and injury patterns in the emergency department. Geriatr Nurs. 2012;33(2):105-112. Rinker AG. Recognition and perception of elder abuse by prehospital and hospital-based care providers. Arch Gerontol Geriatr. 2009;48(1):110-115. Nusbaum NJ, Cheung VM, Cohen J, Keca M, Mailey B. Role of first responders in detecting and evaluating elders at risk. Arch Gerontol Geriatr. 2006;43(3):361367. White SW. Elder abuse: critical care nurse role in detection. Crit Care Nurs Q. 2000;23(2):20-25. Palmer M, Brodell R, Mostow E. Elder abuse: dermatologic clues and critical solutions. J Am Acad Dermatol. 2013;68(2):e37-e42. Wiglesworth A, Austin R, Mosqueda L, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196. Mosqueda L. Forensic markers of elder abuse and neglect (Webinar). www.napsa-now.org/event/ webinar-forensic-markers-of-elder-abuse-and-neglect/. Published January 12, 2015. Accessed January 12, 2015. Friedman L, Avila S, Tanouye K, Joseph K. A casecontrol study of severe physical abuse of older adults. J Am Geriatri Soc. 2011;59(3):417-422.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Indicators of Abuse in the Elderly ICU Patient 16. Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64(1):10-14. 17. Young LM. Elder physical abuse. Clin Geriatr Med. 2014;30(4):761-768. 18. Powers JS. Common presentations of elder abuse in health care settings. Clin Geriatr Med. 2014;30 (4):729-741. 19. Burgess AW, Watt ME, Brown KM, Petrozzi D. Management of elder sexual abuse cases in critical care settings. Crit Care Nurs Clin N Am. 2006;18(3):313319. 20. Speck PM, Hartig MT, Likes W, et al. Case series of sexual assault in older persons. Clin Geriatr Med. 2014;30(4):779-806.
297
21. del Carmen T, LoFaso VM. Elder neglect. Clin Geriatr Med. 2014;30:769-777. 22. Penhale B. Responding and intervening in elder abuse and neglect. Ageing Int. 2010;35:235252. 23. Mukherjee D. Organizational structures of elder abuse reporting systems. Admin Soc Work. 2011;35:517531. 24. Halphen JM, Varas GM, Sadowsky JM. Recognizing and reporting elder abuse and neglect. Geriatrics. 2009;64(7):13-18. 25. Burnett J, Achenbaum WA, Murphy KP. Prevention and early identification of elder abuse. Clin Geriatr Med. 2014;30:743-759.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Indicators of Abuse in the Elderly ICU Patient Amy Carney, NP, PhD, FAAFS Elder abuse is a growing problem in the United States. Incidents of physical and sexual abuse, as well as neglect, continue to rise as the population ages. Maltreatment of the elderly is associated with increased morbidity and mortality rate, as well as increased health care costs. Fear, shame, and lack of knowledge contribute to underreporting of elder abuse and put the safety of elders at risk. This paper describes indicators of physical and sexual abuse and neglect in the elderly intensive care unit patient and presents how abuse can be identified in the critical care setting. Key words: critical care, elder abuse, indicators, patient safety, risk management
W
HEN THE ELDER JUSTICE ACT was signed in to law by President Barack Obama on March 23, 2010, as part of the Patient Protection and Affordable Care Act, it provided federal resources for addressing and preventing elder abuse, neglect, and exploitation. Although the literature supports that about 10% of the American population suffers some form of abuse or neglect every year, many more cases go unreported. Because of fear, shame, and lack of understanding, physical and emotional abuse, neglect, and financial exploitation usually go undetected. Elder abuse negatively affects quality of life and violates elders’ rights. It is correlated not only with increased morbidity and mortality rate, but also with an increase in the number of emergency department (ED) visits.1 The Elder Justice Act
Author Affiliation: School of Nursing, California State University San Marcos, San Marcos, California. The author thanks Kayla Hood and Grace Tran for their research excellence. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Amy Carney, NP, PhD, FAAFS, School of Nursing, California State University San Marcos, 333 S. Twin Oaks Valley Rd, San Marcos, CA 92096 (acarney @csusm.edu). DOI: 10.1097/CNQ.0000000000000069
provided for the establishment of the Elder Justice Coordinating Council to propose federal action, the Advisory Board on Elder Abuse, Neglect, and Exploitation, and research protections relating to human subjects.2 Nurses interact with patients in all clinical settings and with more than 3 million registered nurses in the United States, engaging nurses in the effort to identify, assess, and report elder abuse serves to protect a vulnerable population.1 Lack of agreement on the definition of elder abuse, as well as what constitutes elder abuse, has made it difficult to assess incidence and prevalence. According to the World Health Organization, elder abuse is a single or repeated act, or lack of an appropriate action, that occurs in any relationship where there is an expectation of trust and causes distress or harm to the older person. This definition excludes random acts of criminal behavior or violence, and it puts the trusting relationship at the center of the issue.3 It is this trusting relationship that often puts any resulting injuries into question, when physical signs of abuse are taken for the expected signs of aging, such as ulcers or bruising or accidents such as a fall.4 Injuries may be mistaken for result of disease or medication, and the possibility of abuse usually is not considered. In the 30 years since elder abuse was first identified as “granny battering,”5 the medical and legal communities have come together 293
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
294
CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2015
to investigate elder abuse and add to the scientific knowledge in identification and intervention. Medical costs associated with violent injuries to elders in the United States are estimated at $5.3 billion dollars annually. This cost, as well as the morbidity and mortality associated with elder abuse, is expected to rise with the growth of the geriatric population.6 The ability to identify abuse is the first step in assisting the elderly to safety. Barriers to the identification of mistreatment range from lack of awareness of abuse to fear of retaliation. In the setting of the intensive care unit (ICU), patients are treated for severe illness, usually for brief amounts of time. This short period of concentrated care may not include time for exploration of potential abuse.7 This paper provides an overview of indicators of abuse and how mistreatment can be identified in the ICU setting. IDENTIFYING ELDER ABUSE IN THE ICU Physical indicators Many elderly patients are admitted to ICU through the ED. Evaluation of injuries, as well as state of cognitive awareness and functioning, takes place in this milieu. Injury presentation is the pattern of injury incurred by individuals, noting the type of injury and its location on the body. Cognitive evaluation of the elder patient assesses the ability of the patient to recount a history of the injury, as well as the ability to advocate on their own behalf.8 If an elderly patient is unable to do this, the story of how the injury occurred comes from those with the patient. This history is often obtained in part from first responders at the scene, also referred to as prehospital care providers, which include emergency medical technicians, paramedics, and law enforcement. Interaction with first responders may be the first time a neglected or abused elder has had contact with someone who is able to assist them. Prehospital providers can alert ED personnel not only to physical injury but also to the surroundings in which the elder was located, such as a living situation, which shows the patient is in danger of neglect.9,10
The inclusion of this information in the patient’s medical record is of particular importance to ICU personnel, who were not present in the patient’s living environment and may not have been present in the ED. This documentation can serve to heighten the awareness of the ICU nurse during the patient’s evaluation. Dehydration and undernourishment, poor hygiene, fear, and withdrawal may be the first indicators of patient abuse or neglect.11 Critical care nurses can utilize dermatologic evaluation of the skin for more than the presence or absence of decubiti. While aging, fragile skin and the common use of medications such as aspirin and anticoagulants contribute to bleeding and bruising, the patient’s history of the event is valuable in distinguishing accident from inflicted injury.12 Physical location on the body may distinguish abuse from agerelated changes that mimic or mask abuse. Accidental bruises are found on the extremities, not the ears, neck, soles of the feet, genitalia, or buttocks; injuries in these locations are consistent with indicators of abuse. Bruises 5 cm or greater in width on the head, lateral right arm, and posterior torso should also raise the nurse’s index of suspicion. The patient’s mobility status should also be considered; bruises consistent with gait instability or falls will not be present in an immobile patient. Elders who take medications, which interfere with coagulation pathways, are more likely to have multiple bruises; however, color of a bruise has not been shown to be a reliable indicator of how long a bruise has been present, as bleeding and coagulation can be influenced by those medications as well.13,14 Injuries other than bruises are also found in the elder ICU patient. More severe mechanisms of abuse include burns by hot water, lacerations, strangulation, and being pushed or thrown. These victims of abuse are often female and have a history of dementia or depression; the perpetrator is often the partner, spouse, or child.15 Inflicted injuries to the periocular region and eyelid are common in abused elders. Injuries to the skull and brain, comprising the most serious inflicted wounds, are often found only on autopsy.16
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Indicators of Abuse in the Elderly ICU Patient In the setting of the ICU, care must be given to the assessment of the relationship of the potentially abused elder and those who care for them. This is particularly true of the elderly patient who cannot speak, such as in aphasia or mechanical ventilation, or has a history of dementia. Certain characteristics of the relationship between the caregiver and elder victim are correlated with increased risk of abuse—caregivers who are financially dependent on an elder are at high risk for perpetrating instances of abuse, whereas a disabled elder may be more vulnerable due to disturbances of vision or balance. Socially isolated, with a poor social support system, the elder may not have been able to previously seek care.17 Sexual abuse Sexual mistreatment of an elder is a separate and distinct type of elder abuse, legally and clinically.16 Sexual abuse often occurs in the frail or incompetent elder, usually in a home setting, more often than in a care facility. Indications may be genital tenderness, dysuria, or the presence of a sexually transmitted infection. The ICU patient may exhibit fear of a visiting caregiver or signs of depression.18 Sexual abuse is defined as any nonconsensual sexual contact, of any kind, with an elderly person or sexual contact with a person who is incapable of giving consent. It includes unwanted touching and all forms of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photography. In addition to physical injuries such as welts or rope marks, or in more highly visible locations, such as a black eye, critical care nurses must observe for bruises on the breasts or genitalia, vaginal or anal bleeding, and torn or stained underclothing. If a rape examination has been done, this will be noted in the chart. Intensive care unit nurses can monitor and describe the course of healing wounds and injuries, as well as provide clear written descriptions in the documentation.19 Obtaining an oral history of sexual assault from an elderly ICU patient may be difficult for various reasons. Trauma and shock may
295
keep the patient from being able to process information in a predictable manner. Cognitive decline may inhibit giving an accurate history, and the elderly with a diagnosed cognitive impairment prior to the sexual assault may experience accelerated dementia afterward.20 Fear and embarrassment, by both the victim and the family, may prevent obtaining an accurate history; however, any suspicion of sexual assault warrants further investigation by the ICU nurse. Neglect Neglect is defined as failure to provide basic necessities and care to a person by someone who has accepted caregiving responsibilities. This includes failure to provide the basic needs of daily living, such as water and food, failure to provide a safe and clean living environment, and failure to provide medications. Although some neglect is found to be from the elder victim on their own, such as selfneglect, intentional neglect by another is the knowing failure to provide necessary care. Indicators of intentional neglect include malnutrition, dehydration, and poor hygiene, all of which can contribute to the development of pressure sores. Assistive devices may be missing or withheld, such as dentures or glasses. A sudden decline in the patient’s health, often seen as “normal” in the elderly, may also be a sign of neglect. The ICU nurse may notice that the caregiver is reluctant to leave the patient alone or to allow the patient to speak for themselves.21 Multiple theories on causation of neglect exist in the literature. Changes in family structure and relationships have taken place, leading to multigenerational families sharing a home. Changes in marital status and income lead adult children to move home with their parents, eventually becoming caregivers. Caregiver stress is cited frequently, but is often noted to be associated with the use of medication, alcohol, or drugs.22 As in the cases of physical and sexual abuse, the ICU nurse should be prepared to asses for, and document, findings of neglect to reduce morbidity and mortality for the patient and bring
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
296
CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2015
them to the attention of the team of professionals who will respond to the abuse. INTERVENTION IN THE ABUSE OF THE ELDERLY ICU PATIENT When a case of elder abuse, either suspected or confirmed, has been identified by the critical care nurse, the safety of the patient must be assured. This could take the form of separating the suspected abuser from the elderly patient to prevent further harm, notifying the admitting physician of findings, or calling hospital security staff. The protocol of both the facility and local laws should be followed. In most states, Adult Protective Services and law enforcement agencies are notified.23 Social work and geriatric care teams may be called for assistance, and a multidisciplinary approach applied. In preparation for the potential recognition of elder abuse in the ICU setting, barriers to identification and intervention must be determined. These may include lack of time to
screen and assess; lack of knowledge of warning signs and risk factors; fear of retaliation by a family member, such as being involved in a lawsuit; and the desire of the family not to report.24 Once identified, these barriers form a basis for education for both the ICU nurse and the larger elder abuse response team. CONCLUSIONS Elder abuse is a widespread and common problem. As the population ages, reporting of incidents of elder abuse is increasing. The critical care nurse must have the knowledge and tools to identify and intervene in elder abuse. Understanding of the processes of what constitutes “normal” aging and being able to differentiate these from signs of abuse is essential.25 The ability to be able to intervene in elder physical abuse, sexual abuse, and neglect in the ICU will lead to decreased morbidity and mortality rate, increased quality of life for patients, and provide a basis for research and practice in the ICU setting.
REFERENCES 1. Kleba PA, Falk NL. The Elder Justice Act: what nurses need to know. Am J Nurs. 2014;114(9): 65-68. 2. Colello K. The elder justice act: background and issues for Congress. Congressional Research Service. www.fas.org/sgp/crs/misc/R43707.pdf. Published September 3, 2014. Accessed December 1, 2014. 3. Mysyuk Y, Westendorp RG, Lindenberg J. Added value of elder abuse definitions: a review. Ageing Res Rev. 2013;12(1):50-57. 4. Gibbs LM. Understanding the medical markers of elder abuse and neglect: physical examination findings. Clin Geriatr Med. 2014;30(4):687-712. 5. Phelan A. Elder abuse and neglect: the nurse’s responsibility in care of the older person. Int J Older People Nurs. 2009;4(2):115-119. 6. Lofaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):713-728. 7. Daly J, Klein A, Jogerst G. Critical care nurses’ perspectives on elder abuse. Nurs Crit Care. 2012;17(4):172-179. 8. Ziminski C, Phillips L, Woods D. Raising the index of suspicion for elder abuse: cognitive impairment,
9.
10.
11. 12.
13.
14.
15.
falls, and injury patterns in the emergency department. Geriatr Nurs. 2012;33(2):105-112. Rinker AG. Recognition and perception of elder abuse by prehospital and hospital-based care providers. Arch Gerontol Geriatr. 2009;48(1):110-115. Nusbaum NJ, Cheung VM, Cohen J, Keca M, Mailey B. Role of first responders in detecting and evaluating elders at risk. Arch Gerontol Geriatr. 2006;43(3):361367. White SW. Elder abuse: critical care nurse role in detection. Crit Care Nurs Q. 2000;23(2):20-25. Palmer M, Brodell R, Mostow E. Elder abuse: dermatologic clues and critical solutions. J Am Acad Dermatol. 2013;68(2):e37-e42. Wiglesworth A, Austin R, Mosqueda L, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196. Mosqueda L. Forensic markers of elder abuse and neglect (Webinar). www.napsa-now.org/event/ webinar-forensic-markers-of-elder-abuse-and-neglect/. Published January 12, 2015. Accessed January 12, 2015. Friedman L, Avila S, Tanouye K, Joseph K. A casecontrol study of severe physical abuse of older adults. J Am Geriatri Soc. 2011;59(3):417-422.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Indicators of Abuse in the Elderly ICU Patient 16. Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64(1):10-14. 17. Young LM. Elder physical abuse. Clin Geriatr Med. 2014;30(4):761-768. 18. Powers JS. Common presentations of elder abuse in health care settings. Clin Geriatr Med. 2014;30 (4):729-741. 19. Burgess AW, Watt ME, Brown KM, Petrozzi D. Management of elder sexual abuse cases in critical care settings. Crit Care Nurs Clin N Am. 2006;18(3):313319. 20. Speck PM, Hartig MT, Likes W, et al. Case series of sexual assault in older persons. Clin Geriatr Med. 2014;30(4):779-806.
297
21. del Carmen T, LoFaso VM. Elder neglect. Clin Geriatr Med. 2014;30:769-777. 22. Penhale B. Responding and intervening in elder abuse and neglect. Ageing Int. 2010;35:235252. 23. Mukherjee D. Organizational structures of elder abuse reporting systems. Admin Soc Work. 2011;35:517531. 24. Halphen JM, Varas GM, Sadowsky JM. Recognizing and reporting elder abuse and neglect. Geriatrics. 2009;64(7):13-18. 25. Burnett J, Achenbaum WA, Murphy KP. Prevention and early identification of elder abuse. Clin Geriatr Med. 2014;30:743-759.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
