Elder Abuse at End of Life

Factitious Disorder Imposed on Another in Palliative Care: A Case Report

In palliative care, many end-of-life (EOL) patients are physically dependent on their caregivers. These patients may also have difficulty expressing their needs because of their underlying disease and are vulnerable to abuse. Factitious disorder imposed on another (FDIA) describes a condition in which an individual intentionally feigns physical or psychological signs or symptoms in another person with the intention of deceiving medical providers. Although FDIA is a form of abuse that palliative care workers must be aware of because of its multiple impacts on EOL care, it has never been reported in the palliative care literature. In this case discussion, we highlight a woman with advanced dementia who was subjected to FDIA. We discuss the impact of FDIA on EOL care and the management of FDIA in palliative care.

Nonaccidental Injury in the Elderly: What Radiologists Need to Know

Elder abuse may result in serious physical injuries and long-term psychological consequences and can be life threatening. Over the past decade, attention to elder abuse has increased owing to its high prevalence, with one in six people aged 60 years and older experiencing some form of abuse worldwide. Despite this, the detection and reporting rates remain relatively low. While diagnostic imaging is considered critical in detection of child abuse, it is relatively underused in elder abuse. The authors discuss barriers to use of imaging for investigation and diagnosis of elder abuse, including lack of training, comorbidities present in this vulnerable population, and lack of communication among the intra- and interdisciplinary care providers. Moreover, imaging features that should raise clinical concern for elder abuse are reviewed, including certain types of fractures (eg, posterior rib), characteristic soft-tissue and organ injuries (eg, shoulder dislocation), and cases in which the reported mechanism of injury is inconsistent with the imaging findings. As most findings suggesting elder abuse are initially discovered at radiography and CT, the authors focus mainly on use of those modalities. This review also compares and contrasts elder abuse with child abuse. Empowered with knowledge of elderly victims' risk factors, classic perpetrator characteristics, and correlative imaging findings, radiologists should be able to identify potential abuse in elderly patients presenting for medical attention. Future recommendations for research studies and clinical workflow to increase radiologists' awareness of and participation in elder abuse detection are also presented. An invited commentary by Jubanyik and Gettel is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Patient Safety in Palliative and End-of-Life Care: A Text Mining Approach and Systematic Review of Definitions

BACKGROUND

Patient safety has gained an increasing profile as a crucial element of healthcare. However, not only is there little evidence on the relevance of the term in the palliative and end-of-life care literature but also a lack of a precise and uniform definition.

METHOD

With a text mining approach occurrence of the term patient safety was determined in all available abstracts of 10 palliative and end-of-life care journals. Furthermore, 4 electronic databases (MEDLINE, EMBASE, CINAHL and PSYCINFO) were searched supplemented by hand-searching of relevant literature to identify and conceptualize published definitions of patient safety in the palliative and end-of-life care context. Publications were independently assessed against inclusion criteria by 2 authors.

RESULTS

Our search of 14,351 abstracts yielded 41 hits for "patient safety" ranking 2,345 in the list of most commonly encountered tokens. We identified 11 definitions of patient safety stemming from 11 publications. Definitions differed with regard to the concept of process or outcome. They also allowed distinctive perspectives on the extent to which patient care influences patient safety. Lastly, exact wording led to discrepancies in the understanding of unsafe care and generalizability of definitions.

CONCLUSION

Our results indicate that patient safety has gradually gained importance in palliative and end-of-life care. However, as key elements of definientia varied considerably no consensus definition could be identified. Nevertheless, a universal definition would help to facilitate communication and exchange of information among individuals and organizations involved in palliative and end-of-life care.

Work Environment and Elderly Abuse in Nursing Homes: The Mediating Role of Burnout

The present study focuses on elderly abuse committed by nurses and nurses' aides in nursing homes. Elderly abuse includes neglect and abusive behaviors deleterious to the health and welfare of the elderly. The study aimed at a better understanding of neglect and abusive behaviors by considering caregiver burnout and the work context of these professionals. To achieve this goal, direct effects of job demands (workload and emotional demands) and organizational resources (quality of relationships with colleagues and with the supervisor) on elderly abuse were analyzed. Moreover, the mediating role of caregiver burnout was explored by suggesting that job demands and lack of organizational resources were related to neglect and abusive behaviors through burnout. The study was conducted among 481 nurses and health care assistants from different French nursing homes. Correlations, multiple regressions, and mediation analyses were performed. Results globally confirmed our hypotheses. Emotional demands and poor quality relationships with colleagues and the team supervisor were the most predictive variables for caregiver burnout, neglect, and abusive behaviors toward the elderly. Moreover, the results contributed to the literature by highlighting the mediating effect of burnout and give rise to potential implications in preventing elderly abuse in nursing homes.

Treatment for cases of violence by Brazilian emergency services focusing on family relationships and life cycles

This article analyzes data regarding cases of domestic violence treated by the emergency services through the following: the sociodemographic characteristics of the people who were treated; the events themselves; the evolution of care (from childhood to old age by gender); and the factors that differentiate cases of domestic violence compared to those committed by non-family members. Data from 24 Brazilian state capitals and the Federal District were analyzed, comprising 86 emergency services: a total of 4,893 individuals were surveyed. Of those people who were treated by emergency services, 26.6% suffered domestic violence: 40.0% were children/adolescents, 57.2% were adults and 2.8% were elderly. The adjusted model, which compared victims of violence committed by other family members with those who were not family members, showed that males were less likely to suffer from domestic violence; those that had fewer years of education were at increased risk; and that women were more likely to commit domestic violence compared to the category of "both genders". This study reinforces the fact that health sector professionals need to be able to deal with domestic violence by providing support, performing good practices, abiding by care protocols, taking care of injuries, and facilitating access to other services.

A Case of Elder Abuse and Undue Influence

Elder abuse is a pervasive problem that can have lasting emotional and physical consequences, increasing its victims’ risk of mortality. Healthcare providers are frequently involved in the detection and intervention of elder abuse. Because of the complexity of these cases, applying treatment interventions within an interdisciplinary care team has been recommended to ensure older adults’ safety and welfare. Psychologists in particular are frequently relied upon in these situations because of their expertise in cognitive, psychiatric, and capacity assessment, as well as their ability to intervene in a variety of difficult situations. The following is a report examining the case of Mr. B, who was a victim of elder abuse involving financial exploitation and undue influence. Assessment and treatment interventions were used within the context of an interdisciplinary care team, using a bio-psychosocial approach. A decision-tree model describing the steps to take in assessing and treating financial elder abuse is proposed.

Elder abuse in residential long-term care: an update to the 2003 National Research Council report

A synthesis of the last decade of literature on elder abuse in residential long-term care (i.e., Nursing Homes and Assisted Living) is discussed. Presented are definitions of abuse, theoretical and conceptual models, prevalence rates of abuse, outcomes and costs, and sources of abuse. The synthesis represents an update to the literature in the influential 2003 National Research Council report. We identify many of the same issues and concerns exist that were surfaced in this prior report. Many theoretical and conceptual models need further elaboration. Conflicting definitions of abuse are pervasive. Rates of abuse are generally inaccurate, and probably under-reported. However, we also identify progress in many areas. An increase in empirical studies that exist in this area (although very few in Assisted Living). Other forms and types of abuse have also been identified as important, such as resident-to-resident abuse. These areas are discussed, along with potential suggestions for additional research.

[Prevalence of elder abuse in Spanish dwelling in community]

BACKGROUND AND OBJECTIVE

Although elder abuse is not a new phenomenon, it remains hidden. There have been carried out various preliminary studies about the prevalence of elder abuse in different countries. The aim of this study is to estimate the prevalence of suspicion of elder abuse in old persons without cognitive impairment, dwelling in community, who were attended in Primary Health Care or Social Services Centres.

PATIENTS AND METHOD

We carried out a transverse study in which 340 elders participated.

RESULTS

We found a 12.1% prevalence of suspicion of elder abuse. Psychological abuse suspicion was the most frequent type and it was very common the simultaneous presence of different types of abuse (psychological and physical and sexual). The suspicion of elder abuse was more frequent in women and spouses were responsible in a high great frequency.

CONCLUSIONS

The information obtained allows advancing in the knowledge of elder abuse in Spain, where the research about this issue is poor. However, the prevalence found neither has to be considered as a social alarm nor as a social slackness.

Aspects of care culture in municipal care for elderly people: a hermeneutic documentary analysis of reports of abuse

INTRODUCTION

Care culture is an important contextual factor in care practice. Care culture refers to a process of creating meaning out of tradition, horizon and bildung. The care culture is often taken into consideration in situations that go beyond the everyday routine, such as cases of abuse. In Sweden, health care professionals are obliged to document and report any suspected bad conditions. Although the reports have the potential to communicate underlying values and assumptions about the care culture, such studies have not been performed.

AIM

The aim of this study was to understand how elderly care abuse in institutions could be understood from a care culture perspective.

DESIGN AND METHODS

A hermeneutic documentary analysis was conducted on 269 incident reports concerning suspected mistreatment of the elderly in three municipalities in Sweden. The hermeneutic analysis followed a four-stage process: selecting and reading the text, setting out the context, closing the hermeneutic circle, and finally creating a conceptual bridge towards a critical understanding from a phenomenological lifeworld perspective.

FINDINGS

  The care of the elderly in the municipality was based on a social culture that placed residents' needs at the centre. Following routines were considered important in preventing mistreatment and were intended to ensure that all patients were treated fairly and equally. Care was described as task oriented and often lacking in interpersonal relations. From a phenomenological lifeworld perspective, it was interpreted that in the municipalities' care of the elderly, there was a focus on elderly people's freedom at the expense of the vulnerability aspects of well-being.

CONCLUSION

Raising awareness of the care culture underlying abuse could help to improve understanding of care practice. Change may be only possible when reflected on the existing perspectives underpinning the care culture, and integrate them into a broader framework for caring.

Evidence-based approaches to remedy and also to prevent abuse of community-dwelling older persons

Elder abuse is a global issue, with an estimated 4–10% of older persons in Canada abused each year. Although Canadian legislation has been created to prevent and punish the abuse of older persons living in nursing homes and other care facilities, community-dwelling older persons are at greater risk of abuse. This paper highlights the importance of evidence-based actions targeted at three determinants of health: (a) personal health practices and coping skills, (b) social support networks, and (c) social environments. Two research studies are profiled as case studies that illustrate the ready possibility and value of two specific types of actions on community-based older-person abuse. This paper argues for the immediate and widespread adoption of these evidence-based measures and for additional empirical evidence to guide the correction of underreporting of abuse, raise awareness of its serious nature, and increase options to not only stop it but ultimately prevent it.

Violation of ethical principles in institutional care for older people

This study focuses on issues of elder abuse in residential settings. Violation of ethical principles is shown in the results of this quantitative study aimed at defining the extent, nature and causes of such abuse by employees’ unethical conduct towards clients in senior homes (i.e. residential nursing homes) in the Moravian-Silesian region of the Czech Republic. The research sample comprised 454 employees and 488 clients from 12 residential homes for older people. The data were collected from interviews with clients, who also received a questionnaire concerning their satisfaction with the institution. Two questionnaires were administered to the employees, one based on a pilot qualitative study and a second to investigate burnout. Outcomes were assessed according to the extent and form of elder abuse, the causes of elder abuse and the violation of basic ethical principles. The responses, in particular those of employees, revealed both psychological and physical abuse of older clients, and thus violation of two basic principles: respect for the person and non-maleficence. The group at risk of elder abuse comprised aggressive and dissatisfied clients, as well as those with mental problems and dementia. The employees most at risk of being abusers were those who had been employed in institutional care for more than five years, had inadequate knowledge about social services and suffered from burnout. The prevention of elder abuse is recommended to be through education focused on ethical principles, increasing employees’ satisfaction by promoting a friendly and safe organizational culture, and providing adequate working conditions.

[Factors potentially associated to domestic negligence among elders assisted in home assistance program]

The cases of abuse against elderly people have been growing significantly throughout the entire world. Among the various forms of abuse, one of the less known and denounced is the domestic negligence. As it occurs mostly inside family and nursing homes, it is hardly identified. This article presents the results of a cross-sectional descriptive/analytical study that pointed out the existing factors potentially associated to domestic negligence towards elderly patients attended by the Elderly Home Care Program as part of the discipline of Geriatrics of the Paulista Medical School, Federal University of São Paulo, Brazil. Interviews were made with 40 familiar caregivers of these patients who had functional disability. The profiles of those patients and their caregivers were identified by questionnaires and the impact on those familiars by the Caregiver Burden Scale. The results revealed the existence of the following factors potentially associated with domestic negligence among elderly people, in the study population: the dimensions general tension and isolation, as well as depression and stress on the caregiver's side, and the elder's functional ability, are the causes that impact the most on caregivers.

Caregiver factors contributing to psychological elder abuse behavior in long-term care facilities: a structural equation model approach

BACKGROUND

Identification of caregiver risk factors associated with psychological elder abuse is crucial for preventing and managing such abuse. The aim of this study was to test the most effective model for explaining caregiver factors contributing to caregiver psychological abuse behavior. We hypothesized that caregiver hours worked each day, years of education, age, geriatric care-giving training, gerontological care knowledge, social resources, and self-reported work stress are factors contributing to psychological abuse behavior of caregivers.

METHODS

A cross-sectional study design was used. The sample included a total of 183 caregivers recruited from seven long-term care facilities in southern areas of Taiwan. Instruments included the Caregiver Psychological Elder Abuse Behavior (CPEAB) scale, the Work Stressors Inventory Chinese version (WSI-C), the Personal Resources Questionnaire (PRQ-2000), and Knowledge of Gerontological Nursing Scale (KGNS). The structural equation modeling (SEM) procedure was used to analyze the data.

RESULTS

All the model-fit indexes (chi2 = 87.84, df = 70, p = 0.073; CMIN/DF = 1.26; GFI = 0.94, AGFI =0.91, TLI = 0.96, RMSEA = 0.037) of the final model exceeded their respective common acceptance levels except for the normed fit index (NFI) value (0.88). The study results suggest that caregivers who work fewer hours, received fewer years of education, lack social resources, and had more work stress showed higher levels of psychological abuse behavior in caring for the elderly (p = 0.000-0.037).

CONCLUSIONS

These findings should be incorporated into practice by intervening to reduce caregiver stress and reduce elder abuse behaviors. To help reduce elder psychological abuse, caregivers would benefit from stress management and social resource interventions provided by employers or government programs.

Elder mistreatment reporting: differences in the threshold of reporting between hospice and palliative care professionals and adult protective service

BACKGROUND

Underreporting of elder mistreatment by health professionals is a significant problem.

PURPOSE

To investigate differences in elder mistreatment reporting threshold between hospice/palliative care (HPC) professionals and Adult Protective Services (APS); explore factors for not reporting elder mistreatment.

DESIGN

Cross-sectional questionnaire.

SETTING/PARTICIPANTS

Four HPC teams and 42 APS workers in one county.

METHODS

Five hypothetical elder mistreatment case vignettes along a spectrum of severity were scored on Likert scales for likelihood of reporting or accepting the cases. HPC professionals were surveyed about their knowledge and beliefs about reporting elder mistreatment.

RESULTS

All 42 APS workers and 74% of 73 (n = 54) HPC professionals completed the survey. In all but the most severe case of abuse, APS was more likely to accept reports of elder mistreatment than HPC professionals were in reporting (p < 0.002). HPC professionals had reported a mean of 2.5 (+/-2.8, standard deviation [SD]) cases in the last 5 years. Thirty percent of HPC professionals had suspected cases of elder mistreatment that was not reported in the last 5 years. The median difference between the total number of suspected and reported cases was 2 (+/-4.6, SD). Eleven percent had ethical concerns about reporting and 63% were concerned about practical consequences of reporting. Only 37% correctly identified the reporting agencies that have jurisdiction over abuse that occurs in long-term care. Correct identification of long-term care reporting agencies correlated with whether the HPC professional had training in elder mistreatment (r = 0.35, p = 0.009). Although 96% would report physical abuse that they witnessed, only 63% would report abuse verbalized by the patient.

CONCLUSION

There is evidence that significant differences exist in elder mistreatment reporting thresholds between APS and HPC professionals. This finding should encourage HPC professionals to discuss with APS the cases they are unsure about reporting. Future research is need on elder mistreatment in the HPC setting.

End-of-Life Preferences: A Theory-Driven Inventory

The study aimed at making a theory-driven inventory of end-of-life preferences. Participants were asked about a variety of preferences representing all eight motivational states described in Apter's Metamotivational Theory (AMT; Apter, 2001). Data from a convenience sample of 965 community participants and a convenience sample of 81 persons suffering from a terminal illness were examined using exploratory and confirmatory factor analysis. Ten factors were evidenced; they were easily interpretable in the AMT framework. In decreasing order of importance, people would, at the time of their death, like to have an understanding doctor, to be at peace with themselves, to remain autonomous, to keep a sense of humor, to remain able to oppose any decision taken without their consent, to remain an object of love, to remain a reference for others, to have resolved conflicts with others, to leave their businesses in good order, and to find themselves at peace with God.

The application of crime science to the prevention of elder abuse

The abuse of older people is a significant problem, with estimates intimating that there may be over 340,000 cases per year in the United Kingdom. Despite improvements in screening and assessment to identify and treat those who are abused or at risk of abuse, the healthcare community remains preoccupied with prevalence rather than prevention. In light of the paucity of health-related research evidence to support the effectiveness of preventative measures, the application of crime prevention theory and knowledge is appropriate. Routine activity theory and situational crime prevention literature acknowledges the vulnerability of older people to abuse and the potential of any person employed as a carer to be an abuser. Preventative measures are focused on techniques that make abuse more difficult and more risky for the perpetrator and, therefore, less 'rewarding'. The regulation of healthcare support workers and increased workplace surveillance are examples of the 25 techniques of situational prevention that could be applied in a healthcare setting.

Conceptualizing Alzheimer's disease as a terminal medical illness

Alzheimer's disease is a common illness of the elderly population, with an estimated prevalence of 4.5 million people in the United States and 24.3 million worldwide. Despite current pharmaceutic advances in delaying disease progression, there is no cure. This article reviews the evidence for conceptualizing Alzheimer's disease as a terminal medical illness. Discussed are principles of palliative care as applied to the patient with Alzheimer's disease and the patient's family.

Managing Pain, Managing Ethics

Noncompliance of family caregivers can present home hospice nurses with difficult ethical choices and powerful feelings about those choices. This is particularly so when family members do not adequately palliate their loved ones, resulting in treatable symptom distress during the dying process. This article presents a case study, moral analysis, and an evidence-based, practical plan of action for engaging family members of palliative care patients on a home hospice service.

Safeguarding adults at end of life: audit and case analysis in a palliative care setting

This paper reports an audit of safeguarding adults' cases arising over two years from the introduction of an adult protection policy in a UK palliative care service serving a diverse area with 48 beds, over 600 home care and 100 day care patients. Twenty cases were identified, involving institutional, physical, verbal, and financial abuse and neglect. Most patients wanted protective work, but some did not want to disturb personal care and relationships in spite of abuse. Protection from abuse increased support for patients and carers. An analysis of cases where neglect was associated with physical abuse identified a large proportion of cases where difficulties in existing family relationships, sometimes associated with alcohol and drug misuse and histories of mental illness, exacerbated the stresses of caring at end of life, leading to abuse allegations or concerns. Assessment of family relationships and interventions to clarify and organize family caring responsibilities, and deliver services that can support carers and monitor potential abuse are useful social work contributions.