By Elizabeth Hanink, RN, PHN, BSN
Child abuse is routinely reported in gruesome detail and we wonder how anyone could do such things to a youngster. Sadly, elder abuse is a growing criminal problem, much less reported, barely acknowledged even. It often involves the very caregivers who have responsibility for an older or disabled person. Abuse respects no one and can happen anywhere: the victim’s own home, a relative’s home, or an assisted living or nursing home.
The mistreatment takes many forms: physical, mental, financial. Sexual abuse is not unheard of, nor is the growing problem of guardianship or conservator abuse. The latter is particularly ironic since it takes advantage of a system that seeks to protect the interests of a person at risk. The problem arises when the state does not supervise adequately and when it allows poorly trained public guardians, even well-intentioned ones, take advantage of their wards. And once appointed, a guardian is entrenched. It becomes very difficult for the family or the ward to reverse the court’s decision and regain control over property, life savings, even where the dependent person lives.
How can we not notice such things? Part of the reason is the ease with which abuse can be hidden. It is not uncommon for older people in frail health or the chronically ill to limit trips outside the house. It is also not uncommon for them to have unrelated caregivers who change frequently and come and go at will. And of course, family members might very well be the ones inflicting the abuse. Victims may be too embarrassed to report abuse because they feel it is evidence they can no longer make decisions independently. Dementia may prevent them from recognizing some forms of mistreatment.
Significant abuse occurs within institutions like extended care facilities, assisted living homes and nursing homes. When you consider that research done on “elder orphans” by Joyce Varner DNP ANP, GNPBC of the University of South Alabama found that 60 percent of nursing home patients don’t receive visitors, it is not hard to understand (The Alabama Nurse, September 2005; 32 (3) 19-20). Some studies show that close to 22 percent of older adults have no one, no one closely related, no one appointed to care, no one to extend friendship. (“Elder Orphans Hiding in Plain Sight: A Growing Vulnerable Population.” Current Gerontology and Geriatrics Research, vol. 2016, Id 4723250). They are alone. Perhaps they cannot speak for themselves or have no one they can trust. Is it any wonder that in such circumstances a culture of abuse might arise? Understaffed with underpaid and poorly trained workers, nursing homes often medicate residents with too many drugs and inappropriate drugs just to maintain control (“’They Want Docile’: How Nursing Homes in the United States Overmedicate People with Dementia”www.hrw.org/node/314334. Human Rights Watch, 2018)).
What are some clues, you might ask, that all is not well? Depending on the type of abuse, there are usually signs. For physical, including sexual abuse: unexplained injuries of any type, injuries that recur, bruises or unexpected bleeding can be the tipoff.
Psychological abuse is more subtle. Threats, yelling, name calling are all part of the pattern, yet leave no discernable mark. So too is ignoring a person or controlling what he does, who she sees and where he goes. When a loved one acts withdrawn or frightened, has unexplained changes in behavior, and engages in mumbling to himself or loses interest in things he once enjoyed or has trouble sleeping, there might be a reason related to a change in health or medication or abuse.
Financial abuse against the elderly or dependent is rampant. Senator Susan Collins (R-Maine) calls it “a growing epidemic that cost seniors an estimated $2.9 billion annually.” (“Declaring War on Financial Abuse of Older People.” New York Times, April 14, 2017.) Identity theft may go unrecognized by the person affected. He might not understand he is being tricked into changing a legal document like a will or power of attorney. Abuse can also involve the unscrupulous overcharges for home repair or medical care. Fake charities prey particularly on the good-nature of some older people. Unexplained withdrawals, a new “friend,” unpaid bills, missing financial statements and signatures that seem forged are other clues that exploitation or fraud are afoot.
Not all abuse involves overt action. Neglect is also a feature and it need not be complete abandonment. Not providing enough food, water, clothing, medication, or supervision is also harmful. Bedsores, weight loss, an unkempt appearance or missing assistive devices like hearing aids, dentures, eye glasses walkers can all point to an attendant’s lack of care.
Everyone has a responsibility to come to the aid of a person who is in a dangerous situation. Calls to Adult Protective Service can be made anonymously and without certain proof. This flexibility can be problematic. Some things get reported that are innocent, and some are reported out of spite. And there is no reason to think a government bureaucrat is the best judge of a situation. But trusting an imperfect system is better than having someone be seriously injured or worse, dead while onlookers did nothing.
When necessary the state will appoint a conservator, maybe a relative, maybe a professional. States vary but in California the minimum is that any person who is a conservator for two or more people must be licensed by the California Department of Consumer Affairs, and among other things, have at least thirty hours of education, pass an exam and submit to background and credit checks. Other states like Florida and Nevada are in the process of tightening rules including requiring that conservatees be represented, at least in court, by attorneys.
And how can you protect yourself? According to Jan Copley, an attorney specializing in elder law and estate planning, with proper planning almost everyone can avoid a conservatorship (Elder Law Update, Jan Copley Newsletter 2017). First select the right person to look after you if you are not able to do so. Remember, children are not always the best choice here. Second, keep your plan updated, especially if you change your mind about the appropriateness of the individual. Make sure your wishes are in writing in the form of an Advance Health Care Directive that includes a Durable Power of Attorney for Healthcare. You also need a regular power of attorney for other matters. And last, but not least, if someone you trust tells you that you need help, take what they say seriously and get help, rather than forcing someone to go to court to protect you from yourself and others.
Physician-assisted suicide and euthanasia are, of course, the ultimate abuse of unprotected and suffering adults. Scholl continues its work in striving to protect the vulnerable among us through publications, seminars, speakers and other outreach. Please join our efforts by becoming a member, inviting a speaker, or passing along this copy of our quarterly review on elder abuse.
Elizabeth Hanink is a member of the Scholl Executive Committee and a registered nurse with fifty years of community and hospital nursing experience.