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Elderly abuse and neglect دکتر احمد باقری مقدم متخصص پزشکی ورزشی سرپرست پژوهشی پزشکی قانونی مقدمه روند رو به تزاید جمعیت سالمندان پدیده جدید حوزه پیچیده ومشکل در ایران سال 1375جمعیت سالمندان 3977000معادل 6/6درصد سال 1385جمعیت سالمندان 5119000معادل 7/3درصد What is elder abuse? تمام اشکال سوء رفتار با سالمند را سالمند آزاری میگویند در تعریف دیگر فعل یا ترک فعل آسیب رسان به سالمند را گویند Elderly abuse was defined as an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Incidence of elderly abuse Abuse in institutional settings is difficult to measure, yet is thought to exceed that in community settings. In the USA,10% of nursing staff in institutional settings admitted committing physical and 40% psychological abuse against residents . میزان گزارش بسیار متغیر است و بستگی به تعاریف دارد “mistreatment of adults, including abuse, neglect, and exploitation, affects more than 1.8 million older Americans” (Pavlik, Hyman, Festa, Bitondo, andDyer, 2001, p. 45) self-neglect accounts for one-third to one-half of all abuse cases (Gray-Vickrey, 2000, 2004; Levine, 2003; Paris, 2003) است کهself neglect شایع ترین نوع آن خود غفلتی است تشخیص آن نیز بسیار مشکل است سالمند آزاری فیزیکی در شهر اصفهان پایین است و بیشترین نوع آزار به سالمندان از نوع استفاده از اموال بدون رضایت سالمند میباشد. Distribution of Abuse تقریبا بین زنان و مردان مساوی است ولی برخی تحقیقات نشان داده در مردان بیشتر بوده است. الگوی آزار بسیار فرهنگی است و در بین جوامع مختلف و محل های مختلف متفاوت است (.خانه یا بیمارستان و شهر های مختلف) Perpetrators of Abuse آزار رسان ها چه کسانی هستند؟ elder abuse can be perpetrated by nearly anyone including: paid or volunteer caregivers medical and long-term care employees, family members strangers such as a person who befriends an elderly person for the purpose of exploiting them Who is Committing the Abuse? SON 1% 1% 2% DAUGHTER 24% HUSBAND 2% 4% 24% 5% WIFE BROTHER SISTER 16% 21% NIECE NEPHEW GRANDCHILD UNRELATED CAREGIVER Risk factors for elderly abuse factor related to the abused elderly: The intensity of an elderly person’s illness or dementia Social isolation The elder’s role, at an earlier time, as an abusive parent or spouse A history of domestic violence( (خشونت خانگیin the home Dependency factors related to the abuser: Inability to cope with stress (lack of resilience) Depression, which is common among caregivers Lack of support from other potential caregivers The caregiver’s perception that taking care of the elder is burdensome and without psychological reward Substance abuse Greatest Risk Factors for Causing Abuse being male being related history of mental illness recent decline in mental health abusing alcohol primary caregiver change in family roles from being cared for to being the care provider prior history of violence Types of elder abuse Abuse by others Frequency Physical 16% Sexual 2% Financial 29% Neglect 27% Abandonment ترک 1% Isolation 2% Abduction ربایش 0.2% Psychological 24% Physical abuse Physical abuse means at least one act of physical violence against the elderly Forms of physical abuse Direct beatings Hitting Slapping Cutting Burning shaking Unreasonable physical restraints Maltreatment of medical conditions Sexual assault Prolonged deprivation of food or water. Sings of physical abuse bruises Broken bones, sprains, or dislocations Report of drug overdose or apparent failure to take medication regularly Broken eyeglasses or frames Signs of being restrained, such as rope marks on wrists Caregiver’s refusal to allow you to see the elder alone Bruising A bruise, or contusion, occurs when blunt forces distort soft tissues to an extent sufficient to result in disruption and leakage of blood vessels Escape of blood from blood vessels produces discoloration When is bruising suspicious trauma versus accidental trauma? Which looks more like abuse: A or B? A B Accidental or Inflicted? You decide Accidental or Inflicted? You decide Bruising Study con’t Location of Bruises Caused by Abuse Patterned Injury An injury that possesses features or configuration with objects or surfaces that produced it Bruising Physically abused older adults had significantly larger bruises than those in comparison group who were not abused and more knew the cause of their bruises Patterned Injury Grip marks around arms or neck Rope marks or welts on wrists or ankles Imprints from belts, belt buckles, straps, cords, hangers, hairbrushes, combs, cigarettes and cigarette lighters Handprints, fingerprints, knuckle prints and footprints o o More on strangulation… More on burns… Fracture Broken bones Includes severing of the bone or compression of intact bone Avulsion The tearing away of a structure or part; often seen as a partial avulsion Abrasion A wound in which the outermost layer of the skin is removed by a compressive or sliding force Laceration Blunt force injuries resulting from tearing, ripping, crushing, overstretching, pulling apart, bending and shearing soft tissue. Lacerations are usually found over a bony surface and are ragged or irregular in appearance Incision Incision, known as a cut, is a wound made by a sharp instrument or object, such as a scalpel, knife, razor or paper coming against the skin with pressure to cause an injury 35 Stab Wound Result whenever a sufficiently sharp and narrow object is forced upward Unlike a cut, depth exceeds width in stab wounds Mechanical Restraints Means of controlling behavior, especially in hospitals and nursing facilities Only acceptable reason for temporarily restraining someone is to prevent significant harm Sexual abuse is unwanted sexual contact with an elder including touching, sexual assault, and rape or sodomy Sexual Abuse Sexual abuse is unwanted sexual contact with an elder including: touching , Fondling نوازش کردن sexual assault(rape or sodomy) Verbal or suggestive behavior Unnecessary help with dressing/hygiene Signs of sexual abuse Signs Bruises around breasts or genitals Unexplained venereal disease or genital infections Unexplained vaginal or anal bleeding Torn, stained, or bloody underclothing Neglect The failure of a designated caregiver to meet the needs of an elderly person, and withholding of physical, material, or emotional necessities of physical and mental health, whether intentionally or unintentionally. This includes failure to assist in personal hygiene or the provision of clothing for an elder, failure to provide medical care for the physical and mental health needs of an elder, and failure to protect an elder from health and safety hazards. NEGLECT Denial of care: – – – food, water, shelter personal hygiene, clothing, bedding medical care, medicines, assistive devices Isolation: – – – control of time, activities, contacts disinformation tactics false imprisonment Minimal personal care Passive Neglect ناتوانی غیر عمدی به انجام تعهدات مراقبت اعمال دیسترس بدون قصد آگاهانه و یا عمدی Active Neglect شکست عمدی به تعهدات مراقبت، اعمال استرس جسمانی یا عاطفی و یا آسیب رها کردن ،محرومیت از غذا ،دارو، بهداشت شخصی SELF-NEGLECT Basic activities of daily living are neglected, threatening personal health and safety: hygiene food, water clothing and bedding shelter and surroundings finances health care Signs of neglect Malnutrition, dehydration Lack of personal care Inadequate heating Unclean clothes or bedding Lack of needed medications, eye glasses, hearing aids, or dentures Contractures, decubitus ulcers, wasting and muscle atrophy Psychological abuse or emotional abuse o Psychological abuse is more difficult to define and operationalize. Usually defined as an act carried out with the intention of causing emotional pain or distress. Psychological abuse often accompanies physical abuse. Emotional abusers can use verbal and non verbal to inflict elder damage. Psychological Abuse Humiliationتحقیر Isolationانزوا Intimidationارعاب Threatsتهدید Removal of decision making powers Verbal insults, yelling فریاد،توهین کالمی Verbal forms of emotional elder abuse تهدید و ارعاب از طریق فریاد فحش دستورات سخت تحقیر و تمسخر سرزنش Nonverbal psychological elder abuse : نادیده گرفتن جدا کردن از دوستان جلوگیری از مالقاتی Signs of psychological abuse Anxiety (mild to severe) . Depression, hopelessness, helplessness, thoughts of suicide Confusion, disorientation Trembling((لرزش دست و بدن lack of eye contact Agitation Abandonment ترک و رها کردن In addition to an actual complaint by older person of being deserted, signs of possible abandonment include: A vulnerable older adult with cognitive and physical impairments is left at a hospital emergency department without caregiver contact information A vulnerable older adult with cognitive impairments is put on a bus with a one-way ticket to another town or state A vulnerable older adult with cognitive impairments is left at a public building Financial or material abuse از دست دادن غیر قابل توضیح درآمد ،دارایی ها، اموال ،کمبود غذا ،از دست رفته پرداخت وام ها هر سرقت یا سوء استفاده از پول یا اموال افراد مسن توسط فرد مورد اعتماد اختالس یا سوء استفاده از منابع مالی و یا اموال Forms of financial abuse : سوء استفاده های شخصی چک ،کارت های اعتباری ،و یا حساب های سالمندان سرقت پول نقد ،چک ،درآمد ،و یا کاالهای خانگی جعل امضا سالمندان Institutional elder abuse Refers to abuse that occur in residential institutions such as nursing facilities usually by someone who is paid caregiver, such as nursing facility staff member. Residents at the greatest risk for institutional abuse or neglect includes resident with dementia, resident who seldom have visitors Domestic abuse Refer to forms of maltreatment by someone who has a special relationship with the elder such as family member or caregiver recognition of elder abuse: examination Detection and Treatment Barriers detection of elder abuse is difficult because denial is an integral feature of abuse, victims may feel too ashamed to disclose maltreatment or believe they are to blame for or deserve the abuse dependence on an abuser can make a victim reluctant to report for fear of how he/she will survives without the perpetrators help Detection/Treatment Barriers )(continued ممکن است این آزار ها در یک جامعه ،نرمال تلقی شود ممکن است سالمند به دلیل مشکالت بینائی یا شنوائی یا ادراکی و یا به دلیل زندانی و محدود شدن قادر به گزارش سوء رفتار نباشد Detection/Treatment Barriers (continued) گذر زمان و بروز اختالالت شناختی گزارش آزار را دشوار .میکند physical injuries may be masked by clothing or by isolating the victim Detection/Treatment Barriers )(continued وجود یک سرویس مشخص و حمایتی است که میتواند به گزارش سوء رفتار بینجامد. عدم وجود آمار های کافی نیز مانع شناخت این پدیده است Preventing elder abuse and neglect Preventing elder abuse means doing three things: Listening to elderly and their caregivers Intervening when you suspect elder abuse Educating others about how to recognize and report elder abuse Reporting elder abuse If you are an elder who is being abused, neglected, or exploited, tell at least one person. Tell your doctor, a friend, or a family member whom you trust. Protective Measures توصیه هایی به سالمند Stay sociable and active Stay involved with neighbors, friends, church or musque or community activities Get regular medical and dental care Open and post your own mail Increase social network as you age Have friends visit you at home Have a “best friend” with whom you can confide in Keep in touch with old friends if you move Instructions to a concerned friend or family member Watch for warning signs that might indicate elder abuse. If you suspect abuse, report it. Take a look at the elder’s medications. Does the amount in the vial matched with the date of the prescription? Watch for possible financial abuse. Ask the elder if he may scan bank accounts and credit card statements for unauthorized transactions. Call and visit as often as you can. Help the elder consider you a trusted confidante. Offer to stay with the elder so the caregiver can have a break — on a regular basis, if you can. Instructions to the elderly Make sure your financial and legal affairs are in order. If they aren’t, enlist professional help to get them in order, with the assistance of a trusted friend or relative if necessary. Keep in touch with family and friends and avoid becoming isolated, which increases your vulnerability to elder abuse. If you are unhappy with the care you’re receiving, whether it’s in your own home or in a care facility, speak up. Tell someone you trust and ask that person to report the abuse or neglect. با سپاس از توجه شما Forms of Abuse فیزیکی :پرت کردن، زدن ،هل دادن ،بستن، به زور غذا دادن روانی :تمسخر کردن، ارعاب ،خشونت کالمی جنسی :هر گونه تماس بدن رضایت )Forms of Abuse (continued مادی :دزدیدن پول یا اموال، قرارداد های اجباری ،سوء استفاده از اموال سالمند تجاوز به حقوق فردی: پیشگیری از هر گونه حق انسانی مثل آزادی ،حریم خصوصی ... طبی :ندادن دارو یا درمان یا درمان بیش از حد OVERMEDICATION Forms of Abuse (continued) ترک کردن سالمند در شرائط: ترک بحرانی در حالی که فرد مسئولیت وی را بر عهده گرفته است Neglect - failure to provide necessary physical or mental care of an elderly person Self-neglect - behavior that threatens one’s own health or safety Indicators of Abuse Physical - multiple fractures or bruises at various stages of healing, burns, patterned injuries, patchy hair loss, frequent visits to ER, delay in seeking medical treatment for injuries Psychological - withdrawn behavior, wasting or failure to thrive, depression Sexual - genital injury, vaginal or rectal bleeding, bruises, chipped teeth, sexually transmitted disease or infestations Indications of Abuse (continued) ، کمبود غذا، اموال، دارایی ها، از دست دادن غیر قابل توضیح درآمد:مالی از دست رفته پرداخت وام ها Violation of Rights - isolation, failure to attend religious vices or community events as one did previously Medical - no improvement in condition for which one was prescribed medication, blood tests indicate greater or lower than expected levels of medications, sleepiness, groggy Indications of Abuse (continued) Abandonment - isolation, not seen outside home, disrepair or unkempt environment, missed medical or other appointments or engagements, wandering, being left somewhere to fend for self Neglect - uncared for appearance, inappropriate clothing, failure to thrive, lack of medical or dental care, isolation Self-neglect – (similar to neglect) Thank you Elder Abuse The Forgotten Side of Domestic Violence Kay Hurd, RN, MSN Who Is Being Abused The US has: 44 million persons age 60+. 36 million people with disabilities. 364,512 cases of people living at home were reported with 43% confirmed. In the last 10 years abuse of elder persons has increases 150+%. Domestic Elder Abuse is a family problem, almost 90% of the abusers were family members. Who Are The Abusers More than 2/3rds of the abusers are family members of the victims and are typically serving in the caregiving role. Risk Factors Domestic Violence grown old. A partnership in which one member of the couple has traditionally exerted power and control over the other through emotional abuse, physical violence and threats, isolation and other tactics. Risk Factors - Continued Personal problems of the abusers. Adult children who are still dependant upon parent for financial assistance, housing or other means of support. Mental Illness. Substance Abuse. Risk Factors - Continued Caregiver stress. Cycle of violence is learned behavior transmitted from one generation to the next. Personal characteristics of the elder. Dementia. Disruptive behavior. Problematic personality traits. Significant needs of assistance. Amendments to Older Americans Act First appeared in 1987 and Provided Definitions Domestic Elder Abuse Domestic Abuse Grown Old. Maltreatment of an older person by someone who has a special relationship with the elder. (e.g. spouse, sibling, child, friend, caregiver). Spouses make up a large % of elder abusers. Partnerships in which one member of a couple has traditionally tried to exert power and control over the other. Institutional Elder Abuse Abuse that occurs in residential facilities for older persons. (e.g. nursing homes, foster homes, group homes, board and care facilities. Abusers are persons who have legal or contractual obligation to provide elder victims with care and protection. (e.g. staff, professionals, paid caregivers). Self-neglect – Self-abuse Self Neglect is behavior of an elderly person that threatens his/her own health/safety. *Self-neglect EXCLUDES a situation in which a mentally competent person who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her safety as a matter of personal choice. Signs of Self-Neglect Dehydration, malnutrition Untreated medical conditions Lack of necessary medical aids Hazardous or unsafe living conditions Unsanitary or unclean living quarters Inappropriate and/or inadequate clothing Homelessness Physical Abuse Physical force that may result in bodily injury, physical pain or impairment. Striking with or without an object. Signs of Physical Abuse Bruises, black eyes, welts, lacerations. Rope/restraint marks. Open wounds, cuts, punctures, untreated injuries in various stages of healing. Sprains, dislocations, internal injuries. Signs of Physical Abuse – continued Laboratory findings of medication overdose. An elder’s report of being hit, slapped kicked or mistreated. An elder’s sudden change in behavior. The caregiver’s refusal to allow visitors to see and elder alone. Sexual Abuse Sexual abuse is non consensual sexual contact of any kind with an elderly person. It includes unwanted touching Sexual assault or battery such as rape, sodomy, coerced nudity and sexually explicit photographing. Signs of Sexual Abuse Bruises around breasts or genital area. Unexplained venereal disease or genital infections. Unexplained vaginal or anal bleeding. Torn, stained, or bloody underclothing. An elder’s report of being sexually assaulted or raped. Emotional or Psychological Abuse The infliction of anguish, pain, or distress through verbal or nonverbal acts. Includes, verbal assaults, insults, threats, intimidation, humiliation, harassment Treating the older person like an infant Isolating an elderly person from his/her family, friends or regular activities. Giving an older person the “silent treatment” or enforced social isolation. Signs of Emotional/Psychological Abuse Emotionally upset or agitated Extremely withdrawn Non-communicative or non-responsive Unusual behavior usually attributed to “dementia” )e.g. sucking, biting, rocking) Neglect The refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Failure of a person who has fiduciary responsibilities to provide for an elder. Failure to provide an elderly person with necessities, food water, clothing, shelter, personal hygiene, medicine, comfort, personal safety. Abandonment The desertion of an elderly person by an individual who has assumed the responsibility for providing care to the elder, or by the person who has physical custody of the elder. Financial or Material Exploitation The illegal or improper use of an elder’s funds, property, or assets. Cashing an elder’s checks without authorization or permission. Forging an elder’s signature, Misusing or stealing an elder’s money or possessions, Coercing or deceiving an elder into signing any document, (contracts or wills). Improper use of guardianship or power of attorney. Signs of Financial or Material Exploitation. Sudden changes in bank account or banking practice. Inclusion of additional names on a bank signature card. Unauthorized banking, remaking of wills, advanced directives, or other legal matters of any kind. Is Elder Abuse a Crime? Physical, sexual, and financial/material abuses are considered crimes. Certain emotional abuse and neglect are subject to criminal prosecution. SELF-NEGLECT IS NOT CONSIDERED A CRIME. Where to Find Help Adult Protection Services. Somerset County Adult Protective Services. Board of Social Services. Somerville, 08876. 908-526-8800. Someone from the Agency will investigate reported cases. Provide victims with treatment and protective services. Local Police, sheriff’s offices and prosecuting attorneys will investigate and prosecute abuse. Long distance caregivers can call a nationwide toll-free number. (1-800-677-1116). Health education to prevent elder abuse Instructions to a caregiver:If the caregiver overwhelmed by the demands of caring for an elder, instruct (he /she ) to do the following: Request help, from friends, relatives, or local respite care agencies, so you can take a break, if only for a couple of hours. Find an adult day care program. Stay healthy and get medical care for yourself when necessary. Adopt stress reduction practices. Seek counseling for depression, which can lead to elder abuse. Find a support group for caregivers of the elderly. If caregiver is having a problems with drug or alcohol abuse, get help. Protective Measures (continued) Keep your possession organized Tell someone you trust where your important paperwork and bank account information is kept Have checks direct deposited into your account Use an answering machine to screen phone calls Don’t leave cash or valuables visible Notify the police if you will be away from home for an extended time period Protective Measures (continued) Consult with an attorney Make arrangement for the future such as power of attorney Get legal advise before making/signing agreements regarding your care or possessions Be aware of your financial situation Protective Measures (continued) Know where to ask for help Find out about community resources before you need them such as rape and abuse hotlines, senior centers, and adult protective services mental health service centers crisis centers private counselors clergy local police