WOUNDED IN THE WINTER OF LIFE - A BROWN

Making healthcare remarkable
Wounded in the Winter of Life:
Women Facing Violence at Advanced Age
Allison T. Brown, MCE
Piedmont Triad Regional Council
Area Agency on Aging

Objectives
11/21/2014
Novant Health: Wounded in the Winter of LIfe
2
1. Present the high prevalence of partner, domestic, and
caregiver abuse directed toward women as they
mature in age.
2. Describe the mental and physical healthcare outcomes
of elder abuse in women
3. Discuss the evaluation and action steps healthcare
providers should follow when evaluating women for
risk of violence.

What is Violence?
11/21/2014
3
Noun.
1. swift and intense force;
2. rough or injurious physical
force, action, or treatment;
3. an unjust or unwarranted
exertion of force or power, as
against rights or laws;

What is Elder Abuse?
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4
“Elder Abuse refers to any
physical, sexual, or psychological
abuse, neglect, abandonment, or
financial exploitation of an older
person either:
1) within a relationship where
there is an expectation of trust
and / or
2) when an older person is
targeted based on age or
disability.”
—National Clearinghouse on Abuse in Later Life (NCALL)

True or False?
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5
Women are just as likely as men
to be abusers.
FALSE.
Men are more prevalent as
perpetrators of elder abuse.

True or False?
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6
Elder Abuse is gender-neutral:
women and men suffer abuse
equally.
FALSE.
Women are more prevalent as
victims of elder abuse.

True or False?
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7
The rate of abuse is much higher
than reported cases indicate.
TRUE.
For every 1 reported
case, 13 are
unreported.

True or False?
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8
In elder abuse cases, the care
recipient is typically dependent
in some way on the abuser.
FALSE.
The abuser is often dependent in
some way on the care recipient .

Prevalence of Abuse Toward
Women as They Mature in Age

10 8 6 4 2 0 2 4 6 8 10
PERCENT OF TOTAL POPULATION
AGEGROUP
Males
Females
N.C. Population 1900
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10

10 8 6 4 2 0 2 4 6 8 10
AGEGROUP
Males
Females
11
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10 8 6 4 2 0 2 4 6 8 10
AGEGROUP
Males
Females
12
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Women’s Abuse Rate is Double That of Men
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13
67%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Women Men

Women’s Abuse Rates by Ethnicity
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14
66%
19%
10%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
White
Black
Hispanic

Types of Abuse
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59%16%
12%
7% 5% Reported Cases Neglect
Physical Abuse
Financial
Exploitation
Emotional
Abuse
Other
Unknown

Abusers are Family Members
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90%
10%
Frequency of Abuse
Family
Member
Non-
Family
Member

Abusers are Most Often Spouses
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17
0% 20% 40% 60% 80% 100%
Violation of Rights
Sexual Abuse
Physical Abuse
Neglect
Financial Abuse
Spouse Son / Daughter

Why Would They Abuse?
• Life-long circumstance of abuse: domestic
violence grown old
• Changes in the older woman’s behaviors and
attitudes
• Entitlement
18
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Mental & Physical Healthcare
Outcomes of Elder Abuse in
Women

Mortality
Risk of Death: 300 times higher for mistreated elders
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Source: The American College of Obstetricians and Gynecologists, Committee Opinion, Number 568, July 2013.
0%
20%
40%
60%
80%
100%
Abused by
Spouse or
Children
Killed by
Children
Killed by Spouse
66%
42%
24%

Medical Costs of Violent Injuries
$ 5.3 Billion
ANNUALLY
21
11/21/2014

Impact of Abuse on Health Outcomes
Type of Abuse Health Outcomes
Physical or Sexual
Substance abuse; depression;
PTSD
Sexual PTSD arousal & avoidance
Physical Assault
Alcohol abuse; depression; PTSD
re-experiencing
Sexual Assault
Increased rates of physician-
diagnosed arthritis and breast
cancer
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22

Type of Abuse Health Outcomes
Intimate Partner Violence
Poorer self-reported physical
health; greater medication use
Two or More Traumas
Increased depressed symptoms
and emotional distress
Any Type of Abuse
Twice as likely to manifest
depression and anxiety
Multiple Assaults
Double to triple the likelihood
and intensity of negative health
outcomes
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Increased
Incidence of:
● Bone & joint problems
● Depression & anxiety
● Chronic pain
● High blood pressure
● Heart problems
● Digestive problems
● Sleep disturbances
Nonphysical Abuse
> Physical Abuse
● Panic attacks
● Acute anxiety
● Drug & alcohol dependence
● Five times more likely to use
sedatives and antidepressants
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Correlation of Head Trauma and
Alzheimer’s Disease
…the risk of Alzeheimer’s
is FOUR times higher.
In settings of sustained
Intimate Partner Violence
over time…
25
11/21/2014

Why Don’t Abused Older Women Report?
Fears
• Escalated abuse or retaliation
• Institutional placement
• Poverty
Beliefs
• Permanent marriage commitment
• Optimistic view of abuser
• Denial
• Promise
● Protective laws
● Protective services
● Legal recourse
● Availability of safe houses
● Availability of domestic violence
services
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Lack of AwarenessFears & Beliefs

Other Vulnerable Populations
67% report physical abuse
53% report sexual abuse
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Women With Disabilities
50% report abuse
47% mistreated by caregivers
Women With Dementia

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• 65% report victimization due
to sexual orientation
• 29% had been physically
attacked
• 8.3% reported abuse or
neglect due to caregiver’s
homophobia
• 8.9% experienced blackmail
or financial exploitation
LGBT

• 95% report neglect or abuse of
another resident
• 50% of nursing home staff admitted
to mistreating older patients
• Of CNAs:
17% admitted pushing, grabbing, or
shoving
51% reported yelling
23% reported insulting or swearing
at a resident
11/21/2014
29
Long-Term Care
• 40% of people over age 65 will
enter a nursing home before they
die.
• 2 out of 3 residents are female
• 44% report physical abuse

Evaluating Older Women
for Risk of Violence

Neglect
The failure of a
caretaker to provide
goods or services
necessary to avoid
physical harm,
mental anguish, or
mental illness.
11/21/2014
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If She Is Neglected
Examples
 Abandonment
 Denial of food, hydration, health
care, or medications
 Lack of assistance with eating,
bathing, or toileting
 Ignoring cries for help
 Not providing adequate fluids
 Turning off the call-light and taking
no action
Indicators
 Bedsores
 Dehydration
 Rashes or sores
 Malnutrition
 Weight loss or gain
 Poor hygiene
 Falling
 Burns
 Soiled Briefs
32
11/21/2014

Physical Abuse
The use of physical force that may result in
bodily injury, physical pain, or impairment.
Intentionally causing pain or harm.
33
11/21/2014

If She is Physically Abused
Examples
 Hitting
 Kicking
 Pinching
 Rough handling
 Force-feeding
 Pulling too hard
 Unnecessary or incorrect
medications
Indicators
 Bruising
 Broken bones
 Open wounds
 Burns
 Rope or hand marks
 Injury that is not treated
 Injury with no explanation for its
cause
34
11/21/2014

Physical Abuse Examination
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Physical Abuse Examination
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Sexual Abuse
Non-consensual sexual
contact of any kind with
an elderly person.
Engaging in sexual
relationships with an
elder who is not
competent to give
consent.
37
11/21/2014

If She is Sexually Abused
Examples
 Unwanted touching
 Rape
 Coerced nudity
 Coercion to perform sexual acts
 Sexual harassment
 Sexually explicit photography or
videography
Indicators
 Bruises around the breasts and genital
areas
 Unexplained venereal disease or genital
infection
 Torn, stained, or bloody underclothing
 An elder’s report of being sexually
abused
38
11/21/2014

Exploitation
The improper act or process of an
individual using the resources of an older
person without his/her consent for
someone else’s benefit.
39
11/21/2014

If She is Financially Exploited
Examples
 Cashing an elder’s check without
permission
 Forging a signature
 Misusing or stealing money or
possessions
 Coercing or deceiving a person into
signing any document
Indicators
 Frequent, expensive gifts from elder to
caregiver
 Numerous unpaid bills
 A new will, or other legal documents,
when the elder is incapable
 Unusual activity in bank account
 Caregiver’s refusal to spend money on
the elder
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40

Emotional Abuse
.
Infliction of anguish, pain, or distress
through verbal or non-verbal acts.
Includes any derogatory or disparaging
language within hearing distance of
anyone.
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41

If She is Emotionally Abused
Examples
 Yelling or speaking in a harsh tone
 Cursing
 Threats or intimidation
 Treating an elder like a child
 Isolation or giving the elder the “silent
treatment”
Indicators
 Fear
 Anxiety
 Depression
 Anger
 Resignation
 Isolation or withdrawal
 Hesitation to talk openly
42
11/21/2014

Medical History for EA Victims
 Missed appointments
 Social withdrawal
 Failure to adhere to referrals or
medications
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 Lack of health
maintenance
 Reports of depression,
sadness, anxiety, or
boredom
 Frequent falls
 Many ED visits
 Lack of explanation of
trauma
 Delay in seeking care
for trauma

Examination Indicators of EA
 Social withdrawal
 Depression or anxiety
 Insomnia
 Anorexia
 Vague reports of health problems
 Patient declines full examination
 Physical injuries, such as bruises on neck,
upper back, and arms; extensive burns;
multiple pressure ulcers; scratches; fractures;
belt marks
 Cowers when approached
 Passivity
 Poor engagement
 Flat affect
 Weight loss
 Poor hygiene
 Lack of assistive devices
 Inappropriate clothing
 Malnutrition
 Dehydration
 Pressure ulcers
 Uncontrolled diseases
(diabetes, hypertension, or congestive heart
failure)
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Performing an Elder Mistreatment
Examination
 Interview the patient separately – be
aware that family members and
caregivers may be abusers
 Start with general, open-ended
questions and progress to more
specific questions
 Note inconsistent or frequently
changing stories
 Observe patient’s reactions to
accompanying family members or
caregivers
 Be trustworthy
11/21/2014
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Sample Screening Questions
 Do you feel safe in your home?
 Are you afraid of anyone in your home?
 Has anyone threatened you or verbally
assaulted you?
 Has anyone touched you without your
permission?
 Does anyone ever ask you to sign documents
that you don’t understand?
 Does anyone ever take your things without
your permission?
 Are you alone a lot?
 Has anyone ever failed to help you when you
were unable to help yourself?
 Do you have anyone to share your worries
with?
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Take Action
REPORT
 911 or law
enforcement (life
threatening or
possible crime)
 Adult Protective
Services
 Licensing board (if
abuse occurs in a
facility)
REFER
 Domestic violence or
sexual assault
organization
 Aging network
agency
 Ombudsman (if
abuse is in a facility)
NCEA Elder Abuse Presentation: Abuse in Later Life • www.ncea.aoa.gov 47
11/21/2014
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“Over the
next few
years, elder
abuse will
become one
of this
country’s
major
crimes.”
— Paul R.
Greenwood
Deputy District
Attorney
San Diego County,
California
11/21/2014
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Protective Legislation
1974: Child Abuse Prevention Act
1994: Violence Against Women Act
2010: Elder Justice Act
2014: Administration on Community Living
(ACL): “Repurposing the Office of Elder Rights
to become the new Office of Elder Justice and
Adult Protective Services, which will house the
federal home of APS.”
11/21/2014
49

Older Americans Act Funding
11/21/2014
50
0
10
20
30
40
50
60
70
80
90
100
$0.0
$0.5
$1.0
$1.5
$2.0
$2.5
2004 2008 2012 2016 2020 2024
Millions
Billions
OAA FUNDING & U.S. AGE 60+ POPULATION GROWTH
U.S. 60+ POPN OAA ANNUAL FUNDING

Save the Date:
June 20, 2015
Elder Abuse
Awareness Walk
www.ptrc.org
11/21/2014
51

Thank you.
Allison Brown
abrown@ptrc.org
11/21/2014
52

References
11/21/2014
53

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