Mary Shaw, PhD, ARNP, CS, associate director of The Geriatric, Research, Education and Clinical Center at the Gainesville Veterans Affairs Medical Center
in Florida, once assisted in an investigation involving a 62-year-old man whose health declined dramatically soon after being admitted to an assisted living facility.
had a wandering problem due to Alzheimer's disease, so his
family transferred him from one facility to another with a fence so he
couldn't wander away," Dr. Shaw
was admitted, the man could walk, talk, feed himself, dress himself, and knew himself and his
wife.But within 3 months, he
weighed 86 pounds and was hospitalized with contractures, pressure ulcers, bruises and lacerations.He
died a week later."
Thanks to the efforts of Dr. Shaw
and an investigator from the state, the institution was closed 18 months after the patient's death.The facility owner, convicted of felony manslaughter and abuse and neglect of an elder, received a 15-year prison term for the crime.
Why Aides, Caregivers Abuse While not all institutions deserve to be lumped into the same category as the assisted living facility in this case, Dr. Shaw
says there is cause for widespread concern."I'd be concerned if a relative of mine was in an institution," she
says."A lot of it depends on the quality of the institution itself and the presence of professional nursing staff, which makes a difference in quality patient care.But the intimidation, harsh voices and scolding of emotional abuse are probably pretty common in many institutions."
In a telephone survey of nursing home aides and nurses published in The Gerontologist about a decade ago (Pillemer K, Moore DW.Abuse of patients in nursing homes: findings from a survey of staff.1989; 29(3):314-320), 10% admitted they had physically abused patients.
According to Dr. Shaw
, institutional abusers are of two basic types: the pathological abuser and the reactive abuser.Pathologic abusers often have histories of violence and arrests and have difficulty holding jobs."These are sick, pathological people who should never be working in an institution, or with elderly people at all," says Dr. Shaw
."One person I heard about would wake up a patient every day by punching his
ribcage, and another stuffed washcloths down patients' throats to keep them quiet."
More common are reactive abusers, emotionally and physically exhausted people who abuse when pushed passed their already low tolerance levels.Poor wages, lack of recognition and heavy workloads typically plague the majority of nursing home aides, who provide 80% to 90% of patient care, Dr. Shaw points out.And many have home situations that present additional pressures: kids, single-parent families, financial problems, even another job.The combination of stressors can produce sparks of abuse when conflict becomes too strong.
"If a mentally incapacitated resident becomes aggressive toward them, their reaction might be to hit back, scream at the person, or react in some other negative way that would constitute abuse," Dr. Shaw
says."While abusing the patient is still wrong, the dynamics of the abuse are different from those with a pathological abuser."
Identifying Abuse, Following Law
According to Dr. Shaw
, if an elder is cognitively able and decides not to report an abuser, health care professionals aren't required to report the offender either.
"It's a very difficult issue to deal with," says Dr. Shaw
."There is emergency removal in Florida if a situation seems life-threatening, but it's a very complex issue here."
Avoiding Abuse Risk The NCEA estimates that only one of every six elder abuse and neglect cases is actually reported."I believe a lot of elder abuse occurs that we just don't know about," Dr. Shaw
says."It's not reported, not detected and sometimes not even recognized as elder abuse--particularly the emotional and verbal abuse."
To help end institutional abuse, Dr. Shaw
suggests adding staff and allowing employees to better pace their work--and to take breaks to reduce stress.In domestic situations, the potential for abuse decreases when more than one person is involved in caregiving.Multiple caregivers can provide social support, help monitor one another for inappropriate conduct, and reduce a senior's dependence on one person, making the victim less fearful to speak out if abuse does occur.
Finally, health care providers need to monitor and assess patients for potential abuse, as well as muster the courage to take action when necessary.