When the Elderly Person is Abusive
- Linda D. Pershall, R.N., B.S.N., L.N.C.
Elder abuse grabs headlines and is a
topic of television documentaries. What elder abuse is and its prevalence
in our society is often clouded by sensationalism then forgotten with
little or no changes being implemented for the
elderly victim. The abuse of the elderly is a real and serious problem.
Elder rights and HIPAA are measures intended to decrease abuse as outlined
in the article “Elder Rights and HIPAA Regulations”.
There is a flip side to the elderly person being the victim of abuse. That is when the elderly person is the abuser. The elderly person with dementia, delusional behavior, schizophrenia, depression, anger, confusion and frustration may express these problems/emotions as verbal and/or physical assault. The target of this assault is often the spouse, who is often frail and generally elderly.
Frequently the spouse endures this assault for years. It goes unreported for fear of loss of that person’s income should institutionalization occur or embarrassment of expressing the perceived "bad behavior" of the spouse. Frequently behavior is perceived as a social or moral failing, not as an illness. Untreated, these behaviors will continue to escalate. The spouse and family may be unable to distinguish these behaviors for an onset of increased depression, Alzheimer’s or other type of dementia. Violence and aggression may be a new onset for the elderly individual and signal the need for immediate medical evaluation and intervention. Also persons with a history of family violence, physical abuse, alcoholism or substance abuse will continue those behaviors as an elderly person. Acute or chronic changes indicate a need for medical intervention. Medication and psychological intervention is beneficial for the elderly as well as the younger population.
Not all aggressive, violent, elderly individuals have Alzheimer’s dementia, and Alzheimer’s dementia does not necessarily equate with aggressive and violent behavior. There are a growing number of Alzheimer’s special care, long-term care facilities or facilities with specific Alzheimer’s units. There are few long-term care facilities dedicated solely to elderly patients with psychological disorders. Frequently these patients in need of psychological therapy are placed in a general care facility. This may limit their therapeutic treatment as not all facilities have the staff with the specific skills needed to provide therapeutic psychological intervention.
The institutionalized elderly person with violent behavior may express that behavior toward caregivers and fellow patients. It is not uncommon for staff members to receive bites, bruises, cuts, torn clothing, verbal abuse, racial slurs, sexual advances, sexual groping and sometimes serious physical injury. It is not uncommon for a female staff member to be assaulted (grabbed) in a sexual manner while rendering routine care. Male staff members experience similar assaults. It is not uncommon for a fellow patient to be the recipient of a violent patient’s assault. The facility caring for these individuals has the responsibility for protecting staff and other patients while providing quality care for the aggressive or violent patient.
Dementia associated with physical and/or verbal violence is behavior difficult to medically manage. This behavior is emotionally draining for caregivers and family members. These individuals are among the most likely to be neglected and abused by caregivers or family members. Neglect may be subtle, i.e., not providing personal care as frequently, not having human interaction as frequently, etc. It may also be overt, with the demented patient being physically assaulted. Avoidance is a normal human response to this type of behavior. Staff and family tend to decrease interacting with these individuals for fear of starting an episode of aggression/violence. Medical staff members need to be educated to these individuals’ special needs and in turn need to educate family members.
Often aggression is an expression of a need for assurance and human interaction, yet the aggressive behavior tends to make meeting these needs difficult. The challenge for the medical caregiver is to provide the human need for comfort, contact and interaction to these difficult and needy patients and educate staff and family as to the patient’s needs. This requires more staff input and planning of care as well as detailed observations to determine what is the most beneficial approach for that patient. Planned regular one to one contact helps prevent the aggression born of isolation. A period of quiet time, when aggressive behavior starts, is often useful in defusing aggressive episodes. These individuals often respond to re-direction and a change of focus, a quiet, gentle approach and a loving tone.
Severe brain damage from injury (stroke) or progressive dementia may limit effective therapeutic psychological intervention, but it does not exclude the medical professional’s responsibility in attempting therapeutic intervention to evaluate potential benefits. Skilled intervention often has amazing benefit in even more damaged and delusional individuals. This intervention may be a less stimulating environment with more structure in daily routines and medication adjustments as opposed to traditional psychotherapy. It is a breach in care standards to not offer the aggressive and violent patient access to psychological assessment and intervention.
Standards of Care:
Specific care plans detailed to the individual needs of a specific patient is the standard of nursing care. This is especially necessary when behavior issues interfere with the patient’s activities of daily living (ADL). The standard of care is breached when care/care plans do not address aggressive behavior.
Routine maintenance medication is helpful to control depression or other underlying symptoms. Redirection of the patient’s focus to a quiet environment, providing human contact, etc., are the preferred first line of intervention when aggression is first evident before it escalates to the need for medications. The standard of care is breached when the only intervention for aggressive episodes is the administration of additional medication.
Safety is essential for all patients, especially those prone to impulsive and aggressive behavior. Some safety measures are beds in low position, pads on the floor to prevent injury from falls, quick release restraints, wheelchairs designed to prevent tipping and removal of injurious objects along with ongoing staff education. The standard of care is also breached when safety measures are not in place for injury prevention.
Restraining an impulsive or violent person should only be used in an extreme emergency situation. It should only be used for a few minutes and it requires a physician’s order. The routine use of restraints is still practiced, but it is rarely beneficial and it has been shown to increase serious injuries. The use of restraints for punishment or staff convenience is a violation of national standards and an illegal act.
Aggressive, impulsive and violent patients may sustain injury even under the best of situations considering the nature of their disorders, however caregivers must take all reasonable measures to protect these patients.
These individuals are actually among the most vulnerable elderly patients.
These patients need more monitoring for injury (bruises, cuts), weight loss, symptoms of illness, etc., due to their inability to express their symptoms or needs. Lethargic behavior may be an indication of illness, stroke or in some situations overmedication. Failure to provide that additional monitoring and assessment is below nursing standards.
Biography - Linda D. Pershall R.N., B.S.N., L.N.C.
Linda Pershall is a registered nurse with a bachelor’s degree in nursing and 30 years of experience in working with elderly patients in long-term care facilities, community and home settings. She has a passion for quality elder care and an extensive knowledge of elder issues.
Her other passion is wound care, specifically treatment and prevention of pressure wounds or decubitus ulcers which are a frequent problem for the elderly individual.
She formed LDHP Medical Review Services Corp. in 1995 to support quality care standards and provide a resource to the public and medical or legal professional.
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