SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.

COLLEGE OF NURSING
NCM 14N-RELATED LEARNING EXPERIENCES
Care of the older Person
Week 13 – December 18, 2020

I. MAIN TOPIC: Abuse to the Older Adult

II. LEARNING OBJECTIVES:

1. Students will be able to identify the different types of abuse in the elderly.
2. Use the assessment tool in identifying the presence of elder abuse.
3. Apply the role of the health professionals in the prevention of abuse in the ageing
population.

III. DISCUSSION

Elder abuse is an important public health problem. Globally, the number of cases of
elder abuse is projected to increase as many countries have rapidly ageing populations
whose needs may not be fully met due to resource constraints. Predicted that by the year
2050, the global population of people aged 60 years and older will more than double, from
900 million in 2015 to about 2 billion, with most older people living in low- and middle-
income countries. If the proportion of elder abuse victims remains constant, the number of
victims will increase rapidly due to population ageing, growing to 320 million victims by
2050, (WHO, 2020).
 Abuse to an older adult involves physical, emotional, or sexual abuse and can
involve neglect or economic exploitation.
 Individuals at most risk include those who are dependent because of their
immobility or altered mental status.
 Factors that contribute to abuse and neglect include long-standing family violence,
caregiver stress, and individual’s increasing dependence on others.
 Victims may attempt to dismiss injuries as accidental, and abusers may prevent
victims from receiving proper medical care to avoid discovery.
 Victims often are isolated socially by their abusers.

Elder Assessment Instrument (EAI) allow professionals “in all clinical settings” to screen
for suspected elder abuse victims. EAI is designed for use only by clinicians screening their
patients. The screening instrument is not a questionnaire with a scoring mechanism like many
other tools, but rather a Likert scale and tracker for the clinician to rate whether there is no
evidence, possible evidence, probably evidence, or definite evidence of elder abuse along five
main categories of 41 health indicators. The instrument categories include a space for general
 assessment, “Possible Abuse Indicators,” “Possible Neglect Indicators,” “Possible Exploitation
Indicators, and “Possible Abandonment Indicators” with room for an overall summary at the
end. The author directs clinicians using EAI to refer their patients to social services if there is
any positive evidence of abuse (without clinical explanation) on any health indicator, or if the
patient complains of mistreatment.

ELDER ASSESSMENT INSTRUMENT (EAI)

Purpose: To be used as a comprehensive approach for screening suspected elder abuse victims in all
clinical settings.
Instructions: There is no “score” for this instrument. A patient should be referred to social services
if the following exists: 1) if there is any positive evidence without sufficient clinical explanation, 2)
whenever there is a subjective complaint by the older adult of elder mistreatment, or 3) whenever the
clinician deems there is evidence of abuse, neglect, exploitation, or abandonment.

1. General Assessment Very Good Good Poor Very Poor Unable to Assess
a. Clothing
b. Hygiene
c. Nutrition
d. Skin integrity
Additional Comments:
2. Possible Abuse No Possible Probable Definite Unable to Assess
Indicators Evidence Evidence Evidence Evidence
a. Bruising
b. Lacerations
c. Fractures
d. Various stages of healing
of any bruises or fractures

e. Evidence of sexual abuse

f. Statement by older adult
related to abuse

Additional Comments:
3. Possible Neglect No Possible Probable Definite Unable to Assess
Indicators Evidence Evidence Evidence Evidence
a. Contractures
b. Decubiti
c. Dehydration
d. Diarrhea
e. Depression
f. Impaction
g. Malnutrition
h. Urine Burns
i. Poor hygiene
j. Failure to respond to
warning of obvious disease

k. Inappropriate medications
(over/under)

l. Repetitive hospital admissions

due to probable failure of health
care surveillance
m. Statement by older adult
related to neglect
Additional Comments:

4. Possible Exploitation No Possible Probable Definite Unable to

Indicators Evidence Evidence Evidence Evidence Assess
a. Misuse of money
b. Evidence
c. Reports of demands for
goods in exchange for services

d. Inability to account for

money/property

e. Statement by older adult

related to exploitation

Additional Comments:
5. Possible No Possible Probable Definite Unable to
Abandonment Evidence Evidence Evidence Evidence Assess
Indicators
a. Evidence that a caretaker has
withdrawn care precipitously
without alternate arrangements
b. Evidence that older adult is left alone in
an unsafe environment for extended periods
of time without adequate support

c. Statement by older adult related to

abandonment
Additional Comments:
Summary No Possible Probable Definite Unable
Evidence Evidence Evidence Evidence To Assess
Evidence of Abuse
Evidence of Neglect
Evidence of Exploitation
Evidence of Abandonment
Additional Comments:

Comments:
___________________________________________________________________________________

_____________________________________________________________________________________

Source:

Fulmer, T. (2003). Elder abuse and neglect assessment. Journal of Gerontological Nursing, 29(6), 4-5.
Reprinted by permission: SLACK, Incorporated, Thorofare, New Jersey
 IV. LEARNING ACTIVITIES
Each group will be assigned with different case scenario of elder abuse and will answer
the guided questions.

GROUP 1.

Case Scenario 1
PHYSICAL ABUSE

An older woman comes to the clinic for a regular follow-up visit post left hip arthroplasty. The
nurse, Christine, gleans the following information from the chart before meeting Mrs. Sable and making
her initial assessment. Winnie Sable is an 84-year-old woman who lives with her husband, Alfred, aged
89 years. The Sables have been married for 54 years and have no children. They reside in their own two-
level home in a small suburban neighborhood where most of the neighbors keep to themselves. Winnie
used to enjoy participating in church activities, but after “falling down the stairs” and breaking her hip 6
months ago, she does not venture out like she used to. Alfred has recently been diagnosed with mild
cognitive problems (progressive memory loss) suggestive of early Alzheimer's disease (AD). Winnie
depends on Alfred to drive them for groceries and to doctor appointments.

1. At this point, are there any risk factors for physical abuse for either Mr. or Mrs. Sable that the
nurse should be alert to?

Christine obtains Mrs. Sable's height and weight. She is 5 ft 2 in. tall and 91 lbs, reflecting a loss
of 7 lbs in the past month. Mrs. Sable's vital signs are within normal limits, except her heart rate is 90
beats per minute. She seems quiet, withdrawn, does not make eye contact with the nurse, and seems
hesitant when asked to put on a gown before the doctor comes to see her.

2. What signs, if any, suggest that the nurse should ask some follow-up questions regarding safety
in the home for Mrs. Sable?

Mr. Sable is present in the room when Mrs. Sable is asked to put on a gown so the doctor can
examine her. Christine asks Mr. Sable whether he would like to wait in the waiting room or step out for
a minute. Mr. Sable answers the nurse angrily and refuses to leave the room saying that his wife does
not need to put on a gown to see the doctor. Seeing Mrs. Sable's obvious discomfort with having her
husband in the examining room, Christine speaks calmly and quietly to Mr. Sable and offers him a cup of
coffee. He reluctantly agrees to wait in the waiting room. Christine returns to Mrs. Sable who has
donned a gown. The nurse notice bruises of various colors on her back and forearms.

3. At this point, what questions should the nurse be asking?

 Christine asks how Mrs. Sable became bruised. Mrs. Sable lowers her eyes and whispers that she
falls a lot. Christine makes a more thorough assessment and documentation of the bruising and gently
probes for additional information. She uses the Elder Assessment Instrument (EAI) (Fulmer, 2008).

4. What additional questions should Christine ask?

Mrs. Sable begins to cry and confesses that her husband hits and pushes her. She says it is not
his fault, but that since his memory began to fail, she has seen a change in his personality. He becomes
angry and abusive over small things and hits her in the back and on the arms with his fists. Christine
provides comfort to Mrs. Sable, documents her findings, and tells her that the doctor will be in soon.

5. What is the next course of action that Christine should take? Explain the important role of
nurses to prevent physical abuse among elderly.

GROUP 2

CASE SCENARIO 2

PHYSICAL NEGLECT

Mr. Edward McKay is an 82-year-old African American man who lives in a two- bedroom house
with his daughter and son-in-law. Mr. McKay has a history of having had two cerebral vascular accidents
(CVA) in the past that have left him partially paralyzed and unable to speak. He is bedridden with
contractures of both lower extremities, incontinent, and dysphasic. His social history includes being
married with one daughter, whom he lives with, and two siblings who are in skilled nursing facilities. He
does not have anyone who visits him on a regular basis. Mr. McKay is a retired plumber, and his only
income is his monthly Social Security benefit check. Mr. McKay was referred to the local home health
agency approximately 3 months ago by his medical doctor. His daughter states that they are unable to
get him out to a doctor's office for routine check-ups, so he is seen by a physician who makes home
visits every 6 months. The doctor did not obtain any labs or weights the last time he visited the patient.
The skilled nurse assigned to the case is visiting Mr. McKay for the third time today. The nurse obtained
blood from the patient at the last visit and has the results with her today. The nurse notes that the
patient's albumin level is 2.8 and his prealbumin level is 18. The nurse is still unable to obtain a height
and weight on the patient because he is bedbound, but the daughter does tell the nurse that her father
is 6 ft 3 in. and that the last time he was weighed (which was over a year ago), he weighed 160 lbs. The
nurse observes several things during this visit and in previous visits that she finds concerning. These
issues include the following: (1) according to the daughter, she does not care for her father, she leaves
the care to her husband, even though she does not work and is at home with the patient during the day,
(2) the son-in-law feeds, cleans, and gives the patient his medicine, so when he is not there, the
daughter does not do things for the patient, and she waits for her husband to get home, (3) the
daughter is unable to answer any of the nurse's questions related to the patient's status, (4) the patient
is developing a pressure ulcer on his sacrum, (5) every time the nurse has visited the home, the patient
has had stool on him and his bed sheets appeared dirty, (6) there is cold food on the overbed table, and
a glass of water is on the dresser. The patient is unable to feed himself and is dysphasic, and (7) when
the daughter comes in the room, she is rough and harsh with the patient and he appears to be
frightened of her. The nurse teaches the daughter about the dangers of aspiration and ways to prevent
it including carefully monitoring/assisting patient when eating, no thin liquids such as water, no straws,
and so on. The daughter states, “Okay, I already know all of that but since you think it is so important, I
will tell my husband who takes care of him.” The nurse tries to set up a time when she can visit when
the husband will be home, but the daughter states, “He works a lot. I can't tell you when he'll be here.”

1. What areas of the patient's assessment should the nurse concentrate on to evaluate his risk for
physical neglect?
2. What are Mr. McKay's risk factors for being the victim of physical neglect?
3. Identify the general warning signs of physical neglect?
4. What are two psychosocial nursing diagnoses that Mr. McKay might be experiencing?
5. How should the nurse prioritize the physiological issues that Mr. McKay is experiencing?
6. What interventions/actions should the visiting nurse take to ensure this patient's safety and
well-being?

GROUP 3
CASE SCENARIO 3
FINANCIAL MISTREATMENT

Teresa Jones is a 70-year-old widowed female residing alone in her own home in an affluent
subdivision in a large Midwestern town. Lisa is her friend and works as a nurse at the local assisted living
center. Ms. Jones has 3 children and 10 grand- children. Her oldest daughter, Marjorie, lives nearby and
helps her mother with things around the house. Marjorie's teenage son, Joe, recently has moved in with
his grandmother, because he does not get along with his mother. Although Ms. Jones is happy for the
companionship and feels that Joe is “good” to her, she notices that some of her checks are missing, and
she cannot find a few pieces of her gold jewelry. The jewelry is valued at over $11,000 and includes her
precious wedding ring. These items went missing during the first 3 weeks after Joe moved in with her.

The bank calls to tell Ms. Jones that her checking account is overdrawn. They called as a courtesy
because this has never happened before, and a check was cashed for a large sum over $3,000. Ms. Jones
goes to the bank and finds that someone has forged her signature on one of her checks. She suspects
that Joe may have done it, but she says nothing to the bank officials about this. Ms. Jones rectifies the
situation and returns home, then calls Lisa to ask her advice.

Ms. Jones confides that she thinks Joe stole some checks from her and now is cashing them. She
tells Lisa that she talked to Joe and he denied everything, saying he was insulted that his grandmother
would think he would ever do such a thing. Ms. Jones does not know what to do, but she is adamant
that she will not allow anyone to steal her hard-earned money, even if it is a grandson. Ms. Jones also
confesses that her jewelry is missing. The two of them decide on an action plan that includes Ms. Jones
first talking to her daughter Marjorie, Joe's mother.

When Ms. Jones talks to Marjorie about her suspicions that Joe is stealing from her, Marjorie
confesses to her mother that she kicked Joe out of her own house because he has a drug problem and
had stolen money from her as well. Marjorie says she is sorry that she did not tell her mother this
before, but she was trying to protect her son and hoped he would change. Ms. Jones and Marjorie both
agree that this theft must be reported to the police and they will go in person to talk to someone
together the next day.

Ms. Jones calls Lisa the next day to tell her that she and her daughter reported what they knew
about the missing checks, stolen money and jewelry, Joe's possible forgery of one of Ms. Jones checks,
and Joe's drug problem. The police agree to investigate. Joe is now missing, and nobody can locate him.
He does not return any phone calls. Ms. Jones and Marjorie begin to be afraid that he will break into
their homes to steal more money as he gets desperate to support his drug habit. They both have the
locks changed on their doors and agree that Joe's behavior cannot be tolerated. Joe will no longer be
welcome in their homes.

1. What risk factors for financial mistreatment are present in Ms. Jones's situation?
2. What type of mistreatment or abuse is present in this situation?
3. Are there any other actions that Ms. Jones could take to ensure that she is not a victim of
any future financial mistreatment from her grandson or other family members?
4. How can older adults protect themselves from ever becoming victims of financial abuse or
mistreatment?
5. How do nurses intervene to this kind of elder abuse to ensure patient’s safety and well-
being?

V. POST ASSESSMENT
Submit your answer to our google classroom on or before January 08, 2021, and it will be discussed
via synchronous meeting on the said date.

References:
https://www.scribd.com/read/58281805/Gerontology-Nursing-Case-Studies#
https://www.nursinghomeabusecenter.com/blog/elder-abuse-assessment-questions/www.elder-
law.lawyers.com/Elder-Abuse.html

https://ncvc.dspacedirect.org/handle/20.500.11990/1641