Preventing Elder Abuse Training For All Staff

An Introduction to Elder Abuse for Professionals:

Physical Abuse

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov1Presenters Note

Please review the document A Guide to Planning Your Elder Abuse Presentation prior to using these slides for tips on creating your presentation. This document lists other PowerPoint slide sets on elder abuse and related phenomenon, including an overview, that can be blended with this module. The guidelines include suggested interactive methods for presenting some of the material in this slide set. This document can be found at ****.

For information on suggested videos and a references on this topic, refer to the Supplemental Materials for this slide set located at ****.

Prior to using this PowerPoint, replace or remove the placeholder slides with red lettering.

NCEA Elder Abuse Presentation: Physical Abuse1Understanding Physical Abuse2NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govNCEA Elder Abuse Presentation: Physical Abuse2Learning ObjectivesAt the end of this training, you will be able to:Define and describe physical abuseIdentify indicators of physical abuseIdentify strategies to respond to possible physical abuse situations

3NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Point

Review the learning objectives on the slide.3NCEA Elder Abuse Presentation: Physical AbuseCase ExampleMaria, an 87-year-old woman who is paralyzed, lives in a nursing home.Her family installs a video camera in her bedroom.Video shows her being repeatedly hit by a nursing home employee who says: Lady, why dont you die?

4NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govPresenters note Consider using a video example of an older victim, or one that highlights an actual elder physical abuse case if time permits (see Supplemental Materials for suggested videos****).

Teaching Points

Review the case examples on this slide and the next slide to illustrate some key dynamics of physical abuse.

This is a case example of abuse in a facility committed by paid staff.

Concerned family members documented the abuse to initiate an investigation.4NCEA Elder Abuse Presentation: Physical AbuseCase Example (cont.) Chris, the grandson of an elderly man, George, demanded money. When George refused, Chris strangled him until a neighbor yelled that she had called police.

5NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

This case reminds us that older victims can be strangled. Some elder abuse cases are life threatening.

Presenters Note

After discussing these two case examples, consider asking participants for examples of physical abuse. If asking for case examples, request that participants keep victim privacy and their agency confidentiality policies in mind.

Keep these case examples in mind during the presentation. Refer back to them whenever possible to illustrate key teaching points.

5NCEA Elder Abuse Presentation: Physical AbusePhysical AbuseThe use of physical force that may result in bodily injury, physical pain, or impairment

(National Center on Elder Abuse)

6NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

Review the National Center on Elder Abuse (NCEA) definition of physical abuse.

The definition includes domestic violence committed against an older adult.

Presenters Note

If you discuss prevalence and incidence physical abuse, consider using the following studies:

Cooper and Colleagues (2008) found prevalence rates for physical abuse in the seven studies with the best methodology to be between 1.2 and 4.3 percent.

In a national incidence study, Acierno (2010) found a rate of physical abuse of 1.6%

Laumann and colleagues (2008) found a rate of 0.2 percent

The New York Under the Radar study (2011) found a documented rate of 1.3/1000 and a self reported rate of 22.4/1000

6NCEA Elder Abuse Presentation: Physical AbuseConsider adding state, tribal, or territorial statutes relating to physical abuse here. These may be found in criminal law, protective services, or other statutes.

Consider discussing reporting laws in the Response Section (slide 25).

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov7Presenters Note

Consider adding state, tribal or territorial statutes. These laws are most often found in criminal, restraining order, and protective services statutes.

This placeholder slide should be replaced by your local statutes slides if you decide to include them. This slide should be deleted.

Keep your audience in mind when creating the slides. Statutes may not be relevant for all audiences. Others will be interested in an overview. Participants from disciplines such as the justice system and/or adult protective services may want to see and discuss some of the specific language in statutes.

Be sure to create slides that are easy to read from anywhere in the room. Consider putting fewer words on the slides and using handouts for specific language.

7NCEA Elder Abuse Presentation: Physical AbuseSame sentences as in the first presenation. Physical Abuse Can Include8NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govHitting, slapping, pushing, shaking, kicking, or burningInappropriately using drugs or physical restraints Force feedingPhysical punishment Homicide or homicide/suicideStrangulation and suffocation

Presenters Note

Determine a method of presenting this material (small group, large group or lecture)

Teaching Points

Hitting, slapping, pushing, shaking, kicking or burning are common forms of physical abuse.In elder abuse cases, you may also see inappropriate use of drugs (unauthorized use of medications, whether through over, under, or mis-medicating), that make an older person confused, sleepy, or unsteady on his or her feet to control the older persons level of cognitive and physical functioning)Inappropriate use of physical restraints may include bindings, ropes, cords, locks on the outside of the elder persons bedroom door Force-feeding is forcing a person to eat against his or her will.Physical punishment such as withholding food when an older adult complains too much Homicide and homicide/suicide (discussed in more detail on separate slide)Strangulation and suffocation (discussed in more detail on next slide)

8NCEA Elder Abuse Presentation: Physical AbuseStrangulation and SuffocationStrangulation: Closure of the blood vessels and air passages due to external pressure on the neck.

Suffocation: Obstruction of air passage by pressure on the chest, pinching of nostrils, pillow or plastic bag over nose and mouth.

Both may be hard to detect and report may be minimized.May be part of domestic violence and sexual assaultMay not result in visible injuries, even if fatal attack

9NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

Review definitions on the slide

Strangulation and suffocation are often undetected and ignored even when reported by an older person. They are frequently part of domestic violence, sexual assault, and homicide.

Unconsciousness can occur in seconds; death within minutes. Loss of consciousness may be accompanied by involuntary urination and defecation, restlessness, hostility shortly after the attack, and changes in personality. 9NCEA Elder Abuse Presentation: Physical AbuseStrangulation InjuriesMay leave no bruises or marks When injuries are present they may include:Neck painSorenessScratch marksPetechiae (tiny red spots or dots from capillaries bursting from pressure) above the area where pressure was appliedRaspy throatDifficulty swallowingRedness in the eyesLight headedness and faintnessLigature marks (when ligatures are used).

10NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

Review points on the slide.

Presenters Note

Photo(s) is/are on next slide(s).10NCEA Elder Abuse Presentation: Physical AbuseStrangulation Injuries (cont.)These are some of the signs that strangulation has occurred:

Petechiae: Pinpoint, round spots that appear on the skin as a result of bleeding under the skin. Commonly cluster or rash

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov11Teaching Point

Add after photo has been inserted

NCEA Elder Abuse Presentation: Physical Abuse11Homicide and Homicide-SuicideHomicides of older adults may be overlooked or considered natural Homicide-suicide is more common in the elderly than in younger populations. Most frequently committed by male intimate partners using a firearmHigh incidence of mental health problems, especially depression, which are often undiagnosedApproximately 25-30% are domestic violence (Cohen and Malphurs, 2001)

12NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

Because the elderly are expected to die, homicides may go unrecognized. Homicides are overlooked because the elderly often have serious or terminal underlying medical conditions, the injuries may be subtle and internal and/or they may be staged to look like natural deaths.

Homicide-suicide involves one person murdering the other and then killing himself. Homicide-suicide is more common in older adults than in younger persons. Most homicide-suicides are committed by spouses and partners (83%), most frequently by male partners using a firearm (Cohen, 2000). 50% involve dependent/protective relationships where the male is dominant and one of the parties is ill or is believed to be ill. Perpetrators have a high incidence of untreated mental health problems, especially depression. (Cohen, 1998, 2000).About 25% to 30% involve parties with a prior domestic violence history.

12NCEA Elder Abuse Presentation: Physical AbuseIndicators: VictimBruises, lacerations, open wounds, cuts, punctures, burn marksSprains, dislocations, broken bonesInternal injuries/bleeding Patterned injuriesPhysical signs of being restrained or strangled

13NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govPresenters Note

Consider making this segment more interactive by using a small group activity or class discussion. Please refer to A Guide to Planning Your Elder Abuse Presentation for directions.

Teaching Points

Review the indicators on this slide.

There are no gold standard injuries that can only be caused by abuse. (Dyer et al., 2003).

Instead, the location, extent, appearance, severity, and number of injuries are significant. Injuries to the head and neck, fractures of the head, spine, or trunk, and internal injuries suggest abuse (Bonnie & Wallace, 2003).

13NCEA Elder Abuse Presentation: Physical AbusePatterned Injury

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov14Teaching Point

This is a picture of a patterned injury. ADD DESCRIPTION OF PHOTO AFTER WE HAVE SEEN THE PHOTO.

NCEA Elder Abuse Presentation: Physical Abuse14Bruising and Elder AbuseOlder victims had significantly larger bruisesOlder victims generally knew the cause of their bruisesOlder victims were significantly more likely to have bruises on theface upper arms torsoBruises cannot be aged by their color

(UC Irvine, 2009)15NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov15NCEA Elder Abuse Presentation: Physical AbuseTeaching Points

The University of California, Irvine, bruising study of 101 older adults who had been abused found the following results:

While everyone bruises, physically abused older adults had larger bruises and they remembered the cause of the bruise.

Professionals should suspect abuse if the bruises are found on the face, upper arms and torso.

Bruises cannot be aged by their color. Bruises do not change color in a predictable pattern as they develop and heal. Multiple bruises of various colors does not mean that the person has been assaulted on more than one occasion.

Bruising and Elder Abuse (cont.)Does the story fit the physical evidence?Size? Shape? Location? Multiple?

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov16Teaching Points

Add after seeing photos.

NCEA Elder Abuse Presentation: Physical Abuse16Indicators: Potential VictimUntreated injuries in various stages of healingDelayed seeking of medical careLaboratory findings of medication overdose or under utilization Changes in speaking, swallowing, or breathing with a report of strangulationAn elder's report of being hit, slapped, kicked, or mistreated

17NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

Review the additional signs listed on this slide.

Accounts from an older person that they have been abused should not be discounted out of hand, even if the older adult has dementia.

17NCEA Elder Abuse Presentation: Physical AbuseIndicators: EnvironmentOverturned furniture, holes in wallsBroken itemsPresence of items that match injury patternWeapons presentBindings and restraintsMedications prescribed for older adult are missing, empty, or unfilled18NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

In addition to signs that indicate physical abuse, the professional may make observations that raise a suspicion of abuse or support a report of abuse. This slide lists examples. 18NCEA Elder Abuse Presentation: Physical AbuseResponse to Physical Abuse19NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov19NCEA Elder Abuse Presentation: Physical AbuseVictim SafetyAll responses and interventions must consider and prioritize victim safety.

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov20Teaching Point

This section focuses on potential responses. Consider victim safety when asking potential victims questions, responding to potential elder abuse cases, reporting or referring. Participants should always be mindful of victim safety and undertake actions in ways that do not increase danger.NCEA Elder Abuse Presentation: Physical Abuse20What You Can DoRecognize the signs of Physical AbuseAskReport or refer

21NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

What can you do to help? Everyone of us can make a difference in the life of a victim of elder abuse.

With this training you will have information that will assist you and those with whom you work to recognize the signs of abuse that should raise suspicion that physical abuse is present.

When you see something suspicious, you can show empathy and compassion to the older victim. You may be the first person to validate the victim's feelings or experiences.

You can and in some instances may be required by law to report suspected abuse. Whether a report is made or not, you can refer or link the older victim to community services.

The following slides will discuss these responses in more detail.

NCEA Elder Abuse Presentation: Physical Abuse21If The Older Adult Can Answer Questions, Consider Asking:Are you afraid? Worried?Is anyone hurting you or frightening you?Is anyone threatening or intimidating you?Are you taking all your medications as prescribed? How do the medications make you feel?

*Ask privately, in an area where you will not be overheard22NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govPresenters Note

Consider making this segment more interactive using a small group activity or class discussion. Please refer to A Guide to Planning Your Elder Abuse Presentation for directions.

Additional questions are listed on the next slide.

22NCEA Elder Abuse Presentation: Physical AbuseIf The Older Adult Can Answer Questions, Consider Asking (cont.):Has anyone done something to you that caused you pain or discomfort?I noticed the bruises on your arm. Can you tell me what happened?Have you seen your doctor or received medical care?

*Ask privately in an area where you will not be overheard

23NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

Remind participants to exercise care when asking a potential victim about physical abuse.

Make sure the older adult is in a safe place where responses cannot be overheard.

When information is obtained, protect the confidentiality and safety of the older person.

Unless a release of information has been signed, information should only be shared if required by statute, such as mandatory reporting laws.

Presenters Note

Ask participants if they have other questions they would pose. Transition by commenting now that you have a concern about physical abuse, we will look at reporting and referral options.

23NCEA Elder Abuse Presentation: Physical Abuse

Report - ReferREPORT

911 or law enforcement (life threatening or possible crime)Adult protective servicesLicensing board (if abuse occurs in a facility)REFER

Domestic violence or sexual assault organizationAging network agencyOmbudsman (if abuse is in a facility)

24NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govTeaching Points

When professionals report physical abuse because they have been asked by the older abused person to do so, because of a duty to do so, or for other reasons they will typically report to law enforcement, adult protective services, or a state or federal licensing or regulatory agency. The purpose of a report is to enable an investigation to be conducted.Each of these agencies conducts a different kind of investigation with a different purpose and focus.If there is an immediate threat to human life, the report should be made to local law enforcement as it is typically the only entity providing a 24-hour response.

Separate from, or in addition to a report, a professional may want to refer an older victim of physical abuse for help from a community-based organization. These may include:A domestic violence organization or program (depending on relationship between the older person and the offender.An agency in the aging services network (e.g., senior center, meals on wheels, case management program, financial management program).The long-term care ombudsman program for older adults who reside in nursing facilities..NCEA Elder Abuse Presentation: Physical Abuse24Consider inserting slides describing the local jurisdictions elder abuse/vulnerable adult reporting law

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov25Presenters Note

The presenter should consider if he or she wants to present information on:

The jurisdictions elder abuse/vulnerable adult abuse reporting law

Where reports could be made, e.g. Adult Protective Services, local or state Law Enforcement Agencies, licensing and regulatory agencies, Long-Term Care Ombudsman Programs, etc.

What happens when a report is made?

If there is no duty to report, every state authorizes voluntary reporting.

Replace or delete this slide before your presentation.

25NCEA Elder Abuse Presentation: Physical AbuseConsider adding local resources and programs. (See A Guide to Planning Your Elder Abuse Presentation at ***** for more information.)

NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.gov26Presenters Note

Research local programs, resources, and contact information. Create one or more slides describing services and programs including hours of operation and contact information.

This placeholder slide should be replaced or deleted.

NCEA Elder Abuse Presentation: Physical Abuse26Additional Resources27NCEA Elder Abuse Presentation: Physical Abuse www.ncea.aoa.govNational Center on Elder Abuse (NCEA) National Adult Protective Services Resource Center (NAPSRC)National Domestic Violence Hotline: 1-800-799-SAFENational Clearinghouse on Abuse in Later Life (NCALL)The National Consumer Voice for Quality Long-Term CareNational Long-Term Care Ombudsman Resource CenterTeaching Point

Here are some additional national resources and websites that may also provide useful information.27NCEA Elder Abuse Presentation: Physical AbuseFor more information, visit us!ncea.aoa.govAlso on Facebook, Twitter, YouTubecenteronelderabuse.orgAlso on Facebook, YouTube

NCEA Elder Abuse Presentation: Abuse in Later Life www.ncea.aoa.gov28Teaching Points

Are additional questions or comments?Thank participants for attending. Refer participants to the websites of the National Center on Elder Abuse and the Center of Excellence on Elder Abuse & Neglect for additional information and references on elder abuse.

NCEA Neglect28For additional resources, visit www.ncea.aoa.govThis slide set was created for the National Clearinghouse on Abuse in Later Life for the National Center on Elder Abuse and is supported in part by a grant (No. 90AB0002/01) from the Administration on Aging, U.S. Department of Health and Human Services (DHHS). Grantees carrying out projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions do not necessarily represent official Administration on Aging or DHHS policy.

NCEA Elder Abuse Presentation: Abuse in Later Life www.ncea.aoa.gov29