بدرفتاری و غفلت در سالمندان

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Elderly abuse and neglect ۳ دکتر احمد باقری مقدم متخصص يزشكى ورزشى سرپرست پژوهشی پزشکی قانونی 

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© روند رو به تزايد جمعيت سالمندان 0 پدیده جدید اه 

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Projected growth in the global population aged 60 years and older, 1995-2025 1200 ‏#ا‎ 1995 805 72 1000 0 = 800 i: #2 600 و = 400 a & 20 0 Male Female Total 

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و © سال 1375 جمعيت سالمندان 3977000 معادل 6/6 درصد © سال 1385 جمعيت سالمندان 5119000 معادل 7/3 درصد 

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What is elder abuse? 000 py mn ees One pan een| Pn FY Ce PUT Orne Cov) Peta. ‏در تعريف ديكر فعل .يا ترك فعل آسيب رسان به سالمند را‎ 9 ‏كويند‎ ‎©EFlderly abuse was defined as an act or ۱0۱۸۱۱۱۰۱۵۸۱0۱ 017 threatened harm to the health or welfare of an elderly person. 

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Incidence of elderly abuse © Abuse in institutional settings is difficult to measure, yet is thought to exceed that in community settings. ° Inthe USA,10% of nursing staff in institutional settings admitted committing physica: and 40% psychologica| abuse against residents . 

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ل ا ل و( ‎of adults, including‏ ال ۱ ‎abuse, neglect, and exploitation, affects‏ ‎more than 1.8 million older Americans”‏ ‎(Pavlik, Hyman, Festa, Bitondo, andDyer, 2001, p. 45)‏ ‎Oself-neglect accounts for one-third to‏ one-half of all abuse cases (Gray-Vickrey, 2000, 2004; Levine, 2003; Paris, 2003) ROOT =) | ae -\s | (10 Mowe) pee Et ane ana Eee ey SI vied ‏که تشخیص آن نیز بسیار مشکل است‎ 

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۱ ‏ا‎ nS Ce led ‎ey Sway eens reel ren Pre eal reeel ore Te‏ ا می‌باشد. ‎ 

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Distribution of Abuse © تقريبا بين زنان و مردان مساوى است ولى برخى تحقيقات ‎Se TNS) a) oe)‏ ۱ Pye lee eS) eee owe Wee Se Pern Tye] ed ‏محل هاى مختلف متفاوت است١( خانه يا بيمارستان و شهر‎ ‏هاى مختلف)‎ 

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Perpetrators of Abuse ‏آزار يسازها جه كسان هستند؟‎ © elder abuse can be perpetrated by nearly anyone including: © paid or volunteer caregivers © medical and long-term care employees, ° family members © strangers such as a person who befriends an elderly person for the purpose of exploiting them 

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Who is Committing the Abuse? 50 ape nase ‏تست كا‎ ‏کین(‎ ‏هه‎ 880128 ‏18م‎ ‏تاك‎ 0 صابت‌طلامعه 5 MUNRELATED ‏6ع ص‎ 

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پسر و همسر (عروس) ساير بستگان 

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factor related to the abused (۵1: ۱2۱۱۱2۱۱۱۱۵۱۱۵۱۸ ۵۰۱۰6 15 illness or dementia ° Social isolation ©The elder’s role, at an earlier time, as an abusive parent or spouse °A history of domestic violence((site4,2+ in the home 9 

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factors related to the user: ۳ Ue to cope with stress (lack of resilience) © Depression, which is common among caregivers © Lack of support from other potential caregivers © The caregiver's perception that taking care of the elder is burdensome and without psychological reward © Substance abuse 

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Greatest Risk Factors for Causing Abuse ° being male ° change in ‎family roles‏ 160 وستعط ه ‎history of from being‏ ه ‎mental illness cared for to‏ ‎© recent decline being the ‎in mental health care provider ‎S abusing alcohol o prior history ‎° primary of violence caregiver ‎ 

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Types of elder abuse Abuse by others dete] | Sexual لوأعمدمداع6 أععاوعلزه 5 ل ا نانك ‎°lsolation‏ ‏پبلیش ‎CAbduction‏ ©Psychological 

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Physical abuse Physical abuse means | __ at least one act of physical ‏عابت كان‎ | against the elderly ۱ 

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۲ ۷۱ ۷ ۱۱۱-۰ 8 ۱۱۱ او ‎Unreasonable‏ © ۵6۷ ه ‎beatings physical restraints © Hitting © Maltreatment of © Slapping medical conditions ° Cutting © Sexual assault © Burning ° Prolonged Crayne deprivation of food ‏ان 0 ‎ 

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Sings of physical abuse © bruises 6 Broken bones, sprains, or dislocations © Report of drug overdose or apparent failure to take medication regularly 6 Broken eyeglasses or frames © Signs of being restrained, such as rope marks on wrists © Caregiver’s refusal to allow you to see the elder alone 

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2511151120 ° A bruise, or contusion, occurs when ۱۰۱۱۱۰۱۱۱ ‏15]011ل د5ع15017‎ 5011 155115 0 an extent sufficient to result in disruption and leakage of blood vessels © Escape of blood from blood vessels produces discoloration 

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۲۱ ae bd ee Re ct ‏ها‎ TRO en ad 7 سج © :وصحاه 

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Table 4. Older Adults with Bruising: Comparison of Lo- cation Between Abused and Not Abused Physical Abuse —_— No Abuse* Region = 48 (%) n=68 (%) PNalue™ Head and neck 10 (20.8) 3 (4.4) -006 Anterior torso 4 (8.3) 5 (7.3) 85 Posterior torso 7 (14.6) 2 (2.9) 02 Lateral right arm 12 (25.0) 5 (7.3) -008 Right arm, not lateral 13 (27.1) 25 (36.8) 27 Left arm lz 25 (36.8) 10 Right leg T (14.6) 5 (7.3) 21 Left leg 8 (16.7) 9 (13.2) -61 * Participants in an earlier study of accidental bruising in the geriatric pop- ulation.* Only participants with bruises were included. * Calculated using ewo-way contingency table analysis Pearson chi-s tistics comparing older adults who had at least one bruise on the stated region. 

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Table 3. Participants According to the Size of Their Largest Bruise n(%) Physical Abuse No Abuse* Bruise Size (cm) (n= 48) (n = 68) Small (0.1-1.0) 0 (0.0) 24 (35.3) Medium (1.1-4.9) 21 (43.7) 39 (57.3) Large (5.0-25.0) ۲. | 5 (7.3) Pearson chi-square, P<.001. * Participants in an earlier study of accidental bruising in the geriatric pop- 3 1 1 : ulation.” Only participants with bruises were included. 

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۱۳ ‏کر‎ Oise = 

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مدنا لا © An injury that possesses features or configuration with objects or surfaces that produced it 

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Bruising ° Physically abused older adults had significantly larger bruises than those in comparison group who were not abused and more knew the cause of their bruises 

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Patterned Injury کت etic Rm Rm Slay or ankles buckles, straps, cords, hangers, hairbrushes, combs, cigarettes and cigarette lighters knuckle prints and footprints 0 Ase ° More on burns... - Grip marks around arms or : Imprints from belts, belt - Handprints, fingerprints, 

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Fracture © Broken bones © Includes severing of the bone or compression of intact bone 

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Avulsion © The tearing away of a structure or part; often seen as a partial avulsion 

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۲۰۹۱۱۰۱۷۱ اا ا ل لت ‎outermost layer of the skin‏ ‎is removed by a compressive‏ ‎or sliding force‏ 

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Laceration © Blunt force injuries resulting from tearing, ripping, crushing, 9 2221, bending and shearing soft tissue. © Lacerations are usually found over a bony surface and are ragged or irregular in appearance 

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Incision ° Incision, known as a cut, is a wound made by a sharp instrument or object, such as a scalpel, knife, razor or paper coming against the Cet AUAR tM KCNA CM KORO Lem T injury 35 

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Stab Wound © Result whenever a sufficiently sharp and narrow object is forced upward ° Unlike a cut, depth exceeds width in stab wounds 

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Mechanical Restraints © Means of controlling behavior, Cr) ‏ات(‎ ۱۱۵۱۱۱۱۱۱ (۱۱۱۱۱۱9 ie Colbie) ° Only acceptable reason for temporarily restraining someone is to prevent significant harm 

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Sexual abuse is unwanted sexual contact with an elder including touching, sexual assault, and rape or sodomy 

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Sexual Abuse © Sexual abuse is ‘ unwanted sexual ۱9۵۱۰۱۲۰۱۱۵۵۵۱۱۱ including: © touching , Fondling ‏تسرد ری‎ © sexual assault(rape or sodomy) © Verbal or suggestive behavior © Unnecessary help with dressing/hygiene 

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Signs of sexual abuse © Signs Bruises around breasts or ‏علعاتجوو‎ © Unexplained venereal disease or genital infections 6 Unexplained vaginal or anal bleeding 6 Torn, stained, or bloody underclothing 

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Neglect ت۱۵ ‎designated caregiver to‏ ‎meet the needs of an‏ ‎elderly person, and‏ ‎withholding of physical,‏ ‎material, or emotional‏ ‎necessities of physical‏ ‎and mental health,‏ و ات لتنا ‎unintentionally.‏ 

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©This includes failure to assist in personal hygiene or the provision of clothing for an elder, failure to provide medical care for the physical and mental health needs of an elder, and failure to protect an elder from health and safety hazards. 

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(۵ ‎oP coe:‏ سا ‎Pood, water, sheler‏ - ‎a AST‏ ای ۱ ‎Oe cied‏ ا ‎Sos PAs eat a RCC oa‏ شم 1 مس م۱ ‎35 ‎ 

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6011111111121 personal care 

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Passive Neglect © ناتوانى غير عمدى به انجام 5300106 00 eRe Semer ceo 0200111 

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Active Neglect POW POM) RUSE CRU CONN Ovi) 1 nes اسيب ا 0 50 

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GELP-OEGELECT ۷ ) wiuites oP daly ivicg oe ‏,لته‎ ‎thrededduy persocd edly cod sof ey! ‏ی و۳‎ 

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Signs of neglect © Malnutrition, dehydration © Lack of personal care © Inadequate heating © Unclean clothes or bedding © Lack of needed medications, eye glasses, hearing aids, or dentures © Contractures, decubitus ulcers, wasting and muscle atrophy 

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ل تش ا مت هن ها اد abuse ° Psychological abuse is more difficult to define and operationalize. © Usually defined as an act carried out with the intention of causing emotional pain or 1۰ ۱ abuse often accompanies physical abuse. Emotional abusers can use verbal and non verbal to inflict elder damage. 

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Psychological Abuse ° Humiliation i. لمنزوا 1501211012 6 ۹ Hea) ۱ eV © Removal of decision making 121011 Aa rer Lie ۷61100 ‏تسوهیرک اهی فریاد‎ 

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aaa elder abuse ‎٩‏ تهدید و ارعاب از طریق فریاد ‎os ‏ا‎ ‏تون سید‎ ae ‎۵ © © 0 ‎Nonverbal psychological elder abuse : ‏© ناديده كرفتن ل | ‎٩‏ جلوگیری از ملاقاتی ‎ 

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Signs Of psychological abuse © Anxiety (mild to severe) . © Depression, hopelessness, helplessness, thoughts of suicide © Confusion, disorientation ۵ ‏لرزش‌دستو بدن) 0طناط1۲6‎ © lack of eye contact © Agitation 

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لل ال ان ترک ‎In addition to an actual complaint by older person‏ © ‎of being deserted,‏ © signs of possible abandonment include: ° Avulnerable older adult with cognitive and physical impairments is left at a hospital emergency department without caregiver contact information ° Avulnerable older adult with cognitive impairments is put on a bus with a one-way ticket to another town or state ° Avulnerable older adult with cognitive impairments is left at a public building 

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Financial or material abuse 9 از دست دادن غير قابل توضيح درآمد. دارايى ها. اموال. کمبود غذا. از دست رفته پرداخت وام ها ۳ er rend Cet Senge od ‏توسط فرد مورد اعتماد‎ 1 © Forms of financial abuse :- © سوء استفاده هاى شخصى جك. كارت هاى اعتبارى. و با حساب های سالمندان 1 5200 

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Domestic abuse © Refer to forms of maltreatment by someone who has a special relationship ۱۸۱۱ METS family member or caregiver Institutional elder abuse Refers to abuse that occur in residential institutions such as nursing facilities usually by someone who is paid caregiver, such as nursing facility staff member. Residents at the greatest ۱۰۱۹۰۱۱۰۱۵۱ or neglect includes resident with dementia, resident who seldom have visitors 

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Detection and Treatment Barriers OM Cel KeroinCiyeWey me) Ce (cy as V el oe (en because denial is an integral feature of abuse, victims may feel too ashamed to disclose maltreatment or believe they are to blame for or deserve the abuse © dependence on an abuser can make a victim reluctant to report for fear of how he/she will survives without the perpetrators help 

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Detection/Treatment Barriers (continued) Res a pre ere een iso noen ieee Bes [Fee reer Carpe Cee Come Rene] PRON IC TS) ‏ادراکی و با به دلیل زندانی و محدود شدن قادر به گزارش‎ 50 

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Detection/Treatment Barriers (continued) ‎٩‏ گذر زمان و بروز اختلالات شناختی گزارش آزار را دشوار ‎° physical injuries may be masked by clothing or by isolating the victim ‎ 

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Detection/Treatment Barriers (continued) 0 ese Cao ips] tt we ee PERT ROSE eT ae ۱ ‏كزارش‎ oer) 

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Preventing elder abuse and neglect Preventing elder abuse means doing three things: © Listening to elderly and their caregivers © Intervening when you suspect elder ‏اك‎ © Educating others about how to recognize and report elder abuse 

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Reporting elder abuse If you are an elder who is being abused, neglected, or exploited, tell at least one person. Tell your doctor, a friend, or a family member whom you trust. 

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Protective Measures © Stay sociable and active ° Stay involved with neighbors, friends, church or musque or community activities ° Get regular medical and dental care ° Open and post your own mail ° Increase social network as you age ° Have friends visit you at home ° Have a “best friend” with whom you can confide in ° Keep in touch with old friends if you move 

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Instructions to a concerned friend or family member Watch for warning signs that might indicate elder abuse. If you suspect abuse, report it. Take a look at the elder’s medications. Does the amount in the vial matched with the date of the prescription? Watch for possible financial abuse. Ask the elder if he may scan bank accounts and credit card statements for unauthorized transactions. Call and visit as often as you can. Help the elder consider you a trusted confidante. Offer to stay with the elder so the caregiver can have a break — on a regular basis, if you can. 

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101177 عطخ 6غ 1025 ۱۱۱ © Make sure your financial and legal affairs are in order. If they aren’t, enlist professional help to get them in order, with the assistance of a trusted friend or relative if necessary. © Keep in touch with family and friends and avoid becoming isolated, which increases your vulnerability to elder abuse. © If you are unhappy with the care you're receiving, whether it’s in your own home or in a care facility, speak up. Tell someone you trust and ask that person to report the abuse or neglect. 

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Forms of Abuse 

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Forms of Abuse continuea) مادی: دزدیدن پول یا اموال» قرارداد هاى اجبارى» سوء استفاده از اموال سالمند اتجاوز به حقوق فردى: پیشگیری از هر گونه حق انسانی مثل آزادی؛ حریم [۹ en kcreng ۱ 9 

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Forms of Abuse continuea) 

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Physical - multiple fractures or bruises at various stages of healing, burns, patterned injuries, patchy hair loss, frequent visits to ER, delay in seeking medical treatment for injuries ‎ET LUISA)‏ ا ‎cosy‏ سای انا ‎ ‎ ‎ ‎ ‎ 

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Indications of Abuse (continued) ‎Were eer Freie renown is ree)‏ ل ل 0 ‎Violation of Rights - isolation, failure to attend religious vices or community events as one did previously ‎Medical - no improvement in condition for which one was prescribed medication, blood tests indicate greater or lower than expected levels of medications, sleepiness, groggy ‎ ‎ ‎ ‎ ‎ ‎ ‎ 

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Indications of Abuse (continued) 

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اناا 

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اللا ۳ ۱ ۷۱۱۹۱ ۱۱ CeCe) Domestic Violence Kay Hurd, RN, MSN 

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Who Is Being Abused ۱۷3 ° 44 million persons age 60+. © 36 million people with disabilities. 364,512 cases of people living at home were reported with 43% confirmed. In the last 10 years abuse of elder persons has increases 150+%. ‎BCE TIM meyer rite‏ عبط۸ ۴۱0 »تاعمصو1 ‎almost 90% of the abusers were family‏ ‎members.‏ ‎ 

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Who Are The Abusers More than 2/3rds of the ‏2ه كتتععتتطة‎ ETON E A members of the victims and are typically serving in the care-giving role. 

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۳ Risk Factors © Domestic Violence grown old. ° A partnership in which one member of the couple has traditionally exerted power and control over the other through emotional abuse, physical violence and threats, isolation and other tactics. 

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Risk Factors - Continued © Personal problems of the abusers. © Adult children who are still dependant upon parent for financial assistance, housing or other means of support. bam Cooke ‏ا‎ ‎* Substance Abuse. 

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Risk Factors - Continued © Caregiver stress. ° Cycle of violence is learned behavior transmitted from one generation to the next. ° Personal characteristics of the elder. ۶ Dementia. ۰ Disruptive behavior. ° Problematic personality traits. ° Significant needs of assistance. 

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Amendments to Older Americans Act First appeared in 1987 and Provided Definitions 

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Domestic Elder Abuse © Domestic Abuse Grown Old. ° Maltreatment of an older person by someone who has a special relationship with the elder. (e.g. spouse, sibling, child, friend, caregiver). © Spouses make up a large % of elder abusers. Partnerships in which one member of a couple has traditionally tried to exert power and control over the other. 

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Institutional Elder Abuse NMA mea ena Cary facilities for older persons. (e.g. nursing homes, foster homes, group homes, board and care facilities. 9 ‏ما كدهك2عم 212 عوبطم‎ 276 1۱۵021 ۲ contractual obligation to provide elder victims with care and protection. (e.g. staff, professionals, paid caregivers). 

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Self-neglect - Self-abuse ° Self Neglect is behavior of an elderly person that threatens his/her own health/safety. © *Self-neglect EXCLUDES a situation in which a mentally competent person who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her safety as a matter of personal choice. 

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Signs of Self-Neglect © Dehydration, malnutrition ° Untreated medical conditions © Lack of necessary medical aids © Hazardous or unsafe living conditions © Unsanitary or unclean living quarters © 2201/01 ع1126مم تم مس1 6 ‎clothing‏ ‎Homelessness‏ © 

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Physical Abuse © Physical force that may result in bodily 11 ‏كسان‎ UN ‏ا الل‎ © Striking with or without an object. 

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Signs of Physical Abuse ° Bruises, black eyes, welts, lacerations. ۱۳ ‏ل‎ Ae T EOLA V a ee © Open wounds, cuts, punctures, untreated injuries in various stages of healing. ۱ a-te Mme i Ce ia CMe nicely tine (ete 

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Signs of Physical Abuse -« 0 © Laboratory findings of medication overdose. © An elder’s report of being hit, slapped kicked or mistreated. © An elder’s sudden change in behavior. © The caregiver’s refusal to allow visitors 10 ‏ثمع10ء سه عع5‎ 02. 

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Sexual Abuse © Sexual abuse is non consensual sexual ‏لسكا تجسه 1ه أعماصمه‎ B IAM 4 person. © It includes unwanted touching © Sexual assault or battery such as rape, sodomy, coerced nudity and sexually explicit photographing. 

صفحه 90:
Signs of Sexual Abuse © Bruises around breasts or genital area. © Unexplained venereal disease or genital infections. © Unexplained vaginal or anal bleeding. ° Torn, stained, or bloody underclothing. © An elder’s report of being sexually assaulted or raped. 

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Emotional or Psychological Abuse © The infliction of anguish, pain, or distress through verbal or nonverbal acts. ° Includes, verbal assaults, insults, threats, intimidation, humiliation, harassment © Treating the older person like an infant ° Isolating an elderly person from his/her ‏.ك1 أتتاعة تملسوع؟ مده كلسعتط رجلتسه]‎ © Giving an older person the “silent treatment” or enforced social isolation. 

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5101225 01 Emotional/Psychological Abuse ° Emotionally upset or agitated © Extremely withdrawn ° Non-communicative or non- responsive © Unusual behavior usually attributed to “dementia” (e.g. sucking, biting, rocking) 

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Neglect 5 ‏عستتطلتدظ عده لدكعتك؟ع2 عطل'‎ ROB ATT TUM DN 221 of a person’s obligations or duties to an elder. © Failure of a person who has fiduciary ‏.1061ء سه 10 1010م 0غ 115ل تطتكسام مودعم‎ ° Failure to provide an elderly person ‏,وصنطاماه ردعاج ۲۵0۵0 رعه‌تانوعم666ظ طازس‎ shelter, personal hygiene, medicine, comfort, personal safety. 

صفحه 94:
Abandonment © The desertion of an elderly person by an individual who has assumed the responsibility for providing care to the elder, or by the person who has physical custody of the elder. 

صفحه 95:
Financial or Material Exploitation 101©15» 21 01 115 122210617 عده لهوعة111 عط[]' 6 funds, property, or assets. ° Cashing an elder’s checks without authorization or permission. Bae yas ptilemre vim) CC ate (es tt Lali aoe ° Misusing or stealing an elder’s money or possessions, ° Coercing or deceiving an elder into signing any document, (contracts or wills). رت 01 اتطاعصه12101ان 014 م15 تاعمه: 7مس[ » 7ك 

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Signs Of Financial or Material Exploitation. © Sudden changes in bank account or banking practice. ° Inclusion of additional names on a bank signature card. © Unauthorized banking, remaking of wills, advanced directives, or other tert eee 

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Is Elder Abuse a Crime? © Physical, sexual, and financial/material abuses are considered crimes. ° Certain emotional abuse and neglect are subject to criminal prosecution. ° SELF-NEGLECT IS NOT CONSIDERED A CRIME. 

صفحه 98:
Where to Find Help © Adult Protection Services. ° Somerset County Adult Protective Services. Board of Social Services. Somerville, 08876. 908-526-8800. ‏ات‎ eR MAMA MMVII BTN Ae Roma) a Klee ‏ات‎ ‎Provide victims with treatment and protective services. Local Police, sheriff's offices and prosecuting ] ‏دور و ی‎ tom Long distance caregivers can call a nationwide toll- free number. (1-800-677-1116). 3 

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Health education to prevent elder abuse Instructions to a caregiver:- If the caregiver overwhelmed Le the demands of caring for an elder, instruct (he /she ) to do the following: © Request help, from friends, relatives, or local respite care agencies, so you can take a break, if only for a couple of hours. © Find an adult day care program. © Stay healthy and get medical care for yourself when necessary. © Adopt stress reduction practices. © Seek counseling for depression, which can lead to elder abuse. © Find a support group for caregivers of the ۰ © If caregiver is having a problems with drug or alcohol abuse, get help. 

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۱ Measures (continued) © Keep your possession organized © Tell someone you trust where your important paperwork and bank account information is kept ° Have checks direct deposited into your account © Use an answering machine to screen phone calls * Don’t leave cash or valuables visible » Notify the police if you will be away from home for an extended time period 

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۱ Measures (continued) © Consult with an attorney ° Make arrangement for the future such as ۱۹ 015 210117 * Get legal advise before making/signing agreements regarding your care or possessions ©» Be aware of your financial situation 

صفحه 102:
۱ Measures (continued) © Know where to ask for help ° Find out about community resources before you need them such as rape and abuse hotlines, senior centers, and adult protective services ۱۵۰۱۱۵۱۱۰۱۱۱۱ ‏ات‎ ac) °crisis centers © private counselors clergy ©local police 

‏Elderly abuse and neglect دکتر احمد باقری مقدم متخصص پزشکی ورزشی سرپرست پژوهشی پزشکی قانونی مقدمه ‏ ‏ ‏ روند رو به تزاید جمعیت سالمندان پدیده جدید حوزه پیچیده ومشکل در ایران ‏ ‏ سال 1375جمعیت سالمندان 3977000معادل 6/6درصد سال 1385جمعیت سالمندان 5119000معادل 7/3درصد What is elder abuse? تمام اشکال سوء رفتار با سالمند را سالمند آزاری میگویند در تعریف دیگر فعل یا ترک فعل آسیب رسان به سالمند را گویند  Elderly abuse was defined as an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Incidence of elderly abuse  Abuse in institutional settings is difficult to measure, yet is thought to exceed that in community settings.  In the USA,10% of nursing staff in institutional settings admitted committing physical and 40% psychological abuse against residents . عاریف داردBیر است و بستگی بهتBمیزان گزارش بسیار متغ “mistreatment of adults, including abuse, neglect, and exploitation, affects more than 1.8 million older Americans” (Pavlik, Hyman, Festa, Bitondo, andDyer, 2001, p. 45) self-neglect accounts for one-third to one-half of all abuse cases (Gray-Vickrey, 2000, 2004; Levine, 2003; Paris, 2003) استself neglect شایع ترین نوع آن خود غفلتی است که تشخیص آن نیز بسیار مشکل است  سالمند آزاری فیزیکی در شهر اصفهان پایین است و بیشترین نوع آزار به سالمندان از نوع استفاده از اموال بدون رضایت سالمند می‌باشد. Distribution of Abuse ‏ تقریبا بین زنان و مردان مساوی است ولی برخی تحقیقات نشان داده در مردان بیشتر بوده است. ‏ الگوی آزار بسیار فرهنگی است و در بین جوامع مختلف و محل های مختلف متفاوت است (.خانه یا بیمارستان و شهر های مختلف) Perpetrators of Abuse ستند؟BیهBسانBBه کBسانها چBآزار ر      elder abuse can be perpetrated by nearly anyone including: paid or volunteer caregivers medical and long-term care employees, family members strangers such as a person who befriends an elderly person for the purpose of exploiting them Who is Committing the Abuse? SON 1%1% 2% DAUGHTER 24% HUSBAND 2% 4% 24% 5% WIFE BROTHER SISTER 16% 21% NIECE NEPHEW GRANDCHILD UNRELATED CAREGIVER Risk factors for elderly abuse factor related to the abused elderly:  The intensity of an elderly person’s illness or dementia  Social isolation  The elder’s role, at an earlier time, as an abusive parent or spouse  A history of domestic violence(( خشون تخان گیin the home  Dependency factors related to the abuser:  Inability to cope with stress (lack of resilience)  Depression, which is common among caregivers  Lack of support from other potential caregivers  The caregiver’s perception that taking care of the elder is burdensome and without psychological reward  Substance abuse Greatest Risk Factors for Causing Abuse being male  being related  history of mental illness  recent decline in mental health  abusing alcohol  primary caregiver  change in family roles from being cared for to being the care provider  prior history of violence  Types of elder abuse Abuse by others Frequency Physical 16% Sexual 2% Financial 29% Neglect 27% Abandonment رکB Bت Isolation Abduction 1% 2% شBبایBر Psychological 0.2% 24% Physical abuse Physical abuse means at least one act of physical violence against the elderly Forms of physical abuse       Direct beatings Hitting Slapping Cutting Burning shaking     Unreasonable physical restraints Maltreatment of medical conditions Sexual assault Prolonged deprivation of food or water. Sings of physical abuse bruises  Broken bones, sprains, or dislocations  Report of drug overdose or apparent failure to take medication regularly  Broken eyeglasses or frames  Signs of being restrained, such as rope marks on wrists  Caregiver’s refusal to allow you to see the elder alone  Bruising   A bruise, or contusion, occurs when blunt forces distort soft tissues to an extent sufficient to result in disruption and leakage of blood vessels Escape of blood from blood vessels produces discoloration When is bruising suspicious trauma versus accidental trauma? Which looks more like abuse: A or B? A B Accidental or Inflicted? You decide Accidental or Inflicted? You decide Bruising Study con’t Location of Bruises Caused by Abuse Patterned Injury  An injury that possesses features or configuration with objects or surfaces that produced it Bruising Physically abused older adults had significantly larger bruises than those in comparison group who were not abused and more knew the cause of their bruises Patterned Injury     Grip marks around arms or neck Rope marks or welts on wrists or ankles Imprints from belts, belt buckles, straps, cords, hangers, hairbrushes, combs, cigarettes and cigarette lighters Handprints, fingerprints, knuckle prints and footprints o o More on strangulation… More on burns… Fracture   Broken bones Includes severing of the bone or compression of intact bone Avulsion  The tearing away of a structure or part; often seen as a partial avulsion Abrasion A wound in which the outermost layer of the skin is removed by a compressive or sliding force Laceration   Blunt force injuries resulting from tearing, ripping, crushing, overstretching, pulling apart, bending and shearing soft tissue. Lacerations are usually found over a bony surface and are ragged or irregular in appearance Incision  Incision, known as a cut, is a wound made by a sharp instrument or object, such as a scalpel, knife, razor or paper coming against the skin with pressure to cause an injury 35 Stab Wound   Result whenever a sufficiently sharp and narrow object is forced upward Unlike a cut, depth exceeds width in stab wounds Mechanical Restraints   Means of controlling behavior, especially in hospitals and nursing facilities Only acceptable reason for temporarily restraining someone is to prevent significant harm Sexual abuse is unwanted sexual contact with an elder including touching, sexual assault, and rape or sodomy Sexual Abuse Sexual abuse is unwanted sexual contact with an elder including:  touching , Fondling ن وازشک ردن  sexual assault(rape or sodomy)  Verbal or suggestive behavior  Unnecessary help with dressing/hygiene  Signs of sexual abuse  Signs Bruises around breasts or genitals  Unexplained venereal disease or genital infections  Unexplained vaginal or anal bleeding  Torn, stained, or bloody underclothing Neglect The failure of a designated caregiver to meet the needs of an elderly person, and withholding of physical, material, or emotional necessities of physical and mental health, whether intentionally or unintentionally.  This includes failure to assist in personal hygiene or the provision of clothing for an elder, failure to provide medical care for the physical and mental health needs of an elder, and failure to protect an elder from health and safety hazards. NEGLECT Denial of care: – – – food, water, shelter personal hygiene, clothing, bedding medical care, medicines, assistive devices Isolation: – – – control of time, activities, contacts disinformation tactics false imprisonment Minimal personal care Passive Neglect ‏ ‏ ناتوانی غیر عمدی به انجام تعهدات مراقبت اعمال دیسترس بدون قصد آگاهانه و یا عمدی Active Neglect ‏ شکست عمدی به تعهدات مراقبت، اعمال استرس جسمانی یا عاطفی و یا آسیب ‏ رها کردن ،محرومیت از غذا ،دارو، بهداشت شخصی SELF-NEGLECT Basic activities of daily living are neglected, threatening personal health and safety: hygiene food, water clothing and bedding shelter and surroundings finances health care Signs of neglect       Malnutrition, dehydration Lack of personal care Inadequate heating Unclean clothes or bedding Lack of needed medications, eye glasses, hearing aids, or dentures Contractures, decubitus ulcers, wasting and muscle atrophy Psychological abuse or emotional abuse   o Psychological abuse is more difficult to define and operationalize. Usually defined as an act carried out with the intention of causing emotional pain or distress. Psychological abuse often accompanies physical abuse. Emotional abusers can use verbal and non verbal to inflict elder damage. Psychological Abuse       HumiliationحقیرBBت IsolationنزواBا Intimidation عابBار ThreatsهدیدBBت Removal of decision making powers Verbal insults, yellingریادBیفB ، المBBینکBوهBBت Verbal forms of emotional ‏elder abuse ‏ ‏ ‏ ‏ ‏ تهدید و ارعاب از طریق فریاد فحش دستورات سخت تحقیر و تمسخر سرزنش ‏Nonverbal psychological elder abuse : ‏ ‏ ‏ نادیده گرفتن جدا کردن از دوستان جلوگیری از مالقاتی Signs of psychological abuse Anxiety (mild to severe) .  Depression, hopelessness, helplessness, thoughts of suicide  Confusion, disorientation  Trembling(( ل رزشدستو ب دن  lack of eye contact  Agitation  Abandonment نBردBBها کBو ر رکBBت   In addition to an actual complaint by older person of being deserted, signs of possible abandonment include:  A vulnerable older adult with cognitive and physical impairments is left at a hospital emergency department without caregiver contact information  A vulnerable older adult with cognitive impairments is put on a bus with a one-way ticket to another town or state  A vulnerable older adult with cognitive impairments is left at a public building Financial or material abuse ‏ از دست دادن غیر قابل توضیح درآمد ،دارایی ها، اموال ،کمبود غذا ،از دسBت رفته پرداخت وام ها ‏ هر سرقت یا سوء استفاده از پول یا اموال افراد مسن توسط فرد مورد اعتماد اختالس یا سوء استفاده از منابع مالی و یا اموال ‏ ‏Forms of financial abuse : ‏ ‏ ‏ سوء استفاده های شخصی چک ،کارت های اعتباری، و یا حساب های سالمندان سرقت پول نقد ،چک ،درآمد ،و یا کاالهای خانگی جعل امضا سالمندان Domestic abuse Institutional elder abuse Refers to abuse that occur in residential institutions such as nursing facilities usually by someone who is paid caregiver, such as nursing facility staff member. Residents at the greatest risk for institutional abuse or neglect includes resident with dementia, resident who seldom have visitors  Refer to forms of maltreatment by someone who has a special relationship with the elder such as family member or caregiver recognition of elder abuse: examination Detection and Treatment Barriers  detection of elder abuse is difficult because denial is an integral feature of abuse, victims may feel too ashamed to disclose maltreatment or believe they are to blame for or deserve the abuse  dependence on an abuser can make a victim reluctant to report for fear of how he/she will survives without the perpetrators help Detection/Treatment )Barriers (continued ‏ ‏ ممکن است این آزار ها در یک جامعه ،نرمال تلقی شود ممکن است سالمند به دلیل مشکالت بینائی یا شنوائی یا ادراکی و یا به دلیل زندانی و محدود شدن قادر به گزارش سوء رفتار نباشد Detection/Treatment Barriers (continued) گذر زمان و بروز اختالالت شناختی گزارش آزار را دشوار .میکند   physical injuries may be masked by clothing or by isolating the victim Detection/Treatment )Barriers (continued ‏ ‏ وجود یک سرویس مشخص و حمایتی است که میتواند به گزارش سوء رفتار بینجامد. عدم وجود آمار های کافی نیز مانع شناخت این پدیده است Preventing elder abuse and neglect Preventing elder abuse means doing three things:    Listening to elderly and their caregivers Intervening when you suspect elder abuse Educating others about how to recognize and report elder abuse Reporting elder abuse If you are an elder who is being abused, neglected, or exploited, tell at least one person. Tell your doctor, a friend, or a family member whom you trust. Protective Measures لمندBاBه سBBیبBیه هایBوصBBت  Stay sociable and active Stay involved with neighbors, friends, church or musque or community activities Get regular medical and dental care Open and post your own mail Increase social network as you age Have friends visit you at home Have a “best friend” with whom you can confide in Keep in touch with old friends if you move Instructions to a concerned friend or family member  Watch for warning signs that might indicate elder abuse. If you suspect abuse, report it.  Take a look at the elder’s medications. Does the amount in the vial matched with the date of the prescription?  Watch for possible financial abuse. Ask the elder if he may scan bank accounts and credit card statements for unauthorized transactions.  Call and visit as often as you can. Help the elder consider you a trusted confidante.  Offer to stay with the elder so the caregiver can have a break — on a regular basis, if you can. Instructions to the elderly  Make sure your financial and legal affairs are in order. If they aren’t, enlist professional help to get them in order, with the assistance of a trusted friend or relative if necessary.  Keep in touch with family and friends and avoid becoming isolated, which increases your vulnerability to elder abuse.  If you are unhappy with the care you’re receiving, whether it’s in your own home or in a care facility, speak up. Tell someone you trust and ask that person to report the abuse or neglect. با سپاس از توجه شما Forms of Abuse Forms of Abuse (continued) Forms of Abuse (continued) Indicators of Abuse Indications of Abuse (continued) Indications of Abuse (continued) Thank you Elder Abuse The Forgotten Side of Domestic Violence Kay Hurd, RN, MSN Who Is Being Abused     The US has:  44 million persons age 60+.  36 million people with disabilities. 364,512 cases of people living at home were reported with 43% confirmed. In the last 10 years abuse of elder persons has increases 150+%. Domestic Elder Abuse is a family problem, almost 90% of the abusers were family members. Who Are The Abusers  More than 2/3rds of the abusers are family members of the victims and are typically serving in the care-giving role. Risk Factors  Domestic Violence grown old.  A partnership in which one member of the couple has traditionally exerted power and control over the other through emotional abuse, physical violence and threats, isolation and other tactics. Risk Factors - Continued  Personal problems of the abusers. Adult children who are still dependant upon parent for financial assistance, housing or other means of support.  Mental Illness.  Substance Abuse.  Risk Factors - Continued    Caregiver stress. Cycle of violence is learned behavior transmitted from one generation to the next. Personal characteristics of the elder. Dementia.  Disruptive behavior.  Problematic personality traits.  Significant needs of assistance.  Amendments to Older Americans Act First appeared in 1987 and Provided Definitions Domestic Elder Abuse  Domestic Abuse Grown Old. Maltreatment of an older person by someone who has a special relationship with the elder. (e.g. spouse, sibling, child, friend, caregiver).  Spouses make up a large % of elder abusers. Partnerships in which one member of a couple has traditionally tried to exert power and control over the other.  Institutional Elder Abuse   Abuse that occurs in residential facilities for older persons. (e.g. nursing homes, foster homes, group homes, board and care facilities. Abusers are persons who have legal or contractual obligation to provide elder victims with care and protection. (e.g. staff, professionals, paid caregivers). Self-neglect – Self-abuse  Self Neglect is behavior of an elderly person that threatens his/her own health/safety.  *Self-neglect EXCLUDES a situation in which a mentally competent person who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her safety as a matter of personal choice. Signs of Self-Neglect        Dehydration, malnutrition Untreated medical conditions Lack of necessary medical aids Hazardous or unsafe living conditions Unsanitary or unclean living quarters Inappropriate and/or inadequate clothing Homelessness Physical Abuse  Physical force that may result in bodily injury, physical pain or impairment.  Striking with or without an object. Signs of Physical Abuse     Bruises, black eyes, welts, lacerations. Rope/restraint marks. Open wounds, cuts, punctures, untreated injuries in various stages of healing. Sprains, dislocations, internal injuries. Signs of Physical Abuse – continued     Laboratory findings of medication overdose. An elder’s report of being hit, slapped kicked or mistreated. An elder’s sudden change in behavior. The caregiver’s refusal to allow visitors to see and elder alone. Sexual Abuse    Sexual abuse is non consensual sexual contact of any kind with an elderly person. It includes unwanted touching Sexual assault or battery such as rape, sodomy, coerced nudity and sexually explicit photographing. Signs of Sexual Abuse      Bruises around breasts or genital area. Unexplained venereal disease or genital infections. Unexplained vaginal or anal bleeding. Torn, stained, or bloody underclothing. An elder’s report of being sexually assaulted or raped. Emotional or Psychological Abuse      The infliction of anguish, pain, or distress through verbal or nonverbal acts. Includes, verbal assaults, insults, threats, intimidation, humiliation, harassment Treating the older person like an infant Isolating an elderly person from his/her family, friends or regular activities. Giving an older person the “silent treatment” or enforced social isolation. Signs of Emotional/Psychological Abuse Emotionally upset or agitated  Extremely withdrawn  Non-communicative or nonresponsive  Unusual behavior usually attributed to “dementia” (e.g. sucking, biting, rocking)  Neglect    The refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Failure of a person who has fiduciary responsibilities to provide for an elder. Failure to provide an elderly person with necessities, food water, clothing, shelter, personal hygiene, medicine, comfort, personal safety. Abandonment  The desertion of an elderly person by an individual who has assumed the responsibility for providing care to the elder, or by the person who has physical custody of the elder. Financial or Material Exploitation  The illegal or improper use of an elder’s funds, property, or assets. Cashing an elder’s checks without authorization or permission.  Forging an elder’s signature,  Misusing or stealing an elder’s money or possessions,  Coercing or deceiving an elder into signing any document, (contracts or wills).  Improper use of guardianship or power of attorney.  Signs of Financial or Material Exploitation.    Sudden changes in bank account or banking practice. Inclusion of additional names on a bank signature card. Unauthorized banking, remaking of wills, advanced directives, or other legal matters of any kind. Is Elder Abuse a Crime?    Physical, sexual, and financial/material abuses are considered crimes. Certain emotional abuse and neglect are subject to criminal prosecution. SELF-NEGLECT IS NOT CONSIDERED A CRIME. Where to Find Help  Adult Protection Services.      Somerset County Adult Protective Services. Board of Social Services. Somerville, 08876. 908-526-8800. Someone from the Agency will investigate reported cases. Provide victims with treatment and protective services. Local Police, sheriff’s offices and prosecuting attorneys will investigate and prosecute abuse. Long distance caregivers can call a nationwide tollfree number. (1-800-677-1116). Health education to prevent elder abuse Instructions to a caregiver:If the caregiver overwhelmed by the demands of caring for an elder, instruct (he /she ) to do the following:        Request help, from friends, relatives, or local respite care agencies, so you can take a break, if only for a couple of hours. Find an adult day care program. Stay healthy and get medical care for yourself when necessary. Adopt stress reduction practices. Seek counseling for depression, which can lead to elder abuse. Find a support group for caregivers of the elderly. If caregiver is having a problems with drug or alcohol abuse, get help. Protective Measures (continued)  Keep your possession organized Tell someone you trust where your important paperwork and bank account information is kept  Have checks direct deposited into your account  Use an answering machine to screen phone calls  Don’t leave cash or valuables visible  Notify the police if you will be away from home for an extended time period  Protective Measures (continued)  Consult with an attorney Make arrangement for the future such as power of attorney  Get legal advise before making/signing agreements regarding your care or possessions  Be aware of your financial situation  Protective Measures (continued)  Know where to ask for help  Find out about community resources before you need them such as rape and abuse hotlines, senior centers, and adult protective services  mental health service centers  crisis centers  private counselors  clergy  local police