Detection of elder mistreatment In: Evidence-based geriatric nursing protocols for best practice


Guideline Developer(s)

Hartford Institute for Geriatric Nursing

Date Released

2012

Evidence Supporting the Recommendations

References Supporting the Recommendations

Cowen HJ, Cowen PS. Elder mistreatment: dental assessment and intervention. Spec Care Dentist. 2002 Jan-Feb;22(1):23-32. [78 references] PubMed
Jayawardena KM, Liao S. Elder abuse at end of life. J Palliat Med. 2006 Feb;9(1):127-36. [72 references] PubMed
Perel-Levin S. Discussing screening for elder abuse at the primary health care level. World Health Organization (WHO); 2008.
Phillips LR. Abuse of aging caregivers: test of a nursing intervention. ANS Adv Nurs Sci. 2008 Apr-Jun;31(2):164-81. PubMed
Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W. Screening for abuse and neglect of people with dementia. J Am Geriatr Soc. 2010 Mar;58(3):493-500. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms
Foreign Language Translations
Mobile Device Resources
Resources

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Patients

  • Reduction of harm through referrals
  • Increased use of interdisciplinary interventions and/or relocation to a safer situation and environment
  • Improved understanding of how to access appropriate services

Caregivers

Increased use of services such as respite care or treatment for mental illness or substance use

Health Care Provider

Improved evaluation of progress in relationships between caregiver and older adult through screening instruments such as the Modified Caregiver Strain Index and Geriatric Depression Scale

Institution

Establishment of clear and evidence-based guidelines for management of elder mistreatment cases

Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Not stated

Identifying Information and Availability

Bibliographic Source(s)

Caceres B, Fulmer T. Mistreatment detection. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 544-61.

Adaptation

Not applicable: The guideline was not adapted from another source.

Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Authors: Billy A. Caceres, RN, BSN, BA, Research Assistant, New York University, New York, NY; Terry Fulmer, PhD, RN, FAAN, Dean of the Bouve College of Health Sciences, Northeastern University, Boston, MA

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.

Availability of Companion Documents

The following are available:

  • Try This® - issue 4: The Geriatric Depression Scale (GDS). New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in Portable Document Format (PDF) in English and Spanish from the Hartford Institute for Geriatric Nursing Web site.
  • Try This® - issue 15: Elder mistreatment assessment. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in PDF in English and Spanish from the Hartford Institute for Geriatric Nursing Web site.
  • The Geriatric Depression Scale (GDS) Short Form Assessment. How to Try This video. Available from the Hartford Institute for Geriatric Nursing Web site.
  • Elder mistreatment assessment. How to Try This video. Available from the Hartford Institute for Geriatric Nursing Web site.

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 24, 2013. The information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Scope

Disease/Condition(s)

Elder mistreatment

Guideline Category

Counseling
Evaluation
Management
Risk Assessment
Screening

Clinical Specialty

Family Practice
Geriatrics
Nursing

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Hospitals
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

To provide a standard of practice protocol to identify best practices in identifying and responding to cases of elder mistreatment

Target Population

Adults aged 65 years and older

Interventions and Practices Considered

Screening/Evaluation

  1. Physical assessment
  2. Use of subjective information
  3. Use of data gathered from screening instruments

Management

  1. Development of trusting relationship with patient
  2. Early intervention by interdisciplinary teams
  3. Education of victims
  4. Referral to regulatory agencies
  5. Follow-up
Major Outcomes Considered
  • Incidence of harm from mistreatment
  • Interdisciplinary interventions

Recommendations

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Parameters of Assessment

Type of Mistreatment Questions to Assess Type of Mistreatment Physical Assessment and Signs and Symptoms

Physical abuse

Has anyone ever tried to hurt you in any way?

Have you had any recent injuries?

Are you afraid of anyone?

Has anyone ever touched you or tried to touch you without permission?

Have you ever been tied down?

Suspected evidence of physical abuse (i.e., black eye) ask:

  • How did that get there?
  • When did it occur?
  • Did someone do this to you?
  • Are there other areas on your body like this?
  • Has this ever occurred before?

Assess for: bruises (more commonly bilaterally to suggest grabbing), black eyes, welts, lacerations, rope marks, fractures, untreated injuries, bleeding, broken eyeglasses, use of physical restraints, sudden change in behavior.

Note if a caregiver refuses an assessment of the older adult alone.

Review any laboratory tests. Note any low or high serum prescribed drug levels.

Note any reports of being physically mistreated in any way.

Emotional/psychological abuse

Are you afraid of anyone?

Has anyone ever yelled at you or threatened you?

Has anyone been insulting you and using degrading language?

Do you live in a household where there is stress and/or frustration?

Does anyone care for you or provide regular assistance to you?

Are you cared for by anyone who abuses drugs or alcohol?

Are you cared for by anyone who was abused as a child?

Assess cognition, mood, affect, and behavior.

Assess for: agitation, unusual behavior, level of responsiveness, and willingness to communicate.

Assess for delirium.

Assess for dementia.

Assess for depression.

Note any reports of being verbally or emotionally mistreated.

Sexual abuse

Are you afraid of anyone?

Has anyone ever touched you or tried to touch you without permission?

Have you ever been tied down?

Has anyone ever made you do things you didn't want to do?

Do you live in a household where there is stress and/or frustration?

Does anyone care for you or provide regular assistance to you?

Are you cared for by anyone who abuses drugs or alcohol?

Are you cared for by anyone who was abused as a child?

Assess for: bruises around breasts or genital area; sexually transmitted diseases; vaginal and/or anal bleeding; or discharge, torn, stained, or bloody clothing/undergarments.

Note any reports of being sexually assaulted or raped.

Financial abuse/exploitation

Who pays your bills? Do you ever go to the bank with him/her? Does this person have access to your account(s)? Does this person have power of attorney?

Have you ever signed documents you didn't understand?

Are any of your family members exhibiting a great interest in your assets?

Has anyone ever taken anything that was yours without asking? Has anyone ever talked with you before about this?

Assess for: changes in money handling or banking practice, unexplained withdrawals or transfers from patient's bank accounts, unauthorized withdrawals using the patient's bank card, addition of names on bank accounts/cards, sudden changes to any financial document/will, unpaid bills, forging of the patient's signature, appearance of previously uninvolved family members.

Note any reports of financial exploitation.

Caregiver neglect

Are you alone a lot?

Has anyone ever failed you when you needed help?

Has anyone ever made you do things you didn't want to do?

Do you live in a household where there is stress and/or frustration?

Does anyone care for you or provide regular assistance to you?

Are you cared for by anyone who abuses drugs or alcohol?

Are you cared for by anyone who was abused as a child?

Assess for: dehydration, malnutrition, untreated pressure ulcers, poor hygiene, inappropriate or inadequate clothing, unaddressed health problems, non-adherence to medication regimen, unsafe and/or unclean living conditions, animal/insect infestation, presence of lice and/or fecal/urine smell, soiled bedding.

Note any reports of feeling mistreated.

Self-neglect

How often to you bathe?

Have you ever refused to take prescribed medications?

Have you ever failed to provide yourself with adequate food, water, or clothing?

Assess for: dehydration, malnutrition, poor personal hygiene, unsafe living conditions, animal/insect infestation, fecal/urine smell, inappropriate clothing, non-adherence to medication regimen.

Nursing Care Strategies

  • Detailed screening to assess for risk factors for elder mistreatment (EM) using a combination of physical assessment, subjective information, and data gathered from screening instruments (Perel-Levin, 2008 [Level I]).
  • Strive to develop a trusting relationship with the older adult as well as the caregiver. Set aside time to meet with each individually (Perel-Levin, 2008 [Level I]).
  • The use of interdisciplinary teams with a diversity of experience, knowledge, and skills can lead to improvements in the detection and management of cases of EM. Early intervention by interdisciplinary teams can help lower risk for worsening abuse and further deficits in health status (Jayawardena & Liao, 2006 [Level V]; Wiglesworth et al., 2010 [Level IV]).
  • Institutions should develop guidelines for responding to cases of EM (Perel-Levin, 2008 [Level I]; Wiglesworth et al., 2010 [Level IV]).
  • Educate victims about patterns of EM such that EM tends to worsen in severity over time (Cowen & Cowen, 2002 [Level VI]; Phillips, 2008 [Level II]).
  • Provide older adults with emergency contact numbers and community resources (Cowen & Cowen, 2002 [Level VI]).
  • Referral to appropriate regulatory agencies

Follow-up Monitoring of Condition

Follow-up monitoring in the acute care setting is limited compared to the follow-up that may be performed in the community or long-term care settings.

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

End of Life Care
Getting Better
Living with Illness
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

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