AGCNS-BC Adult-Gerontology CNS Exam

Elder abuse encompasses any knowing, intentional, or negligent act by a caregiver or other person that causes harm or serious risk of harm to a vulnerable older adult. The National Center on Elder Abuse identifies seven types: physical abuse, emotional or psychological abuse, sexual abuse, neglect, abandonment, financial exploitation, and self-neglect.

Physical abuse involves intentional use of physical force that may result in bodily injury, physical pain, or impairment. Examples include hitting, slapping, pushing, kicking, pinching, burning, force-feeding, inappropriate use of physical restraints, and inappropriate use of medications for sedation.

Emotional or psychological abuse involves verbal or nonverbal acts that cause anguish, pain, or distress. Examples include verbal assault, threats, intimidation, humiliation, isolation, and harassment. This type of abuse often co-occurs with other forms.

Sexual abuse is non-consensual sexual contact of any kind, including unwanted touching, sexual assault, rape, coerced nudity, and sexually explicit photography.

Neglect is failure or refusal to provide necessary food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, or other essentials. Neglect may be intentional or unintentional. Caregiver neglect should be distinguished from self-neglect.

Abandonment occurs when a person responsible for providing care deserts a vulnerable elder.

Financial exploitation involves illegal or improper use of an elder's funds, property, or assets. Examples include cashing checks without permission, forging signatures, coercing property transfer, and identity theft.

Self-neglect refers to behaviors of an older person that threaten their own health or safety, such as refusing food, water, medication, or medical treatment.

Elder abuse is significantly underreported, with estimates suggesting only 1 in 14 cases comes to professional attention. Prevalence studies indicate 10% of community-dwelling adults over age 60 experience some form of abuse annually. Psychological abuse is most common, followed by financial exploitation, neglect, and physical abuse.

Risk factors for victims include cognitive impairment, physical disability, functional dependence, social isolation, history of family violence, and shared living situation. Risk factors for perpetrators include mental illness, substance abuse, caregiver stress, financial dependence on the elder, and history of violence.

The CNS must maintain high clinical suspicion for elder abuse. Warning signs vary by abuse type but include unexplained injuries, poor hygiene, malnutrition, dehydration, medication non-adherence, depression, anxiety, fearfulness, withdrawal, and sudden changes in financial situation.

Physical abuse indicators include bruises in unusual locations (bilateral arms, inner thighs, face), bruises in various stages of healing, burns, fractures, lacerations, and injuries inconsistent with stated cause. Patterned injuries suggest intentional harm.

Neglect indicators include poor hygiene, inappropriate clothing, dehydration, malnutrition, untreated medical conditions, pressure injuries, medication non-adherence, and unsafe living conditions.

Financial exploitation indicators include sudden inability to pay bills, unexplained withdrawal of funds, sudden changes in will or power of attorney, missing belongings, and unnecessary purchases.

Psychological abuse indicators include depression, anxiety, withdrawal, fearfulness, agitation, and low self-esteem. The victim may appear hesitant to speak openly.

Routine screening for elder abuse should occur in various healthcare settings. Several validated tools exist, including the Elder Abuse Suspicion Index (EASI), Vulnerability to Abuse Screening Scale (VASS), and Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST).

Documentation must be thorough and objective. Record patient statements in quotes. Describe injuries precisely, including location, size, shape, color, and pattern. Document demeanor and behavior. Photograph injuries with patient consent when possible. Include body diagrams. Document caregiver behavior and interactions observed.

All 50 states have mandatory reporting laws for elder abuse, though specific requirements vary. Healthcare providers, including CNSs, are typically mandated reporters. Reports go to Adult Protective Services or local law enforcement depending on state law. Mandated reporters are protected from liability for good-faith reports.

The CNS must know their state's specific reporting requirements, including who must report, when reports must be made, and to whom. Failure to report can result in civil or criminal penalties.

Immediate safety assessment is paramount. If the patient is in imminent danger, emergency intervention may be required. If the patient has capacity and is not in immediate danger, respect their autonomy while providing support and resources.

Interventions may include medical treatment, safety planning, referral to Adult Protective Services, social work consultation, legal consultation, community resources, support groups, and counseling. Care coordination across multiple agencies is often necessary.

For patients who choose to remain in abusive situations, the CNS should document their capacity, provide information about resources, establish a safety plan, and maintain ongoing contact. Repeated gentle inquiry over time may eventually lead to acceptance of help.

Caregiver interventions may include respite care, caregiver support groups, education, stress management, and treatment of underlying conditions such as depression or substance abuse.

Prevention occurs at primary, secondary, and tertiary levels. Primary prevention includes public education, professional training, and policies that reduce social isolation. Secondary prevention includes screening programs and early intervention. Tertiary prevention focuses on preventing recurrence through ongoing support and monitoring.

The CNS plays a vital role in prevention through patient education, caregiver support, advocacy, policy development, and community engagement.