The elderly is often seen as one of the most vulnerable groups in society. As Americans age they are faced with additional challenges to their health, finances and even family relationships. The aging process becomes even more strenuous on those who are unable to adequately meet the financial requirements of health care and health services. Especially for this group of elderly, the aging process is extremely challenging. When the issue of financial constraints are coupled with terminal illnesses, particularly those which leave the elderly unable to adequately carry out normal daily functions, the challenge is even greater and not only the elderly but their relatives and/or caregivers also have to bear the brunt of these burdens. Given the dilemmas faced by the elderly such as abuse and complex health conditions including various manifestations of impaired brain cognition, America has an obligation to take care of the health care needs of its vulnerable elderly population to ensure that no elderly is left behind.
As individuals age certain normal daily functions become more and more challenging. The loss of some cognitive brain functions and the onset of dementia as a result of diseases such as Alzheimer’s exacerbate these difficulties and place the elderly in a more dependent position on their caregivers who are often relatives. Elder abuse is a common outcome faced by the elderly in such positions. Additionally the costs of accessing health care increases daily and insurance and government sponsored health care options are becoming less and less able to adequately cater to the medical needs of the elderly population. Further financial and legal issues need to be addressed by the elderly. These concerns bundled together means that the elderly are less and less capable of meeting their financial obligations specifically with regards to health and therefore suggests that the American government needs to do all it can to ensure the comfort of the elderly as they face the final period of their lives.
One of the greatest, and probably one of the most unnoticed challenges faced by the elderly is the issue of abuse. The ill-treatment of the elderly is felt to be a very serious problem in the United States. The U.S. Department of Health and Human Services (HSS) define elder abuse as “… any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult”[1] Elder abuse refers to the mistreatment of adults who are older than 65 years and it is believed that more than 10% of all Americans within this age group are suffering abuse. One writer suggests that well over 2 million incidents of elder abuse occur annually (Wieland 41) and the problem of elder abuse is as significant as diabetes, and certain cancers. Unfortunately only a small portion of elder abuse incidents are reported. Collins believes that only 1 in every 13 or 14 such cases reach the authorities (1290).
Often abuse in the elderly is difficult to detect. Redness, swelling, bruises, abrasions and lacerations may be visible upon examination of the victim’s body. More severe injuries of the head, neck, chest wall, abdomen and genitals have also been noticed in abuse victims (Brown, Struebert, and Burgess 24-27).
The causes of elder abuse are usually accounted to two sources – caregiver stress and the need for power and control. Since the majority of caregivers are relatives, the majority of cases of elder abuse are perpetrated by these same family members. Anetzberger explains that the stresses of having to care for an elderly person in ways that the caregiver was otherwise unprepared for, can bring on significant stress and frustration. When these feelings are vented on the victim and they lead to abuse. “Many professionals believe caregiver stress is the primary cause of domestic elder abuse” but Brandl does not agree with this position (39). According to Brandl “some caregivers or family members hurt older people to exert power and control. Many abusers harm older people to get their own needs met, believing they are entitled to use any means necessary to achieve their goals (40).
There are various types and categories of elder abuse. The major forms of elder abuse are physical, emotional or psychological, financial, neglect, sexual abuse, self-abuse and others. Financial abuse is where the elderly is taken advantage of financially. This may be in the form of stealing. The theft of Social Security and pensions check have often been reported (Wieland). The caregiver may also misuse the financial resources of the elderly or coerce them into handing over cash, making changes on a will, deed, getting them to sign contracts or assign them the power of attorney or even getting them to purchase items.
Sexual abuse of the elderly is not very highly reported but is believed to be of concern. This refers to making intimate contact with the elderly person without their permission. Examples include touching or fondling the genital area, breast, anus and other areas (Wieland). Especially the elderly are often unable to resist sexual advances because of their physical condition, due to cognitive difficulties or because they are not in a position to report such abuse
Self-neglect is also considered a form of elder abuse. With self-neglect the elderly undertakes actions that are dangerous to his own health and safety. The elderly themselves therefore have to be careful that they do not do anything to compromise their own safety.
Emotional or psychological abuse is also perpetrated against the elderly. This form of abuse may involve any action that lowers the morale of the elderly. Some examples of this kind of abuse are abandonment particularly for long periods of time, punishment, keeping the elderly away from family, relatives, associates and activities or other forms of social relationships, verbal or nonverbal insults, issuing threats, harassment, humiliation and others (Wieland). This form of abuse may further lead to other problems such as depression or aggravated illness in the elderly.
According to Collins neglect is the most common form of elder abuse. Neglect refers to the caregiver failing to provide basic care for the elderly which may include food, water or taking care of their personal hygiene. Neglect is further characterized as either active or passive neglect. In active neglect the caregiver intentionally withholds these basic things from the elderly so as to prevent their physical harm or emotional discomfort (Collins). Passive neglect is where the caregiver unintentionally fails to provide these basics for the elderly. This may arise because the caregiver is either not aware of his responsibilities or does not have the appropriate skills to adequately meet all the needs of the elderly or is facing pressure from external stressors. Among things that could be considered as neglect are where the caregiver may fail to provide physical aids such as eyeglasses, hearing aids, dentures and other assistive devices (Wieland).
Physical abuse is another form of elder abuse. Statistics reveal that physical abuse is responsible for as much as 14% of all cases of elder trauma. Reports further state that trauma in the elderly leads much more easily to death than in younger patients (Collins 1291). Physical abuse may involve a variety of actions that compromise the overall physical safety of the elderly. Some examples may include hitting or slapping, force feeding, over, under or improper medication, biting, pinching, burning, pushing, improperly using physical restraints or any other action that causes bodily harm (Collins 1291, Wieland 42).
Since elder abuse is so multifaceted and quite difficult to detect it is imperative that the government takes a greater responsibility in ensuring that the rights of the elderly are respected by caregivers. Unless there are very stringent penalties for abusing the elderly and improved mechanisms for detecting its occurrence the elderly will continue to be abused and the government will continue to fail in its obligations and responsibilities to the elderly.
In caring for the elderly the government needs to ensure that ethical principles are followed by the caregivers so that abuse is avoided and the wishes of the elderly are respected. The elderly still need to feel a sense of autonomy especially in making decisions with regards to their treatment and care. Their privacy, especially when they are committed to private or public institutions, must be respected. Even in simple matters such as eating, bathing, clothing and movement the elderly’s wishes should be respected (Teeri, Leino-Kilpi & Valimaki, 117).
The rights of all patients, including the elderly, are clearly stated in the Patient’s Bill of Rights which was adopted in 1998 by the U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Among the rights laid down in this document are the rights to respect and non-discrimination, participate in treatment decisions, to choose health care providers and protection of their records. [2] These rights are simplistic, in the least, but there are also separate bills of rights which govern patients with particular illnesses and these are more specific and detailed. However the Bill of Rights does not speak directly to the unique and special needs of the elderly (Hashimoto 84) and leaves the majority of the elderly population behind as their rights are not adequate addressed. Hashimoto argues that the Bill does not address inequalities in care that are faced by the elderly even though, according to him, “… the elderly may have a greater need to be protected by a system that safeguards patients’ rights (84).
Guaranteeing equal and fair treatment to the elderly is even more important when they suffered from cognitive dysfunction which often makes them incapable of making some important decisions for themselves. According to the American Institute of Stress “it’s not unusual for middle-aged people to occasionally complain of forgetting a familiar name, where they left their glasses or something they meant to buy when going shopping. Memory loss for recent events … tends to worsen with age” (1). The nature of impaired brain cognition in the elderly can range from mild to severe. In severe cases dementia, a condition closely linked with Alzheimer’s disease may develop. According to the National Health Service dementia:
“is the loss (usually gradual) of mental abilities such as thinking, remembering, and reasoning … There are many different types of dementia, each with their own causes. The most common dementia symptoms include loss of memory, confusion, and changes in personality, mood and behaviour. About 6 in 100 of those over the age of 65 will develop some degree of dementia, increasing to about 20 in 100 of those over the age of 85.”[3]
Alzheimer’s disease (AD) is the most common form of dementia among older people (Ward). “Alzheimer’s disease accounts for 60-80% of cases in the elderly” (Patel and Hope 457). AD begins slowly. It first involves the parts of the brain that control thought, memory and language. People with AD may have trouble remembering things that happened recently or names of people they know. According to Carradice, Beail and Shankland this disease is more common among those persons older than eighty years. Given that there is a noted increase in life expectancy where more and more persons are living longer it is quite understandable that the incidents of dementia are also increasing (Zarit & Edwards).
The prognosis for elderly patients with AD is quite dismal. While there are treatment options available that may improve some of the behavioural and cognitive ill effectives of the disease. Everyday life and routine daily activities are significantly hampered by Alzheimer’s disease. No treatment currently exists that will halt the progression of the disease or lead to full recovery (Mittelman).
Even with impaired brain function, individuals may still be able to have some autonomy in the decisions pertinent to their health care. Legal documents, known as Advance Directives, can give patients suffering from cognitive impairment or other difficulties the power to decide on their options for treatment. These documents allow the individual to specify, beforehand, preference for treatment such as whether or not they desire to be placed on life support machines or receive certain types of medications. In this way patients are able to effectively communicate their wishes to their family members, friends, caregivers and other health professionals.[4] In this way some of the burden that family members especially face in caring for their loved ones may be eliminated as the patient has already made the important decisions. Such documents can eliminate much confusion and even diminish some of the stress that caregivers experience in caring for the elderly and thus may impact the rate of elder abuse in the society.
Some critics have argued that the government is already spending considerable amounts of money in providing health care for the elderly and in fact these spending are too much and could be invested into other areas of the country’s economy. Under Medicare which is the health insurance program geared specifically at persons aged 65 or older well over 300 million dollars is spent annually to subsidize care and medication for the elderly. Medicare consists of four parts and the beneficiaries may choose which cover they wish to enjoy. Part A covers hospital insure, Part B covers services not eligible under Part A, Part C allows beneficiaries to receive healthcare through a provider organization and Part D covers some prescription drugs.[5]
Given that the government is already investing much resource into Medicare, some are suggesting that rather than increase their obligations to the elderly, the government needs to decrease its contributions. Furthermore the prevalence of insurance scams which attempt to rip off the government is calling into question the merits of the government subsidizing healthcare. Among the deceptive techniques used to swindle government funds the most noted are phantom treatments which bill insurers for fictitious medical treatment and double billing where the insurer is billed more than once for the same treatment. Additionally some health providers give substandard care to patients or treat them for conditions they do not have. There is the case of identity theft as well as individuals involved in rolling labs which provide mobile diagnostic facilities which conduct fake examination of patients.[6]
However, the call to decrease government spending on healthcare for the elderly cannot be justified simply on the basis of fraud. The government has an obligation to the elder population to ensure that it receives adequate healthcare coverage and that those who care for them are as comfortable as possible. Rather what the government needs to do instead is to ensure that all institutions that claim to offer health services are properly monitored and that records sent to Medicare are also audited so that the losses to fraud will be decreased. Additionally the government needs to explore additional avenues, besides healthcare services, where more can be done for the elderly. Those who care for the elderly must be considered when planning such programs. In the end the needs of the elderly will be taken care of and none will be left behind.
References
“Advance Directives.” National Cancer Institute 25 Jan 2007 <http://www.cancer.gov/cancertopics/factsheet/support/advance-directives>
“Aging: How can I Recognize Elder Abuse.” U.S. Department of Health and Human Services 25 Jan 2007 < http://www.hhs.gov/faq/aging/911.html>
Anetzberger, Georgia J. “Caregiving: Primary Cause of Elder Abuse?” Generations 24.2 (2000): 46-51.
“Basics of Alzheimer’s Disease What it is and what you can do.” Alzheimer’s Association 25 Jan 2007 <http://www.alz.org/national/documents/brochure_basicsofalz_low.pdf>
Brandl, Bonnie. “Power and Control: Understanding Domestic Abuse in Later Life.” Generations 24.2 (2000): 39-45.
Brown, Kathleen, George E. Streubert, and Ann W. Burgess. “Effectively Detect and Manage Elder Abuse.” The Nurse Practitioner 29.8 (2004): 22-31.
Carradice, A., N. Beail, and M. C. Shankland. “Interventions with Family Caregivers for People with Dementia: Efficacy Problems and Potential Solution.” Journal of Psychiatric & Mental Health Nursing 10.3 (2003): 307-15.
“Citations and Clinicians’ Notes: Neurology and Psychiatry: Alzheimer’s Disease and Other Dimentias.” Current Medical Literature: Health Care of Older People, 16.4 (2003): 96-103.
Collins, Kim A. “Elder maltreatment: A review.” Archives of Pathology & Laboratory Medicine 130.9 (2006): 1290-96.
“Dementia.” NHS Direct 25 Jan 2007 <http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=124>
Hashimoto ,Dean M. “The Proposed Patients’ Bill of Rights: The Case of the Missing Equal Protection Clause.” Yale Journal of Health Policy, Law, and Ethics I(2001): 77-93. 25 Jan 2007 <http://www.yale.edu/yjhple/volume_1/pdf/077%20(hashimoto).pdf>
“Medicare and you 2008.” Center for Medicare and Medicaid services 25 Jan 2007 <http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf>
Mittelman, Mary S. “Family caregiving for people with Alzheimer’s disease: Results of the NYU spouse caregiver intervention study.” Generations 26.1 (2002): 104-6.
Patel, Vikram, and Tony Hope. “Aggressive Behavior in Elderly People with Dementia: A Review. International Journal of Geriatri Psychiatry 8 (1993): 457-72.
“Patient’s Bill of Rights, The.” American Cancer Society. 25 Jan 2007 <http://www.cancer.org/docroot/MIT/content/MIT_3_2_Patients_Bill_Of_Rights.asp>
Pountney, David. “Dementia, Delirium or Depression.” Nursing Older People 19.5 (2007): 12-14.
“Scam Alerts: Health Fraud.” Coalition Against Insurance Fraud 25 Jan 2007 <http://www.insurancefraud.org/health_scams.htm>
Teeri, Sari, Helena Leino-Kilpi, and Maritta Välimäki. “Long-Term Nursing Care of Elderly People: Identifying Ethically Problematic Experiences Among Patients, Relatives and Nurses in Finland.” Nursing Ethics 13.2 (2006): 116-29.
Ward, Malcolm. “Biomarkers for Alzheimer’s disease.” Expert Review of Molecular Diagnostics 7.5 (2007): 635-46.
Wieland, Diane. “Abuse of older persons: An overview.” Holistic Nursing Practice 14.4 (2000): 40-50.
Zarit S. H. and A. B. Edwards “Family care giving: Research and clinical intervention.” In Handbook of the Clinical Psychology of Ageing. Ed. B. Woods. Chichester: John Wiley and Sons, 1996. 333-68.
[1] “Aging: How can I Recognize Elder Abuse.” U.S. Department of Health and Human Services 25 Jan 2007 < http://www.hhs.gov/faq/aging/911.html>
[2] “The Patient’s Bill of Rights.” American Cancer Society. 25 Jan 2007 <http://www.cancer.org/docroot/MIT/content/MIT_3_2_Patients_Bill_Of_Rights.asp>
[3] “Dementia.” NHS Direct 25 Jan 2007 <http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=124>
[4]“Advance Directives” National Cancer Institute 25 Jan 2007 <http://www.cancer.gov/cancertopics/factsheet/support/advance-directives >
[5] “Medicare and you 2008.” Center for Medicare and Medicaid services 25 Jan 2007 <http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf>
[6] “Scam Alerts: Health Fraud.” Coalition Against Insurance Fraud 25 Jan 2007 <http://www.insurancefraud.org/health_scams.htm>
