Objective: To explore the abuse and neglect phenomenon in long-term care facilities for the elderly population.
Method: The systematic review comprised search on PubMed, CINAHL, MEDLINE and ScienceDirect databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The key words used were older people care, long-term care, older people and older adults. Articles published in the last 5 years between 2017 to 2021 in recognised English-language journals and whose full text was available on the websites were included. Details of the selected studies were noted and analysed.
Results: Of the 336 studies initially identified, 15(4.46%) were reviewed in detail. Of them, 3(20%) had been done in North America, 6(40%) in Europe and 6(40%) in Asia. The prevalence of abuse and neglect in long-term care facilities for the elderly was generally high, with nursing home staff mostly involved due to burnout syndrome or related to personal factors, such as childhood adversity and work-related stress.
Conclusion: Better understanding is critical for improving the quality of care in long-term care facilities to prevent abuse and neglect with the elderly.
Keywords: Aged, Caregivers, Healthcare quality and services, Long-term care. (JPMA 73: S-175 [Suppl. 2]; 2023)
The phrase “older folks” was coined by the World Health Organisation (WHO) to describe persons age 60 years or more, also referred to as the group of people who have reached the late phase of life.1 This group, labelled as older adults, go through the aging process. A common problem in the process is a progressive decline in physiological functions which could then increase the vulnerability of older people to suffer from diseases. The pace and impact of the aging process are different for each individual because they are influenced by genetic and environmental factors.2 The aging process, also known as lifecycle, is characterised by stages of decline in various organ functions, and increases the body’s vulnerability to multiple and complex diseases that could lead to mortality, such as problems with the cardiovascular system, respiratory system, decreased function of digestive system, such as dysphagia, and so on.3 This is caused by changes in the structure and function of cells, tissues and organ systems as people get older. These changes often aggravate the elder’s physical and mental health. In general, the condition would also have impact on the elder’s day-to-day activities.4
The nurses as professionals or non-formal caregivers who work in long-term care facilities, such as nursing homes, have the responsibility to provide basic care to fulfill the nutritional needs of older adults.5 One of the roles of the nurses in providing nutrition includes preparing food, providing food, evaluating the adequacy of eating, and ensuring safety while eating.6 Safety problems, such as choking, often arise when nurses do not assess the level of swallowing difficulty, and leave the elders to eat without assistance. This issue might be a sign of negligence which occurs through factors, such as the level of knowledge of nurses about dysphagia and choking in older adults. A study stated that the knowledge of nurses about the definition, diagnosis and clinical management of dysphagia are still low.7
A report by the National Indian Council on Ageing (NICOA) to the National Centre on Elder Abuse (NCEA) stated that neglect among older people ranked second at 45%, after psychological violence at 63%, according to the National Centre for Health Statistics. The prevalence of older people’s abuse and neglect in Asia ranged from 0.22 per 1,000 to 62%. China also reported that the prevalence rate of neglect among older adults was 36.2%, with psychological neglect 27.3%, followed by caregiver neglect 15.8%. In Taiwan, 195 elders who lived in a long-term care (LTC) institution experienced psychological abuse, which averaged 6.32 in the context of the total elder population of the centre. A report from a counselling centre in Japan showed a total of 46% cases of psychological abuse, 35.3% physical abuse, 21.3% neglect, 1.35% self-abandonment, and 0.7% sexual harassment.8
The Ministry of Social Affairs in Indonesia reported that neglect was the most common case experienced by 68.55% older people in 2018. The age factor affected the ability of physical conditions in older people, which resulted in a decline in their independent and social roles both in the family and in the community to the extent that their dependence on other people’s help increased. Other people’s assistance in question included meeting basic human needs, such as nutrition (eating and drinking), self-care (washing face, brushing teeth, shampooing and bathing), and fulfilling elimination (urination and defecation), and the needs for recreation. The declines and changes in body conditions or functions in older people made them vulnerable. In other words, an improper understanding of older people make them an often neglected section of population.9 Building emotional bonds professionally during treatment would increase caring for the clients. Additionally, it was necessary to socialise the concept of caring to provide a deeper understanding of what nurses had to do when they came into contact with clients, especially the elder population.10
A strengthening strategy was needed especially for service staff in LTC facilities. The concept of LTC is defined as the care given to older people who need help in meeting their basic daily needs due to physical and mental incapacity, needing long-term assistance by non-formal and professional caregivers.11 The WHO defines LTC as an activity carried out by non-formal or professional caregivers to ensure that older people, who are not fully capable of caring for themselves, can maintain the highest quality of life, according to their and their families’ wishes, and with the greatest possible freedom, autonomy, participation, and fulfillment of personal and humanitarian needs.12
Preliminary data received from 15 nursing home staff around the East Java province in Indonesia showed there were no rules regarding the management of swallowing difficulty or feeding assistance for the elders.13 The current systematic review was planned to explore the abuse and neglect phenomenon in LTC facilities.
Materials and Methods
The systematic review comprised search on PubMed, CINAHL, MEDLINE and ScienceDirect databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.14
The key words used were older people care, long-term care, older people and older adults. Articles published in the last 5 years between 2017 to 2021 in recognised English-language journals and whose full text was available on the websites were included.
The main features of the studies were noted and analysed with the aim of making relevant recommendations for LTC facilities meant for older adults.
Of the 336 studies initially identified, 15(4.46%) were reviewed in detail (Figure). Of them, 3(20%) had been done in North America, 6(40%) in Europe and 6(40%) in Asia. The majority of the studies were surveys, retrospective-longitudinal cohorts, cross-sectional or descriptive-analytical, with sample sizes ranging from 80 to 1500 participants. 15-29
The studies explained the prevalence and related factors of elder abuse and neglect. High prevalence of abuse and neglect was found in the implementation of LTC facilities regardless of the region. There were some kind of interventions, such as community-based intervention, intervention mapping, and knowledge transaction activity, in search of an elder abuse detection tool. Abuse and neglect were mostly found on the part of the nursing home staff due to burnout syndrome or because of personal factors, such as childhood adversity and work-related stress. Finally, determination of advanced care planning for the elderly with swallowing issues prolonged the survival rate in relation to the mortality-related negative implementation of LTC (Table).
The current review showed insufficient evidence to effectively prevent or reduce abuse, indicating the need for high-quality cohort trials. However, some promising practices were identified. Abuse and neglect of older individuals must be prevented or reduced through effective treatment.15 In 2017, the first national survey of reported violence and abuse by community-dwelling adults aged 65 years or above was undertaken, with an overall prevalence rate of 6.8% to 9.2% projected. Because the geriatric population is more vulnerable and physically weaker than younger people, even slight physical injuries might result in catastrophic or long-term consequences.30 Nursing home residents frequently suffer from a variety of physical and cognitive issues. Choking or aspiration during eating and feeding may be caused by adverse respiratory events and may also result in dyspnoea episodes.23 Nursing homes can be a challenging workplace for specialists. Anxiety and despair are common among staff and family caregivers. After a time of profound consideration and multiple consultations with health specialists, most family caregivers decide to institutionalise their older adult relatives.31 The problem of abuse experienced by the older adults in nursing homes is multifaceted and complex, and involves personal, social and organisational factors.32 The findings illustrated the importance of gender in the care of older people and its health repercussions despite the fact that the subject has not been properly examined.25 Men and women are affected differently by type of abuse in terms of suicidal thoughts and attempts, stress, anxiety, sleep issues, and health utilisation. In treatment, for example, gender is a crucial factor to consider.16
A collaboration with the elders plays a very important role in LTC implementation because being a mentor requires patience and physical strength. As a companion, the nurses at LTC facilities have the responsibility to avoid the impact of physical and psychological problems. It is necessary to consider the needs and skills of collaboration.32 The mistreatment of older people is not just a social issue, but contributes to the elder’s morbidity and mortality. Hospital and inpatient emergency services are being used more frequently. LTC appears to be becoming increasingly important in understanding the intricacies of older abuse manifestations, their detection, management and possible prevention.17 Victimisation of older adults was found to be strongly linked to early life issues, such as childhood adversity. Social and emotional help for coping with abuse should take into account that some elders may be vulnerable to abuse for the rest of their life. Care in old age is important to be carried out and monitored by nurses.33 Despite the fact that institutional abuse and neglect are more common than in the community, older abuse in institutions has not received the same public health attention as other forms of abuse. Nursing homes and residential institutions need more attention and resources to create a balance between providing care for the complex needs of the older adults while also ensuring proper assistance from staff through training, education and adequate labour and wages for quality upkeep. The findings bolster the case for global action to extend efforts to research, prevent and help victims of institutional abuse, especially due to the rapidly aging population. Public health officials should prioritise creating interventions for older adults and personnel in institutional settings.34 Patients need to have access to health professionals who specialise in mental health to be able to help them to be stronger in dealing with any psychological problem they face.26 Fear about the future is often a great concern for patients, and it is not uncommon for them to sometimes feel the need to disclose it. Palliative care in LTC requires a specialised and collaborative team of doctors, nurses and other medical professionals with expertise in palliative care. They are in charge of assisting patients with life-threatening illnesses, as well as their families, in preparing for death.18 Investigating changes in health outcomes over time necessitates research, although high attrition rates are common in longitudinal studies involving older populations. The loss to follow-up (38.3%) in a study consisted mainly of those with lower socioeconomic backgrounds.19
Prevention against abuse and neglect will reduce mistreatment during LTC implementation. The communication barrier perceived by nurses was due to hearing loss as part of the aging process, the inability of older people to communicate due to the disease process, or differences in the language between staff or residents. Such reasons should be evaluated regularly. The way of communicating must be adapted to the demands of the older adults. Communication is an important part of client care which determines LTC quality.28 The number of older people is increasing very rapidly, accompanied by a decrease in various systems, which have an impact on the health of older adults in need of LTC.29 LTC necessitates the assistance of health cadres or caregivers, but health cadres must be well versed in LTC for the older adults. The increase in life expectancy has led to an increase in the dependency ratio. One of the ways to manage this is LTC for older people carried out by the family or the community.26 Abuse prevention programmes must be carefully monitored because there is a risk of abuse worsening.30 To improve the quality of evidence, there is an urgent need for specific monitoring and evaluation of preventative strategies through studies. Poor-quality and thoughtless research should be avoided because it fails to address critical issues concerning efficacy, can be deceptive, and leads to confusion and doubt among practitioners and policymakers.20 Education is a process that can help nurses in conveying health messages properly. Nurses have a good ability to understand concepts or materials about LTC in older people and within a single session they can improve their LTC ability.35 LTC is an activity carried out by informal or professional caregivers to ensure that older people who are not fully capable of caring for themselves can maintain the highest quality of life, according to their wishes, and with the greatest possible freedom, autonomy, participation, fulfillment of personal and humanitarian needs.36
In the context of autonomous older persons’ care and social protection, it is important to build regulations, institutions and community potential in order to achieve an increasingly large, independent, and prosperous older population. The importance of developing comprehensive legislation, policies and databases for older persons linked with regional population data and poverty alleviation programmes is undeniable. The regional level can be improved and updated to reflect the current state of affairs in a region. In the context of Indonesia, improving the wellbeing of older people by learning from the experiences of North America, Europe and some parts of Asia, particularly community or community-based older people care institutions, should be encouraged. In the community, cities have a lot of social capital and improving the care and welfare of older people requires an independently managed social pension policy so that older people may have dignity about their existence.
It is critical to improve the quality of care in LTC facilities to prevent abuse, neglect and mistreatment. LTC issues, like the choking phenomenon felt by the older people and care workers, can be used as evaluation material for policymakers in the future.
Limitation: The limitation of the current systematic review is that it was not registered with the international prospective register of systematic reviews, PROSPERO.37
Acknowledgment: We are grateful to Universitas Airlangga, Indonesia, for providing all kinds of support.
Disclaimer: One of the authors is the Dean of the Faculty of Nursing at Universitas Airlangga, and in that capacity signed the approval letter.
Conflict of Interest: None
Source of Funding: Universitas Airlangga, Indonesia.
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