The number of older adults in the United States is expected to double to nearly 90 million by 2050.1 Elder abuse is one of the most compelling challenges facing this population. Because of underreporting, a lack of clear definitions of what constitutes abuse, and other factors, no one knows how often elder abuse occurs in the United States. Estimates range from about 500,000 elder abuse and neglect incidents per year to 4 to 5 million2-the latter estimate consistent with data suggesting that as many as 10% of older adults experience some form of abuse or neglect each year.3 Reports indicate that only one in five to one in 14 cases actually gets reported.4, 5 For decades, advocates have worked to bring attention to elder abuse and convey the urgency of the problem to society at large and to the federal government. In 2010, tucked inside the Affordable Care Act, the Elder Justice Act (EJA) became law. This article defines elder abuse and discusses the challenges and opportunities surrounding this issue. It also provides an overview of the EJA and identifies where and how nurses can become more involved in preventing and eliminating abuse and helping to ensure justice. A resource box with useful links is included.

The Many Faces of Elder Abuse

The Centers for Disease Control and Prevention has defined elder abuse as "any abuse and neglect of persons age 60 and older by a caregiver or another person in a relationship involving an expectation of trust."6 Often referred to as elder mistreatment, this abuse can take a number of forms, including

* physical abuse

* psychological/emotional abuse

* sexual abuse

* neglect

* self-neglect

* financial abuse and exploitation

Unsurprisingly, elder abuse is often not reported by older adults. They may not know where and how to report abuse, be ashamed or afraid to do so, or fear retribution from perpetrators. Family members, care providers, and health professionals may perpetuate the problem when they fail to identify or report suspected cases of abuse.

In 2011, the iconic actor Mickey Rooney testified before the U.S. Senate Special Committee on Aging.7 Rooney described his helplessness, fear, and anger during his years as a victim of elder abuse and implored the committee to pass legislation to stop elder abuse and make it a crime. Thousands of people with similar experiences are in our communities and health care systems today.

Challenges and Opportunities

Abuse violates elders' rights and negatively affects their health, well-being, and overall quality of life. It is associated with increases in morbidity, mortality, and ED visits.8, 9 However, the signs and symptoms of abuse are not always easy to recognize. Nurses, the largest group of caregivers at the bedside and beyond, interact daily with patients in a variety of practice settings and have the opportunity to make a difference by understanding laws about elder abuse, recognizing and reporting the problem, and taking other actions that can lead to prevention and amelioration of the problem.

Overview of the law. The EJA authorizes expenditures for identifying, addressing, and preventing elder abuse. Key provisions include

* civil and monetary consequences for failure to report crimes that occur in long-term care facilities.

* penalties to long-term care facilities that punish an employee for reporting violations.

* funding for adult protective services in all 50 states (state and local levels) to improve services and access to databases that provide best practice information.

* grants for long-term care staff training and recruitment, improvements to long-term care facilities, enhancement of care provided by RNs, and support of electronic health record technology.

* state and local support for programs training long-term care ombudsmen.

* the establishment of forensic centers and support for development of forensic expertise.

Despite that expenditures for the above have been authorized in the EJA, many of the provisions have been underfunded, if funded at all.

Three key EJA initiatives.

* The Elder Justice Coordinating Council is chaired by the secretary of the U.S. Department of Health and Human Services and includes representatives from key agencies and departments, such as the Social Security Administration, Department of Justice, Department of Veterans Affairs, Consumer Financial Protection Bureau, and others. The intention is to ensure that the federal government will lead a coordinated effort to address issues related to elder abuse, neglect, and exploitation. Nurses with geriatric and related expertise who work within the federal government might consider contacting their agency or department representative to inquire how they can participate in the council activities.

* The Advisory Board on Elder Abuse, Neglect, and Exploitation was created to bring the perspective of ordinary citizens with relevant expertise to national initiatives. The board, composed of 27 members of the public, focuses on "multidisciplinary strategic plans for the development of the field of elder justice"10 in order to make recommendations to the Elder Justice Coordinating Council. Each member, serving from one to three years, will have specific expertise in areas such as identification, prevention, and treatment of abuse. Nurses are ideal candidates for the board because of their knowledge of the health care system and of concerns particular to geriatric care. Announcements to fill board openings are made in the Federal Register. When there is a call for nominees, nurses may use this opportunity to volunteer to serve on the board.

* The establishment and support of elder abuse, neglect, and exploitation forensic centers is intended to improve investigation by increasing forensic expertise in recognizing when a crime has been committed. The expansion of forensics resources via creation of mobile and stationary forensics centers and increased research into specific markers of abuse, neglect, and exploitation will result in more protection for elders.

Engaging nurses in the effort. The EJA is timely and vital to protecting the steadily increasing numbers of older adults in the United States. In passing the EJA, the legislative and executive branches of our government are now poised to build and sustain a coordinated elder justice effort. With over 3 million RNs nationwide, nursing is well positioned to play a significant role in a coordinated action against elder abuse. Each nurse has a professional and ethical responsibility to protect vulnerable populations, especially the elderly.

Identification, assessment, and reporting. Nurses interacting with patients in all clinical settings have opportunities to identify, assess, and report elder abuse. Instruments and tools are available to aid in this process. The Elder Assessment Instrument is a "51-item Likert scale assessment[horizontal ellipsis] comprised of seven sections that review signs, symptoms and subjective complaints of elder abuse, neglect, exploitation and abandonment."11 This instrument can provide an invaluable framework for organizing data and detecting potential areas of concern when clinicians and patients interact.11

Elder justice reporting is complex and the process varies from state to state. It is important that nursing professionals understand where and how to report abuse in their states, including the information and documentation required when filing reports. Many states require mandatory reporting by nurses and hold them liable for failing to report abuse. To learn more about reporting requirements in a specific location, visit the National Council of State Boards of Nursing Web site (see Resources). Nurses, whether mandated reporters or not, should take responsibility and report suspected cases of abuse and neglect.

Nurse leaders and administrators should examine policies within their health system to ensure that staff members understand the required steps in identifying and reporting elder abuse. Discussion-including case studies on elder abuse best practices and policies-can be incorporated into clinical orientation and in-service programs to ensure that nurses are familiar with how to approach a given situation.

Education and awareness. Elder abuse education can be crucial to helping caregivers, including nursing assistants, understand the seriousness and scope of this problem and the signs, symptoms, and recommended reporting practices.12, 13 Familiarity with best practices for combating the physical, psychosocial, financial, and legal aspects of elder abuse prepares nurses to help improve quality of life for elders.

Nurse educators can incorporate elder abuse education into nursing and interprofessional programs. Education can include lessons on how to identify, report, and prevent elder abuse. Students in bachelor's-degree, master's-degree, and doctoral programs can be exposed to case studies and other educational projects to improve their competencies in cases of suspected elder abuse. Bachelor's-degree students can be assigned community education projects to raise the level of awareness and to help prevent abuse; master's and doctoral students can be encouraged to develop elder abuse educational programs as part of their graduate learning experience.

Participation in World Elder Abuse Awareness Day (June 15 of each year) can create opportunities to educate both lay and professional audiences. Relevant resource kits and press releases are available through the International Network for the Prevention of Elder Abuse (http://www.inpea.net).

In a joint project between the Center of Excellence on Elder Abuse and Neglect and the University of California, Irvine (http://www.centeronelderabuse.org), downloadable elder abuse training materials are available for nursing faculty. Nurses can also distribute educational tools, such as the two-page Elder Abuse: Clinician Reporting information sheet, available as a downloadable PDF through the Arizona Center on Aging. Nurses might consider customizing this information sheet with their organizational logo and distributing it as an educational tool.

Forensic nursing as a career. Those interested in becoming forensic nurses with a geriatric focus can obtain information from the International Association of Forensic Nurses (http://www.forensicnurses.org). A list of forensic educational programs is available on the organization's Web site, as well as a 24-hour, 12-module curriculum, Nursing Responses to Elder Mistreatment; this continuing education opportunity can train RNs who provide care to vulnerable elders across settings. Those in leadership roles wishing to educate their nursing staff and fellow team members may find this curriculum helpful.

Policy and advocacy. Eliminating abuse will require both clinical and policy efforts. Owing to the orientation of their education and its focus on health and wellness, nurses may gravitate toward advocacy within the clinical arena. Yet it's equally important that nurses engage in public policymaking. There are many avenues for nurses to influence policy at the federal, state, and local levels. For instance, professional associations visit federal and state elected officials regularly to raise the visibility of key health issues. Nurses with and without policy advocacy experience can join in such efforts. Nurses can also reach out-through phone calls, letters, e-mail, or in-person visits-to educate elected officials and their staff on the importance of supporting hearings and activities geared toward preventing and responding to elder abuse.

The importance of adequate funding. In making contact with elected officials, it is particularly vital to ask for financial support of elder justice. The EJA authorizes approximately $757 million, allocated over a four-year period, to back local and state efforts that address elder abuse and neglect and to improve the overall quality of life of our country's aging population. This is a major step forward. However, authorization does not automatically result in appropriations. The federal budget process is the primary vehicle for allocating such funds. When the economy is strong, funding is available to support key programs such as those provided for in the EJA. During our current economic climate, as we face challenges such as lack of bipartisan cooperation, sequestration, budget ceilings, and competition with other special interest groups for more limited discretionary funds, gaining traction and fiscal support are immense hurdles.

Since the EJA became law, progress has continued, but slowly. The Obama administration included $25 million in its proposed 2015 budget for support of the Elder Justice Initiative, with another $5 million to support data sharing across federal and state adult protective services databases and $11.2 million for elder abuse research. It's not yet clear how much of this funding has been or will be approved by Congress.14 This is a good start, but funding is always under threat. The program needs momentum and support from nurses and others nationwide.

Elder abuse is a human rights violation resulting in depression and anxiety as well as physical harms ranging from minor injuries to permanent damage or death. The EJA provides a real opportunity for nurses to come together to support this compelling cause. It's time that nurses collectively consider how to operationalize and sustain efforts to prevent and eliminate elder abuse. Let us address this crisis together as part of the worldwide elder justice effort.

Resources

Advocacy

Elder Justice Coalition

http://www.elderjusticecoalition.com

Assessment

Elder Mistreatment Screening Instruments

http://www.medicine.uiowa.edu/familymedicine/emscreeninginstruments

How to Try This Video: Elder Mistreatment Assessment

http://bit.ly/1o95chM

Elder Abuse Reporting

Arizona Center on Aging

Elder Abuse: Clinician Reporting

http://dev.aging.medicine.arizona.edu/sites/default/files/elder_abuse_clinician_

National Center on Elder Abuse-Administration on Aging

http://www.ncea.aoa.gov

National Council of State Boards of Nursing

http://www.ncsbn.org/index.htm

World Elder Abuse Awareness Day

International Network for the Prevention of Elder Abuse

World Elder Abuse Awareness Day

http://www.inpea.net/weaad.html

Contacting Your Elected Officials

United States House of Representatives

https://writerep.house.gov/writerep/welcome.shtml

United States Senate

http://www.senate.gov/pagelayout/general/one_item_and_teasers/contacting.htm

Elder Abuse Training Materials

Center of Excellence on Elder Abuse and Neglect, University of California, Irvine

http://www.centeronelderabuse.org/information_by_professional_discipline.asp#nur

REFERENCES