Tradition of Excellence

SALAH PERLAKUAN, DEPRESI, DAN

BUNUH DIRI PADA LANJUT USIA

Oleh:
Tim Keperawatan Keluarga, Komunitas, dan Gerontik
Fakultas Keperawatan
Universitas Jember
GOALS Tradition of Excellence
• Improve quality of life for people with abuse, neglect, depression, and suicide
conditions
• Increase community awareness that abuse, neglect, depression, and suicide is
a preventable public health problem
• Change public perception about the stigma of mental illness, especially about
abuse, neglect, depression, and suicide
• Increase the ability of the public to recognize and intervene when someone
they know is abuse, neglect, depression, and suicide
• Advance understanding and treatment through research, prevention, and
education
• Support for increased research funding
 Types of Abuse
Physical Tradition of Excellence

Sexual

Neglect

Emotional/Psychological

Financial Exploitation
 Definitions
•ABUSE – The causing or allowing to be caused the infliction of physical Tradition of Excellence
pain, injury or mental anguish. Abuse includes unreasonable restraint or
confinement, verbal abuse and sexual abuse. OKLA.STAT.tit.43A § 10-103(A)(8)(2001)
•NEGLECT - A failure to provide protection, adequate shelter, clothing,
nutrition, health care, or causing or permitting harm or risk of harm
through the action, inaction or lack off supervision by another individual.
OKLA. STAT.tit.43A§10-103(A)(10)(2001)

•FINANCIAL EXPLOITATION – The improper use of a vulnerable adult’s

financial, real or personal resources for the benefit of another person,
through the use of undue influence, coercion, harassment, duress,
deception, false representation or false pretense. OKLA. STAT.tit.43A§10-103(A)(9)(2001)
 Tradition of Excellence
WHAT IS ELDER ABUSE?

• Elder abuse is the mistreatment or neglect of an elderly

person, usually by a relative or other caregiver. At greatest
risk are the frail and/or isolated.

• Elder abuse may include physical violence, threats of assault,

verbal abuse, financial exploitation, physical or emotional
neglect, or sexual abuse.
 Types of Elder Abuse
Tradition of Excellence
1. Financial or Material Exploitation: the illegal or improper use of an elderly
person’s funds, property or assets.
• Unusual or inappropriate activity in bank accounts.
• Signatures on checks, etc. that do not resemble the older person’s signature
or signed when the older person cannot write.
• Power of attorney given, or recent changes or creation of a will, when the
person is incapable of making such decisions.
• Unusual concern by caregiver that an excessive amount of money is being
expended on the care of the older person.
• Numerous unpaid bills, overdue rent, when someone is supposed to be
paying the bills for a dependent elder.
 Tradition of Excellence
• Lack of amenities, such as TV, personal grooming
items, appropriate clothing, that the estate can
well afford.
• Missing personal belongings such as art,
silverware, or jewelry.
• Deliberate isolation, by a housekeeper of an older
adult from friends and family, resulting in the
caregiver having total control.
2. Emotional /Psychological Tradition of Excellence

The infliction of anguish, pain or distress through verbal or non-

verbal acts such as: humiliating, insulting, name calling or
threatening, treating like a child
• Helplessness Fear
• Hesitation to talk openly Agitation
• Withdrawal Confusion
• Depression Denial
• Implausible stories Anger
3. Neglect Tradition of Excellence

the refusal or failure to fulfill any part of a person’s obligations or

duties to an elderly person; failure to provide necessary care
• Dirt, fecal/urine smell, or other health and safety hazards in
elder’s living environment.
• Rashes, sores, lice
• Elder is inadequately clothed
• Elder is malnourished or dehydrated
• Elder has an untreated medical condition
4. Physical & Sexual Tradition of Excellence

Any physical pain or injury which is willfully inflicted upon an elder by a

person who has care or custody of, or who stands in a position of trust with
that elder. This includes direct beatings, sexual assault, unreasonable
physical restraint, and prolonged deprivation of food or water.
• Cuts, lacerations, puncture wounds
• Bruises, welts, discoloration
• Any injury incompatible with history
• Injuries not properly cared for
• Poor skin condition, poor hygiene
Tradition of Excellence
• Absence of hair and/or hemorrhaging below scalp
• Dehydration and/ or malnourished without illness-
related cause
• Loss of weight
• Burns, which may be caused by cigarettes, caustics,
acids, friction from ropes or chains
• Soiled clothing or bed
• Genital bruising or irritation
5. Abandonment Tradition of Excellence

desertion or willful forsaking of an elder by

any person having the care and custody of
that elder, under circumstances in which a
reasonable person would continue to
provide care of custody.
6. Self Neglect Tradition of Excellence

behavior of an elderly person that threatens his or her own safety

or health
• Inability to manage personal finances, e.g. hoarding,
squandering, giving money away, failure to pay bills
• Inability to manage ADLs
• Suicidal acts, wanderings, refusing medical attention, isolation,
substance abuse
• Lack of toilet facilities or animal infested living quarters
 Tradition of Excellence
• Rashes, sores, fecal/urine smell, inadequate clothing,
malnourished, dehydration
• Changes in intellectual functioning, e.g. confusion,
inappropriate or no response, disorientation to time and
place, memory failure, incoherence, etc.
• Not keeping medical appointments
• Refusal of medication
Elder Abuse Tradition of Excellence

• The National Center on Elder Abuse (NCEA) broadly defines

and places elder abuse into three categories:
- Domestic Abuse
- Institutional Abuse
- Self-Neglect or Self Abuse
Domestic Abuse Tradition of Excellence

• This is abuse within a person's own home or the home

of a caregiver. This applies to several forms of
maltreatment of an older adult by someone such as a
spouse, adult child, or other relative. Additionally, a paid
caregiver providing home care services may also
mistreat an older adult.
Institutional Abuse Tradition of Excellence

• This is defined as maltreatment that occurs to older adults residing in a

facility such as a nursing home, assisted living facility, foster home, or
group home. In instances of institutional abuse, the perpetrator is usually a
staff member or other paid care provider who has a legal or contractual
agreement to provide care to the victim. In some instances another
resident may be the cause of the abuse.
• Contrary to conventional belief, reports indicate that 60.7% of abuse
claims occurred in domestic settings, while 8.3% of reports occurred within
a facility. However, this does not minimize the incidence of facility abuse.
With a rapidly growing elderly population, long-term residential facility use
is expected to rise. Studies monitoring abuse in long-term care residential
facilities are ongoing.
Neglect Tradition of Excellence

• The refusal or failure of an individual to fulfill any part of his or her duties or
obligations to an older person, including failing to provide an older person
with
• necessities such as food, shelter, personal safety, clothing, medicine, and
needed care. Neglect may also include the failure of a person who has
financial
• responsibilities to provide care such as paying for needed home care
services or the
• failure of an in-home paid care provider to deliver needed care.
Self-Neglect or Self Abuse Tradition of Excellence

• Self neglect or abuse refers to the fact that individuals may threaten their
own health or safety by failing to provide for their own basic daily needs.
This may result when an individual is cognitively impaired or when an
individual has a chronic illness that leads to the person being physically
not capable of providing for his or her own needs. It is important to
recognize that individuals who are mentally competent and physically
capable may also neglect themselves.
• Understanding the consequences of their actions, they may make a
conscious and voluntary decision to engage in acts that
threaten their health or safety. According to the 2004 Adult Protective
Services survey, self-neglect was the most common category of reported
incidences of maltreatment, accounting for 26.7 % of all investigated
reports.
Self-Neglect or Self Abuse - Indicators Tradition of Excellence

• Bedsores
• Dehydration and malnutrition
• Unsafe or Unsanitary living conditions
• Allowing an Alzheimer’s patient to wander unsupervised
• Increased medical complications due to lack of/improper
medication or care
 Crimes range from:
Tradition of Excellence

• Financial crimes: embezzlement, forgeries, robberies and larcenies

• Identity thefts
• Physical abuse
• Domestic violence
• Sexual abuse
• Serious neglect
• Coercion/threats/emotional abuse (often coupled with a financial
crime)
Prevention….Identify the risk factors : Tradition of Excellence

• Avoid isolation
• Stay social/active – volunteer, see friends
• Avoid living with a person with a history of abuse or violence
• Beware of family members with financial motivations or with substance
abuse issues
• Consider respite services to relieve caregivers
• Have friends and relatives remain involved and observant
• Consider Counseling
• Communicate
• Have relatives and friends visit at various times of the day – unannounced
Warning Signs Tradition of Excellence

• Abuser Often speaks for elder

• Abuser isolates elder
• Abuser controls mail, visits and phone calls
• Elder appears helpless, confused, hesitant to speak freely
• Elder has insufficient food and basic necessities
• Elder exhibits poor hygiene
• Untreated medical conditions
• Visible injuries
• Change in sleep, appetite or behavior
 Impact of Elder Abuse
Tradition of Excellence

§ Higher risk of death

§ Higher level of
psychological distress
§ Physical injuries
§ Pain and suffering
§ Loss of dignity
§ Loss of property and items of value
§ Profound financial cost
 Why Elders Don’t Report
Tradition of Excellence

vFear of repercussions
vFear of loss of independence
vEmbarrassment for not being able to protect
themselves or being duped
vDoesn’t want to get the perpetrator in trouble
vIncapacitated or unable to report
vElder doesn’t recognize abuse is happening
Indicators of Abuse from the Caregiver Tradition of Excellence

• Elder not given opportunity to speak for him/herself or

see others without the presence of the caregiver
• Attitudes of indifference or anger toward the
dependent person, or the obvious absence of
assistance
• Family member or caregiver blames the elder (e.g.
accusation that incontinence is a deliberate act)
• Aggressive behavior by caregiver toward the elder
 Tradition of Excellence
• Previous history of abuse to others
• Problems with alcohol or drugs
• Inappropriate displays of affection by caregiver
• Flirtations, coyness, etc as possible indications of inappropriate sexual
relationship
• Social isolation of family or isolation or restriction of activity of the older
adult within the family unit by the caregiver
• Conflicting accounts of incidents by family, supporters or victim
• Unwillingness or reluctance by the caregiver to comply with service
providers in planning for care and implementation
• Inappropriate or unwarranted defensiveness by caregiver
Depression Tradition of Excellence

• Affects some 10% of people aged 65 and above

• Depression in older people sometimes a continuation of depression from
earlier periods of life and sometimes a new development
• Appears to have multiple origins
• Can be connected with the personality factor of neuroticism
• Possible structural changes in the brain
• Possible genetic predisposition to imbalances of the neurotransmitter
noradrenaline; may be link between depression and physical illnesses
such as Alzheimer’s disease, heart disease, stroke, Parkinson’s
disease, cancer
Depression (cont’d) Tradition of Excellence

• Depression is connected with the loss of friends and loved ones, but
depression is a mental disorder that goes beyond sadness or bereavement.

• Loss of companions and friends will cause profound sadness, but mentally
healthy people bounce back within a year or so.

• Depression goes undetected, untreated in older people much of the time.

• May be overlooked because symptoms are masked by physical
complaints such as low energy, loss of appetite, and insomnia
• Healthcare providers tend to focus on older people’s physical health
than their mental health
Depression (cont’d) Tradition of Excellence

• Depression connected with memory lapses and other cognitive

impairment, such as difficulty concentrating

• Some cases of depression are simply attributed to the effects of

aging or misdiagnosed as dementia, even Alzheimer’s disease

• Depression in older people can usually be treated successfully

with the same means that work in younger people, such as
antidepressant drugs and cognitive-behavioral psychotherapy.
Depression (cont’d) Tradition of Excellence

• Untreated depression can lead to suicide, which is most common

among older people.
• Highest rates of suicide found among older men who
• have lost their wives or their partners
• lost their social networks
• fear the consequences of physical illnesses and loss of freedom of action
• Fewer older adults suffer from depression than younger adults,
suicide is more frequent among older adults, especially Caucasian
men.
Depression Tradition of Excellence

• Depression occurs 16-65% of elders living in the

community.
• Depression including: sleep disturbance, lake of
interest, feelings of guilt, lack of energy,
decreased concentration and, loss of appetite.
• Losses can lead to depression.
 Tradition of Excellence
Thoughts of death or suicide
• Weary of life
• Life isn’t worth living
• “I’d be better off dead.”
• “You’d be better off if I weren’t here.”
• Passive suicide
• Refuse to eat
• Refuse medications
Tradition of Excellence
Causes of Depression Tradition of Excellence

• Interaction of biological and psychosocial factors

• Possible genetic contribution
• Reaction in response to losses
• Unresolved grief
• Physical illnesses may lead to depression
• Medications may cause symptoms of depression
 Risk Factors Of Elderly Depression
Tradition of Excellence
1. Female gender
2. Being widowed or divorced
3. Medical illness, e.g. stroke, neurological disorders
4. Functional disability
5. Family and personal history of depression
6. Social isolation
7. Life events
8. Medications, e.g. antihypertensives, steroids and antiparkinsonian drugs
9. Caregiving, e.g. carers of people with dementia
Etiology (1) Tradition of Excellence
• Social: reduced social networks, loneliness, bereavement, poverty,
physical ill health
• Psychological: low self-esteem, lack of capacity for intimacy, physical ill
health
• Biological: neuronal loss/neurotransmitter loss, genetic risk, physical ill
health
• Disease:
• Direct: CVA, Parkinson's disease, thyroid disease, Cushing's disease,
Hungtington's disease
• Indirect: pain, disability, chronicity, poor diet, decreased activity
Etiology (3) Tradition of Excellence

• Drugs:
• Digoxin, L-dopa, steroid
• Beta-blockers, methyldopa
• Chronic benzodiazepine use
• Phenobarbitone
• Neuroleptics in chronic use
The research evidence is overwhelming - depression is far more than a
sad mood. It includes: Tradition of Excellence
1. Weight gain/loss
2. Sleep problems
3. Sense of tiredness, exhaustion
4. Sad or angry mood
5. Loss of interest in pleasurable things, lack of motivation
6. Irritability
7. Confusion, loss of concentration, poor memory
8. Negative thinking (Self, World, Future)
9. Withdrawal from friends and family
10.Sometimes, suicidal thoughts
(DSMIVR, 2002)
39
 Warning Signs : Depression Tradition of Excellence

Physical Changes in Thoughts and Feelings

• Aches, pains, or other physical complaints • Feelings of hopelessness and helplessness
• Marked changes in appetite • Feelings of worthlessness
• Change in sleep patterns • Impaired concentration
• Fatigue • Problems with memory
• Indecisiveness
Emotional • Recurrent thoughts of death and suicide
• Pervasive sadness Changes in Behavior
• Apathy • Loss of interest in previously enjoyed activities
• Decreased pleasure • Neglect of personal appearance
• Crying for no apparent reason • Withdrawal from people
• Indifference to others • Increased use of alcohol
• Increased agitation
• Talking about the "end"
Verbal Expressions
Tradition of Excellence

• Common statements
• I shouldn't be here
• I'm going to run away
• I wish I were dead
• I'm going to kill myself
• I wish I could disappear forever
• If a person did this or that ., would he/she die
• Maybe if I died, people would love me more
• I want to see what it feels like to die
Some Behavioral Warning Signs Tradition of Excellence

• Common signs
• Previous suicidal thoughts or attempts
• Expressing feelings of hopelessness or guilt
• (Increased) substance abuse
• Becoming less responsible and motivated
• Talking or joking about suicide
• Giving away possessions
• Having several accidents resulting in injury; "close calls" or
"brushes with death"

ElderCare Gatekeeper Training 42

Assessment of suicidal risk Tradition of Excellence

• Asking about suicidal inclinations does not make suicidal

behaviour more likely
• Willingness to make tactful but direct enquiries about a patient’s
intention
• Be alert to factors that signify an increased risk of suicide
• Consider known risk factors
• Assess current suicidal risk
• Assess suicidal intent – planning, preparation, precaution
against discovery, final rite, verbal cues, suicide note
• Collateral information
Suggested questioning sequence Tradition of Excellence

• Whether the patient:

• hopes things turn out well
• gets pleasure out of life
• feels hopeful from day to day
• feels able to face each day
• ever despairs about things
• feels life to be a burden
• wishes it would all end
Suggested questioning sequence Tradition of Excellence

• Whether the patient:

• knows why he/she feels this way
• has thought of ending life
• has thought about the possible methods
• has ever acted on any suicidal thoughts or intentions
• feels able to resist any suicidal thoughts
Impact Of Depression On Religious Beliefs Tradition of Excellence

• Many older people have strong religious faith, or have been involved in their religion
all their lives
• Most find more comfort than strain associated with religion
• But depression is associated with feelings of alienation from God
• Suicidality can be associated with religious fear and guilt, particularly with belief in
having committed an unforgivable sin for simply thinking of suicide
• This religious strain is associated with greater depression and suicidality, regardless of
religiosity levels or the degree of comfort found in religion
(Sanderson, 2000)

ElderCare Gatekeeper Training 46

Interventions for Depression Tradition of Excellence
• Involve the person’s family
• Obtain an evaluation by a professional
• Every interaction has the potential to help
• Communicate a caring attitude
• Support and encourage
• Provide opportunity for social interactions
• Involve in scheduled or structured activities
• Spend time with the person and listen
Interventions for Depression Tradition of Excellence

• Encourage physical activity

• Mobilize support systems
• Monitor physical health
• Medication monitoring
• Nutrition and weight
• Sleep
• Comfort and relaxation
• Management of pain
• Beware of being “too cheerful”
 Interventions for Depression Tradition of Excellence

• Antidepressant medications take time to exert a therapeutic

effect
• Monitor for suicidal thoughts, especially as depression starts
to improve
• Promote a positive attitude toward the future – “I know that
you feel this way now, but you won’t always.”
• Remember that depression is usually very treatable over time
Psychosocial interventions Tradition of Excellence

• Basic psychotherapeutic processes:

• Listening and talking
• Release of emotion
• Giving information
• Providing a rationale
• Restoration of morale
• Suggestion
• Guidance and advice
• The therapeutic relationship
Psychoeducation Tradition of Excellence

• Nature and pathogenesis of depression

• Use of a “Stress-diathesis” model
• Proposed treatment, expected side effects, delay in onset of
therapeutic response
• Expected duration of continuation and maintenance treatment
 Focus on Prevention
Evaluate the impact of…… Tradition of Excellence

q Facility management style

q Physical environmental
q Screening & hiring practices
q Consistency of the staffing model
q Staffing patterns & ratios
q Staff training on Abuse Prevention
q Staff empowerment
q Relationship-based culture change models
 References
Tradition of Excellence
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American Association of Suicidology. (n.d.). USA state suicide rates and rankings among the elderly and
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Journal of the American Geriatrics Society, 56(11), 2107-2111.
 References continued

National Institute of Mental Health, NIHM. (2007, April). Older adults: depression and suicide facts. Retrieved Tradition of Excellence
from http://www.nimh.nih.gov/health/publications/older-adults-depression-and- suicide-facts-fact-
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 www.suicidology.net/epa.
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Tradition of Excellence
Haw, C., Hawton, K., Niedzwiedz, C., & Platt, S. (2013). Suicide clusters: A review of risk Factors and Mechanisms.
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Hawton

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Tradition of Excellence