Tradition of Exce

SALAH PERLAKUAN,
DEPRESI, DAN BUNUH DIRI
PADA LANJUT USIA
Oleh:
Tim Keperawatan Keluarga, Komunitas, dan
Gerontik
Fakultas Keperawatan
Universitas Jember
GOALS Tradition of Exce
• 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 Exce

Sexual

Neglect

Emotional/Psychologic
al

Financial Exploitation
 Definitions
•ABUSE – The causing or allowing to be caused theTradition of Exce
infliction of physical 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 Exce
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
1. Financial or Material Exploitation: the illegal or Tradition of Exce
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 Exce
• 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 Exce

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 Exce

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 Exce

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 Exce
• 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 Exce

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 Exce

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 Exce
• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

 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 Exce

Fear of repercussions
Fear of loss of independence
Embarrassment for not being able to
protect themselves or being duped
Doesn’t want to get the perpetrator
in trouble
Incapacitated or unable to report
Elder doesn’t recognize abuse is
happening
Indicators of Abuse from the Tradition of Exce
Caregiver
• 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 Exce
• 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
 Depression Tradition of Exce
• 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 Tradition of Exce
(cont’d)

• 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
Depression Tradition of Exce
(cont’d)

• 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
Depression Tradition of Exce
(cont’d)
• 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 Exce

• 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.
Thoughts of death or Tradition of Exce

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 Exce
Causes of Tradition of Exce
Depression
• 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 Exce
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 Exce
• 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 Tradition of Exce
(3)
• 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 Exce
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 39
 Warning Signs : Tradition of Exce
Depression
Physical Changes in Thoughts and
• Aches, pains, or other physical complaints Feelings
• Marked changes in appetite • Feelings of hopelessness and
helplessness
• Change in sleep patterns
• Feelings of worthlessness
• Fatigue • Impaired concentration
• Problems with memory
Emotional • Indecisiveness
• Pervasive sadness • Recurrent thoughts of death and
• Apathy suicide
• Decreased pleasure
Changes in Behavior
• Crying for no apparent reason
• Loss of interest in previously
• Indifference to others enjoyed activities
• Neglect of personal appearance
• Withdrawal from people
• Increased use of alcohol
• Increased agitation
• Talking about the "end"
Verbal
Expressions Tradition of Exce

• 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
Some Behavioral Tradition of Exce
Warning Signs
• 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 Exce
• 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 Tradition of Exce
sequence
• 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 Exce

• 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 Tradition of Exce
Religious Beliefs
• 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 Exce
• 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
Interventions for
Depression Tradition of Exce

• 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 Exce

• 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 Exce

• 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 Exce

• 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 Exce

 Facility management style

 Physical environmental
 Screening & hiring practices
 Consistency of the staffing
model
 Staffing patterns & ratios
 Staff training on Abuse
Prevention
 Staff empowerment
 Relationship-based culture