Physiotherapeutic interventions aimed at old people in situations of violence: a scope review

Dias, Adriana Luna Pinto; Almeida, Ana Maria de; Schveitzer, Mariana Cabral; Souto, Rafaella Queiroga

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Revista Brasileira de Geriatria e Gerontologia

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Review Articles • Rev. bras. geriatr. gerontol. 23 (3) • 2020 • https://doi.org/10.1590/1981-22562020023.200100 copy

Physiotherapeutic interventions aimed at old people in situations of violence: a scope review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

Identify physical therapy interventions aimed at old people in situations of violence.

Method

This is a scope review, in which the following databases/libraries/search engines and gray literature were accessed: VHL, PubMed, Web of Science, Scopus, CINAHL, PEDro, BDTD, OpenGrey, OpenThesis, RCAAP, CAPES Thesis and Dissertation Portal, DART-Europe E-theses Portal and Theses Canada Portal. The searches used the descriptors and keywords, which were combined using the Boolean operators OR and AND: Fisioterapeutas, Fisioterapia, “Physical Therapists”, Physiotherapy, “Physical Therapy”, “Physical Therapy Specialty”, “Physical Therapy Modalities”, Rehabilitation, Reabilitação, “Elder Abuse”, “Maus-tratos ao Idoso”, “Physical Abuse”, “Elder Neglect”, “Aged Abuse” e “Elder Mistreatment”.

Results

Of the 601 records found, 46 were excluded because they were duplicated, and 555 were selected to read the respective titles and abstracts. 548 publications were excluded because they did not meet the inclusion criteria, and 7 papers were pre-selected. Through the Snowballing strategy, one was identified, resulting in a final result of 8 studies.

Conclusion

Physical therapy interventions aimed at old people in situations of violence include: health education, measures of caregiver stress, community resources, screening/triage, evaluation, identification, therapeutic/rehabilitation plan and reporting. In view of the findings, it is observed that, despite the lack of knowledge on this topic, the physiotherapist plays an essential role in the conduct of cases of violence against old people.

Keywords
Helth of the Elderly; Violence; Elder Abuse; Delivery of Health Care; Physical Therapy Specialty

Databases/ Libraries/ Search engines/ Gray Literature	Search Strategies
VHL (BIREME)	(tw:(fisioterapeutas OR fisioterapia OR "Physical Therapists")) AND (tw:("maus-tratos ao idoso" OR "elder abuse"))
PubMed Central: PMC	((“Physical Therapists” OR “Physical Therapy Specialty” OR “Physical Therapy Modalities” OR Rehabilitation OR “Physical therapy” OR “Physiotherapy”)) AND (“Elder abuse” OR “Physical abuse” OR “Elder neglect” OR “Aged abuse” OR “Elder mistreatment”)
Web of Science: Coleção Principal	(“Physical Therapists” OR “Physical Therapy Specialty” OR “Physical Therapy Modalities” OR Rehabilitation OR “Physical therapy” OR “Physiotherapy”) AND (“elder abuse” OR “Physical abuse” OR “Elder neglect” OR “Aged abuse” OR “Elder mistreatment”)
Scopus (Elsevier)	((Physical Therapists OR Physical Therapy Specialty OR Physical Therapy Modalities OR Rehabilitation OR Physical therapy OR Physiotherapy) AND (Elder abuse OR Aged abuse))
CINAHL (EBSCO)	(“physical therapists” OR “physical therapy” OR rehabilitation OR “physical therapists specialty”) AND (“elder abuse” OR “aged abuse” OR “elder neglect”)
PEDro	Simple search: “Elder abuse”, “Aged abuse”, “Physical abuse”, “Elder Neglect”, “Elder mistreatment”
BDTD	Fisioterapeutas OR fisioterapia OR reabilitação AND “maus-tratos ao idoso”
OpenGrey	((“physical therapists” OR “physical therapy” OR rehabilitation) AND (“elder neglect” OR “physical abuse” OR “elder abuse” OR “aged abuse”))
OpenThesis	("physical therapists" OR "Physical therapy" OR rehabilitation) AND ("elder abuse" OR "aged abuse" OR "elder neglect")
RCAAP	fisioterapia OR "physical therapists" AND "elder abuse" OR "maus- tratos ao idoso"
CAPES Thesis and Dissertation Portal	fisioterapeutas OR fisioterapia OR reabilitação AND “maus-tratos ao idoso”
DART	("physical therapists" OR "Physical therapy" OR rehabilitation) AND ("elder abuse" OR "aged abuse" OR "elder neglect")
Theses Canada Portal (Aurora and Voilà)	("physical therapists" OR "physical therapy" OR rehabilitation OR "physical therapist modalities") AND ("elder abuse" OR "aged abuse" OR "elder neglect" OR "physical abuse")

Author(s), Year/Type of study	Main Author Formation	Professional category(ies) addressed	Study objective(s)
Dalton, 2005¹⁸18 Dalton A. Family Violence: Recognizing the Signs, Offering Help. PT Magazine. 2005;13(1):34-40./ Editorial	Not identified	Physiotherapist	Discuss child violence, by the intimate partner and old people, examining the multiple ways that physical therapists and their assistants can recognize and provide care to the victims of such violence.
Saliga et al., 2004¹⁹19 Saliga S, Adamowicz C, Logue A, Smith K. Physical Therapist’s Knowledge of physical elder abuse: signs, symptoms, laws, and facility protocols. J Geriatr Phys Ther. 2004;27(1):5-12./ Quantitative Descriptive	Physiotherapist	Physiotherapist	Determine the extent of knowledge of Physiotherapists in an urban Michigan segment, in three areas of violence management against old people: signs/symptoms of physical violence; mandatory state reporting laws; and professionals' knowledge about institutional reporting protocols. In addition to investigating whether the participants had already suspected or reported a case of violence against old people.
Little, 2002¹⁷17 Little CD. What every Physical Therapist should know about Elder Abuse. Gerinotes. 2002;9(4):5-9./ Reflection	Physiotherapist	Physiotherapist	Assist physiotherapists to recognize signs and symptoms of violence against old people; show prevalence and provide guidelines for determining this type of violence; and recommend interventions in suspected cases.
Camaratta et al., 2000²⁰20 Camaratta F, Fenstermaker J, Hoffman AJ, Kolongowski M, Tecklin JS. Elder Abuse and the Physical Therapist. Issues Aging. 2000;23(1):9-12./ Reflection	Physiotherapist	Physiotherapist	Provide a protocol for physical therapists who face possible violence against old people; provide information on signs and symptoms, laws governing complaints and an approach to intervention and documentation in these cases of violence.
Foose, 1999²¹21 Foose D. Elder Abuse: Stepping in and Stopping It. PT Magazine. 1999;7(1):56-62./ Editorial	Not identified	Physiotherapist	Share experiences of physical therapists' interventions in cases of violence against old people.
Holland et al., 1987²²22 Holland LR, Kasraian KR, Leonardelli CA. Elder Abuse: an analysis of the current problem and the potential role of the rehabilitation professional. Phys Occup Ther Geriatr. 1987;5(3):41-50./ Reflection	Occupational Therapist	Physiotherapist and Occupational Therapist	Review the literature on violence against old people and describe the potential role of the Physiotherapist and Occupational Therapist in their detection, treatment and prevention.
Mildenberger e Wessman, 1986²³23 Mildenberger C, Wessman HC. Abuse and neglect of elderly persons by family members: a special communication. Phys Ther. 1986;66(4):537-9./ Reflection	Physiotherapist	Physiotherapist	Provide physiotherapists with recognition of violence against old people, intervention procedures, prevention points and available community resources.
Tomita, 1982²⁴24 Tomita SK. Detection and treatment of elderly abuse and neglect: a protocol for health care professionals. Phys Occup Ther Geriatr. 1982;2(2):37-51./ Reflection	Social Worker	Occupational Therapist, Social Worker, Nurse, Physician and Physiotherapist	Describe a protocol for an integrated response by health professionals in the problem of violence against old people.

Author(s), Year	Physiotherapeutic interventions recognized and/or implemented by physical therapists aimed at old people in situations of violence
Dalton, 2005¹⁸18 Dalton A. Family Violence: Recognizing the Signs, Offering Help. PT Magazine. 2005;13(1):34-40.	Routine screening and triage (incorporate into the evaluation protocol); Observation of the patient's behavior (nervousness and tendency to distance themselves from others; non-adherence to the treatment program) and family members (impatience and unreasonable expectations on the part of family members); Documentation (history of multiple fractures, contusions, bruises or unusual skin injuries), using body maps; Report to the supervising physiotherapist; Guidelines (where to get advice, shelter and assistance from professionals); Provision of informative material to the patient; Complaint in accordance with current state law.
Saliga et al., 2004¹⁹19 Saliga S, Adamowicz C, Logue A, Smith K. Physical Therapist’s Knowledge of physical elder abuse: signs, symptoms, laws, and facility protocols. J Geriatr Phys Ther. 2004;27(1):5-12.	Observations/behaviors identified by professionals as potential sources of violence: malnutrition, wound healing, behavior changes, untreated injuries, inconsistent wound sites, caregiver refusal to leave the old person alone during visits, unilateral contusion, difficulty for the old person to walk/sit without evidence of musculoskeletal disease, family/caregiver who answer questions and do not allow decision making by the old person; poor hygiene with the use of inappropriate clothing. Knowledge of local laws; contact with a social worker or supervisor when faced with a case of violence; and complaint.
Little, 2002¹⁷17 Little CD. What every Physical Therapist should know about Elder Abuse. Gerinotes. 2002;9(4):5-9.	Identification: warning signs and indicators of physical abuse (multiple fractures/injuries at various stages of healing, contusions grouped in a regular pattern, bilateral bruises, groin injuries, dental fractures, injuries around the face and neck, glove and sock-shaped burns, irregular hair loss); emotional (confusion and disorientation, fear of strangers and the environment, depression or anger, ambivalence about the caregiver, hesitation of the patient to speak in the presence of the caregiver, low self-esteem, yearning for attention); financial (unexplained loss of social security, anxiety and lack of knowledge about financial status, lack of payment for contracted services, lost belongings); and negligence (deterioration of health, dehydration or malnutrition, dirt and excessive odor on clothes/body, absent auxiliary devices, inappropriate clothing for environmental conditions, unexplained apathy or fatigue, over/under-medication causing sedation). Assessment: interview with questions about security; observation of the patient's general condition, behavior and care; caregiver-patient interaction; neuro-musculoskeletal review (including fractures) and functional activities; geriatric scales. Interventions: documentation (description of injuries, use of body model and photos) and report to the authorities; educating the patient about his/her protection (staying active, sociable and informed about financial, legal and protection obligations for old people); functional independence plan (through therapeutic exercises and functional activities).
Camaratta et al., 2000²⁰20 Camaratta F, Fenstermaker J, Hoffman AJ, Kolongowski M, Tecklin JS. Elder Abuse and the Physical Therapist. Issues Aging. 2000;23(1):9-12.	Screening and triage incorporated into the care routine, involving direct questions away from family members/caregivers and observation of general signs of violence (frequent unexplained crying, anxiety, tremors, irritability, abuse of alcohol or prescription drugs, fear or suspicion of certain people in the residence); physical violence (bruises, black eyes, rope marks, open wounds, cuts, punctures, burns, fractures, broken glasses, laboratory findings of over/under-dosage medications, untreated injuries and in various stages of centralized healing - head, neck, breasts, abdomen, back and genitals); negligence (dehydration, malnutrition, untreated bed sores and poor hygiene). In all American states (with the exception of six of them), there are laws that require health professionals to report cases of violence against old people. Assessment including complaints, financial status, social support, emotional stress, observation of patient-family/caregiver interaction and physical examination to provide evidence. Intervention involving a specific security plan, education and validation of patient rights. Documentation, containing a record with body graphic, descriptions and photos of injuries.
Foose, 1999²¹21 Foose D. Elder Abuse: Stepping in and Stopping It. PT Magazine. 1999;7(1):56-62.	Recognition of the signs of violence, understanding its origins, referring to social services and reporting. Differentiation between real violence and the result of an accident/illness. Assessment of the need to indicate institutionalization in the absence of a family support network and/or caregiver. Screening for: physical/biomechanical problems; physical evidence of violence (contusions, hand-shaped bruises, head/neck injuries, dislocations, open wounds, broken glasses); signs of neglect (malnutrition, dehydration, poor care, multiple contractures and decubitus ulcers); inappropriate emotional interactions (aggressive behavior); social well-being. Assessment of the caregiver's physical, cognitive and social capacity to provide assistance to old person; need for additional assistance in care; and ways to relieve caregiver stress. Caregiver education regarding patient safe positioning/transfers, hygiene care, skin inspection and health-disease process. Ensuring fitness for the old person through exercise, making them less vulnerable, as part of the Conditioning against Crime Program.
Holland et al., 1987²²22 Holland LR, Kasraian KR, Leonardelli CA. Elder Abuse: an analysis of the current problem and the potential role of the rehabilitation professional. Phys Occup Ther Geriatr. 1987;5(3):41-50.	Detection of violence during assessment and treatment. More direct intervention consists of the rehabilitation of adaptive self-care skills (decreasing the old person's dependence), as well as information on energy conservation and the recommendation of auxiliary devices; in addition to helping the old person to rescue old leisure interests, identifying new areas of potential skills in domestic tasks, strengthening the family unit and increasing their self-esteem. Intervention in the family and caregiver structure, providing information on available community support resources (transportation and recreation services for old people, friendly visitors and geriatric daycare centers), alleviating the day-to-day responsibilities of caregivers. Community education on violence against old people.
Mildenberger e Wessman, 1986²³23 Mildenberger C, Wessman HC. Abuse and neglect of elderly persons by family members: a special communication. Phys Ther. 1986;66(4):537-9.	Recognition of warning signs for violence: physical (bruises on the chest, shoulders, back, arms or legs; cigarette burns; rope/chain marks resulting from physical restrictions; lacerations on the face; head injuries, absence of hair or scalp hemorrhage); psychological (behavior changes, being scared or upset, avoiding talking about the family); interruption of physical therapy treatment; family prevents the old person from remaining alone during visits; financial (the old person reports loss of money or valuables); negligence (physical deterioration, malnutrition, weight loss, neglected or broken teeth, broken glasses, poor hygiene, repeatedly used clothing); violation of rights (caregivers impose unrealistic restrictions on decision making by the old person, on physical mobilizations and opportunities for socialization). Interventions include family counseling and specific training for dependent old people caregivers; use of community support services (day care, home nursing service, accessible transport, financial assistance - allowing caregiver stress relief), social and health education. In suspected cases, the action will depend on the type of abuse and physical danger to the old person. If it threatens life, professionals must know local protection agencies to report.
Tomita, 1982²⁴24 Tomita SK. Detection and treatment of elderly abuse and neglect: a protocol for health care professionals. Phys Occup Ther Geriatr. 1982;2(2):37-51.	Functional assessment: assess activities of daily living (ability to self-care and prepare meals, use transport, shopping) and walking condition; observation of trauma or bruising, consistent with the patient's condition of dependence. Request a description of a typical day and your expectations about yourself and your caregiver. Physical examination: if there is an injury resulting from an accident, document the circumstances and record in sketches and graphics of the upper body and extremities; examine effects of over/under-medication, nutrition, hygiene and personal care. Assessment of burns, physical injuries to the head, bruises (bilaterally on the arm, clusters on the upper body), presence of bruises and injuries at different stages of resolution, fractures, falls, contractures, poor muscle tone and evidence of physical restriction; walking condition (if disabled it may suggest sexual aggression). Observation if the bruises presented on a hospital admission disappear during hospitalization (in this case, suspecting violence). Interview with the caregiver: age and sources of income of the caregiver, responsibilities inside and outside the home, expectations of the caregiver in relation to the patient and their difficulties experienced in caring for the old person; assessment of the caregiver's ability to withstand the stress of care and the support systems available to the caregiver. Educational plan: self-care education for the patient; inform the caregiver about the aging process. Therapeutic plan: instruction in self-care techniques to reduce dependence on caregivers; helping the patient with alternative arrangements, changing his life situation (using day centers, congregating housing or nursing homes).

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[1] Correspondence Rafaella Queiroga Souto rqs@academico.ufpb.br