1. Simmons, Barbara PhD, RN
  2. Baxter, Jennifer Scotese BSN


Older women can be victims of intimate partner violence (IPV), and home healthcare clinicians should know what they can do. Although there is no instrument specific to screening for IPV in older women within the home environment, home healthcare clinicians can use currently available resources and lobby for better resources to screen for and serve older women who may be victims of IPV. Forensic nursing education can provide additional skills to identify possible victims of violence, gather evidence, document findings, and provide treatment and referrals.


Article Content

Home healthcare clinicians are in a unique position to assess for IPV in older women during routine home visits as they provide care to patients, as well as their families and caregivers (American Nurses Association [ANA], 2008), but there is little published literature regarding this issue. Shortened hospitalizations and the prevalence of chronic disease have increased the demand for community-based services. Unlike a hospital or clinic setting, home healthcare allows providers to see the same patients, over a prescribed period of time, where they live. This continuity of care enables the clinician to assess and determine if violence is occurring in the home and the options that are available to the patient if disclosure takes place. Clinicians practice independently and rely on their advanced skills in assessment, planning, implementation, and referral as part of their clinical practice. They may determine that additional physical, psychosocial, or environmental problems exist that require intervention and/or mandatory reporting. Recognizing and screening for IPV needs to be routinely included in home healthcare (ANA). The purpose of this article is to increase awareness among clinicians of the problem of IPV in older women, to discuss possible screening techniques for use in home healthcare, and to discuss implications for clinicians.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

IPV and Older Women: What we Know

Older women have been overlooked as victims of IPV (Beaulaurier et al., 2007; Zink et al., 2004). However, physical and verbal abuse from intimate partners occurs at similar rates for independent older woman as for younger women (Mouton, 2003). In that sample of 1,245 postmenopausal women ages 50 to 79 years, 5.25% reported being physically abused and 22.8% reported being verbally abused in the past year. The lack of attention to IPV in this population has resulted in limited screening as well as few available age-appropriate screening instruments and community resources.


IPV is defined as "physical and sexual violence, emotional abuse, and controlling behavior by a current or former partner" (Garcia-Moreno, C. et al., 2006). The Centers for Disease Control and Prevention (CDC) further categorize IPV as not only actual but also threatened acts of violence and abuse, including verbal insults, humiliation, isolation, and limited access to means of transportation and communication (Saltzman et al., 2002). In a study that included 9,178 Canadian women, the age group with the second-highest rate for all forms of IPV was women ages 55 and older (Romans et al., 2007). Overlapping types of IPV included financial abuse, in which women were prevented from knowing about or accessing family income. Most of the older women in this study were married (70%), had a college education (42%), were employed (54%), and considered themselves to be in good health (80%). However, they also reported nonsevere physical and/or sexual (8.7%), financial (4.1%), and emotional abuse (19.3%) (Romans et al.). IPV has typically been associated with younger women. However, the effects of IPV are the same at any age and include physiological and psychological problems (see Table 1) (Campbell, 2002; Woods et al., 2008).

Table 1 - Click to enlarge in new windowTable 1. Effects of Intimate Partner Violence on Health


There are few IPV statistics regarding older women. Numbers from older women are often omitted from reports on IPV due to statistical unreliability. Lower reported rates of victimization among mature women may be due to many factors (see Table 2) (Rennison & Rand, 2003; Zink, Jacobson Jr., Pabst, et al., 2006; Zink, Jacobson Jr., Regan, et al., 2006).

Table 2 - Click to enlarge in new windowTable 2. Barriers to Reporting IPV

Incidence and Prevalence

Bonomi et al. (2007) found that while the lifetime incidence of physical IPV for women 65 years of age and older was 18.1%, the incidence of controlling behavior and threats (verbal put-downs, humiliation, isolation, limiting activity) was 61.2%. Older women who disclosed being in abusive relationships for multiple years reported that emotional/verbal abuse (94%) was higher in incidence than physical (71%), economic (68%), or sexual abuse (34%) (Zink et al., 2004). Grossman and Lundy (2003) found that approximately 59% of a sample of women 55 years and older who were already using domestic violence programs stated that they were victims of abuse from their husband or ex-husband. Over 95% of those women were victims of emotional abuse, 70% physical abuse, and 10% sexual abuse. These findings are consistent with a study that found that the spouse was the perpetrator of abuse in 62% of victimized women ages 55 and older (Rennison & Rand, 2003).


Population-Specific Problems

Women of all ages face similar consequences of abuse. However, older women may also be at risk for other problems unique to their age (Paranjape et al., 2009). Older women may:


* be more likely than younger women to endure violence from intimate partners for a longer duration, to be in a current violent relationship, and to have negative physical and psychological effects (Vinton, 2003; Wilke & Vinton, 2005)


* be more vulnerable to having forced sex with an intimate partner who has engaged in risky behavior (Sormanti & Shibusawa, 2008)


* be at risk for more sexual health consequences due to their possible lack of knowledge of safe sex practices, such as how to appropriately use a condom or negotiate its use, and sexually transmitted infection issues (Sormanti & Shibusawa, 2008)


* lack marketable work experience and encounter ageism in the hiring process, thereby hindering financial independence that might help them leave an abusive relationship (Straka & Montminy, 2006)


* have personal and health-related barriers that prevent them from seeking help, especially if they depend on a spouse for transportation, medical insurance, and financial support (Phillips, 2000).



Barriers to Help-Seeking

The majority of abused women continue to stay in their abusive relationship (Grossman & Lundy, 2003). Older women's attitudes, beliefs, and needs are not well understood, nor are the strategies and interventions that will help them. Beaulaurier et al. (2005, 2007) conducted focus groups of 134 women ages 45 to 54 who agreed to talk about conflict in their personal relationships. Multiple factors were identified that prevented these women from seeking help for IPV. Internal barriers (emotions and perceptions) to help-seeking included:


* powerlessness


* self-blame


* secrecy


* hopelessness


* protection of the family.



External barriers (social and community) to help-seeking included the negative response or lack of response from:


* family


* clergy


* the justice system


* the community.



Thus, traditional gender roles, cultural norms, and the reluctance to discuss "private" issues isolate abused older women. As women age, their social support networks change, friends and family move, and community resources decrease. In seeking services from domestic violence programs, women most often requested emotional/personal support and/or legal assistance (Grossman & Lundy, 2003).


Other issues that impact whether or not an older woman seeks help from an abusive relationship are finances, employment, housing, and healthcare. Clinicians must be aware of such internal and external barriers when caring for older women. They also should pursue suspicious situations with empathy and acknowledgement of the added difficulties that older women in abusive relationships may face if they disclose their abuse or ask for help.



Few studies look at IPV screening of older women by healthcare providers (Sormanti & Shibusawa, 2008). Sixty percent of physicians and nurses have reported not having specific education in IPV-related issues (Gutmanis et al., 2007). This is particularly alarming because reports of victimization in general are most likely to come from physicians or other healthcare providers rather than the victims themselves (Nelson et al., 2004). Based on the research, there are various other reasons that older women are not screened. For example, some clinicians only screen for IPV in older women when physical injuries are noted (Nelson et al.). Additionally, the clinician's personal attitudes about the nature and privacy of abuse, limited knowledge of resources to which the patient can be referred once abuse is determined, and discomfort with the topic of abuse (Han, 2007) are all possibly obstacles to screening procedures and protocols in older women.


Cassidy (1999) suggested that the Domestic Violence Screening/Documentation Form, developed by the Family Violence Prevention Fund in 1996, be used in home healthcare to record disclosed or suspected IPV, assess patient safety, provide referrals and phone numbers, and indicate whether a report was made to child or adult protective services or law enforcement. Cassidy lists warning signs of IPV that the clinician may assess on a home visit, including:


* a recurrent history of injury


* unexplained injuries


* depression


* anxiety


* chronic pain


* substance abuse.



Clinicians can start the conversation about IPV by asking, "Has this ever happened to you?," "Do you feel safe?," "Have you ever been threatened?," or "Does anyone in the home get angry often?." Another method that the provider can use is to say that the screening is routine and no different than other screenings. This may relieve women from feeling singled out. Clinicians must become more comfortable with asking questions about IPV and documenting answers appropriately. Documentation should include the screening questions that were asked and the patient's responses. Clinicians should note if they identify any injuries and include a detailed description of the shape, location, and current state of the injury. Finally, the clinician should document what referrals were given to the patient. Even if the woman does not disclose abuse, thorough documentation will provide a history of the home healthcare encounter and information with which to follow up on future visits.


Based on the recommendations of Zink, Jacobson Jr., Regan et al. (2006), a specific instrument for assessing IPV in older women needs to be developed and tested. However, until then, the following is a list of currently available IPV screening tools and resources for general use:


* Family Violence Prevention Fund: Techniques for Screening (


* CDC: Screening Instruments (


* Family Violence Prevention Fund: IPV Identification and Response





* Domestic Violence Screening Questionnaire (Mouton, 2003)


* National Center on Elder Abuse (


* National Domestic Violence Hotline (


* National Advisory Council on Violence Against Women (


* IPV and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (


* IPV Screening Tools (Rabin et al., 2009)


* IPV Reporting Requirements (


* Elder Abuse Laws (;



Home Healthcare Clinicians: Responsibilities and Options

Home healthcare clinicians are in a unique position to screen for IPV. Since they provide care in the actual environment in which most abuse occurs, they have the opportunity to observe interactions between intimate partners and detect warning signs in abused women. Older women may be more comfortable in the familiar setting of their homes, allowing them to more freely disclose abusive relationships, describe their current coping mechanisms in dealing with abuse, and/or discuss available resources. However, the clinician must also remember that if the abuser is present, the home is not a safe environment for such discussions. In such cases, the clinician may arrange a time to talk with the woman while the potential abuser is absent. Clinicians must be sensitive to the needs of older female IPV victims. For example, many abused older women have been with their spouses for many years, and leaving may not be a realistic option for them. The clinician must be willing to accept her patient's decision and base care and prevention efforts on the context of that individual. Home healthcare nurses must know the state, county, and city services that are available for victims of IPV if disclosure occurs during a home visit. Telephone numbers for services should include the primary care physician, local shelters in the area, the national domestic violence hotline (1-800-799-SAFE[7223]), counseling services, government-sponsored programs for housing and education, help for immigrants, educational and employment opportunities, Department of Aging for each state, National Council on Aging (, senior services for each town/county, senior education opportunities (, local police department, and legal assistance, to name a few.


Health professionals are only mandated to report injuries resulting from IPV in a few states. However, state laws on the reporting requirements for healthcare providers vary dramatically, and each clinician should be aware of her local legal obligations. Mandated reporting of IPV is a controversial subject. While reporting can lead to prosecution of the abuser and help for the victim, there is also the potential that mandated reporting may increase risk for the victim. For example, if a woman seeks medical help or if a clinician suspects abuse and the crime is reported by the clinician against the wishes of the woman or before safe arrangements for the woman can be made, an abused woman may face retaliation by her abuser, lose her sense of autonomy, and lose trust in the confidentiality of the medical system. This may make women less likely to report IPV to a clinician. When caring for older victims of IPV, in addition to mandatory reporting laws regarding IPV, clinicians must also be aware if they are mandatory reporters of elder abuse. Therefore, even if a clinician is not mandated to report IPV, he or she may need to report elder abuse, regardless of what type of abuse is suspected or who the abuser is. Again, state laws differ on elder abuse reporting, but clinicians are responsible for knowing their local requirements. Discussions on whether IPV of an older woman should fall into an IPV or elder abuse category are needed to ensure that local laws and clinicians are acting in the best and safest way to benefit the patient. Whether clinicians are mandated to report or not by local laws, they should document their care and actions including assessment of injuries, safety plans discussed with the patient, and referrals given to the patient for further assistance.


Courses in forensic nursing will enable clinicians to better identify behavioral and physical symptoms of abuse, screen possible victims, preserve and collect evidence, report findings according to state and federal mandates, document findings thoroughly and objectively, and give legal testimony. According to the International Association of Forensic Nurses (IAFN) forensic nursing is the intersection of nursing science, criminal justice, and the law in the treatment of victims and/or perpetrators of violence across the lifespan (ANA & IAFN, 2009). Healthcare providers, with nurses often as first responders, work collaboratively with law enforcement agencies to holistically address the needs of victims of violence. Forensic nursing education adds an important component to home healthcare nursing. It provides nurses with additional and crucial skills to identify possible victims of violence, gather evidence, document findings, and provide treatment and referrals. Forensic nursing knowledge is rarely incorporated into basic nursing education. Unfortunately, every nurse, regardless of specialty or population served, will observe and respond to violence and its consequences in their career. Educators need to incorporate forensic knowledge into the curriculum so that nurses can provide the best care to all victims of violence. Research and the expansion of forensic nursing science will direct best practice in each specialty.


Since home healthcare clinicians interact with patients and family over time, it is easier for them to establish a long-term relationship in which victims are more comfortable discussing options. Clinicians are also are more familiar with city, state, and federal regulations that affect their practice, as well as community services that are available for patients. Nurses are part of a collaborative team of home health providers that may include social workers, physical therapists, occupational therapists, and aides. Nurses with forensic knowledge can more confidently screen and interview patients, assess for physiologic and behavioral symptoms of IPV, and determine what interventions or referrals are best used in the situation.


The clinician must explore appropriate social services, resources, and options for this population. While services may differ per community, the following are a few possibilities.


* Career services. The Tennessee Department of Labor and Workforce Development has established the Boomer Careers Web site and services to help Tennesseans ages 40 and above who need to acquire new job skills and find employment in a changing economic market. In addition, they designed the Senior Community Service Employment Program to assist low-income Americans ages 55+ to find jobs. In New York City, the Charlotte W. Newcombe Foundation has joined with Fordham University to assist mature women reentering the workplace (


* Legal resources. In Pennsylvania, the Elderly Victims of Domestic Violence Legal Project of the SeniorLAW Center provides comprehensive legal and social services to not only protect older women from abuse but also address their issues of housing, financial stability, custody and support, and long-term-care planning (


* Victim support groups. In Maricopa, Arizona, services have been specifically designed for older female victims of IPV to provide education, networking, support, and information on helpful community agencies. In addition, this community has a program that provides free, safe housing for up to 2 weeks for older victims of abuse, with more than 25 assisted-living facilities and nursing homes participating (




Home healthcare clinicians are an integral component of the care and well-being of older adults in the United States. Awareness of IPV among older adults is therefore necessary for clinicians working in the community. Older women are often invisible victims of IPV, and home healthcare clinicians are in a good position not only to assess for it but also to provide their patients with appropriate information and knowledge of available resources. This article has discussed options for screening for IPV. It has also identified the need for more awareness and population-specific tools for older women. Acknowledging barriers and demanding appropriate resources is vital to protecting older women from the unnecessary health consequences of abuse and restoring their voices as victims of IPV. Forensic nursing education might help clinicians respond best to patients in whom abuse is suspected. Home healthcare clinicians are uniquely positioned to play an important role in offering such help to lower rates of IPV among older adults.



The authors wish to thank Kevin Grandfield for editorial assistance.


This review was supported in part by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration.




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