¹Hayla Nunes da Conceição

²Hidalia Silvestre Rodriguez Bernal

³Milena France Alves Cavalcante

⁴Ana Maria Ribeiro dos Santos

⁵Maria do Livramento Fortes Figueiredo

⁶Grazielle Roberta Freitas da Silva

¹Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brasil. ORCID: https://orcid.org/0000-0001-6035-8280.

²Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brasil. ORCID: https://orcid.org/0000-0001-6556-9730.

³Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brasil. ORCID: https://orcid.org/0000-0003-2580-9976.

⁴Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brasil. ORCID: https://orcid.org/0000-0002-5825-5335.

⁵Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brasil. ORCID: https://orcid.org/0000-0003-4938-2807.

⁶Universidade Federal do Piauí (UFPI), Teresina, Piauí, Brasil. ORCID: https://orcid.org/0000-0002-0402-6801.

Autora correspondente

Hayla Nunes da Conceição

Pós-Graduação de Enfermagem, sala 02, 1º andar. Campus Universitário Ministro Petrônio Portella, Bairro Ininga- Teresina, Piauí- Brasil. Bloco SG 12. CEP 64049-550. Contato: +55 (99) 98208-6669 - Email: haylanunes_cx@hotmail.com

FINANCIAMENTO

A pesquisa foi financiada pelas autoras

RESUMO

Objetivo: mapear os protocolos clínicos para atenção a idosos vítimas de violência. Métodos: revisão de escopo desenvolvida nas seguintes bases de dados/bibliotecas/buscadores: Biblioteca Virtual em Saúde, PubMed; Web of Science e Portal de Teses e Dissertações da CAPES. As buscas foram conduzidas por meio descritores constantes no MeSH e no DeCS, combinados com os operadores booleanos AND e OR. Resultados: foram selecionados nove artigos. Verificou-se iniciativas pontuais de protocolos estaduais e municipais, bem como a necessidade de constante atualização dos profissionais de saúde para o manejo e abordagem dos casos de violência contra o idoso. Considerações finais: a escassa quantidade de protocolos para a atenção a pessoa idosa vítima de violência deixa claro a necessidade da condução de pesquisa metodológicas para a elaboração e validação de protocolo, destinados a especificidade de atuação de diferentes profissionais que possam atuar frente a violência, possibilitando assim o trabalho baseado em evidências.

Palavras-chave: Idosos; Violência; Maus-tratos aos Idosos; Protocolo Clínico; Revisão.

ABSTRACT

Objective: to map clinical protocols for care for elderly victims of violence. Methods: scope review developed in the following databases/libraries/search engines: Virtual Health Library, PubMed; Web of Science and CAPES Theses and Dissertations Portal. Searches were conducted using constant descriptors in MeSH and DeCS, combined with the Boolean operators AND and OR. Results: nine articles were selected. Specific initiatives of state and municipal protocols were verified, as well as the need for constant updating of health professionals for the management and approach of cases of violence against the elderly. Final considerations: the scarce number of protocols for the care of elderly victims of violence makes clear the need to conduct methodological research for the elaboration and validation of protocols, aimed at the specificity of the performance of different professionals who can act in the face of violence, thus enabling evidence-based work.

Keywords: Elderly; Violence; Mistreatment of the Elderly; Clinical Protocol; Revision.

RESUMEN

Objetivo: mapear protocolos clínicos de atención a ancianos víctimas de violencia. Métodos: revisión de alcance desarrollada en las siguientes bases de datos/bibliotecas/motores de búsqueda: Biblioteca Virtual en Salud, PubMed; Web of Science y Portal de Tesis y Disertaciones de la CAPES. Las búsquedas se realizaron utilizando descriptores constantes en MeSH y DeCS, combinados con los operadores booleanos AND y OR. Resultados: se seleccionaron nueve artículos. Se verificaron iniciativas específicas de protocolos estatales y municipales, así como la necesidad de actualización constante de los profesionales de la salud para el manejo y abordaje de los casos de violencia contra el anciano. Consideraciones finales: el escaso número de protocolos para la atención de ancianos víctimas de violencia pone de manifiesto la necesidad de realizar investigaciones metodológicas para la elaboración y validación de protocolos, encaminados a la especificidad de la actuación de los diferentes profesionales que pueden actuar frente a la violencia, permitiendo así el trabajo basado en la evidencia.

Palabras clave: Anciano; Violencia; Maltrato a los Ancianos; Protocolo Clínico; Revisión.

INTRODUCTION

The demographic profile of the world population has been going through an intense transition with the increase in life expectancy and consequently the increase in the number of the elderly population worldwide. It is estimated that there are currently 962 million elderly people, considering the classification of elderly people for developing countries, and projections indicate that in 2100 this number will be three times greater(1).

The increase in the number of elderly people makes evident a problem associated with this public, violence. Violence against the elderly is defined as a single act, or repetition, or lack of appropriate action, occurring within any relationship where there is an expectation of trust that causes harm to the elderly(2). Worldwide, violence occurs among 1 in 6 elderly people, representing about 15% of this population. Thus, abuse of the elderly represents a challenge for public health because it is widely found in all countries of the world(3).

Although the occurrence of violence against the elderly is observed in all social classes, ethnic groups and in different contexts, the elderly who live alone or with their children, who are dependent to carry out activities of daily living, who are separated or divorced and the who have a low socioeconomic level have been identified as the most vulnerable to the occurrence of violence(4). Furthermore, being female has been identified as a factor that increases vulnerability to victimization(5).

Violence against the elderly population is not just a social problem, it comprises an important cause of early morbidity and mortality and increased use of health services(6). However, although it is in a privileged situation to act in an intersectoral response in the prevention, care and confrontation of violence, health services still have flaws in the management of violence against the elderly, either due to the lack of professional training or the disarticulation of the care network. violence with health services, interfering with care for the elderly and families(7-9).

The knowledge, skills and efforts of multidisciplinary teams are essential to prevent, investigate and provide assistance to elderly victims of violence. In this sense, there is a need for instruments that standardize the work of professionals to deal with cases of victimization of the elderly, such as protocols(10).

Clinical protocols for managing violence, as they are based on recent research that can be classified according to the level of evidence, allow professionals to make structured decisions regarding cases, manage resources and protect patient safety. In addition, it makes it possible to refer the patient to the health network to guarantee comprehensive care(10).

Despite the relevance of the theme, no studies were found in the scientific literature that propose to analyze and summarize the clinical protocols that guide the work of professionals in cases of violence against the elderly. From this perspective, the present study aims to map the clinical protocols for care for elderly victims of violence(1).

METHODS

This is a scoping review study. Scope reviews are very useful for scaling research evidence, mapping the existing literature in a given field and signaling gaps in the scientific literature(11). The research was carried out as proposed by the Joanna Briggs Institute (JBI) and presents 5 essential steps: 1) identification of the research question; 2) identification of relevant studies; 3) selection of studies for review; 4) data mapping; and 5) collection, summary and reporting of results(12). The review phases were previously structured in a protocol prepared by the researchers.

For the elaboration of the research question, the PCC strategy was followed, an acronym for Population (P), Concept (C) and Context (C)(13); being P (elderly), C (protocols) and C (violence). Based on these definitions, the guiding question was established: What clinical protocols exist in the literature for the care of elderly victims of violence?

Systematic searches were carried out between September and October 2021 and updated in November 2022, in the databases/data platforms: Virtual Health Library (VHL) and PubMed; Web of Science. The gray literature search was carried out on the CAPES Portal of Theses and Dissertations through the Federated Academic Community (CAFe).

This was followed by the definition of the descriptors and keywords contained in the MeSH (Medical Subject Headings) and DeCS (Health Sciences Descriptors): “Elderly abuse”, “Elderly abuse”, “Elderly abuse”, “ Abuse, Elder”, “Abuse, Aged”, “Elder Neglect”, “Neglect, Elder”, “Elder Maltreatment”, “Violence against the Elderly”, “Protocols”, “Protocols”, “Protocol, Clinical”, Clinical Protocol ”, “Clinical Protocols”. These descriptors and keywords were combined with the Boolean operators AND and OR, as shown in Chart 1.

Chart 2 - Description of studies included in the scope review on clinical protocols for care for elderly victims of violence.

Publication	Author and year	Country	Language	Kind of Study	Aim
P1⁽¹⁰⁾	Moore C, Browne C, 2017	United States	English	Systematic review	Identify and describe a range of innovations, best practices, and evidence-based practices, models, and programs in the field of elder abuse.
P2⁽¹⁶⁾	Choo WY, Hairi NN, Othman S, Francis DP, Baker PR, 2013	Malasia	English	Systematic review	Evaluate the effectiveness of primary, secondary, and tertiary intervention programs used to reduce or prevent, or both, elder abuse in organizational, institutional, and community settings
P3⁽¹⁷⁾	Frieiro-Padín P, González-Rodríguez R, 2020	Spain	Spanish	Document Review	Describe the current situation of mistreatment of older people, detailing existing protocols in the different autonomous communities of the Spanish State, in addition to studying the perspective of different professionals who work with older people and adults with disabilities
P4⁽¹⁸⁾	Jones J, Dougherty J, Schelble D, Cunningham W, 1988	United States	English	Review	Summarize the literature on geriatric abuse and describe an emergency department protocol for identifying and notifying suspected victims.
P5⁽¹⁹⁾	Navarro-Escayola E, Oliver-Moreno P, 2019	Spain	Spanish	Review	Describe the forensic medical action protocols for the recognition of elder abuse
P6⁽²⁰⁾	Barba-Martínez JM, Ferrer-Prior V, Gea-Serrano A, Guillén-Martínez RM, López-Asensio C, Tourné-García M, 2005	Spain	Spanish	Protocol	Establish guidelines for action, both in the area of public and private health, that facilitate the detection of indicators of maltreatment / mistreatment, establishing a multidisciplinary intervention.
P7⁽²¹⁾	Londrina, 2016	Brazil	Portuguese	Protocol	Updating the systematized information that will help and streamline the service process in our service network for people who are victims of interpersonal and self-inflicted violence
P8⁽²²⁾	Rio de Janeiro, 2020	Brazil	Portuguese	Protocol	Improve the flow of assistance to people in situations of violence in health units in the state of Rio de Janeiro
P9⁽²³⁾	Curitiba, 2012	Brazil	Portuguese	Protocol	Promoting and strengthening municipal actions for violence prevention and care and protection for elderly people who are at risk of violence or in situations of violence, through articulation and intersectoral and integrated action.

Source: Prepared by authors

DISCUSSION

Studies show that the accelerated increase in the elderly population, in Brazil and in the world, is due to multiple factors, including increased life expectancy, better access to health services and the creation of programs for healthy aging. In contrast to the increase in longevity, there is an abusive number of notifications that describe acts of violence against the elderly, which highlights the need for discussions about care for elderly victims of violence through clinical protocols(20,21). With this understanding, it is necessary to discuss the protocols of this review in two categories: Concepts, classification and risk factors for violence against the elderly; and Protocols for assisting elderly victims of violence.

Concepts, classification and risk factors for violence against the elderly

Violence against the elderly constitutes a serious public health problem, being responsible for the aggravation of diseases that affect aging. Violence is the intentional act of causing harm, be it physical, sexual, psychological, moral or patrimonial. Among the individual factors that most lead elderly people to be victims of violence are the loss of autonomy and dependence(4).

Physical violence is the damage caused by the use of physical force, leading to injuries. Sexual violence is that resulting from actions of sexual origin, such as forced sexual intercourse and libidinous gestures; psychological violence is the damage resulting from verbal abuse, oppression and threats; moral violence consists of slander, insults and defamation; and patrimonial violence, which corresponds to the usurpation of the elderly's goods and resources without their consent (4,5). According to the WHO, abuse, abandonment, negligence and self-neglect are configured as violence against the elderly(4,5).

The risk factors for violence against the elderly take into account characteristics of the victim and also the aggressor, the inherent factors are: quality of the relationship between the elderly and their children in the past, presence of stress in the caregiver or some psychopathology among the aggressors, physical disability/ elderly, dependency relationship between abuser and victim, substance use and abuse between caregivers/elderly and intergenerational violence (adults abused in childhood can become abusers of their elderly parents in a situation of dependence)(24).

The identification of risk factors is crucial so that prevention can be worked on, clarifying that violence against the elderly can often be unintentional and configures as a lack of preparation of the caregiver/family member to deal with the situation(21,22).

It should be clarified that the concept of domestic violence is different from family violence, in the former the intentional act of aggression was committed in the domestic sphere, not necessarily by a relative/family member (no blood ties), while in the latter the violence was perpetrated by a relative/ relative (with blood ties). Most cases of violence against the elderly occur at home, that is, at home, with elderly people over 70 years of age, who are dependent or frail(4).

Protocols for caring for elderly victims of violence

The protocols addressed in this review the guideline focus on the three levels of care, namely: primary level with educational programs and actions to prevent violence against the elderly; secondary level with early detection and approach in situations of violence, and tertiary level with rehabilitation programs and actions for victims and aggressors. The support network for the elderly is also an important device for the prevention, support and management of cases of violence against the elderly, as it allows responsible sharing of cases(23).

Most protocols provided comprehensive care for victims of violence, establishing specific skills for certain health professionals, with ethics and confidentiality being values that permeate all care and establishing the following care flow: prioritize care by risk classification; provide for the administration of medications, according to medical prescription; provide the supply of drugs for STI/HIV prophylaxis and emergency contraception, whenever necessary; complete the SINAN/MS individual notification form for interpersonal/self-inflicted violence, jointly (members of the multidisciplinary team), in case of suspected or confirmed violence(22).

Professionals who deal with cases of violence must be constantly attentive to the subtleties that accompany many cases, the way in which the victim and the aggressor are approached, many situations of violence can be detected with clear questions such as: if they can report occurrences of rough handling, confinement, or verbal or emotional abuse. Risk factors for violence are strong indicators, studies indicate that the risk of psychological and moral abuse is greater when the caregiver is a woman, and the risk of physical abuse is increased for male caregivers. Violence against the elderly occurs predominantly at home, the home becomes the stronghold of aggression(18).

Therefore, it will be up to the professionals to perform a detailed examination, as more than one type of violence could occur, pay attention to the presence of injuries, psychiatric, psychological and social examination. Faced with this need, it would explain why most of the studied protocols are multidisciplinary and a minority are specific, seeking to assist the elderly who are in institutions, as well as those who are outside them (home/network). It should be noted that for institutionalized elderly people, health surveillance is responsible for monitoring their living conditions(19).

Within the follow-up of the urgency and emergency network, the care flow of the emergency hospitals for the elderly victim is centered on the guidelines of the Reception with Risk Classification (ACCR) and is based on the typification of violence, the needs presented and the services of the network who will provide support, according to this classification: Psychological violence/negligence/others – (Green) refer to UBS/Health Department; Physical violence – depending on the type of injury, there may be a Green-Yellow and Red flow being forwarded to UBS, Health Department, Elderly Police Station and IML; and sexual violence, depending on the severity, the Green-Yellow and Red flow being referred to specialized services, the Elderly Police Station, IML, health department and UBS(21).

In the studied studies, it is evident that violence against the elderly must be seen with a preventive approach, in the early detection of cases of abuse and intervention, as well as in the permanent education of the health teams that provide assistance in the network. Violence against the elderly requires policies and interventions systematized in a network, the presented protocols seek to intervene in this problem in a broad way with the purpose of promoting health and preventing violence. Early detection of cases of violence and sharing on the network allows the different actors responsible for protecting the elderly to be held accountable. This serious public health problem requires constant updates from the professionals involved, with a better approach, better records and greater resolution(18-23).

Study limitations

Some limitations of this review need to be considered. First, because it is a scope review, several studies were included, not worrying about the quality or level of evidence. Few studies were found, which makes evident the scarcity of protocols for the management of violence against the elderly and hinders the in-depth analysis of the theme.

Contributions to the practice

The findings of this review contributed to the synthesis of knowledge about existing protocols in the literature, which favors the awareness of professionals, students, researchers and public authorities regarding the importance of the existence of protocols that subsidize assistance in the face of violence against the elderly, acting from prevention to effective care for victims, clearly demonstrates the need to formulate protocols that guide care at each level of care in the health care network.

FINAL CONSIDERATIONS

This review provided a summary of the protocols for managing violence against the elderly, which range from preventive actions to reducing the damage caused by violent episodes, aimed at primary, secondary and tertiary health services.

Despite this, a shortage of protocols for the care of elderly victims of violence developed by municipalities, states and national health care agencies was identified.
Based on this review, methodological research is suggested for the development and validation of protocols for care for violence against the elderly, aimed at the specificity of the work of different professionals who can act in the face of violence, thus enabling evidence-based work.

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20. Barba-Martínez JM, Ferrer-Prior V, Gea-Serrano A, Guillén-Martínez RM, López-Asensio C, Tourné-García M. Protocolo regional de prevención y detección de violencia en la mujer mayor de 65 años [Internet]. Madri: Consejería de Sanidad; 2005. [cited 2021 Sep 18]. 50 p. Available from: https://sms.carm.es/ricsmur/bitstream/handle/123456789/4084/Protocolo.regional.d.135083.0.pdf?sequence=1.

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Submission: 05-01-2023

Approval: 06-01-2023

Databases/ Libraries/ Search Engines/ Gray Literature	Search Strategy
BVS (BIREME)	(elderly) OR (elderly person) AND (protocols) AND (Elderly Abuse)
PubMed/ Medline	((“Aged” [Mesh] OR (Elderly)) AND (“Clinical Protocols”[Mesh] OR (Protocol, Clinical) OR (Protocols, Clinical) OR (Clinical Protocol))) AND (“Violence”[Mesh] OR (Atrocities) OR (Structural Violence) OR (Violence, Structural) OR (Assaultive Behavior) OR (Behavior, Assaultive) “Abuse, Elder” [Mesh] OR (Aged Abuse) OR (Abuse, Aged) OR (Elder Neglect) OR (Neglect, Elder) OR (Elderly Abuse) OR (Abuse, Elderly) OR (Elderly Abuses) OR (Senior Abuse) OR (Abuse, Senior) OR (Senior Abuses) OR (Elder Mistreatment) OR (Mistreatment, Elder) OR (Elder Maltreatment) OR (Maltreatment, Elder))
Web of Science: Core Collection	"elderly" (topic) OR "seniors" (topic) OR "Aged" AND "Protocols" (topic) AND "elderly abuse" (topic) OR "Elder Maltreatment” (topic) OR "Violence against the Elderly"
CAPES Theses and Dissertation Portal	“Elderly” AND “Clinical Protocol” OR “Clinic Protocol” AND “elderly violence” OR “elderly violence”

Publication	Title of protocols	Professional category addressed	Service for which it is intended	Type of interventions
P6⁽²⁰⁾	Regional Protocol for the Prevention and Detection of Violence in Women over 65 years of age	All public and private health professionals	Public and private health institutions	Prevention, detection and care for women over 65 years of age abuse victims.
P7⁽²¹⁾	Protocols for assistance to people in situations of violence. Interpersonal/ Self-provoked	Administrative assistant, social worker, psychologist, nursing assistant/technician, nurses, pharmacists, doctors, dental staff, physical educator, physiotherapist, speech therapist and others	-Health Care Network in the Municipality of Londrina.	Health promotion and violence prevention, presents general norms for clinical care, general and specific conduct according to the situation of violence and presents the care and social protection network for comprehensive care for people in situations of violence
P8⁽²²⁾	Protocol for Assistance to People in Situations of Violence	Nursing technicians, nurses, pharmacists, social workers, psychologists, physicians, on-duty managers, unit managers and areas at the central level of the Health Department of the State of Rio de Janeiro.	-Hospitals; -Maternity; - Ready Units Service – SES-RJ 24h UPS.	Promote the prevention of cases and protection of victims, comprehensive health care