Elder Abuse Module 1 Overview Debra Mostek M

Elder Abuse Module 1 Overview Debra Mostek, M. D Asst. Professor Section of Geriatrics UNMC, 981320 Omaha, NE 68198 -1320 demostek@unmnc. edu April 2006

Elder Abuse • Module 1: Overview of Elder Abuse • Module 2: Self-Neglect • Module 3: Intervention

Objectives • Discuss screening for elder abuse • Identify historical features and physical findings associated with elder abuse • Demonstrate appropriate documentation of findings in the evaluation of suspected elder abuse

Definition Acts of omission or commission that result in harm or threatened harm to the health or welfare of an older adult. Diagnostic and Treatment Guidelines on Elder Abuse and Neglect AMA 1992

Prevalence • Data limited • 4% of individuals 65 years and older • Community prevalence: 32 per 1000 • 700, 000 to 1. 2 million • Underreported

Barriers to detection of elder abuse • Reluctance of victim to report • Lack of awareness • Failure to screen • Isolation of victims • Reluctance of healthcare provider to report

Screening all elders • Interview patient without caregiver: “Is there any difficult behavior in your family you would like to tell me about? ” § Ask yourself: Are the needs of this elder being met? § Most important: Victim Safety

Types of Elder Mistreatment • • Physical abuse Psychological abuse Abandonment Neglect (intentional or unintentional) – By others – Self-neglect (50 - 75% of all elder mistreatment) • Financial exploitation • Sexual abuse

Risk Factors • • Poverty Dependency Caregiver stress Age Race Isolation Depression • Frailty • Functional impairment • Cognitive impairment • Demented patient with behavioral disorder

History Red Flags • History inconsistent with physical findings? • Conflicting accounts from patient & caregiver • Failing to respond to usual therapy • Frequent use of ER, multiple providers, hospitals

History Red Flags • Delay in presenting for treatment • Hesitation to talk openly • Patient not allowed to speak for self without presence of caregiver • History of alcohol or drug abuse

Physical Examination Red Flags • Pattern of injuries • Multiple injuries • Injuries in different stages of healing • Unusual location of injuries

Physical examination findings: look for constellation suggesting neglect • Poor hygiene • Overgrown nails, matted overgrown hair • Infestations (lice, scabies, fleas)—multiple excoriated lesions over torso, extremities • Functional impairment • Pressure ulcers • Malnutrition • Dehydration Dyer CB: The Medical Management of Elder Abuse: A Practical Approach. Presentation. August, 2003

Evaluation • • History and physical Nutritional assessment Functional status Cognitive assessment: MMSE; Decisionmaking capacity; emotional assessment • Social assessment • Lab/radiographic exam

Documentation • Quote patient • Physical descriptions • Distinguish between aging, illness and injury, abuse indicators • Photographs • Concluding statement regarding the likelihood of abuse • Avoid the word “alleged”

Special issues re: dementia • Unreliable historian • Particularly vulnerable • Clinical clues may include behavioral changes • Missed appointments, failure to fill prescriptions

Medical Consequences of Elder Abuse • • • Decline in function Malnutrition Injuries Psychologic decline Increased risk of institutionalization Decreased life expectancy Clinics in Geriatric Medicine 21 (2005) 293

Reporting Elder Abuse • All healthcare providers are legally required to report any suspected elder abuse in the state of Nebraska • (402) 595 -3474 • 1 -800 -652 -1999

References • • Dyer CB: “Neglect”. Presentation at Conference: The Medical Management of Elder Abuse: A Practical Approach. August 22, 2003 Gunstone S. Risk assessment and management of patients whom selfneglect: a ‘grey area’ for mental health workers. Journal of Psychiatric and Mental Health Nursing. 2003; 10: 287 -296. Dong X. Medical Implications of Elder Abuse and Neglect. Clinics in Geriatric Medicine. 2005; 21: 293 -313 Hazelton LD, Sterns GL, et al. Decision-making capacity and alcohol abuse: clinical and ethical considerations in personal care choices. General Hospital Psychiatry. 2003; 25: 130 -135. Friedman SM, Williamson JD, et al. Increased Fall Rates in Nursing Home Residents After Relocation to a New Facility. Journal of the American Geriatrics Society. 1995; 43: 1237 -1242. Lachs MS, Williams CS, et al. Adult Protective Service Use and Nursing Home Placement. The Gerontologist 2002; 42(6): 734 -739 Dyer CB, Pavlik VN et al. The High Prevalence of Depression and Dementia in Elder Abuse or Neglect. Journal of the American Geriatrics Society. 2000; 48: 205 -208 Tierney MC, Charles J, et al. Risk Factors for Harm in Cognitively Impaired Seniors Who Live Alone: A Prospective Study. Journal of the American Geriatrics Society. 2004; 52: 1435 -1441

Post-test • A 75 -year-old man who has a history of heart disease is brought to the emergency department after an unwitnessed cardiac arrest. Resuscitation efforts are unsuccessful. The patient lived with his son and had been seen in the emergency department on numerous occasions for avoidable medical problems. Old rib fractures also were noted on chest radiographs. Medication adherence appeared to be poor. Which of the following statements is correct regarding elder mistreatment?

Which of the following statements is correct regarding elder mistreatment? A. It is an independent risk factor for mortality. B. It is the cause of this patient’s death. C. Cardiac disease is more likely to have caused this patient’s death. D. The majority of mistreated elderly persons die as a result of their injuries. Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

Correct Answer: A. It is an independent risk factor for mortality. Feedback: Older adults have a higher burden of chronic disease than younger victims of family violence; estimating the independent contribution of elder mistreatment on mortality can be difficult. Nonetheless, at least one large study, after adjusting for comorbidity and other factors known to predict death in older persons, demonstrated that mistreatment confers an independent risk for death. Although this patient’s home environment was not ideal, his death cannot be ascribed to abuse. However, to ascribe it primarily to cardiac disease also may be erroneous. The independent risk of death associated with elder mistreatment rivals the risks associated with many chronic diseases. No data support the idea that most victims of mistreatment die as a result of their injuries.