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Elder MistreatmentChallenges in Identification

and AssessmentDaniel Swagerty, MD, MPH

Professor of Family Medicine and Internal MedicineAssociate Director, Landon Center on Aging

Director of Clinical Geriatrics,University of Kansas School of Medicine

Definition of Elder Abuse *Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

* There’s lots of room for interpretation

Target PopulationOlder Adults: Aged 65 and Older

Dependent Adult: Age 18 - 64 Physical or Mental Impairments that Restrict Ability to Carry out Normal Activities or to Protect Own Rights.

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Epidemiology

More than 2 million US older adults per year The actual extent is unknown

UnderreportingUnderreportingPoor definitions

Prevalence about 5% of all older adults

Identification

Types of Elder MistreatmentPhysical Abuse – Least commonPhysical Neglect – Most commonPsychological Abusey gFinancial ExploitationViolation of Rights

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Physical AbuseAct resulting in pain, injury, impairment, or illnessExamples :

• Pulling a patient’s hair

• Slapping, hitting, and punching

• Throwing food or water on a patient

• Tightening a restraint to cause pain

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Physical NeglectFailure of caregiver to provide goods or services needed for optimal function or to avoid harm

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NeglectFailure of Caregiver or Patient to Exercise a Reasonable Degree of Care Failure to:

P id F d Cl thi Sh lt P l H iProvide Food, Clothing, Shelter, Personal HygieneObtain Needed Medical CareProtect from Health and Safety HazardsPrevent Malnutrition and Dehydration

Clues of NeglectRecurrent ER Visits or Hospital Admissions for Same ConditionInappropriate Delay in Seeking CareMalnutrition and DehydrationNon-Compliance with Medication RegimenMissed Medical AppointmentsPoor Hygiene and Disheveled AppearancePressure Ulcers

Psychological AbuseConduct that causes mental anguishExamples :Terrorizing and/or threatening a patient with a word or gesture

Inappropriate isolation of a patient

Yelling at a patient in anger

Denying food or privileges

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Financial ExploitationMisrepresentation of an older adult’s assets for benefit of another personExamples : Taking, Hiding, or Misappropriating Money or Property for Personal Use or Gain in Violation of the Older Adult’s Wishes or Trust.

Violation of RightsDeprivation of any inalienable rights

Personal LibertyPersonal PropertyAssemblySpeechPrivacyVoting

Reasons for Poor Identification/ Underreporting by Providers

Lack of training in identifying mistreatmentAgeismDisbeliefIsolation of victimsIsolation of victimsSubtle presentationReluctance to confront offendersReluctance to report suspected abuseUnsure about reporting proceduresFear of jeopardizing relationships with hospitals or nursing facilities

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Patient Risk Factors for Elder Mistreatment

Older AgeLack of access to resourcesLow incomeSocial IsolationMinority statusLow level education

Substance abuse by caregiver and/or older adultPsychological disorder and/or character

Caregiver Risk Factors for Elder Mistreatment

pathologyPrevious history of family violenceCaregiver burnout and/or frustrationCognitive impairment

AssessmentAssessment

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Physical AbuseAssault, Battery, or Force Likely to Produce InjurySexual AssaultProlonged or Continual Deprivation of Food and Water Punitive or Inappropriate Physical or Chemical Restraint

Signs of Physical AbusePattern InjuriesBruises and BleedsBurnsBurnsFracturesLacerations and AbrasionsHemorrhage

Injury AssessmentTypes of Injuries

BruisesP l

What to look for

LocationWhether history isPressure ulcers

FracturesBurns

Whether history is consistent with exam Old injuriesDelay in seeking care

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Pattern Injuries - Caveat

• Before Judging too Quickly...- Findings May Have

I t Eti l i

Heated “cups”

Innocent EtiologiesMark left by cupping

Pattern Injury

Whip Marks Left by Looped TelephoneTelephoneCord

Pattern Injury

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Pattern Injury

Suspicious Bruises in Older AdultsSuspicious Bruises

Face, MouthTorso, BackButtocksButtocksInner Aspect of Thighs or ArmsGenitalia

Multiple Bruises - Various StagesInaccuracy of Dating Bruises

Physical Abuse - Bruising

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BurnsCigar or CigaretteImmersion

Sock or Glove

PatternsRope, Iron, Burner

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FracturesSkull or FaceMultiple LocationsMultiple Stages of Healingp g gMisalignmentSpiral FracturesOccult Fractures

Lacerations and Abrasions

Neglect – Poor Hygiene78 Year Old Woman With Mild Alzheimer DiseaseDisease, Painful Walking, and Recurrent Falls. Lives with 50 Year-Old Son.

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Don’t Forget the Mouth!Potential Clues to Abuse & Neglect

34 Year Old Schizophrenic Male Living in Residential Care Facility

66 Year Old Former Attorney 6 Years after Cerebrovascular Accident

Care Facility

Financial AbuseAssess Mental StatusAssess Vulnerability

Depression and AnxietyBereavementPersonality

Neuropsychiatric Testing

DocumentationDocumentation

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Documentation * PhotosLab WorkLegible Writingg g

* May be used as evidence in a criminal trial!

How to DocumentLegible (Handwriting/EHR) and No AlterationsPertinent Positive and Negative FindingsReport Facts ObjectivelyUse Patient’s Own WordsDocument Each Source of InformationDates, Names and TimesNote Interactions between Patient and Caregiver

Forensic Documentation – Body Map

Detailed Descriptions, Sketches, and/or Photographs of InjuriesNote Size, Color, Shape, Location of Injuries and Bruises

Red

BRUISESjDocument Size, Depth, Stage, and Presence/Color of Exudate for Pressure UlcersPhoto documentation

Purple

Yellow-brown

Abrasion

BRUISES

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Elder Mistreatment Report Concise Statement Regarding the History and InjuryConcluding Statement Summarizing Likelihood of Abuse

Definite AbuseAccidentIndeterminate

ManagementPatient involved with resolutionDetermine decisional capacityMay need competency determinationSocial work resourcesMulti-disciplinary teams – Primary care physician/geriatrician, social worker, case management, RN, representatives from legal, finance, and adult protective services

ReportingReporting

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Reporting Elder MistreatmentAll health care providers and administrators are mandated by law to report suspected elder mistreatment !Laws differ from state to state You are immune from civil liability if you act in good faith and without malice.

Reporting Elder MistreatmentIf you fail to report you risk fines, jail, or loss of license.Report to state or county division of adult protective services, or child and family services.p yArea Agency on Aging are usually a great resourceNational Domestic Violence Hot Line: (800) 799-SAFEOlder Women’s League: (800) 825-3695

Elder MistreatmentConclusion

Prevalent – About 5 % of all older adultsPhysical Abuse most common and Physical Neglect least commonPoorly Identified and Reportedy pPatient Risk factors – Cognitive and Physical Impairment, Isolation, Substance Abuse, Low Income and EducationCaregiver Risk Factors – Substance Abuse, Psychological/Character Pathology, Caregiver Burnout, Cognitive Impairment