2. Approximately 450,000 non-institutionalized
elderly person aged 60 and over were victims of
abuse and/or neglect, or about 1% to 2% of the
total population.
---National Elder Abuse Incidence Study pub. By
the US Administration on Aging (AOA)
Approx. 80% went unreported to adult protective
series (APS) agencies
3. ABUSE CATEGORIES
Physical Abuse
Willful infliction of physical pain or injury
Hitting, slapping, shaking, striking with objects, use of
physical or chemical restraints
Sexual Abuse
Nonconsensual sexual contact.
Rape, unwanted touching, sexual advances, or innuendos
4. Psychological Abuse
Conduct resulting in mental or emotional
anguish.
Threats to institutionalize or withhold medication,
nutrition, or hydration
Financial or Material Exploitation
Misappropriating an older person’s assets for
someone else’s benefit.
Theft and blackmail, coercion to change wills or other legal
documents to counter to the victim’s best interest
5. Neglect
Failureto provide the goods or services
necessary for maintaining health and avoiding
harm or illness
Active:
Intentional refusal to provide basic needs assoc. w/ hygiene
assistance, medications, food, and physical assistance when
needed for personal safety
Passive:
Unintentional ; the result of caregiver ignorance or inability
to provide for the patients’ basic needs.
6. Self- neglect
“A pattern of intentionally neglecting prescribed
self-care activities despite available resources and
knowledge”
Difficult to define due to conflicting individual and
ethnic perspectives
Concerns regarding mental competence frequently
complicate intervention, as do ethical issues
related to patient autonomy.
7. RISK FACTORS
Characteristics
common to victims of
abuse and neglect:
Female
>75 y.o
Poor health
Low income
Isolation
Alcohol abuse
History of mental illness or domestic violence
8. Warning signs assoc. w/ those who are at
risk of abusing or neglecting others:
Male
Financial dependence on the victim
History of substance abuse
History of prior violent acts
Current/prior history of psychiatric disorders
Caregiver burnout
10. Physician-Related
Underestimate prevalence of elder abuse
Don’t know how to assess for abuse
Failure to develop a systematic plan on how to
respond to identified abuse
Denials; reluctance to intervene, fear of
reprisal
11. ASSESSMENT
Careful history
Both patient and caregiver should be present
to observe their relationship, anxiety on part
of the patient or an overbearing attitude of the
caregiver
Patient must be interviewed privately; current
health status, living arrangements, financial
status, emotional stressors, and social support;
History of alcohol and drug abuse; sexual
history
12. Physical exam
Poor physical care and signs of psychosocial distress
Bruising; burns
Cognitive function
Injuries sec. to fall and abuse
Injuries that can’t be explained by patient’s history
Findings of sexual abuse
13. When elder abuse is suspected; document all
findings:
Written note
Diagram of injuries
Photographs
X-rays
Laboratory testing (CBC, BUN, Creatinine,
total protein, and albumin levels)
14. MANAGEMENT
Discuss concerns related to suspected abuse or neglect
Include in the treatment plan and enlist their active
support and participation
Involve professionals from other disciplines
To assist in the evaluation
Continued contact w/ a trusted family physician
Significantly enhance the intervention process
15. PREVENTION
Identifying those at risk
FPs developed long-term relationships w/ patients
and their families
Advantage in assessing and addressing patient as well as
caregiver risk factors
Homehealth care professionals or other
home-based service providers
Can observe both in the home environment
Office and home-based assessment
An excellent opportunity to determine the appropriate
level of care needed
16. COMMUNITY SERVICES
Coordination w/ community agencies staffed with
interdisciplinary teams trained
To deal w/ abuse and neglect situations from a social
and medical perspective
17. CONCLUSION
Proper care of elderly individual at risk for
abuse can and should be provided by FPs.
Adequate understanding of associated
warnings
Working relationship w/ supportive
community services
Meaningful doctor-patient relationship
All these can have a significant impact on the
emotional and physical well-being of older
patients.
There are many similarities between elder abuse and child abuse. At-risk seniors are frequently more difficult to identify than at-risk children due to social isolation, and problematic to treat given their assumed legal competence. For many abused and neglected older individuals, a visit to their FP may be the only point of contact with a professional capable of both identifying their concerns and coordinated needed intervention.
Failure to identify elder abuse and take appropriate action can have tragic results, as the risk of death among elderly individuals who experience abuse is 3x greater than that of the general population. Therefore, it is imperative for FP to develop the skills necessary to identify elderly patients at risk for abuse and create an effective management strategy. In addition, FPs need to be able to develop strategies to assist patients and their caregivers prevent abuse even before it takes place. This chapter covers the current definitions of abuse , risk factors for abuse associated with both the elderly and their caregivers , and barriers that elderly patients and their physicians face when dealing with abuse issues . It also reviews how to assess suspected elderly abuse victims, reporting guidelines, and treatment and prevention strategies.
Commonly used definitions related to elder abuse and neglect are as follows.
Self neglect is frequently omitted or reported separately in statistical summaries. Described in one study as a pattern….
There are a number of characteristics common to many victims of abuse and neglect. These include the ff:…… One important characteristic is the development of dementia. This disease frequently has a subtle onset that can go unrecognized for several years. Cognitive impairments greatly limit individuals’ ability to care for themselves, while impaired decision-making capabilities limit the autonomy and subsequent ability of depressed individuals to protect themselves from abusive and/or neglectful situations. While cause-and-effect relationships are difficult to establish, there does appear to be a significant comorbid association between psychiatric illness and elder abuse.
Similarly, there are warning signs…..these include…. Another important characteristics to recognize is caregiver burnout. Elderly patients who depend on others for care can generate significant amounts of stress for caregivers. While caregivers may be able to cope with day-to-day demands, they may decompensate when a crisis develops or simply exhaust themselves over time. It is vital that FPs identify caregiver stress and coordinate the support services necessary to relieve these stressors.
-One obstacle to recognizing elder abuse is that a substantial number of elderly individuals are socially isolated. A significant number live alone, and many are dependent on caregivers or other individuals for transportation. Physical limitations can further contribute to isolation by making it more difficult for the elderly to travel. -Often the patient-related barrier to recognition of abuse include fear of retribution. Older individuals may be reluctant to discuss problems with health care providers due to concern that will only make matters worse or result in in nursing home placement. -Cognitive impairments may prevent some individuals from recognizing the abusive nature of their situation, while others may rationalize that the treatment they receive as “normal” or acceptable given their circumstances
Physician barriers reducing the likelihood of identifying elder abuse are primarily knowledge –based. The strongest factor in predicting physician recognition of elder abuse is an understanding of the associated risk factors listed….. >Physicians also underestimate the prevalence of elder abuse, >do not know how to assess for abuse, > and fail to develop a systematic plan for how to respond to identified abuse. >Denials regarding the presence of abuse, reluctance to intervene, and >fear of reprisal further hamper appropriate identification.
Appropriate assessment of elderly patients where abuse is suspected includes a careful history and a targeted physical examination. Whenever possible, the initial portion of the history should be taken with both the patient and caregiver present. This allows the physician to observe their relationship, w/ particular attention given to anxiety on the part of the patient or an overbearing attitude on the part of the caregiver. Following the interview w/ both the patient and caregiver,px must be interviewed privately. Information should be obtained regarding curent health status, living arrangements, financial status, emotional stressors, and social support. A history of alcohol and drug abuse for the patient as well as the other members of the household should also be included as should a sexual history regarding any unwanted advances or physical contact.
Any individual suspected of being abused should have a comprehensive PE, w/c is best performed with the patient completely undressed. GENERAL SIGNS in an elderly individual suggesting abuse include appearance of physical care and signs of psychosocial distress. Particular attention should be given to the patient’s general appearance, skin integrity, neurologic status, and musculoskeletal and genitourinary system. A complete skin examination should include evaluation for bruising on flexor surfaces, bruises of different ages, and burns. Assessment of ambulatory skills, an important component in establishing if reported injuries occurred secondary to falls or represent signs of abuse, should also be considered as part of the neurologic evaluation. Musculoskeletal examination should consider possible signs of injury that cannot be explained by the patient’s history, whereas GUT exam includes findings suggestive of sexual abuse.
When elder abuse is suspected it is important to carefully document all findings. Documentation in addition to a written note, should also include a diagram of all injuries noted during the examination. If possible, dated polaroid photographs should be taken of each injury. Xrays of any injured area should be performed and if there is any suspicion that the elderly patient may have suffered a head injury –a CT brain scan should be done If clinical findings suggest malnutrition or dehydration, lab testing should be requested to document findings consistent w/ either of these conditions. An important component of assessing for elder abuse includes observing caregiver and patient interactions. Defensiveness and/ or irritability on the part of caregivers may be a sign of burnout. Prompt identification and intervention may be instrumental in preventing the occurrence of abuse or reducing the likelihood of continuing abuse
Whenever feasible, discuss concerns related to suspected abuse or neglect directly with the patient. Involve professionals from other disciplines to assist in the evaluation -Hospital social workers and case managers offer additional skills and are generally knowledgeable regarding available community services Even after referring the patient to an outside community, remain involved Continued contact w/ a trusted FP can significantly enhance the intervention process.
Prevention of elder abuse starts by identifying those at risk >FP who have developed long-term relationships with px and their families have a distinct advantage in assessing and addressing px as well as caregiver risk factors. Home healthcare professionals or other home based service providers can further extend this advantage by observing both the elderly patient and the caregivers in the home environment Combining office and home-based assessment can provide primary care physician an excellent opportunity to determine the appropriate level of care needed
The best adjustment to care provided by a FP is… A number of communities are looking to volunteer providers as well in an effort to expand the scope of available services