Elder Abuse

1
Elder Abuse

• Christi Stewart, MD
• November 23, 2006

2
Objectives

• Obtain a better understanding of the prevalence
  of elder abuse
• Differentiate types of elder abuse
• Recognize risk factors for elder abuse
• Discuss medical implications of elder abuse
• Understand reporting regulations for PA in
  regards to elder abuse

3
A Little Bit of History

• Classical Greek culture supported euthanasia for
  the incurable old.
• Diogenes Syndrome - named for 4th century BC
  philosopher who shunned common comforts to live
  in a tub.
• Some ancient cultures supported ritual suicide of
  tribal elders during drought so food and water
  could be reserved for the more productive young.
• King Lear Shakespeare writes about the kings
  maltreatment by his sons.

4
Medical Community Response

• 1975 2 British journals published reports on
  Granny battering
• 1981 House of Representatives issues a report
  on Elder Abuse to bring problem to national
  attention.
• 1987 amendment to the Older Americans Act
  defined term of elder abuse
• 1990 Elder Abuse Task Force was formed
• Eventually evolved into the National Center on
  Elder Abuse (NCEA)

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Prevalence of Elder Abuse

• Actual incidence and prevalence of elder abuse is
  unknown and difficult to measure.
• It is believed that 3-5 of all elders have been
  a victim at some time.
• Some studies quote as high as 12 of elders.
• There are roughly 1 to 2.5 million abused seniors
  annually.
• Only 1 out of every 6 victims is likely to be
  reported to the authorities.

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Why so difficult to measure?

• Vast majority of cases go unreported or
  unsubstantiated.
• Definitions of elder abuse can differ from agency
  to agency, and person to person.
• Subject to cultural interpretation

7
Definition of Elder Abuse

• The willful infliction of injury, unreasonable
  confinement, intimidation or cruel punishment
  with resulting physical harm or pain or mental
  anguish, or the willful deprivation
  by a caretaker of goods or services
  which are necessary to avoid
  physical harm, mental anguish or
  mental illness.
• 1985 Elder Abuse Prevention, Identification
  Treatment Act

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Types of Elder Abuse

• As defined by the NCEA
• Physical abuse
• Sexual abuse
• Emotional/psychological abuse
• Financial or material exploitation
• Abandonment
• Neglect
• Self-neglect

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Physical Abuse

• The use of physical force that might result in
  bodily injury, physical pain, or impairment.
• Most readily substantiated form of abuse
• Example Mr. Smith is Mrs. Smiths caregiver.
  Frustrated by Mrs. Smiths refusal to
  bathe, Mr. Smith finally
  forces her into a bath and holds
  her there to clean her, resulting
  in bruises on her arms.

10
Sexual Abuse

• Nonconsensual sexual contact of any kind with an
  elderly person.
• Example Mr. Jones, a demented resident of a
  nursing home mistakes Mrs. Doe, another resident,
  for his wife, and is found one afternoon lying on
  top of her in her bed and stroking her.

11
Emotional Abuse

• The infliction of anguish,
  pain, or distress
• Example Bill lives with his daughter, Susan, who
  provides him care. However, Susan constantly
  reminds Bill of the sacrifices she makes for him,
  tells him that he is ruining her life, and
  complains that he is a chore and a burden for her.

12
Financial Exploitation

• The illegal or improper use of an elders funds,
  property, or assets.
• Example In exchange for providing his mother
  with care, a son insists that she
  buy him alcohol and cigarettes,
  not leaving her enough money
  to pay for all of her medications.

13
Abandonment

• The desertion of an elderly person by an
  individual who had physical custody or otherwise
  had assumed responsibility for providing care for
  an elder.
• Example Susan gets so frustrated with her
  demanding, agitated, demented father, that she
  storms out of the house one weekend for a
  break, leaving him completely alone and
  unsupervised for a number of days.

14
Neglect

• The refusal or failure to fulfill
  any part of a persons obligations
  or duties to an elder
• The most common form of
  abuse
• The most difficult form of
  abuse to validate
• Example Glenda is attempting to care for her
  frail mother while also caring for her four young
  children. Glenda is so busy with her children
  and home that her mother often goes unchanged
  after episodes of incontinence, resulting in a
  sacral ulceration.

15
Self-Neglect

• The behaviors of an
  elderly person that
  threaten his/her
  own
  health or safety.
• Example Beth tries to convince her father, John,
  to move into assisted living after he is
  diagnosed with early Alzheimers disease. He
  refuses, and when she finally visits him to speak
  to him in person, she finds him sitting alone in
  his house, physically weak and covered in filth.
  The house is filled with garbage and half-eaten
  meals, and infested with roaches.

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Prevalence of specific types of abuse

• Neglect 48.7
• Psychologic 35.4
• Financial 30.2
• Physical 25.6
• Abandonment 3.6
• Miscellaneous 1.4
• Sexual 0.3

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Risk Factors for Abuse

• Substance abuse history by the caregiver
• Most likely alcoholism
• Incidence of addiction in an abuser is 35
• Older age
• Elderly in the 80 age group are 2-3 times more
  likely to be abused or neglected.
• History of depression or mental illness of the
  care recipient
• Occurs in 45-50 of victims

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Risk Factors Continued

• Low income
• Social isolation
• Minority status
• Low level of education
• Previous history of family violence

19
Caregiver Burnout?

• Caregiver depression is sited as a separate risk
  factor for abuse.
• Perception of stress by the caregiver was
  correlated with increased abuse.
• Actual stress level in the home was not.
• Victims aggressive behavior toward caregivers
  has been shown to increase the probability of
  physical abuse.

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Recognizing the Abuser

• 47 of abuse cases were committed by the spouse.
• 19 of abuse cases were committed by the adult
  child.
• Males abuse more often than females.
• Caregiver dependence on the victim for financial
  assistance, housing, or other needs increases the
  risk for abuse.
• Alcohol abuse is the most common risk factor for
  physcial abuse.
• A poor premorbid relationship between caregiver
  and care recipient is a predictor of stress that
  leads to abuse.

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Recognizing the Abused

• Suspicious factors
• Frequent admissions to
  multiple hospitals
• Surgeries secondary to
  trauma
• Irregular medical follow-up
• Inattention to established
  medical needs
• Missed appointments
• Unfilled prescriptions
• Multiple, vague, somatic complaints

22
Recognizing the Demented Abused

• History of recent behavior changes
• Pseudo-seizures
• Elective mutism
• Aggressive behaviors
• Refusal of medications
• Withdrawal
• Limited eye contact
• Changes in appetite
• Changes in sleep

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Physical signs of abuse

• Poor hygeine
• Poor nutrition
• Poor skin integrity
• Contractures
• Excoriations
• Pressure ulcers
• Dehydration
• Impaction
• Malnutrition
• Inappropriate dress

• Unexplained bruises
• Restraint marks on wrists
• Lacerations
• Abrasions
• Head injury
• Unexplained fractures
• Traumatic alopecia
• Bite marks
• Inguinal rash
• Genital pain, itching

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Medical Implications of Abuse

• Reduced quality of life of abused patients
• Worsened functional status
• Progressive dependency
• Poorly rated self-health
• Feelings of helplessness
• Continued and worsened social isolation, stress
  and further psychologic decline
• Frequent ER visits
• Higher rate of hospitalization of abused elders
• Higher nursing home placement
• Abuse is an independent predictor for higher
  mortality.
• Abused elders are 3 times more likely to die.

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Why Physicians Dont Ask

• Lack of training in recognizing abuse
• Lack of time in office to deal with issues
• Reluctance to attribute signs of mistreatment
• Victim isolation
• Subtle presentations
• Reluctance in confronting the offender
• Reluctance to report if abuse is only suspected
• Lack of knowledge of how to report
• Empathy with abuser
• Request of victim

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How to Ask

• American Medical Association has recommended that
  all older adults be asked by physicians about
  family violence, even in the absence of overt
  symptoms that are suspicious for abuse or
  neglect.
• Interview should be conducted privately.
• Should take the form of dialogue when possible.
• Make questions a routine part of the interview.
• Document answers meticulously, using interviewees
  own words whenever possible.

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AMA Screening Questions

• Has anyone ever touched you without your consent?
• Has anyone ever made you do things you didnt
  want to do?
• Has anyone taken anything that was yours without
  asking?
• Has anyone ever hurt you?
• Has anyone ever scolded or threatened you?
• Have you ever signed documents you didnt
  understand?
• Are you afraid of anyone at home?
• Are you alone a lot?
• Has anyone ever failed to help you take care of
  yourself when you needed help?

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Physician Responsibilities

• To recognize or suspect elder abuse and neglect
  when present.
• To treat any medical problems associated with
  such maltreatment.
• To ensure a safe
  disposition for the
  patient.

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Who Reports Abuse?
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How to Report

• Call in the report of suspected abuse
• Office of Aging (717-299-7979)
• 9-1-1 or local police for serious life
  threatening or dangerous situations
• Eldercare Locator (1-800-677-1116)
• PA Protective Services for Adults
  (1-800-490-8505)
• PA Dept of Health (1-800-254-5146)
• National Domestic Violence Hotline
  (1-800-799-SAFE)

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Reporting Process

• Staff assign a priority to report depending on
  suspected urgency
• Urgent/threatening situations are investigated
  within 24 hours
• Less urgent cases are investigated within 72
  hours.
• Staff investigate reports
• Alleged victims are visited.
• Staff contact other parties who might know about
  suspected mistreatment.

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• Once the incident has been identified as
  protective and it has been determined that
  service provision is necessary, the Area Agency
  on Aging in most cases must have the older
  adult's consent to provide protective services.
• Permission is not required if the services have
  been ordered by a court, requested by the older
  adult's court appointed guardian, or provided as
  part of an involuntary, emergency intervention
  court order because of imminent risk of death or
  serious physical injury.

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• If staff cannot confirm maltreatment
• Case is closed.
• When staff confirm maltreatment
• Services are offered to the victim of abuse in
  the form of a written service plan.
• Competent victims have the right to approve or
  refuse the service plan.
• Competent adults have every right to refuse help
  from adult protective services.

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And the Others?

• If an abused elder is determined to be
  incompetent
• A state guardian is appointed to make decisions
  for the patient.
• Abused elder is removed from the dangerous
  situation and temporarily moved to a long-term
  care facility.
• The majority of those placed in long term care
  for their own protection end up becoming
  permanent residents.
• Fear of placement leads many abused elders to
  turn down their right to investigation.

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Pennsylvania Abuse Reporting Laws

• Mandatory reporting
• Employees and administrators of nursing homes,
  personal care homes, domiciliary care homes,
  adult day care centers and home health care are
  mandated to immediately report any suspected
  abuse of a recipient of care to the Area Agency
  on Aging.
• If the abuse involves serious injury, sexual
  abuse or suspicious death, reporters must also
  call police and the Pennsylvania Department of
  Aging at [phone].

36
Voluntary Reporting

• Any person who believes that an older adult is
  being abused, neglected, exploited or abandoned
  may file a report 24 hours a day.
• Abuse reports can be made on behalf of an older
  adult whether the person lives in the community
  or in a care facility such as a nursing home,
  personal care home, hospital, etc.
• Reporters may remain anonymous.
• Reporters have legal protection from retaliation,
  discrimination and civil or criminal prosecution.

37
Other Facts

• PA is one of four states in the US that does not
  require mandatory reporting of suspected elder
  abuse by physicians.
• PA spends 3.80 per person 75 yrs old residing
  in PA for elder abuse investigations and
  services.
• PA spends 45.20 per child in PA for child abuse
  services.
• There exists no federal policy or financing for
  investigation of suspected cases of elder abuse
  in the community.
• State statutes are the only engine for combating
  elder abuse.

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Summary

• Elder abuse is a very prevalent problem among the
  quickly expanding geriatric population.
• Recognition of risk factors for abuse will help
  the physician to know when to further question
  patients for signs of abuse.
• Only through awareness and a healthy suspicion
  are physicians able to detect elder mistreatment.
• Elders rely on physicians to provide help and
  strategies in dealing with abuse.
• Once it is reasonably suspected, elder
  mistreatment should be reported to adult
  protective services.

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• A 79 year old man comes to the office for
  follow-up. He lives with his son, who moved in
  with him last year to care for his father in
  exchange for room and board. In response to
  questions about his home situation, he reports
  that his son treats me pretty rough sometimes.
  The patient does not want to be separated from
  his son, nor does he want to move out on his own.
  The son works full time and drinks heavily at
  home. Sometimes he doesnt provide dinner for
  his father, and has left him for prolonged
  periods without helping him change his clothes or
  ensuring that he has food. The patient has a
  history of severe osteoarthritis of the knees and
  left hip, heart failure, and diabetes. He
  ambulates using a walker with moderate assistance
  from another person, is unable to transfer
  independently, and is afraid of falling.
• Physical exam reveals significant peripheral
  neuropathy and multiple bruises on his forearms.
  HR is 80 and regular. He has crackles at the
  bases of both lungs. Cognitive exam is normal,
  but he is depressed. His diaper is wet, and the
  skin in his perianal area is covered with dried
  feces.

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Resources

• Pennsylvania Dept of Aging
• www.aging.state.pa.us
• National Center on Elder Abuse
• www.elderabusecenter.org
• National Committee for the Prevention of Elder
  Abuse
• www.preventelderabuse.org

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References

• Geroff AJ, Olshaker JS. Elder abuse. Emerg Med
  Clin N Am 200624491-505.
• Gorbien MJ, Eisenstein AR. Elder abuse and
  neglect an overview. Clin Geriatr Med
  200521279-292.
• Hansberry MR, Chen E, Gorbien MJ. Dementia and
  elder abuse. Clin Geriatr Med 200521315-332.
• Joshi S, Flaherty JH. Elder abuse and neglect in
  long term care. Clin Geriatr Med 200521333-354.
• Koenig RJ, DeGuerre CR. The legal and
  governmental response to domestic elder abuse.
  Clin Geriatr Med 200521383-398.
• Simpson AR. Cultural issues and elder
  mistreatment. Clin Geriatr Med 200521355-364.
• Swagerty DL, Takahashi PY, Evans JM. Elder
  mistreatment. Am Fam Phy 1999592804-2808.
• Elder Abuse Awareness Kit. (n.d.). Retrieved Nov
  21, 2006 from http//www.elderabusecenter.org/pdf/
  basics/speakers.pdf
• State Elder Abuse Helplines and Hotlines. (n.d.).
  Retrieved Nov 21, 2006 from www.elderabusecenter.o
  rg/default.cfm?pstatehotlines.cfmpa
• Protective Services for Older Adults (n.d.).
  Retrieved Nov 21, 2006 from www.aging.state.pa.us/
  aging/cwp/view.asp?A284Q173897