Transcript Elder Abuse

Elder Abuse
Christi Stewart, MD
November 23, 2006
Objectives
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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
A Little Bit of History
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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 king’s
maltreatment by his sons.
Medical Community Response
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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
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Eventually evolved into the National Center on Elder
Abuse (NCEA)
Prevalence of Elder Abuse
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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.
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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.
Why so difficult to measure?
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Vast majority of cases go unreported or
unsubstantiated.
Definitions of elder abuse can differ from
agency to agency, and person to person.
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Subject to cultural interpretation
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
Types of Elder Abuse
As defined by the NCEA:
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Physical abuse
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Sexual abuse
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Emotional/psychological abuse
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Financial or material exploitation
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Abandonment
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Neglect
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Self-neglect
Physical Abuse
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The use of physical force that might result in
bodily injury, physical pain, or impairment.
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Most readily substantiated form of abuse
Example: Mr. Smith is Mrs. Smith’s caregiver.
Frustrated by Mrs. Smith’s refusal to
bathe, Mr. Smith finally forces her
into
a bath and holds her there to
clean
her, resulting in bruises on
her
arms.
Sexual Abuse
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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.
Emotional Abuse
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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.
Financial Exploitation
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The illegal or improper use of an elder’s 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.
Abandonment
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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.
Neglect
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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.
Self-Neglect
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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 Alzheimer’s 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.
Prevalence of specific types of
abuse
Neglect
Psychologic
Financial
Physical
Abandonment
Miscellaneous
Sexual
48.7%
35.4%
30.2%
25.6%
3.6%
1.4%
0.3%
Risk Factors for Abuse
Substance abuse history by the caregiver
1.
Most likely alcoholism
Incidence of addiction in an abuser is 35%
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Older age
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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
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Occurs in 45-50% of victims
Risk Factors Continued
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Low income
Social isolation
Minority status
Low level of education
Previous history of family violence
Caregiver Burnout?
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Caregiver depression is sited as a separate
risk factor for abuse.
Perception of stress by the caregiver was
correlated with increased abuse.
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Actual stress level in the home was not.
Victim’s aggressive behavior toward
caregivers has been shown to increase the
probability of physical abuse.
Recognizing the Abuser
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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.
Recognizing the Abused
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Suspicious factors:
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Frequent admissions to
multiple hospitals
Surgeries secondary to
trauma
Irregular medical follow-up
Inattention to established
medical needs
Missed appointments
 Unfilled prescriptions
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Multiple, vague, somatic complaints
Recognizing the Demented Abused
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History of recent behavior changes
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Pseudo-seizures
Elective mutism
Aggressive behaviors
Refusal of medications
Withdrawal
Limited eye contact
Changes in appetite
Changes in sleep
Physical signs of abuse
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Poor hygeine
Poor nutrition
Poor skin integrity
Contractures
Excoriations
Pressure ulcers
Dehydration
Impaction
Malnutrition
Inappropriate dress
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Unexplained bruises
Restraint marks on wrists
Lacerations
Abrasions
Head injury
Unexplained fractures
Traumatic alopecia
Bite marks
Inguinal rash
Genital pain, itching
Medical Implications of Abuse
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Reduced quality of life of abused patients
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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.
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Abused elders are 3 times more likely to die.
Why Physicians Don’t Ask
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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
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.
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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.
AMA Screening Questions
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Has anyone ever touched you without your consent?
Has anyone ever made you do things you didn’t 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 didn’t 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?
Physician Responsibilities
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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.
Who Reports Abuse?
How to Report
Call in the report of suspected abuse
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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)
Reporting Process
Staff assign a priority to report depending
on suspected urgency
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Urgent/threatening situations are investigated
within 24 hours
Less urgent cases are investigated within 72
hours.
Staff investigate reports
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Alleged victims are visited.
Staff contact other parties who might know
about suspected mistreatment.
3.
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.
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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:
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Case is closed.
When staff confirm maltreatment:
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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.
And the Others?
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If an abused elder is determined to be
incompetent:
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A state guardian is appointed to make decisions
for the patient.
Abused elder is removed from the dangerous
situation and “temporarily” moved to a longterm 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
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Mandatory reporting:
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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 (717) 783-6207.
Voluntary Reporting
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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.
Other Facts
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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.
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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.
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State statutes are the only engine for combating elder
abuse.
Summary
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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.
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 doesn’t 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.
Resources
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Pennsylvania Dept of Aging
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National Center on Elder
Abuse
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www.aging.state.pa.us
www.elderabusecenter.org
National Committee for the
Prevention of Elder Abuse
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www.preventelderabuse.org
References
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Geroff AJ, Olshaker JS. Elder abuse. Emerg Med Clin N Am 2006;24:491505.
Gorbien MJ, Eisenstein AR. Elder abuse and neglect: an overview. Clin
Geriatr Med 2005;21:279-292.
Hansberry MR, Chen E, Gorbien MJ. Dementia and elder abuse. Clin Geriatr
Med 2005;21:315-332.
Joshi S, Flaherty JH. Elder abuse and neglect in long term care. Clin Geriatr
Med 2005;21:333-354.
Koenig RJ, DeGuerre CR. The legal and governmental response to domestic
elder abuse. Clin Geriatr Med 2005;21:383-398.
Simpson AR. Cultural issues and elder mistreatment. Clin Geriatr Med
2005;21:355-364.
Swagerty DL, Takahashi PY, Evans JM. Elder mistreatment. Am Fam Phy
1999;59:2804-2808.
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.org/default.cfm?p=statehotlines.cfm#pa
Protective Services for Older Adults (n.d.). Retrieved Nov 21, 2006 from
www.aging.state.pa.us/aging/cwp/view.asp?A=284&Q=173897