Transcript Elder Abuse in Long Term Care

Elder Mistreatment in Long
Term Care
Laura Mosqueda, M.D.
Director of Geriatrics
Professor of Family Medicine
University of California, Irvine School of Medicine
Abuse is the willful infliction of
injury, unreasonable confinement,
intimidation, or punishment with
resulting physical harm, pain, or
mental anguish.
…. Or the potential for harm.
Comparisons with Child Abuse
• Many have compared the current
state of medical knowledge about
elder mistreatment with the state of
knowledge about child abuse and
neglect 30 years ago
Difficulty with Detection/Diagnosis
• Medical picture of the elderly much
more complex than that of a child
• Bad outcomes and death are more
likely for the elderly than for children
• Abuse and neglect are rarely observed
• Difficult to link physical signs with
diagnoses
Types of Abuse
• Physical
• Psychological/Emotional
• Neglect
• Abduction
• Sexual
• Financial
Types of Abuse
• Physical
• Psychological/Emotional
• Neglect
• Abduction
• Sexual
• Financial
Examples of Physical Abuse
• Pulling a patient’s hair
• Slapping/hitting/punching
• Throwing food or water on a patient
• Tightening a restraint to cause pain
Examples of Psychological Abuse
• 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
Examples of Neglect
• Person is lying in urine and feces for
extended periods of time
• Person develops malnutrition and/or
dehydration and/or pressure sores due to
lack of appropriate care
• Person is dirty, has elongated nails, is
living in filthy environment
Abuse Occurs in a Variety of Patterns
• Perpetrator works at the facility
• Perpetrator is another resident
• Good facilities
• Bad facilities
Abuse at the Person Level
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Resident to resident
Resident to staff
Family member to resident
Staff to resident
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CNAs
nurses
doctors
outside/paid help
janitors
etc.
Abuse among CNAs
• 10% committed physically abusive act(s)
– excessive restraint 6%
– pushing/grabbing/shoving/pinching 3%
– hitting/slapping 3%
• 40% committed psychologically abusive act(s)
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yelling 33%
insulting/swearing 9%
denying food/privileges as punishment 2%
threatening physical violence 2%
Pillemer 1991
Predictors of Abuse among CNAs
• High level of job stress/burnout
• Aggressive patient
• Frequent verbal conflict with patients
Great Facility/One Bad Egg
• Reasonable staffing ratio
• Good administration
• High quality care
• Sociopath gets hired
Great Facility/Unusual Circumstance
• High quality care
• Difficult resident
– physically dependent
– verbally abusive
• Stressed CNA
– usually great with residents
– trouble at home, stress at work
– pushed “over the edge”
Abuse at the Facility Level
• Neglect
• Poor care
• Atmosphere of threats/reprisal
Poor Quality Facility
• Many residents receive poor care (i.e.
pattern of poor care)
– pressure sores: common and improperly treated
– malnutrition: common and improperly treated
• Lack of leadership/administrative support
• Employee morale is poor
• Absentee medical director
Recipe for Abuse
Vulnerable person
High risk caregiver
Context/Right circumstance
The Problem with the Problem
Complexity
• Age-related changes
• When does it cross the line?
• Impaired Capacity
• Mandated roles of multiple agencies
• Lack of coordinated, comprehensive system
Normal & Common Changes
• Integument
– thinner epidermis
– capillary fragility
• Renal: decrease in creatinine clearance
• Sensory system
– slower reaction time
– presbycussis
– macular degeneration, cataracts
Normal & Common Changes
• Musculoskeletal
– sarcopenia
– osteopenia/osteoporosis
• Cardiovascular
– orthostatic hypotension
– congestive heart failure
• Function
– gait/falls
– ADLs
When does bad care cross the
line to become neglect?
neglect
poor
acceptable
great
Dementia is a disease process
which causes loss of intellectual
abilities and inability to perform
one’s usual activities.
Types of Dementia
• Alzheimer’s Disease
• Vascular Dementia
• Frontal Temporal Lobe Dementia
• Primary Progressive Aphasia
• Dementia with Lewy Bodies
Dementia and Abuse
• Provocative behaviors
• May be unable to recognize abuse
• May be unable to report abuse
• May be the perpetrator of abuse
• May not be believed
Interviewing People with Dementia
• Understand the type of dementia
• Know the pattern of cognitive loss
• When do you “take it seriously”?
Types of Memory
• Verbal
• Visual
• Emotional
Delirium
• Problems with attention
• Fluctuation in cognition
• Reversible (e.g. infections, medications,
dehydration)
• Cannot make a diagnosis of dementia if
delirium is present
Delirium and Abuse
• Delirium may be a marker of abuse
– Neglect
– Over-medication
– Delay in seeking care
• Delirium will interfere with victim’s ability
to explain what happened
When Abuse is Suspected...
• Context
• History
• Physical Examination
• Mental Status examination
• Laboratory testing
• Cognitive/behavioral changes
Context
• Circumstances/Events leading up to the
alleged abuse
• Personality and behavioral characteristics
– victim
– perpetrator
• Medical history
• Cognitive capacity
Red Flags: History
• Implausible/vague explanations
• Delay in notification
• Unexplained injuries - past or present
• Inconsistent stories
• Change in behavior
Interviewing Issues
• Establish cognitive ability level
• Vision
• Hearing
• Comfort
• Best time of day
Observations
• Observe the alleged victim and the perpetrator
– Interaction
– Behavioral indicators of state of mind
• Depression
• Fear
• Confusion
Physical Exam
• Injury assessment
• Functional status
• Skin examination
• Pelvic examination
Clues on Physical Exam
• Sores, bruises, other wounds
• Unkempt appearance
• Poor hygiene
• Malnutrition
• Dehydration
Functional Assessment
• Range of motion
• Pain
• Gait and balance
• Sensory
Injury Assessment:
The Challenge in Elders
• Normal changes
• Common changes
• Medication effects
• Dementia
Injury Assessment
Types of Injuries
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Bruises
Pressure sores
Fractures
Burns
What to look for
• Hx consistent with exam?
• Old injuries
• Delay in seeking care
• Location
Bruising
• Age-related changes
• Medications
• Dating by color
• Multiple stages of healing
• History consistent with injury?
• Location
Summary of Results
Nearly 90% of the bruises were on the extremities.
No bruises on the neck, ears, genitalia, buttocks, or soles
of the feet.
Subjects were more likely to know the cause of the bruise
if the bruise was on the trunk.
16 bruises were predominately yellow within the first 24
hours of onset.
Those people on medications known to impact
coagulation pathways and those with compromised
function were more likely to have multiple bruises.
Location of Bruises
(108 bruises at Day 1)
Progression of color
300
200
Red
Purple
Blue
100
Yellow
Sum
Black
0
Green
0
6
3
12
9
Day Number
18
15
24
21
30
27
36
33
42
39
48
45
54
51
Dating of Injuries
Color
Estimated Age
Red
Blue/Purple
Green/Yellow
Yellow/Brown
Resolved
0-1 days
1-4 days
5-7 days
8-10 days
1-3 weeks
Laboratory Evidence
• Malnutrition
• Dehydration
• Coagulation studies
• Medication levels
• Radiographs
• Neuroimaging (MRI, CT)
Mental Status Exam
• Best to have a formal mental status exam
such as the Folstein Mini Mental State exam
(MMSE) documented
• At a minimum, get some observations and
statements about the victim’s cognitive
status
Look for…
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Residents in restraints
Mood
Medication errors
Infection control
Pressure sores
Staffing levels
Complaints
How To Reach Me:
Laura Mosqueda, M.D.
714-456-5530
[email protected]