Elder Abuse 11/21/2011

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Myles Long
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1 Elder Abuse Laura Mosqueda, M.D. Chair and Professor of Family Medicine Director of Geriatrics University of California, Irvine School of Medicine 1

2 Elder Abuse and Neglect Abuse: causing any physical, mental, or sexual injury, including exploitation of financial resources Mandated reporter: medical, social service, law enforcement professionals Why have a special law for older adults? Because older adults are vulnerable. Aging is accompanied by changes that make us susceptible to physical and emotional injury. Vulnerabilities to Mistreatment Difficulty defending oneself, physically and emotionally May be more dependent on others for assistance than in the past Fear of losing independence if a report is made, so more susceptible to threats 2

3 Types of Abuse Financial Physical Sexual Neglect Financial Abuse Misuse or withholding of older adult s resources to the disadvantage of the elder or profit of another Examples of Financial Abuse Obtaining the password and then stealing the ATM card Threatening to put mom in a nursing home if she doesn t co-sign for the car Withholding pain medication unless the house is signed over 3

4 Physical Abuse physical, sexual, or emotional maltreatment or willful confinement Examples of Physical Abuse Pulling a person s hair Slapping/hitting/punching Throwing food or water on a person Tightening a restraint to cause pain Neglect Failure of caregiver to provide the necessities of life, including food, clothing, shelter, and medical care. Neglect may be passive or willful. 4

Examples of Neglect Person is lying in their urine and feces for extended periods of time Person develops malnutrition and/or dehydration and/or pressure sores due to lack of appropriate

5 Examples of Neglect Person is lying in their 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 The Challenge in Elders Normal changes of aging Multiple co-morbidities Medication effects Cognitive impairment 5

6 NATIONAL ELDER MISTREATMENT STUDY Acierno, et al J Geron 2010 National Elder Mistreatment Study Used telephone to randomly call older adults in the community Asked about emotional, physical, sexual, and potential neglect Asked about financial abuse by family members but not by others National Elder Mistreatment Study, Results 11% of older adults (people between 60 and 85 years) reported at least one form of past year mistreatment (excluding financial abuse). 6

7 National Elder Mistreatment Study, (cont d) Did not include people with dementia Did not include people over the age of 85 Elder Mistreatment in the United States: Prevalence Estimates From a Nationally Representative Study Laumann et al., 2008, University of Chicago, Illinois Laumann et al., 2008, Prevalence Sample community-residing participants aged 57 to 85 yielding 3,005 respondents out of a possible 4,400 (1,455 men and 1,550 women). 7

8 Laumann et al., 2008, Prevalence Methodology Professional interviewers conducted in-home interviews Asked respondents about verbal, financial and physical abuse they have experienced within the past 12 months and their relation to abuser. Laumann et al., 2008, Prevalence Reported Mistreatment Linked to Family Member 9% verbal abuse 3.5% financial abuse 0.2% physical abuse Laumann et al., 2008, Prevalence Age excluded older than 85 Mental capacity Older adults deemed by interviewers to be too impaired to give formal consent were excluded from the study. 8

Caregivers Screening for Abuse and Neglect of

Mulnard R, Liao S, Gibbs L, Fitzgerald W.

9 More research?! Mistreatment of People with Dementia by their Caregivers Screening for Abuse and Neglect of People with Dementia Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W. Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society Mar;58(3) Funded by the California Department of Health Services 9

Methods 129 People with dementia and their caregivers were

The Findings 47% of participants with dementia (61) had been

10 Methods 129 People with dementia and their caregivers were assessed for evidence of mistreatment as well as factors that might be related to mistreatment. Most of the data were provided by the caregivers. The Findings 47% of participants with dementia (61) had been mistreated by their caregivers. 42% (54) experienced psychological abuse 10% (13) physical abuse 14% (18) caregiver neglect. 10

11 Interviewing Issues Cognitive level Pay attention to body language Reliability of history Deciding upon when to take it seriously History Implausible/vague explanations Delay in seeking care Unexplained injuries - past or present Interaction between patient and caregiver The Importance of Context All bruises are due to the same thing: a blood vessel ruptures and blood extravasates into the surrounding tissue All pressure sores are due to the same thing: there s inadequate blood supply to maintain perfusion of the tissues All fractures are due to the same thing: an external force greater than the strength of the bone was applied. 11

12 Context (cont d) Our job is to figure out why these things happened Most of the time, understanding the context is key to making a determination Sometimes, though, it s pretty darn obvious and I don t really need to know much about the context! Physical Abuse and Neglect: Clues on Physical Exam Sores, bruises, other wounds Unkempt appearance Poor hygiene Malnutrition Dehydration Injury Assessment Types of Injuries Bruises Pressure sores Fractures Burns What to look for Location Old injuries Delay in seeking care History & exam consistent? 12

13 Accidental Anterior Physical Abuse Unknown Accidental Inflicted Accidental Posterior Physical Abuse Unknown Accidental Inflicted 13

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Laboratory Findings in Abuse (direct and indirect) Chemistry panel Malnutrition, Dehydration Electrolyte imbalances Impaired renal (kidney) function CBC (complete blood count) with differential

16 Laboratory Findings in Abuse (direct and indirect) Chemistry panel Malnutrition, Dehydration Electrolyte imbalances Impaired renal (kidney) function CBC (complete blood count) with differential Malnutrition Anemia Medication levels Prevention and Early Detection The possibility needs to be on our radar Differential diagnosis might include abuse/neglect Recognize high risk situations Ask 16

17 ASK Patients Are you afraid of anybody? Has anyone hurt you? Caregivers How are you doing with all this stress? Have you ever hit your mom, or are you worried that you might? What Else Can We Do? On the home front Be willing to consult and help each other Serve on an interdisciplinary team Be available when needed Educate Colleagues in your own and other disciplines Lay public Policy makers These are tough issues and we need to be cautious We don t want to accuse unfairly We need to ask the right questions and listen with a critical ear to explanations Let s not miss an abusive situation and fail to protect a vulnerable person 17

18 Sherrie s Mom Plumber Shame & Withdrawal Missed M.D. appts Fear of losing Independence Escalating cost HF SNF Hospitalization 18

24-hour Senior HELPLINE: 602.264.HELP (602.

19 To make a report in AZ Adult Protective Services (APS)- Adult Abuse Hotline: SOS.ADULT ( ) Area Agency on Aging - 24-hour Senior HELPLINE: HELP ( ) Learn More

Forensic Markers of Elder Abuse

Forensic Markers of Elder Abuse Laura Mosqueda, M.D. Director of Geriatrics Professor of Family Medicine University of California, Irvine School of Medicine Caveats This lecture is primarily designed for