1. Elder Maltreatment Elder Abuse 2011 Vicken Y. Totten MD 1

2. AMA Definition of Elder Abuse “… an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Abuse includes intentional affliction of physical or medical injury; sexual abuse; or withholding of necessary food, clothing, and medical care to meet the physical and mental needs of an elderly person by one having the care, custody, or responsibility of an elderly person” 2

3. Legal Definition The law defines elder abuse as "physical abuse, neglect, financial abuse, abandonment, isolation, abduction or other treatment with resulting in physical harm or pain or mental suffering, or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering." (Welfare & Institutions Code, Section 15610.07 and in Penal Code 368) "Elders" are defined as persons 65 years of age or older. 3

4. Exploitation is a form of abuse Resources Financial Sexual 4

5. Types of Elder Maltreatment Physical Abuse: Violence to person Sexual Abuse: Sexual use solely for another’s gratification Physical Neglect: Failing to provide a safe environment, clean water, sufficient food and medications Psychological Abuse or Neglect: Failing to provide for the social / psychological needs of the elder Material Exploitation or Neglect: Failing to use the elder’s resources for the elders benefit 5

6. Physical Abuse: Assault, battery, sexual assault, battery or rape, prolonged or continual deprivation of food or water, or medications use of physical or chemical restraints for punishment, convenience or without or beyond the scope of the doctor's order. 6

7. Physical Abuse Pushing, shoving, slapping “he steps on my feet” Visible and non-visible Discovery depends on entertaining the dx. More common in the helpless 7

8. Sexual Abuse Oral, Anal, vaginal, rectal, stomal A source of post-menopausal vaginal bleeding “My son-in-law needs me” Sexual predators get old too. Happens in nursing homes. Not all sexual congress in the elderly is abuse 8

9. Neglect: The failure to exercise that degree of care that a reasonable person in a care providing capacity would exercise such as failure to assist in personal hygiene, provision of food, clothing or shelter, provision of medical care, or to protect from health and safety hazards or to prevent malnutrition or dehydration. Note: This includes self-neglect; one of the most common forms of abuse occurring in community settings. 9

10. Falls 10

11. Physical Neglect Failing to provide, or deliberately withholding necessities: Hearing aid, eyeglasses, walker, cane, wheelchair, medications Food, help in bathing, clean clothes Failure to provide appropriate physical precautions 11

12. Psychological Abuse or Neglect Threats of deprivation or harm “Nobody else wants you, you are useless. You should be grateful I even do…” Failure to provide transportation Failure to permit access to social contacts 12

13. Financial AbuseFinancial Abuse: Financial Abuse The illegal or unauthorized taking or using of an elder's funds, property or assets by an individual or entity. 13

14. Control over finances 14

15. Material exploitation or Neglect Theft of money, possessions Keeping the elder for their social security check Getting power of financial attorney Preying on the elder’s gullibility, helplessness, or ignorance 15

16. Mental Suffering: Causing fear, agitation, confusion, severe depression or other forms of emotional distress that is brought about by threats, harassment, or other forms of intimidating behavior. (Legal definition) 16

17. PSYCHOLOGICAL ABUSE Threats – of violence, of abandonment Insults Harassment Belittlement Retaliation 17

18. Threats and intimidation 18

19. Isolation: The intentional preventing or restraining an elder from receiving mail, telephone calls or visitors. 19

20. Scope of the problem 20

21. EPIDEMIOLOGY 1-5% of elderly are victims of abuse Others cite larger numbers 21

22. CAUSES (often in combination) Physical dependency Caregiver stress - 36-hour day, frustration, lack of finances, lack of employment - often combined with a triggering event - treatment = relieve the stress if possible Supervision, continued 22

23. CAUSES (continued) Family violence pattern Abused children become abusive adults who then abuse own children and also their parents (treatment often to separate them). Pathological abuser - Drugs and alcohol abuse - Mental illness - Treatment = separation 23

24. Factors that increase Risks of Elder Maltreatment Victim Factors Caregiver Factors Environmental / System Factors A permission micro- environment 24

25. Screening and Assessment for Elder maltreatment Similar to screening for domestic violence –Use open-ended questions How do you feel about your safety at home? Who helps you at home? –How is this working out for you? What happens when there are disagreements at home? How are financial decisions made? Do you get out of your home very much? Who else do you see/talk to besides (caregiver)? 25

26. THE TYPICAL VICTIM Widow > 70 years old insufficient income to live independently increasing dependency cognitive impairment, especially if recent more problem behaviours: shouting, incontinence, wandering, paranoia, stubborn, critical 26

27. Victim Factors: –Elder’s cognitive impairment Dementia – less able to protect self Elder gets abusive, violent, socially inappropriate –Poor health - > Elder requires much care –Social isolation of both the care give and the elder 27

28. Caregiver Factors: History of violence, or victim of abuse Substance abuse External stressors 28

29. The typical abuser – a relative  40% of time spouse / 50% c hild or grandchild  In relationship with victim for average of 9.5 years  Under stress:  alcohol or drugs  marital problems  social isolation  employment and or financial difficulties 29

30. The abusive child of the elder  Often least socially integrated child  (the well functioning children have left the home)  May be from family where violence is norm.  “payback” 30

31. Environmental/System Factors: Victim and perpetrator in shared living situation Financial and other dependence on caregiver Perpetrator financially dependent on the elder 31

32. Warning signs Abuser Often speaks for elder Abuser isolates elder Abuser controls mail, visits and phone calls Elder appears helpless, confused, hesitant to speak freely Elder has insufficient food and basic necessities Elder exhibits poor hygiene Untreated medical conditions Visible injuries Change in sleep, appetite or behavior 32

33. DIAGNOSIS Signs of physical injury Conflicting and/or vague histories from the patient and caregiver History inappropriate to degree of injury Denial Long delay between injury and presentation History of being “accident prone” 33

34. Look For Changes And/or Extremes: Unkempt appearance Emaciated or bloated appearance Dirty or inappropriate clothing Unshaven face Uncombed hair Unusual or extreme body odors 34

35. Bruises not consistent with history Bruises not consistent with history 35

36. Physical Findings Welts, laceration, fractures Excess drugs / AMS / unexplained lethargy Burns, Bruises Lack of clothes, heat, medication, food, water Sometimes frequent falls. “Who helped you to fall?” 36

37. On examination On examination injuries at different stages of resolution bruises in the shape of weapons injuries in places normally covered by clothes or around mouth, face, eyes alopecia and haemorrhage under scalp may indicate hair pulling bruises, burns, bite-marks. 37

38. Examination - continued Physical neglect (much more common) - pallor, wasting, dehydration, decubitus ulcers. Note that these may also occur in non-abused elderly. Psychological abuse - paranoia, infantile, depressed, withdrawn, agitated. 38

39. Hurdles Mental health (competency issues) Physical health & disability/ willingness to testify – Mistrust of others 39

40. Fear Fear of losing loved one Fear of the unknown Fear of being alone Fear of losing living essentials 40

41. Legal problems of intervening When neither the victim nor the abuser is co- operative, may need guardianship No provision for mandatory reporting (as for child abuse) in many places No legal protection for doctors against libel. 41

42. Intervention Talk to victim privately If danger suspected, admit person with a “medical diagnosis” Counsel caregiver - provide information about pt’s condition - meet needs of caregiver (relieve stress) - talk to caregiver about how to respond to patient’s behavioural problems 42

43. Intervention (continued) Respite or alternative care if burden too great for caregiver Help the caregiver maximise the elderly individual’s abilities. 43

44. Tips for Caregivers Answering "yes" to just one of these questions could indicate that you need some assistance in your care giving role. Consider some of the following avenues. Seek out a support group for caregivers. Consider hiring support services-a home health aide, chore worker, or homemaker. Enlist the help of family and friends; be specific in what help you need (e.g., "Could you come over for two hours on Saturday morning while I run some errands?"). 44

45. More tips Look into available respite care in your community. Make an honest effort to give yourself needed time to relax, exercise, and eat right. Look to community resources for support. Start with the Area Agency on Aging for your area or call the Eldercare Locator. Consider a Daily Money Management Program 45

46. Management of Elder Maltreatment Most states have mandatory reporting for suspected elder abuse –American Medical Association Guidelines Elder Abuse and Neglect 46

47. Prevention Avoid isolation Stay social/active – volunteer, see friends Avoid living with a person with a history of abuse or violence Beware of family members with financial motivations or with substance abuse issues Consider respite services to relieve caregivers Have friends and relatives remain involved and observant Consider Counseling Communicate Have relatives and friends visit at various times of the day – unannounced 47

48. Resources In an emergency dial 911 American Association of Daily Money Management Program www.aadmm.comwww.aadmm.com www.AARP.org www.Eldercare.gov {Eldercare Locator}www.Eldercare.gov Administration on Aging (AOA) www.aoa.gov/eldfam/Elder Rights/Elder Abuse/Elder Abuse.asp www.aoa.gov/eldfam/Elder Rights/Elder Abuse/Elder Abuse.asp 48

49. More resources National Center on Elder Abuse (NCEA): www.elderabusecenter.org www.elderabusecenter.org National Committee for the Prevention of Elder Abuse: www.preventelderabuse.orgwww.preventelderabuse.org National Consumer League (NCL): www.nclnet.org www.nclnet.org http://fraud.org/ National Long-term Care Ombudsman Resource Center: www.ltcombudsman.org/static pagesombudsmen.cfmwww.ltcombudsman.org/static pagesombudsmen.cfm 49

50. References Cline, Ma, Tintinalli, Kelen, Stapczynaki (2001). Just the facts in Emergency Medicine. ISBN: 0-07-134549-3 Goldman, Wise, Brody, (1998). Psychiatry for Primary Care Physicians. ISBN: 0-89970-892-7 50

51. References National Women’s Health Information Center, US Department of Health and Human Services, Office of Women’s Health URL:http://www.4woman.gov/violence h ttp://www.seniorcitizensguide.com/clevela nd/index.htm 51

52. Why a man needs 3 wives 52