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Elder Abuse Christi Stewart, MD November 23, 2006.

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1 Elder Abuse Christi Stewart, MD November 23, 2006

2 Objectives Obtain a better understanding of the prevalence of elder abuse Obtain a better understanding of the prevalence of elder abuse Differentiate types of elder abuse Differentiate types of elder abuse Recognize risk factors for elder abuse Recognize risk factors for elder abuse Discuss medical implications of elder abuse Discuss medical implications of elder abuse Understand reporting regulations for PA in regards to 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. Classical Greek culture supported euthanasia for the incurable old. Diogenes Syndrome - named for 4 th century BC philosopher who shunned common comforts to live in a tub. Diogenes Syndrome - named for 4 th 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. 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. King Lear – Shakespeare writes about the king’s maltreatment by his sons.

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

5 Prevalence of Elder Abuse Actual incidence and prevalence of elder abuse is unknown and difficult to measure. 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. 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. Some studies quote as high as 12% of elders. There are roughly 1 to 2.5 million abused seniors annually. 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. Only 1 out of every 6 victims is likely to be reported to the authorities.

6 Why so difficult to measure? Vast majority of cases go unreported or unsubstantiated. Vast majority of cases go unreported or unsubstantiated. Definitions of elder abuse can differ from agency to agency, and person to person. Definitions of elder abuse can differ from agency to agency, and person to person. Subject to cultural interpretation 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

8 Types of Elder Abuse As defined by the NCEA: Physical abuse Physical abuse Sexual abuse Sexual abuse Emotional/psychological abuse Emotional/psychological abuse Financial or material exploitation Financial or material exploitation Abandonment Abandonment Neglect Neglect Self-neglect Self-neglect

9 Physical Abuse The use of physical force that might result in bodily injury, physical pain, or impairment. The use of physical force that might result in bodily injury, physical pain, or impairment. Most readily substantiated form of abuse 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. 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.

10 Sexual Abuse Nonconsensual sexual contact of any kind with an elderly person. 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. 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 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. 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 elder’s funds, property, or assets. 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. 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. 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. 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 refusal or failure to fulfill any part of a persons obligations or duties to an elder The most common form of abuse The most common form of abuse The most difficult form of abuse to validate 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. 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. 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. 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.

16 Prevalence of specific types of abuse Neglect48.7% Psychologic35.4% Financial30.2% Physical25.6% Abandonment3.6% Miscellaneous1.4% Sexual0.3%

17 Risk Factors for Abuse 1. Substance abuse history by the caregiver  Most likely alcoholism  Incidence of addiction in an abuser is 35% 2. Older age Elderly in the >80 age group are 2-3 times more likely to be abused or neglected. Elderly in the >80 age group are 2-3 times more likely to be abused or neglected. 3. History of depression or mental illness of the care recipient Occurs in 45-50% of victims Occurs in 45-50% of victims

18 Risk Factors Continued 4. Low income 5. Social isolation 6. Minority status 7. Low level of education 8. Previous history of family violence

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

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

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

22 Recognizing the Demented Abused History of recent behavior changes History of recent behavior changes Pseudo-seizures Pseudo-seizures Elective mutism Elective mutism Aggressive behaviors Aggressive behaviors Refusal of medications Refusal of medications Withdrawal Withdrawal Limited eye contact Limited eye contact Changes in appetite Changes in appetite Changes in sleep Changes in sleep

23 Physical signs of abuse Poor hygeine Poor hygeine Poor nutrition Poor nutrition Poor skin integrity Poor skin integrity Contractures Contractures Excoriations Excoriations Pressure ulcers Pressure ulcers Dehydration Dehydration Impaction Impaction Malnutrition Malnutrition Inappropriate dress Inappropriate dress Unexplained bruises Restraint marks on wrists Lacerations Abrasions Head injury Unexplained fractures Traumatic alopecia Bite marks Inguinal rash Genital pain, itching

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

25 Why Physicians Don’t Ask Lack of training in recognizing abuse Lack of training in recognizing abuse Lack of time in office to deal with issues Lack of time in office to deal with issues Reluctance to attribute signs of mistreatment Reluctance to attribute signs of mistreatment Victim isolation Victim isolation Subtle presentations Subtle presentations Reluctance in confronting the offender Reluctance in confronting the offender Reluctance to report if abuse is only “suspected” Reluctance to report if abuse is only “suspected” Lack of knowledge of how to report Lack of knowledge of how to report Empathy with abuser Empathy with abuser Request of victim Request of victim

26 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.

27 AMA Screening Questions 1. Has anyone ever touched you without your consent? 2. Has anyone ever made you do things you didn’t want to do? 3. Has anyone taken anything that was yours without asking? 4. Has anyone ever hurt you? 5. Has anyone ever scolded or threatened you? 6. Have you ever signed documents you didn’t understand? 7. Are you afraid of anyone at home? 8. Are you alone a lot? 9. Has anyone ever failed to help you take care of yourself when you needed help?

28 Physician Responsibilities 1. To recognize or suspect elder abuse and neglect when present. 2. To treat any medical problems associated with such maltreatment. 3. To ensure a safe disposition for the patient.

29 Who Reports Abuse?

30 How to Report  Call in the report of suspected abuse  Office of Aging ( )  or local police for serious life threatening or dangerous situations  Eldercare Locator ( )  PA Protective Services for Adults ( )  PA Dept of Health ( )  National Domestic Violence Hotline ( SAFE)

31 Reporting Process 1. 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. 2. Staff investigate reports  Alleged victims are visited.  Staff contact other parties who might know about suspected mistreatment.

32 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. 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. 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.

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

34 And the Others? If an abused elder is determined to be incompetent: If an abused elder is determined to be incompetent: A state guardian is appointed to make decisions for the patient. 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. 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. 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. Fear of placement leads many abused elders to turn down their right to investigation.

35 Pennsylvania Abuse Reporting Laws Mandatory reporting: 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. 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) If the abuse involves serious injury, sexual abuse or suspicious death, reporters must also call police and the Pennsylvania Department of Aging at (717)

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. 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. 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 may remain anonymous. Reporters have legal protection from retaliation, discrimination and civil or criminal prosecution. 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 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 $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. 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. 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. State statutes are the only engine for combating elder abuse.

38 Summary Elder abuse is a very prevalent problem among the quickly expanding geriatric population. 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. 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. 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. 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. Once it is reasonably suspected, elder mistreatment should be reported to adult protective services.

39 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.

40 Resources Pennsylvania Dept of Aging Pennsylvania Dept of Aging National Center on Elder Abuse National Center on Elder Abuse National Committee for the Prevention of Elder Abuse National Committee for the Prevention of Elder Abuse

41 References Geroff AJ, Olshaker JS. Elder abuse. Emerg Med Clin N Am 2006;24: Geroff AJ, Olshaker JS. Elder abuse. Emerg Med Clin N Am 2006;24: Gorbien MJ, Eisenstein AR. Elder abuse and neglect: an overview. Clin Geriatr Med 2005;21: Gorbien MJ, Eisenstein AR. Elder abuse and neglect: an overview. Clin Geriatr Med 2005;21: Hansberry MR, Chen E, Gorbien MJ. Dementia and elder abuse. Clin Geriatr Med 2005;21: Hansberry MR, Chen E, Gorbien MJ. Dementia and elder abuse. Clin Geriatr Med 2005;21: Joshi S, Flaherty JH. Elder abuse and neglect in long term care. Clin Geriatr Med 2005;21: Joshi S, Flaherty JH. Elder abuse and neglect in long term care. Clin Geriatr Med 2005;21: Koenig RJ, DeGuerre CR. The legal and governmental response to domestic elder abuse. Clin Geriatr Med 2005;21: Koenig RJ, DeGuerre CR. The legal and governmental response to domestic elder abuse. Clin Geriatr Med 2005;21: Simpson AR. Cultural issues and elder mistreatment. Clin Geriatr Med 2005;21: Simpson AR. Cultural issues and elder mistreatment. Clin Geriatr Med 2005;21: Swagerty DL, Takahashi PY, Evans JM. Elder mistreatment. Am Fam Phy 1999;59: Swagerty DL, Takahashi PY, Evans JM. Elder mistreatment. Am Fam Phy 1999;59: Elder Abuse Awareness Kit. (n.d.). Retrieved Nov 21, 2006 from Elder Abuse Awareness Kit. (n.d.). Retrieved Nov 21, 2006 from State Elder Abuse Helplines and Hotlines. (n.d.). Retrieved Nov 21, 2006 from State Elder Abuse Helplines and Hotlines. (n.d.). Retrieved Nov 21, 2006 from Protective Services for Older Adults (n.d.). Retrieved Nov 21, 2006 from Protective Services for Older Adults (n.d.). Retrieved Nov 21, 2006 from


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