Dr. Steve Tam of UC Irvine explains the growing issue of elder abuse and why it is likely to grow in the coming decades. Know the signs of different types of abuse and how to respond to suspected cases.
Content - There are 7 types of reportable abuse in California Note new additions based on new law SB 2199 - Self-Neglect, Abandonment, Abduction. The 8th type of abuse, emotional/psychological abuse, is clinically recognized but not mandatory to report. Of course, it can still be reported even though it’s not covered by the mandated reporting laws. Underlined within California Regulations
Content - There are 7 types of reportable abuse in California Note new additions based on new law SB 2199 - Self-Neglect, Abandonment, Abduction. The 8th type of abuse, emotional/psychological abuse, is clinically recognized but not mandatory to report. Of course, it can still be reported even though it’s not covered by the mandated reporting laws.
Assessing Barriers to the Identification of Elder Abuse and Neglect: A Communitywide Survey of Primary Care Physicians. D. Kay Taylor, Journal of the National Medical Association, v 98, no 3, March 2006, 403-404.
This finding is very important in understanding just how large the problem of elder abuse is. There are likely many victims of abuse being seen in clinics and ER’s without having it recognized. Key finding of study listed in previous slide.
Background Information: Since the NEAIS is a self reporting study some of the percentages here are not the same as you might see in other studies. The definitions of the types of abuse were not specified and left up to the reporter to determine if in their mind they had suffered that type of abuse. Numbers add up to more than 100 as they allowed people to report more than one type of abuse.
Since we live in California it’s important to recognize the size of the problem in our own state. California department of Adult Protective Services compiles statistics each year on numbers and types of reports by counties. It also separates founded vs. unfounded reports. The statistics on the slide are from 1997, the most recent we could get from APS. If you consider the data from the NEAIS valid then there are 5 times as many cases of elder abuse than are actually reported.
Elder financial abuse costs older Americans more than $2.6 billion per year and is most often perpetrated by family members and caregivers, according to the MetLife Mature Market Institute (MMI) report, Broken Trust: Elders, Family and Finances, MetLife Mature Market Institute, Broken Trust: Elders, Family and Finances, March 2009. Also, older individuals often have less opportunity to make the money back. Physical and emotional recovery may take longer in older adults. Sometimes, they never recover at all. Researchers at Baylor College of Medicine found a higher prevalence of depression (62% vs 12%) and dementia (51% vs 30%) in neglected and self-neglecting patients compared to patients referred for other reasons. Social consequences of abuse include emotional and financial toll on family members, divisiveness between family members, spreading crime in the community, lowering expectations for what old age should be like
Potential reasons for reluctance to screen include lack of knowledge on how to proceed if abuse is suspected, unfounded legal concerns including the mandatory reporting requirements, reluctance to become involved, a sense of powerlessness in the belief change is not possible, fear of offending, minimization and denial, fear of the abuser and concern about time constraints secondary to an increased workload. Ignoring the problem will not only place the patient in continued jeopardy, but will result in more time spent with the patient in repeated health visits, multiple workups and the treatment of the adverse impact of the abuse.
CLINICAL ASSESSMENT The patient’s demeanor can range from flat affect, listless, apathetic, hesitant, fearful, evasive, anxious and withdrawn to hostile, aggressive, uncooperative and suspicious. An abrupt change in behavior, personality and/or communication of a patient known to the clinician can be an important clue to abuse.
Injuries on the outer aspect of the extremities may be a result of the elder’s usual everyday activities or the result of battering. Injuries on the head, neck, central part of the body, wrists, ankles and inner aspects of the extremities are most suspicious of being caused by abuse. Thus, the location and shape of bruising and injuries such as abrasions, avulsions, burns and cuts is relevant. When asked about what caused the injury, some patients will say: “I’ve been beaten”, but some will not. Other clues to abuse are a vague, inconsistent or implausible explanation of the cause of the injury, multiple injuries in different stages of healing, delay in seeking care and unusual patterns of alopecia. The observations of the relationship and conversation between the victim and the caregiver can be very important clues to what’s happening in the home. Interaction: Watch to see if the caregiver always answers for the patient. Is the cargiver rough with the patient. Does the caregiver yell at the patient?
Know purpose of interview - gather pertinent info, help direct physical exam, “bridge” between crime and regular medical exams Interviewing Strategies Leading question - Your son did that to you, isn’t that right? Open ended - Tell me about that bruise you have on your arm More direct - How did you get that bruise? Videotaping might be eligible to be used in court, new Ca law and Florida precedent Interview Protocol 1. Rapport gathering 2. Credibility Assessment Right from wrong, truth vs.. lie, suggestibility 3. Intro of task and info gathering 4. Strategies for resistance 5. Closure
Remember the role of the physician may not be to necessarily to determine the full details Cognitive dysfunction can influence whether the abused elder recognizes the abuse, is believed when reporting it or can decide on options for intervention. Impairment is characterized by variable loss of memory, loss of function and the loss of at least one cognitive domain [language, spatial relations, judgment]. Clues to its presence include appearing befuddled, repetitive speech, difficulty in comprehending speech, confabulation and distraction techniques. Office tools that a provider can use to screen for cognitive status related to short term memory, language, orientation and concentration include the Folstein Mini-Mental State Exam, the Mini-Cog, the Montreal Cognitive Assessment and the Six-item Screener. The clinician’s responsibility is to make observations and provide an opinion. The actual diagnosis of the type and cause of impairment requires a detailed assessment usually performed by professionals knowledgeable and skilled in this area.
The medical chart should include all verbatim reports of abuse and answers to relevant questions by the victim, findings on physical examination including statements about the patient’s appearance, emotional status and cognitive function, physical signs of abuse and neglect with a body map or photography [with consent] when appropriate, medical opinions, a follow-up plan, what referrals were provided and that legal reporting requirements were met with a phone call made when practically possible and the submission of the required written form [SOC 341].
California health practitioners are mandated reporters. They are required to telephone as soon as practicably possible, and mail/fax a formal written report [SOC 341] within two working days when a competent elder or dependent adult ages 18-64 years directly reports abuse or when abuse is suspected. It is not required that the abuse be confirmed by the reporter. Legal protection of reporters acting in good faith from reasonable suspicion is provided. The name of the reporting party is confidential and is not disclosed to the victim, family or alleged abuser. Failure to report is a misdemeanor punishable by jail, fine or both.
Safety planning involves providing information about community resources and viable alternatives. As it is essential to respect the autonomy of a competent adult to make decisions, this is done in the context of inquiry about and then responding to the patient’s wishes relative to intervention. Referrals reflect the importance of a team approach to elder abuse. The phone numbers and hot lines of community resources should be provided. The relevant agencies can include Adult Protective Services, Long-term care ombudsman and the local law enforcement agencies. Organizations such as the Caregiver Alliance can provide guidelines to minimize burden and stress when there are non-abusing family caregivers who will benefit from a clear plan defining their role and division of responsibilities of care. Emergency planning has to be instituted if lethality is a possibility. This can include hospitalization of the patient who is not competent, and notification of the local law enforcement agency of the potential risk.
Elder Abuse: What You Need to Know
Steven Tam, MDAssistant Clinical ProfessorUCI Internal Medicine/Geriatrics
Objectives Describe the definitions, categories,impact and prevalence of Elder Abuseand Neglect Recognize historical and physical signsof elder abuse and neglect, and reviewother markers Discuss proper documentation offindings in suspected elder abuse andproper reporting procedures.
The Case of “Just a HygieneProblem” 78 year old woman, who lives with herson (primary caregiver), history ofdiabetes, difficulty walking (spinalstenosis?) – wheelchair bound, chronicedema Brought in to the ER for altered mentalstatus, found to have a UTI
The Case of “Just a HygieneProblem” Skin not checked until the patienttransferred to the ward floor The RN notifies the Attending regardingthe skin The Attending says “just a hygieneproblem” to nurse, in front of all otherlearners. Nurse calls APS.
What does this populationlongevity mean? As Age increases, so do the number ofhealth, social, and psychological isses thatmake older people more dependent:Chronic illness, More medicationsDepression & DementiaQuantity and Quality of social support/situation Decrease in Reserves Increase in vulnerability to AbuseDifficulty defending self, more likely to getinjured
Definitions From National Center on Elder Abuse: “Any knowing, intentional, or negligent act by a caregiveror any other person (paid or unpaid) that causes harm ora serious risk of harm to a vulnerable adult.” PC 368[b]:Any person who knows or reasonably should know that aperson is an elder or DA and who, under circumstancesor conditions likely to cause GBH or death .....having thecare or custody of any elder or DA, willfully causes orpermits the person or health of the elder or DA to beinjured, or willfully causes or permits the elder or DA tobe placed in a situation in which his or her person orhealth is endangered.....
In California: an “Elder is…” 65 years and older ALSO don’t forget:“Dependent adult” is 18-64 years AND“who has physical or mental limitations thatrestrict his or her ability to carry out normalactivities or to protect his or her rights,including, but not limited to, persons whohave physical or developmental disabilities,or whose physical or mental abilities havediminished because of age.” (W&I Code15610.23)
Types of Elder Abuse: Physical Abuse: use of physical force that may result in bodily injury, pain orimpairment Financial Abuse: Illegal or improper use of an adult’s resources through deceit,theft, coercion, fraud, undue influence or other means Emotional Abuse: Infliction of anguish, distress or intimidation through verbal ornon-verbal acts or threats Sexual Abuse: Non-consensual sexual contact, harassment, inappropriatecomments or threats. Consider non-consensual if the persondoes not make, or incapable of making an informed choice Neglect: Failure to provide basic neecessary care or services when suchfailure may lead to harm or risk of serious harm
Sexual Abuse Case• 81 year old gentleman cognitively impairedis allegedly sexually abused by a hiredcare giver at home (for respite) while wifeis attending to other matters. Abuseradmits to performing the acts, but says thatthe gentleman consented to it.• Our VAST team was asked by law enforcementto assess the capacity of the gentleman• He had a MOCA score of 6/30. Upon furtherhistory with wife, she revealed, he wasdiagnosed with dementia years prior.
Types of Abuse Self-Neglect: (often included within neglect) Abandonment: A Caregiver’s desertion places the adult in serious risk ofharm Involuntary Seclusion(Isolation): Confinement, restriction or isolation of an adult for theconvenience of a caregiver or to discipline the adult Wrongful restraint: The use of a physical or chemical restraint to limit themovement of an adult for the convenience of the caregiveror to discipline the adult. Abduction: Removal from this state and the restraint from returning to thisstate, of an elder or dependent adult who does not have thecapacity to consent
Incidence and Prevalence: True Numbers not known:○ Difficulties: Reluctance to admit- Shame, fear of losing independence- Fear of being moved Older adults may quietly disappear from society without muchinquiry Maybe too incapacitated to report Signs of abuse maybe missed or mistaken for “usual aging.” National Elder Abuse Incidence Study, 1998:○ 236,000 reports of seniors abused at home in oneyear○ 50,000 reports of abuse in nursing homes in oneyear
Elder Abuse Estimated that 4-10% of people 65 or olderare victimized by relatives, caretakers orstrangers.Up to 4.3% of older adults physically abusedannuallyIt is not known how big the problem exactly is! Physicians are mandated to reportsuspected abuse <2% of APS reports are filed by physicians.Lack of understanding of reporting mechanismsrepresented the most significant obstacle
Elder Abuse Incidence FOR EVERY REPORT OFABUSE…. 55 GO UNREPORTEDNational Elder Abuse Incidence Study, 1998
Elder Abuse – CaliforniaIncidence• 47,000 reports of abuse• “235,000” abused elders, when youconsidered unreported cases• CA APS Report 1997• Approximately 110,000 reports of abusewere received statewide during Statefiscal year 2006-07• CA APS Report 2007
APS serves adults with physical or mental impairments, as well as theelderly. Elder and Dependent Adult Victims – Orange County, APS 2010reportYEAR REPORTS ELDERS DEPENDENTADULTS2010 7422 72% 28%2009 6870 71% 29%2008 6567 70% 30%2007 6355 70% 30%2006 5650 71% 29%2005 5418 70% 30%2004 5219 69% 31%2003 5049 69% 31%2002 5273 71% 29%2001 4973 72% 28%2000 4503 77% 23%Abuse by others FrequencyPhysical 16%Sexual 2%Financial 29%Neglect 27%Abandonment 1%Isolation 2%Abduction 0.2%Psychological 24%
Dependent Adult Abuse Little known about the abuse ofdependent adults 1999 - the federal government conveneda group of experts to identify○ 4 to 10 times higher risk of becoming victims ofabuse○ 10 times higher risk of being sexually assaulted○ Less likely to report abuse○ Lower rates of police follow-up and successfulconviction of perpetratorsVictimization of Dependent AdultsVictimization of Dependent AdultsConference, 1999Conference, 1999
Risk Factors – the abused Over 80 years are 2-3 times more likelyto be abused Female: in 2/3 of all reports, victim is awoman Presence of cognitive impairment Dependent, Dementia, PhysicallyAggressive, Verbally Abusive
Risk Factors – the abuser Depressive symptoms Financial ties Felt they had a poor emotional status andhad role limitations in activities and/orwork as a result of caregiving role People with inadequately treated mentalhealth and/or substance abuse problemsare more likely to be abusive People who feelstressed/burdened/resentful are morelikely to be abusive
Risk Factors – the context! People with inadequately treated mentalhealth and/or substance abuse problemsare more likely to be abusive People who feelstressed/burdened/resentful are morelikely to be abusive Providing care for an older adult who isphysically combative and/or verballyabusive Financial, Marital, Employment, Change inElder/Caregiver Dependency Relationship
Risk Factors-Special Issues Adults with Disabilities○ 44% of those age 75 years and over living in thecommunity reported having a limitation in their usualactivity due to a chronic condition.○ In 1989 survey of 245 women with a disability: 40%reported being abused; 12% reported being raped.○ Survey of 90 men and women with a disability – 40%experienced financial abuse. Dementia○ Physical Abuse: 9.3%○ Psychological Abuse: 41.8%○ Caregiver Neglect: 16.9%○ Any Abuse: 47.3% Long-term Care FacilitiesScreening for Abuse and Neglect of People with DementiaWiglesworth, Mosqueda, et al. Journal of American Geriatric Society, March 2010
Risk Factors-Special Issues DementiaStudies estimate any where from 1-13% forthose over age 65Memory loss, other cognitive loss, functionalloss Undue Influence“The substitution of one person’s will for thetrue desires of another.”Excessive pressureUsually for financial gain
Consequences of Elder Abuse Financial—Income, savings, home Emotional—Feelings of self-worth,safety Physical—Compromising health thatmight already be vulnerable Cognitive—Depression, dementia Social—Family dynamics, communitysafety, societal expectations of old age
Consequences of Elder Abuse Elder financial abuse costs older Americans more than $2.6billion per year and is most often perpetrated by familymembers and caregivers, according to the MetLife MatureMarket Institute (MMI) report, Broken Trust: Elders, Family andFinances, MetLife Mature Market Institute, Broken Trust: Elders,Family and Finances, March 2009. Physical and emotional recovery may take longer in olderadults. Sometimes, they never recover at all. Researchers at Baylor College of Medicine found a higherprevalence of depression (62% vs 12%) and dementia (51% vs30%) in neglected and self-neglecting patients compared topatients referred for other reasons. Social consequences of abuse include emotional and financialtoll on family members, divisiveness between family members,spreading crime in the community, lowering expectations forwhat old age should be like
Consequences of Elder Abuse -Testimonies“She picked me up at the hospital. I said,‘I’ll be so glad to get home.’ She said,‘You’re not going home. I’ve moved you inwith me.’“You don’t want to get close to anotherperson and call them your friend. You’reafraid of it.”○Mrs. Crewey, at age 90, lost her home and furniture to, andhad her bank account compromised by, her good friend○(Elder Justice Now campaign by WITNESS and NationalCouncil on Aging)
Consequences of Elder Abuse -Testimonies“I thought our marital problems were allmy fault... He had me so totallybrainwashed and convinced that I wascrazy, lazy, stupid, and worthless, that Iwas a walking zombie.I spent every waking hour trying to be abetter wife and mother but the harder Itried, the worse I became.”○Older woman in WI who had been married for 24years to her abuser○(Brandl & Spangler, National Clearinghouse on Abuse in Later Life,“Golden Voices” 2003)
Role of the Health CareProvider Barriers to detecting/reporting ElderAbuseLack of knowledgeLegal concernsDiscomfort in showing ignoranceSense of powerlessnessFear of offending patient or the abuserMinimization and denialReluctance to become involvedTime constraints
The role of the Health Care Provider–Do we screen for elder abuse? Are you afraid of anyone in your family? Has anyone close to you tried to hurt orharm you? Has anyone close to you called younames or put you down or made youfeel bad recently? Does someone in your family makeyou stay in bed or tell you you’re sickwhen you know you aren’t? Has anyone forced you to do thingsthat you didn’t want to do? Has anyone taken things that belong toyou without your OK?*Sengstock-Hwaleck, M., 1987. “A Review and Analysis of Measure forthe Identification of Elder Abuse.” Journal of GerontologicalSocial Work 10 (3/4):21-36
The role of the Health Care Provider–Do we screen for elder abuse? • The USPSTF found insufficientevidence to recommend for or againstroutine screening …of older adults ortheir caregivers for elder abuse. ACOG and AMA45recommend thatphysicians routinely ask elderly patientsdirect, specific questions about abuse- Am Fam Physician. 2004 Aug 15;70(4):747-751.
The Role of the Health CareProvider Do look for clues in the patient that maymake you think of abuse:○ Flat affect, listless, apathetic○ Hesitant, evasive○ Fearful, anxious○ Hostile, aggressive○ Uncooperative, suspicious Abrupt change in a known patient
The Role of the Health CareProvider– Injuries, Red Flags Bruises, Fractures, Pressure Sores Location and shape Multiple injuries Various healing stages Suspicious explanation Delay seeking care Circumstances/Events leading up to the allegedabuse (inconsistent stories) Lack of concern on the part of the caregiver Interactions between patient and caregiver
Role of the Health CareProvider History Physical Mental Status Exam Laboratory Exam How do we use this when thinking aboutElder Abuse?
Role of the Health CareProvider Keep in mind Red Flags Open-ended questionsproceed to more specific questionsAvoid leading questions Separate the victim from the caretaker,if needed Keep in mind cognitive ability/capacityWhen to take it seriously? When unreliable?
Clues on Physical Exam: Neglect Pressure sores, Poor hygiene Unkempt appearance, Poor foot care Low weight, Dehydration Body language of patient Types of InjuriesTypes of Injuries Bruises Fractures Burns What to look for:○ Location○ Hx consistent with exam?○ Old injuries○ Delay in seeking care
Role of the Health CareProvider Mental Status and CapacityEvaluation and assessment:○ History suggestive of loss of memory, other cognitivedomains, function○ office tools: Mini-Mental State Exam, Mini-Cog, Six-item screen, MoCA Clinician’s role: observe, provide opinion,not make a specific diagnosis
The Role of the Physician –Markers: Bruises Most common Hard to tell what’sabuse and what’s not Age-related changes Medications Dating by color Multiple stages ofhealing History consistent withinjury? Location
Bruising Study- WIGLESWORTH ET AL. JAGS JULY 2009–VOL.57, NO. 7
When is bruising suspicious traumaversus accidental trauma? Which looksmore like abuse: A or B?A B
Strangulation Difficulty breathing Hoarse voice “Sniffing position” Ask:○ Did he/she○ choke you?○ Did you○ lose consciousness?○ Can be a medical emergency
Fractures Accidental or abusive May be due to medical condition○ Osteoporosis○ Cancer Many types of fractures○ Correlate fracture type to mechanism of injury○ Spiral fractures or fractures with a rotationalcomponent are suspicious○ Sites other than hip, vertebra, or wrist maymore likely be markers of abuse.
Burns Persons over the age of 65 have 2X thenational average death rate due to burns Seen in physical abuse, neglect and selfneglect Limited studies reveal that between 36-70%of burns in adult abuse were due to abuse orneglect (Bowden 1998; Burns 1998)
Pressure Sores Can be common Often preventable Usually treatable Things to think about Nutritional status○ Able to get own food?○ Able to feed self? Mobility status○ Moved? Repositioned?○ Tied down in one position Medical Followup
Are all pressure sores signs ofabuse??? Pressure Sores: what an expert may beable to tell youWhether this was a high risk situation inwhich a pressure sore may have beeninevitableWhether this is typical in appearanceWhether this is typical in locationWhether treatment was sought or carried outappropriately
Role of the Physician -Laboratory tests Malnutrition Dehydration Bleeding times Medication levels
Medication Review: their role inmistreatmentCan be:○Overused: to sedate, causedelirium○Underused: to reduce mobility(e.g., L dopa), cause illnessexacerbations (insulin, inhalers,antibiotics)○Misused: used for unapprovedeffects (antihistamines to sedate)
Role of the Health CareProvider Other Red Flags/cluesSexual Abuse: bruising of the breasts,unexplained STDs, perineal and inner thighbruising, inappropriate modesty, fear oftouchEmotional abuse: withdrawn, evasiveness,hostilityNeglect: absence of medical devicesFinancial: not following medical regimens,failure to get medicines, disparity betweenassets and condition
Role of the Health CareProvider Don’t forget the caregiver!Majority = adult children & partnersClues on observation:○ speech, tone, touch interactions○ stands watch, monitors interactions○ overly protective or lacking concern○ answers questions directed to patient○ continually tests limits of the visit○ refuses to leave room when asked Hostile and surly to staff
Role of the Health CareProvider– Elder Abuse Proper Documentation/Medical Recordshould include:Date, timeIdentifying informationPatient’s statementsFindings on physical examinationMedical opinion/diagnosisTreatment recordFollow-up and referral plansReporting requirements fulfilled
Role of the Physician – ElderAbuse ReportingCalifornia:○ Health practitioners are mandated reporters○ legal protection of reporter○ name not disclosed to victim, family, abuser○ Requirements when abuse suspected:abuse does not need to be confirmedtelephone when practically possibleformal written report [SOC 341], mail or fax within 2working days○ Financial institutionsFailure to report: jail, fine or both!Failure to report: jail, fine or both!
After the report APS involvementAppropriate cross-reporting and referrals toagencies to assist/investigate○ Long-term care ombudsman○ Family Caregiver Alliance○ Law enforcement agencies○ Emergency planning
After the report• Adult day healthcare• Meals on Wheels• Senior centers• Support groups• Transportation• Mental health• Multipurpose seniorservices program(MSSP)• Home equipment• In home supportservices (IHSS)• Home repair
What APS May do -• Recommend conservatorship• Call the police- Request a 5150 evaluation- File a report• Suggest, persuade, and bargain with theclient to get help• Arrange for case management• Work collaboratively with supportsystems
What APS May NOT Do• Enter the home without permission• Remove the person from theirresidence against their will• Force a client to accept services
UCI Experience During the calendar year 2011,Orange County Elder Abuse ForensicCenter met 52 times (every week)○ assisted with 78 new elder abuse/neglectcases and reviewed 126 updates.○ The Vulnerable Adult Specialist Team (VAST)conducted 15 high intensity in-home medicalassessments, 19 high intensity in-homepsychological evaluations, performed 9medium intensity medical record reviews,and made 3 low-intensity doctor-to-doctorconsultations.
The Future What is our responsibility as a society? What role could/should the governmentplay in this issue? What policies currently exist that eitherallow or prevent elder abuse?Unifying terminology and definitions/policies Research:How do we better screen and assess issuessuch as capacity, forensic markers such asbruising and sores?