There are many similarities between elder abuse and child abuse. At-risk seniors are frequently more difficult to identify than at-risk children due to social isolation, and problematic to treat given their assumed legal competence. For many abused and neglected older individuals, a visit to their FP may be the only point of contact with a professional capable of both identifying their concerns and coordinated needed intervention.
Failure to identify elder abuse and take appropriate action can have tragic results, as the risk of death among elderly individuals who experience abuse is 3x greater than that of the general population. Therefore, it is imperative for FP to develop the skills necessary to identify elderly patients at risk for abuse and create an effective management strategy. In addition, FPs need to be able to develop strategies to assist patients and their caregivers prevent abuse even before it takes place. This chapter covers the current definitions of abuse , risk factors for abuse associated with both the elderly and their caregivers , and barriers that elderly patients and their physicians face when dealing with abuse issues . It also reviews how to assess suspected elderly abuse victims, reporting guidelines, and treatment and prevention strategies.
Commonly used definitions related to elder abuse and neglect are as follows.
Self neglect is frequently omitted or reported separately in statistical summaries. Described in one study as a pattern….
There are a number of characteristics common to many victims of abuse and neglect. These include the ff:…… One important characteristic is the development of dementia. This disease frequently has a subtle onset that can go unrecognized for several years. Cognitive impairments greatly limit individuals’ ability to care for themselves, while impaired decision-making capabilities limit the autonomy and subsequent ability of depressed individuals to protect themselves from abusive and/or neglectful situations. While cause-and-effect relationships are difficult to establish, there does appear to be a significant comorbid association between psychiatric illness and elder abuse.
Similarly, there are warning signs…..these include…. Another important characteristics to recognize is caregiver burnout. Elderly patients who depend on others for care can generate significant amounts of stress for caregivers. While caregivers may be able to cope with day-to-day demands, they may decompensate when a crisis develops or simply exhaust themselves over time. It is vital that FPs identify caregiver stress and coordinate the support services necessary to relieve these stressors.
-One obstacle to recognizing elder abuse is that a substantial number of elderly individuals are socially isolated. A significant number live alone, and many are dependent on caregivers or other individuals for transportation. Physical limitations can further contribute to isolation by making it more difficult for the elderly to travel. -Often the patient-related barrier to recognition of abuse include fear of retribution. Older individuals may be reluctant to discuss problems with health care providers due to concern that will only make matters worse or result in in nursing home placement. -Cognitive impairments may prevent some individuals from recognizing the abusive nature of their situation, while others may rationalize that the treatment they receive as “normal” or acceptable given their circumstances
Physician barriers reducing the likelihood of identifying elder abuse are primarily knowledge –based. The strongest factor in predicting physician recognition of elder abuse is an understanding of the associated risk factors listed….. >Physicians also underestimate the prevalence of elder abuse, >do not know how to assess for abuse, > and fail to develop a systematic plan for how to respond to identified abuse. >Denials regarding the presence of abuse, reluctance to intervene, and >fear of reprisal further hamper appropriate identification.
Appropriate assessment of elderly patients where abuse is suspected includes a careful history and a targeted physical examination. Whenever possible, the initial portion of the history should be taken with both the patient and caregiver present. This allows the physician to observe their relationship, w/ particular attention given to anxiety on the part of the patient or an overbearing attitude on the part of the caregiver. Following the interview w/ both the patient and caregiver,px must be interviewed privately. Information should be obtained regarding curent health status, living arrangements, financial status, emotional stressors, and social support. A history of alcohol and drug abuse for the patient as well as the other members of the household should also be included as should a sexual history regarding any unwanted advances or physical contact.
Any individual suspected of being abused should have a comprehensive PE, w/c is best performed with the patient completely undressed. GENERAL SIGNS in an elderly individual suggesting abuse include appearance of physical care and signs of psychosocial distress. Particular attention should be given to the patient’s general appearance, skin integrity, neurologic status, and musculoskeletal and genitourinary system. A complete skin examination should include evaluation for bruising on flexor surfaces, bruises of different ages, and burns. Assessment of ambulatory skills, an important component in establishing if reported injuries occurred secondary to falls or represent signs of abuse, should also be considered as part of the neurologic evaluation. Musculoskeletal examination should consider possible signs of injury that cannot be explained by the patient’s history, whereas GUT exam includes findings suggestive of sexual abuse.
When elder abuse is suspected it is important to carefully document all findings. Documentation in addition to a written note, should also include a diagram of all injuries noted during the examination. If possible, dated polaroid photographs should be taken of each injury. Xrays of any injured area should be performed and if there is any suspicion that the elderly patient may have suffered a head injury –a CT brain scan should be done If clinical findings suggest malnutrition or dehydration, lab testing should be requested to document findings consistent w/ either of these conditions. An important component of assessing for elder abuse includes observing caregiver and patient interactions. Defensiveness and/ or irritability on the part of caregivers may be a sign of burnout. Prompt identification and intervention may be instrumental in preventing the occurrence of abuse or reducing the likelihood of continuing abuse
Whenever feasible, discuss concerns related to suspected abuse or neglect directly with the patient. Involve professionals from other disciplines to assist in the evaluation -Hospital social workers and case managers offer additional skills and are generally knowledgeable regarding available community services Even after referring the patient to an outside community, remain involved Continued contact w/ a trusted FP can significantly enhance the intervention process.
Prevention of elder abuse starts by identifying those at risk >FP who have developed long-term relationships with px and their families have a distinct advantage in assessing and addressing px as well as caregiver risk factors. Home healthcare professionals or other home based service providers can further extend this advantage by observing both the elderly patient and the caregivers in the home environment Combining office and home-based assessment can provide primary care physician an excellent opportunity to determine the appropriate level of care needed
The best adjustment to care provided by a FP is… A number of communities are looking to volunteer providers as well in an effort to expand the scope of available services
Approximately 450,000 non-institutionalized elderly person aged 60 and over were victims of abuse and/or neglect, or about 1% to 2% of the total population. ---National Elder Abuse Incidence Study pub. By the US Administration on Aging (AOA) Approx. 80% went unreported to adult protective series (APS) agencies
ABUSE CATEGORIES Physical Abuse Willful infliction of physical pain or injury Hitting, slapping, shaking, striking with objects, use of physical or chemical restraints Sexual Abuse Nonconsensual sexual contact. Rape, unwanted touching, sexual advances, or innuendos
Psychological Abuse Conduct resulting in mental or emotional anguish. Threats to institutionalize or withhold medication, nutrition, or hydration Financial or Material Exploitation Misappropriating an older person’s assets for someone else’s benefit. Theft and blackmail, coercion to change wills or other legal documents to counter to the victim’s best interest
Neglect Failureto provide the goods or services necessary for maintaining health and avoiding harm or illness Active: Intentional refusal to provide basic needs assoc. w/ hygiene assistance, medications, food, and physical assistance when needed for personal safety Passive: Unintentional ; the result of caregiver ignorance or inability to provide for the patients’ basic needs.
Self- neglect “A pattern of intentionally neglecting prescribed self-care activities despite available resources and knowledge” Difficult to define due to conflicting individual and ethnic perspectives Concerns regarding mental competence frequently complicate intervention, as do ethical issues related to patient autonomy.
RISK FACTORS Characteristics common to victims of abuse and neglect: Female >75 y.o Poor health Low income Isolation Alcohol abuse History of mental illness or domestic violence
Warning signs assoc. w/ those who are at risk of abusing or neglecting others: Male Financial dependence on the victim History of substance abuse History of prior violent acts Current/prior history of psychiatric disorders Caregiver burnout
IDENTIFICATION BARRIERS Patient-Related Socially isolated Fear of retribution Cognitive impairments
Physician-Related Underestimate prevalence of elder abuse Don’t know how to assess for abuse Failure to develop a systematic plan on how to respond to identified abuse Denials; reluctance to intervene, fear of reprisal
ASSESSMENT Careful history Both patient and caregiver should be present to observe their relationship, anxiety on part of the patient or an overbearing attitude of the caregiver Patient must be interviewed privately; current health status, living arrangements, financial status, emotional stressors, and social support; History of alcohol and drug abuse; sexual history
Physical exam Poor physical care and signs of psychosocial distress Bruising; burns Cognitive function Injuries sec. to fall and abuse Injuries that can’t be explained by patient’s history Findings of sexual abuse
When elder abuse is suspected; document all findings: Written note Diagram of injuries Photographs X-rays Laboratory testing (CBC, BUN, Creatinine, total protein, and albumin levels)
MANAGEMENT Discuss concerns related to suspected abuse or neglect Include in the treatment plan and enlist their active support and participation Involve professionals from other disciplines To assist in the evaluation Continued contact w/ a trusted family physician Significantly enhance the intervention process
PREVENTION Identifying those at risk FPs developed long-term relationships w/ patients and their families Advantage in assessing and addressing patient as well as caregiver risk factors Homehealth care professionals or other home-based service providers Can observe both in the home environment Office and home-based assessment An excellent opportunity to determine the appropriate level of care needed
COMMUNITY SERVICES Coordination w/ community agencies staffed with interdisciplinary teams trained To deal w/ abuse and neglect situations from a social and medical perspective
CONCLUSION Proper care of elderly individual at risk for abuse can and should be provided by FPs. Adequate understanding of associated warnings Working relationship w/ supportive community services Meaningful doctor-patient relationship All these can have a significant impact on the emotional and physical well-being of older patients.