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.
3. Objectives
Describe the definitions, categories,
impact and prevalence of Elder Abuse
and Neglect
Recognize historical and physical signs
of elder abuse and neglect, and review
other markers
Discuss proper documentation of
findings in suspected elder abuse and
proper reporting procedures.
4.
5. The Case of “Just a Hygiene
Problem”
78 year old woman, who lives with her
son (primary caregiver), history of
diabetes, difficulty walking (spinal
stenosis?) – wheelchair bound, chronic
edema
Brought in to the ER for altered mental
status, found to have a UTI
6. The Case of “Just a Hygiene
Problem”
Skin not checked until the patient
transferred to the ward floor
The RN notifies the Attending regarding
the skin
The Attending says “just a hygiene
problem” to nurse, in front of all other
learners.
Nurse calls APS.
9. What does this population
longevity mean?
As Age increases, so do the number of
health, social, and psychological isses that
make older people more dependent:
Chronic illness, More medications
Depression & Dementia
Quantity and Quality of social support/situation
Decrease in Reserves
Increase in vulnerability to Abuse
Difficulty defending self, more likely to get
injured
13. Definitions
From National Center on Elder Abuse:
“Any knowing, intentional, or negligent act by a caregiver
or any other person (paid or unpaid) that causes harm or
a serious risk of harm to a vulnerable adult.”
PC 368[b][1]:
Any person who knows or reasonably should know that a
person is an elder or DA and who, under circumstances
or conditions likely to cause GBH or death .....having the
care or custody of any elder or DA, willfully causes or
permits the person or health of the elder or DA to be
injured, or willfully causes or permits the elder or DA to
be placed in a situation in which his or her person or
health is endangered.....
14. 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 that
restrict his or her ability to carry out normal
activities or to protect his or her rights,
including, but not limited to, persons who
have physical or developmental disabilities,
or whose physical or mental abilities have
diminished because of age.” (W&I Code
15610.23)
15. Types of Elder Abuse:
Physical Abuse:
use of physical force that may result in bodily injury, pain or
impairment
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 or
non-verbal acts or threats
Sexual Abuse:
Non-consensual sexual contact, harassment, inappropriate
comments or threats. Consider non-consensual if the person
does not make, or incapable of making an informed choice
Neglect:
Failure to provide basic neecessary care or services when such
failure may lead to harm or risk of serious harm
16. Sexual Abuse Case
• 81 year old gentleman cognitively impaired
is allegedly sexually abused by a hired
care giver at home (for respite) while wife
is attending to other matters. Abuser
admits to performing the acts, but says that
the gentleman consented to it.
• Our VAST team was asked by law enforcement
to assess the capacity of the gentleman
• He had a MOCA score of 6/30. Upon further
history with wife, she revealed, he was
diagnosed with dementia years prior.
17. Types of Abuse
Self-Neglect: (often included within neglect)
Abandonment:
A Caregiver’s desertion places the adult in serious risk of
harm
Involuntary Seclusion(Isolation):
Confinement, restriction or isolation of an adult for the
convenience of a caregiver or to discipline the adult
Wrongful restraint:
The use of a physical or chemical restraint to limit the
movement of an adult for the convenience of the caregiver
or to discipline the adult.
Abduction:
Removal from this state and the restraint from returning to this
state, of an elder or dependent adult who does not have the
capacity to consent
18.
19. 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 much
inquiry
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 one
year
○ 50,000 reports of abuse in nursing homes in one
year
20. Elder Abuse
Estimated that 4-10% of people 65 or older
are victimized by relatives, caretakers or
strangers.
Up to 4.3% of older adults physically abused
annually
It is not known how big the problem exactly is!
Physicians are mandated to report
suspected abuse
<2% of APS reports are filed by physicians.
Lack of understanding of reporting mechanisms
represented the most significant obstacle
21. Elder Abuse Incidence
FOR EVERY REPORT OF
ABUSE….
55 GO UNREPORTED
National Elder Abuse Incidence Study, 1998
23. Elder Abuse – California
Incidence
• 47,000 reports of abuse
• “235,000” abused elders, when you
considered unreported cases
• CA APS Report 1997
• Approximately 110,000 reports of abuse
were received statewide during State
fiscal year 2006-07
• CA APS Report 2007
24. APS serves adults with physical or mental impairments, as well as the
elderly. Elder and Dependent Adult Victims – Orange County, APS 2010
report
YEAR REPORTS ELDERS DEPENDENT
ADULTS
2010 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 Frequency
Physical 16%
Sexual 2%
Financial 29%
Neglect 27%
Abandonment 1%
Isolation 2%
Abduction 0.2%
Psychological 24%
25. Dependent Adult Abuse
Little known about the abuse of
dependent adults
1999 - the federal government convened
a group of experts to identify
○ 4 to 10 times higher risk of becoming victims of
abuse
○ 10 times higher risk of being sexually assaulted
○ Less likely to report abuse
○ Lower rates of police follow-up and successful
conviction of perpetrators
Victimization of Dependent AdultsVictimization of Dependent Adults
Conference, 1999Conference, 1999
26.
27. Risk Factors – the abused
Over 80 years are 2-3 times more likely
to be abused
Female: in 2/3 of all reports, victim is a
woman
Presence of cognitive impairment
Dependent, Dementia, Physically
Aggressive, Verbally Abusive
28. Risk Factors – the abuser
Depressive symptoms
Financial ties
Felt they had a poor emotional status and
had role limitations in activities and/or
work as a result of caregiving role
People with inadequately treated mental
health and/or substance abuse problems
are more likely to be abusive
People who feel
stressed/burdened/resentful are more
likely to be abusive
29. Risk Factors – the context!
People with inadequately treated mental
health and/or substance abuse problems
are more likely to be abusive
People who feel
stressed/burdened/resentful are more
likely to be abusive
Providing care for an older adult who is
physically combative and/or verbally
abusive
Financial, Marital, Employment, Change in
Elder/Caregiver Dependency Relationship
30. Risk Factors-Special Issues
Adults with Disabilities
○ 44% of those age 75 years and over living in the
community reported having a limitation in their usual
activity 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 Facilities
Screening for Abuse and Neglect of People with Dementia
Wiglesworth, Mosqueda, et al. Journal of American Geriatric Society, March 2010
31. Risk Factors-Special Issues
Dementia
Studies estimate any where from 1-13% for
those over age 65
Memory loss, other cognitive loss, functional
loss
Undue Influence
“The substitution of one person’s will for the
true desires of another.”
Excessive pressure
Usually for financial gain
32.
33. Consequences of Elder Abuse
Financial—Income, savings, home
Emotional—Feelings of self-worth,
safety
Physical—Compromising health that
might already be vulnerable
Cognitive—Depression, dementia
Social—Family dynamics, community
safety, societal expectations of old age
34. Consequences of Elder Abuse
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.
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
35. 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 in
with me.’
“You don’t want to get close to another
person and call them your friend. You’re
afraid of it.”
○Mrs. Crewey, at age 90, lost her home and furniture to, and
had her bank account compromised by, her good friend
○(Elder Justice Now campaign by WITNESS and National
Council on Aging)
36. Consequences of Elder Abuse -
Testimonies
“I thought our marital problems were all
my fault... He had me so totally
brainwashed and convinced that I was
crazy, lazy, stupid, and worthless, that I
was a walking zombie.
I spent every waking hour trying to be a
better wife and mother but the harder I
tried, the worse I became.”
○Older woman in WI who had been married for 24
years to her abuser
○(Brandl & Spangler, National Clearinghouse on Abuse in Later Life,
“Golden Voices” 2003)
37.
38. Role of the Health Care
Provider
Barriers to detecting/reporting Elder
Abuse
Lack of knowledge
Legal concerns
Discomfort in showing ignorance
Sense of powerlessness
Fear of offending patient or the abuser
Minimization and denial
Reluctance to become involved
Time constraints
39. 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 or
harm you?
Has anyone close to you called you
names or put you down or made you
feel bad recently?
Does someone in your family make
you stay in bed or tell you you’re sick
when you know you aren’t?
Has anyone forced you to do things
that you didn’t want to do?
Has anyone taken things that belong to
you without your OK?
*Sengstock-Hwaleck, M., 1987. “A Review and Analysis of Measure for
the Identification of Elder Abuse.” Journal of Gerontological
Social Work 10 (3/4):21-36
40. The role of the Health Care Provider–
Do we screen for elder abuse?
• The USPSTF found insufficient
evidence to recommend for or against
routine screening …of older adults or
their caregivers for elder abuse.
ACOG and AMA45
recommend that
physicians routinely ask elderly patients
direct, specific questions about abuse
- Am Fam Physician. 2004 Aug 15;70(4):747-751.
41. The Role of the Health Care
Provider
Do look for clues in the patient that may
make you think of abuse:
○ Flat affect, listless, apathetic
○ Hesitant, evasive
○ Fearful, anxious
○ Hostile, aggressive
○ Uncooperative, suspicious
Abrupt change in a known patient
42. The Role of the Health Care
Provider– 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 alleged
abuse (inconsistent stories)
Lack of concern on the part of the caregiver
Interactions between patient and caregiver
43. Role of the Health Care
Provider
History
Physical
Mental Status Exam
Laboratory Exam
How do we use this when thinking about
Elder Abuse?
44. Role of the Health Care
Provider
Keep in mind Red Flags
Open-ended questions
proceed to more specific questions
Avoid leading questions
Separate the victim from the caretaker,
if needed
Keep in mind cognitive ability/capacity
When to take it seriously? When unreliable?
45. 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
46. Role of the Health Care
Provider
Mental Status and Capacity
Evaluation and assessment:
○ History suggestive of loss of memory, other cognitive
domains, function
○ office tools: Mini-Mental State Exam, Mini-Cog, Six-
item screen, MoCA
Clinician’s role: observe, provide opinion,
not make a specific diagnosis
47. The Role of the Physician –
Markers: Bruises
Most common
Hard to tell what’s
abuse and what’s not
Age-related changes
Medications
Dating by color
Multiple stages of
healing
History consistent with
injury?
Location
51. When is bruising suspicious trauma
versus accidental trauma? Which looks
more like abuse: A or B?
A B
52. Strangulation
Difficulty breathing
Hoarse voice
“Sniffing position”
Ask:
○ Did he/she
○ choke you?
○ Did you
○ lose consciousness?
○ Can be a medical emergency
53. 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 rotational
component are suspicious
○ Sites other than hip, vertebra, or wrist may
more likely be markers of abuse.
54. Burns
Persons over the age of 65 have 2X the
national average death rate due to burns
Seen in physical abuse, neglect and self
neglect
Limited studies reveal that between 36-70%
of burns in adult abuse were due to abuse or
neglect (Bowden 1998; Burns 1998)
55. 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
56. Are all pressure sores signs of
abuse???
Pressure Sores: what an expert may be
able to tell you
Whether this was a high risk situation in
which a pressure sore may have been
inevitable
Whether this is typical in appearance
Whether this is typical in location
Whether treatment was sought or carried out
appropriately
57. Role of the Physician -
Laboratory tests
Malnutrition
Dehydration
Bleeding times
Medication levels
58. Medication Review: their role in
mistreatment
Can be:
○Overused: to sedate, cause
delirium
○Underused: to reduce mobility
(e.g., L dopa), cause illness
exacerbations (insulin, inhalers,
antibiotics)
○Misused: used for unapproved
effects (antihistamines to sedate)
59. Role of the Health Care
Provider
Other Red Flags/clues
Sexual Abuse: bruising of the breasts,
unexplained STDs, perineal and inner thigh
bruising, inappropriate modesty, fear of
touch
Emotional abuse: withdrawn, evasiveness,
hostility
Neglect: absence of medical devices
Financial: not following medical regimens,
failure to get medicines, disparity between
assets and condition
60. Role of the Health Care
Provider
Don’t forget the caregiver!
Majority = adult children & partners
Clues 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
61. Role of the Health Care
Provider– Elder Abuse
Proper Documentation/Medical Record
should include:
Date, time
Identifying information
Patient’s statements
Findings on physical examination
Medical opinion/diagnosis
Treatment record
Follow-up and referral plans
Reporting requirements fulfilled
62. Role of the Physician – Elder
Abuse
Reporting
California:
○ 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 confirmed
telephone when practically possible
formal written report [SOC 341], mail or fax within 2
working days
○ Financial institutions
Failure to report: jail, fine or both!Failure to report: jail, fine or both!
63.
64. After the report
APS involvement
Appropriate cross-reporting and referrals to
agencies to assist/investigate
○ Long-term care ombudsman
○ Family Caregiver Alliance
○ Law enforcement agencies
○ Emergency planning
65. After the report
• Adult day healthcare
• Meals on Wheels
• Senior centers
• Support groups
• Transportation
• Mental health
• Multipurpose senior
services program
(MSSP)
• Home equipment
• In home support
services (IHSS)
• Home repair
66. What APS May do -
• Recommend conservatorship
• Call the police
- Request a 5150 evaluation
- File a report
• Suggest, persuade, and bargain with the
client to get help
• Arrange for case management
• Work collaboratively with support
systems
67. What APS May NOT Do
• Enter the home without permission
• Remove the person from their
residence against their will
• Force a client to accept services
70. UCI Experience
During the calendar year 2011,
Orange County Elder Abuse Forensic
Center met 52 times (every week)
○ assisted with 78 new elder abuse/neglect
cases and reviewed 126 updates.
○ The Vulnerable Adult Specialist Team (VAST)
conducted 15 high intensity in-home medical
assessments, 19 high intensity in-home
psychological evaluations, performed 9
medium intensity medical record reviews,
and made 3 low-intensity doctor-to-doctor
consultations.
71. The Future
What is our responsibility as a society?
What role could/should the government
play in this issue?
What policies currently exist that either
allow or prevent elder abuse?
Unifying terminology and definitions/policies
Research:
How do we better screen and assess issues
such as capacity, forensic markers such as
bruising and sores?
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.