Rosen & Barkin's 5-Minute Emergency Medicine Consult (23 page)

Elder abuse may include the following:

• Emotional abuse:
  
  • Insults
    
  • Humiliation
    
  • Threats to institutionalize or abandon
    
• Physical and/or sexual abuse:
  
  • Hitting
    
  • Slapping
    
  • Pushing
    
  • Burning
    
  • Inappropriate restraining
    
  • Forced sexual activity
    
• Material exploitation:
  
  • Stealing or coercion involving patient money or property
    
• Neglect:
  
  • Behaviors by a patient or caregiver that compromise the patient’s health or safety
    
  • Failure to provide adequate food, shelter, hygiene, and/or medical attention
    

• In the US., 1–2 million cases age 65 or older mistreated by someone on whom they depend (these numbers likely will increase in the near term as US age demographics shift):
  
  • 55% neglect
    
  • 14.6% physical mistreatment
    
  • 12.3% financial exploitation
    
  • 7.7% emotional mistreatment
    
  • 0.3% sexual abuse
    
  • 6.1% all other types
    
  • 4% unknown
    
• Family members, including partners and adult children, are perpetrators in approximately 90% of cases
  
• For every case of financial exploitation reported, 25 cases likely unreported
  
• Elder abuse (even modest abuse) is associated with a 300% greater risk of death as well as increased rates of additional health problems such as chronic pain, bone/joint, digestive or psychological disorders (compared to the non-abused)
  

• Caregiver stress, dependency, or psychopathology
  
• Victim dependency or diminishment of ability to perform activities of daily living
  

DIAGNOSIS

Variable, possibly inconsistent, history or physical findings

• Not willing or able to obtain adequate food/clothing/shelter
  
• Not providing for personal hygiene/safety
  
• Delay in obtaining medical care/previously untreated medical condition
  
• Vague (or implausible/inappropriate) explanations
  
• Disparities between histories given by patient and caregiver
  
• Caregiver who insists on giving the patient’s history
  
• Medication difficulties:
  
  • Incorrect doses
    
  • Lost medications
    
  • Unfilled prescriptions
    
• Altered interpersonal interactions:
  
  • Withdrawn
    
  • Indifferent
    
  • Demoralized
    
  • Fearful
    
  • Substance abuse
    
• Caregiver with:
  
  • Financial dependence on patient
    
  • Substance abuse or psychiatric or violence history
    
  • Controlling behavior (may refuse to leave elder alone with physician) or poor knowledge
    
  • Significant life stressors
    
  • Relationship issues
    
  • Financial difficulties
    
  • Legal problems
    

• Inconsistent findings:
  
  • Patterns or variable-age bruises, burns, lacerations/abrasions
    
  • Unusual sites of bruising (inner arm, torso, buttocks, scalp)
    
  • Poor hygiene (inadequate care of skin, nails, teeth)
    
• Unexplained injuries:
  
  • Bruised or bleeding genital or rectal area
    
  • Wrist or ankle lesions suggestive of restraint use
    
• Findings that may be consistent with neglect or delay in seeking/obtaining medical attention:
  
  • Dehydration
    
  • Weight loss
    
  • Decubitus ulcer
    
  • Malnutrition
    

Perform any exam and lab or radiographic studies as indicated by the patient’s condition.

• Obtain history without family members/caregivers present:
  
  • Abused elders may fear institutionalization if they report caregivers.
    
  • Many may feel embarrassment and responsibility for abuse.
    
  • Frequently will not volunteer information
    
  • Ask patient specifically about abuse or neglect (in private)
    
• Patient’s medical condition may influence quality of history obtained
  
• Obtain history from caregivers/other relatives/friends/neighbors
  
• Document a clear and detailed description of findings including the following:
  
  • Statements of the patient as they pertain to the abuse
    
  • Psychosocial history:
    
    • Family and other social relationships
      
    • Caregiver burdens/coping mechanisms
      
    • Drug/ethanol (Etoh) use
      
    • Prior adult protective services reports
      
  • Skin and other physical findings:
    
    • Photographic documentation
      
    • Safety assessment
      

As appropriate for medical condition(s)

As appropriate for medical condition(s)

As appropriate for medical condition(s)

• Patient may present with any chief complaint:
  
  • Potential differential diagnosis is nonspecific.
    
  • Abuse best identified by asking patient directly in a setting apart from caregivers/family and correlating with risk factors and provider findings
    
• Differentiate findings consistent with other disease entities from abuse/neglect:
  
  • Dehydration
    
  • Ill-fitting dentures
    
  • Burns
    
  • Ecchymosis
    
  • Insomnia
    
  • Medication noncompliance
    
  • Dementia
    
  • Depression
    

TREATMENT

Observe details of the patient’s environment that may not be immediately available to the hospital care team, including the following:

• Interpersonal interactions at the scene:
  
  • Embarrassment
    
  • Shame
    
  • Fear of reprisal, abandonment, and/or institutionalization
    
• Conditions in the physical environment that present a potential danger
  

• ABCs
  
• Treat life-threatening medical/traumatic conditions as appropriate.
  

• May require separation of the patient and the caregiver or family member
  
• Social work referral:
  
  • Safety planning
    
  • Respite planning for caregiver
    
  • Adult protective services referral
    
• Competent elder patients are free to accept or decline treatment or disposition despite risks they may incur.
  
• General measures appropriate to the medical/traumatic conditions identified, including:
  
  • Fluids
    
  • Medications
    
  • Surgery
    
  • Diet
    
  • Activity
    
  • Nursing care
    
  • Physical therapy
    

FOLLOW-UP

Disposition determined by medical condition and home environment:

• Medical condition requiring admission
  
• Abuse or neglect renders home conditions unsafe.
  
• Need for more information or time to enhance objective decision making and patient management
  

• Medical condition(s) addressed
  
• Safe environment available
  
• Abuse or neglect successfully countered by social services and/or law enforcement
  

• Many states have mandatory reporting requirements:
  
  • Comply with area legal requirements.
    
• Alcohol/drug treatment as appropriate
  
• Notify adult protective services.
  

As appropriate for medical condition(s)

• Entertaining the possibility of abuse or neglect in an elder patient offers the best possibility of diagnosis and successful intervention.
  
• Only ∼1/3 of healthcare providers identified a case of elder abuse in the past year.
  
• Current data are inconclusive about the effectiveness of interventions for diminishing recurrence of elder abuse.
  
• Obtain the aid of social worker, physicians trusted by the patient, even an ethics consultant, should a vulnerable competent elder seek to decline an elder abuse/neglect investigation.
  

• Clarke ME, Pierson W. Management of elder abuse in the emergency department.
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  . 1999;17:631–644.
  
• Cooper C, Selwood A, Livingston G. Knowledge, detection, and reporting of abuse by health and social care professionals: A systematic review.
  Am J Geriatr Psychiatry
  . 2009;17(10):826–838.
  
• http://www.ncea.aoa.gov/Resources/Publication/docs/FinalStatistics050331.pdf
  
• http://www.ncea.aoa.gov/Library/Data/index.aspx
  
• http://www.ncea.aoa.gov/Resources/Publication/docs/fact1.pdf
  
• Lachs MS, Pillemer K. Elder abuse.
  Lancet
  . 2004;364:1263–1272.
  
• Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States; prevalence estimates from a nationally representative study.
  J Gerontol B Psychol Sci Soc Sci
  . 2008;63(4):S248–S254.
  
• Ploeg J, Fear J, Hutchison B, et al. A systematic review of interventions for elder abuse.
  J Elder Abuse Negl
  . 2009;21(3):187–210.
  

CODES