| A Primer On Elder Abuse | | Counselor, Elder abuse is a phenomenon that has been growing over the past ten years and will continue to grow well into the future. Please note: This is the last newsletter for 2007, no newsletter will be sent the weeks of 24/Dec/2007 and 31/Dec/2007. As such, we would like to take this opportunity to thank you for your interest over the past year in AMFS and our newsletters, and we especially want to wish you a safe, happy holiday season, and a healthy, prosperous New Year! We value all your comments, so, if you have a suggestion for a newsletter subject but haven't submitted it yet, or if you have already submitted one but think of another, please take a minute to let us know by clicking on your "Reply" button and dropping us a note. To learn more about AMFS, Inc., the organization run by Physicians and Attorneys that provides medical experts and case review services nationwide, and has produced the following informational newsletter to aid you in understanding complex medical issues, please click here - www.medicalexperts.com. |
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|  History: People are living longer with current medical advances and healthier lifestyles. In 1990, it was estimated that older persons comprised just 13% of the US population. By the year 2050, this proportion is projected to increase to 25%; the number of people older than 85 years is expected to double. As a result, the number of elder abuse cases will increase, and the impact of elder abuse as a public health issue will grow. Aging adults involved in abusive relationships often visit the ED for treatment. Emergency physicians are well positioned to help these victims. Seven categories of elder abuse have been described by the National Center on Elder Abuse (NCEA), formerly the National Aging Resource Center on Elder Abuse. Categories include the following: Physical abuse is defined as any act of violence that causes pain, injury, impairment, or disease, including striking, pushing, force-feeding, and improper use of physical restraints or medication. Psychological or emotional abuse is conduct that causes mental anguish. Examples include threats, verbal or nonverbal insults, isolation, and humiliation. Some legal definitions require identification of at least 10 episodes of this type of behavior within a single year to constitute abuse. Financial abuse is misuse of an elderly person's money or assets for personal gain. Acts such as stealing (eg, money, social security checks, possessions) or coercion (eg, changing a will, assuming power of attorney) constitute financial abuse. Neglect is the failure of a caretaker to provide for the patient's basic needs. As in the previous examples of abuse, neglect can be physical, emotional, or financial. Physical neglect is failure to provide eyeglasses or dentures, preventive health care, safety precautions, or hygiene. Emotional neglect includes failure to provide social stimulation (eg, leaving an older person alone for extended periods). Financial neglect involves failure to use the resources available to restore or maintain the well-being of the aging adult. Sexual abuse is defined as nonconsensual intimate contact or exposure or any similar activity when the patient is incapable of giving consent. Family members, friends, institutional employees, and fellow patients can commit sexual abuse. Self-neglect is behavior in which seniors compromise their own health and safety, as when an aging adult refuses needed help with various daily activities. When the patient is deemed competent, many ethical questions arise regarding the patient's right of autonomy and the physician's oath of beneficence. The miscellaneous category includes all other types of abuse, including violation of personal rights (eg, failing to respect the aging person's dignity and autonomy), medical abuse, and abandonment. |
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| Frequency and Prevalence: In the US: Due to the inconsistencies in definitions of elder abuse, obtaining accurate information on elder abuse incidence is difficult. A 1991 report from the House Select Committee on Aging suggests that 1-2 million adults older than 60 years are abused each year. Other studies suggest that 3-10% of elders are abused or neglected. Many factors (eg, fear, shame, guilt, ignorance) play a role in the likely underestimation of the number of abused elders. In addition, many studies routinely exclude certain populations (eg, persons possibly unable to respond to a survey, speakers of languages other than English, persons with mental illness), further complicating accurate tallies of the number of older persons who are abused. |
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| | Race, Sex, and Age: Elder abuse occurs among members of all racial, socioeconomic, and religious backgrounds. The NCEA found the following racial and ethnic distribution among older persons who had been abused: White, non-Hispanic - 66.4%, Black - 18.7%, Hispanic - 10%, Other - 4.9%. Women are believed to be the most common victims of abuse, perhaps because they report abuse at higher rates or because the severity of injury in women typically is greater than in men. Numerous studies, however, have found no differences based on sex. By definition, elder abuse occurs in the elderly, although there is no universally accepted definition of when old age begins. Typically, 60 or 65 years is considered the threshold of old age. |
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| | Clinical - History: The American Medical Association recommends that doctors routinely ask geriatric patients about abuse, even if signs are absent. Keeping questions direct and simple and asking in a nonjudgmental or nonthreatening manner increases the likelihood that patients will respond candidly. The patient and the caregiver should be interviewed together and separately to detect disparities offering clues to the diagnosis of abuse. Accurate, objective documentation of the interview is essential. Questions should be those directly related to physical, psychological, sexual, neglect, and financial abuse. |
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| | Clinical - Physical: As with other abusive relationships, elder abuse rarely resolves itself and probably will escalate over time. Signs of abuse may be blatant or subtle. A number of clinical findings and observations make elder abuse a strong possibility. They include several injuries in various stages of evolution, unexplained injuries, delay in seeking treatment, injuries inconsistent with historyc, contradictory explanations given by the patient and caregiver, laboratory findings indicating underdosage or overdosage of medications, bruises, welts, lacerations, rope marks, burns, venereal disease or genital infections, dehydration, malnutrition, decubitus ulcers, poor hygiene, signs of withdrawal, depression, agitation, or infantile behavior. |
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| | Evaluaton - Lab Studies: Search for evidence of infection, dehydration, electrolyte abnormalities, malnutrition, improper medication administration, and substance abuse in patients who have been abused. The standard lab studies include a CBC, electrolytes, glucose, renal function tests, urine analysis, calcium, magnesium, phosphorus, serum medication levels, urine drug screen. Imaging studies include detection of fractures and a head CT scan to detect intracranial bleeding. |
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| | Treatment: Treatment usually begins in the Emergency Department. Many factors are involved in the management of older persons who have been abused, including immediate care, long-term assessment and care, education, and prevention. Intervention can be a lengthy process, especially in a busy ED. Many hospitals have developed multidisciplinary teams (ie, social workers, physicians, nurses, administrators) to help in these situations. The ultimate goal is to provide the aging adult with a more fulfilling and enjoyable life. But the immediate care focuses on treating the physical manifestations of abuse and assuring the safety of the patient. The approach should be multi-disciplinary and should include specialists in Psychiatry, Social Work, Geriatric Medicine, Neurology, and Orthopedics when necessary. |
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| | Medical/Legal Pitfalls: All cases of suspected elder abuse must be reported to Adult Protective Services. Practically every state has a law mandating that physicians report elder mistreatment, and many have penalties for failing to report. Forty-three states mandate reporting of suspected cases of elder abuse. Some statutes require that licensed professionals who have not fulfilled their obligations to report elder abuse can be reported to the appropriate licensing authority. Mandatory reporting of elder abuse in competent patients is a controversial topic. A mandate to report domestic violence is seen by some as disempowering the abused individual, violating the right of autonomy. Therefore, reporting is not mandated in domestic violence cases. Many use the same logic that mandatory reporting of abuse of mentally competent victims of elder abuse disempowers the abused individual. The laws created for elder abuse were based upon child abuse laws; therefore, the inability of patients to make decisions in their own best interests was presumed. The laws are weak on matters such as financial abuse, since children generally have no money to exploit. |
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