Elder Abuse and Neglect in a Medical Setting

1. Elder Abuse and Neglect in a Medical Setting • Steven Tam, M.D. • Assistant Clinical Professor, Internal Medicine and Geriatrics • Center of Excellence on Elder Abuse and Neglect • University of California, Irvine School of Medicine

2. No disclosures

3. Outline • Explain the scope of the problem of elder abuse and neglect • Distinguish the different types of elder abuse and neglect • Identify the prevalence of elder abuse and neglect and difficulties in establishing it • Identify the impact of elder abuse on both the patient and society • Identify common signs and symptoms of elder abuse and neglect • Recognize the risk factors for elder abuse and neglect • Identify what to look for in the patient • Identify what to look for in the caregiver • Define the role of the medical professional in elder abuse and neglect situations • Recognize barriers to proper detection and reporting of abuse and neglect by the medical professional. • Review proper reporting procedures for elder abuse and neglect. • Review proper documentation and findings in suspected elder abuse and neglect situations.

4. 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

5. Picture

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.

7. What should’ve be done??? • Picture

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

10. Definitions –Elder Abuse • Elder: any person residing in California who is 65 years of age or older. • Elder abuse: acts of omission or commission by a person who stands in a trust relationship that result in harm or threatened harm to the health and or welfare of an older adult. • Caregiver: any person who has the care, custody or control of, or stands in a position of trust with, an elder or dependent adult.

11. Definitions – Types of Elder Abuse • Abandonment • Abduction • Financial exploitation • Self-neglect • Physical abuse • Sexual abuse • Emotional abuse • Neglect

12. PHYSICAL ABUSE • Use of physical force that causes or may cause non-accidental physical pain, harm or bodily injury. • beating *pinching • shaking *burning • kicking *choking • throwing objects *unreasonable restraint • force feeding *misuse of medication • assault with deadly weapons 5

13. Physical Abuse - Bruising • 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

14. Bruising Study • WIGLESWORTH ET AL. JAGS JULY 2009–VOL. 57, NO. 7

15. Location of Bruises Caused by Abuse

16. Bruising Study con’t

17. When is bruising suspicious trauma versus accidental trauma? Which looks more like abuse: A or B? B A

18. Accidental or Inflicted? You decide

19. Accidental or Inflicted? You decide

20. EMOTIONAL ABUSE • The infliction of mental anguish, pain or distress upon another person. • Threatening • criticizing *yelling • debasing *humiliating • ridiculing *intimidating • ignoring *socially isolating 6

21. SEXUAL ABUSE • Any form of sexual contact or exposure • without consent. • unwanted touching and fondling • sexual name calling • forced and coerced sexual acts • purposefully hurtful sex • sodomy • rape 7

22. Sexual Abuse • 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.

23. NEGLECT • Denial of care: • food, water, shelter • personal hygiene, clothing, bedding • medical care, medicines, assistive devices • Isolation: • control of time, activities, contacts • disinformation tactics • false imprisonment 8

24. Neglect – Decubitus Ulcers

26. Decubitus ulcer – Stage II

27. What stage is this pressure sore?

28. Are all pressure sores a sign 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

31. ABANDONMENT • Willful unattended care or custody by an identified caregiver who has assumed responsibility when a reasonable person in a like situation would not do so: • home • public place 9

32. FINANCIAL ABUSE • Exploitation of property, resources and assets: • denying access • stealing, hiding • purposeful mismanagement, deception • fraud, extortion, forging • improper use of legal documents 10

33. ABDUCTION • The removal of a person from California (or other state) or restraining a person from returning to California (or other state) who does not have the capacity to consent to this action. 11

34. Possible Abduction Case • Grandson moved the client, an elderly woman, to live with him in Texas. Concern for financial abuse initially as APS started to get involved in the case. • Grandson moved her without notifying APS. • What role can APS play in another state, after the client is moved?

35. SELF-NEGLECT • Basic activities of daily living are neglected, threatening personal health and safety: • hygiene • food, water • clothing and bedding • shelter and surroundings • finances • health care • hoarding 12

36. Prevalence?

37. Elder Abuse Incidence • FOR EVERY REPORT OF ABUSE…. • 5 GO UNREPORTED National Elder Abuse Incidence Study, 1998

38. Types of Elder Abuse • Neglect 49% • Emotional 35% • Physical 30% • Financial 26% • Abandonment 4% • Sexual 1% National Elder Abuse Incidence Study, 1998

39. 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

40. APS serves adults with physical or mental impairments, as well as the elderly. Elder and Dependent Adult Victims – Orange County, APS 2010 report Abuse by others Frequency Physical 16% Sexual 2% Financial 29% Neglect 27% Abandonment 1% Isolation 2% Abduction 0.2% Psychological 24%

41. Oregon • APS Annual Report 2010, DHS • In 2010, the Department of Human Services Adult Protective Services received more than 27,000 reports of potential abuse. • 2,608 Oregon seniors and adults with physical disabilities were victims of abuse or self-neglect in 2010. • Fewer than 2% of residents in licensed care facilities were found to have been victims of abuse in 2010. Neglect was the most common type of abuse experienced by seniors in Oregon facilities in 2010. Financial exploitation was the most common abuse found in community settings. • 85% of founded abuse happened to seniors and adults with physical disabilities in their own homes, 15 percent of founded abuse happened in licensed care settings. • In facilities, a direct caregiver was the most common perpetrator. In the community, family members or close friends were the most common perpetrators of adult abuse in 2010.

42. 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 Adults Conference, 1999

43. Impact

44. Impact of 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

45. Known Effects of Abuse: health • Increased Mortality • Lachs et al. 1998, Dong et al. 2009 • Poorer physical outcomes (probable) • Anetzberger 2004; American Medical Association 1990; Lindbloom et al. 2007 • Increased pain • Exacerbation of existing conditions • Welts, wounds, injuries • Increased susceptibility to infection

46. Known Effects of Abuse: psychological • Poorer psychological outcomes • Established psychological effects of elder maltreatment include higher levels of distress and depression (Comijs et al 1999; Pillemer & Prescott 1989). • Other potential psychological consequences that need further scientific study are: • increased risks for developing fear/anxiety reactions, • learned helplessness, • post traumatic stress syndrome • Suicide?

47. Known Effects: financial • Effects • Restitution often not forthcoming or too late • No time to rebuild assets • Loss of choices- • Reliance on others for financial support • Intergenerational transfer of wealth impacted • More quickly spending down to Medicaid • Care of aging parents with reduced pool

48. Risk factors

49. Risk Factors: What We Know About Abusers

50. Abuse Predictors: Care Provider • Depressive symptoms • 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