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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. No disclosures. Outline.

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Elder Abuse and Neglect in a Medical Setting

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elder abuse and neglect in a medical setting
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
  • 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.
the case of just a hygiene problem
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
the case of just a hygiene problem1
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.
what does this population longevity mean
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
definitions elder abuse
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.
definitions types of elder abuse
Definitions – Types of Elder Abuse
  • Abandonment
  • Abduction
  • Financial exploitation
  • Self-neglect
  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Neglect
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


physical abuse bruising
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
bruising study
Bruising Study
emotional abuse
  • The infliction of mental anguish, pain or distress upon another person.
      • Threatening
      • criticizing *yelling
      • debasing *humiliating
      • ridiculing *intimidating
      • ignoring *socially isolating


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


sexual abuse1
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.
  • 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


are all pressure sores a sign of abuse
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
  • 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


financial abuse
  • Exploitation of property, resources and assets:
    • denying access
    • stealing, hiding
    • purposeful mismanagement, deception
    • fraud, extortion, forging
    • improper use of legal documents


  • 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.


possible abduction case
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?
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


elder abuse incidence
Elder Abuse Incidence

National Elder Abuse Incidence Study, 1998

types of elder abuse
Types of Elder Abuse
  • Neglect 49%
  • Emotional 35%
  • Physical 30%
  • Financial 26%
  • Abandonment 4%
  • Sexual 1%

National Elder Abuse Incidence Study, 1998

elder abuse california incidence
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

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%

  • 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.
dependent adult abuse
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

impact of abuse
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
known effects of abuse health
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
known effects of abuse psychological
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?
known effects financial
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
abuse predictors care provider
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

Risk Factors: Abusers

  • ■ RI court record review of prosecutions
    • About 50% had prior criminal history
    • 25%+ had prior court case for DV
    • 2 in 10 - prior record for drug/etoh event
    • 14% prior for (non-domestic) crime against person
    • 16% sentenced to prison for prior charge
  • ■ Phone Survey 6,000 elders
    • 57% perps of physical abuse were partners/spouses
    • 3 in 10 had history of mental illness
    • 33% were unemployed
    • 4 in 10 were socially isolated
risk factors the abused
Risk Factors: the Abused
  • Older
  • Female
  • Cognitively impaired
  • Isolated
special issue abuse of people with dementia wiglesworth 2010
Special Issue: Abuse of people with dementia (Wiglesworth, 2010)
  • 129 Community-dwelling people with dementia and their caregivers were assessed for evidence of mistreatment as well as factors that might be related to mistreatment.
  • 47% of participants with dementia (61) had been mistreated by their caregivers.
    • 42% (54) experienced psychological abuse
    • 10% (13) physical abuse
    • 14% (18) caregiver neglect
criteria for dementia
Criteria for Dementia
  • Loss of memory
  • Loss in at least one other cognitive domain (e.g. language, spatial relations, judgment)
  • Loss of function
the demography of dementia
  • 4 million in U.S. currently
  • 14 million in U.S. by 2050
  • 1 in 20 persons aged 65+ and nearly half of those aged 85+ have dementia
  • Life expectancy of 8-12 years after symptoms begin
  • The issue of decision making capacity often arises in Elder Abuse
    • Can be extremely difficulty to determine in patient’s with impaired cognition, such as due to dementia.
    • What tools do we have to determine cognitive status and decision making capacity? MMSE? MOCA?
  • Lack of professional awareness/education/training
  • Emergency Placement
  • Lack of resources & funding
  • Many professionals unaware of reporting requirements
  • Lack of communication/Collaboration/between agencies
  • Inadequate sharing of information between agencies
  • Reporting (Failure to report/Delay in reporting)
  • In this population, what is a suspicious death? A suspicious injury?
attitude adjustments
Attitude Adjustments
  • If a 12 year old dies suddenly, that’s suspicious. If a 65 year old dies suddenly, …..;
  • They (older victims) have Alzheimer’s;
  • They (older victims) make terrible witnesses;
  • They (older victims) bruise easily;
  • They (older victims) get broken bones;
  • They (older victims) get pressure ulcers (bed sores);
  • They (older victims) fall a lot; and,
  • “He/She was going to die anyway from his/her underlying (fillin the blank health condition).”
adult protective services
  • Reporting:
    • 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 (CA)
    • Failure to report: jail, fine or both!


who reports to report who
Who reports to report who?
  • Long Term Care Facility  Ombudsman
  • State Mental Health Hospital  state dept of mental health
  • State Developmental Center  state dept of developmental services
  • Other than above  APS and Law enforcement
what if
What if...
  • You report and you’re wrong?
    • Nothing as long as the report was made in good faith
after the report is made
After the report is made
  • APS: each report is assigned to a Senior Social Worker for investigation and case planning
  • LTC Ombudsman: volunteer and paid Ombudsmen gather information and problem-solve to help uphold residents’ rights
  • Law Enforcement: if a crime is suspected, an officer will investigate and collect evidence to hold the offender accountable
  • Any of these might identify and contact other relevant agencies to help address the problem
other agencies that receive reports when the setting is a long term care facility
Other agencies that receive reports when the setting is a long-term care facility
  • Assisted Living: Community Care Licensing
  • Nursing Home: Licensing and Certification
  • Bureau of Medi-Cal Fraud and Elder Abuse
  • Patient’s Medical Record:
  • date, time
  • patient identifying information
  • patient's statements
  • findings on physical examination
  • medical opinion/diagnosis
  • treatment required
  • follow-up and referral plans
  • reporting requirements fulfilled


forensic documentation
Forensic Documentation
  • Creates a paper trail
  • Demonstrates competency
  • Avoids Liability
categories of documentation
Written history

Body diagram



Categories of Documentation
written history
Legible handwriting

Patient identification

Date and time

Direct quotes

Record interactions between patient and caregiver

Written History
  • Specifics regarding timing and mechanism, alleged perpetrator, how it happened
body diagram
Characteristics of injuries

Specific locations

Size and shape

Color changes



Body Diagram
Use a good camera

Far away and close up

Ring flash

Identifier (name plate)

Consent typically needed for documenting injuries

other red flags clues
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
other red flags clues1
Other Red Flags/clues
  • 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
uci experience1
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.
the future
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?

University of California, Irvine School of Medicine Program in Geriatrics

  • www.centeronelderabuse.org