elder mistreatment challenges in identification and assessment · elder mistreatment challenges in...
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Elder MistreatmentChallenges in Identification
and AssessmentDaniel Swagerty, MD, MPH
Professor of Family Medicine and Internal MedicineAssociate Director, Landon Center on Aging
Director of Clinical Geriatrics,University of Kansas School of Medicine
Definition of Elder Abuse *Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
* There’s lots of room for interpretation
Target PopulationOlder Adults: Aged 65 and Older
Dependent Adult: Age 18 - 64 Physical or Mental Impairments that Restrict Ability to Carry out Normal Activities or to Protect Own Rights.
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Epidemiology
More than 2 million US older adults per year The actual extent is unknown
UnderreportingUnderreportingPoor definitions
Prevalence about 5% of all older adults
Identification
Types of Elder MistreatmentPhysical Abuse – Least commonPhysical Neglect – Most commonPsychological Abusey gFinancial ExploitationViolation of Rights
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Physical AbuseAct resulting in pain, injury, impairment, or illnessExamples :
• Pulling a patient’s hair
• Slapping, hitting, and punching
• Throwing food or water on a patient
• Tightening a restraint to cause pain
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Physical NeglectFailure of caregiver to provide goods or services needed for optimal function or to avoid harm
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NeglectFailure of Caregiver or Patient to Exercise a Reasonable Degree of Care Failure to:
P id F d Cl thi Sh lt P l H iProvide Food, Clothing, Shelter, Personal HygieneObtain Needed Medical CareProtect from Health and Safety HazardsPrevent Malnutrition and Dehydration
Clues of NeglectRecurrent ER Visits or Hospital Admissions for Same ConditionInappropriate Delay in Seeking CareMalnutrition and DehydrationNon-Compliance with Medication RegimenMissed Medical AppointmentsPoor Hygiene and Disheveled AppearancePressure Ulcers
Psychological AbuseConduct that causes mental anguishExamples :Terrorizing and/or threatening a patient with a word or gesture
Inappropriate isolation of a patient
Yelling at a patient in anger
Denying food or privileges
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Financial ExploitationMisrepresentation of an older adult’s assets for benefit of another personExamples : Taking, Hiding, or Misappropriating Money or Property for Personal Use or Gain in Violation of the Older Adult’s Wishes or Trust.
Violation of RightsDeprivation of any inalienable rights
Personal LibertyPersonal PropertyAssemblySpeechPrivacyVoting
Reasons for Poor Identification/ Underreporting by Providers
Lack of training in identifying mistreatmentAgeismDisbeliefIsolation of victimsIsolation of victimsSubtle presentationReluctance to confront offendersReluctance to report suspected abuseUnsure about reporting proceduresFear of jeopardizing relationships with hospitals or nursing facilities
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Patient Risk Factors for Elder Mistreatment
Older AgeLack of access to resourcesLow incomeSocial IsolationMinority statusLow level education
Substance abuse by caregiver and/or older adultPsychological disorder and/or character
Caregiver Risk Factors for Elder Mistreatment
pathologyPrevious history of family violenceCaregiver burnout and/or frustrationCognitive impairment
AssessmentAssessment
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Physical AbuseAssault, Battery, or Force Likely to Produce InjurySexual AssaultProlonged or Continual Deprivation of Food and Water Punitive or Inappropriate Physical or Chemical Restraint
Signs of Physical AbusePattern InjuriesBruises and BleedsBurnsBurnsFracturesLacerations and AbrasionsHemorrhage
Injury AssessmentTypes of Injuries
BruisesP l
What to look for
LocationWhether history isPressure ulcers
FracturesBurns
Whether history is consistent with exam Old injuriesDelay in seeking care
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Pattern Injuries - Caveat
• Before Judging too Quickly...- Findings May Have
I t Eti l i
Heated “cups”
Innocent EtiologiesMark left by cupping
Pattern Injury
Whip Marks Left by Looped TelephoneTelephoneCord
Pattern Injury
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Pattern Injury
Suspicious Bruises in Older AdultsSuspicious Bruises
Face, MouthTorso, BackButtocksButtocksInner Aspect of Thighs or ArmsGenitalia
Multiple Bruises - Various StagesInaccuracy of Dating Bruises
Physical Abuse - Bruising
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BurnsCigar or CigaretteImmersion
Sock or Glove
PatternsRope, Iron, Burner
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FracturesSkull or FaceMultiple LocationsMultiple Stages of Healingp g gMisalignmentSpiral FracturesOccult Fractures
Lacerations and Abrasions
Neglect – Poor Hygiene78 Year Old Woman With Mild Alzheimer DiseaseDisease, Painful Walking, and Recurrent Falls. Lives with 50 Year-Old Son.
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Don’t Forget the Mouth!Potential Clues to Abuse & Neglect
34 Year Old Schizophrenic Male Living in Residential Care Facility
66 Year Old Former Attorney 6 Years after Cerebrovascular Accident
Care Facility
Financial AbuseAssess Mental StatusAssess Vulnerability
Depression and AnxietyBereavementPersonality
Neuropsychiatric Testing
DocumentationDocumentation
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Documentation * PhotosLab WorkLegible Writingg g
* May be used as evidence in a criminal trial!
How to DocumentLegible (Handwriting/EHR) and No AlterationsPertinent Positive and Negative FindingsReport Facts ObjectivelyUse Patient’s Own WordsDocument Each Source of InformationDates, Names and TimesNote Interactions between Patient and Caregiver
Forensic Documentation – Body Map
Detailed Descriptions, Sketches, and/or Photographs of InjuriesNote Size, Color, Shape, Location of Injuries and Bruises
Red
BRUISESjDocument Size, Depth, Stage, and Presence/Color of Exudate for Pressure UlcersPhoto documentation
Purple
Yellow-brown
Abrasion
BRUISES
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Elder Mistreatment Report Concise Statement Regarding the History and InjuryConcluding Statement Summarizing Likelihood of Abuse
Definite AbuseAccidentIndeterminate
ManagementPatient involved with resolutionDetermine decisional capacityMay need competency determinationSocial work resourcesMulti-disciplinary teams – Primary care physician/geriatrician, social worker, case management, RN, representatives from legal, finance, and adult protective services
ReportingReporting
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Reporting Elder MistreatmentAll health care providers and administrators are mandated by law to report suspected elder mistreatment !Laws differ from state to state You are immune from civil liability if you act in good faith and without malice.
Reporting Elder MistreatmentIf you fail to report you risk fines, jail, or loss of license.Report to state or county division of adult protective services, or child and family services.p yArea Agency on Aging are usually a great resourceNational Domestic Violence Hot Line: (800) 799-SAFEOlder Women’s League: (800) 825-3695
Elder MistreatmentConclusion
Prevalent – About 5 % of all older adultsPhysical Abuse most common and Physical Neglect least commonPoorly Identified and Reportedy pPatient Risk factors – Cognitive and Physical Impairment, Isolation, Substance Abuse, Low Income and EducationCaregiver Risk Factors – Substance Abuse, Psychological/Character Pathology, Caregiver Burnout, Cognitive Impairment