Assessing Patients for Signs of Elder Mistreatment

1. Assessing Patients for Signs of Elder Mistreatment Module 7 Nursing Responses to Elder Mistreatment An IAFN Education Course

2. Learning Objectives • Discuss steps of assessment for elder mistreatment (EM) • Recognize signs in cases of neglect, physical abuse, emotional/psychological mistreatment, sexual abuse, abandonment, financial exploitation and violation of personal rights

3. Case Study: Mrs. Amos • What are the signs of potential mistreatment in this case? • What is the nurse’s role in this situation? What else does she need to do?

4. Assessment Steps • Identify • Evaluate • Document

5. Identification through… • Physical examination • Discussions with patients, family members and caregivers • Review of medical records

6. Evaluation Considerations • Patient issues and circumstances that influence findings • Implausible explanations and inconsistencies regarding history of injury and illness • Whether nature of signs agree with what patient, family members and/or caregiver tell you

7. Documentation • Thorough • Accurate • Objective • In accordance with agency policy

8. General Assessment Approach AMA’s Diagnostic and Treatment Guidelines for Elder Abuse and Neglect (1992) • Safety • Access to Patient • Cognitive Status • Emotional Status • Health and Functional Status • Social and Financial Resources • Frequency and Severity • Assessing for intent is not nurses’ duty.

9. Signs of Neglect Return to Case of Mrs. Amos: • What are some of the signs of neglect you identified in this case?

10. Signs of Neglect • Poor hygiene • Malnutrition • Dehydration • Inadequate medical care • Absence of physical aids • Over/under medication • Contractures • Pressure ulcers, untreated or under-treated Adapted from T. Fulmer, G. Paveza, I. Abraham & S. Fairchild, Elder neglect assessment in the emergency department, Journal of Emergency Nursing, 2000 Source for Photo: The John A. Hartford Foundation Institute for Geriatric Nursing, New York University, College of Nursing. Photography by James Schuck.

11. Stage 1 Pressure Ulcer • Intact skin with non-blanchable redness of a localized area usually over a bony prominence • Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area • Area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue • Stage I may be difficult to detect in individuals with dark skin tones • May indicate "at risk" persons (a heralding sign of risk) Slide 11-15 from National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System, 2007, in M. Baker, The Scope and Consequences of Elder Mistreatment: The Tip of the Iceberg (handouts from presentation), Northwest Geriatric Education Center Geriatric Health Promotion Series, University of Washington. Seattle, WA; March 2010

12. Stage 2 Pressure Ulcer • Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough • May also present as an intact or open/ruptured serum-filled blister • Presents as a shiny or dry shallow ulcer without slough or bruising

13. Stage 3 Pressure Ulcer • Full thickness tissue loss • Subcutaneous fat may be visible but bone, tendon or muscle are not exposed • Slough may be present but does not obscure the depth of tissue loss • May include undermining and tunneling • Depth of a Stage III pressure ulcer varies by anatomical location

14. Stage 4 Pressure Ulcer • Full thickness tissue loss with exposed bone, tendon or muscle • Slough or eschar may be present on some parts of the wound bed • Often include undermining and tunneling • The depth of a Stage IV pressure ulcer varies by anatomical location • Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible • Exposed bone/tendon is visible or directly palpable

15. Unstageable Pressure Ulcers • Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed

16. Signs of Neglect • Emotional/psychological • Withdrawal • Depression • Agitation • Infantile behavior • Ambivalent feelings toward family members or caregivers

17. Signs of Physical Abuse • Context and location of injuries critical • Injuries in various stages of healing may indicate abuse • Hidden injuries typical of abuse • Abuse tends to be central, accidents distal California District Attorneys Association, CDAA elder physical and sexual abuse: The medical piece, part 1 & 2 (Learning point summaries template), 2003

18. Bruising • A bruise, or contusion, occurs when blunt forces distort soft tissues to an extent sufficient to result in disruption and leakage of blood vessels • Escape of blood from blood vessels produces discoloration P. Besant-Matthews, Blunt and sharp injuries, in V. Lynch, Forensic nursing, 2006

19. Bruising in Geriatric Pop. • 2009 study by A. Wigglesworth, R. Austin, M. Corona, D. Schneider, S. Liao, L. Gibbs, and L. Mosqueda, Bruising as a Marker of Physical Elder Abuse, Journal of the American Geriatric Society • Physically abused older adults had significantly larger bruises than those in comparison group who were not abused and more knew the cause of their bruises • Physically abused older adults more likely to have bruises on face, lateral aspect of right arm and posterior torso than older adults from an earlier study who had not been abused

20. Bruising in Geriatric Pop. Earlier study- • Nearly 90% of bruises on extremities • Not a single accidental bruise observed was on neck, ears, genitalia, buttocks or soles of feet • Of 20 large bruises in this study, only one was on trunk • Older adults are significantly more likely to know how the bruise happened if it is on the trunk L. Mosqueda, K. Burnight & S. Liao, Bruising in the geriatric population, 2006, as cited in Baker

21. Patterned Injury • An injury that possesses features or configuration with objects or surfaces that produced it W. Smock, Forensic emergency medicine, in J. Olshaker, M. Jackson and W. Smock (Eds.), Forensic emergency medicine, 2001

22. Patterned Injury • Grip marks around arms or neck • Rope marks or welts on wrists or ankles • Imprints from belts, belt buckles, straps, cords, hangers, hairbrushes, combs, cigarettes and cigarette lighters • Handprints, fingerprints, knuckle prints and footprints • More on strangulation… • More on burns…

23. Fracture • Broken bones • Includes severing of the bone or compression of intact bone C. Bitondo Dyer, M. Connolly & P. McFeeley, The clinical and medical forensics of elder abuse and neglect, in R. Bonnie & R. Wallace, Elder mistreatment, abuse, neglect and exploitation in an aging America, 2003

24. Avulsion • The tearing away of a structure or part; often seen as a partial avulsion

25. Abrasion • A wound in which the outermost layer of the skin is removed by a compressive or sliding force Besant-Matthews

26. Laceration • Blunt force injuries resulting from tearing, ripping, crushing, overstretching, pulling apart, bending and shearing soft tissue. • Lacerations are usually found over a bony surface and are ragged or irregular in appearance Besant-Matthews

27. Incision • Incision, known as a cut, is a wound made by a sharp instrument or object, such as a scalpel, knife, razor or paper coming against the skin with pressure to cause an injury Besant-Matthews

28. Stab Wound • Result whenever a sufficiently sharp and narrow object is forced upward • Unlike a cut, depth exceeds width in stab wounds Besant-Matthews

29. Mechanical Restraints • Means of controlling behavior, especially in hospitals and nursing facilities • Only acceptable reason for temporarily restraining someone is to prevent significant harm B. Knight (Ed.), Simpson’s forensic medicine (11 ed.), 1997

30. Emotional/Psychological Abuse • Feelings and behaviors associated with emotional/psychological abuse may not be obvious at time of assessment—have to ask questions • Same flags may also be reactions to other types of mistreatment

31. Sexual Abuse • During assessment of a vulnerable older adult who has been sexually abused, what injuries, behaviors and evidence might the nurse describe? • For nurse, what are some important things to consider, questions to ask and next steps to take when she suspects sexual abuse?

32. Signs of Sexual Abuse Examples of physical signs • Bruising, inflammation, tenderness, abrasions or trauma around the breast or anogenital area • Unexplained venereal disease or genital infections • Unexplained vaginal or anal bleeding • Torn, stained or bloody underclothing May/may not be obvious physical signs

33. Assessing Sexual Abuse • Refer to sexual assault forensic examiners • Type of sexual victimization suspected will influence what is assessed • Ask when last known sexual contact occurred • Care of acute injuries and patient safety a priority over evidence collection • Cooperation of the patient needed for exam • Preserve bodily evidence

34. Financial Exploitation, Abandonment, Violation of Personal Rights • What are your experiences with vulnerable older adults who have been financially exploited? What are questions a nurse can ask to find out about possible financial exploitation? • What are your experiences with vulnerable older adults who have been abandoned? What are questions a nurse can ask to find out about possible abandonment? • What are your experiences with vulnerable older adults who have had their rights violated? What are questions a nurse can ask to find out about possible violation of personal rights?

35. Abandonment • In addition to an actual complaint by older person of being deserted, signs of possible abandonment include: • A vulnerable older adult with cognitive and physical impairments is left at a hospital emergency department without caregiver contact information • A vulnerable older adult with cognitive impairments is put on a bus with a one-way ticket to another town or state • A vulnerable older adult with cognitive impairments is left at a public building B. Brandl, C. Bitondo Dyer, C. Heisler, J. Marlatt Otto, L. Stiegel & R. Thomas, Elder abuse detection and intervention: A collaborative approach, 2007

36. Financial Exploitation • Not always obvious—question for more info • Examples: • Denying the vulnerable older adult a home • Stealing a vulnerable older adult’s money or possessions • Coercing a vulnerable older adult into signing contracts or assigning power of attorney • Purchasing goods with a vulnerable older adult’s money for personal gain • Coercing a vulnerable older adult into making changes in his/her will • When a person entrusted to care for a vulnerable older adult fails to use available resources necessary to sustain/restore health and well-being of person Baker

37. Violation of Rights • Not always obvious—question for more info • Examples • Denial of older adult’s right to privacy • Not allowing older adult to make own decisions regarding health care or personal matters • Restricting interactions with others • Forcible eviction and/or placement in a nursing home Elder abuse and neglect for EMS, EMSTopics.com, 2007