Elder Maltreatment Elder Abuse

1. Elder MaltreatmentElder Abuse • 2011 • Vicken Y. Totten MD

2. AMA Definition of Elder Abuse “… an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Abuse includes intentional affliction of physical or medical injury; sexual abuse; or withholding of necessary food, clothing, and medical care to meet the physical and mental needs of an elderly person by one having the care, custody, or responsibility of an elderly person”

3. Legal Definition • The law defines elder abuse as "physical abuse, neglect, financial abuse, abandonment, isolation, abduction or other treatment with resulting in physical harm or pain or mental suffering, or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering." (Welfare & Institutions Code, Section 15610.07 and in Penal Code 368) "Elders" are defined as persons 65 years of age or older.

4. Exploitation is a form of abuse • Resources • Financial • Sexual

5. Types of Elder Maltreatment • Physical Abuse: Violence to person • Sexual Abuse: Sexual use solely for another’s gratification • Physical Neglect: Failing to provide a safe environment, clean water, sufficient food and medications • Psychological Abuse or Neglect: Failing to provide for the social / psychological needs of the elder • Material Exploitation or Neglect: Failing to use the elder’s resources for the elders benefit

6. Physical Abuse: • Assault, battery, • sexual assault, battery or rape, • prolonged or continual deprivation of food or water, or medications • use of physical or chemical restraints for punishment, convenience or without or beyond the scope of the doctor's order.

7. Physical Abuse • Pushing, shoving, slapping • “he steps on my feet” • Visible and non-visible • Discovery depends on entertaining the dx. • More common in the helpless

8. Sexual Abuse • Oral, Anal, vaginal, rectal, stomal • A source of post-menopausal vaginal bleeding • “My son-in-law needs me” • Sexual predators get old too. • Happens in nursing homes. Not all sexual congress in the elderly is abuse

9. Neglect: • The failure to exercise that degree of care that a reasonable person in a care providing capacity would exercise such as failure to assist in personal hygiene, provision of food, clothing or shelter, provision of medical care, or to protect from health and safety hazards or to prevent malnutrition or dehydration.      Note: This includes self-neglect; one of the most common forms of abuse occurring in community settings.

10. Falls

11. Physical Neglect • Failing to provide, or deliberately withholding necessities: • Hearing aid, eyeglasses, walker, cane, wheelchair, medications • Food, help in bathing, clean clothes • Failure to provide appropriate physical precautions

12. Psychological Abuse or Neglect • Threats of deprivation or harm • “Nobody else wants you, you are useless. You should be grateful I even do…” • Failure to provide transportation • Failure to permit access to social contacts

13. Financial Abuse: • The illegal or unauthorized taking or using of an elder's funds, property or assets by an individual or entity.

14. Control over finances

15. Material exploitation or Neglect • Theft of money, possessions • Keeping the elder for their social security check • Getting power of financial attorney • Preying on the elder’s gullibility, helplessness, or ignorance

16. Mental Suffering: • Causing fear, agitation, confusion, severe depression or other forms of emotional distress that is brought about by threats, harassment, or other forms of intimidating behavior. • (Legal definition)

17. PSYCHOLOGICAL ABUSE • Threats – of violence, of abandonment • Insults • Harassment • Belittlement • Retaliation

18. Threats and intimidation

19. Isolation: • The intentional preventing or restraining an elder from receiving mail, telephone calls or visitors.

20. Scope of the problem

21. EPIDEMIOLOGY • 1-5% of elderly are victims of abuse • Others cite larger numbers

22. CAUSES (often in combination) • Physical dependency • Caregiver stress- 36-hour day, frustration, lack of finances, lack of employment- often combined with a triggering event- treatment = relieve the stress if possible • Supervision, continued

23. CAUSES (continued) • Family violence patternAbused children become abusive adults who then abuse own children and also their parents (treatment often to separate them). • Pathological abuser- Drugs and alcohol abuse- Mental illness- Treatment = separation

24. Factors that increase Risks of Elder Maltreatment • Victim Factors • Caregiver Factors • Environmental / System Factors • A permission micro-environment

25. Screening and Assessment for Elder maltreatment • Similar to screening for domestic violence • Use open-ended questions • How do you feel about your safety at home? • Who helps you at home? • How is this working out for you? • What happens when there are disagreements at home? • How are financial decisions made? • Do you get out of your home very much? • Who else do you see/talk to besides (caregiver)?

26. THE TYPICAL VICTIM • Widow > 70 years old • insufficient income to live independently • increasing dependency • cognitive impairment, especially if recent • more problem behaviours: shouting, incontinence, wandering, paranoia, stubborn, critical

27. Victim Factors: • Elder’s cognitive impairment • Dementia – less able to protect self • Elder gets abusive, violent, socially inappropriate • Poor health - > Elder requires much care • Social isolation of both the care give and the elder

28. Caregiver Factors: • History of violence, or victim of abuse • Substance abuse • External stressors

29. The typical abuser – a relative • 40% of time spouse / 50% child or grandchild • In relationship with victim for average of 9.5 years • Under stress: • alcohol or drugs • marital problems • social isolation • employment and or financial difficulties

30. The abusive child of the elder • Often least socially integrated child • (the well functioning children have left the home) • May be from family where violence is norm. • “payback”

31. Environmental/System Factors: • Victim and perpetrator in shared living situation • Financial and other dependence on caregiver • Perpetrator financially dependent on the elder

32. Warning signs • Abuser Often speaks for elder • Abuser isolates elder • Abuser controls mail, visits and phone calls • Elder appears helpless, confused, hesitant to speak freely • Elder has insufficient food and basic necessities • Elder exhibits poor hygiene • Untreated medical conditions • Visible injuries • Change in sleep, appetite or behavior

33. DIAGNOSIS • Signs of physical injury • Conflicting and/or vague histories from the patient and caregiver • History inappropriate to degree of injury • Denial • Long delay between injury and presentation • History of being “accident prone”

34. Look For Changes And/or Extremes: • Unkempt appearance • Emaciated or bloated appearance • Dirty or inappropriate clothing • Unshaven face • Uncombed hair • Unusual or extreme body odors

35. Bruises not consistent with history

36. Physical Findings • Welts, laceration, fractures • Excess drugs / AMS / unexplained lethargy • Burns, Bruises • Lack of clothes, heat, medication, food, water • Sometimes frequent falls. “Who helped you to fall?”

37. On examination • injuries at different stages of resolution • bruises in the shape of weapons • injuries in places normally covered by clothes or around mouth, face, eyes • alopecia and haemorrhage under scalp may indicate hair pulling • bruises, burns, bite-marks.

38. Examination - continued • Physical neglect (much more common) - pallor, wasting, dehydration, decubitus ulcers. Note that these may also occur in non-abused elderly. • Psychological abuse - paranoia, infantile, depressed, withdrawn, agitated.

39. Hurdles • Mental health (competency issues) • Physical health & disability/ willingness to testify – • Mistrust of others

40. Fear • Fear of losing loved one • Fear of the unknown • Fear of being alone • Fear of losing living essentials

41. Legal problems of intervening • When neither the victim nor the abuser is co-operative, may need guardianship • No provision for mandatory reporting (as for child abuse) in many places • No legal protection for doctors against libel.

42. Intervention • Talk to victim privately • If danger suspected, admit person with a “medical diagnosis” • Counsel caregiver- provide information about pt’s condition- meet needs of caregiver (relieve stress)- talk to caregiver about how to respond to patient’s behavioural problems

43. Intervention (continued) • Respite or alternative care if burden too great for caregiver • Help the caregiver maximise the elderly individual’s abilities.

44. Tips for Caregivers • Answering "yes" to just one of these questions could indicate that you need some assistance in your care giving role. Consider some of the following avenues. • Seek out a support group for caregivers. • Consider hiring support services-a home health aide, chore worker, or homemaker. • Enlist the help of family and friends; be specific in what help you need (e.g., "Could you come over for two hours on Saturday morning while I run some errands?").

45. More tips • Look into available respite care in your community. • Make an honest effort to give yourself needed time to relax, exercise, and eat right. • Look to community resources for support. Start with the Area Agency on Aging for your area or call the Eldercare Locator. • Consider a Daily Money Management Program

46. Management of Elder Maltreatment • Most states have mandatory reporting for suspected elder abuse • American Medical Association Guidelines • Elder Abuse and Neglect

47. Prevention • Avoid isolation • Stay social/active – volunteer, see friends • Avoid living with a person with a history of abuse or violence • Beware of family members with financial motivations or with substance abuse issues • Consider respite services to relieve caregivers • Have friends and relatives remain involved and observant • Consider Counseling • Communicate • Have relatives and friends visit at various times of the day – unannounced

48. Resources • In an emergency dial 911 • American Association of Daily Money Management Program www.aadmm.com • www.AARP.org • www.Eldercare.gov {Eldercare Locator} • Administration on Aging (AOA) www.aoa.gov/eldfam/Elder Rights/Elder Abuse/Elder Abuse.asp

49. More resources • National Center on Elder Abuse (NCEA): www.elderabusecenter.org • National Committee for the Prevention of Elder Abuse: www.preventelderabuse.org • National Consumer League (NCL): www.nclnet.org • http://fraud.org/ • National Long-term Care Ombudsman Resource Center: • www.ltcombudsman.org/static pagesombudsmen.cfm

50. References • Cline, Ma, Tintinalli, Kelen, Stapczynaki (2001). Just the facts in Emergency Medicine. ISBN: 0-07-134549-3 • Goldman, Wise, Brody, (1998). Psychiatry for Primary Care Physicians. ISBN: 0-89970-892-7