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Recognition and Management of Elder Mistreatment



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Am Fam Physician. 1999 Dec 1;60(9):2677-2678.

Elder mistreatment includes physical abuse, neglect, psychologic abuse or financial exploitation of an older adult. Self-neglect is the most commonly reported type of abuse, followed by neglect by others. Chronic abuse may result in repeated medical crises. All forms of mistreatment directly or indirectly affect the health and heath care of older patients.

Physicians too often attribute the medical consequences of abuse to aging or underlying disease, or may be uncertain of their ability to recognize abuse as well as the ability of their state resources to deal with it. Mandatory reporting may violate trust and confidentiality, affecting the therapeutic relationship between the clinician and the caregiver-abuser. A change of physicians may result in disruption of the continuity of care and the loss of an opportunity to work with the care-giver to eliminate abuse. The outcomes of an investigation following a report of abuse may be against the patient's wishes and may result in heightened tensions between the victim and the abuser and, possibly, lead to institutionalization. Also, filing a report does not guarantee an investigation or a beneficial outcome for the patient.

Despite these concerns, the best weapon that physicians have against elder abuse is to file a report with state authorities. Most physicians do not have the training or the time to successfully intervene or to counsel the abused patient and the alleged abuser. Providing good quality information in the report and being willing to cooperate with the investigation can improve the likelihood of a useful investigation and a satisfactory resolution.

Recognition of elder mistreatment is enhanced by knowledge of risk factors that include: (1) a higher degree of patient-caregiver interdependence, (2) a stressed caregiver, (3) a history of family violence, (4) psychopathology in the caregiver and (5) other sociocultural and environmental factors that include inadequate housing, resentment and cultural sanctions against seeking outside help.

Physicians should be alert to clues to possible elder mistreatment (see accompanying table). If abuse is suspected, the patient and caregiver should each be interviewed alone to allow safer disclosure and elicit inconsistencies. The physician should avoid blame and always appear sympathetic to the suspected abuser's perceived burden of care. If a referral is to be made to the appropriate state agency, the patient and caregiver should be told. The referral can then be discussed as a source of additional help. If the patient or caregiver refuses the referral, physicians should explain that the state law requires referrals of elders who are not receiving all the care they need to such agencies, and that physicians are mandated to make these referrals.

Indicators of Possible Elder Mistreatment

General

Caregiver of cognitively impaired elder is absent for appointment

Failure of caregiver to visit patient in hospital

Reluctance to answer questions about a suspicious physical finding or illness

Implausible or vague explanations for injuries given by caregiver or patient

A history of “doctor hopping”

Tension or indifference between caregiver and patient

Physical signs

Multiple bruises or bruises at different stages of healing

Bruises in unusual locations

Pattern injuries (i.e., bite marks, cigarette burns)

Evidence of old injuries not previously documented or radiographic evidence of old, misaligned fractures

Broken nose or teeth

Subtherapeutic levels of medications

Patient lacks eyeglasses, dentures or hearing aid

Caregiver

Poor knowledge of patient's medical problems

Excessive concern about costs

Attempts to dominate medical interview

Verbal abuse or hostility toward elder or health care provider during encounter

Evidence of substance abuse or mental health problems

Evidence of financial dependence on elder

Elder

Fearfulness toward caregiver

Flinching or reluctance to make eye contact

Diagnosis of dementia with history of disruptive behavior

In a demented person, unexplained resistance to, or fear of, physical touch, removing clothes, toileting or bathing of private parts

Depression, anxiety, insomnia


Adapted with permission from Hirsch CH, Stratton S, Loewy R. The primary care of elder mistreatment. West J Med 1999; 170:356.

Indicators of Possible Elder Mistreatment

View Table

Indicators of Possible Elder Mistreatment

General

Caregiver of cognitively impaired elder is absent for appointment

Failure of caregiver to visit patient in hospital

Reluctance to answer questions about a suspicious physical finding or illness

Implausible or vague explanations for injuries given by caregiver or patient

A history of “doctor hopping”

Tension or indifference between caregiver and patient

Physical signs

Multiple bruises or bruises at different stages of healing

Bruises in unusual locations

Pattern injuries (i.e., bite marks, cigarette burns)

Evidence of old injuries not previously documented or radiographic evidence of old, misaligned fractures

Broken nose or teeth

Subtherapeutic levels of medications

Patient lacks eyeglasses, dentures or hearing aid

Caregiver

Poor knowledge of patient's medical problems

Excessive concern about costs

Attempts to dominate medical interview

Verbal abuse or hostility toward elder or health care provider during encounter

Evidence of substance abuse or mental health problems

Evidence of financial dependence on elder

Elder

Fearfulness toward caregiver

Flinching or reluctance to make eye contact

Diagnosis of dementia with history of disruptive behavior

In a demented person, unexplained resistance to, or fear of, physical touch, removing clothes, toileting or bathing of private parts

Depression, anxiety, insomnia


Adapted with permission from Hirsch CH, Stratton S, Loewy R. The primary care of elder mistreatment. West J Med 1999; 170:356.

If necessary, victims may be hospitalized to separate them from the abuser. Patients, however, can refuse this intervention. For those who refuse, more frequent monitoring with medical visits or home care might be an acceptable temporary alternative. Reports to the appropriate protective services agency should include documentation as complete as possible because the report is used to triage cases. Social workers can be helpful in providing communication between the physician and the involved agencies.

Hirsch CH, et al. The primary care of elder mistreatment. West J Med. June 1999;170:353–8, and Wolf RS. Curbside consultation: Suspected abuse in an elderly patient. Am Fam Physician. March 1, 1999;59:1319–20.

editor's note: Asking appropriate questions to screen for elder abuse is difficult. In another recent article, Wolf suggests general questions such as, “How are things at home for you?” A follow-up question, when indicated, can be, “Has anyone tried to hurt you?” or “Have you been forced to do things that you do not want to do?” These questions are best asked without any other family members present. If a physician has questions about a patient's competency, complete neuropsychologic testing should be a part of the evaluation.—r.s.

 


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