Case Scenario

A 75-year-old woman presented to my clinic for the treatment of edema and hypertension. She seemed quiet and unconcerned during our visit. The next day, I received an angry telephone call from her daughter, who told me that she thought her mother was incompetent and should be placed in a nursing home. During the conversation, I learned that my patient's daughter, adult son and several grandchildren lived with her, and that her son was a home health care worker and her daughter was receiving welfare.

I decided to make a home visit. Although I had asked that my patient's children be present during my visit, her daughter was not there and her son was asleep and, according to my patient, couldn't be awakened. The house and its interior were once elegant but now had fallen into decay. I performed a mental status examination on my patient, and she scored 20 points out of 30.

When asked, my patient told me that both of her children were living with her rent-free in exchange for providing her care, but they were seldom at home. She told me that her daughter had a history of drug abuse and, during that time, had stolen from her and had physically assaulted her a number of times. Nevertheless, according to my patient, this had not occurred recently and her drug abuse was currently under control.

I brought up the issue of moving to a nursing home, but my patient said “My daughter wants to get the house. That's why she wants me in a nursing home.” When asked, my patient said that she thought her children took care of her adequately.

Commentary

In many ways, this case represents a typical elder-abuse situation and the challenges that health care professionals face when trying to resolve it. Presumably, the physician was familiar with the patient's history since he or she thought that a home visit was important even though the patient was not home-bound or seriously ill. Given the patient's vulnerability to further abuse, a more comprehensive examination at the clinic should have been performed to determine whether she was being abused physically and financially at that time and to assess her present living conditions, her relationship with her children and her level of competency.

If this was the patient's first visit to the clinic, the physician should have screened for abuse¹ by asking her a very general question, such as “How are things at home for you?” If indicated, this question should be followed by more specific questions, such as “Has anyone tried to hurt you?”, “Have you been forced to do things you did not want to do?” or “Has anyone threatened to place you in a nursing home?”

If there was reason to suspect that abuse was occurring or reoccurring, the physician would be obligated to report this to the local adult protective services agency (if the patient lived in a state that mandates reporting elder abuse) or could voluntarily make a report. The agency would then conduct an investigation, make an assessment and develop a care plan.

The patient's home remains a potentially unsafe environment for her, even though the daughter's drug abuse seems to be under control. Her children are financially dependent on her for housing and, most likely, for other necessities, and her well-being is apparently of little concern to them. They may really want to get her out of the house so that they can claim it for themselves. However, the daughter may discover that, if her mother is placed in a nursing home, she could remain in the house but would not own it. Under Medicaid rules, the state government can place a lien on a house to recoup the cost of nursing home care. Often, in cases of this nature, adult children want to keep their parents at home even when nursing home placement would be most appropriate because they have no other place to live, they need the parent's social security or pension check or they do not want to have any of their parent's assets depleted.

Despite her children's neglectful and abusive behavior, this patient prefers to remain at home, whether out of guilt, fear or love. Like many elderly people who have survived months or years of abuse, the nursing home or the unknown is more terrifying than remaining in familiar, albeit abusive, surroundings.

The real question here is whether this patient has the capacity to make her own decisions.² In this case, the results of the mental status test were not decisive. Hence, a more extensive assessment should be performed, including neuropsychologic testing. A ruling of incompetency is indicated only if it is determined that she lacks the capacity to make informed decisions. Even then, the court might limit the ruling to certain aspects of her life. For example, if it is determined that she can understand her situation and the possible consequences of her decisions and still wants to remain at home, the question facing the physician is how to ensure her safety.

The physician should contact the local adult protective services or a social service agency that deals with abuse and neglect cases and request an investigation. A meeting should be called that includes all of the professionals involved with the family (e.g., the physician, the representative from the adult protective services agency, the legal representative, the daughter's social worker and drug counselor) and the family members to work out a care plan.

While other housing arrangements should be suggested to the family (i.e., that the adult children and grandchildren move out of the house or that this patient move into a small apartment or assisted living complex if she can afford it), in all likelihood the family would probably not want to separate.

The patient and her adult children should be informed about the laws regarding nursing home placement, transfer of assets, and the legal ramifications of financial exploitation and neglect. Arrangements can be made so that the children do not have access to their mother's money (e.g., by assigning responsibility to an outside person). The patient's home situation should be monitored on a regular basis by visits from the local adult protective services, as well as by the daughter's social worker. Should the physical abuse reoccur, the mother could ask the daughter to move, or she could obtain a restraining order to make certain that she does and file charges against her.

If the results of neuropsychologic testing and the patient's medical records indicate that she lacks the capacity to understand her situation and make informed decisions, then an application for a guardianship hearing should be made to the court. This hearing would probably result in placing her in a nursing home. Given the relationship between the patient and her children, it would be advisable that her interests be represented in court and that a person outside of the family be appointed as her guardian.