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Am Fam Physician. 2022;106(1):96-99

Author disclosure: No relevant financial relationships.

Case Scenario

My 81-year-old patient, E.P., has a history of hypertension, hypothyroidism, and mild chronic obstructive pulmonary disease, but I have not seen them since the initial COVID-19 shutdown. The county Adult Protective Services agency has requested a medical assessment because of concerns for E.P.’s safety and possible self-neglect following reports of E.P. appearing confused and wandering in the neighborhood. As a family physician, what are my responsibilities to the patient and to Adult Protective Services in this situation? What is the best clinical approach to addressing the concerns for E.P.’s welfare?

Commentary

Elder abuse (in this Curbside Consultation, “elder” refers to a person 60 years or older) affects at least one in 10 older adults but is often undetected and underreported, even compared with any other form of abuse.1 Elder abuse can take several forms, including neglect and physical, emotional, financial, or sexual maltreatment. Adult self-neglect is the most common form of elder abuse2 (Table 124). Most of these adults live in private residences; approximately 10% of reports to Adult Protective Services involve older adults who are living in residential care facilities.2 Many states use a centralized or combined local and state hotline model to report allegations of maltreatment. Nationally, the Eldercare Locator (1-800-677-1116) can direct people to individual state resources. Approximately 60% of reports come from professionals such as police, social services, or visiting nurses or aides; other reporters include relatives, nonprofessionals (e.g., neighbors), caregivers, and the individual involved (self-report).2 Physicians and medical personnel are mandated reporters.2

Abuse
Emotional (10%): inflicting mental pain, anguish, or distress through verbal or nonverbal acts (e.g., humiliating, intimidating, threatening)
Physical (8%): inflicting physical pain or injury (e.g., slapping, bruising, restraining by physical or chemical means)
Sexual (0.7%): nonconsensual sexual contact of any kind
Exploitation
Financial or material exploitation (16.5%): illegal taking, misuse, or concealment of funds, property, or assets of an older adult for someone else’s benefit
Neglect
Neglect (14%) and abandonment (0.3%): failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder adult; desertion of a vulnerable elder adult by anyone who has assumed the responsibility for care or custody of that person
Self-neglect (65%): a form of maltreatment resulting from an individual’s inability (mental or physical) to perform essential self-care tasks. These include obtaining essential food, clothing, shelter, and medical care; obtaining goods or services necessary to maintain health and general safety; managing financial affairs; paying attention to hygiene and environment; accepting services that reasonably improve quality of life; and avoiding self-endangerment through unsafe behaviors

Adult Protective Services first screens any report of potential abuse for eligibility and authority to investigate based on state laws. Initial caseworker involvement includes prioritizing risk and contacting the client. The caseworker may assess emergency needs, general physical and mental health, medication adherence, nutritional status, financial affairs, cognitive abilities, substance and alcohol use, and overall environment and support systems. Emergency protective action is taken when urgent action is needed. Supervisors of the caseworker, other experts (law enforcement, legal services), and Adult Protective Services team members review the collected information and evidence (e.g., photos, financial records, interviews) to decide next steps, including health and service needs, safeguarding the patient’s rights and monitoring to ensure long-term safety and satisfactory fulfillment of care goals. If a perpetrator is involved, associated risks will be addressed by making the appropriate referrals to regulatory agencies, law enforcement, or perpetrator registries.

As part of the investigation, Adult Protective Services may request information from the patient’s physician, including medication review, physical and cognitive function assessment, anticipated prognosis, and recommendations for health care. Because patients experiencing mal-treatment commonly have undiagnosed medical conditions,5 physicians should be alert for and address the conditions listed in Table 2.2,515 Family physicians should also consider the possibility of patient maltreatment when an older patient presents with any of the conditions identified in Table 2.2,515

Diagnostic findingPrevalence rate (%)Associated category of elder maltreatmentAssessment tools
Dementia62Caregiver neglect
Financial exploitation
Self-neglect
Cognitive testing
 Mini-Mental State Examination,6 Saint Louis University Mental Status Examination,7 Montreal Cognitive Assesssment8
Laboratory testing
 Complete blood count, comprehensive metabolic panel, vitamin B12/folate, thyroid-stimulating hormone, thiamine, others as indicated
Imaging
 Noncontrast brain magnetic resonance imaging or noncontrast head computed tomography
Depression37Geriatric Depression Scale9 or Patient Health
Questionnaire-910
Hypertension36
Weight loss34
Pain32
Falling26Timed Up and Go test,11 30-Second Chair Stand (five times)12
Limited food access25
Incontinence23Caregiver neglect (both sexes)
Sensory impairment22Caregiver neglectRoutine vision and hearing assessment
Diabetes mellitus16
Substance and alcohol use10Physical abuseTobacco, alcohol, prescription medication, and other substance use screening tools13
Impaired capacityNAAll types (e.g., driving, financial, legal, medical)Aid to Capacity Evaluation (ACE) tool14
Physical abuse8Physical abuseGeriatric Injury Documentation Tool15

Gathering further information to evaluate the presence and severity of maltreatment can present multiple challenges, even in the setting of a referral from Adult Protective Services. When a patient is reluctant to provide information or appears to downplay disabilities or injuries, self-neglect or abuse should be suspected. Undiagnosed cognitive impairment may present as a lack of concern for personal hygiene or adequate nutrition; it may also manifest as unsafe driving or disregard for personal safety or social conventions. Observational information from a family member, neighbor, or close friend can clarify a patient’s ability to perform activities of daily living, such as dressing, toileting, feeding, and instrumental activities of daily living that include shopping, housekeeping, and food preparation. This information may also provide a timeline of the progression of any cognitive impairment or neglect. The IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly) is a useful tool for gathering information about how well the patient is functioning at home.16 A physician house call or a home health referral can also provide a basic home-based evaluation of the patient to assess cognition, safety, and ability to perform activities of daily living and instrumental activities of daily living.

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

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