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 1^2–4). 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

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.^2,5–15 Family physicians should also consider the possibility of patient maltreatment when an older patient presents with any of the conditions identified in Table 2.^2,5–15

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.