Key Clinical Questions
When should you suspect elder mistreatment? What are the signs or red flags?
How do you assess for elder mistreatment?
What should you document in your assessment?
When does a patient require hospital admission?
If you suspect elder mistreatment, when must you report it and who should you contact?
Which experts are available for consultation?
How do you create a safe discharge plan to ensure a smooth transition to the next setting?
Introduction
Multiple definitions of elder abuse and neglect exist. For practitioners of hospitalist medicine, a useful definition comes from the American Medical Association (AMA), which classifies elder abuse and neglect as “acts of commission or omission that result in harm or threatened harm to the health or welfare of an older adult.”1 This broad description reminds the clinician to look beyond the image of the bruised and battered victim for the often subtle signs of neglect and other types of abuse. Both the World Health Organization and the U.S. National Academy of Sciences definitions add that the “perpetrators” of abuse and neglect are typically persons whom the older adult holds in a position of trust.2,3 These responsible individuals may either cause the mistreatment or fail to prevent it. The AMA emphasizes, however, that mistreatment may be intentional or unintentional. Unintentional mistreatment is often due to a caregiver’s ignorance, inexperience, or inability, often stemming from his or her own medical or mental health problems.
Despite the varying definitions of abuse and neglect, agreement exists for the following six types of mistreatment (listed in order of frequency substantiated by Adult Protective Services in the 1998 National Elder Abuse Incidence Study).4
Neglect: The refusal or failure of a designated caregiver to meet needs necessary for an older adult’s physical and mental well-being. Neglect includes, but is not limited to, the failure to provide basic necessities like food, water, clothing, shelter, and medicine. It also encompasses the failure to ensure an older adult’s comfort, safety, and personal hygiene.
Self-neglect: The refusal or failure of an older adult to meet his or her own physical and mental needs resulting in threats to personal health or safety. Self-neglect includes, but is not limited to, an elder’s failure to take medications, adhere to medical treatment or maintain adequate nutrition, personal hygiene, and shelter. In its most extreme form, self-neglect is manifest by domestic squalor, social withdrawal, hoarding behaviors, lack of shame, and refusal to accept help. While self-neglect is a fundamentally different phenomenon than elder abuse by another actor, hospitalists may confront it even more frequently than elder abuse when neglected health problems cause or contribute to the reasons for hospital admission. Additionally, the same community resources (ie, adult protective services) are often called upon to address self-neglect.
Psychological abuse: Verbal or nonverbal acts intended to cause anguish, pain, or distress. Psychological abuse includes, but is not limited to verbal assaults, insults, threats (including threat of abandonment or institutionalization), intimidation, humiliation, and harassment. Additional examples include the infantilization or the social isolation of an older adult.
Financial or material exploitation: The illegal or improper use of an elder’s funds, property, or assets. Financial abuse includes, but is not limited to, cashing an older adult’s checks without permission, forging an older adult’s signature, stealing money or possessions, coercing or deceiving an older adult into signing documents (eg, contracts, wills, or property deeds), and improper use of conservatorship, guardianship, or power of attorney status.
Physical abuse: Acts intended to cause impairment, physical pain, or bodily injury. Physical abuse includes, but is not limited to, acts of violence such as striking (with or without an object), pushing, shoving, shaking, kicking, pinching, and burning. Additional examples include the inappropriate use of drugs or physical restraints, force feeding, and physical punishment of any kind.
Sexual abuse: Any type of nonconsensual sexual contact including situations in which an older adult is unable to consent. Sexual abuse includes, but is not limited to unwanted, sexually explicit photographing, and all types of sexual assault and battery such as rape, sodomy, and coerced nudity.
Many quoted statistics on elder mistreatment are outdated and reported frequencies depend on the definition employed and the setting(s) examined. The commonly cited 1998 National Elder Abuse Incidence Study (NEAIS) utilized Adult Protective Services records from 15 states and reports from “sentinels” at community agencies who frequently work with elderly clients. The NEAIS found more than 550,000 adults age 60 and older reported experiencing abuse, neglect, or self-neglect in domestic settings. This figure is considered a gross underestimate, as nearly 80% of incidents were not reported to Adult Protective Services, the major agency tasked with receiving and investigating reports of abuse and neglect.
Two recent studies have shed more light on the prevalence of abuse and neglect in community-dwelling older Americans. In 2008, Laumann, et al surveyed 3005 adults ages 57 to 85 years about physical, verbal, and financial abuse experienced in the last year by adding three questions about mistreatment to the National Social Life, Health, and Aging Project.5 Verbal abuse was most frequently reported (9%), followed by financial (3.5%) and physical abuse (0.2%). Female sex and physical vulnerability appeared to be associated with a higher risk of verbal mistreatment and African-Americans were more likely to report financial abuse. In February 2010, Acierno and colleagues published the results of a national survey of 5770 cognitively intact, community-dwelling adults age 60 and older. They found 11.4% experienced some form of neglect or abuse within the last year. The study specifically assessed reports of “potential neglect” defined as an identified but unmet need for assistance, financial mistreatment perpetrated by family, and physical, sexual, and emotional abuse. The majority of the respondents self-identified as white (88%), 60% were female, and the average age was 71.5 years. The prevalence of mistreatment by type was 5.2% for financial abuse by a family member, 5.1% for potential neglect, 4.6% for emotional abuse, 1.6% for physical abuse, and 0.6% for sexual abuse. Factors associated with increased risk of mistreatment included a history of trauma, low social support, and dependence in activities of daily living.
Elder mistreatment occurs among men and women of all racial, ethnic, and socioeconomic groups. Risk factors associated with the older victim of mistreatment include a shared living situation, social isolation, and conditions that increase his or her dependence on others (eg, cognitive impairment, functional decline, and mental illness). In cases of financial abuse, however, the older adult more often lives alone. Characteristics that appear more frequently amongst perpetrators of elder mistreatment include mental illness, substance abuse, and emotional or financial dependency on the older adult, and a history of violence or antisocial behavior. Other commonly cited perpetrator risk factors include external stressors (medical illness, financial stress), inexperience, and caregiver burnout.
In clinical practice, risk factors that create an imbalance between the older adult’s needs and the ability of the caregiver/support system to meet those needs led to increased vulnerability. Three key risk factors leading to this critical imbalance include cognitive impairment, physical frailty, and social isolation.
Clinicians should also be aware that elder mistreatment is an independent risk factor for death. Lachs and colleagues conducted a prospective cohort study of 2800 community-dwelling adults age 65 and older. The mortality rate was three times higher in the elder mistreatment group and 1.7 times greater in the self-neglect group. In the group with any elder mistreatment, the survival rate was 9% versus 40%.
Despite being ideally suited to detect, manage, and prevent elder mistreatment, a 2004 study conducted by the National Center on Elder Abuse found that physicians are one of the least likely groups of individuals to report abuse and neglect. Explanations for physician underreporting include insufficient knowledge of assessment protocols and mandatory reporting guidelines, concerns about a negative effect on relationships with patients and caregivers, reluctance to get involved with the legal system, and time constraints. While the intent of this chapter is to equip hospitalists with the knowledge and skills to assess and intervene on elder mistreatment, time constraints are a valid concern. An assessment for elder abuse and neglect is rarely a quick and simple endeavor. It often requires taking a detailed history from the patient and other caregivers and a thorough physical exam that includes a cognitive evaluation. A comprehensive evaluation may conflict with pressures to manage length of stay by focusing on the diagnosis and treatment of only the acute medical issues. We will discuss how to utilize an interdisciplinary team as well as expert consultants to lessen the burden on any one provider. Hospitalists can also make use of time-based billing in order to maximize reimbursement for managing these complex cases. Elder mistreatment cases often unfold over time, for example, over the course of a single lengthy admission or multiple admissions, and hospitalists commonly “hand off” these complex patients to their colleagues in subacute, home care, or ambulatory settings. Because we understand the limitations of what can be reasonably accomplished in an acute care setting, we have devoted portions of this chapter to “handoffs” and how to ensure safe transitions between care providers.
Unique Challenges and Opportunities for Hospitalists
Most importantly, the busy practicing clinician may encounter at least one victim of elder abuse for every 20 to 40 older adults seen. Hospitalists are caring for an increasing proportion of older adults in acute care settings. A 2009 study of Medicare patients by Yong-Fan, et al in the New England Journal of Medicine revealed that the odds of a hospitalized older adult being cared for by a hospitalist increased nearly 30% every year from 1997 to 2006.6 This underscores the imperative for hospital-based clinicians to know which older adults are at greatest risk for elder mistreatment and how to properly assess them.
While we acknowledge the challenges of performing assessments for elder mistreatment in an acute care setting, the critical opportunity inpatient providers to positively impact on the lives elder mistreatment victims and their caregivers must be emphasized. The acute care admission may signal a crisis coming to a head or the first sign that an older adult is being abused or neglected. Both represent chances to intervene to ensure safety and prevent further harm. For example, the elderly woman with dementia admitted with a fall in the setting of hypoglycemia is being cared for by her increasingly frail husband who left her alone while he went to his doctor’s office. She didn’t feel well and assuming it was her “sugar” took an extra dose of her oral diabetes medications. The husband’s decision to leave his wife alone at home is most likely unintentional neglect but the resulting hospitalization provides an opportunity to educate and to intervene. Perhaps the patient’s medication regimen can be simplified and short-term home care services ordered for nursing and physical therapy visits. While she is receiving home health care, a social worker can also visit the home to explore entitlements since the husband and wife will require additional help and supervision once the short-term services end.
Hospital-based providers may be the only individuals outside of family allowed access to an abused or neglected older adult and are uniquely qualified to order the proper workup to document the presence or absence of mistreatment, to recommend admission or transfer to another setting, and to order services such as home health care. For known cases of ongoing abuse in the community, hospitalization is often a sentinel juncture that provides new opportunities such as (1) the ability to assess clients free from the influence of abusers or their environments, (2) to counsel victims in a different setting about the range of possible options, and (3) an opportunity to bring new resources to bear on the problem that would prove difficult in other settings (including psychiatric consultation, physical therapy, and social services).
Conversely, when the hospital-based clinician fails to recognize the signs of abuse or neglect and misses an opportunity for intervention, significant harm can come to the patient and his/her caregivers. For example, the frail bed-bound elderly female with multiple sclerosis admitted with several worsening pressure ulcers may confide in the physician that she fears her son because he frequently yells and shakes his fist at her. Recently he broke the hospital bed and air mattress she had at home and would not allow her aides to turn and reposition her. If the patient’s report was dismissed and she was not asked, in private, whether she wanted to return home or go to a subacute facility for wound care, she could suffer increasing morbidity or mortality if violence at home escalates. Furthermore, if the inpatient provider “fumbles the handoff” and fails to properly document the assessment and planned intervention, the patient and the health care system could pay the consequences. If the example patient was discharged to a subacute facility that was unaware of the patient’s fears of her son, the receiving clinicians might inadvertently discharge the patient home several weeks later. Or, should the patient be readmitted to the acute care setting under a different hospitalist, that physician might also unknowingly involve the patient’s son in discharge planning.
THE “SOCIAL ADMIT” An 86-year-old woman with a history of diabetes mellitus, hypertension, atrial fibrillation, and venous insufficiency presents to the emergency department after a fall at home. The patient was admitted two weeks ago after a similar fall at home and was discharged with home care services. The patient reports she was walking to the bathroom and tripped over a throw rug falling forward onto her hands and knees. She did not lose consciousness or bump her head. The patient lives with her adult son who helps with chores, shopping, and medication, including insulin administration. Triage vital signs: Temperature 98.0°F BP 180/90 mm Hg HR 110 irregularly irregular O2 sat 99% Finger stick blood sugar: 300 Laboratory data:
The social worker is concerned about the patient’s safety at home and is unable to reach the patient’s son who is at work. The patient reports the home care services ended and she no longer has a home health aide. The patient is admitted to the hospitalist service as a “social admission.” A closer look at the “Social Admit” In this case, multiple red flags suggest that she is the victim of elder neglect. Concerning details from her history include the recent admission, her repeated falls, the discontinuation of home care services, and the inability to reach her primary caregiver. She has signs of poorly controlled chronic illness such as an elevated blood pressure and blood glucose level, tachycardia, and glucosuria. The subtherapeutic PT/INR level suggests an inadequate amount of warfarin or missed doses. Finally, the low albumin level and elevations in her serum BUN and creatinine and urine specific gravity imply possible malnutrition and dehydration. Any one of these “medical diagnoses” like rapid atrial fibrillation, poorly controlled diabetes, and volume depletion could be used to “medically justify” an acute care admission and further evaluation for neglect. Recommendations In this case, much could be gained by speaking separately with the patient and with her son. The hospitalist’s role consists of evaluating her understanding of her medical problems, explaining her current health status, and assessing her functional status.
Similar questions could be directed toward her son. As caregiver neglect may be due to ignorance, inexperience or inability, perhaps the son does not understand the importance of adhering to a diabetic diet or is unaware of what foods she should or should not eat. He may not be comfortable administering her insulin or believes she does not require it every day. He may not understand the impact of her poorly controlled illnesses on her functional status. |
THE “FREQUENT FLIER” An 86-year-old woman with a history of coronary artery disease, chronic systolic congestive heart failure with an ejection fraction of 35%, hypothyroidism, and atrial fibrillation presents to the emergency room with progressive dyspnea on exertion and chest pain. She always comes in with the same diagnosis, responds quickly to diuretics, she is “in and out in 3 days.” Triage vital signs: Temperature 96.7°F, BP 110/60 mm Hg, heart rate 130 irregularly irregular, room air O2 saturation 90%. Her examination is notable for signs of congestive heart failure; she has decreased breath sounds at the lung bases, rales in the mid and upper lung fields, and 3+ lower extremity edema. Laboratory data:
She is admitted to the hospitalist service for acute systolic congestive heart failure and rapid atrial fibrillation. A closer look at Case 167-2 Several red flags indicate possible elder neglect, including frequent admissions for decompensated congestive heart failure and a quick positive response to medications provided in the hospital. On exam, she has the expected signs of heart failure but her laboratory values suggest an inadequate amount of both warfarin and digoxin. While the indication for acute hospital admission is not disputed in this situation, the hospitalist should take the extra time to investigate the reasons behind the failed hospital-to-home transition. Recommendations The evaluation and documentation of decision-making capacity in a potential elder mistreatment victim are critical. The description “alert and oriented times three” is insufficient documentation of a patient’s decision-making capacity. To demonstrate capacity, the individual must be able to understand the relevant information or choices being presented, articulate a choice, and provide a reasonable explanation for that choice. Cognitive impairment does not automatically indicate a lack of capacity. The assessment of capacity must be decision-specific (eg, does this patient have capacity to participate in discharge planning?). |
These two cases may on the surface appear as routine admissions that hospitalists see every week on their services. However, subtle red flags in each case should raise the possibility of elder mistreatment. This chapter will help hospitalists recognize the signs of elder abuse and neglect and provide them with the skills to perform an assessment and devise appropriate multidisciplinary interventions. These examples underscore the need for hospital-based providers to be aware of the signs and symptoms of elder mistreatment and the appropriate forms of intervention. We now detail the components of assessment, intervention, and follow-up.
How to Conduct an Assessment for Elder Mistreatment
Hospitalists should adopt the practice of “universal precautions” for elder mistreatment. This entails maintaining a high index of suspicion, especially when a patient’s caregiver and support system is clearly inadequate to meet his or her needs. The risk factors for elder abuse and neglect that most often lead to an imbalance between needs and supports are cognitive impairment, physical frailty, and social isolation. If one type of abuse or neglect is suspected, the hospitalist should screen for all other forms. The American Medical Association considers certain signs “red flags” indicating potential elder neglect or abuse (Table 167-1).
Related posts:
Strategies for Cost-Effective Care
Building, Growing, and Managing a Hospitalist Practice
Designing a Hospitalist Compensation and Bonus Plan
The Face of Health Care Emerging Issues for Hospitalists
Medical Malpractice
Preventing and Managing Adverse Patient Events: Patient Safety and the Hospitalist
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