Elder mistreatment can take many forms, not all of which are obvious, and family members are often but not always the perpetrators, Carmel Bitondo Dyer, MD, FACP, told attendees at a session titled “Exploring Mistreatment in the Vulnerable Elderly” at Internal Medicine Meeting 2018.
“A case comes to mind where one of our caseworkers, our nurse practitioners, walked in and watched the grandson bringing grandmother a cigarette and a cup of coffee as her breakfast,” Dr. Dyer said. “He was using her funds to buy drugs.”
An estimated 2% to 11% of older adults in the U.S. are abused or neglected each year, but only two of every 10 cases of elder abuse in the U.S. are detected, said Dr. Dyer, who is a professor of geriatric and palliative medicine at the University of Texas Health Science Center at Houston. “Patients don't want to admit, ‘My daughter is taking my money, somebody is neglecting me, I'm going to wind up in a nursing home.’ There's many, many reasons,” she said.
The consequences of abuse and neglect are dire, including functional decline and dependency, worsening chronic conditions, social isolation, and early mortality, Dr. Dyer said. In data from 2009, elder mistreatment and self-neglect, including financial exploitation, were associated with a twofold increase in mortality. “These are morbid events, these kill people, and it's pretty scary,” she said. “Nearly half of self-neglectors die within a year. That's chilling. That means that we have a very narrow window to intervene in these cases.”
Patients with cognitive impairment are the most vulnerable to abuse and neglect, Dr. Dyer said. “If there's one thing to take away from this lecture as a risk factor, it's that people that … can't perform their [activities of daily living], … that the family says, ‘Oh, don't listen to him, he's a little off, sometimes he gets confused’—those are the patients that are at the greatest risk,” she said.
Other risk factors include female sex, advanced age, social isolation, poor social support networks, mental health problems, frailty, substance abuse, and reliance on others. “If there's a dependency on another, or frailty, we really have to look for abuse,” Dr. Dyer said.
Regarding perpetrators, it can be difficult to tell who might be likely to mistreat an elderly patient, Dr. Dyer said. “Sometimes you see the family members and they're straight-up people, they really want to help their parent, the self-neglector's refusing, or the wounds are developing despite good care. So how do you and I sort out who might be a bad actor and who's just trying to do a good job?” she said.
One clue can be a family history of child abuse. “Children who were abused when they were younger … whether it's retaliation or that's a pattern of life that they grew up with, we see abusive behaviors,” she said.
Perpetrators of abuse or neglect are also more likely to be male, to have mental health problems, and to be over 40 years of age. Cognitive impairment in the caregiver can be a risk factor for elder neglect, Dr. Dyer said, because it can indicate a lack of ability to provide good care.
For elder self-neglect, depression and executive dysfunction are the most common characteristics, since elderly patients with these conditions aren't able to plan, sequence, and carry out activities of daily living, Dr. Dyer said.
“Frankly, think about maybe members of your own family.… grandparents, parents who became frail … if they didn't accept the social support … they might be falling in these categories as well,” she said. “Really, it's when the social support is not there that you and I have to step in and try to halt this process of decline and premature death.”
What to look for
Distinguishing physical abuse from normal aging can be difficult, Dr. Dyer said. The fact of a fracture itself, for example, does not necessarily mean a patient is being abused. “Generally, what we see is fractures that occur in unusual places, that are not the typical osteoporotic fractures, though they could be. Or you see multiple fractures,” she said.
Location is also a key indicator for bruising. “Basically, if you and I see bruises on the head, the neck, or the torso, then that should give us a little more sense that this may be elder abuse,” Dr. Dyer said. Delayed care can also be a sign, for example, if a patient presents at the hospital with a fracture and the caregiver reports that the injury occurred in a fall over a week ago, she noted.
Clinical indicators of sexual abuse include difficulty walking or sitting; pain or itching in the genital area; unexplained sexually transmitted diseases; vaginal or anal bleeding; torn, stained, or bloody underclothing; and bruising around the genital or breast regions. Research has shown that abdominal bruising can also be a sign, Dr. Dyer said. She stressed that data need to be collected in cases of suspected sexual abuse, regardless of the age of the patient.
“They need to do rape kits, they need to get the patient to or have a sexual assault nurse examine her, come out to the facility or bring the person out to the hospital where that's being done and get this assessment done, because so many times there's no data collected,” she said.
Patients who have adequate income but suddenly can't afford their medications or show evidence of malnutrition may be victims of financial exploitation, Dr. Dyer said. Other signs are caregivers who accompany patients to appointments and talk over them, or a patient who suddenly makes a new friend and spends a lot of time with him or her. Dr. Dyer also pointed out that it's not always money that's stolen, using the example of a retired patient who lived alone and was systematically robbed of his valuable gun collection. The average amount stolen in a financial elder abuse case is $120,000, she said.
Clinical indicators of caregiver neglect can be hardest to determine, Dr. Dyer said. Decubitus ulcers can be one sign, but usually only those at later stages, she said. “Generally when we look at decubitus ulcers if they're stage 1 or stage 2, this is not 100%, but it's less likely to be abuse and neglect. We start seeing stage 3 and stage 4, then it raises our suspicion.”
Missed appointments can be another indicator, Dr. Dyer said, and one potential fix may be for offices to begin to track patients who have not been in to see the physician in a while. “Maybe our staff can tell us when they see a patient is repeatedly not coming in,” she said. “Maybe if you and I were to … look at those data, we would pick up these cases.”
Dr. Dyer said that ideally, screening is something that will be facilitated in the future by the electronic health record.
“We should identify the red flags and then you should get some printout that says they have X amount of red flags for abuse and neglect. … And then we can put it together with our clinical acumen and physical exam and see if we can determine suspected mistreatment,” she said.
Until then, screening can be done using instruments like the Senior Aid Tool, which asks questions such as “In the last six months, has anyone close to you called you names or put you down?” and “Has anyone tried to force you to sign papers or use your money against your will?” Questionnaires are often filled out for patients by potential perpetrators of abuse, however, so be mindful of that, Dr. Dyer said.
In general, what physicians and staff should be looking for are patients who have “some constellation of geriatric syndromes, like dementia and dehydration, depression, poor hygiene, a lot of delirium episodes,” Dr. Dyer said. “You see that they don't take their meds, they don't pay their bills, repeated admissions … these are the red flags.”
Once those warning signs are noted, there's a decision to make, Dr. Dyer said. If a patient is in immediate danger from abuse or neglect, the physician should call either the police or Adult Protective Services. “In most states, you have to call Adult Protective Services whether or not you call the police,” she said.
If a patient exhibits unexplained physical findings, or gives inconsistent explanations for something a clinician considers suspicious, he or she should be referred to Adult Protective Services and to emergency services. “The truth of the matter is, you and I don't have to diagnose elder abuse, elder mistreatment, financial exploitation. That's not the burden. What we have to do is recognize that something might not be right, and send the patient to the authorities,” Dr. Dyer said.
In Texas, state law holds that everyone is considered a mandatory reporter of suspected elder abuse and self-neglect, and clinicians have 48 hours to make a report to the Department of Family Protective Services after becoming suspicious, Dr. Dyer noted. Reporting regulations for each state can be found at the website of the National Center on Elder Abuse, she said.
Physicians used to proving their diagnoses may feel reluctant to report suspicions of elder abuse and self-neglect, but Dr. Dyer reminded her audience that proof, in this case, is not necessary. “All we have to do is document the findings, say we're suspicious, and as long as the report is made in good faith, we are not held liable, and that's anywhere in the U.S.,” she said. “So we should really have a heightened reason and drive to report these cases.”