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MANAGEMENT OF ELDER ABUSE IN THE EMERGENCY DEPARTMENT
DOMESTIC VIOLENCE IN THE EMERGENCY DEPARTMENT
0733-8627/99 $8.00
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MANAGEMENT OF ELDER ABUSE IN THE EMERGENCY DEPARTMENT Melissa E. Clarke, MD, FACEP, and Wendell Pierson, MD
The problem of elder abuse in our society is more widespread than is thought by many health care professionals. Unlike other forms of domestic violence, elder abuse has been slow in gaining the attention of the general community, although its prevalence is estimated to be just slightly less than that of child abuse.16 First recognized as a problem 1970s, when the term granny battering appeared in the literature; two decades later there are still many unresolved issues and unanswered questions. Emergency physicians are in a unique position regarding the diagnosis and management of elder mistreatment. Because of the relative isolation of many elders who are mistreated, an unexpected visit to the emergency department (ED) may be the only opportunity for detection of abuse; however, ED studies have shown that not only do many departments lack protocols for elder abuse, physicians are not even aware of it as an entity6 In one Michigan study, only 2% of all cases reported in the state were made by physicians.12The following is a discussion intended to familiarize physicians with the problem of elder abuse in this country, including its historical background, definition, prevalence, detection, and management. DEFINITIONS Definitions associated with elder abuse vary significantly among researchers, legislators, and enforcement officials. Clear definitions are From the Division of Emergency Medicine, Howard University Hospital, Washington, DC
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needed to implement appropriate interventions. In some cases of unintentional neglect, for example, education of the caretaker may be the only intervention required. Conversely, physical abuse may warrant mandatory reporting and possible removal of the victim from the environment. Although judgments in extreme cases may be in concordance in different states, varied definitions of abuse in different jurisdictions can lead to differing outcomes in borderline cases? Despite conflicting definitions, general categories remain that many authorities use in the medical and legal literature. The National Center on Elder Abuse defines the seven types of elder abuse listed below.31 Physical abuse, the most recognizable form, involves injury or harm to a person carried out with the intention of causing suffering, pain, or impairment.21,31 Physical abuse comprises a wide range of behavior, including slapping, biting, burning, pushing, striking with objects, and even the improper use of physical or chemical restraint~.~~ Physical abuse is generally considered the most extreme form of elder mistreatment, and there is no disagreement from authorities regarding this definition. Sexual abuse, sometimes included in the definition of physical abuse, is nonconsensual sexual involvement of any kind with an elderly person.31 The spectrum ranges from rape to verbal sexual innuendoes and includes unwanted touching, advances, or indecent exposure. Emotional or psychological abuse is the intentional infliction of anguish, pain, or distress through verbal or nonverbal acts.31This type of abuse usually is associated with physical abuse but can occur alone. Perpetrators often humiliate and harass the victim, causing stress and anxiety. Threats to institutionalize the victim or to withhold medicines, food, or water are some of the commoner forms of psychological mistreatment of elders.21 Financial or material exploitation is the illegal or improper use of an elder’s funds, property, or assets.31Perpetrators often depend on the elderly victim for shelter or finances. Incidents can range from blatant theft or coercion to blackmail. Those guilty of this kind of abuse often attempt to force the victim into changing a will or other document for their benefit. Although much of the current literature on elder abuse does not focus heavily on this type of abuse, it is undoubtedly important. It was not until the 1990s that the passive form of elder abuse, neglect, was seen as equally important, whether occurring at home or in an institution.2Definitions of neglect are probably the most disputed of any category; however, neglect is defined as the refusal or failure of a caregiver to fulfill his or her obligations or duties to an elderly including (but not limited to) providing any food, clothing, medicine, shelter, supervision, and medical care and services that a prudent person would deem essential for the well-being of a n ~ t h e r Neglect .~ may be intentional or unintentional. There is debate over the importance of this distinction because legally it is often difficult to prove intent.5Intentional neglect includes refusal of the caregiver to provide for basic needs such as hygiene and nutrition, and medical care, such as giving medications or cleaning wounds. Unintentional neglect is defined as the failure to
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fulfill a caregiver role, either through ignorance or inability to care for the person. Two other categories sometimes considered neglect are abandonment and self-neglect.Abandonment is the desertion of an elderly person by an individual who is his/her custodian or who has assumed responsibility for providing care to the elder. Self-neglect is recognized by some state laws and refers to the failure of a person to provide himself with the care and services necessary to maintain physical and mental health.31
LEGAL ISSUES RELATED TO ELDER ABUSE
States have been making laws against elder abuse since 1973.15 Currently, elder abuse is defined by state and not federal laws, but state definitions vary considerably from one jurisdiction to another. The statutes vary widely in several factors: the age at which a victim is covered, the definition of elder abuse, the classification of the abuse as criminal or civil, types of abuse covered, reporting requirements, investigation procedures, and remedies. The laws, however, were written as many as 20 years ago and were based on the laws addressing child abuse, which primarily concern physical abuse. As a result, older laws are weak on matters, such as financial exploitation (children have no money to exploit). These laws offer few remedies other than removal of the abused person from the setting in which the abuse is occurring or provision of services intended to alleviate or terminate the abuse.29 Mandatory reporting laws exist in all 50 states and the District of Columbia.30Forty-three states mandated reporting of suspected cases, but only 30 of these contain penalties for failing to report. Penalties for failure to report vary. People who are required to report elder abuse who fail to fulfill this responsibility may be found guilty of a misdemeanor and either jailed or fined. Some state laws provide that such a person may be held liable for damages incurred by an abused person as a result of failure to make a report. In addition, some statutes specify that a mandated reporter who is a licensed professional may be reported to the appropriate licensing authority for failure to report. Conversely, some states impose no sanctions. In only four states (i.e., Colorado, New York, Wisconsin, and Illinois) is reporting voluntary. Mandatory reporting by physicians is in itself controversial, having also been based on child protection laws that presume an inability of minors to make decisions in their own best interest.29The key difference is that mandatory reporting with resultant investigation can interfere with the an adults’ autonomy and right to privacy. Requiring that physicians report cases may be viewed as patronizing to older persons who “cannot make decisions for themselves,” especially if they are competent.I6 In addition, elders may be dissuaded from seeking assistance because of fear of consequences. A degree of anxiety over mandatory reporting laws also has been noted because physicians are con-
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cemed about possible retaliatory litigation from the victim or the family. Every state has at least one statute providing immunity from civil or criminal liability to anyone who makes a report of abuse in good faith. Most such statutes also provide that the immunity does not apply if the person making the report is also the person who committed the abuse.z1 The federal government drafted the first laws regarding elder abuse in 1981 in the US House Select Committee on Aging. In 1985, the Elder Abuse Prevention, Identification, and Treatment Act (HR 1674) was introduced in Congress in an attempt to clarify and standardize the language relating to geriatric abuse.14Federal definitions of elder abuse, neglect, and exploitation were further addressed in the 1987 Amendments to the Older Americans Act. The law provided these definitions only as guidelines for identifying the problems and not for enforcement purposes. The 1992 version of the bill led to a national elder abuse policy and provided additional funding, but omitted the mandatory reporting requirement. DEMOGRAPHICS
The true incidence of elder abuse is unknown. Most statistics that have been compiled regarding prevalence have been from agencies who collect data retrospectively by report.z6,31 It is highly likely that the numbers generated from these types of surveys greatly underestimate the true incidence. It is estimated that up to 2,000,000 elders are abused per year in this countryzo,31 A study done by the National Center on Elder Abuse reports that there has been a steady increase in the reporting of elder abuse, with 117,000 reports in 1986 and 293,000 in 1996.31The median age of the victims was 77.9 years. The commonest type of abuse was neglect, accounting for 55% of their population. Physical abuse accounted for 14.6% and financial exploitation represented 12.3%. Racially, 66.4% of their victims were white, 18.7% were black, and 10% Hispanic. All other groups account for fewer than 1% of the study groups. These statistics vary when compared with other studies, particularly among racial differences and risk factors.18,z4, 26, 31 Other studies have performed random population studies to determine the true incidence and also to delineate risk factors?, 8, lo, z6 ABUSE OF OLDER PATIENTS IN INSTITUTIONS
Approximately 5% of elderly patients live in long-term care instituto reports of widespread neglect and abuse in nurst i o n ~In . ~response ~ ing homes in the 1980s, in 1987, Congress enacted legislation that requires nursing homes participating in the Medicare and Medicaid programs to comply with certain quality of care requirements. The legislation, included in the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), also known as the Nursing Home Reform Act, specifies
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Table 1. EXAMPLES OF ABUSE IN INSTITUTIONAL SETTINGS
Falls and fractures Physical or chemical restraints Malnutrition or dehydration Improper, wrong, or overmedication Bed sores Defective equipment Lack of supervision (e.g., allowing residents to wander away from the facility) Physical abuse or unexplained injury
Weight gain or loss Theft of money and personal property Unexpected or wrongful death Unsanitary conditions Untrained or insufficient staff Oversedation Substandard medical care Poor personal hygiene Sexual assault
Data from refs. 21, 23, and 29.
that a nursing home must document and adhere to the assessments, plans of care, and the care provided in the resident’s clinical record.29 In one random survey of staff members in long-term care facilities, 10% of nurses’ aides reported at least one act of physical abuse and 40% reported at least one act of psychological abuse in the preceding year.2l Factors leading to caregiver stress include low job status of the primary caregiver, the attitude that residents are childlike and need discipline, and staff that has a high level of personal or job stressz3In addition to staff, visitors and family can also be responsible for abuse.21Examples of abuse are listed in Table 1. Every state has a nursing home ombudsman program that responds to reports of neglect or abuse of nursing home elderlyz1Every resident must have access to the ombudsman for that facility. Physicians who suspect abuse in institutions should report their suspicions to the state ombudsman, Adult Protective Services, or the Department of Aging for the State. OBSTACLES TO DETECTING ELDER ABUSE
For various reasons, abuse of the elderly can go undetected even when the victim presents to the hospital for a related reason. The reasons for cases being missed can be attributed to both the patient and the physician. There are factors that prevent the senior from reporting the abuse, and reasons for the health care provider’s failing to detect it. Both sources result in a delay of the elderly patient getting help for their circumstance. The Patients Themselves
Sometimes, seniors themselves act can participate, either knowingly or unknowingly, in hiding the abuses they suffer. Many elderly people become isolated and rarely leave the house, resulting in less opportunity for detection of abuse by others.6 Reasons for this are varied. The
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victim may be isolated because of concomitant illnesses that prevent communication or freedom of movement. The abuser may control access to others and may stay around when there are encounters with outsiders, to ensure that secrecy is maintained.6Health care visits may be the only contact with the outside world, so medical personnel are in a unique position to detect abuse if it is present. Victims sometimes voluntarily withhold information about their circumstances. They may feel embarrassed or guilty about the abuse and, therefore, do not want it to be known publicly. In addition, they may worry about retaliation against the abuser or the consequences of exposure. One such consequence could be fear of being removed from the home and being placed in a nursing institution. They may also worry about further abuse from the abuser for having divulged information. Finally, many elders are unwilling to press charges against a family member, even if abuse is detected.6 Elderly patients also can have different definitions of abuse, based on cultural or ethnic backgrounds. Victims may have ageist beliefs and feel that old people are supposed to be mistreated because they are a burden to their families.6 One study done with Korean, African-American and white older women in the Midwest showed that when presented with different abusive scenarios, definitions of abuse can vary based on cultural beliefs as well as the perception of the intent of the abuser.24For example, a woman who sedated her senile mother when company came was not considered an abuser because she did it so that the family would not be embarrassed. A neighbor surreptitiously taking nude photos of an elderly woman without her permission was considered abusive, however.24 In summary, when dealing with elderly patients, consider their personal views and circumstances when interviewing them about a potentially abusive situation. What may seem a clearcut case of abuse to medical personnel may be to the senior involved not a topic for open discussion.
Health Care Personnel Health care providers themselves can contribute to cases of abuse going undetected. Physicians underreport and notify the appropriate authorities in only 1 of every 13 cases they identify.9Many physicians feel uncomfortable or resistant to discussing potential abuse with their patients.'j Few medical school curricula have formal training in screening for occult abuse of elderly patients and interviewing techniques for potential victims and abusers." Physicians, therefore, can feel uncomfortable, primarily because of a lack of knowledge. In addition, most hospitals have no protocols for identifying or addressing elder abuse7 therefore, even if the physician did recognize a case, he or she may not know the proper management involved. Many doctors may not maintain a high enough index of suspicion
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with their older patients to recognize a case. One study found that physicians, by self-report, did not know the prevalence of elder abuse and, therefore, did not think of it as a potential problem they might In a busy ED, physicians also do not always have the time enco~nter.~ to conduct an in-depth interview separately with the victim and then with other family members. Last, a fear of litigation can make many physicians reluctant to ask questions about potential abuse.6, DETECTION OF ELDER ABUSE
Elder abuse and neglect are not problems that can be assessed quickly. Resources exist in the community to aid in difficult or complex cases, but often physicians do not know how to access these resources. Unless there is a finding that suggests a threat to life or imminent serious harm, a thorough evaluation can span several visits and include many sources.21The role of the physician should be to maintain a high index of suspicion in the ED because this is where many elders come to the attention of the community. Once suspicion of abuse is established, a referral can be made to the appropriate social service agency. Hospital protocols have been recommended by the American Medical Association (AMA),l ACEP:7 and others to aid in the detection and proper management of elder abuse. Knowing the Red Flags
Given the prevalence of elder mistreatment and the fact that it can appear asymptomatic, AMA guidelines suggest that all older persons be asked about abuse or neglect.' Knowledge of those who are at risk is often helpful to identify those patients who need more in-depth assessment. Many retrospective and prospective studies have been done to identify those who are at higher risk of abuse; however, debate still remains. Characteristics such as having a cognitive impairment, being female, and being dependent are universally considered risk factors.8,15, 16,18,26 Other risk factors, however, such as age, race, economic status, and religion, are not as clear.18,24, 26, 31 Researchers offer several suggestions for the disparity in statistics regarding risk factors. The most notable is that much of the data in this area are gathered retrospectively and are subject to reporting bias.18 One prospective community-based study in New York found that the cases of elder abuse that tended to warrant investigation were those involving the poorly educated, the very old (over age 75 years), and minorities,2O suggesting that these categories of seniors be considered at high risk as well. Several characteristics are reliably considered to be associated with a higher risk of elder abuse. The first group of elders at risk are those who live with others.4,l6 They seem to be at higher risk if they are physically or financially dependent or live with a stressed or isolated
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caregiver. In addition, a patient's functional status determines the extent of care needed.4 Physical or mental impairment increases dependence on others and, therefore, the risk of mistreatment. Extensive dependence by an elderly person can lead to feelings of being overwhelmed or frustrated on the part of the caregiver, leading to mistreatment. Functional impairment also limits the person's ability to seek help or defend himself or h e r ~ e l fLast, . ~ the emotional status of the elderly person is also an important risk factor. Persons who are depressed or have significant stress in their lives are at an increased risk for abuse, most likely because of the added tension between victims and caregivers?, l6 Many studies suggest that it is the characteristics of the abuser and not the victim that are the greater predictor of abuse.16A caregiver who has a financial or emotional dependence on the victim is more often seen in a situation of elder abuse. This dependence is often exacerbated by underlying problems, such as legal or financial difficulties, alcohol or drug dependence, or psychiatric disease.16 Alcohol abuse by the caregiver was the factor most predictive of elder abuse.12 A family history of violence also is a factor that has a high correlation with the occurrence of elder abuse. One study showed that mutually abusive relationships exist in many of the 56 caregiver-patient pairs they studied.12The percentage of individual acts of violence by patients increase if the patient is demented. Patient aggression or behavior such as wandering, verbal outbursts, or embarrassing actions also increases caregiver violence.16 Finally, certain chief complaints may alert the physician to the possibility of elder mistreatment. For patients older than 75 years, the commonest complaints are falls, dehydration, and failing self-care, which all can signal neglect or self-neglect.22 Taking a Careful History
The presence of any of the above "red flags" indicates that a more in-depth history should be taken. The first step is using interviewing techniques that are likely to elicit an accurate history. Keep questions direct and simple, without a judgmental or threatening The patient, the suspected abuser, and other family members should be interviewed separately and without other staff or family in the room. There may be disparities in histories that offer clues, and seniors may be more likely to be forthcoming with just the physician present. Establish a nonconfrontational environment by starting off with general questions about safety in the home (e.g., do you feel safe where you live?) and caretaking issues (e.g., who cooks for you?, who handles your finances?).21Establish if there is a regular pattern of medical care or if the patient is taken to the ED only as needed.4 More direct questions about mistreatment can then follow, such as the use of physical violence, restraints, or neglect. A list of more direct questions appears in Table 2.4, 16, 21, 23 In addition, ask the detailed circumstances of each injury while keeping alert for any
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Table 2. INTERVIEW QUESTIONS TO ASSESS ELDER ABUSE Physical Abuse Are you afraid of anyone at home? Do you feel safe at home? Have you been struck, slapped, or kicked? Have you been locked in a room or tied down? Psychological Abuse Do you feel isolated or alone? Do the people who care for you threaten you with punishment or being put in an institution? Have you been ignored? Are medications or foods forced on you? What happens if you and your caregiver disagree? Sexual Abuse Has anyone touched you sexually without your permission? Neglect Do you have access to hearing aids, eyeglasses or dentures if you need them? Are you left alone for long periods? Is your home safe? Has anyone not helped you when you need it? Do you get your medicines on a regular basis? Financial Exploitation Is your money used without your permission or stolen? Have you been forced to sign any legal document against your will? Does your caregiver depend on you for shelter or money? Follow-up Questions (If Abuse Is Identified) How long has it been going on? Is it an isolated incident? Why does the patient think this happens? When does the patient think the next episode will occur? Is the abuser present in the ED? Is it safe for the patient to return home? What would the patient like to see happen? Has the patient ever received help for this problem before? Datafrom refs. 4, 12, 21, and 23
inconsistencies. Finally, accurate and objective documentation of the interview is essential. Using exact quotations from patients and their families, where appropriate, will aid in the level of detail recorded? Assessing a patient for psychological abuse is more challenging. Unless the physician witnesses overt threats, insults, or humiliation, subtler signs must be sought. Keeping a high index of suspicion is the first step, especially in the face of known risk factors such as caregiver stress. In addition, signs from the caregiver of an unwillingness to cooperate with healthcare providers, or anger or indifference to the patient, can signal a dysfunctional situation.23A formal mood assessment of the patient revealing withdrawal, depression, or fear also gives clues that he or she is a victim of psychological abuse.2I
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Physical Assessment of Potential Elder Abuse Victims
Cases of elder abuse do not always present with dramatic physical manifestations. In a review of 36 ED cases, neglect was a commoner manifestation of mistreatment than injury.14 The physician must, therefore, stay vigilant during the physical examination and be knowledgeable regarding the constellation of signs indicative of abuse. Common physical injuries include unexplained bruises, fractures, lacerations, or abrasions, and head injury.,, Conversely, dehydration and malnutrition, late-stage bed sores, inappropriate clothing, and improper administration of medicines are more often indicators of neg1e~t.I~ Although the physician should maintain a high index of suspicion and be alert to any signs, elder abuse often occurs with a cluster of signs and symptom^.^ Use clinical judgment in deciding whether isolated findings indicate abuse. Examples of the need for clinical skill include the facts that skin in elderly patients is more easily bruised and that their higher incidence of osteoporosis leads to more fractures.21Isolated findings may not signal abuse, but pathology that occurs more frequently in the elderly. A complete physical examination, including the neurologic system, observation of gait, and an assessment of competency, should be performed. Cognitive impairment is a risk factor for abuse and can impair the patient’s ability to give an accurate history and their ability to make decisions in his or her best interest.21A head-to-toe examination of the body, including the genitalia, should be done, with special attention to the size, age, and location of any lesions. Table 3 lists the positive findings suggestive of abuse on the physical examination. If necessary, obtain photographs of the lesions to be placed in the chart for documentation. It can sometimes be appropriate to assess the financial and social resources of the patient. The availability of such resources in the face of unmet needs such as nutrition and hygiene calls into question exploitation of the elder patient. Although a detailed assessment might not be in the realm of the emergency physician, any clues that contribute to the suspicion of an abusive situation are worth noting. In addition, this information can assist in considering interventions, including alternative living arrangements or home services.21 MANAGEMENT
Reacting to abuse requires a multidisciplinary approach. Because of the wide variations of types of abuse, interventions vary from simple social service referral to actual removal of the patient from the home. The clinician’s highest priority in suspected abuse cases is in balancing the safety of the patient with his or her autonomy.16 In situations of suspected abuse, the physician must first determine if the patient wants intervention. If they refuse, the next step is to
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Table 3. PHYSICAL EXAMINATION FINDINGS SUGGESTIVE OF ELDER ABUSE Physical Examination
General Behavior Skin mucosa
HEENT
Ttunk Genitourinary system Extremities Neuropsychiatric
Imaging / laboratory studies
Notations to Be Made
Poor hygiene, inappropriate dress, cachexia Caregiver who insists on giving history or who insults, threatens, or infantalizes the patient; withdrawal of patient Dehydration, multiple lesions in various stages of healing, bruises, decubiti, lacerations healing by secondary intention, poor care of existing skin lesions Signs of head injury, traumatic alopecia, broken teeth, eye injury Pattern bruises inflicted by an object with a characteristic shape, (i.e., belt, iron), clustering of bruises Pain, itching, bleeding, discharge or lacerations in the rectum or vagina, infestations, extensive bedsores, urine bums, fecal impaction Bilateral arm bruises (shaking), friction bums around wrists of ankles (restraints), immersion bums, cigarette/cigar bums, occult fractures/dislocations Limping gait indicative of occult fracture; focal deficits, mental status and mood testing for depression, anxiety, or withdrawal Perform cognitive testing to assess competency As indicated from clinical examination; serum levels of medications to assess compliance
Data from Lachs M, Pillemer K Abuse and neglect of elderly persons. N Engl J Med 332437443, 1995
determine if he or she is competent enough to make decisions. If the patient is competent, although it may be frustrating, his or her wishes must be honored. In these cases, a patient should be educated about the need to change the situation because abuse tends to escalate and not improve with time. Written information regarding emergency assistance numbers, a system for safety, and follow-up plan should be developed with the patient.21 If the patient is no longer competent to decide for himself or herself, APS the next step should be to contact Adult Protective Services (APS).23 agencies were established by state statutes and have the capability for immediate evaluation, counseling, and relocation in suspected cases of elder mi~treatment.~~ APS in larger areas are under social service agencies, whereas in smaller jurisdictions they are under the local law enforcement agency. They can establish a court-ordered guardianship or conservatorship to arrange shelter, finances, and care. The physician should document carefully the findings of mistreatment or self-neglect and reasons for declaring the patient incapable of acting in his or her own best interest.*l When a patient is agreeable to intervention, a variety of options can be exercised, depending on the type of abuse. If the situation involves physical abuse, severe neglect, or abandonment, hospital admission may
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be warranted.16 Admission provides the necessary medical treatment and additional time to activate the appropriate social support resources and also separates the victim from the abuser. Admissions for a specific problem (i.e., decubiti, dehydration) tend to be more acceptable to the patient and his or her family. In the long term, sometimes alternative living situations must be arranged if the home situation cannot be amended. This is particularly true in cases of psychopathology of the abuser (e.g., substance abuse, mental illness) or in cases in which the patient is too disabled to live on his or her own. It is necessary to note that third-party payers may not always approve hospital admission based on neglected medical problems or non-life-threatening injuries.21 In non-life-threatening situations, a solution can be tailored to fit the individual circumstances. Even though the family is often the source of abuse in many cases, they can also provide the most support for the victim. Whenever possible, crisis intervention with family members should be undertaken. Options for support should be provided to family in an attempt to diffuse the stress and anxiety that preceded the abuse. Examples include home health aides, respite services, day programs, or accessible transportation if the caregiver is overburdened or ill equipped to deal with the patient's needs.I6 FUTURE DIRECTIONS
Geriatric abuse as a public health issue is still in its infancy and continues to evolve. Systematic prospective research is needed in most areas related to this problem. There is still a need for outcomes research on effective elder abuse detection and management protocols, the frequency and causes of the problem, and the most effective intervention techniques, especially in the ED setting.15 Other areas in need of development include the training of healthcare personnel in detection. Elder abuse can be introduced in preclinical curricula in psychiatry, introduction to clinical medicine courses, community medicine, and public health. Rotations in emergency medicine, psychiatry, family medicine, and gynecology can include material on elder abuse in case-based formats, lectures, or bedside instruction." Physicians educate themselves concerning the laws, legislation, and channels for reporting abuse. The development of ED protocols could help improve reporting by health care professional^.^, l4 From a public policy perspective, there are several fronts on which the management of elder abuse cases can improve. Funding shortages to the social service and law enforcement agencies responsible for adult protection result from a decrease in federal block grants to states.l5This results in decreased staff for evaluation and relocation of elders, as well as for prosecution of abusers if needed. In addition, many different local agencies are authorized to handle case evaluation and investigation. Lack of coordination can result in a poor level of service.15Lobbying for attention to these issues on a state and federal level is necessary to result
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in a systematic approach to a problem that has yet to be thoroughly confronted.
References 1. American Medical Association: AMA Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago, American Medical Association, 1992 2. Anon: Letter to the Editor. Mrs. Bodgers was abused. Lancet 342691-692, 1993 3. Block M, S h o t J: The battered elder syndrome [abstr]. College Park Maryland Center On Aging, 1979 4. Bloom J, Ansell P, Bloom M, et al: Detecting elder Abuse: A guide for physicians. Geriatrics 44:40-56,1988 5. Brewer R, Jones J: Reporting elder abuse: Limitations of statutes. Ann Emerg Med 18~1217-1221,1989 6. Cammer Paris BE: Violence against elderly people. Mt. Sinai J Med 63:97-100, 1996 7. Clark-Daniels CL et a1 Abuse and neglect of the elderly: Are emergency department personnel aware of mandatory reporting laws? Ann Emerg Med 19:970-977,1990 8. Comijs H Elder abuse in the community: Prevalence and consequences. J Am Geriatr SOC46885488,1998 9. Conlin M Silent suffering: A case study of elder abuse and neglect. J Am Geriatr SOC 43:1303-1308,1995 10. Giolio G, Blakemore P: Elder Abuse in New Jersey: The Knowledge and Experience of Abuse Among Older New Jerseyans. Trenton, NJ, Division of Aging, unpublished manuscript 11. Hazzard W Elder abuse: Definitions and implications for medical education. Acad Med 70979-981,1995 12. Homer AC, Gilleard C: Abuse of elderly people by their caregivers. Br Med J 301:13591362,1992 13. Hwalek M, Neale A, Goodrich C, Qumn K The association of elder abuse and substance abuse in the Illinois elder abuse system. The Gerontologist 36694700,1996 14. Jones J, Dougherty J, Shelble D, Cunningham W Emergency department protocol for the diagnosis and evaluation of geriatric abuse. Ann Emerg Med 17100&1015,1988 15. Jones J S Elder abuse and neglect Responding to a national problem. Ann Emerg Med 2384!%848,1994 16. Kleinschmidt KC, Krueger P, Patterson C: Elder abuse: A review. Ann Emerg Med 30463472,1997 17. Krueger P, et a1 Detecting and managing elder abuse: Challenges in primary care. Can Med Assoc J 1571095-1100,1997 18. Lachs MS, Williams C, OBrien S Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. The Gerontologist 37469474,1997 19. Lachs M, Williams C, O'Bnen S, et a1 The morality of elder mistreatment. JAMA 280428432,1998 20. Lachs M, Berkman L, Fulmer T, Horwitz R A prospective community-based pilot study of risk factors for the investigation of elder mistreatment. J Am Geriatr Soc 42:169-173,1994 21. Lachs M, Pillemer K Abuse and nedect of elderly persons. N Engl J Med 332437443,1995 22. Lowenstein SR, Crescenzi CA, Kern DC,et a 1 Care of the elderly in the emergency department. Ann Emerg Med 15528-535, 1986 23. Lynch SH: Elder abuse what to look for, how to intervene. Am J Nurs 9727-32, 1997 24. Moone A, Williams 0 Perceptions of elder abuse and help-seeking patterns among African-American, Caucasian-American, and Korean-American elderly women. The Gerontologist 33386395,1993 25. Paveza G, Cohen D, EisdorferC, et a1 Severe family violence and Alzheimer's disease: prevalence and risk factors. The Gerontologist 32493-497, 1992
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26. Pillemer C, Finkelhor D. The prevalence of elder abuse: A random sample survey. The Gerontologist 2851-57, 1988 27. Policy Statement: American College of Emergency Physicians: Management of elder abuse and neglect. Ann Emerg Med 31:149-150, 1998 28. Rosenblatt D, Cho KH, Durance PW Reporting mistreatment of older adults: The role of physicians. J Am Geriatr Soc 446570,1996 29. Stiegel LA Recommended Guidelines for State Courts Handling Cases Involving Elder Abuse. American Bar Association, 1995 30. Subcommittee on Health and Long-Term Care of the Select Committee on Aging, House of Representatives: Elder Abuse: A Decade of Shame and Inaction. Washington, DC, US Government Printing Office, 1992 31. Tatara T, Kuzmeskus L Elder abuse in domestic settings. Elder Abuse Information Series, No 1. Washington, DC, National Center on Elder Abuse (NCEA), 1996-1997
Address reprint requests to Melissa E. Clarke, MD, FACEP Howard University Hospital Division of Emergency Medicine 2041 Georgia Avenue NW Washington, DC 20060 e-mail: [email protected]
0733-8627/99 $8.00
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MANAGEMENT OF ELDER ABUSE IN THE EMERGENCY DEPARTMENT Melissa E. Clarke, MD, FACEP, and Wendell Pierson, MD
The problem of elder abuse in our society is more widespread than is thought by many health care professionals. Unlike other forms of domestic violence, elder abuse has been slow in gaining the attention of the general community, although its prevalence is estimated to be just slightly less than that of child abuse.16 First recognized as a problem 1970s, when the term granny battering appeared in the literature; two decades later there are still many unresolved issues and unanswered questions. Emergency physicians are in a unique position regarding the diagnosis and management of elder mistreatment. Because of the relative isolation of many elders who are mistreated, an unexpected visit to the emergency department (ED) may be the only opportunity for detection of abuse; however, ED studies have shown that not only do many departments lack protocols for elder abuse, physicians are not even aware of it as an entity6 In one Michigan study, only 2% of all cases reported in the state were made by physicians.12The following is a discussion intended to familiarize physicians with the problem of elder abuse in this country, including its historical background, definition, prevalence, detection, and management. DEFINITIONS Definitions associated with elder abuse vary significantly among researchers, legislators, and enforcement officials. Clear definitions are From the Division of Emergency Medicine, Howard University Hospital, Washington, DC
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needed to implement appropriate interventions. In some cases of unintentional neglect, for example, education of the caretaker may be the only intervention required. Conversely, physical abuse may warrant mandatory reporting and possible removal of the victim from the environment. Although judgments in extreme cases may be in concordance in different states, varied definitions of abuse in different jurisdictions can lead to differing outcomes in borderline cases? Despite conflicting definitions, general categories remain that many authorities use in the medical and legal literature. The National Center on Elder Abuse defines the seven types of elder abuse listed below.31 Physical abuse, the most recognizable form, involves injury or harm to a person carried out with the intention of causing suffering, pain, or impairment.21,31 Physical abuse comprises a wide range of behavior, including slapping, biting, burning, pushing, striking with objects, and even the improper use of physical or chemical restraint~.~~ Physical abuse is generally considered the most extreme form of elder mistreatment, and there is no disagreement from authorities regarding this definition. Sexual abuse, sometimes included in the definition of physical abuse, is nonconsensual sexual involvement of any kind with an elderly person.31 The spectrum ranges from rape to verbal sexual innuendoes and includes unwanted touching, advances, or indecent exposure. Emotional or psychological abuse is the intentional infliction of anguish, pain, or distress through verbal or nonverbal acts.31This type of abuse usually is associated with physical abuse but can occur alone. Perpetrators often humiliate and harass the victim, causing stress and anxiety. Threats to institutionalize the victim or to withhold medicines, food, or water are some of the commoner forms of psychological mistreatment of elders.21 Financial or material exploitation is the illegal or improper use of an elder’s funds, property, or assets.31Perpetrators often depend on the elderly victim for shelter or finances. Incidents can range from blatant theft or coercion to blackmail. Those guilty of this kind of abuse often attempt to force the victim into changing a will or other document for their benefit. Although much of the current literature on elder abuse does not focus heavily on this type of abuse, it is undoubtedly important. It was not until the 1990s that the passive form of elder abuse, neglect, was seen as equally important, whether occurring at home or in an institution.2Definitions of neglect are probably the most disputed of any category; however, neglect is defined as the refusal or failure of a caregiver to fulfill his or her obligations or duties to an elderly including (but not limited to) providing any food, clothing, medicine, shelter, supervision, and medical care and services that a prudent person would deem essential for the well-being of a n ~ t h e r Neglect .~ may be intentional or unintentional. There is debate over the importance of this distinction because legally it is often difficult to prove intent.5Intentional neglect includes refusal of the caregiver to provide for basic needs such as hygiene and nutrition, and medical care, such as giving medications or cleaning wounds. Unintentional neglect is defined as the failure to
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fulfill a caregiver role, either through ignorance or inability to care for the person. Two other categories sometimes considered neglect are abandonment and self-neglect.Abandonment is the desertion of an elderly person by an individual who is his/her custodian or who has assumed responsibility for providing care to the elder. Self-neglect is recognized by some state laws and refers to the failure of a person to provide himself with the care and services necessary to maintain physical and mental health.31
LEGAL ISSUES RELATED TO ELDER ABUSE
States have been making laws against elder abuse since 1973.15 Currently, elder abuse is defined by state and not federal laws, but state definitions vary considerably from one jurisdiction to another. The statutes vary widely in several factors: the age at which a victim is covered, the definition of elder abuse, the classification of the abuse as criminal or civil, types of abuse covered, reporting requirements, investigation procedures, and remedies. The laws, however, were written as many as 20 years ago and were based on the laws addressing child abuse, which primarily concern physical abuse. As a result, older laws are weak on matters, such as financial exploitation (children have no money to exploit). These laws offer few remedies other than removal of the abused person from the setting in which the abuse is occurring or provision of services intended to alleviate or terminate the abuse.29 Mandatory reporting laws exist in all 50 states and the District of Columbia.30Forty-three states mandated reporting of suspected cases, but only 30 of these contain penalties for failing to report. Penalties for failure to report vary. People who are required to report elder abuse who fail to fulfill this responsibility may be found guilty of a misdemeanor and either jailed or fined. Some state laws provide that such a person may be held liable for damages incurred by an abused person as a result of failure to make a report. In addition, some statutes specify that a mandated reporter who is a licensed professional may be reported to the appropriate licensing authority for failure to report. Conversely, some states impose no sanctions. In only four states (i.e., Colorado, New York, Wisconsin, and Illinois) is reporting voluntary. Mandatory reporting by physicians is in itself controversial, having also been based on child protection laws that presume an inability of minors to make decisions in their own best interest.29The key difference is that mandatory reporting with resultant investigation can interfere with the an adults’ autonomy and right to privacy. Requiring that physicians report cases may be viewed as patronizing to older persons who “cannot make decisions for themselves,” especially if they are competent.I6 In addition, elders may be dissuaded from seeking assistance because of fear of consequences. A degree of anxiety over mandatory reporting laws also has been noted because physicians are con-
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cemed about possible retaliatory litigation from the victim or the family. Every state has at least one statute providing immunity from civil or criminal liability to anyone who makes a report of abuse in good faith. Most such statutes also provide that the immunity does not apply if the person making the report is also the person who committed the abuse.z1 The federal government drafted the first laws regarding elder abuse in 1981 in the US House Select Committee on Aging. In 1985, the Elder Abuse Prevention, Identification, and Treatment Act (HR 1674) was introduced in Congress in an attempt to clarify and standardize the language relating to geriatric abuse.14Federal definitions of elder abuse, neglect, and exploitation were further addressed in the 1987 Amendments to the Older Americans Act. The law provided these definitions only as guidelines for identifying the problems and not for enforcement purposes. The 1992 version of the bill led to a national elder abuse policy and provided additional funding, but omitted the mandatory reporting requirement. DEMOGRAPHICS
The true incidence of elder abuse is unknown. Most statistics that have been compiled regarding prevalence have been from agencies who collect data retrospectively by report.z6,31 It is highly likely that the numbers generated from these types of surveys greatly underestimate the true incidence. It is estimated that up to 2,000,000 elders are abused per year in this countryzo,31 A study done by the National Center on Elder Abuse reports that there has been a steady increase in the reporting of elder abuse, with 117,000 reports in 1986 and 293,000 in 1996.31The median age of the victims was 77.9 years. The commonest type of abuse was neglect, accounting for 55% of their population. Physical abuse accounted for 14.6% and financial exploitation represented 12.3%. Racially, 66.4% of their victims were white, 18.7% were black, and 10% Hispanic. All other groups account for fewer than 1% of the study groups. These statistics vary when compared with other studies, particularly among racial differences and risk factors.18,z4, 26, 31 Other studies have performed random population studies to determine the true incidence and also to delineate risk factors?, 8, lo, z6 ABUSE OF OLDER PATIENTS IN INSTITUTIONS
Approximately 5% of elderly patients live in long-term care instituto reports of widespread neglect and abuse in nurst i o n ~In . ~response ~ ing homes in the 1980s, in 1987, Congress enacted legislation that requires nursing homes participating in the Medicare and Medicaid programs to comply with certain quality of care requirements. The legislation, included in the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), also known as the Nursing Home Reform Act, specifies
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Table 1. EXAMPLES OF ABUSE IN INSTITUTIONAL SETTINGS
Falls and fractures Physical or chemical restraints Malnutrition or dehydration Improper, wrong, or overmedication Bed sores Defective equipment Lack of supervision (e.g., allowing residents to wander away from the facility) Physical abuse or unexplained injury
Weight gain or loss Theft of money and personal property Unexpected or wrongful death Unsanitary conditions Untrained or insufficient staff Oversedation Substandard medical care Poor personal hygiene Sexual assault
Data from refs. 21, 23, and 29.
that a nursing home must document and adhere to the assessments, plans of care, and the care provided in the resident’s clinical record.29 In one random survey of staff members in long-term care facilities, 10% of nurses’ aides reported at least one act of physical abuse and 40% reported at least one act of psychological abuse in the preceding year.2l Factors leading to caregiver stress include low job status of the primary caregiver, the attitude that residents are childlike and need discipline, and staff that has a high level of personal or job stressz3In addition to staff, visitors and family can also be responsible for abuse.21Examples of abuse are listed in Table 1. Every state has a nursing home ombudsman program that responds to reports of neglect or abuse of nursing home elderlyz1Every resident must have access to the ombudsman for that facility. Physicians who suspect abuse in institutions should report their suspicions to the state ombudsman, Adult Protective Services, or the Department of Aging for the State. OBSTACLES TO DETECTING ELDER ABUSE
For various reasons, abuse of the elderly can go undetected even when the victim presents to the hospital for a related reason. The reasons for cases being missed can be attributed to both the patient and the physician. There are factors that prevent the senior from reporting the abuse, and reasons for the health care provider’s failing to detect it. Both sources result in a delay of the elderly patient getting help for their circumstance. The Patients Themselves
Sometimes, seniors themselves act can participate, either knowingly or unknowingly, in hiding the abuses they suffer. Many elderly people become isolated and rarely leave the house, resulting in less opportunity for detection of abuse by others.6 Reasons for this are varied. The
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victim may be isolated because of concomitant illnesses that prevent communication or freedom of movement. The abuser may control access to others and may stay around when there are encounters with outsiders, to ensure that secrecy is maintained.6Health care visits may be the only contact with the outside world, so medical personnel are in a unique position to detect abuse if it is present. Victims sometimes voluntarily withhold information about their circumstances. They may feel embarrassed or guilty about the abuse and, therefore, do not want it to be known publicly. In addition, they may worry about retaliation against the abuser or the consequences of exposure. One such consequence could be fear of being removed from the home and being placed in a nursing institution. They may also worry about further abuse from the abuser for having divulged information. Finally, many elders are unwilling to press charges against a family member, even if abuse is detected.6 Elderly patients also can have different definitions of abuse, based on cultural or ethnic backgrounds. Victims may have ageist beliefs and feel that old people are supposed to be mistreated because they are a burden to their families.6 One study done with Korean, African-American and white older women in the Midwest showed that when presented with different abusive scenarios, definitions of abuse can vary based on cultural beliefs as well as the perception of the intent of the abuser.24For example, a woman who sedated her senile mother when company came was not considered an abuser because she did it so that the family would not be embarrassed. A neighbor surreptitiously taking nude photos of an elderly woman without her permission was considered abusive, however.24 In summary, when dealing with elderly patients, consider their personal views and circumstances when interviewing them about a potentially abusive situation. What may seem a clearcut case of abuse to medical personnel may be to the senior involved not a topic for open discussion.
Health Care Personnel Health care providers themselves can contribute to cases of abuse going undetected. Physicians underreport and notify the appropriate authorities in only 1 of every 13 cases they identify.9Many physicians feel uncomfortable or resistant to discussing potential abuse with their patients.'j Few medical school curricula have formal training in screening for occult abuse of elderly patients and interviewing techniques for potential victims and abusers." Physicians, therefore, can feel uncomfortable, primarily because of a lack of knowledge. In addition, most hospitals have no protocols for identifying or addressing elder abuse7 therefore, even if the physician did recognize a case, he or she may not know the proper management involved. Many doctors may not maintain a high enough index of suspicion
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with their older patients to recognize a case. One study found that physicians, by self-report, did not know the prevalence of elder abuse and, therefore, did not think of it as a potential problem they might In a busy ED, physicians also do not always have the time enco~nter.~ to conduct an in-depth interview separately with the victim and then with other family members. Last, a fear of litigation can make many physicians reluctant to ask questions about potential abuse.6, DETECTION OF ELDER ABUSE
Elder abuse and neglect are not problems that can be assessed quickly. Resources exist in the community to aid in difficult or complex cases, but often physicians do not know how to access these resources. Unless there is a finding that suggests a threat to life or imminent serious harm, a thorough evaluation can span several visits and include many sources.21The role of the physician should be to maintain a high index of suspicion in the ED because this is where many elders come to the attention of the community. Once suspicion of abuse is established, a referral can be made to the appropriate social service agency. Hospital protocols have been recommended by the American Medical Association (AMA),l ACEP:7 and others to aid in the detection and proper management of elder abuse. Knowing the Red Flags
Given the prevalence of elder mistreatment and the fact that it can appear asymptomatic, AMA guidelines suggest that all older persons be asked about abuse or neglect.' Knowledge of those who are at risk is often helpful to identify those patients who need more in-depth assessment. Many retrospective and prospective studies have been done to identify those who are at higher risk of abuse; however, debate still remains. Characteristics such as having a cognitive impairment, being female, and being dependent are universally considered risk factors.8,15, 16,18,26 Other risk factors, however, such as age, race, economic status, and religion, are not as clear.18,24, 26, 31 Researchers offer several suggestions for the disparity in statistics regarding risk factors. The most notable is that much of the data in this area are gathered retrospectively and are subject to reporting bias.18 One prospective community-based study in New York found that the cases of elder abuse that tended to warrant investigation were those involving the poorly educated, the very old (over age 75 years), and minorities,2O suggesting that these categories of seniors be considered at high risk as well. Several characteristics are reliably considered to be associated with a higher risk of elder abuse. The first group of elders at risk are those who live with others.4,l6 They seem to be at higher risk if they are physically or financially dependent or live with a stressed or isolated
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caregiver. In addition, a patient's functional status determines the extent of care needed.4 Physical or mental impairment increases dependence on others and, therefore, the risk of mistreatment. Extensive dependence by an elderly person can lead to feelings of being overwhelmed or frustrated on the part of the caregiver, leading to mistreatment. Functional impairment also limits the person's ability to seek help or defend himself or h e r ~ e l fLast, . ~ the emotional status of the elderly person is also an important risk factor. Persons who are depressed or have significant stress in their lives are at an increased risk for abuse, most likely because of the added tension between victims and caregivers?, l6 Many studies suggest that it is the characteristics of the abuser and not the victim that are the greater predictor of abuse.16A caregiver who has a financial or emotional dependence on the victim is more often seen in a situation of elder abuse. This dependence is often exacerbated by underlying problems, such as legal or financial difficulties, alcohol or drug dependence, or psychiatric disease.16 Alcohol abuse by the caregiver was the factor most predictive of elder abuse.12 A family history of violence also is a factor that has a high correlation with the occurrence of elder abuse. One study showed that mutually abusive relationships exist in many of the 56 caregiver-patient pairs they studied.12The percentage of individual acts of violence by patients increase if the patient is demented. Patient aggression or behavior such as wandering, verbal outbursts, or embarrassing actions also increases caregiver violence.16 Finally, certain chief complaints may alert the physician to the possibility of elder mistreatment. For patients older than 75 years, the commonest complaints are falls, dehydration, and failing self-care, which all can signal neglect or self-neglect.22 Taking a Careful History
The presence of any of the above "red flags" indicates that a more in-depth history should be taken. The first step is using interviewing techniques that are likely to elicit an accurate history. Keep questions direct and simple, without a judgmental or threatening The patient, the suspected abuser, and other family members should be interviewed separately and without other staff or family in the room. There may be disparities in histories that offer clues, and seniors may be more likely to be forthcoming with just the physician present. Establish a nonconfrontational environment by starting off with general questions about safety in the home (e.g., do you feel safe where you live?) and caretaking issues (e.g., who cooks for you?, who handles your finances?).21Establish if there is a regular pattern of medical care or if the patient is taken to the ED only as needed.4 More direct questions about mistreatment can then follow, such as the use of physical violence, restraints, or neglect. A list of more direct questions appears in Table 2.4, 16, 21, 23 In addition, ask the detailed circumstances of each injury while keeping alert for any
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Table 2. INTERVIEW QUESTIONS TO ASSESS ELDER ABUSE Physical Abuse Are you afraid of anyone at home? Do you feel safe at home? Have you been struck, slapped, or kicked? Have you been locked in a room or tied down? Psychological Abuse Do you feel isolated or alone? Do the people who care for you threaten you with punishment or being put in an institution? Have you been ignored? Are medications or foods forced on you? What happens if you and your caregiver disagree? Sexual Abuse Has anyone touched you sexually without your permission? Neglect Do you have access to hearing aids, eyeglasses or dentures if you need them? Are you left alone for long periods? Is your home safe? Has anyone not helped you when you need it? Do you get your medicines on a regular basis? Financial Exploitation Is your money used without your permission or stolen? Have you been forced to sign any legal document against your will? Does your caregiver depend on you for shelter or money? Follow-up Questions (If Abuse Is Identified) How long has it been going on? Is it an isolated incident? Why does the patient think this happens? When does the patient think the next episode will occur? Is the abuser present in the ED? Is it safe for the patient to return home? What would the patient like to see happen? Has the patient ever received help for this problem before? Datafrom refs. 4, 12, 21, and 23
inconsistencies. Finally, accurate and objective documentation of the interview is essential. Using exact quotations from patients and their families, where appropriate, will aid in the level of detail recorded? Assessing a patient for psychological abuse is more challenging. Unless the physician witnesses overt threats, insults, or humiliation, subtler signs must be sought. Keeping a high index of suspicion is the first step, especially in the face of known risk factors such as caregiver stress. In addition, signs from the caregiver of an unwillingness to cooperate with healthcare providers, or anger or indifference to the patient, can signal a dysfunctional situation.23A formal mood assessment of the patient revealing withdrawal, depression, or fear also gives clues that he or she is a victim of psychological abuse.2I
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Physical Assessment of Potential Elder Abuse Victims
Cases of elder abuse do not always present with dramatic physical manifestations. In a review of 36 ED cases, neglect was a commoner manifestation of mistreatment than injury.14 The physician must, therefore, stay vigilant during the physical examination and be knowledgeable regarding the constellation of signs indicative of abuse. Common physical injuries include unexplained bruises, fractures, lacerations, or abrasions, and head injury.,, Conversely, dehydration and malnutrition, late-stage bed sores, inappropriate clothing, and improper administration of medicines are more often indicators of neg1e~t.I~ Although the physician should maintain a high index of suspicion and be alert to any signs, elder abuse often occurs with a cluster of signs and symptom^.^ Use clinical judgment in deciding whether isolated findings indicate abuse. Examples of the need for clinical skill include the facts that skin in elderly patients is more easily bruised and that their higher incidence of osteoporosis leads to more fractures.21Isolated findings may not signal abuse, but pathology that occurs more frequently in the elderly. A complete physical examination, including the neurologic system, observation of gait, and an assessment of competency, should be performed. Cognitive impairment is a risk factor for abuse and can impair the patient’s ability to give an accurate history and their ability to make decisions in his or her best interest.21A head-to-toe examination of the body, including the genitalia, should be done, with special attention to the size, age, and location of any lesions. Table 3 lists the positive findings suggestive of abuse on the physical examination. If necessary, obtain photographs of the lesions to be placed in the chart for documentation. It can sometimes be appropriate to assess the financial and social resources of the patient. The availability of such resources in the face of unmet needs such as nutrition and hygiene calls into question exploitation of the elder patient. Although a detailed assessment might not be in the realm of the emergency physician, any clues that contribute to the suspicion of an abusive situation are worth noting. In addition, this information can assist in considering interventions, including alternative living arrangements or home services.21 MANAGEMENT
Reacting to abuse requires a multidisciplinary approach. Because of the wide variations of types of abuse, interventions vary from simple social service referral to actual removal of the patient from the home. The clinician’s highest priority in suspected abuse cases is in balancing the safety of the patient with his or her autonomy.16 In situations of suspected abuse, the physician must first determine if the patient wants intervention. If they refuse, the next step is to
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Table 3. PHYSICAL EXAMINATION FINDINGS SUGGESTIVE OF ELDER ABUSE Physical Examination
General Behavior Skin mucosa
HEENT
Ttunk Genitourinary system Extremities Neuropsychiatric
Imaging / laboratory studies
Notations to Be Made
Poor hygiene, inappropriate dress, cachexia Caregiver who insists on giving history or who insults, threatens, or infantalizes the patient; withdrawal of patient Dehydration, multiple lesions in various stages of healing, bruises, decubiti, lacerations healing by secondary intention, poor care of existing skin lesions Signs of head injury, traumatic alopecia, broken teeth, eye injury Pattern bruises inflicted by an object with a characteristic shape, (i.e., belt, iron), clustering of bruises Pain, itching, bleeding, discharge or lacerations in the rectum or vagina, infestations, extensive bedsores, urine bums, fecal impaction Bilateral arm bruises (shaking), friction bums around wrists of ankles (restraints), immersion bums, cigarette/cigar bums, occult fractures/dislocations Limping gait indicative of occult fracture; focal deficits, mental status and mood testing for depression, anxiety, or withdrawal Perform cognitive testing to assess competency As indicated from clinical examination; serum levels of medications to assess compliance
Data from Lachs M, Pillemer K Abuse and neglect of elderly persons. N Engl J Med 332437443, 1995
determine if he or she is competent enough to make decisions. If the patient is competent, although it may be frustrating, his or her wishes must be honored. In these cases, a patient should be educated about the need to change the situation because abuse tends to escalate and not improve with time. Written information regarding emergency assistance numbers, a system for safety, and follow-up plan should be developed with the patient.21 If the patient is no longer competent to decide for himself or herself, APS the next step should be to contact Adult Protective Services (APS).23 agencies were established by state statutes and have the capability for immediate evaluation, counseling, and relocation in suspected cases of elder mi~treatment.~~ APS in larger areas are under social service agencies, whereas in smaller jurisdictions they are under the local law enforcement agency. They can establish a court-ordered guardianship or conservatorship to arrange shelter, finances, and care. The physician should document carefully the findings of mistreatment or self-neglect and reasons for declaring the patient incapable of acting in his or her own best interest.*l When a patient is agreeable to intervention, a variety of options can be exercised, depending on the type of abuse. If the situation involves physical abuse, severe neglect, or abandonment, hospital admission may
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be warranted.16 Admission provides the necessary medical treatment and additional time to activate the appropriate social support resources and also separates the victim from the abuser. Admissions for a specific problem (i.e., decubiti, dehydration) tend to be more acceptable to the patient and his or her family. In the long term, sometimes alternative living situations must be arranged if the home situation cannot be amended. This is particularly true in cases of psychopathology of the abuser (e.g., substance abuse, mental illness) or in cases in which the patient is too disabled to live on his or her own. It is necessary to note that third-party payers may not always approve hospital admission based on neglected medical problems or non-life-threatening injuries.21 In non-life-threatening situations, a solution can be tailored to fit the individual circumstances. Even though the family is often the source of abuse in many cases, they can also provide the most support for the victim. Whenever possible, crisis intervention with family members should be undertaken. Options for support should be provided to family in an attempt to diffuse the stress and anxiety that preceded the abuse. Examples include home health aides, respite services, day programs, or accessible transportation if the caregiver is overburdened or ill equipped to deal with the patient's needs.I6 FUTURE DIRECTIONS
Geriatric abuse as a public health issue is still in its infancy and continues to evolve. Systematic prospective research is needed in most areas related to this problem. There is still a need for outcomes research on effective elder abuse detection and management protocols, the frequency and causes of the problem, and the most effective intervention techniques, especially in the ED setting.15 Other areas in need of development include the training of healthcare personnel in detection. Elder abuse can be introduced in preclinical curricula in psychiatry, introduction to clinical medicine courses, community medicine, and public health. Rotations in emergency medicine, psychiatry, family medicine, and gynecology can include material on elder abuse in case-based formats, lectures, or bedside instruction." Physicians educate themselves concerning the laws, legislation, and channels for reporting abuse. The development of ED protocols could help improve reporting by health care professional^.^, l4 From a public policy perspective, there are several fronts on which the management of elder abuse cases can improve. Funding shortages to the social service and law enforcement agencies responsible for adult protection result from a decrease in federal block grants to states.l5This results in decreased staff for evaluation and relocation of elders, as well as for prosecution of abusers if needed. In addition, many different local agencies are authorized to handle case evaluation and investigation. Lack of coordination can result in a poor level of service.15Lobbying for attention to these issues on a state and federal level is necessary to result
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in a systematic approach to a problem that has yet to be thoroughly confronted.
References 1. American Medical Association: AMA Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago, American Medical Association, 1992 2. Anon: Letter to the Editor. Mrs. Bodgers was abused. Lancet 342691-692, 1993 3. Block M, S h o t J: The battered elder syndrome [abstr]. College Park Maryland Center On Aging, 1979 4. Bloom J, Ansell P, Bloom M, et al: Detecting elder Abuse: A guide for physicians. Geriatrics 44:40-56,1988 5. Brewer R, Jones J: Reporting elder abuse: Limitations of statutes. Ann Emerg Med 18~1217-1221,1989 6. Cammer Paris BE: Violence against elderly people. Mt. Sinai J Med 63:97-100, 1996 7. Clark-Daniels CL et a1 Abuse and neglect of the elderly: Are emergency department personnel aware of mandatory reporting laws? Ann Emerg Med 19:970-977,1990 8. Comijs H Elder abuse in the community: Prevalence and consequences. J Am Geriatr SOC46885488,1998 9. Conlin M Silent suffering: A case study of elder abuse and neglect. J Am Geriatr SOC 43:1303-1308,1995 10. Giolio G, Blakemore P: Elder Abuse in New Jersey: The Knowledge and Experience of Abuse Among Older New Jerseyans. Trenton, NJ, Division of Aging, unpublished manuscript 11. Hazzard W Elder abuse: Definitions and implications for medical education. Acad Med 70979-981,1995 12. Homer AC, Gilleard C: Abuse of elderly people by their caregivers. Br Med J 301:13591362,1992 13. Hwalek M, Neale A, Goodrich C, Qumn K The association of elder abuse and substance abuse in the Illinois elder abuse system. The Gerontologist 36694700,1996 14. Jones J, Dougherty J, Shelble D, Cunningham W Emergency department protocol for the diagnosis and evaluation of geriatric abuse. Ann Emerg Med 17100&1015,1988 15. Jones J S Elder abuse and neglect Responding to a national problem. Ann Emerg Med 2384!%848,1994 16. Kleinschmidt KC, Krueger P, Patterson C: Elder abuse: A review. Ann Emerg Med 30463472,1997 17. Krueger P, et a1 Detecting and managing elder abuse: Challenges in primary care. Can Med Assoc J 1571095-1100,1997 18. Lachs MS, Williams C, OBrien S Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. The Gerontologist 37469474,1997 19. Lachs M, Williams C, O'Bnen S, et a1 The morality of elder mistreatment. JAMA 280428432,1998 20. Lachs M, Berkman L, Fulmer T, Horwitz R A prospective community-based pilot study of risk factors for the investigation of elder mistreatment. J Am Geriatr Soc 42:169-173,1994 21. Lachs M, Pillemer K Abuse and nedect of elderly persons. N Engl J Med 332437443,1995 22. Lowenstein SR, Crescenzi CA, Kern DC,et a 1 Care of the elderly in the emergency department. Ann Emerg Med 15528-535, 1986 23. Lynch SH: Elder abuse what to look for, how to intervene. Am J Nurs 9727-32, 1997 24. Moone A, Williams 0 Perceptions of elder abuse and help-seeking patterns among African-American, Caucasian-American, and Korean-American elderly women. The Gerontologist 33386395,1993 25. Paveza G, Cohen D, EisdorferC, et a1 Severe family violence and Alzheimer's disease: prevalence and risk factors. The Gerontologist 32493-497, 1992
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26. Pillemer C, Finkelhor D. The prevalence of elder abuse: A random sample survey. The Gerontologist 2851-57, 1988 27. Policy Statement: American College of Emergency Physicians: Management of elder abuse and neglect. Ann Emerg Med 31:149-150, 1998 28. Rosenblatt D, Cho KH, Durance PW Reporting mistreatment of older adults: The role of physicians. J Am Geriatr Soc 446570,1996 29. Stiegel LA Recommended Guidelines for State Courts Handling Cases Involving Elder Abuse. American Bar Association, 1995 30. Subcommittee on Health and Long-Term Care of the Select Committee on Aging, House of Representatives: Elder Abuse: A Decade of Shame and Inaction. Washington, DC, US Government Printing Office, 1992 31. Tatara T, Kuzmeskus L Elder abuse in domestic settings. Elder Abuse Information Series, No 1. Washington, DC, National Center on Elder Abuse (NCEA), 1996-1997
Address reprint requests to Melissa E. Clarke, MD, FACEP Howard University Hospital Division of Emergency Medicine 2041 Georgia Avenue NW Washington, DC 20060 e-mail: [email protected]