Detecting and Diagnosing Elder Mistreatment

Laura Mosqueda, M.D.

Director of Geriatrics

Professor of Family Medicine

University of California, Irvine School of Medicine

Why is this important?

“People with dementia don’t feel pain.”

E.R. nurse

“She did the best she could.”

Primary Care Doctor

“I see old people who die in this condition all the time.”

Coroner Investigator

“He was just doing it to annoy me so I finally hit him - it’s not my fault.”

Daughter

Vulnerability• Emotional: fear of losing independence, more

susceptible to threats

• Physical: more difficult to defend oneself or escape

• Cognitive

• More assistance is required, especially with intimate aspects of life

Common and normal age-related changes mask and mimic signs of elder mistreatment. So it can be difficult to distinguish when an injury is innocent and when related to abuse.

The Challenge of Detecting Abuse

• Normal changes of aging

• Medication effects

• Multiple co-morbidities

• Cognitive impairment

We cannot and must not let these challenges stop us.

Health care providers that specialize in geriatrics are in the very best position to help colleagues in other disciplines (medical, social service, and criminal justice) sort through the challenges.

Types of Abuse by Caregivers

• Financial

• Physical

• Sexual

• Neglect/Abandonment

Examples of Financial Abuse

• A 55 year old woman threatens her mother with placement in a nursing home if she doesn’t buy her a car and sign over her house.

• A 30 year old man befriends a widow who is feeling lonely & depressed. He obtains the password for her ATM card so he can help her buy groceries and then helps himself to extra cash.

Examples of Physical Abuse

• The great-grandson of an 82 year old woman hits her repeatedly with his cell phone when she won’t give him the remote control.

• A 96 year old woman with advanced Alzheimer’s Disease is beaten on the head, face, and chest by the man who is paid to care for her.

Examples of Neglect

• A 78 year old woman, found lying in urine and feces, is dehydrated and malnourished because no one has attended to her for at least 5 days.

• A 68 year old man who had a spinal cord injury 20 years ago develops multiple Stage IV pressure sores on his back and heels because he has not been repositioned for two days.

Diagnosing Abuse

• Red Flags

• Observations

• Interview

• Physical Examination

• Laboratory Evidence

Red Flags

• Implausible/vague explanations

• Delay in seeking care

• Unexplained injuries

• Inconsistent stories

• Sudden change in behavior

Observations

• Interaction of the alleged victim and perpetrator

• Behavioral indicators of state of mind • Withdrawal

• Fear

• Confusion

Ask

• Has anyone hurt you?

• Are you afraid of anybody?

• Is anyone using your money without your

permission?

Physical Abuse and Neglect:Clues on Physical Exam

• Sores, bruises, other wounds

• Unkempt appearance

• Poor hygiene

• Malnutrition

• Dehydration

Injury Assessment

Types of Injuries

• Bruises

• Pressure sores

• Fractures

• Burns

What to look for

• Location

• Old injuries

• Delay in seeking care

• History & exam consistent?

Bruising Study: I

Results: Location

• Nearly 90% of the bruises were on the extremities.

• There were no bruises on the neck, ears, genitalia, buttocks, or soles of the feet.

(108 bruises at Day 1)

Posterior Anterior

Progression of color

Day Number

5451

4845

4239

3633

3027

2421

1815

129

63

0

Sum

300

200

100

0

Red

Purple

Blue

Yellow

Black

Green

Bruising Study: II

Major findings

• Mean number of bruises significantly greater in abused participants

• Abused participants more likely to remember cause of bruise

• Inflicted bruises significantly more likely than accidental bruises to be on head or trunk

• Size of bruised areas >> in abused participants

Abuse of People with Dementia is…

• a real problem

• more common than we may think

• often ongoing for years before being recognized as such

• preventable

Stages of dementia may correlate with types of abuse

• Early: financial

• Middle: physical

• Late: neglect

• Psychological abuse occurs throughout

More research?!

Caregiver Research Study

• Interviewed 140 dyads at home

• Incidence of abuse by caregiver– Psychological 42%

– Physical 9%

– Neglect 17%

– Any 47%

The Findings • 47% of participants with dementia (61) had been

mistreated by their caregivers.

• 42% (54) experienced psychological abuse

• 10% (13) physical abuse

• 14% (18) caregiver neglect.

Take Home Messages from this Study

• About half of people with dementia are being mistreated, usually by a family member.

• Caregivers can be questioned to find out about mistreatment.

Implications

• Caregivers should be asked about the behavior of the person with dementia.

• Based on their responses, follow-up questions about their own behavior may bring mistreatment to light.

Techniques for Asking

• Normalize the question• Give permission• Empathize• Ask in a direct manner• Be prepared for the answer & response

– No abuse– Tempted to abuse– Did abuse

These are tough issues and we need to be cautious

• Don’t want to accuse unfairly

• We need to ask the right questions and listen with a critical ear to explanations

• Don’t want to miss an abusive situation and fail to protect a vulnerable person

Reporting

• You need to know the laws in your state. In most states, physicians are mandated reporters

• It is not your job to confirm abuse. If you have a reasonable suspicion it is your duty to make a report.

• Reporting rarely solves the problem, but it can help make things better.

We Must Work toward Prevention

• Identify high-risk situations

• Ask

• Intervene

• Follow up

• Reassure

Health care providers that specialize in geriatrics are in the very best position to help colleagues in other disciplines (medical, social service, and criminal justice) sort through the challenges.

Remember this?Remember this!

You can make a difference.

University of California, Irvine School of Medicine Program in Geriatrics

Center of Excellence on Elder Abuse and Neglect

www.centeronelderabuse.org