Elder abuse

Based on notes originally written by James Hayes

OVERVIEW

  • Elder abuse refers to any form of maltreatment of an older dependent person
  • The abuser typically has a close relationship to the elderly person e.g. spouse, sibling, child or be a friend or care giver
  • elder abuse is under recognised

TYPES OF ELDER ABUSE

Categories

  • ● Domestic (in the home of the elderly person or the carer)
  • ● Institutional (occurring in a residential facility such as a hostel or nursing home)

Forms of elder abuse

  • Physical
  • Neglect, including abandonment
  • Financial or material
  • Psychological or emotional
  • Sexual (rare)

RISK FACTORS

  • Poor health with functional impairment (unable to defend self)
  • Cognitive impairment (aggressive behaviour from dementia may trigger abuse)
  • Substance abuse or mental illness afflicting the abuser
  • Dependence of the abuser on the victim (abuse is an attempt to gain resources/ greater independence)
  • Shared living arrangements (conflict is more likely and more frequent)
  • External factors causing stress (adds strain to relationships)
  • Social isolation (able to be targeted as a victim, less likely to detect abuse; lack of supports decreases resilience to stress)
  • History of violence (e.g. by spouse)

ASSESSMENT

Take a history from the suspected victim privately using tailored questions such as:

  • Do you feel safe where you live?
  • Who prepares your meals?
  • Who pays your bills? If you want money to buy something, how do you get it? Who does your banking?
  • How do you get on with your husband / wife / son / daughter?
  • Do you ever have disagreements? Tell me about what happens when you have a disagreement.
  • Does your husband / wife / son / daughter ever get angry or upset with you? What happens when they get angry? Are you ever frightened when your husband / wife / son / daughter gets angry? Do they ever hurt you?

Look for features on history and examination of the different forms of abuse (see below)

PHYSICAL ABUSE

Definition

  • the use of physical force or violent acts that result in bodily injury, pain or impairment.
  • for example striking, hitting, beating, pushing, shaking, slapping, kicking, pinching and burning
  • also includes forced feeding and physical restraints.

Possible indicators include:

  • Inappropriate delays between injuries and presentation for medical attention (e.g. lacerations healing by secondary intention or radiological evidence of healed fractures for which no medical attention was sought)
  • Disparity in histories given by the patient and the suspected abuser
  • Implausible or vague explanations provided by either party (e.g. fractures that are not explained by the purported mechanism of injury)
  • Multiple physical injuries seen of variable ages
  • Multiple bruising, including black eyes, welts, lacerations and rope/belt marks
  • Skull fractures
  • Repeated falls / injuries
  • Wrist or ankle lesions, suggesting the use of restraints

NEGLECT AND ABANDONMENT

Definition

  •  the failure or refusal to fulfil any part of the person’s obligations or duties of care to the elder
  • Neglect means the failure to provide an elderly person with such life necessities as food, water, clothing, shelter, heating, personal hygiene, medicine, comfort, safety
  • Institutional neglect is used when an aged care facility fails to provide adequate supervision and safety necessary for the well being of the elder
  • Abandonment is defined as the desertion of an elder person for any length of time deemed to be unsafe and inappropriate

Possible indicators include:

  • Dehydration
  • Malnutrition
  • Untreated injuries
  • Severe and untreated pressure sores
  • Poor personal hygiene
  • Frequent visits to the ED for exacerbation of chronic disease despite a plan for medical care and adequate resources
  • Presentation of a functionally impaired patient without his/her designated caregiver, e.g. a patient with significant dementia who presents to the ED alone
  • Lack of medication or inappropriate use of medication, this may include lab evidence showing findings that are inconsistent with the history provided, e.g. subtherapeutic drug levels despite compliance reported by care giver, or toxicologic evidence of psychotropic agents that have not been prescribed
  • Unkempt appearance, e.g. dirt, fleas, lice, soiled bedding, fecal, /urine smell, long uncut nails
  • Inappropriate delays between onset of illness and the seeking of medical help
  • Repeated Falls / Injuries
  • Prolonged periods of no visitation (without credible reason)
  • Unexplained banking withdrawals or unexplained loss of elder person’s money,(financial abuse)
  • Abrupt changes in will or banking details
  • Lack of adequate heating, running water, or electricity

FINANCIAL OR MATERIAL ABUSE

Definition

  • deliberate misuse of a person’s property or financial resources
  • includes misuse, misappropriation of money, valuables or property, denial of right of access to or control of personal funds and interference in financial decisions.

Possible indicators include complaints or allegations that:

  • The patient does not have appropriate access to their funds
  • The patient does not have access to spending money for personal items such as toiletries and clothing
  • An Enduring Power of Attorney is not being executed appropriately and in the patient’s best interests
  • Funds or assets are being misappropriated

PSYCHOLOGICAL OR EMOTIONAL ABUSE

Definition

  • inflicting pain, distress and anxiety through verbal and non- verbal acts.

Possible indicators include:

  • Agitation and distress in the presence of Carer
  • Extremely withdrawn, non communicative and/or non responsive
  • Scared, takes foetal position avoids eye contact
  • Helplessness
  • Hesitation to talk openly

SEXUAL ABUSE

Definition

  •  non-consensual sexual acts with the older person
  •  also includes sexual acts with an older person incapable of giving consent
  • includes examples such as any form of unwanted touching, explicit photographing, nudity, and acts of sexual contact such as rape and abuse

Possible indicators include the following:

  • Contusions around the breasts or genital area
  • Venereal disease or other genital infections
  • Unexplained vaginal or anal bleeding

MANAGEMENT

General

  • Attend to any life-threats and treat any specific medical issues

Management of potential abuse

  • Document any concerns about elder abuse in the medical record
    • carefully document why you are concerned that abuse may be occurring
    • notes should be detailed and accurate particularly with respect to any physical injuries
    • drawings are useful
  • Determine competency as may influence management
  • no legal requirement for mandatory reporting in Australia or New ZEaland

Disposition

  •  issues of either home or institutional neglect / abandonment may be managed as an outpatient
  •  hospital admission is mandated if there is genuine concern for the safety of a patient such that they are at high risk should they return home

References and Links

Journal articles

  • Geroff AJ, Olshaker JS. Elder abuse. Emerg Med Clin North Am. 2006 May;24(2):491-505, ix. PMID: 16584968.
  • Lachs MS, Pillemer K. Abuse and neglect of elderly persons. N Engl J Med. 1995 Feb 16;332(7):437-43. PMID: 7632211.
  • Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. 2010 Sep;56(3):261-9. PMID: 20619500.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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