The Einstein Geriatrics Fellowship
Core Curriculum
The Einstein Geriatrics
Fellowship Core Curriculum
• A 20 part lecture series designed for first
year geriatrics fellows
• Covers the ACGME content areas for
fellowship training
Elder Abuse and Neglect –
The Physician’s Role
Dr. Karin Ouchida, MD
Debra Greenberg, MSW, PhD
Montefiore Medical Center
Division of Geriatric Medicine
Workshop Goals
• Improve Knowledge of Elder Mistreatment
– Define elder mistreatment
– Identify “red flags”
• Explore attitudes towards intervention
– Appreciate physician’s role
• Introduce skill set for intervention
– Enhance interviewing and documentation
Case
86 year old woman with dementia,
paranoia, gait instability, and hearing
impairment. Lives with 88 year old
husband. Pt often refuses to take
risperidone; very suspicious of husband.
HHA is hired but husband discontinues
services because feels it is not helpful.
Leaves patient alone when has to go to
his own medical appointments.
Is This Elder Abuse?
Yes
No
Not sure/Need more information
Definition of elder mistreatment
• “Acts of commission or omission that
result in harm or threatened harm to the
health or welfare of an older adult”
(American Medical Association)
• May be intentional or unintentional
Statistics
• National Elder Abuse Incidence Study, 1996
– 550,000 adults aged 60+ experienced some form
of mistreatment
– ~80% of cases NOT reported
– ~90% incidents involved family members
• Estimated 50,000 cases/yr in NYC
• 3 fold increase in mortality
• Common enough to be encountered in daily
practice
Barriers to reporting
• PROVIDER
– How to assess?
– Where to go for
help?
– Not enough time
– Negative effect on
relationship with pt
– “Not my job”
– Avoidance of legal
system
• PATIENT
–
–
–
–
Shame
Guilt
Embarrassment
Desire to keep family
intact
– Fear of retaliation
e.g. nursing home
placement
Risk factors – in practice
• Social isolation
• Cognitive
impairment
• Physical frailty
Imbalance between the pt’s needs and the
ability of support system to meet those needs
True or False?
• Financial exploitation is the most
common type of elder
mistreatment.
Types of elder mistreatment
• Passive neglect – unintentional failure to fulfill care
obligations due to inexperience, ignorance, inability
• Self-neglect – behaviors that threaten personal health or
safety
• Psychological abuse – infliction of anguish, pain or
distress through verbal or non-verbal acts
• Financial – exploitation of funds, property, assets
• Active neglect – intentional failure to provide services
necessary to maintain physical and mental health
• Physical abuse
• Sexual abuse
The Medical Provider’s
Role
• Maintain high index of suspicion
• Know the RED FLAGS and if present…
– Assess
– Document
– Refer (investigation carried out by others
e.g., APS, ombudsman, law enforcement)
• Mandated reporting varies by state
Image: http://www.fiu.edu/~preprofc/stethascope1.jpg
Red Flags for Neglect
• Inappropriate dress
• Poor hygiene
• Medication nonadherence
• Uncontrolled illness
• Dehydration
• Malnutrition
• Hypo/hyperthermia
• Pressure ulcers
• No assistive devices
• Abandonment
Red Flags for Psychological
Abuse
•
•
•
•
•
•
•
Depression
Anxiety
Agitation
Passivity
Evasiveness
Fear
Confusion
Red Flags for Financial
Exploitation
• Non-adherence,
uncontrolled illness
• Frequent ED
use/admissions
• Behind the scenes:
– Changes in will or
financial documents
– Changes in bank
account, withdrawals
– Disappearance of
funds or possessions
– Unauthorized credit
card charges
– Unpaid bills
Red Flags for Physical Abuse
• History inconsistent
with injuries
• Delay in presentation
• Repeated ED use/
admissions
• Pattern of bruising/burns
• Change in demeanor or
activity level
• Caregiver refuses to
leave elder alone
• Drug levels
Red Flags for Sexual Abuse
• Difficulty walking or sitting
• Vaginal or urinary symptoms
• Bruising around breasts, genital area, inner
thighs
• Torn, stained under garments
• Unexplained sexually-transmitted infection
• Behavioral changes (withdrawal, depression,
insomnia, aggressive or sexual behavior)
Assessment: History
• Interview patient
and caregiver
separately
• Be empathetic and
non-judgmental
• Repeat and clarify
responses
• Establish timeline
Example Questions
• Patient
– Social history
• Who do you live
with?
• Tell me about
your relationship
with (caregiver)
– Functional status
• Caregiver
– How long have you
been caring for…?
– What are your
responsibilities?
– How are you
coping with your
responsibilities?
Warning: graphic image on next slide!
Assessment: Exam
• Clothing and hygiene
• HEENT: hair,
dentition
• Skin: bruises, ulcers,
rashes
• Feet/nails
• GU/rape kit if
indicated
• Rectal: impaction
• Mental status
Assessment: Determining capacity
• Decision-specific; affects intervention
• Capacity – a person must be able to
– Understand relevant information
– Articulate a choice
– Provide reasonable explanation for the choice
• Cognitive impairment  incapacitated
• A+O x 3  capacity
Documentation
•
•
•
•
Who is present
Verbatim descriptions
Timeline if possible
Exam:
– Demeanor and
reactions
– Hygiene/dress
– Cognitive evaluation
• Referrals made
• Education provided
Examples of documentation
• Pt reports unable to start insulin because “my
daughter says it’s too expensive.”
• Pt says he loaned girlfriend $2000 in March and
another $5000 in December.
• In presence of___, pt subdued, poor eye contact.
• Wearing thin, baggy sweater with several stains.
• I am concerned about worsening heel wound.
Caregiver educated in wound care and
positioning. Referral made to SW.
Goals of intervention
• Protect the patient
– Remove pt from dangerous environment
(hospitalization, nursing home)
– Increase number of caregivers and amount of
oversight (eyes and ears)
– Consider guardianship
• Reduce the risk of future mistreatment
– Try to improve functional capacity (decrease
dependence and caregiver stress)
– Explore entitlements and resources
Referrals and Resources
• Social work
• Adult protective services
• Others
–
–
–
–
Home health agency
Department of Health
District Attorney
Law enforcement
Adult Protective Services
• Who to refer?
– Adults in the community with mental/physical
impairment who can’t manage their own
resources or Activities of Daily Living
• What do they do?
–
–
–
–
–
–
Home visits
Psych evaluation/capacity assessment
Assistance with Medicaid, home care
Heavy duty cleaning
Eviction prevention
Involuntary services ($ management, guardianship)
Back to Case
An 86 year old woman with dementia,
paranoia, gait instability, and hearing
impairment. Lives with 88 year old husband.
Pt often refuses to take risperidone; very
suspicious of husband. HHA is hired but
husband discontinues services because feels it
is not helpful. Leaves patient alone when has
to go to his own medical appointments.
Assessment and plan?
• Is abuse or neglect occurring?
• How would you proceed?
 Assess vulnerability and safety
 Functional status
 Decision-making capacity
 Decide disposition (admission vs. return home)
 Reduce risk of future mistreatment
 Medical interventions to diminish disruptive
behaviors
 Caregiver education
 Enlist other caregivers (“eyes and ears” )
Summary
• Not all elder mistreatment is criminal
• Often there is no villain only victims
• MD role differs from police, law
enforcement – responsibility to the
family unit