geriatrics
Elder Abuse
Diagnosis of Elder Abuse
Elder abuse is difficult to detect because many of the signs are subtle, and the victim is often unwilling or unable to discuss the abuse. Victims may hide abuse because of shame, fear of retaliation, or a desire to protect the perpetrator. Sometimes when abuse victims seek help, they encounter ageist responses from health care practitioners, who may, for example, dismiss complaints of abuse as confusion, paranoia, or dementia. Social isolation of the victim often makes detecting elder abuse difficult. Abuse tends to increase the isolation because the perpetrator often limits the victim’s access to the outside world (eg, denies the victim visitors and telephone calls). Symptoms and signs of elder abuse may erroneously be attributed to a chronic disorder (eg, a hip fracture attributed to osteoporosis). However, the following clinical situations are particularly suggestive of abuse: Delay between an injury or illness and the seeking of medical attention Disparities in the patient’s and caregiver’s accounts Injury severity that is incompatible with the caregiver’s explanation Implausible or vague explanation of the injury by the patient or caregiver Frequent visits to the emergency department for exacerbations of a chronic disorder despite an appropriate care plan and adequate resources Absence of the caregiver when a functionally impaired patient presents to the physician Laboratory findings that are inconsistent with the history Reluctance of the caregiver to accept home health care (eg, a visiting nurse) or leave the older patient alone with a health care practitioner . For screening of Latinx populations, the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS) has been translated and validated in a population of Spanish-speaking older adults in the United States ( Diagnosis reference ). If elder abuse is suspected, the patient should be interviewed alone, at least for part of the time. Other involved people may also be interviewed separately. The patient interview may start with general questions about feelings of safety but should also include direct questions about possible mistreatment (eg, physical violence, restraints, neglect). If abuse is confirmed, the nature, frequency, and severity of events should be elicited. The circumstances precipitating the abuse (eg, alcohol intoxication) should also be sought. Social and financial resources of the patient should be assessed because they affect management decisions (eg, living arrangements, hiring of a professional caregiver). The examiner should inquire whether the patient has family members or friends able and willing to nurture, listen, and assist. If financial resources are adequate but basic needs are not being met, the examiner should determine why. Assessing these resources can also help identify risk factors for abuse (eg, financial stress, financial exploitation of the patient). In the interview with the family caregiver, confrontation should be avoided. The interviewer should explore whether caregiving responsibilities are burdensome for the family member and, if appropriate, acknowledge the caregiver’s difficult role. The caregiver is asked about recent stressful events (eg, bereavement, financial stresses), the patient’s illness (eg, care needs, prognosis), and the reported cause of any recent injuries. In small communities, including rural towns and tribal communities, additional processes must be developed to preserve confidentiality and privacy when screening for and responding to suspected elder abuse because patients, perpetrators of abuse, providers, medical office staff, and interventionists are often known to one another. Reassurance of such processes during interviews is expected to facilitate reporting by victims. The patient should be thoroughly examined, preferably at the first visit, for signs of elder abuse (see table Signs of Elder Abuse ). The physician may need help from a trusted family member or friend of the patient, state adult protective services, or, occasionally, law enforcement agencies to encourage the caregiver or patient to permit the evaluation. If abuse is identified or suspected, a referral to Adult Protective Services is mandatory in most states. Cognitive status should be assessed (see). Cognitive impairment is a risk factor for elder abuse and may affect the reliability of the history and the patient’s ability to make management decisions. Mood and emotional status should be assessed. If the patient feels depressed, ashamed, guilty, anxious, fearful, or angry, the beliefs underlying the emotion should be explored. If the patient minimizes or rationalizes family tension or conflict or is reluctant to discuss abuse, the examiner should determine whether these attitudes are interfering with recognition or admission of abuse. Functional status, including the ability to do Occupational Therapy (OT) (ADLs), should be assessed and any physical limitations that impair self-protection noted. If help with ADLs is needed, the examiner should determine whether the current caregiver has sufficient emotional, financial, and intellectual ability for the task. Otherwise, a new caregiver needs to be identified. Coexisting disorders caused or exacerbated by the abuse should be identified. Imaging and laboratory tests (eg, electrolytes to determine hydration,albuminto determine nutritional status, drug levels to document compliance with prescribed regimens) are done as necessary to identify and document the abuse. The medical record should contain a complete report of the actual or suspected abuse, preferably in the patient’s own words. A detailed description of any injuries should be included, supported by photographs, drawings, x-rays, and other objective documentation (eg, laboratory test results) when possible. Specific examples of how needs are not being met, despite an agreed-on care plan and adequate resources, should be documented. 1.Ramirez M, Solomon J, Riquelme M, et al: Development and Spanish translation of the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS).J Elder Abuse Negl31 (1):38–55, 2019. doi: 10.1080/08946566.2018.1531099 Epub 2018 Nov 8 