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Elder Mistreatment in Long Term Care

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Elder Mistreatment in Long Term Care Laura Mosqueda, M.D. Director of Geriatrics Professor of Family Medicine University of California, Irvine School of Medicine – PowerPoint PPT presentation

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Title: Elder Mistreatment in Long Term Care


1
Elder Mistreatment in Long Term Care
  • Laura Mosqueda, M.D.
  • Director of Geriatrics
  • Professor of Family Medicine
  • University of California, Irvine School of
    Medicine

2
Abuse is the willful infliction of injury,
unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain, or
mental anguish.
. Or the potential for harm.
3
Comparisons with Child Abuse
  • Many have compared the current state of medical
    knowledge about elder mistreatment with the state
    of knowledge about child abuse and neglect 30
    years ago

4
Difficulty with Detection/Diagnosis
  • Medical picture of the elderly much more complex
    than that of a child
  • Bad outcomes and death are more likely for the
    elderly than for children
  • Abuse and neglect are rarely observed
  • Difficult to link physical signs with diagnoses

5
Types of Abuse
  • Physical
  • Psychological/Emotional
  • Neglect
  • Abduction
  • Sexual
  • Financial

6
Types of Abuse
  • Physical
  • Psychological/Emotional
  • Neglect
  • Abduction
  • Sexual
  • Financial

7
Examples of Physical Abuse
  • Pulling a patients hair
  • Slapping/hitting/punching
  • Throwing food or water on a patient
  • Tightening a restraint to cause pain

8
Examples of Psychological Abuse
  • Terrorizing and/or threatening a patient with a
    word or gesture
  • Inappropriate isolation of a patient
  • Yelling at a patient in anger
  • Denying food or privileges

9
Examples of Neglect
  • Person is lying in urine and feces for extended
    periods of time
  • Person develops malnutrition and/or dehydration
    and/or pressure sores due to lack of appropriate
    care
  • Person is dirty, has elongated nails, is living
    in filthy environment

10
Abuse Occurs in a Variety of Patterns
  • Perpetrator works at the facility
  • Perpetrator is another resident
  • Good facilities
  • Bad facilities

11
Abuse at the Person Level
  • Resident to resident
  • Resident to staff
  • Family member to resident
  • Staff to resident
  • CNAs
  • nurses
  • doctors
  • outside/paid help
  • janitors
  • etc.

12
Abuse among CNAs
  • 10 committed physically abusive act(s)
  • excessive restraint 6
  • pushing/grabbing/shoving/pinching 3
  • hitting/slapping 3
  • 40 committed psychologically abusive act(s)
  • yelling 33
  • insulting/swearing 9
  • denying food/privileges as punishment 2
  • threatening physical violence 2

Pillemer 1991
13
Predictors of Abuse among CNAs
  • High level of job stress/burnout
  • Aggressive patient
  • Frequent verbal conflict with patients

14
Great Facility/One Bad Egg
  • Reasonable staffing ratio
  • Good administration
  • High quality care
  • Sociopath gets hired

15
Great Facility/Unusual Circumstance
  • High quality care
  • Difficult resident
  • physically dependent
  • verbally abusive
  • Stressed CNA
  • usually great with residents
  • trouble at home, stress at work
  • pushed over the edge

16
Abuse at the Facility Level
  • Neglect
  • Poor care
  • Atmosphere of threats/reprisal

17
Poor Quality Facility
  • Many residents receive poor care (i.e. pattern of
    poor care)
  • pressure sores common and improperly treated
  • malnutrition common and improperly treated
  • Lack of leadership/administrative support
  • Employee morale is poor
  • Absentee medical director

18
High risk caregiver
Recipe for Abuse
Vulnerable person
Context/Right circumstance
19
The Problem with the Problem
  • Complexity
  • Age-related changes
  • When does it cross the line?
  • Impaired Capacity
  • Mandated roles of multiple agencies
  • Lack of coordinated, comprehensive system

20
Normal Common Changes
  • Integument
  • thinner epidermis
  • capillary fragility
  • Renal decrease in creatinine clearance
  • Sensory system
  • slower reaction time
  • presbycussis
  • macular degeneration, cataracts

21
Normal Common Changes
  • Musculoskeletal
  • sarcopenia
  • osteopenia/osteoporosis
  • Cardiovascular
  • orthostatic hypotension
  • congestive heart failure
  • Function
  • gait/falls
  • ADLs

22
When does bad care cross the line to become
neglect?
great
acceptable
poor
neglect
23
Dementia is a disease process which causes loss
of intellectual abilities and inability to
perform ones usual activities.
24
Types of Dementia
  • Alzheimers Disease
  • Vascular Dementia
  • Frontal Temporal Lobe Dementia
  • Primary Progressive Aphasia
  • Dementia with Lewy Bodies

25
Dementia and Abuse
  • Provocative behaviors
  • May be unable to recognize abuse
  • May be unable to report abuse
  • May be the perpetrator of abuse
  • May not be believed

26
Interviewing People with Dementia
  • Understand the type of dementia
  • Know the pattern of cognitive loss
  • When do you take it seriously?

27
Types of Memory
  • Verbal
  • Visual
  • Emotional

28
Delirium
  • Problems with attention
  • Fluctuation in cognition
  • Reversible (e.g. infections, medications,
    dehydration)
  • Cannot make a diagnosis of dementia if delirium
    is present

29
Delirium and Abuse
  • Delirium may be a marker of abuse
  • Neglect
  • Over-medication
  • Delay in seeking care
  • Delirium will interfere with victims ability to
    explain what happened

30
When Abuse is Suspected...
  • Context
  • History
  • Physical Examination
  • Mental Status examination
  • Laboratory testing
  • Cognitive/behavioral changes

31
Context
  • Circumstances/Events leading up to the alleged
    abuse
  • Personality and behavioral characteristics
  • victim
  • perpetrator
  • Medical history
  • Cognitive capacity

32
Red Flags History
  • Implausible/vague explanations
  • Delay in notification
  • Unexplained injuries - past or present
  • Inconsistent stories
  • Change in behavior

33
Interviewing Issues
  • Establish cognitive ability level
  • Vision
  • Hearing
  • Comfort
  • Best time of day

34
Observations
  • Observe the alleged victim and the perpetrator
  • Interaction
  • Behavioral indicators of state of mind
  • Depression
  • Fear
  • Confusion

35
Physical Exam
  • Injury assessment
  • Functional status
  • Skin examination
  • Pelvic examination

36
Clues on Physical Exam
  • Sores, bruises, other wounds
  • Unkempt appearance
  • Poor hygiene
  • Malnutrition
  • Dehydration

37
Functional Assessment
  • Range of motion
  • Pain
  • Gait and balance
  • Sensory

38
Injury AssessmentThe Challenge in Elders
  • Normal changes
  • Common changes
  • Medication effects
  • Dementia

39
Injury Assessment
  • Types of Injuries
  • Bruises
  • Pressure sores
  • Fractures
  • Burns
  • What to look for
  • Hx consistent with exam?
  • Old injuries
  • Delay in seeking care
  • Location

40
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41
Bruising
  • Age-related changes
  • Medications
  • Dating by color
  • Multiple stages of healing
  • History consistent with injury?
  • Location

42
Summary of Results
  • Nearly 90 of the bruises were on the
    extremities.
  • No bruises on the neck, ears, genitalia,
    buttocks, or soles of the feet.
  • Subjects were more likely to know the cause of
    the bruise if the bruise was on the trunk.
  • 16 bruises were predominately yellow within the
    first 24 hours of onset.
  • Those people on medications known to impact
    coagulation pathways and those with compromised
    function were more likely to have multiple
    bruises.

43
Location of Bruises
(108 bruises at Day 1)
44
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45
Dating of Injuries
46
Laboratory Evidence
  • Malnutrition
  • Dehydration
  • Coagulation studies
  • Medication levels
  • Radiographs
  • Neuroimaging (MRI, CT)

47
Mental Status Exam
  • Best to have a formal mental status exam such as
    the Folstein Mini Mental State exam (MMSE)
    documented
  • At a minimum, get some observations and
    statements about the victims cognitive status

48
Look for
  • Residents in restraints
  • Mood
  • Medication errors
  • Infection control
  • Pressure sores
  • Staffing levels
  • Complaints

49
How To Reach MeLaura Mosqueda,
M.D.714-456-5530mosqueda_at_uci.edu
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