Title: Elder Mistreatment in Long Term Care
1Elder Mistreatment in Long Term Care
- Laura Mosqueda, M.D.
- Director of Geriatrics
- Professor of Family Medicine
- University of California, Irvine School of
Medicine
2Abuse is the willful infliction of injury,
unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain, or
mental anguish.
. Or the potential for harm.
3Comparisons 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
4Difficulty 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
5Types of Abuse
- Physical
- Psychological/Emotional
- Neglect
- Abduction
- Sexual
- Financial
6Types of Abuse
- Physical
- Psychological/Emotional
- Neglect
- Abduction
- Sexual
- Financial
7Examples of Physical Abuse
- Pulling a patients hair
- Slapping/hitting/punching
- Throwing food or water on a patient
- Tightening a restraint to cause pain
8Examples 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
9Examples 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
10Abuse Occurs in a Variety of Patterns
- Perpetrator works at the facility
- Perpetrator is another resident
- Good facilities
- Bad facilities
11Abuse 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.
12Abuse 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
13Predictors of Abuse among CNAs
- High level of job stress/burnout
- Aggressive patient
- Frequent verbal conflict with patients
14Great Facility/One Bad Egg
- Reasonable staffing ratio
- Good administration
- High quality care
- Sociopath gets hired
15Great 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
16Abuse at the Facility Level
- Neglect
- Poor care
- Atmosphere of threats/reprisal
17Poor 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
18High risk caregiver
Recipe for Abuse
Vulnerable person
Context/Right circumstance
19The 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
20Normal Common Changes
- Integument
- thinner epidermis
- capillary fragility
- Renal decrease in creatinine clearance
- Sensory system
- slower reaction time
- presbycussis
- macular degeneration, cataracts
21Normal Common Changes
- Musculoskeletal
- sarcopenia
- osteopenia/osteoporosis
- Cardiovascular
- orthostatic hypotension
- congestive heart failure
- Function
- gait/falls
- ADLs
22When does bad care cross the line to become
neglect?
great
acceptable
poor
neglect
23Dementia is a disease process which causes loss
of intellectual abilities and inability to
perform ones usual activities.
24Types of Dementia
- Alzheimers Disease
- Vascular Dementia
- Frontal Temporal Lobe Dementia
- Primary Progressive Aphasia
- Dementia with Lewy Bodies
25Dementia 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
26Interviewing People with Dementia
- Understand the type of dementia
- Know the pattern of cognitive loss
- When do you take it seriously?
27Types of Memory
28Delirium
- Problems with attention
- Fluctuation in cognition
- Reversible (e.g. infections, medications,
dehydration) - Cannot make a diagnosis of dementia if delirium
is present
29Delirium 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
30When Abuse is Suspected...
- Context
- History
- Physical Examination
- Mental Status examination
- Laboratory testing
- Cognitive/behavioral changes
31Context
- Circumstances/Events leading up to the alleged
abuse - Personality and behavioral characteristics
- victim
- perpetrator
- Medical history
- Cognitive capacity
32Red Flags History
- Implausible/vague explanations
- Delay in notification
- Unexplained injuries - past or present
- Inconsistent stories
- Change in behavior
33Interviewing Issues
- Establish cognitive ability level
- Vision
- Hearing
- Comfort
- Best time of day
34Observations
- Observe the alleged victim and the perpetrator
- Interaction
- Behavioral indicators of state of mind
- Depression
- Fear
- Confusion
35Physical Exam
- Injury assessment
- Functional status
- Skin examination
- Pelvic examination
36Clues on Physical Exam
- Sores, bruises, other wounds
- Unkempt appearance
- Poor hygiene
- Malnutrition
- Dehydration
37Functional Assessment
- Range of motion
- Pain
- Gait and balance
- Sensory
38Injury AssessmentThe Challenge in Elders
39Injury Assessment
- Types of Injuries
- Bruises
- Pressure sores
- Fractures
- Burns
- What to look for
- Hx consistent with exam?
- Old injuries
- Delay in seeking care
- Location
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41Bruising
- Age-related changes
- Medications
- Dating by color
- Multiple stages of healing
- History consistent with injury?
- Location
42Summary 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.
43Location of Bruises
(108 bruises at Day 1)
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45Dating of Injuries
46Laboratory Evidence
- Malnutrition
- Dehydration
- Coagulation studies
- Medication levels
- Radiographs
- Neuroimaging (MRI, CT)
47Mental 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
48Look for
- Residents in restraints
- Mood
- Medication errors
- Infection control
- Pressure sores
- Staffing levels
- Complaints
49How To Reach MeLaura Mosqueda,
M.D.714-456-5530mosqueda_at_uci.edu