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Abuse, Elder, Emergency Medicine

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Abuse, Elder, Emergency Medicine

Basics

Description

Perform any exam and lab or radiographic studies as indicated by the patients condition.

Observe details of the patients environment that may not be immediately available to the hospital care team, including the following:

  • Emotional abuse:InsultsHumiliationThreats to institutionalize or abandon
  • Physical and/or sexual abuse:HittingSlappingPushingBurningInappropriate restrainingForced sexual activity
  • Material exploitation:Stealing or coercion involving patient money or property
  • Neglect:Behaviors by a patient or caregiver that compromise the patients health or safetyFailure to provide adequate food, shelter, hygiene, and/or medical attention
  • Insults
  • Humiliation
  • Threats to institutionalize or abandon
  • Hitting
  • Slapping
  • Pushing
  • Burning
  • Inappropriate restraining
  • Forced sexual activity
  • Stealing or coercion involving patient money or property
  • Behaviors by a patient or caregiver that compromise the patients health or safety
  • Failure to provide adequate food, shelter, hygiene, and/or medical attention

Epidemiology

  • In the US., 1-2 million cases age 65 or older mistreated by someone on whom they depend (these numbers likely will increase in the near term as US age demographics shift):55% neglect14.6% physical mistreatment12.3% financial exploitation7.7% emotional mistreatment0.3% sexual abuse6.1% all other types4% unknown
  • Family members, including partners and adult children, are perpetrators in approximately 90% of cases
  • For every case of financial exploitation reported, 25 cases likely unreported
  • Elder abuse (even modest abuse) is associated with a 300% greater risk of death as well as increased rates of additional health problems such as chronic pain, bone/joint, digestive or psychological disorders (compared to the non-abused)
  • 55% neglect
  • 14.6% physical mistreatment
  • 12.3% financial exploitation
  • 7.7% emotional mistreatment
  • 0.3% sexual abuse
  • 6.1% all other types
  • 4% unknown

Etiology

  • Caregiver stress, dependency, or psychopathology
  • Victim dependency or diminishment of ability to perform activities of daily living

Diagnosis

Signs and Symptoms

  • Not willing or able to obtain adequate food/clothing/shelter
  • Not providing for personal hygiene/safety
  • Delay in obtaining medical care/previously untreated medical condition
  • Vague (or implausible/inappropriate) explanations
  • Disparities between histories given by patient and caregiver
  • Caregiver who insists on giving the patients history
  • Medication difficulties:Incorrect dosesLost medicationsUnfilled prescriptions
  • Altered interpersonal interactions:WithdrawnIndifferentDemoralizedFearfulSubstance abuse
  • Caregiver with:Financial dependence on patientSubstance abuse or psychiatric or violence historyControlling behavior (may refuse to leave elder alone with physician) or poor knowledgeSignificant life stressorsRelationship issuesFinancial difficultiesLegal problems
  • Incorrect doses
  • Lost medications
  • Unfilled prescriptions
  • Withdrawn
  • Indifferent
  • Demoralized
  • Fearful
  • Substance abuse
  • Financial dependence on patient
  • Substance abuse or psychiatric or violence history
  • Controlling behavior (may refuse to leave elder alone with physician) or poor knowledge
  • Significant life stressors
  • Relationship issues
  • Financial difficulties
  • Legal problems
  • Inconsistent findings:Patterns or variable-age bruises, burns, lacerations/abrasionsUnusual sites of bruising (inner arm, torso, buttocks, scalp)Poor hygiene (inadequate care of skin, nails, teeth)
  • Unexplained injuries:Bruised or bleeding genital or rectal areaWrist or ankle lesions suggestive of restraint use
  • Findings that may be consistent with neglect or delay in seeking/obtaining medical attention:DehydrationWeight lossDecubitus ulcerMalnutrition
  • Patterns or variable-age bruises, burns, lacerations/abrasions
  • Unusual sites of bruising (inner arm, torso, buttocks, scalp)
  • Poor hygiene (inadequate care of skin, nails, teeth)
  • Bruised or bleeding genital or rectal area
  • Wrist or ankle lesions suggestive of restraint use
  • Dehydration
  • Weight loss
  • Decubitus ulcer
  • Malnutrition

Diagnosis Tests & Interpretation

Essential Workup

  • Obtain history without family members/caregivers present:Abused elders may fear institutionalization if they report caregivers.Many may feel embarrassment and responsibility for abuse.Frequently will not volunteer informationAsk patient specifically about abuse or neglect (in private)
  • Patients medical condition may influence quality of history obtained
  • Obtain history from caregivers/other relatives/friends/neighbors
  • Document a clear and detailed description of findings including the following:Statements of the patient as they pertain to the abusePsychosocial history:Family and other social relationshipsCaregiver burdens/coping mechanismsDrug/ethanol (Etoh) usePrior adult protective services reportsSkin and other physical findings:Photographic documentationSafety assessment
  • Abused elders may fear institutionalization if they report caregivers.
  • Many may feel embarrassment and responsibility for abuse.
  • Frequently will not volunteer information
  • Ask patient specifically about abuse or neglect (in private)
  • Statements of the patient as they pertain to the abuse
  • Psychosocial history:Family and other social relationshipsCaregiver burdens/coping mechanismsDrug/ethanol (Etoh) usePrior adult protective services reports
  • Skin and other physical findings:Photographic documentationSafety assessment
  • Family and other social relationships
  • Caregiver burdens/coping mechanisms
  • Drug/ethanol (Etoh) use
  • Prior adult protective services reports
  • Photographic documentation
  • Safety assessment

Diagnosis Tests & Interpretation

Differential Diagnosis

  • Patient may present with any chief complaint:Potential differential diagnosis is nonspecific.Abuse best identified by asking patient directly in a setting apart from caregivers/family and correlating with risk factors and provider findings
  • Differentiate findings consistent with other disease entities from abuse/neglect:DehydrationIll-fitting denturesBurnsEcchymosisInsomniaMedication noncomplianceDementiaDepression
  • Potential differential diagnosis is nonspecific.
  • Abuse best identified by asking patient directly in a setting apart from caregivers/family and correlating with risk factors and provider findings
  • Dehydration
  • Ill-fitting dentures
  • Burns
  • Ecchymosis
  • Insomnia
  • Medication noncompliance
  • Dementia
  • Depression

Treatment

Pre-Hospital

  • Interpersonal interactions at the scene:EmbarrassmentShameFear of reprisal, abandonment, and/or institutionalization
  • Conditions in the physical environment that present a potential danger
  • Embarrassment
  • Shame
  • Fear of reprisal, abandonment, and/or institutionalization

Initial Stabilization/Therapy

  • ABCs
  • Treat life-threatening medical/traumatic conditions as appropriate.

Ed Treatment/Procedures

  • May require separation of the patient and the caregiver or family member
  • Social work referral:Safety planningRespite planning for caregiverAdult protective services referral
  • Competent elder patients are free to accept or decline treatment or disposition despite risks they may incur.
  • General measures appropriate to the medical/traumatic conditions identified, including:FluidsMedicationsSurgeryDietActivityNursing carePhysical therapy
  • Safety planning
  • Respite planning for caregiver
  • Adult protective services referral
  • Fluids
  • Medications
  • Surgery
  • Diet
  • Activity
  • Nursing care
  • Physical therapy

Follow-Up

Disposition

  • Medical condition requiring admission
  • Abuse or neglect renders home conditions unsafe.
  • Need for more information or time to enhance objective decision making and patient management
  • Medical condition(s) addressed
  • Safe environment available
  • Abuse or neglect successfully countered by social services and/or law enforcement
  • Many states have mandatory reporting requirements:Comply with area legal requirements.
  • Alcohol/drug treatment as appropriate
  • Notify adult protective services.
  • Comply with area legal requirements.

Followup Recommendations

Pearls and Pitfalls

  • Entertaining the possibility of abuse or neglect in an elder patient offers the best possibility of diagnosis and successful intervention.
  • Only ~1/3 of healthcare providers identified a case of elder abuse in the past year.
  • Current data are inconclusive about the effectiveness of interventions for diminishing recurrence of elder abuse.
  • Obtain the aid of social worker, physicians trusted by the patient, even an ethics consultant, should a vulnerable competent elder seek to decline an elder abuse/neglect investigation.

Additional Reading

  • Clarke ME, Pierson W. Management of elder abuse in the emergency department. Emerg Med Clin North Am. 1999;17:631-644.
  • Cooper C, Selwood A, Livingston G. Knowledge, detection, and reporting of abuse by health and social care professionals: A systematic review. Am J Geriatr Psychiatry. 2009;17(10):826-838.
  • http://www.ncea.aoa.gov/Resources/Publication/docs/FinalStatistics050331.pdf
  • http://www.ncea.aoa.gov/Library/Data/index.aspx
  • http://www.ncea.aoa.gov/Resources/Publication/docs/fact1.pdf
  • Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364:1263-1272.
  • Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States; prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):S248-S254.
  • Ploeg J, Fear J, Hutchison B, et al. A systematic review of interventions for elder abuse. J Elder Abuse Negl. 2009;21(3):187-210.

Codes

ICD9

  • 995.80 Adult maltreatment, unspecified
  • 995.81 Adult physical abuse
  • 995.82 Adult emotional/psychological abuse
  • 995.83 Adult sexual abuse
  • 995.84 Adult neglect (nutritional)
  • 995.85 Other adult abuse and neglect

ICD10

  • T74.11XA Adult physical abuse, confirmed, initial encounter
  • T74.31XA Adult psychological abuse, confirmed, initial encounter
  • T74.91XA Unspecified adult maltreatment, confirmed, initial encounter
  • T74.21XA Adult sexual abuse, confirmed, initial encounter
  • T74.01XA Adult neglect or abandonment, confirmed, initial encounter

SNOMED

  • 95921002 elderly person maltreatment (event)
  • 242041001 Emotional abuse of elderly person
  • 242040000 Physical abuse of elderly person
  • 242042008 Deprivation of nourishment of elderly person
  • 242043003 Abandonment of elderly person