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

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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.
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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

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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

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Types of Abuse

• Physical
• Psychological/Emotional
• Neglect
• Abduction
• Sexual
• Financial

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Types of Abuse

• Physical
• Psychological/Emotional
• Neglect
• Abduction
• Sexual
• Financial

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Examples of Physical Abuse

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

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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

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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

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Abuse Occurs in a Variety of Patterns

• Perpetrator works at the facility
• Perpetrator is another resident
• Good facilities
• Bad facilities

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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.

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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
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Predictors of Abuse among CNAs

• High level of job stress/burnout
• Aggressive patient
• Frequent verbal conflict with patients

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Great Facility/One Bad Egg

• Reasonable staffing ratio
• Good administration
• High quality care
• Sociopath gets hired

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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

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Abuse at the Facility Level

• Neglect
• Poor care
• Atmosphere of threats/reprisal

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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

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High risk caregiver
Recipe for Abuse
Vulnerable person
Context/Right circumstance
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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

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Normal Common Changes

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

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Normal Common Changes

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

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When does bad care cross the line to become
neglect?
great
acceptable
poor
neglect
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Dementia is a disease process which causes loss
of intellectual abilities and inability to
perform ones usual activities.
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Types of Dementia

• Alzheimers Disease
• Vascular Dementia
• Frontal Temporal Lobe Dementia
• Primary Progressive Aphasia
• Dementia with Lewy Bodies

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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

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Interviewing People with Dementia

• Understand the type of dementia
• Know the pattern of cognitive loss
• When do you take it seriously?

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Types of Memory

• Verbal
• Visual
• Emotional

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Delirium

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

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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

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When Abuse is Suspected...

• Context
• History
• Physical Examination
• Mental Status examination
• Laboratory testing
• Cognitive/behavioral changes

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Context

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

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Red Flags History

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

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Interviewing Issues

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

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Observations

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

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Physical Exam

• Injury assessment
• Functional status
• Skin examination
• Pelvic examination

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Clues on Physical Exam

• Sores, bruises, other wounds
• Unkempt appearance
• Poor hygiene
• Malnutrition
• Dehydration

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Functional Assessment

• Range of motion
• Pain
• Gait and balance
• Sensory

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Injury AssessmentThe Challenge in Elders

• Normal changes

• Common changes

• Medication effects

• Dementia

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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

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Bruising

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

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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.

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Location of Bruises
(108 bruises at Day 1)
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Dating of Injuries
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Laboratory Evidence

• Malnutrition
• Dehydration
• Coagulation studies
• Medication levels
• Radiographs
• Neuroimaging (MRI, CT)

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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

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Look for

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

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