Tips to help you detect elder abuse
The next time an elderly person comes to your ED with falls, bruising, and vague aches, consider the fact that abuse may be occurring. There are an estimated 1 to 2 million victims for all types of elder abuse, but less than 10% are estimated to be reported.1
Abuse may be present in four forms: physical, psychological, exploitation, and neglect. "Neglect is the most common form of elder abuse," says Stephen Meldon, MD, an attending physician in the ED at MetroHealth Medical Center in Cleveland. "This is the failure of the caretaker to provide services which are necessary, whether intentional or unintentional."
Here are some things to consider about elder abuse:
• Know signs of abuse.
Signs of elder abuse are similar to those of child abuse, Meldon says. "Typical things to be concerned about include a delay in presentation of injury, discrepancies in history between what the patient and caregiver tells you, or if the story seems implausible," he notes. Physical exam findings might include multiple bruises, fractures, unkempt appearance, poor nutrition, or dehydration.
Another sign red flag is subdued or withdrawn behavior. "However, that might be very hard to pick up older patients who may have dementia or depression," notes Meldon. "In fact, those patients are at higher risk, because they need a lot of assistance and may be difficult to take care of, which places them at higher risk for neglect and abuse."
Other risk factors are substance abuse or psychiatric illness, in either the patient or the caregiver.
• Consistently screen.
Ask the same questions for each client, and develop specific criteria for which patients to screen. "For example, it might be anyone over 65 with a chronic illness," suggests Kidd. "Or if the patient is on three or more meds, that can be a financial indicator, particularly if they are also uninsured. We can’t [do] everything for everybody, particularly on a busy Saturday night, but a quick screening can be a very effective intervention."
• Interview the patient and the caregiver separately.
Compare the consistency of the stories and look for subtle signs, says Kidd. "It may not be full-blown abuse, but neglect can be physical, emotional, financial, such as failure to get medications filled, or not following up on clinic appointments," she says. "If you check and find out they’ve missed many, either it’s a transportation issue or a caregiver problem."
When you interview caregiver alone, do so in a nonjudgmental manner that gives them permission to express their feelings. "Ask them directly, Tell me what it is like to care for this patient. What is your day like?’ Those open-ended questions may encourage them to open up and tell you, Well, it starts at 2:00 in the morning when they wake me up to go to the bathroom,’" says Kidd.
Underlying resentment is a red flag. "If they say the patient puts them into conflict with other obligations and work, or say they can’t take care of their own needs, that is a true source of resentment," says Kidd. "When they start to blame the patient, saying they can do something better but won’t, it shows they are reaching the end of the rope and abuse could happen."
• Know reporting laws.
Most states have mandatory reporting laws for geriatric abuse. Hospital lawyers, social work departments, or local nursing associations can provide this information, Meldon advises.
• Find out if your ED has a protocol for elder abuse.
"I guarantee you’ll have one for pediatric abuse, but there may not be one for elder abuse," says Meldon.
If you don’t have an elder abuse protocol, take the initiative and develop one with your social work department and present it to hospital administration, he recommends.
• Consider hospitalization for abused patients.
If you suspect abuse, consider admitting the patient for protection until the issue is resolved.
"If there is a real concern about a patient, the best thing to do is admit the patient, saying you are concerned about abuse and need further evaluation." Meldon recommends. "We certainly do that for pediatric patients all the time."
Nurses can play an important patient advocacy role in this scenario and should express concerns to physicians.
• Ask patient about abuse.
"With the caregiver not present, interview the patient and ask about abuse," recommends Meldon. "Then interview the caregiver afterward. They may tell you they can’t afford the medicines, which is unintentional neglect."
Nurses may be the best candidates to interview patients about abuse, says Meldon. "The patient may not want to tell the doctor or bother anyone. Nurses often spend time with the patient during assessment and provide education," he notes. Also, elderly patients may feel less intimidated by nurses, he adds.
Here are three key questions to ask:
1. Has anyone ever hurt you?
2. Has anyone ever left you alone without food or water or medicine?
3. Have you been threatened by your caregiver?
Many elderly patients are reluctant to admit abuse is occurring, says Meldon. "They depend on their caregiver or are very stoic, and are concerned about being placed in a nursing home," he emphasizes. "It’s a complex problem without an easy solution, but nurses should be aware and try to help."
Reference
1. Jones JS, Veenstra TR, Samon JP, et al. Elder Mistreatment: National survey of emergency physicians. Ann Emerg Med 1997; 30:473-479.
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