In recent years, the num-ber of reports of elder abuse has risen as a result of greater family involvement in caregiving relation-ships with the elderly as well as the increase in the nu
Trang 1Elder abuse is a pervasive social and
medical problem that is suspected to
be a major source of morbidity and
mortality In recent years, the
num-ber of reports of elder abuse has
risen as a result of greater family
involvement in caregiving
relation-ships with the elderly as well as the
increase in the number of elderly
persons with chronic debilitating
diseases.1 Because of the increasing
public outcry about the widespread
public health problem of elder
abuse, all states now have abuse laws that are specific for older adults, and most states mandate reporting of elder abuse by health-care professionals However, physi-cians infrequently report elder abuse for a number of reasons, among them lack of familiarity with the reporting laws, fear of offending pa-tients or infringing on the autonomy
of competent individuals, concerns about time limitations and paper-work, or the belief that they do not
have the appropriate evaluation skills.2
Approximately 2.5 million cases
of elder abuse are reported
annual-ly, and as the population grows, this number will likely increase As this number represents only reported cases, it is undoubtedly an underes-timation of the actual incidence.3 A recent investigation reported the results of the first nationwide inci-dence study of abuse and neglect in noninstitutionalized elderly per-sons, estimating that 1% to 2% of older persons living in their homes are abused physically, emotionally, sexually, and/or financially, and that as many as five times more incidents go unreported.4 The exact magnitude of the problem is not easily quantifiable, although the most frequently cited estimate of community prevalence of elder abuse is 32 cases per 1,000 persons.3
Dr Chen is Resident, Department of Ortho-paedic Surgery, New York University–Hospital for Joint Diseases Orthopaedic Institute, New York, NY Dr Koval is Associate Professor and Chief, Fracture Service, Department of Orthopaedic Surgery, New York University– Hospital for Joint Diseases Orthopaedic Institute.
Reprint requests: Dr Koval, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17th Street, New York, NY 10003.
Copyright 2002 by the American Academy of Orthopaedic Surgeons.
Abstract
Increased awareness of elder abuse has led to the recognition that mistreatment of
individuals over the age of 65 years is a widespread public health problem It is
estimated that the prevalence of elder abuse is 32 cases per 1,000 persons and is
increasing with the growing elderly population Elder abuse is suspected to be a
major source of morbidity and mortality, representing a high economic burden to
society The diagnosis of elder abuse is seldom straightforward due to social
issues, cognitive impairment, and comorbid conditions, and requires careful
cor-relation of historical and clinical findings Comprehensive evaluation, including
a detailed history, systematic physical examination, and appropriate laboratory
and radiographic assessment, is essential The orthopaedic surgeon consulted to
evaluate an elderly individual with musculoskeletal injuries must be cognizant
of the potential for elder abuse, especially when circumstances are suspect The
role of the orthopaedic surgeon is often fundamental to establishing whether
musculoskeletal injuries are consistent with the stated mechanism of injury.
Due to the variety of presentations, there are no fracture patterns considered
pathognomonic of elder abuse Rather, the nature and pattern of injury must be
viewed in the context of the general health and psychosocial environment of the
patient to determine whether abuse has occurred Once the diagnosis of elder
abuse has been made, a comprehensive, multidisciplinary long-term care plan
must be formulated to ensure patient safety while respecting the autonomy of a
competent individual Physicians have an ethical and legal responsibility to
pro-tect patients from suspected abuse, and most states mandate reporting by
health-care personnel.
J Am Acad Orthop Surg 2002;10:25-31
Surgeon in Diagnosis and Management
Andrew L Chen, MD, MS, and Kenneth J Koval, MD
Trang 2The difficulty of collecting more
accurate statistics is likely related to
underrecognition or denial of abuse
by community members and health
professionals This is compounded
by a poor understanding of the signs
and symptoms associated with elder
abuse, which may be mistaken for
age-related changes or signs of
dis-ease.5 Elderly persons may be
reluc-tant to report abuse because of fear
of family embarrassment, fear of
iso-lation from caregivers, or stoicism.6
Furthermore, negative stereotyping
of the elderly and age-related
dis-crimination may result in the
unjus-tified labeling of elderly persons as
demented, thus diminishing the
credibility of abuse reports
Definition of Abuse
The precise definition varies by
state agency, but in general the
term “elder abuse” refers to the
in-fliction of physical pain, injury,
mental anguish, or deprivation by a
caretaker who performs services
necessary for the physical and
men-tal well-being of an individual over
the age of 65 years Elder
mistreat-ment may occur as a result of
abu-sive behavior, in which purposeful
acts of harm or injury are inflicted
by the abuser, or neglectful
behav-ior, in which attention to specific
needs is withheld or delayed
Ac-tive neglect occurs when the
re-sponsible party is cognizant of his
or her neglectful actions Passive
neglect implies a lack of awareness
of the mistreatment and what
spe-cific needs are not being met.5 For
example, the intentional
withhold-ing of necessary medications from
an elderly individual constitutes
active neglect, but unintentional
failure to provide adequate
nutri-tion to an elderly individual may
constitute passive neglect
Abuse extends to any violation of
the individual’s sphere of well-being
and includes physical,
psychologi-cal, financial, and material forms
Physical abuse refers to any unwanted physical contact, including the inflic-tion of bodily injury, physical pain,
or unsolicited sexual contact Psy-chological abuse refers to the inflic-tion of mental or emoinflic-tional anguish
Financial or material abuse involves the exploitation of an individual for financial or material gain.7
Abuse that occurs in a medical, long-term care, or board-and-care facility is referred to as “institutional abuse.” Although a minority of physicians provide care in that set-ting, patients living in such facilities may be encountered in outpatient offices, inpatient facilities, or emer-gency settings, thus providing op-portunities for physicians to recog-nize sequelae of abuse Abuse in the institutional setting may be perpe-trated by visitors, other residents of the institution, or members of the staff In a random-sample survey of nursing home staff members, 10% of nurses’ aides reported that they had committed at least one act of physi-cal abuse in the preceding year, and 40% reported at least one act of psy-chological abuse.8 Institutional abuse may also include unreason-able restraint, isolation from other re-sidents, failure to respect the wishes
of a competent individual, and fail-ure to devise or implement a goal-oriented extended-care plan.9
Risk Factors for Abuse
Approximately 1% to 2% of elderly persons living in their own homes are abused.10 The term “victim char-acteristics” refers to a constellation of psychosocial traits, conditions, and behaviors that may increase the risk
of abuse These include dementia, poor physical and emotional health, disruptive or aggressive behavior, social dysfunction, and prior vio-lence or abusive acts by the victim toward the abuser.11 Other risk fac-tors are listed in Table 1 Gender has
not been identified as an indepen-dent risk factor Pooled logistic regression analysis has identified increasing age, race, poverty, func-tional disability, and cognitive im-pairment as additional risk factors for elder mistreatment.10 A strong association between reported child abuse and reported elder abuse
with-in a regional population has been reported, suggesting a correlation between geographic demographics and risk of elder abuse.12
Abusers are predominantly adult children, spouses, and other rela-tives, and are often financially de-pendent on the abused person.10 A caregiver history of psychiatric ill-ness, including depression, person-ality disorder, social dysfunction, or alcohol abuse, may increase the risk
of elder abuse The “caregiver stress hypothesis,” which maintains that elder abuse is the result of resent-ment and frustration engendered by the long-term responsibility for care
of dependent elders, is controver-sial.2,9 Stress for the caregiver arises from social isolation, especially when the elderly person needs full-time care; the frustration of dealing with declining health or terminal ill-ness; the possible strain of financial resources; and a lack of understand-ing of the patient’s needs This may
be compounded by the lack of in-volvement of other family members
or by a sense of ingratitude Among institutional caregivers, risk factors for abuse include a history of previ-ous abuse, job dissatisfaction, de-pression, burnout, a tendency to in-fantilize the elderly, and a stressful personal life
History and Clinical Features
A detailed history is essential when elder abuse is suspected The pa-tient, caregiver, and any other rele-vant persons should all be inter-viewed individually Any conflicting
Trang 3information should be noted and
investigated Patients typically are
reluctant to discuss the abuses they
have received because of a fear of
reprisal, a sense of being thought ungrateful, or unwillingness to im-plicate a friend or relative The in-terview must, therefore, be
comfort-able and psychologically supportive;
an accusatory or probing tone may result in disinclination on the pa-tient’s part to reveal any abuse that has occurred
The interview should be initiated with general questions concerning the patient’s perceptions about his
or her own care within the house (or institution) and should progress
to more specific questions about feelings of safety, disagreements, delayed meals or medication, and any aggressive behavior or unso-licited contact on the part of anyone toward the patient Early con-frontation is likely to be counter-productive in terms of disclosure of information; a nonaggressive, im-partial approach that is cognizant of the suspected abuser’s feelings and stresses is more conducive to an effective informational interview.5
Elderly persons suffer a variety
of chronic diseases that can mimic the signs and symptoms of abuse Dramatic cases of abuse are typically not difficult to diagnose, but subtle
or contradictory physical and psy-chological signs and symptoms may require high-level clinical investiga-tion or diagnostic testing Common physical findings consistent with abuse include bodily injury without reasonable cause or explanation and multiple wound sites in various stages of healing Evidence of dehy-dration, long-standing malnutrition, poor hygiene, and unmet medical needs are pertinent findings if they are inconsistent with the patient’s standard of living Finally, with-drawal, refusal to make eye contact, and wariness of contact with the suspected abuser are also warning signs Other presentations that are suggestive of abuse or neglect are listed in Table 2
Physical Examination
When elder abuse is suspected, a de-tailed, systematic, multidisciplinary
Table 1
Risk Factors for Abuse of the Elderly *
Poor health and functional - Disability reduces the elderly
impairment person’s ability to seek help
and defend himself or herself
Cognitive impairment Aggression toward the caregiver
and disruptive behavior resulting from dementia may precipitate abuse Higher rates of abuse have been found among patients with dementia
Substance abuse or mental illness on Abusers are likely to abuse alcohol
the part of the abuser or drugs and to have serious mental
illness, which in turn leads to abusive behavior
Dependence of the abuser on the Abusers are very likely to depend on
victim the victim financially, for housing,
and in other areas Abuse results from attempts by a relative (espe-cially an adult child) to obtain resources from the elderly person
Shared living arrangements Abuse is much less likely among
elderly people living alone A shared living situation provides greater opportunities for tension and conflict, which generally pre-cede incidents of abuse
External factors causing stress Stressful life events and continuing
financial strain decrease the family’s resistance and increase the likeli-hood of abuse
Social isolation Elderly people with fewer social
con-tacts are more likely to be victims
Isolation reduces the likelihood that abuse will be detected and stopped In addition, social support can buffer the effects of stress
History of violence Particularly among spouses, a history
of violence in the relationship may predict abuse in later life
* Reprinted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly
persons N Engl J Med 1995;332:437-443 Copyright 1995 by the Massachusetts
Medical Society All rights reserved.
Trang 4evaluation is required (Table 3) An
informal mental status examination
should be performed initially, and
risk factors for abuse, such as
cogni-tive impairment, noted A
compre-hensive physical examination should
also be performed, with close
atten-tion paid to the interacatten-tion of the
patient with the suspected abuser
The general appearance of the patient
should be noted, including the
man-ner in which the patient is dressed
and the level of cleanliness The skin
should be scrutinized for evidence of old injuries The head and scalp should be examined for evidence of trauma, lacerations, or alopecia, which may be suggestive of hair-pulling The oral cavity and nares should be carefully examined for evi-dence of dental or mucosal injury that may otherwise go unrecognized
on an external examination.13
Frequent manifestations of phy-sical abuse include bruises, sprains, abrasions, lacerations (particularly
evidence of old lacerations that healed by secondary intention), head injuries, burns, and unexplained frac-tures.9 With musculoskeletal inju-ries, the role of the orthopaedist is to determine the age and nature of the injury, whether the injury is associ-ated with other injuries that may be suggestive of abuse, and whether there are other fractures in various stages of healing or healed but mal-aligned Musculoskeletal injuries must be carefully evaluated, with correlation of soft-tissue and overly-ing skin injuries (e.g., lacerations, contusions, ecchymoses) Cogni-tively impaired patients require examination and palpation of all extremities The orthopaedist must decide whether the injury is consis-tent with the mechanism of injury, and must remain cognizant of the possibility of an underlying disorder, such as a malignant condition, that may explain a fracture after seem-ingly minor trauma
Diagnostic Evaluation
Laboratory tests may be indicated, depending on the index of suspicion
of abuse and the results of the physi-cal examination Laboratory tests should include (1) a complete blood cell count with platelet count; (2) serum electrolyte, blood urea nitro-gen, and serum creatinine levels (to assess dehydration and diabetic control); (3) prothrombin and partial thromboplastin times (to rule out coagulopathy); (4) liver function tests (to identify alcohol abuse and other metabolic problems); (5) serum albu-min level (to assess nutritional sta-tus); (6) thyroid function tests (to rule out hyperthyroidism as a cause of weight loss); and (7) urinalysis (to assess the source of fever) Toxico-logic screening may be used to demonstrate the presence of drugs or other substances that were not pre-scribed for the patient or that were prescribed at a subtherapeutic level
Table 2
Presentations That Suggest Abuse or Neglect of an Elderly Patient *
Delays between an injury or illness Lacerations healing by secondary
and the seeking of medical atten- intention, radiographic evidence of
tion healed but misaligned fractures,
presentation in extremis with decompensated chronic disease when caregiver has been monitor-ing patient
Disparity in histories from the Different mechanisms of injury
patient and the suspected abuser offered, different chronology of
or a history that is given solely injuries
by the caregiver
Implausible or vague explanations Fractures that are not explained by
provided by either party the purported mechanisms of
injury Frequent visits to the emergency Exacerbations of chronic obstructive
room for exacerbations of chronic pulmonary disease or congestive
disease despite a plan for medical heart failure due to lack or
misad-care and adequate resources ministration of medicines
Presentation of a functionally im- Patient with advanced dementia
paired patient without his or her who presents to the emergency
designated caregiver room alone
Laboratory findings that are incon- Subtherapeutic levels of drugs (e.g.,
sistent with the history provided digoxin) despite compliance
reported by caregiver, toxicologic evidence of psychotropic agents that have not been prescribed
* Adapted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly
persons N Engl J Med 1995;332:437-443 Copyright 1995 by the Massachusetts
Medical Society All rights reserved.
† The indicators of possible abuse or neglect are derived from Jones JS: Geriatric abuse
and neglect, in Bosker G, Schwartz GR, Jones JS, Sequeira M (eds): Geriatric Emergency
Medicine St Louis: CV Mosby, 1990, pp 533-542.
Trang 5Table 3
Clinical Procedures for the Detection of Abuse of an Elderly Patient *
Focus Procedure or Item to Be Noted
History Interview the patient and the suspected abuser separately and alone
Make direct inquiries about physical violence, restraints, or neglect
Request precise details about nature, frequency, and severity of events
Assess the patient’s functional status (independence, activities of daily living)
Inquire who is the designated caregiver if impairment in activities of daily living is present Assess recent psychosocial factors (e.g., bereavement, financial stress)
Elicit caregiver’s understanding of patient’s illness (e.g., care needs, prognosis)
Behavioral observation Withdrawal
Infantilizing of patient by caregiver Caregiver who insists on providing the history General appearance Hygiene
Cleanliness and appropriateness of dress Skin and mucous Skin turgor, other signs of dehydration
membranes Multiple skin lesions in various stages of evolution
Bruises, decubitus ulcers Evaluate care of skin lesions Head and neck Traumatic alopecia (distinguishable from male-pattern alopecia on the basis of distribution)
Scalp hematomas Lacerations, abrasions Trunk Bruises, welts (the shape may suggest an implement, such as an iron or belt)
Genitourinary tract Rectal bleeding
Vaginal bleeding Decubitus ulcers, infestations Extremities Wrist or ankle lesions suggesting the use of restraints or an immersion burn
(stocking-glove distribution) Musculoskeletal system Examine for occult fracture, pain
Observe gait Neurologic-psychiatric status Conduct a thorough evaluation to assess focality
Depressive symptoms, anxiety Other psychiatric symptoms, including delusions and hallucinations Formal mental-status testing
Cognitive impairment suggesting delirium or dementia has a role in assessing decision-making capacity
Imaging and laboratory tests As indicated from the clinical evaluation (serum albumin, blood urea nitrogen, and serum
creatinine levels, toxicologic screening [assess caregiver’s compliance with medical regimen]) Social and financial resources Inquire about other members of the social network available to assist the elderly person
and about financial resources (this information is crucial in considering interventions that include alternative living arrangements and home services)
*Adapted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly persons N Engl J Med 1995;332:437-443.
Copyright 1995 by the Massachusetts Medical Society All rights reserved.
Trang 6Radiographic evaluation should
include plain films of the chest, as
well as any area in which a suspected
injury was noted during the
phy-sical examination If there is
evi-dence of fracture, one should assess
whether the stated history of injury
is consistent with the radiographic
picture The presence of multiple
healed fractures, especially if
mal-aligned, should raise suspicion of
abuse in the absence of a plausible
explanation, such as severe
osteope-nia A skeletal survey may be
indi-cated if the patient has multiple
sites of injury or a severe cognitive
impairment and the examiner has a
strong suspicion of abuse The
pos-sibility of pathologic fracture (e.g.,
due to malignancy or osteomalacia)
must be ruled out with further
eval-uation if the radiographic
presen-tation is suggestive of underlying
disease
If cognitive problems that are
new, unexplained, or correlated
with head injury are identified
dur-ing mental status testdur-ing, computed
tomography of the head may be
indicated If a significant weight
loss cannot be attributed to stress,
drug use, or abuse, a metastatic
workup should be initiated
Appro-priate consultation should be sought
as dictated by the results of
evalu-ation
Differential Diagnosis
The presentation of elder abuse is
extremely variable Acute and
chronic disease states that may
mimic elder abuse include delirium,
dementia, clotting disorder (which
may be manifested by bruises),
depression (malnourishment, poor
hygiene, apathy), alcoholism (falls,
bruises, malnourishment), anorexia,
malignancy (cachexia,
malnourish-ment, fractures), and gait disorders
(falls) An increased propensity
toward fractures may reflect a
dis-ruption of normal bone
homeosta-sis, such as may occur with osteo-porosis, osteomalacia, renal disor-ders, or a malignant condition
Various reports have demonstrated that prolonged bed rest, malnour-ishment, and lack of exposure to sunlight may result in “sponta-neous” long-bone fractures in the absence of obvious trauma.14-16 This emphasizes the need for thorough evaluation and consultation, if nec-essary, before interpretation of a case of suspected elder abuse
Management
After appropriate treatment of injuries, the safety of the patient must be ensured This requires a multidisciplinary approach, with coordination between the treating medical personnel and social work-ers The patient’s autonomy must
be respected during this process of establishing a secure environment
Some patients lack decision-making ability, and others will not permit
an intervention on their behalf In either case, if the physician suspects abuse and perceives that the indi-vidual is in continued danger, every alternative must be explored to maximize the safety of the patient, including removal from the care of the suspected abuser or the abusive environment The reluctance to remove an elderly person from a functional living arrangement, par-ticularly from a family member’s home, must be superseded by the ensured safety of the individual
The physician’s authority to pre-scribe hospitalization can be upheld
on the basis of documented injury
or continuing medical problems.17
The wishes of a competent
elder-ly individual who refuses to leave a confirmed abusive environment must be respected Physicians must detail all possible options of inter-vention to maximize acceptance of a positive treatment plan and empha-size to the patient that the current
situation can be improved Every effort must be made to ensure a safe environment while preserving pa-tient autonomy A court-appointed guardian or conservator may be required for patients without deci-sion-making capacity A thorough evaluation is necessary to optimize living arrangements to ensure a safe environment.5
Reporting Requirements
The Omnibus Budget Reconciliation Act of 1987 established standards for the quality of nursing home care The Older Americans Act of 1976 requires that access to nursing home ombudsmen must be provided for residents and that physicians must report elder abuse to the state om-budsman As a result, most states have laws that require health-care workers to report suspected cases of elder abuse to government or offi-cial state agencies, such as the Department of Adult Protective Ser-vices Each state, however, has de-veloped its own definition of abuse and neglect as well as mandatory-reporting regulations According to
a recent US Government Account-ing Office study, the interstate vari-ability of abuse definition and re-porting requirements obfuscates meaningful analysis and compari-son of state reporting data, although enhanced public awareness of abuse
of the elderly was likely a signifi-cant factor in the disclosure of new elderly abuse cases.14
In most states, suspicion of elder abuse by the physician is sufficient cause to initiate an information-gathering inquiry without absolute proof Many states offer immunity and anonymity to physicians who file reports of suspected abuse If evidence of abuse is established, however, the physician has a moral and legal obligation to ensure the safety of the abused individual and
to solicit permission from the
Trang 7pa-tient for family or professional
inter-vention
Summary
Abuse of individuals over the age of
65 years is a widespread public
health problem that appears to be
increasing with the growing elderly
population Although elder abuse is
suspected to be a major source of morbidity and mortality, the diagno-sis of elder abuse is seldom straight-forward The orthopaedist is fre-quently consulted to manage mus-culoskeletal injuries sustained dur-ing such abuse, and therefore must
be cognizant of the potential for elder abuse, especially when circum-stances are suspect Although there are no fracture patterns considered
pathognomonic of elder abuse, the nature and pattern of injury must be considered in the context of the gen-eral health and psychosocial envi-ronment of the patient Once elder abuse has been established and appropriate treatment rendered, a long-term care plan must be formu-lated to ensure continued patient safety while respecting the
autono-my of a competent individual
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