Investigation of Abuse: Use of Science, Technology and Law in Detection and Resolution

1. Investigation of Abuse:Use of Science, Technology and Law in Detection and Resolution Laura Mosqueda, M.D. Director of Geriatrics Professor of Family Medicine University of California, Irvine School of Medicine

2. Normal & Common Changes • Musculoskeletal • sarcopenia • osteopenia/osteoporosis • Cardiovascular • orthostatic hypotension • peripheral vascular disease • Function • gait/falls • ADLs

3. Normal & Common Changes • Integument • thinner epidermis • capillary fragility • Renal • decrease in creatinine clearance • Sensory system • presbycussis • slower reaction time • macular degeneration, cataracts

5. Injury Assessment:The Challenge in Elders • Normal changes of aging Medication effects Multiple co-morbidities Cognitive impairment

6. Are there ways to improve what we are doing through collaborative efforts?

7. O.C. V.A.S.T.O.C. Vulnerable Adult Specialist Team • Integrates geriatricians and psychologists into the “system” • Consultation: APS, law enforcement, district attorney • Original funding: Archstone Foundation • Current funding: Orange County

8. O.C. VAST • Case presentations at weekly team meetings • Telephone and email consultations • Record review (written, photographs, videotapes) • Examinations (cognitive and/or physical) in appropriate location

9. Team Home Visit • Living conditions • Physical environment • Emotional environment • Social environment • Functional capacity • Caregiver/family dynamics • Mental status exam • Limited physical exam

10. Outgrowths of VAST • Research: bruising, capacity, dementia • Pocket Doc • Publications in medical journals • Interest in reproducing VAST • Elder Abuse training institute • Orange County Coalition for the Prevention of Elder Abuse • Orange County Elder Death Review Team • Forensic Center

11. Orange County Elder Abuse Forensic Center • The Need: coordinated effort among many agencies that deal with criminal justice aspects of mistreatment

12. Elder Abuse Forensic Center

13. Elder Abuse Forensic Center A collaboration between 9 agencies: • Program in Geriatrics, UCI School of Medicine • Adult Protective Services • District Attorney’s Office • Sheriff • Public Administrator/Public Guardian • Human Options (domestic violence experts) • Community Service Programs • Long-Term Care Ombudsman • HCA Older Adult Services (county mental health agency)

14. Elder Abuse Forensic CenterMission Statement Identify and promote the appropriate legal remedies for vulnerable adult mistreatment through collaborative evaluation, research, education, and consultation

15. The Hard Part About Collaboration • May take more time, especially in early phase • Always takes more effort • Frustration with the other party • Cultural differences

16. Cultural Differences • Victim Advocate has victims • Adult Protective Services have clients • Regional Center has consumers • Geriatricians/Psychologists have patients • Law Enforcement has suspects • District Attorney has defendants

17. Benefits of Collaboration • Communication/inclusion • Team approach • Creative solutions • Time efficiency • Improved risk assessment • Support for each other • Education

19. Bruising Study: Objective To summarize the occurrence, progression, and resolution of accidentally acquired bruises in a sample of adults aged 65 and older. Our Hope: The systematic documentation of accidentally occurring bruises in older adults will provide a foundation for comparison when considering suspicious bruising in older adults.

20. Study Procedure • A subject was enrolled in the study if they developed a bruise during a two week period of daily observation. • The bruise was then documented everyday until resolution or up till 6 weeks. • Bruises present at the first visit were documented and not included in the study. • If a new bruise appeared, we knew that it had occurred during the prior 24 hours.

21. Location of Bruises (108 bruises at Day 1)

23. Summary of Results Nearly 90% of the bruises were on the extremities. There were 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. Contrary to the common perception that yellow coloration indicates an older bruise, 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.

24. Abuse of Elders With Dementia: Toward a Model of Prediction UC Irvine Program in Geriatrics UC Irvine Institute for Brain Aging and Dementia (IBAD) Alzheimer’s Association of Orange County (AAOC) County of Orange, Adult Protective Services (APS)

25. Research Design • Pilot, cross-sectional study • Goal is development and testing of a model for assessing risk factors associated with mistreatment of elders with dementia • Two cohorts being recruited: • UCI ARCC/ADRC-based • AAOC community-based • Home visit methodology • Future goal – longitudinal study

26. Flowchart of The System

27. It is time for people who work in the fields of Science, Technology, and Law to wake up and take this seriously.

28. Common Questions • How long did it take for that pressure sore to develop? • She has dementia: can we trust anything she tells us? • His daughter told us “I was doing the best I could”; why should we prosecute her? • Has this crossed the line from poor care to criminal neglect? • Isn’t this inevitable when you’re old?