Elder Mistreatment: A geriatrician’s perspective

1. Elder Mistreatment: A geriatrician’s perspective Hal H. Atkinson, MD, MS Associate Professor Department of Internal Medicine, Section on Gerontology and Geriatric Medicine

2. Objectives of the Talk • Describe challenges for the healthcare provider identifying and managing elder mistreatment (abuse, neglect and fraud) • List risk factors and common presentations of elder mistreatment • Discuss what a healthcare provider can/should do in cases of suspected mistreatment

3. A common scenario • 82 year old man with 5 years of progressive memory loss due to Alzheimer disease is brought by his daughter (the sole full-time caregiver) for a regular check-up • She is concerned that he is not keeping up with his personal hygiene – not bathing daily, wears the same clothes over and over • She tries to get him to bathe, but he often yells at her and tells her to go away • During the interview, the patient says that his daughter won’t let him “do anything” and has taken all of his money -- Daughter argues with him that this is not true and that he just “never wants to do anything”

4. A common scenario • Physical Examination: • Unkempt, urine stains on pants, well-nourished • Bruises on both hands • When asked about them, the patient says it happened while working on the car, and the daughter says that he occasionally gets frustrated and hits things • Significantly impaired short term memory (cannot remember the year, time, day of the week, or where he currently lives) • Cannot perform simple calculations or make change from a dollar

5. The challenge for the physician • Is this man a victim of elder abuse or neglect? • He is vulnerable to abuse/neglect by virtue of his Alzheimer’s disease • His finances have been taken over • Poor hygiene and bruising on his hands • Some strained interaction with the patient and caregiver • But, some big questions come up: • He is not capable of dealing with finances • Forcing daily bathing might be worse in this case • Bruising frequently happens spontaneously • What level of frustration is normal?

6. There are many types of mistreatment • Physical • Sexual • Emotional • Neglect of a vulnerable person • Financial • More than one type often occurs in the same individual

7. Major risk factors for elder mistreatment Older Adult Potential Abuser • Caregiver Stress • Memory Problems • Vulnerability to Mistreatment • Emotional or Financial Dependence • Physical Dependence • Substance abuse/ Psychiatric illness

8. How do we identify it? • Some cases are obvious • E.g. Major injuries that otherwise don’t make sense – certain locations and types of injuries may tip off • Most often, we have to rely upon observation of what is going on • General sense of the room (the “Blink” response) • Caustic interactions between abuser and patient • Not letting the patient speak, not leaving the room, overly secretive • Missing appointments • Reports from others of problems

9. How can physicians/geriatricians help? • Bring concerns to our attention! • Evaluation for vulnerability can be helpful to make recommendations for what appropriate care/oversight might be: • Cognitive • Includes Decision Making Capacity – keep in mind that older adults with decision making capacity have as much right to bad decisions as younger people! • Physical • Medical complexity

10. Things we can do to help • Immediate safety plan: sometimes means admission to a hospital • Referrals for protective services • Education of patient or caregiver to prevent mistreatment: • E.g. in the patient presented: • education about Alzheimer’s disease • reasonable targets for hygiene • dealing with problematic behaviors or violent outbursts • community resources for care • appropriate level of care • support groups • “giving permission” to take mental health breaks

11. Questions?