See, and then stop, elderly abuse

Hospitalization presents prime opportunity to intervene in abuse of elderly patients.

By Stacey Butterfield JANUARY 2019

Elder abuse is a crime, of course, but it often presents as a medical condition.

“A patient who is admitted, for instance, for dehydration and failure to thrive—that may be a reflection of underlying neglect by a caregiver. A patient who comes in with injuries that are reported to be due to a fall may actually be experiencing injuries as a result of physical abuse,” described Ethan Cumbler, MD, FACP, professor of medicine and a hospitalist at the University of Colorado in Aurora.

Such abuse may be less frequently recognized but actually as common among older hospitalized patients as the diagnosis-related groups that hospitalists know best. Research has found a prevalence of abuse between 5% and 10% among elderly Americans.

“That statistic—one in 10—is in the community. If we're talking about the frail elderly who end up being hospitalized . . . I think the rate of abuse is likely to be much higher,” said Dr. Cumbler. “If you ask the average hospitalist to think of the last 10 patients and what their problem list contained, it's unlikely that elder abuse will be on that list, which means we're probably missing it in some patients.”

It's not just hospitalists who struggle with this issue, according to Mark Yaffe, MD, a professor of family medicine at McGill University in Montreal who has researched elder abuse. “There's reasonable data to suggest that physicians in general, regardless of where they are practicing, have a lot of difficulty 1) understanding elder abuse, 2) trying to identify it, 3) knowing what to do once they identify it, and 4) [dealing] with anxiety about the legal and ethical implications of reporting,” he said.

However, if those challenges can be overcome, hospitalization may represent a prime chance to diagnose and treat elder abuse.

“Hospitalists are in a unique place to be able to comprehensively look at a patient . . . They have an opportunity to identify elder abuse and to reach out to the community or make appropriate referrals to break the cycle of violence or neglect,” said Amy Berman, RN, LHD, senior program officer with the John A. Hartford Foundation, a New York-based nonprofit dedicated to improving care for older adults.

Red flags

To help protect their elderly patients from abuse, hospital staff should recognize the most common signs that it may be occurring.

“The hospital is one of the rare places where they can speak with an older adult apart from the caregiver. When the family caregiver doesn't want to separate from that person for a few moments, that is a red flag,” said Dr. Berman.

There may also be clues in the way family members interact with a patient. “Some of the red flags I have noticed are family who are abusive verbally toward the patient while they are in the hospital, which can be a sign of psychological abuse,” said Dr. Cumbler.

Interactions with hospital visitors can reveal another common type of elder abuse—financial exploitation. “If while in the hospital, there are people that come visit the patient that are not their relatives, asking them to sign papers,” that could be an indication of abuse, said Carmel Bitondo Dyer, MD, FACP, professor of geriatric and palliative medicine at the University of Texas Health Science Center at Houston.

Financial abuse may also come from relatives, she noted. “If your patient lacks decision-making capacity and they don't really know how their finances are being handled, this can be picked up in some instances because the power of attorney or the family member doesn't respond” to communications from the patient or hospital staff, Dr. Dyer said.

Or, if the person is present, “You might just get a sense that person responding for your patient doesn't seem to have their best interests at heart,” she added.

Frequent readmissions are often a result of complex illness, but they can also be a sign of abuse. “You may want to have a heightened suspicion if you have people who are readmitted a lot,” said Dr. Dyer.

Most of all, hospitalists should know the physical symptoms of abuse. “There's obvious injury for which there's no explanation—it's not an osteoporotic fall [or] there's another bone that was broken other than the usual suspects; the bruising is on the head, neck, torso, or in the perineal area,” said Dr. Dyer. Skin tears in less common spots, that is, not on the extremities, may be another sign, she added.

“Any clinician should ask themselves, ‘Is this consistent with the mechanism of injury which is being reported?’” said Dr. Cumbler.

Raising the subject

After asking themselves about the possibility of abuse, hospitalists should ask the patient. “It's important to pull older adults aside and ask them if they feel safe,” said Dr. Berman. “It may be that they don't want certain things uncovered.”

Hospitalists and patients alike may be hesitant to dive into this delicate topic, noted Dr. Cumbler. “Part of the reason that we miss it may be because we don't ask the questions that would be necessary to elicit it. And one of the reasons that we may miss it is because patients may be unwilling or unable to tell us,” he said. At his hospital, nurses perform an elder abuse screen and bring any positive results to the attention of the physicians.

Patients may be more willing to reveal abuse to a primary care physician than a hospitalist, but that carries its own complications, explained Dr. Yaffe. “The common example that's cited is Mrs. Jones sees her family doctor. She talks about the fact that her son has been gradually taking money out of her bank account and this is causing her some emotional grief and perhaps some financial hardship,” he said.

The doctor responds with a plan to contact adult protective services (APS), but Mrs. Jones says, “Absolutely not, because if APS comes into this and my son is singled out, the consequences of this will be embarrassment to me, embarrassment to my family as a whole, and if somebody chooses to remove my son from our home, then I'm going to end up in a long-term care facility,” Dr. Yaffe said.

Dilemmas like this have caused elder abuse to be considered more of a legal issue than a clinical one, said Dr. Yaffe. For example, he searched for the topic while editing an educational module about geriatric care and couldn't find it until he was directed to the law and ethics section. “It's no wonder doctors aren't reporting stuff or detecting it. You're giving them a message that they're going to get mired in all sorts of legal issues,” he said.

In most states, reporting suspected abuse is a legal requirement for physicians and other clinicians. “If a hospitalist should feel that there is reasonable suspicion of elder abuse, we would be obliged to contact adult protective services and the police,” said Dr. Cumbler.

That responsibility to report applies to all individual clinicians. “When they see these things, they can't assume that somebody else has made the right referrals,” advised Ms. Berman. However, the overall response to potential abuse of an elderly patient should be a team effort, the experts said.

“We don't have to confirm it in the same way that we would confirm a diagnosis of cancer,” said Dr. Dyer. “Report it, and then there are the experts who take the time, make the collateral phone calls, visit the house, look at the bank records. They're the ones that actually confirm the diagnosis.”

The team of experts may be in and outside the hospital. “We have access to resources to help us in navigating concerns about abuse and engaging community resources . . . Hospitalists should recognize that their hospital has a social worker and a case manager with expertise in this,” said Dr. Cumbler.

Positive impacts

It's also important for hospitalists to recognize that the consequences of reporting abuse might not be as dire as Mrs. Jones, the hypothetical patient, envisioned. “Making a report doesn't mean that family is indicted. It means that somebody who is a professional will begin to monitor and look into it,” said Dr. Berman.

Dr. Dyer agreed. “A lot of times through investigations, patients will get more resources. Maybe they'll find that their house is cluttered and they are having trouble meeting these bills. In some states, they bring in a clean-up service or they try to connect them with a social service agency,” she said.

Connecting patients and their caregivers with social services is also key to preventing elder abuse before it starts.

“Elder abuse is a terrible thing when it's happening, but it's not hard to imagine the stresses and pressures on caregivers that can devolve into abuse,” said Dr. Cumbler. “So we try to think about additional supports that we can set up at hospital discharge, caregiver support groups, and involving social work early for caregivers that are taking care of patients with very high care burdens.”

Such apparently small interventions can have a dramatic impact on patient outcomes, since elder abuse has been found to double the risk of mortality, Dr. Dyer reported.

“While making a referral doesn't always feel the same as saving a life, you might indeed be preserving somebody's dignity and function and even their life by getting these cases reported,” she said. 

https://acphospitalist.org/archives/2019/01/see-and-then-stop-elderly-abuse.htm