Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Elder Abuse in Long Term Care
Document related concepts
Transcript
Elder Mistreatment in Long Term Care Laura Mosqueda, M.D. Director of Geriatrics Professor of Family Medicine University of California, Irvine School of Medicine Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. …. Or the potential for harm. Comparisons with Child Abuse • Many have compared the current state of medical knowledge about elder mistreatment with the state of knowledge about child abuse and neglect 30 years ago Difficulty with Detection/Diagnosis • Medical picture of the elderly much more complex than that of a child • Bad outcomes and death are more likely for the elderly than for children • Abuse and neglect are rarely observed • Difficult to link physical signs with diagnoses Types of Abuse • Physical • Psychological/Emotional • Neglect • Abduction • Sexual • Financial Types of Abuse • Physical • Psychological/Emotional • Neglect • Abduction • Sexual • Financial Examples of Physical Abuse • Pulling a patient’s hair • Slapping/hitting/punching • Throwing food or water on a patient • Tightening a restraint to cause pain Examples of Psychological Abuse • Terrorizing and/or threatening a patient with a word or gesture • Inappropriate isolation of a patient • Yelling at a patient in anger • Denying food or privileges Examples of Neglect • Person is lying in urine and feces for extended periods of time • Person develops malnutrition and/or dehydration and/or pressure sores due to lack of appropriate care • Person is dirty, has elongated nails, is living in filthy environment Abuse Occurs in a Variety of Patterns • Perpetrator works at the facility • Perpetrator is another resident • Good facilities • Bad facilities Abuse at the Person Level • • • • Resident to resident Resident to staff Family member to resident Staff to resident – – – – – – CNAs nurses doctors outside/paid help janitors etc. Abuse among CNAs • 10% committed physically abusive act(s) – excessive restraint 6% – pushing/grabbing/shoving/pinching 3% – hitting/slapping 3% • 40% committed psychologically abusive act(s) – – – – yelling 33% insulting/swearing 9% denying food/privileges as punishment 2% threatening physical violence 2% Pillemer 1991 Predictors of Abuse among CNAs • High level of job stress/burnout • Aggressive patient • Frequent verbal conflict with patients Great Facility/One Bad Egg • Reasonable staffing ratio • Good administration • High quality care • Sociopath gets hired Great Facility/Unusual Circumstance • High quality care • Difficult resident – physically dependent – verbally abusive • Stressed CNA – usually great with residents – trouble at home, stress at work – pushed “over the edge” Abuse at the Facility Level • Neglect • Poor care • Atmosphere of threats/reprisal Poor Quality Facility • Many residents receive poor care (i.e. pattern of poor care) – pressure sores: common and improperly treated – malnutrition: common and improperly treated • Lack of leadership/administrative support • Employee morale is poor • Absentee medical director Recipe for Abuse Vulnerable person High risk caregiver Context/Right circumstance The Problem with the Problem Complexity • Age-related changes • When does it cross the line? • Impaired Capacity • Mandated roles of multiple agencies • Lack of coordinated, comprehensive system Normal & Common Changes • Integument – thinner epidermis – capillary fragility • Renal: decrease in creatinine clearance • Sensory system – slower reaction time – presbycussis – macular degeneration, cataracts Normal & Common Changes • Musculoskeletal – sarcopenia – osteopenia/osteoporosis • Cardiovascular – orthostatic hypotension – congestive heart failure • Function – gait/falls – ADLs When does bad care cross the line to become neglect? neglect poor acceptable great Dementia is a disease process which causes loss of intellectual abilities and inability to perform one’s usual activities. Types of Dementia • Alzheimer’s Disease • Vascular Dementia • Frontal Temporal Lobe Dementia • Primary Progressive Aphasia • Dementia with Lewy Bodies Dementia and Abuse • Provocative behaviors • May be unable to recognize abuse • May be unable to report abuse • May be the perpetrator of abuse • May not be believed Interviewing People with Dementia • Understand the type of dementia • Know the pattern of cognitive loss • When do you “take it seriously”? Types of Memory • Verbal • Visual • Emotional Delirium • Problems with attention • Fluctuation in cognition • Reversible (e.g. infections, medications, dehydration) • Cannot make a diagnosis of dementia if delirium is present Delirium and Abuse • Delirium may be a marker of abuse – Neglect – Over-medication – Delay in seeking care • Delirium will interfere with victim’s ability to explain what happened When Abuse is Suspected... • Context • History • Physical Examination • Mental Status examination • Laboratory testing • Cognitive/behavioral changes Context • Circumstances/Events leading up to the alleged abuse • Personality and behavioral characteristics – victim – perpetrator • Medical history • Cognitive capacity Red Flags: History • Implausible/vague explanations • Delay in notification • Unexplained injuries - past or present • Inconsistent stories • Change in behavior Interviewing Issues • Establish cognitive ability level • Vision • Hearing • Comfort • Best time of day Observations • Observe the alleged victim and the perpetrator – Interaction – Behavioral indicators of state of mind • Depression • Fear • Confusion Physical Exam • Injury assessment • Functional status • Skin examination • Pelvic examination Clues on Physical Exam • Sores, bruises, other wounds • Unkempt appearance • Poor hygiene • Malnutrition • Dehydration Functional Assessment • Range of motion • Pain • Gait and balance • Sensory Injury Assessment: The Challenge in Elders • Normal changes • Common changes • Medication effects • Dementia Injury Assessment Types of Injuries • • • • Bruises Pressure sores Fractures Burns What to look for • Hx consistent with exam? • Old injuries • Delay in seeking care • Location Bruising • Age-related changes • Medications • Dating by color • Multiple stages of healing • History consistent with injury? • Location Summary of Results Nearly 90% of the bruises were on the extremities. 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. 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. Location of Bruises (108 bruises at Day 1) Progression of color 300 200 Red Purple Blue 100 Yellow Sum Black 0 Green 0 6 3 12 9 Day Number 18 15 24 21 30 27 36 33 42 39 48 45 54 51 Dating of Injuries Color Estimated Age Red Blue/Purple Green/Yellow Yellow/Brown Resolved 0-1 days 1-4 days 5-7 days 8-10 days 1-3 weeks Laboratory Evidence • Malnutrition • Dehydration • Coagulation studies • Medication levels • Radiographs • Neuroimaging (MRI, CT) Mental Status Exam • Best to have a formal mental status exam such as the Folstein Mini Mental State exam (MMSE) documented • At a minimum, get some observations and statements about the victim’s cognitive status Look for… • • • • • • • Residents in restraints Mood Medication errors Infection control Pressure sores Staffing levels Complaints How To Reach Me: Laura Mosqueda, M.D. 714-456-5530 [email protected]
