Elder Abuse-The Role of the Physician

By Frank Randolph, MD, President

Tristan Svare, Deputy District Attorney, San Bernardino County

Elder Abuse is an important clinical topic
Nationally, the incidence of elder abuse has been estimated at 450,000 annually, with prevalence range of 700,000 to 1.2 million older adults, accounting for approximately 4 per cent of those aged 65 years or older.

Elder abuse reporting increased 50% from 1986 to 1996, despite the fact that the older population increased by only 10% during that period. Women are disproportionately represented as victims, representing 60-76 per cent of those subjected to all forms of abuse and neglect except abandonment (women represent 58 per cent of the elderly population). In the category of financial abuse, 92 per cent of the victims were women. A substantial portion of the victims of neglect (52 per cent) was the oldest old (age 80 and older) neglected at 2-3 times their proportion of the population.

Who is at risk; who are the perpetrators?
Risk factors associated with the elderly that increase their potential for abuse include advanced age (over 75), increased dependency, social isolation, poverty, frailty, dementia, behavioral issues, depression, and incontinence. An elder is also at higher risk if he or she has a personal history of abuse or neglect as a child or a history of family violence. Alcohol use by either the elder or a caregiver is a risk factor. Other caregiver risk factors include mental illness, death of a loved one, loss of employment, drug abuse, lack of social support, and financial dependency. Increasing risk factors increase abuse risk.

Prevention-Recognition of Risk Factors
Prevention begins with reviewing and recognizing possible risk factors in elders. Screening questions may be asked at routine visits, or if there is suspicion of elder abuse. General questions should be asked about any physical or behavioral signs of elder abuse. Physical signs include weight loss, dehydration, poor hygiene, traumatic alopecia, absent or broken devices, subconjunctival or vitreous hemorrhage, hematomas, welts, bites, burns, pressure sores, bruises, inguinal rash, fecal impaction, multiple fractures in various stages of healing, and contractures. Behavioral signs include fearfulness toward caregiver, poor eye contact, or hesitation to talk openly; caregiver insistence on being present continuously for interview or failing to be present in office with dependent elder or visit during hospital stay. Questions should be non-threatening and asked in a variety of ways to characterize different possible mechanisms of abuse. More specific questions such, as "are you afraid of anyone at home? Or "Are you kept isolated from friends and relatives? Patient and caregiver should be interviewed separately. Neither party should be blamed or confronted in a hostile manner. The history should be conducted in privacy, so that the patient and caregiver can speak freely and frankly.

Legal definition of elder abuse
Elder abuse itself refers to any act of abuse, or any act of neglect. Primarily, this means physical assault, such as punching, slapping, hitting, kicking, or beating. It also includes such abuses as burning, shooting, cutting, or stabbing, choking, suffocating, and other acts of violence. Abuse also includes neglect, such as deprivation of food or water, over exposure to the elements, and exposure to danger. Sexual assault is also included in the definition of abuse. California law also recognizes financial abuse as elder abuse-this can be theft or embezzlement, fraud, robbery, identity theft, and any other form of illegal financial loss (California Penal Code Section 368). The key to reporting abuse lies in the intent of the statutes. The intent is to address the problem of abuse, not to overly complicate physician's practices or open them up to further liability (in fact, the mandated reporting statutes specifically provide for reporter confidentiality and limit the liability of mandated reporters-provisions are even made to provide for legal services if someone tries to circumvent this prohibition on civil suits, see W&I sections 1161.9, etc).

Reporting abuse in California
Reporting of elder abuse can be an unnecessarily complex process, full of apparently intimidating and arcane legal procedures that some physicians see as counter-productive to the physician-patient relationship, or sometimes view as unnecessarily exposing themselves or their colleagues to civil liability.

Under California law, physicians, nurses, psychiatrists, resident physicians, interns, psychologists, therapists, and those who are care custodians or heath health practitioners are "mandated reporters"(California Welfare and Institutions Code Section 15630). These are very broad definitions, but generally include anyone providing services or care to an elder or dependent adult. Elders are those age 65 and older, and dependent adults are those ages 18 to 64, suffering from some physical or mental limitation, or anyone who is an inpatient (California Penal Code Sections 368 (g) and (h)).

The other key point to remember is this--what does the law require to be reported? Under W & I section 15630, a mandated reporter must report when in the scope of his or her employment, the reporter has observed, or has knowledge of, what reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect. This includes situations where the mandated reporter is told of such abuse, or where the reporter reasonably suspects such abuse. This is fairly broad, and covers almost every situation where the reporter has information of some abuse being perpetrated. There is another reporting requirement under W & I section 1160, where health practitioners are required to report, immediately, any assaultive or abusive conduct that has resulted in a wound or physical injury. This is similar to the present mandated reporting of sexual assault or gunshot wound situations.

So, once a determination is made that the physician either sees what reasonably appears to be a wound or physical injury as the result of abuse, or even reasonably suspects abuse, the physician must report. The reporter completes a standardized state form (known as the SOC 341) and a phone call is made to the local county Adult Protective Services 24-hour hotline (these numbers vary from county to county). Elder abuse reporting related to individual residing in nursing homes and assisted living facilities must be reported to the Long Term Care Ombudsman Program (*1-800-231-4024). The information required in the phone call and on the SOC 341 is identical. It is important to note that this reporting must be made within 48 hours of the reporter becoming aware of the abuse, and the duty to report is individual. Many hospitals and practice groups have their own protocol for reporting abuse, but the law views each physician as responsible for ensuring that the report is made-regardless of who makes the actual phone call or completes the SOC 341. In a nutshell, reporting elder abuse is simple, quick, and easy-the forms are standard, they are similar to those already being used for other mandated reporting (gunshot sexual assault, child abuse) and they serve a very important function-helping prevent further injury and abuse to our valued senior citizens and dependent adults.

What should you do?
It is advisable to obey the law in your state with respect to reporting suspected abuse, regardless of whether you think they are going to be effective in treating the abuse or neglect. Whether you are a primary care physician or consultant, your advocacy and follow-through may be critical in resolving the problem.

The American Medical Association defines elder abuse and/or neglect as "an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult." The AMA guidelines for elder abuse treatment are as follows: 1) report to APS or other state mandated agencies; 2) ensure safety plan; assess safety, access, cognitive, emotional, functional, and health status. 3) Assess frequency, severity, and intent of abuse. Be proactive. Studies of older individuals referred to adult protective services demonstrate an increased risk of mortality in the decade following the referral. Take a step beyond reporting. Make every effort to assure that this risk is reduced.

References

1. American Medical Association Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago, American Medical Association, 1992.
2. California Office of the Attorney General (http://caag.state.ca.us/ag) web site "Bureau of Medi-Cal Fraud and Elder Abuse." Press release September 12, 2001. "Nation's premiere state prosecutorial agency in the battle against health care fraud and elder abuse."
3. Jones JS, et al. Elder mistreatment: national survey of emergency physicians. Ann Emerg Med 1997 Oct; 30(4):473-9.
4. Lachs MS, Pillemer K. "Abuse and Neglect of Elderly Persons" N.E.J.M.1995; 337 (7) 437-443.
5. Penney, Susan L. Memorandum-Elder and Dependent Adult Abuse and pain management; CMA Board of Trustees, November 12, 2001
6. Reports "Selected Arrest Offenses for Elder Abuse by County (1998-2000) and Report on Violent Crimes Committed Against Senior Citizens in California, 1998; from California Department of Justice Criminal Justice Statistics Center, Special Request Section (doj.cjsc@doj.ca.gov).
7. Rosenblatt DE, Cho KH, Durance PW. "Reporting mistreatment of older adults: the role of physicians" J Am Geriatr Soc 1996 Jan; 44 (1): 65-70.
8. Stiles, MM. Koren C. Walsh K. "Identifying Elder Abuse in the Primary Care Setting," Clinical Geriatrics: vol 10 (&), 33-41, July 2002.
9. The Geriatric Review Syllabus, 5th edition, American Geriatric Society, Blackwell Publishing, 2002 (Chapter 9-Elder Mistreatment).
10. U.S. Administration on Aging (www.aoa.gov/abuse/report) National Elder Abuse Incidence Study, 2001.