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Key Clinical Questions

  • image When should you suspect elder mistreatment?

  • image How do you assess for elder mistreatment and what should you document in your assessment?

  • image Who should you consult and what are the reporting requirements if you suspect elder mistreatment?

  • image How do you create a safe discharge plan to ensure a smooth transition to the next setting?

Elder abuse and neglect represent a growing public health problem with the potential for serious morbidity and mortality. A clinician will likely encounter at least one victim of elder abuse for every 20 to 40 older adults seen. As hospitalists assume care for an increasing proportion of older adults in acute care settings, they need to know which older adults are at greatest risk for elder mistreatment and how to properly assess them. Elder mistreatment is an independent risk factor for death. A prospective cohort study of 2800 ­community-dwelling adults age 65 and older by Lachs, et al. reported that the mortality rate was three times higher in the elder mistreatment group and 1.7 times greater in the self-neglect group. In the group with any elder mistreatment, the survival rate was 9% versus 40%. Every emergency room visit and admission represent critical opportunities for medical providers to positively impact the lives of both elder mistreatment victims and their caregivers.

Elder mistreatment occurs among men and women of all racial, ethnic, and socioeconomic groups. Older adults are at greater risk for mistreatment if they are dependent on others due to cognitive impairment, physical frailty or mental illness. Other risk factors for physical and psychological abuse include a shared living situation and lack of social support. In cases of financial abuse, however, the older adult more often lives alone. The perpetrators of abuse are most likely to be male and an adult child or spouse. Financial abuse may be the fastest growing yet least recognized form of elder mistreatment. In 2009, the direct cost of financial exploitation in the United States was an estimated $2.9 billion. Other characteristics that appear more frequently amongst perpetrators of elder mistreatment include mental illness, substance abuse, emotional or financial dependency on the older adult, a history of violence or antisocial behavior, and external stressors (medical illness, financial stress, caregiver burnout). In long-term care settings, abuse of older residents by other residents is becoming an alarming trend. The so-called resident-to-resident aggression takes the form of physical abuse, verbal abuse, or sexual aggression, and is actually more common than abuse of residents by nursing home staff.

In clinical practice, risk factors that create an imbalance between the older adult’s needs and the ability of the caregiver/support system to meet those needs led to increased vulnerability. Three key risk factors leading to this critical imbalance include cognitive impairment, physical frailty, and social isolation. Despite being ideally suited to detect, manage, and prevent elder mistreatment, a 2004 study conducted by the National Center on Elder Abuse found that physicians are ...

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