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For further information, see CMDT Part 4-04: Management of Common Geriatric Problems

Key Features

  • Defined as “actions that cause harm or create a serious risk of harm to an older adult by a caregiver or other person who stands in a trust relationship to the older adult, or failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm”

  • Self-neglect is the most common form of elder mistreatment and occurs among all demographic strata of the aging population

  • In the United States, according to the best available estimates,

    • About 14% of adults over age 70 experience some sort of mistreatment annually

      • About 12% experience psychological mistreatment

      • Almost 2% experience physical mistreatment

    • Each year, 5–7% of elders may be victims of financial abuse or scams

  • Laws in most states require health care providers to report suspected mistreatment or neglect to Adult Protective Services

    • Agencies are available in all 50 states to assist in cases of suspected elder mistreatment

    • The Web site for the National Center for Elder Abuse is https://www.elderabusecenter.org/

Clinical Findings

  • Clues to the possibility of elder mistreatment include

    • Behavioral changes in the presence of the caregiver

    • Delays between occurrence of injuries and when treatment was sought

    • Inconsistencies between an observed injury and associated explanation

    • Lack of appropriate clothing or hygiene

    • Not filling prescriptions

  • Many elders with cognitive impairment become targets of financial abuse

Diagnosis

  • It is helpful to observe and talk with every older person alone for at least part of a visit to ask questions directly about possible mistreatment and neglect, such as

    • “Has anyone hurt you?”

    • “Are you afraid of anybody?”

    • “Is anyone taking or using your money without your permission?”

  • When self-neglect is suspected, it is critical to establish whether the patient has decision- making capacity in order to determine what course of action needs to be taken

  • A patient who has full decision-making capacity should be provided with help and support but can choose to live in conditions of self-neglect, providing that the public is not endangered by the actions of the person

  • In contrast, a patient with self-neglect who lacks decision-making capacity requires more aggressive intervention, which may include guardianship, in-home help, or placement in a supervised setting

  • Montreal Cognitive Assessment (https://www.mocatest.org/) score may provide some insight into the patient's cognitive status but is not designed to assess decision-making capacity

  • A standardized tool for determining decision-making capacity, such as the “Aid to Capacity Evaluation,” is easy to administer, has good performance characteristics, and is available free online at http://www.jcb.utoronto.ca/tools/documents/ace.pdf

Treatment

  • Hospital admission is appropriate when a patient is unsafe in the community and an alternate plan cannot be put into place in a timely manner

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