Elder mistreatment is a complex medical problem that requires a multidisciplinary treatment approach. Each case of elder abuse or neglect necessitates individualized assessment and treatment planning.
Documentation of the abuse or neglect should be completed regardless of the health care setting. The provider should record the chief complaint in the patient’s own words if possible. Proper documentation should include a complete medical and social history. If appointments are repeatedly canceled, the name of the caller should be noted. If injuries are present, the type, number, size, location, and color, as well as the patient’s overall state of health, the resolution of the problems, and possible causes should be included. The provider should render an opinion on whether injuries were adequately explained by the history. All laboratory or radiologic and imaging studies should be recorded. If it is possible, obtain color photographs. If the police are called, the name of the officer, actions taken, and police incident number should be documented as well as the date and time the report was made to APS and the name of the person taking the report. The diagnosis of elder mistreatment should be included in the medical problem list.
Health care professionals make up the greatest reporting source of potential elder mistreatment to APS agencies. Legal requirements differ from state to state. Knowing your state’s reporting system is crucial. Nearly all states mandate health care providers to report cases of elder abuse. (Colorado, New York, North Dakota, and South Dakota do not currently mandate health care providers to report suspected or identified cases of elder abuse, but have voluntary reporting systems.) In some states, health care providers can be found negligent if they do not report suspected mistreatment. The website for National Center on Elder Abuse, which is part of the Administration on Aging, lists state directory of help lines, hotlines and elder abuse prevention resources (http://www.ncea.aoa.gov).
Discharge or ongoing care planning—
The provider must ensure that the older adult’s medical and safety needs have been met. If the patient does not meet the criteria for admission to the hospital after the provider has documented the findings and filed a report, the provider must be sure that the home environment is safe and that there is assistance at home for functionally and/or cognitively impaired patients. A social work consultation or consultation with an APS specialist may be necessary before discharge in order to develop a safety plan.
Elder mistreatment is often a chronic problem and patient’s with history of elder mistreatment should be referred to a physician or medical team with whom the elder can have an ongoing relationship. Elder mistreatment presents special difficulties for the patient in terms of function, decision-making capacity, and health and social support. These interrelated problems are best handled by a team of professionals from medicine, law, and social services. Clinicians should be skilled in the recognition of geriatric syndromes and familiar with local agencies that provide services to a mistreated older patient. Comprehensive geriatric assessment and intervention may be needed for vulnerable abused or neglected elders (see Chapter 6, “Geriatric Assessment”). It is often helpful to discharge the patient to their home with as many appropriate services as possible. Home health agencies can provide in-home assessments by social workers or nurses. Other referral sources include drug and alcohol rehabilitation services, and legal assistance or advocacy groups.
Assessment of decision-making capacity—
In many instances, the mistreated elder is vulnerable because the elder lacks the capacity to participate fully in decision making. Additionally, acute illness can reduce an older person’s ability to make rational and informed decisions. A competent individual has the right to be a fully informed participant in all aspects of decision making and has the right to refuse care. However, patients who lack decision-making capacity and whose expressed choices may lead to harm or even death need protection and assistance. The determination of neglect versus informed personal choices will hinge on an older adult’s capacity to participate in the elder’s own care. Therefore, it is essential to determine each patient’s decision-making capacity whenever assessment for elder abuse or self-neglect is in question (for more on informed decision making, see Chapter 12, “Ethics & Informed Decision Making”).
Social Services Intervention
APS or similar entities can provide social interventions in almost every jurisdiction in the United States. APS specialists usually receive reports, conduct investigations, and coordinate social interventions. They elicit input from collateral sources such as friends and family members of the patient and consult with other social workers, physicians, and nurses. After the APS specialists complete the investigation and comprehensive in-home assessment of the patient’s situation, they develop plans to address mistreatment issues and other problems they have identified. APS works closely with victims, families, and other involved parties. APS’s goal is to ensure that the service provided is the least-restrictive alternative, reflects the patient’s preferences, and maximizes the older adult’s independence. When a patient has the capacity to make informed decisions, the APS specialists advocate for the right to refuse services if the individual does not want intervention. As advocates of a legal jurisdiction, APS specialists are bound by statutory limitation and may not impose services such as medical care if the patient is capable of making decisions.
Although laws differ from state to state, law enforcement is generally involved in cases in which crimes are committed against older adults, including physical abuse, neglect with malicious intent, financial exploitation and other forms of elder mistreatment. Police officers investigate cases for evidence to help prosecutors pursue perpetrators. Officers of the court and judges participate in guardianship hearings when appropriate. Members of law enforcement and the legal profession help link older persons with agencies and other resources available to victims of crime. Forensic pathologists work closely with law enforcement officers to determine the cause of death in cases of suspected homicide resulting from abuse or neglect.