Evaluating Elder Abuse in the ED
Evaluating Elder Abuse in the ED
Author: Jonathan Glauser, MD, FACEP, Vice Chair, Operations, Department of Emergency Medicine, Cleveland Clinic Foundation; Faculty, Residency Program in Emergency Medicine, MetroHealth Medical Center; Associate Professor of Medicine, Case Western Reserve University, Cleveland, OH.
Peer Reviewer: Ralph Riviello, MD, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.
The age paradigm of our population has shifted in the last few decades. It is thought that by 2030, nearly 20% of us will be older than 65 years, compared to only 12% in 2000. Unfortunately, as the total number and percent of the elderly increase, so will episodes of abuse and neglect. This hidden and growing social epidemic is only now starting to be characterized, but will almost certainly require an increased role by the emergency physician. In this issue of Emergency Medicine Specialty Reports, concepts surrounding abuse of the elderly will be discussed as well as strategies for prevention and intervention.
—The Editor
Introduction and Overview
Elder abuse and neglect has been recognized as a growing problem in the United States. All 50 states have reporting requirements for elder abuse and neglect, although there is no federal policy requiring reporting of elder abuse. Literature suggests that the abusers most frequently appear to be family members and caretakers of the elderly.1 The responsibility for identifying elder mistreatment often falls on emergency care providers.
There are 45 million people older than 60 years in the United States, and 3 million older than 85 years. Those older than 85 years represent the fastest growing segment of the elderly population; it is estimated that the number of persons older than 85 years will be seven times higher in 2050 than it was in 1980.2
Modern reports of elder abuse in the medical literature date from 1975 when the British Medical Journal published a report of "granny battering."3 In the United States, reports of abuse and neglect in nursing homes in the 1970s led to a systematic study of elder mistreatment by the United States Senate Special Committee on Aging.4 Since that time, under the auspices of the Department of Health and Human Services, the National Institute on Elder Abuse was created. The first federal government measures to address elder abuse came in Title XX of the Social Security Act of 1974, which gave individual states authorization to use Social Service Block Grant funds to protect elderly persons as well as children.5
It has been estimated that between 1 and 2 million elderly Americans experience some form of mistreatment annually.6 Other sources cite as many as 2-2.5 million cases of elder abuse each year.7,8 Reports of abuse have certainly increased with time, with 117,000 reports of elder abuse in 1986 and 293,000 in 1996.9 Older men and women have similar per capita abuse rates, estimated at a prevalence rate of 32 for every 1000 adults.8-10 Factors leading to misdiagnosis and under-reporting include denial by both victim and perpetrator, clinicians' reluctance to report victims, disbelief by medical providers, and clinicians' lack of awareness of warning signs.11 For these reasons, it has been estimated that only 1 in 14 cases of elder abuse or neglect comes to the attention of authorities.12
Elder abuse in family settings has increased in recent years for a number of reasons: the increasing proportion of older adults in the total population; the increase in chronic disabling diseases; progressive dependency; and the increasing involvement of families in caregiving relationships with elders. These trends are likely to continue into the foreseeable future.13
It has been shown that elder neglect may be detected in the emergency department by screening protocols.14 Not only have many emergency departments lacked protocols for elder abuse, but many physicians were not even aware of it as an entity, in one report.15 In another study, only 2% of all cases reported in the state of Michigan were made by physicians.16 Hospital protocols have been recommended by the American Medical Association and the American College of Emergency Physicians to aid in the detection and management of elder abuse.17,18
The risk of death for elder abuse and neglect victims is three times higher than for elderly non-victims.19 The human cost of abuse and neglect is stark. One report from 1976 noted that 25% of elderly patients died within three years of admission, tending to become bewildered, restless, and unable to report their needs soon after admission.20 As of 2004, the direct medical costs of violent injuries to the elderly were estimated at $5.3 billion.21
Definitions
Elder abuse and neglect refers to an act or omission resulting in harm, including death, or threatened harm to the health or welfare of an elderly person. It often is referred to globally as elder mistreatment (EM). The types of abuse of older persons include physical, psychological, sexual, and financial—when the elderly person's resources have been misappropriated by the caregiver. The 1985 Elder Abuse Prevention, Identification and Treatment Act defines abuse as the "willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness."22
The American Medical Association in 1987 proposed this definition: "Abuse shall mean an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Abuse includes the intentional infliction of physical or mental injury; sexual abuse; or withholding of necessary food, clothing, and medical care to meet the physical and mental needs of an elderly person by one having the care, custody, or responsibility of an elderly person."23
Other types of EM include violation of rights, denial of privacy, and denial of participation in decision-making.24 EM may entail more subtle practices, which make it fall under the concept of "undue influence." Undue influence is the substitution of one person's will for the true desires of another. Such influence often entails fraud, duress, threats, or other pressures. Undue influence occurs when one person uses his or her role and power to exploit the trust, dependency, or fear of another to gain psychological control over the weaker person's decision-making, often for financial gain. While dependent and impaired people are especially susceptible, this can happen to people who would be considered otherwise competent.25
Elder abuse has been classified into the following six broad categories, each of which is considered individually in this article: physical abuse; sexual abuse; financial exploitation; neglect; psychological abuse; and violation of rights.26
Self-Neglect
Separate from the above categories is self-neglect, which encompass behaviors of an elderly person that threaten his or her own safety. By definition, self-neglect excludes situations in which a mentally competent older person who understands the consequences of his or her decisions makes a conscious decision to engage in acts that threaten his or her own health or safety.27,28 It is the result of an adult's inability due to diminished capacity to perform essential self-care tasks, including the provision of essential food, clothing, shelter, and medical care, as well as the management of financial affairs. A 1997 study indicated that cognitive impairment, poverty, and being of a nonwhite race were independent predictors for self-neglect.29 A later study indicated that self-neglect contributed to increased mortality. In that report of elderly patients, 40% of those in the self-neglect cohort, vs. 17% in the non-investigated cohort, died during a 13-year period.30
Risk Factors
Dependency, either on the part of the victim or of the perpetrator, and caregiver stress are common denominators in abusive situations. Functional impairment leads to dependency and vulnerability of elderly persons, especially those who cannot perform activities of daily living. Institutionalization is recognized as a risk factor for neglect and abuse;11 however, elder abuse occurs most commonly in residential rather than institutional settings.31 Older persons most commonly are abused by the people with whom they live. Frail, very old (older than 75 years) adults who have a diagnosis of depression or dementia are more likely to be mistreated than other elderly people. Physical or cognitive impairment, alcohol abuse, female sex, and a history of domestic violence also are risk factors for elder mistreatment.32-35 Older adults who require assistance with activities of daily living or have poor social networks have been found to be at higher risk as well.35 Victims of caregiver neglect are more likely to be widowed, very old, cognitively impaired, and socially isolated. Developmental disabilities, special medical or psychiatric needs, and lack of experience managing finances all place a person at risk, as do patient aggression, verbal outbursts, or embarrassing actions.9
The risk to the victim may be related more to characteristics of the perpetrator than to those of the victim. Perpetrators of abuse may be financially dependent on the victim. There may be a family history of violence or substance abuse. Abusers most often are the primary caregivers. Adult children tend to be more inclined to abuse than are spouses, although one survey indicated that 58% of domestic elder abuse was by spouses.10,37 Males abuse more than females.27 The risk is greater if the caregiver has a financial or emotional dependence on the victim,37 which may be exacerbated by alcohol or drug abuse, legal or financial difficulties, or psychiatric disease on the part of the caregiver.9,16 Caregivers may be well-intentioned, but simply overwhelmed by the amount of care required. They may themselves be impaired by mental or physical problems, which serve as barriers to the provision of adequate care. A domineering, violent, or bullying category of provider has been described, who is prone to financial abuse and neglect as well as possibly sexual abuse.38
Identification of Elder Abuse
Physical abuse most easily is recognized, although neglect is more common.35 Psychological and financial abuse may be missed more easily. Difficulty arises when an elderly patient's caregiver seems indifferent or angry toward that person and is unwilling to cooperate with health care providers.
The history should entail direct and simple questions. Examples of these may include general queries about who handles the patient's finances, who cooks for him or her, under what circumstances seek medical care is sought, and whether the patient feels safe where he or she lives.39 Specific questions may be posed as to whether the patient has been slapped, struck, kicked, or tied down. The patient, the suspected abuser, and other family members should be interviewed separately without other family members or caregivers in the room. The rationale for this is clear: confidentiality is necessary if the interviewer is to ascertain whether the patient has been touched without consent, has had items taken without permission, or is afraid of anyone at home.
Red flags for abuse include: reluctance of the caregiver to leave the patient alone with the health care provider; lack of caregiver knowledge of the patient's medical conditions; delay in seeking needed medical care; and missed doctors' appointments.40,41
Emergency department clinical presentations of the abused elder may include dehydration, apathy, or depression. The most common complaints for patients older than age 75 are falls, dehydration, and failure of self-care.42 Each major category of abuse is considered in turn.
Specific Categories of Elder Abuse
Physical Abuse. The most recognizable form of abuse is the use of physical force that might result in bodily injury, physical pain, or impairment. It may comprise a wide range of behaviors, including slapping, burning, pushing, or striking with objects, any of which are carried out with the intention of causing suffering, pain, or other physical impairment.43 In one review of 36 emergency cases, neglect actually was more common than frank injury.44 Dehydration, malnutrition, bed sores, inappropriate clothing, and improper administration of medicines may be indicators of neglect.35,44 Because elderly patients bruise more easily, and osteoporosis leads to a higher incidence of fractures, clinical judgment must be used to determine whether or not injuries signal abuse.39
The patient's general appearance should be noted for hygiene or dirty clothing. The skin mucosa should be examined for dehydration, bruises, decubitus ulcers, lacerations healing by secondary intention, or multiple lesions in various stages of healing. The oral cavity may indicate ecchymosis from forced oral sex, lesions from venereal disease, tooth fractures, or cigarette burns. The oral mucosa may exhibit signs of dehydration. There may be clustering of bruises or characteristic shape, as from injuries inflicted with a belt or iron. Examination of the head may reveal traumatic alopecia, vitreous hemorrhage, orbital fractures, or retinal detachment. Evidence for occult fracture, immersion burns, or cigarette/cigar burns may be present.39 Rope or restraint marks on the wrists or ankles may be present.27
Sexual Abuse. This is broadly defined as nonconsensual sexual contact of any kind with an elderly person. The spectrum of sexual abuse ranges from unwanted touching, indecent exposure, or unwanted innuendo to fondling with a non-consenting competent or incompetent person or rape itself. The patient may complain of genital or anal pain, itching, bruising, or bleeding, or he or she may have venereal disease. The patient's underwear may be stained or bloody, as there is a greater likelihood of genital injury than in younger victims.27
Sexual offenders may exhibit certain characteristic tendencies. Specifically, they have been proposed to be domineering or bullying, with a feeling that they are entitled to exert power and authority. They may show narcissistic tendencies and feel that the victim deserved maltreatment.27
Financial Exploitation. This occurs when family members, caregivers, or friends take control of the elderly person's resources. This can include coercion or outright theft, with or without the awareness of the victim. Dependent elderly people unwittingly may sign over access to savings accounts and other assets when they are in an incapacitated state. An elderly person's Social Security check may be used by a younger caregiver for his or her own needs. Perpetrators often rely upon the elderly victim for shelter or assets. Theft also may include the forcible transfer of property, including changing one's will to benefit the perpetrator.
Caregiver Neglect. The term "abuse" refers to acts of commission, while "neglect" refers to acts of omission. Neglect may entail failure to meet nutritional and hygienic needs, or lead as far as manslaughter or suicide.45 The refusal or failure to fulfill his or her obligations or duties to an elderly person may include deprivation of food, clothing, hygiene, medical care, shelter, or supervision that a prudent person would consider essential for the well-being of another.46 Abandonment constitutes the desertion of an elderly person by an individual who is that person's custodian or who has assumed responsibility for providing care to the elder.
Poor nutrition, poor hygiene, poor skin integrity, contractures, dehydration, fecal impaction, or excoriations all may constitute physical evidence of neglect.47
Psychological Abuse. This is defined as the infliction of mental anguish, pain, or distress. This may encompass a variety of actions intended to inflict emotional pain or injury, ranging from verbal threats to threats of institutionalization or humiliating statements. This is harder to prove than other forms of abuse. Patients may present with behavior problems, including self-neglect and psychotic behavior. Depression, suicidal thoughts or actions, or other self-destructive behaviors also may be presentations, and would constitute reasons for hospitalization.48
Violation of Rights. Examples of this may include denial of privacy or participation in decision-making. The patient may have a history of being locked in his or her room or of being tied down. The patient may have been ignored, isolated, or left alone. Any desertion of an elderly person that threatens his or her own health or safety could be construed as a violation of rights as well. Denial of access to glasses, hearing aids, or medications are other examples.
Abandonment may be included in this category as well. This generally applies to any individual who had previously assumed responsibility for providing care to an elder and has not turned over that care to another competent person.
Legal Considerations
State laws against elder abuse date from 1973.35,46 Currently, all 50 states and the District of Columbia have passed legislation to establish adult protective service (APS) programs. State APS statutes authorize agencies to investigate cases of elder mistreatment.49 These laws, in general, were based upon laws addressing child abuse. Since the latter concerned physical abuse primarily—and children had no money to exploit—earlier laws tended to be weak in the area of financial exploitation. The legal remedies offered for various forms of elder abuse tend to emphasize removal of the abused person from the setting in which the abuse is occurring.43,50
The federal government drafted the first laws regarding elder abuse in 1981 in the U.S. House Select Committee on Aging. Federal definitions of elder abuse were standardized in 1985 with the Elder Abuse Prevention, Identification, and Treatment Act (HR 1674), and addressed further in the 1987 Amendments to the Older Americans Act.35,43
Other resources that address the issue of elder abuse include: Criminal Justice Services; National Association of State Units on Aging; National Center on Elder Abuse; National Organization for Victim Assistance; and the National Coalition Against Violence. (See Table below.)
| Table 1. Resources for Managing Elder Abuse |
|
Laws for reporting elder abuse vary from state to state, and physicians should clarify existing law in their own state. Generally, physicians and other reporters are granted immunity when the reporting is done in good faith.31 Documentation should be clear and legible, as it may become evidence in a court of law.
Obstacles to Detection of Elder Abuse
Victims often have low self-esteem, may blame themselves for the abuse, and do not want to betray their families. They may not want to admit their vulnerabilities, or feel disgraced for having raised a child who would betray him or her in any way.9,51 They especially be ashamed to acknowledge their own dependency on the abuser or may be loyal to that abuser and unwilling to press charges against a family member. An abused older adult may be uninformed or misinformed regarding services available.51 He or she may harbor a fear of being removed from the home and placed in a nursing institution. This fear, in fact, may be warranted. In a Connecticut study, 60% of abused and neglected victims admitted for short-term care remained institutionalized permanently.52 The victim may worry about further abuse from a caregiver in retaliation for having divulged information. He or she also may worry about not being believed because the alleged abuser may act differently in public. Many elderly people are isolated and seldom leave the house, resulting in less opportunity for detection of abuse by others. The abuser may control access to others and may stay present during encounters with outsiders to ensure that secrecy is maintained.53
There may be differing definitions of abuse by victims from differing cultural backgrounds based on the perception of the intent of the abuser. One example cited is that of a woman who sedated her elderly mother when company came to prevent embarrassment from her mother's senile dementia. That report listed Korean Americans in particular as unwilling to reveal "family shame" to others or to create conflict among their relatives.54
Healthcare visits may be an elderly person's only contact with the outside world. Physicians infrequently report elder abuse for a variety of reasons. They may not be familiar with reporting laws. They may fear offending patients or their abusers or are concerned with time limitations in the emergency department. Time limitations may be a pervasive and driving fear in other medical specialties as well. There may be a feeling that requiring physicians to report cases may be patronizing to victims, who may be perceived as unable to make decisions for themselves, especially if they are competent.9 Emergency physicians may believe that they do not possess appropriate evaluation skills. A hospital may have no protocols for identifying or addressing elder abuse. One report from 1997 noted that only 31% of responding emergency physicians knew of a written protocol for the reporting of elder abuse and neglect.46 Few medical school curricula as of 1995 had formal training in the detection of elder abuse and neglect and interviewing techniques for potential victims and abusers.55 Physicians may be reluctant to ask questions about potential abuse because of fear of litigation and of possible court appearances.51,61 For whatever reasons, it is reported that physicians notify the appropriate authorities in only 1 of every 13 cases they identify.57 One large survey suggested that home care workers were the largest group of reporters (27%), followed by physicians and other health care professionals (18%), and family members (15%).58 Another review of five years of elder abuse reports in Michigan found that physicians made only 2% of the reports. Community members accounted for 41% of them, with non-physician health care workers filing 26%, and social and mental health workers another 25%.59
Further confounding factors may relate to any underlying medical disorder that the patient may have. Advanced neurologic disease such as multiple sclerosis, amyotrophic lateral sclerosis, or Parkinson's disease may lead to immobilization and severe disability. These individuals are at risk for pressure ulcers, pneumonia, or venous thromboembolism, even with adequate care.27
Abuse in Long-Term Care Facilities
Approximately 5% of elderly patients live in long-term institutions. In 1987 Congress enacted legislation that required nursing homes participating in the Medicare and Medicaid programs to comply with certain quality of care requirements. This legislation was included in the Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act.50 Every state has a nursing home ombudsman program that responds to reports of neglect or abuse in the nursing home elderly. Physicians may report suspicions of abuse to the state ombudsman or to Adult Protective Services.39,43
Abuse in institutional settings may manifest in similar ways to those in residential settings: theft of money or personal property, unsanitary conditions, poor personal hygiene, sexual assault, physical abuse or unexplained injury, bed sores, physical or chemical restraint, or malnutrition and dehydration.39,45,50
Elder abuse in nursing homes is well documented. A 1989 study from a random sample of 577 nurses and nursing aides from long-term care facilities indicated that 36% of respondents had witnessed at least one act of physical abuse in the previous year.60 A study of 2400 deaths in Arkansas nursing homes found 50 cases of suspected abuse or neglect, indicating perhaps a larger role for forensic studies in unexplained deaths of older adults in long-term care facilities.61 Abuse may be related to burnout or personal stress among staff, or to attitudes that residents are childlike and in need of discipline. Primary abusers of nursing home residents were nurse aides and orderlies with no stress training. The Coalition of Advocates for the Rights of the Infirm Elderly (CARIE) has developed an eight-hour program for caregivers working in long-term care facilities. The program focuses on recognizing abuse and possible triggers for abuse.62
Management and Intervention
The emergency physician must maintain a high index of suspicion for abuse when treating elderly patients. This is easier to detect when complaints are specific to sexual or physical abuse. Screening programs may be initiated. As with any emergency presentation, addressing airway, breathing, and circulation (the ABCs) take priority. A detailed history should include functional capacity, who the patient lives with, where the patient lives, and whether he or she feels safe. Laboratory and radiographic analysis should be conducted as indicated by history and physical findings. Photo documentation of injuries, sores, and general patient condition are helpful.
Patients in immediate danger should be hospitalized, transferred to the care of a friend or reliable family member, or placed in emergency shelters. Suspected abuse should be reported to the appropriate state agency, which can provide a more thorough long-term assessment. Local resources may vary, but may include social work, possible home nursing assistance, safe homes for older battered persons, and calls to the local Adult Protective Services (APS) agency.45 In cases of physical or sexual abuse, police should be called in accordance with state law. Patient disposition depends on the medical condition of the patient and the results of APS investigation. The patient may need to be admitted to the hospital for his or her protection until an alternative living situation is found or legal guardianship is established. Admission for a specific medical problem, such as decubitus ulcers or dehydration, may be more acceptable to the patient and the family or caregiver. This may be especially true if the home situation is not easily remedied, as in the case of the abuser with substance abuse or mental illness.
If the patient is not competent to decide for himself or herself, contact with APS should be initiated.63 APS is the official state entity charged with promoting advocacy and protecting victims of elder abuse and neglect. APS agencies broadly provide access to services that address the social, housing, medical, and legal needs of elderly persons.64 APS agencies were established by state statutes and may provide immediate evaluation, counseling, and relocation in cases of suspected elder mistreatment. In smaller jurisdictions they are under local law enforcement. They can establish a court-ordered guardianship or conservatorship to arrange shelter, finances, and care. Once a report has been filed to APS, a social worker is assigned to the case and makes a home visit. After conducting an interview and screening the case, the social worker may suggest solutions. Generally, the patient and the caregiver should be interviewed separately. The patient's decision-making capacity must be assessed. If an adult is suffering from mental illness or cognitive impairment and represents an immediate risk for hurting himself or herself, emergency removal orders may need to be pursued authorizing temporary involuntary hospital admission. Legal guardianship, also called conservatorship, is the permanent removal of a person's right to make his or her own decisions. This requires judicial oversight and due process for wards and conservatees.65
If the patient is competent, his or her wishes must be honored, even if those wishes do not appear to be in the patient's best self-interest. Ultimately, team members recruited to manage elder abuse and neglect cases may include physicians, nurses, social workers, APS caseworkers, law enforcement personnel, prosecutors, clergy, and representatives from financial institutions.64 In non-emergency cases, APS workers usually have between 30 and 60 days to complete an investigation and determine the validity of an allegation.
In 16 states, every citizen is a mandatory reporter for elder abuse, with reporting laws generally applying to professionals who interact with vulnerable populations. Failure to report is a punishable offense in 42 states, and good faith reporters are immune from civil and criminal lawsuits.66 Protective services must keep the identity of the reporter confidential.
Two studies found that, by being referred to APS, elderly persons were more likely to be institutionalized.67,68 With increasing demand for APS, there may be pressure to solve difficult problems through nursing home placement,69 although the irony of using a system intended to protect the health and independence of the vulnerable elderly population by institutionalizing them has not been lost on at least one author.51
On occasion, medical case management teams are convened to provide consultation and support to hospital staff, to assist in the multidisciplinary evaluation of suspected abuse, and to develop treatment plans. Team members generally are composed of a physician, nurses, and social workers.70 They may make house calls. Services provided may include physical and occupational therapy, nutritional improvement, or treatment of disease states. Legal intervention teams have been utilized as well. Their purpose may be to address financial management, probate and guardianships, or other legal and housing issues. Civil courts can issue protective orders, create guardianships, order assets to be frozen, adjudicate lawsuits, and issue emergency removal orders.64 In extreme cases, Fatality Review Teams have been convened to review deaths of older persons. These teams require participation by the medical examiner.71 A variety of agencies exist which offer information, research services, and advice regarding abuse and neglect of the elderly.41,64,72 (See Table.)
In some cases of unintentional neglect, education of the caregiver may be the only intervention necessary. Options for support to decrease the stress and anxiety that preceded the abuse may include home health aides, respite services, day programs, or accessible transportation to unburden the caregiver.9 Ultimately, the goal of treatment is not to punish the victim or the abuser, but to stop the abuse. When mistreatment results from the caregiver being overburdened, intervention may be welcomed by all parties. Options for the caregiver in less acute situations include periodic respite care, support groups, home health services, adult day care, and church activities or pastoral visitations.31
Conclusions
Elder abuse patients have substantial interactions with emergency departments. Geriatric abuse as a health care issue is a relatively recent phenomenon and still is evolving. Millions of elderly persons experience progressive dependency, social isolation, poorly rated self-health, and psychologic decline. Physicians are well situated for detecting and reporting suspected cases, although many barriers exist on the individual level. These visits frequently require hospital admission.
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CME Objectives
Upon completing this program, participants should be able to:
- Understand how to recognize elder abuse in patients who present to the ED;
- Understand the legal and reporting issues related to potential elder abuse; and
- Define the management and intervention of elder abuse presenting to the ED.
Physician CME Questions
1. Which of the following statements is true of self-neglect?
A. It excludes situations in which a mentally competent older person makes a conscious decision to engage in acts that threaten his or her own health or safety.
B. The patient has normal capacity to perform essential self-care tasks.
C. White race and affluence are risk factors.
D. It does not affect mortality.
2. Which of the following constitute risk factors for elder abuse on the part of the victim?
A. Dependency on the part of the victim
B. Very old age (older than 75 years)
C. Cognitive impairment
D. Female sex
E. All of the above
3. What are "red flags" for elder abuse?
A. Unwillingness of caregiver to leave the patient alone with the health care provider
B. Missed medical appointments
C. Poor knowledge of the patient's medical condition by the caregiver
D. Delays in seeking needed medical care
E. All of the above
4. Which physical finding does not suggest neglect?
A. Weight gain
B. Decubitus ulcers
C. Malnutrition
D. Dehydration
5. Obstacles to detection of elder abuse include:
A. Victims unwillingness to betray their families
B. Social isolation of the victim
C. Differing definitions of abuse by people of varying cultural backgrounds
D. Fear on the part of physicians of ending up in court or of time limitations
E. All of the above
CME Answer Key
1. A; 2. E; 3. E; 4. A; 5. E
Elder abuse and neglect has been recognized as a growing problem in the United States. All 50 states have reporting requirements for elder abuse and neglect.Subscribe Now for Access
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