1. Elder Mistreatment: A geriatrician’s perspective Hal H. Atkinson, MD, MS Associate Professor Department of Internal Medicine, Section on Gerontology and Geriatric Medicine

2. Objectives of the Talk  Describe challenges for the healthcare provider identifying and managing elder mistreatment (abuse, neglect and fraud)  List risk factors and common presentations of elder mistreatment  Discuss what a healthcare provider can/should do in cases of suspected mistreatment

3. A common scenario  82 year old man with 5 years of progressive memory loss due to Alzheimer disease is brought by his daughter (the sole full-time caregiver) for a regular check-up  She is concerned that he is not keeping up with his personal hygiene – not bathing daily, wears the same clothes over and over  She tries to get him to bathe, but he often yells at her and tells her to go away  During the interview, the patient says that his daughter won’t let him “do anything” and has taken all of his money -- Daughter argues with him that this is not true and that he just “never wants to do anything”

4. A common scenario  Physical Examination:  Unkempt, urine stains on pants, well-nourished  Bruises on both hands  When asked about them, the patient says it happened while working on the car, and the daughter says that he occasionally gets frustrated and hits things  Significantly impaired short term memory (cannot remember the year, time, day of the week, or where he currently lives)  Cannot perform simple calculations or make change from a dollar

5. The challenge for the physician  Is this man a victim of elder abuse or neglect?  He is vulnerable to abuse/neglect by virtue of his Alzheimer’s disease  His finances have been taken over  Poor hygiene and bruising on his hands  Some strained interaction with the patient and caregiver  But, some big questions come up:  He is not capable of dealing with finances  Forcing daily bathing might be worse in this case  Bruising frequently happens spontaneously  What level of frustration is normal?

6. There are many types of mistreatment  Physical  Sexual  Emotional  Neglect of a vulnerable person  Financial  More than one type often occurs in the same individual

7. Major risk factors for elder mistreatment Emotional or Financial Dependence Substance abuse/ Psychiatric illness Caregiver Stress Physical Dependence Memory Problems Vulnerability to Mistreatment Older Adult Potential Abuser

8. How do we identify it?  Some cases are obvious  E.g. Major injuries that otherwise don’t make sense – certain locations and types of injuries may tip off  Most often, we have to rely upon observation of what is going on  General sense of the room (the “Blink” response)  Caustic interactions between abuser and patient  Not letting the patient speak, not leaving the room, overly secretive  Missing appointments  Reports from others of problems

9. How can physicians/geriatricians help?  Bring concerns to our attention!  Evaluation for vulnerability can be helpful to make recommendations for what appropriate care/oversight might be:  Cognitive  Includes Decision Making Capacity – keep in mind that older adults with decision making capacity have as much right to bad decisions as younger people!  Physical  Medical complexity

10. Things we can do to help  Immediate safety plan: sometimes means admission to a hospital  Referrals for protective services  Education of patient or caregiver to prevent mistreatment:  E.g. in the patient presented:  education about Alzheimer’s disease  reasonable targets for hygiene  dealing with problematic behaviors or violent outbursts  community resources for care  appropriate level of care  support groups  “giving permission” to take mental health breaks

11. Questions?