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STANFORD, CA – Emergency physicians face a dilemma with elderly patients who are severely debilitated when they present for treatment. Are their symptoms caused by an underlying illness or are they victims of willful neglect or even unintentional neglect?
According to the level and type of neglect, clinicians might be obligated to report the case to adult protective services. And, being faced with that decision is not a rarity: Elder abuse has an estimated prevalence of 5% to 10% and has been linked to major adverse health outcomes, including dementia, depression, and mortality, according to recent articles published online by Annals of Emergency Medicine.
"Given the aging of the population, emergency physicians need to be prepared to balance their obligations to the patient by documenting findings, reporting suspicions and referring patients to appropriate agencies," explained lead author of one of the studies, Marguerite DeLiema, PhD, of the Stanford University Center on Longevity in Stanford. "Emergency physicians can also help prevent misunderstandings about elder neglect by encouraging patients to document care preferences, involve others in care planning and communicate with their caregivers about how to fulfill their wishes."
That article documented two case studies, one involving intentional neglect by a son who said he didn’t want to spend money on care for his father “because he is dying,” and another involving a family member who was overwhelmed by her father’s care.
Both patients had symptoms suggestive of neglect, according to the authors, but comprehensive review revealed many layers of complexity.
“We use these cases to illustrate an approach to the assessment of possible elder neglect in ED settings and how to intervene to ensure patient safety,” the researchers write. “We begin with a discussion of the differences between willful, unintentional, and unsubstantiated neglect by a caregiver and then describe when to suspect neglect by evaluating the elder, interviewing the caregiver and first responders, assessing the caregiver’s ability to meet the elder’s needs, and, if possible, obtaining medical history and information about the home care environment. These cases illustrate the importance of careful documentation in cases of suspected neglect to assist investigative agencies, reduce the risk of further harm, and improve patient outcomes.”
A second report defines elder abuse and neglect as “action or negligence against a vulnerable older adult that causes harm or risk of harm, either committed by a person in a relationship with an expectation of trust or when an older person is targeted based on age or disability.” The authors point out that mistreatment could include physical abuse, sexual abuse, neglect, psychological abuse, or financial exploitation, with many victims experiencing a combination of those.
Those researchers recommend a team-based approach across disciplines to identify elder abuse, including emergency medical providers, triage providers, nurses, radiologists and technicians, social workers, and case managers. Study authors emphasize that opportunities to detect abuse exist throughout an episode of emergency care, and involve everyone from paramedics and EMTs to social workers and law enforcement who intervene after a problem is identified.
"Currently, most victims of elder abuse and neglect pass through our emergency departments with a life-threatening condition unidentified," lead author of the second study, Tony Rosen, MD, MPH, of Weill Cornell Medical College in New York, said in an American College of Emergency Physicians press release. "A multi-disciplinary, team-based approach supported by additional research and funding has the potential to improve the identification of elder abuse and improve the health and safety of our most vulnerable patients."