It’s a diagnosis that cannot be made with a basic CBC or CMP. There is no X-ray, CT, or contrast dye available that can detect this horrifying cause of suffering. Yet it affects one of the most vulnerable populations in our society and it is often lurking right beneath the hospital gown. It is up you and me, as future healthcare professionals to put our investigative and astute clinical judgment to use and dissect this problem. The culprit? Elder Abuse.
Research conducted by the National Center on Elder Abuse found that 1/10 elders suffer from some type of abuse. In fact, Orange County’s Adult Protective Services (APS) receives over 700 reports of suspected abuse or neglect each month. Adults over 85 years of age are the fastest growing population in the United States. Laura Mosqueda, M.D, Co-Director of National Center for Elder Abuse and faculty at the University of California, Irvine School of Medicine points out that more ½ of this population suffers from dementia and physical frailty. This means there is an exponential increase in one of most vulnerable groups of our society. As this population grows, the number of providers is decreasing. This intersection is worrisome, as Dr. Mosqueda notes, and it means elder abuse is only going to become more common. In fact, there has been a 46% increase in the number of APS reports received from 2002-2012.
Elder abuse can take many forms: financial, physical, emotional, sexual, and neglect. But they all can have the same life-threatening and devastating consequences for the victim. For example, Dr. Mosqueda tells the story of an elderly patient who was financially scammed and terrorized by her plumber. Soon, the patient started to retreat, avoided leaving her house and missed her doctor’s appointments, and stopped answering calls in order to avoid the scammer. She was found in congestive heart failure in her home and soon ended up in a nursing facility. In a period of just 9 months this elderly patient had lost her independence and her health had deteriorated significantly due to financial abuse by a stranger. Physical abuse includes suspicious bruising, fractured bones, and burns. Unfortunately, the natural age-related changes such as propensity for bruising and osteoporosis mask the signs of physically inflicted abuse, making it easier to miss clues. Sexual abuse is common in dementing illnesses where patients are unable to express themselves or are often not believed to be telling the truth. It is marked by horrible genital bruising with an attempt by perpetrators to contribute it to catheters. Newly developed STD’s can also point to a sexual violation. Finally, signs of neglect include poor hygiene, infected old wounds, malnourishment, and dehydration.
So what can we, as medical students do to prevent elder abuse? The most important thing to do is to educate ourselves and learn what signs and symptoms to look out for. Because if we are missing the obvious signs and ignoring a silent plea for help, we are actually part of the problem. As medical students we have the privilege to spend more time with our patients than our residents and attendings, providing for a golden opportunity to be a leader in the care of our patients. First we must recognize that elder abuse can occur anywhere and it affects seniors across all socio-economic groups, cultures, and races. Recognizing risk factors such as dementia, substance abuse, and isolation can also help guide the diagnosis. For example, seeing untreated pressure “bed” ulcers, lack of medical aids such as glasses, hearing aids, and teeth, and lack of basic hygiene and adequate food should prompt you to further investigate the cause. Uncharacteristic changes in behavior by your patient and sudden panic in the presence of certain individuals may point to emotional and psychological abuse at home. A recent informative study on accidental bruising in older adults revealed many important considerations in assessing the etiology of bruises. 90% of accidental bruises were found on the extremities (rather than head, trunk, or neck), and less than 25% of geriatrics with accidental bruises remembered how they got them. However, 90% of elders who had been physically abused can tell you how they got them (this includes adults with dementia!). Dr. Mosqueda advises that if we regularly see a patient whom we know has a propensity for bruising due to their medications or has had frequent falls and fractures due to osteoporosis, we should carefully chart these findings during every visit so we have a reference in case a suspicion arises in the future.
What should we do if we suspect that one of our geriatric patients is suffering from abuse? We must report our concerns to our local Adult Protective Services. It is not our job to prove abuse, but rather we must bring it up to the professionals to investigate further. Resources such as the Orange County Elder Abuse Forensic Center lead by Dr. Kerry Burnight were created for the sole purpose of educating and training medical students and physicians in elder abuse and conducting multi-agency case reviews in collaboration with the criminal justice system and APS. Such resources are invaluable to our education and the protection of the geriatric community.
And why should we care about elder abuse? Because the moment we surrender to the reality that some of the most vulnerable members of our society are being exploited and abused regularly, we surrender the prospect of a more harmonious society consisting of quality of life and preservation of dignity for all. And when we surrender to this harsh reality, we also abandon an important component of our Hippocratic Oath: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”
Mosqueda L, Burnight K, Liao S. The life cycle of bruises in older adults. J Am Geriatric Soc 2005 Aug;53 (8):1339-43
Findings from an elder abuse forensic center. Wiglesworth A, Mosqueda L, Burnight K, Younglove T, Jeske D. Gerontologist 2006 Apr:46 (2):277-83
MSII, University of California Irvine School of Medicine
A native Californian, Shaudee earned her BS in biological sciences at the University of California, Irvine in 2011. She feels lucky to continue to live in and study medicine at UC Irvine where she can be close to her family and friends with whom she shares a close bond. An Avid yoga practitioner, Shaudee firmly believes in the power of inner peace and a calm mind as keys to health and happiness. She is the founding co-chair of UCI's AMA-MSS chapter and is passionate about health care policy at the local and national level. She continuously strives to educate herself on health policy by interacting with local congressmen and women, advocating for GME funding and other pertinent issues relevant to medical students. She is also the Co-president of UCI's Family Medicine Interest Group and chair of patient education for the student-run Shifa Health Clinic in Orange County.