Mike Magee

In  2012 the Institute of Medicine convened a forum on global violence. In the report they noted that, “Although little discussion took place regarding violence against the elderly, some elements of the framework could apply to elder abuse.”(1)

It should be no surprise to anyone that the care of elder Americans generates a large portion of our annual healthcare expenditure in the United States. Those over 65 represent 13 percent of our population but consume 40 percent of our healthcare dollars. (2,3)

For such a large investment, it’s remarkable how incomplete our understanding of senior care is. This is in part the result of a focus on investigating the treatment of diseases in the elderly rather than on exploration of strategies and tactics to expand functionality and comfort, and in part on not addressing social infrastructure issues such as elder abuse.

New approaches have begun to more thoughtfully approach the challenge of elder health. The approaches are based on a principle well expressed by Jim Firman of the National Council on the Aging, who said, “We mistakenly define long-term care problems as medical concerns, rather than a disability concern…The care needs of most frail older people are primarily supportive: for example, help them move from here to there, help them eat and dress, and help them keep track of their medicines.” (4) In fact, 42 percent of those over 65-some 14 million seniors-are disabled. 12.4 million seniors are home-based, and 1.6 million are institutionalized. (5,6)

A new approach to senior care allows for the identification of vulnerable adults and validates a system for assessing the quality of senior care. It’s called ACOVE, for Assessing Care of Vulnerable Elders, and was developed by the RAND Corporation with a landmark study completed in 2003. (7) According to RAND, “The ACOVE study is the most comprehensive examination of the quality of medical care provided to vulnerable older Americans.”(8)
In the study, a randomly selected population of seniors were surveyed to identify a subpopulation deemed vulnerable. 475 of the 2278 surveyed, or 21 percent, were found to be vulnerable. These patients were four times more likely than healthy seniors to suffer disability or death within two years. The average age of patients in the vulnerable group was 80.6 years. Sixty-four percent were women. The most common health issues were diabetes (23 percent); emphysema (22 percent); a history of falls (13 percent); heart failure (7 percent); incontinence (7 percent) and dementia (6 percent). (7)

The assessment of care quality was based on 236 quality measures. Twenty-six percent of them dealt with screening and prevention. Twenty-one percent focused on proper diagnosis. Thirty-six percent measured treatment of conditions, and 17 percent tracked appropriate follow-up. Each of the 236 indicators laid out a problem and the appropriate response. For example, for osteoarthritis: “IF an ambulatory vulnerable elder receives a new diagnosis…and has no contraindication to exercise… THEN a directed or supervised strengthening and aerobic exercise program should be prescribed within 3 months.” Or for incontinence: “ALL vulnerable elders should have documentation of the presence or absence of urinary incontinence at the initial evaluation.” (7)

No matter how you slice the data, the results show tremendous room for improvement. The overall compliance, or practice patterns that met recommendations, was only 55 percent. And for those problems unique to a geriatric population-such as falls, incontinence, pressure ulcers and end of life care- compliance was a mere 31 percent. Equally striking, there was a much greater emphasis on treatment than on prevention or follow through. On the treatment side, recommendations were followed 81 percent of the time. So if you were diagnosed with a problem, you more than likely received treatment. But that’s a big if, since indicators dealing with appropriate diagnosis were followed only 46 percent of the time. Preventive strategies were an afterthought at 43 percent, and appropriate follow-up occurred in only two out of every three patients. (7)

Where care does occur, it is certainly biased toward some diseases over others. We do best with stroke (82 percent), medication management (81 percent), vision care (79 percent), hearing loss (77 percent), hypertension (77 percent), heart failure (71 percent) and diabetes (57 percent). We do poorest with end-of-life care (9 percent), urinary incontinence (29 percent), depression (31 percent), osteoarthritis (31 percent), fall prevention (34 percent), dementia (35 percent), pressure ulcers (41 percent), malnutrition (47 percent), and pneumonia (49 percent). (7)

And, as it turns out, seniors are at risk at home as well as in clinical care settings. (9)

As Stephanie Lederman, executive director of the American Federation of Aging Research notes, “A large segment of our population is both dependent and frail. Studies on elder abuse now alert us that seniors are also vulnerable and in need of help.” (10) And the problem is getting worse. According to the most recent study from the National Center on Elder Abuse, the incidence rate of elder abuse increased 150 percent between 1986 and 1996. (11)

How large is the at-risk segment? One study of 2,812 adults over age 65 revealed that 6 percent, or 176, of them were seen by elderly protective services over a nine-year period. Nearly three-quarters of these cases involved self-neglect, but the remaining 27 percent were traced to the actions of others – nearly 6 percent of the elderly people experienced physical abuse, 17 percent had been neglected, and almost 5 percent suffered exploitation. (12)

What is elder abuse? The U.S. National Academy of Sciences defines the problem as, “Intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder; or, failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” (13)

Elder abuse not only implies that a person has suffered injury or neglect, but also that a specific individual, entrusted to provide care, is responsible. The abuse may take a variety of forms, including physical abuse, psychological abuse, sexual assault, exploitation of material resources, or neglect.

Studying elder abuse is easier said than done. For example, a simple geriatric study on how to prevent elder fractures due to falls must consider confounding issues such as polypharmacy, visual impairment from cataracts and other conditions, and depression or dementia, to name a few.6 When one then attempts to decipher naturally occurring injuries from deliberate ones, study design and verification become critical. Was an injury due to loss of balance or assault? Did weight loss occur due to chronic disease and cancer or from neglect? Was under- or over-medicating the result of forgetfulness or malevolence of the caregiver? (9,14)

Risk factors associated with elder abuse are increasingly clear. Most incidences occur in shared living situations where there is prolonged access by a family member, friend or entrusted surrogate. Elder dementia creates both a complex management challenge and an unreliable witness to the abuse, which complicates documentation. Social isolation creates stress that can lead to reactive abuse behavior, as well as a hidden environment to harbor abuse, neglect, or exploitation. The presence of caregiver mental illness, including depression or substance abuse, increases the likelihood of harmful behaviors, as does the use of family-member caregivers who are dependent upon and often resentful of the senior for whom they are charged to provide care. (9,12)

Caring for a frail, dependent and vulnerable senior is challenging under the best circumstances. When abuse is interjected, the consequences are significant, including an increase in mortality rates. One study has documented that the three-year mortality rate for seniors who are exposed to elder abuse was 91 percent, compared to 58 percent in a matched dependent senior population that was not abused. (12)

Dr. Mark Lachs and his colleagues note, “It seems plausible that experiencing elder abuse is an extreme form of negative social support. In the same manner that social integration reduces mortality, it may conversely be the case that the extreme interpersonal stress resulting from elder abuse situations may confer additional death risk.” (12)

Screening elders for abuse requires high awareness and good clinical judgment. There is not a clear consensus on routine monitoring or an instrument to be used. (9,12) General concern should be raised when physicians, nurses, and other members of the care team observe a poor social network, poor social functioning, and signs of conflict between a patient and a caregiver. Clinicians should trust their clinical judgment and instincts, do a complete physical assessment with a focus on cognitive function, question the patient in private, and be cautious in discussions with the caregiver, extending empathy while uncovering the individual’s mental status and coping skills. (9)

Similarly, families should trust their instincts. Is mom or dad declining without an obvious reason? What is the level of cleanliness of the patient and the home setting? What is the patient being fed, and, under direct viewing, how gentle and effective is the process? Are there unexplained bruises, blisters, or painful areas? Is the senior’s mobility rapidly declining? What is being said to the senior, not simply with words, but also with messages and tone? And what do your instincts tell you when you make unannounced visits?

So what are the realities and how should we respond to these challenges? First, we’re not doing a great job in elder care delivery with the resources provided. Second, there is a disconnect between patients’ needs and physicians’ focus. Doctors focus on treating diseases and increasing lifespan. Patients focus on comfort, increasing functionality and maintaining independence. Third, the ACOVE list of 236 quality indicators provides an excellent roadmap to quality care. Fourth, the best way to get there is to simultaneously communicate the guidelines to patients, families, doctors and other caregivers so that they can challenge each other to raise the standard and make the grade. Fifth, we need to insert the family caregivers into the care team, arming them with knowledge and emotional support.

Addressing senior abuse requires a continuum of committed individuals from home to care sites and back home again, providing reliable monitoring, oversight, diagnosis, and intervention when necessary. Such a network must be built, and a good place to begin is with an informed discussion of the issue between family members and their care teams.

For Health Commentary, I’m Mike Magee.

References:

1. XinQi. Elder Abuse and The Contagion of Violence. October 4, 2012. IOM. http://bit.ly/SxOJnz

2.Manton KG et al. Monitoring changes in the health of U.S. elderly populations: Correlates with biomedical research and clinical innovations. FASEB J. 1997;11:923-930

3.Hodgson TA, Cohen AJ. Medical expenditures for major diseases 1995. Health Care Finance Rev. 1999; 21:119-164 (PMID:11481772}.

4. New Environments for Mature Living. The Pfizer Journal. Vol. 3: No. 3, 1999

5.Census 2000 Brief. The 65 and over population: 2000. Available at http://www.census.gov/2010census/

6.Census 2000 Brief. Disability status:2000. Available at: http://www.census.gov/2010census/

7.Wegner NS et. al. The quality of medical care provided to vulnerable community-dwelling older patients. Annals of Internal Medicine. 2003;138:740-747

8.RAND corporation. RAND-UCLA study finds significant shortfalls in quality of health care for vulnerable seniors. Press Release. Monday, November 3, 2003.

9. Lachs MS, Pillemer K. Elder abuse. The Lancet. 2004;364:1263-1272.

10.Lederman S. Private communication, 2005.

11.National Center on Elder Abuse. Reports of Domestic Elder Abuse. http://www.ncea.aoa.gov/

12.Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA. 1998;280:428-443.

13.National Academies of Sciences. Bonnie R, Wallace R, eds. Elder abuse: abuse, neglect, and exploitation in an aging America. Washington, D.C.: National Academy Press, 2002.

14.Lachs MS, Pillemer K. Abuse and neglect of elderly persons. NEJM. 1995;333:70, 437

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