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Correspondence: Address correspondence to J. Heath, MD, One RWJ Place, Box 19, New Brunswick, NJ 08903-0019. E-mail: Heathjm{at}UMDNJ.edu
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Abstract |
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Key Words: Elder abuse and neglect • Elder mistreatment • Geriatric assessment • Adult protective services
Health care professionals constitute one of the largest reporting sources of possible elder mistreatment to APS agencies, according to the 2000 State Survey of Adult Protective Services (National Center on Elder Abuse, 2000), though the nature of health conditions among victims of elder mistreatment is ill defined (Jones, Veenstra, Seamon, & Krohmer, 1997). Elder mistreatment, however, has been shown to have a significant impact on the mortality of its victims, independent of other comorbidities (Lachs & Pillemer, 2004; Lachs, Williams, O'Brien, Pillemer, & Charlson, 1998). Other studies based on hospital-based clinical-assessment services (Coyne, Reichman, & Berbig, 1993; Dyer, Pavlik, Murphy, & Hyman, 2000) have identified a high prevalence of dementia and depression among those suffering neglect or abuse. In some settings, APS agencies have established relationships with health care providers to jointly respond to elder-mistreatment occurrences (Dyer et al., 1999; Mosqueda, Burnight, Liao, & Kemp, 2004), often in association with concurrent medical education (Heath, Dyer, Kerzner, Mosqueda, & Murphy, 2002).
Our current study describes the diagnostic findings of medical and functional conditions from one such collaboration between APS agencies and a geriatric-assessment service in assessing homebound older adults who were experiencing various forms of elder mistreatment. Our study objectives were to describe the prevalence of remediable geriatric conditions and to seek associations between such previously undiagnosed findings with the type of mistreatment the APS clients undergoing the assessment were suffering.
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Methods |
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Prior to the initiation of LGAPS, participating geriatric clinicians met with the APS staffs in both counties to review their training in recognizing health issues and to discuss the collaborative process by which the social work and health care teams might work best together. Referrals to the LGAPS in-home assessment service were made by the APS workers from among their clients with substantiated mistreatment who had unmet health needs at the time of the initial APS contact. LGAPS assessment services were limited to those APS clients who did not have an existing health care provider that could be identified by the APS worker or who refused to leave their homes to access a prior source of health care services as recommended by their APS workers.
LGAPS assessments were conducted by a nurse practitioner–geriatrician physician team in collaboration with the referring social worker at the residence of the referred APS client. The assessment process included a detailed medical and functional history along with a limited physical examination, including blood pressure measurements, assessment of gait and mobility, visual and hearing acuities, and formal screening assessment of cognition (Folstein, Folstein, & McHugh, 1975), depression (Yesavage et al., 1983), and nutritional status (American Academy of Family Physicians, 1999).
This retrospective cohort study is based on assessments of 211 APS clients referred for LGAPS assessments from June 1999 through April 2002. The study was approved by the Institutional Review Board for the Protection of Human Subjects of the University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School.
Outcome Measures
The classifications of mistreatment—neglect, financial exploitation, and abuse—that we used came from the APS workers and reflected the state-reporting terminology in use at the time of the study (New Jersey State Department of Health and Senior Services, 2000). These classifications served as independent variables correlated with the findings of the geriatric-assessment process, grouped into medical diagnoses of dementia, depression, hypertension, diabetes, and active pain; involuntary weight loss; and functional issues of falling, incontinence, uncorrected vision or hearing sensory impairments, limited food access, and alcohol abuse.
Data Analysis
We entered data into SPSS for Windows Version 11.0 for descriptive statistics and tests for associations using both parametric and nonparametric statistical measures.
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Results |
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Classification of Elder Mistreatment
Self-neglect was by far the most common manifestation of mistreatment among patients referred for assessment (161 cases), although most APS clients referred for assessment had more than one form of mistreatment identified by the APS workers at the time of referral. There were 100 occurrences of caregiver neglect, 62 reports of exploitation, and 31 reports of physical abuse. Although we noted no significant patterns of age or racial distributions among these classifications of mistreatment, women who were referred for assessment were more likely to have suffered exploitation than men (
2 = 6.5; p =.011). When we examined living circumstances, self-neglect appeared to be associated primarily with women who were living alone (2 = 25.0; p <.0001). Of the 31 cases of physical abuse, 6 of the 7 abused men were living with a caregiver present, whereas for the 24 women there were equal numbers distributed among those living with the perpetrator present and those living alone.
Diagnostic and Functional Findings
Table 1 shows the overall prevalence of assessment findings and statistically significant positive correlations with various forms of mistreatment. Dementia was the most prevalent newly diagnosed condition, found in 62% of referred APS clients. A diagnosis of dementia was positively correlated with caregiver neglect among women (R =.17; p =.03) but not among men. However, the mean Mini-Mental State Examination (MMSE; Folstein et al., 1975) performance score was significantly poorer for APS clients of both genders who had suffered caregiver neglect than for those who had not experienced neglect (14.6 vs 19.6; p <.0001). There were no significant differences in the MMSE performance score among those suffering financial exploitation or physical abuse.
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Nutritional concerns were commonly identified among assessed individuals, with 127 individuals having either unintentional weight loss (34%) or limited food access (25%) identified. These nutritional issues were not associated with any individual type of elder mistreatment, nor were there statistical associations identified with the living situation of those with these nutritional concerns.
A significantly high prevalence of pain (32%) was identified in this cohort. Among these 69 individuals, 28 (13% of the total population) had severe, uncontrolled pain at the time of the assessment that required immediate intervention. Women living alone were more likely to have unaddressed pain-management issues (2 = 11.8, p =.003), as were those with higher cognitive performance scores (mean MMSE of those with pain control issues 22.0 vs 15.2 of those without pain; p <.0001). We did not find pain to be correlated with any single category of elder mistreatment.
Targeted functional conditions included falling, incontinence, and sensory impairment. A total of 58 individuals (26%) had fallen, and no single form of mistreatment was associated with this finding. However, urinary incontinence, which was another highly prevalent functional issue identified among 23% of assessed individuals, was highly correlated with having suffered caregiver neglect (R =.371; p =.003). Sensory impairment of vision or hearing was found in 47 assessed individuals (22%). Caregiver neglect was associated with this sensory impairment among men (R =.31; p =.022) but not among women.
Twenty-two individuals (10.4%) had alcohol misuse identified during their assessment. We found alcohol abuse to be positively correlated with having suffered physical abuse among these 17 women (R =.20; p =.01) but not for the 5 men.
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Discussion |
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The predominance of neglect among the APS clients described here is consistent with the known national distribution of the various forms of elder mistreatment (Lachs & Pillemer, 1995). The high prevalence of dementia and of depression in this study is also consistent with findings in previous studies focused on neglected populations (Coyne et al., 1993; Dyer et al., 2000). The gender differences seen with the associations of exploitation and caregiver neglect among demented women and caregiver neglect among men with uncorrected sensory impairment and with physical abuse occurring among women with alcohol abuse have not been reported previously.
The frequency of pain issues among assessed individuals was not found to be associated with any single form of mistreatment and provides an important modifiable feature that should be sought among older adult victims. Cognitively impaired clients may not have been able to report pain as well as those with better cognitive function. Pain may have been one of the most recognized "unmet health needs" identified by the referring APS social workers, in part reflecting the declining health state of their clients suffering abuse or neglect (Reyes-Gibby, Aday, & Cleeland, 2002).
The frequency of unintentional weight loss was not found to be associated with any individual form of elder mistreatment and identifies another feature that should be investigated among older adult victims, as it may be a marker for serious undiagnosed underlying disease.
Health care providers will encounter older patients presenting with symptoms or signs of possible mistreatment that may include but are not limited to the following: neglect of personal hygiene, health, or welfare; hindered access to needed medical services; inadequately explained multiple bruising, pressure sores, or other trauma; and psychological signs of maltreatment or impoverishment. When such signs are identified, providers must take the appropriate action of reporting such situations to the APS-responding agency for investigation and intervention (Jogerst et al., 2003; Lachs & Pillemer, 2004).
An important limitation of these data is their applicability to other populations of abused or neglected elders living in community settings but not having been identified as having unmet health needs, the determination used by the APS social workers to trigger the LGAPS assessment process described here. Other APS clients with similar unmet health needs will have an identified physician or other source of health care that can be enlisted by the APS workers. In addition, the provision of the assessment process described here was conducted in the home setting and therefore was limited in the thoroughness of some elements of the diagnostic process, although the home setting facilitated other aspects of the assessment process (e.g., falling assessment).
Another common concern in elder mistreatment research is the lack of common terminology across APS agencies to categorize manifestations of elder mistreatment. Prior reports (Levine, 2003; Daly & Jogerst, 2001) have documented the variation between states in the use of mistreatment classification terms such as abandonment (not used in New Jersey) as well as terminology such as self-neglect, which is included among the issues that APS must address in New Jersey. Finally, the prevalence rates and diagnostic associations described here are based on a community-dwelling sample of mistreated adults and may not reflect the experience of mistreated residents living in institutional settings such as nursing homes. This study does have relevance for questions regarding institutionalization, however, because APS-service utilization has been identified as a "risk factor" for nursing home placement (Lachs, Williams, O'Brien, & Pillemer, 2002).
In conclusion, the high prevalence of identification of many remediable geriatric health issues among community-dwelling victims of elder mistreatment resulted from a productive collaboration between geriatric health care providers and APS workers responding to elder abuse and neglect.
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Footnotes |
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1 Department of Family Medicine and Department of Internal Medicine, University of Medicine and Dentistry of New Jersey, New Brunswick.
2 New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark.
3 Department of Geriatrics, Florida State University, Tallahassee, FL.
4 School of Social Work, Rutgers, The State University of New Jersey, Piscataway.
Decision Editor: Linda S. Noelker, PhD
Received for publication November 12, 2004. Accepted for publication April 22, 2005.
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This article has been cited by other articles:
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  S. M. Strasser and T. Fulmer The Clinical Presentation of Elder Neglect: What We Know and What We Can Do Journal of the American Psychiatric Nurses Association, January 1, 2007; 12(6): 340 - 349. [Abstract] [PDF]
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