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How to spot elder abuse and neglect in the ER: Things are not always as they seem

When older adults in severely debilitated states show up for treatment in the emergency department, emergency physicians and staff must be able to identify and document their symptoms and decide whether to report their concerns to adult protective services. This is a difficult decision as the patient’s symptoms may stem from willful neglect, unintentional neglect or sub-acute symptoms caused by an underlying illness than manifest as neglect. Two papers published online recently in Annals of Emergency Medicine highlight a problem that promises to grow rapidly with the aging of the Baby Boom generation.

“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,” said Marguerite DeLiema, Ph.D, of the Stanford University Center on Longevity in Stanford, Calif., the lead study author of “The Forensic Lens: Bringing Elder Neglect into Focus in the Emergency Department.” “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.”

Ms. DeLiema’s team documented two case studies in which seemingly similar symptoms of elder neglect (severe malnutrition, skin ulcers and other physical problems), resulted from very different caregiving situations. In one instance, the patient’s daughter had become frustrated with medical providers after a home health care agency refused to care for him when his condition deteriorated. The daughter believed she could provide better care on her own and brought her father home from the hospital against medical advice. In the other case, the patient’s son intentionally neglected his father for his own financial gain. He reported that he refused to provide medical care because his father didn’t “need to see a doctor or take medicine because he is dying.”

The second paper (“Identifying Elder Abuse in the Emergency Department: Towards a Multi-Disciplinary Team-Based Approach”) recommends 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. Opportunities to detect abuse occur throughout the episode of emergency care, from when paramedics and EMTs enter a patient’s home to the clinical exam in the emergency department through intervention by social workers and/or law enforcement.

“Currently, most victims of elder abuse and neglect pass through our emergency departments with a life-threatening condition unidentified,” said the latter paper’s lead study author, Tony Rosen, MD, MPH, of Weill Cornell Medical College in New York, N.Y. “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.”