Identifying Abuse in the LTC Setting

^{By Julie Gould}

Laura Mosqueda, MD, professor of family medicine in geriatrics at the Keck School of Medicine of USC, highlights current rates of elder abuse cases and explains how long-term care facilities can identify and prevent future instances of abuse.

Please tell us a little bit about yourself.

Dr Mosqueda: I'm a family physician and a geriatrician. I've been a medical director of nursing homes in the past, although I'm not currently. The other thing that might be of interest to folks in annals of long-term care is that I'm also a volunteer long-term care ombudsman.

Currently, I'm professor of family medicine in geriatrics at the Keck School of Medicine of USC. I'm also the dean of the medical school.

Can you briefly highlight current rates of elder abuse, and do you know how often these cases occur in the long-term care setting?

Dr Mosqueda: Of course, we all want to know, how common is elder abuse? Our best estimates are that about 1 in 10 people over the age of 60, or maybe 65, are abused or neglected each year. We don't have those rates in nursing homes or in other long-term care settings.

You can imagine those data are hard to come by. The best we have are some anonymous surveys that show very high rates when you ask a nursing assistant, for example, "Have you ever seen abuse, neglect, or psychological abuse in a nursing home?"

You'll get very high rates of people saying that they've seen it. Even in these anonymous accounts, you can ask if they actually themselves have ever done any abusive sorts of actions, and there will be some admission of that as well.

This is a staff survey, and these are data from 1989. Anonymous survey, where 36 percent of staff said they saw physical abuse, and 10 percent actually admitted that they had committed physical abuse. 80 percent said they saw psychological abuse and 40 percent admitted to committing psychological abuse.

Again, these data are really old, and this was nursing homes. We don't really know what the rates are.

What are the key things to look for to help identify elder abuse cases?

Dr Mosqueda: There are a lot of opportunity in long-term care, because every time we're seeing somebody in long-term care, we're basically going to their home. It's a house call, in a way. Whether it's a nursing home, an assisted living, or some other sort of licensed situation, we have the opportunity to look at not only the individual person, but the context, where they are.

I think anytime you go into a facility, truly important to look around. What does it smell like? What does it look like? What are the interactions? What are the interactions like between staff and the older adults who live there? Being aware as to whether the person is getting visitors or not.

Then the other really important thing at the one-on-one level with an individual, older adult who's your patient, is just to be a good observer. If the person is losing weight, and they can't see themselves, don't just be looking for thyroid disease, but wonder if they're getting fed.

My big plea for healthcare providers is, we have to have abuse and neglect on our differential diagnosis, because if it never occurs to us, then we may not realize that that bruise, that fracture, that pressure sore, or that weight loss might actually be an indicator of abuse or neglect.

How can long-term care facilities utilize the new tool you recently developed?

Dr Mosqueda: Well, I was motivated to work on develop this tool with colleagues, because I occasionally am asked to review a case of possible abuse or neglect, and have been really disappointed at the level of our documentation of an injury in an older adult.

This tool is really for anybody who's documenting an injury in an older adult. In a way, it has nothing to do with abuse or neglect, but it does mean that, if it was due to abuse or neglect, we will have a more well-documented injury.

Sometimes, when we see something like a bruise or a pressure sore, we don't at that time think that it's evidence of elder abuse, but later, it turns out that it actually was. Having that documented really well is really important.

The idea behind the tool is to make it as easy as possible. Just recognizing how busy everybody is, to make it as easy as possible to document it, and also, just to remind people about, what are the important things to document in terms of size, shape, color, depth, depending on what the injury is.

It provides some gentle reminders on not just to make it easy to document, but what you should actually document.

How do you foresee future cases being prevented with use of this tool?

Dr Mosqueda: In terms of prevention? This tool, again, we're not couching it so much as an elder abuse tool. It's a tool to document injuries in older adults. I think what it might do is make you stop and think, if you're documenting something, and it sounding pretty bad, or there's multiple, it's reminding you, when you see a bruise, to look at the whole body and look for bruises elsewhere.

It might help you stop and think that this actually might be evidence of abuse or neglect. If it does turn out to be, then it enables you to put a stop to it. Unfortunately, by the time of lot of cases come to our attention as abuse or neglect, it's been going on for months and years, not hours or days.

What are the challenges of implementing a tool like this into practice? Is there a big learning curve for staff?

Dr Mosqueda: No, it's extremely easy to use. I think it's a matter of getting it incorporated into electronic health records, so that it's easy to use. Nursing homes in particular already have documentation tools for things like pressure sores.

The hope is, this makes it even easier to just circle areas and be able to document these sorts of things. I think most focus, though, related to long-term care, if you don't mind my saying so, isn't so much on this tool.

It really is about raising awareness and having the readers of the journal, again, have abuse and neglect on their differential diagnosis if somebody is presenting with injuries in unusual locations. For example, those of us who practice, or have practiced in long-term care, we're aware when a pressure sore comes up in an unusual place.

Or it is a surprise that this person has this bruise, or somebody who you've known for a long time has a sudden change in behavior, that there's a lot we can do to recognize when something bad might be happening.

Unfortunately, physicians are particular are among the worst at -- well, I'll say "worst" as a judgment -- but we're among the least likely to report suspected abuse or neglect.

Is there anything else you want to add?

Dr Mosqueda: The only other thing I'd add is that one of our great opportunities is the work that we do in teams.

The communication among team members, I think, is also critically important, so that if we're noticing something that seems a little bit off, that we can go to either a social worker, or if we're working with, as a physician, a nurse practitioner or a PA, that we shouldn't also be hesitant to go to director of nursing or other folks who work there to get their take on it as well.

And if you have a concern that something really bad is going on, to encourage people to look at other people who live there as well. For example, just to take an extreme example is, if you have a concern that a resident has been sexually assaulted, many of our older adults who live in long-term care facilities are quite vulnerable.

It's important to also look at the other people who are living there and make sure they're OK.