Elder abuse: is every bruise a sign of abuse?

Each year, between 1 and 2 million older adults in the United States are abused. Physicians are in an ideal position to recognize, manage and prevent elder mistreatment. This article uses a problem-solving format to discuss a case report. This case, which spanned two years, highlights the true difficulty in recognizing and managing elder mistreatment.

Stability of preferences regarding life-sustaining treatment: a two-year prospective study of nursing home residents.

BACKGROUND: The use of advance directives is based on the consensus that physicians should respect preferences expressed by competent patients about future treatments. Patient preferences are, however, subject to change and may be influenced by a number of factors. The purpose of our study was to evaluate the durability over time of decisions made regarding terminal care of mentally intact nursing home patients and the influence of such factors as intervening illness, loss of significant others, and cognitive, emotional and functional decline. METHODS: We undertook a longitudinal prospective cohort study in which 65 mentally competent nursing home patients were interviewed at three intervals (at baseline and after one and two years). For each patient, demographic, medical and socioeconomic data were collected and assessment of mood, function, cognition and preference for life-sustaining therapies (including cardiopulmonary resuscitation and parenteral and enteral nutrition) was obtained. RESULTS: Preferences regarding cardiopulmonary resuscitation and parenteral and enteral nutrition changed over both the 12- and 24-month study periods. Only degree of change in cognitive status proved to be predictive of changes in decision. Gender, presence or absence of depression, change in level of functional abilities and intercurrent illness or stressor did not influence change regarding life-sustaining therapy. CONCLUSIONS: In light of our findings, we suggest that periodic re-evaluation of these advance directives be performed and that ongoing discussions be initiated with their patients by health care professionals.

Why elder abuse continues to elude the health care system.

Elderly men and women of all socioeconomic and ethnic backgrounds are vulnerable to mistreatment, and most often it goes undetected. For many elderly victims of abuse, the hospital is the only potential site for outside contact and support. An elder abuse program has been created at The Mount Sinai Hospital in New York City, and funding was granted to assist victims with compensation claims; provide counsel and advocacy for victims; and provide support via ongoing telephone contact and referrals to community agencies. Simultaneously, hospital-wide educational seminars and rounds have provided the staff and students with information concerning detection of abuse and neglect. Over a 2-year period, 182 cases were identified and assessed. More than 50% of these cases involved patients with a diagnosis of memory impairment. Five percent of the cases involved a long history of domestic violence. In most cases a family member was identified as the abuser, and in a majority of instances the victim either denied the suspected abuse or tried to rationalize the behavior of the abuser. Patients were afraid of reporting abuse or changing their situation, despite being informed of possible resources. To combat this escalating problem in our growing elderly population, interdisciplinary collaboration between physicians and social workers is often crucial. Communication via the medical record can be key to monitoring patients in the community. There also needs to be ongoing education of all hospital staff in an effort to continually heighten awareness of this problem.