My medical school recently hosted a sweet elderly patient to share her experience of living with gout. Mrs. J is a poised, elegant and vibrant lady of 82 years who has the stamina and vitality of a young adult. Her zeal for life and positive attitude—despite the debilitating disease—is contagious. Her openness about her struggles and the challenges she faces as a patient make her an invaluable teacher to us as medical students. She states that seeing our smiling faces in the audience gives her courage to continue teaching medical students for as long as she can. And I can’t help but wonder what a privilege is to learn from and take care of such a priceless teacher.
But what if there was a problem that we couldn’t help Mrs. J with, even with our most astute clinical judgment, because we aren’t paying attention?
It’s a diagnosis that cannot be made with a basic CBC or CMP. There is no X-ray, CT or contrast dye available that can detect this horrifying cause of suffering. Yet it affects one of the most vulnerable populations in our society and it is often lurking right beneath the hospital gown. It is up you and me as future healthcare professionals to put our investigative and astute clinical judgment to use and dissect this problem.
The culprit? Elder abuse.
Research conducted by the National Center on Elder Abuse found thatone in 10 elders suffer from some type of abuse. In fact, Orange County’s Adult Protective Services (APS) receives over 700 reports of suspected abuse or neglect each month.
Laura Mosqueda, MD, co-director of the National Center for Elder Abuse and a professor of family medicine at the University of California Irvine School of Medicine, reported that adults over 85 years of age are the fastest growing population in the United States and that more than half of this population suffers from dementia and physical frailty. This means there is an exponential increase in one of most vulnerable groups of our society. As this population grows, the number of providers for the elderly is decreasing . This intersection is worrisome, as Mosqueda noted, and it means elder abuse is only going to become more common and even harder to uncover. In fact, there has been a 46% increase in the number of APS reports received from 2002 to 2012.
Complicating the issue, elder abuse can take many forms: financial, physical, emotional, sexual and neglect. But they all can have the same life-threatening and devastating consequences for the victim. For example, Mosqueda told the story of an elderly patient who was financially scammed and terrorized by her plumber. Soon, the patient started to retreat, avoided leaving her house, missed her doctor’s appointments, and stopped answering calls in order to avoid the scammer. She was found in congestive heart failure in her home and soon ended up in a nursing facility. In a period of just nine months, this elderly patient had lost her independence and her health had deteriorated significantly due to financial abuse by a stranger.
Physical abuse includes the obvious: suspicious bruising, fractured bones and burns, among other injuries. Unfortunately, natural age-related changes, such as propensity for bruising and osteoporosis, mask the signs of physically-inflicted abuse, making it easier to miss clues.
Sexual abuse is common in dementing illnesses where patients are unable to express themselves or are often not believed to be telling the truth. It is often marked by horrible genital bruising with predictable attempts by perpetrators to blame catheters. Newly developed STIs can also point to a sexual violation.
Finally, signs of neglect include poor hygiene, infected old wounds, malnourishment and dehydration.
So what can we as medical students do to prevent elder abuse? The most important thing to do is to educate ourselves and learn what signs and symptoms to look for. Because if we are missing the obvious signs and ignoring a silent plea for help, we are actually part of the problem.
As medical students, we have the privilege to spend more time with our patients than our residents and attendings, which provides a golden opportunity to be a leader in the care of our patients.
First, we must recognize that elder abuse can occur anywhere and that it affects seniors across all socioeconomic groups, cultures and races. Recognizing risk factors such as dementia, substance abuse and isolation can also help guide the diagnosis.
For example, seeing untreated pressure “bed” ulcers, lack of medical aids such as glasses, hearing aids and teeth, and lack of basic hygiene and adequate food should prompt you to further investigate the cause. Uncharacteristic changes in behavior by your patient and sudden panic in the presence of certain individuals may point to emotional and psychological abuse at home.
Further, a recent study on accidental bruising in older adults revealed many important considerations in assessing the etiology of bruises. 90% of accidental bruises were found on the extremities (rather than head, trunk, or neck) and fewer than 25% of elderly patients with accidental bruises remembered how they got them. However, 90% of elders who had been physically abused could tell you how they got them, including adults with dementia.
Mosqueda advises that if we regularly see a patient whom we know has a propensity for bruising due to their medications or has had frequent falls and fractures due to osteoporosis, we should carefully chart these findings during every visit so we have a reference point in case our suspicion arises in the future.
What should we do if we suspect that one of our geriatric patients is suffering from abuse? We must report our concerns to our local adult protective services. It is not our job to prove abuse, but rather to bring it to the professionals to investigate further.
And lastly, why should we care about elder abuse? Because the moment we surrender to the reality that some of the most vulnerable members of our society, like our 82-year-old friend Mrs. J, are being exploited and abused regularly, we give up the prospect of a just society with a high quality of life and preservation of dignity for all.
And, finally, when we surrender to this harsh reality, we also abandon an important component of our Hippocratic Oath: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”