Cath Lab Digest

E xperts suggest that as many as 10% of older Americans are victims of abuse. Elder abuse can occur at a licensed or accredited healthcare facility or even in the elder's own home. In fact, most abuse is thought to occur at home by family members and may not entail physical abuse.1 This article examines the current legal descriptions of elder abuse. Ethical considerations and professional obligations are presented in particular in the presence of physical manifestations such as pressure ulcer development and other forms of skin injury. A case study is presented.

Defining Elder Abuse
Reports reveal that physical abuse accounts for only one in four cases, although the victim may be subjected to one or more of the five categories of elder abuse. These include neglect, emotional abuse, sexual abuse, financial abuse, or physical abuse. Neglect accounts for 49% of substantiated elder abuse cases and can be intentional or unintentional. Emotional abuse, described as the intentional infliction of emotional stress through verbal threats, intimidation, humiliation and social or physical isolation, is involved in 35% of cases. Sexual abuse is described as nonconsensual sexual contact of any kind, including unwanted touching, all types of sexual assault or battery, and photography of a sexually explicit nature. The misuse of an elder's property or financial resources is referred to as financial abuse. Financial or material exploitation is documented in 30% of cases. Physical abuse accounts for 25% of reported cases and is described as the use of physical force that results in pain, impairment, or bodily injury. Physical abuse can be further described as hitting, slapping, restraining, molesting, biting, pushing, or pulling.2

Case Study
Anna was an 82-year-old woman who died shortly after she was brought into the emergency department after a fall outside her small suburban home. Eight weeks before the hospitalization, Anna cared for her 58-year-old son, Peter, who had never worked and was unable to contribute to his own care because of a brain injury that occurred more than 50 years before. Anna used public transportation, paid bills, shopped, and coordinated household activities - all despite very limited income and other resources.
Two months before the fall that brought her to the hospital, Anna developed a stomach flu that lasted several days and led to dehydration and confusion. Anna forgot to take her routine medications, was unable to prepare meals, and failed to accomplish the required activities of daily living for herself and Peter. The stomach flu escalated to frequent and persistent vomiting and diarrhea, accompanied by weight loss, incontinence, and superficial skin breakdown over most of her trunk and legs.
Like many abused or neglected elders, Anna and her son seemed to have lived in isolation from neighbors, friends, or community members. Adult protective services were immediately notified by paramedics. On admission to the emergency department, further investigation was initiated. The nurses photographed the dried vomit in Anna's hair, skin folds, under her arms, and over her entire trunk. Further photodocumentation was used to illustrate dried fecal matter on her buttocks, perineal area, and legs. Eschar-covered pressure ulcers over Anna's mid-back and sacrum were just beginning to open, with subsequent drainage of a foul-smelling, thick liquid. Although photography failed to capture the essence of this skin injury, every patient and clinician in the emergency department was affected by the odor emanating from Anna's room.
Imagine the disdain that the involved clinicians felt for Peter before he even arrived to visit his mother. Without an understanding of the entire set of circumstances, it was difficult not to form a judgment regarding the emotionally overwhelming situation.
Peter was allowed to visit his mother once she was transferred to the intensive care unit.