Medex Fall BS Final Review Page

MEDEX Objectives Home: http://faculty.washington.edu/alexbert/MEDEX/

WE’RE ALL IN THIS TOGETHER

Elder Abuse:

http://www.aoa.dhhs.gov/may98/abuse.html

http://www.preventelderabuse.org/index.html

http://www.elderabusecenter.org/basic/index.html

Key Points:

Express concern compassion

Demented?

Does he acknowledge abuse

What additional services does he need

Is family overwhelmed? Neglectful?

How do they explain injuries and physical/mental state

Does he need higher level of care than family can provide

Interview elder alone

Interview care providers

Report to DSHS, APS and Law enforcement agency

Do stories match with each other and injuries?

Types:

Elder abuse is any form of mistreatment that results in harm or loss to an older person. It is generally divided into the following categories:

Physical abuse is physical force that results in bodily injury, pain, or impairment. It includes assault, battery, and inappropriate restraint.

• bruises, black eyes, welts, lacerations, and rope marks;
• bone fractures, broken bones, and skull fractures;
• open wounds, cuts, punctures, untreated injuries in various stages of healing;
• sprains, dislocations, and internal injuries/bleeding;
• broken eyeglasses/frames, physical signs of being subjected to punishment, and signs of being restrained;
• laboratory findings of medication overdose or under utilization of prescribed drugs;
• an elder's report of being hit, slapped, kicked, or mistreated;
• an elder's sudden change in behavior; and
• the caregiver's refusal to allow visitors to see an elder alone.

Sexual abuse is non-consensual sexual contact of any kind with an older person.

1. bruises around the breasts or genital area;
2. unexplained venereal disease or genital infections;
3. unexplained vaginal or anal bleeding;
4. torn, stained, or bloody underclothing; and
5. an elder's report of being sexually assaulted or raped.

Domestic violence is an escalating pattern of violence by an intimate partner where the violence is used to exercise power and control.

Emotional abuse. Infliction of anguish, pain, or distress through verbal or non-verbal acts.

Psychological abuse is the willful infliction of mental or emotional anguish by threat, humiliation, or other verbal or nonverbal conduct.

• being emotionally upset or agitated;
• being extremely withdrawn and non communicative or non responsive;
• unusual behavior usually attributed to dementia (e.g., sucking, biting, rocking); and
• an elder's report of being verbally or emotionally mistreated.

Financial abuse is the illegal or improper use of an older person's funds, property, or resources.

Neglect is the failure of a caregiver to fulfill his or her care giving responsibilities.

• dehydration, malnutrition, untreated bed sores, and poor personal hygiene;
• unattended or untreated health problems;
• hazardous or unsafe living condition/arrangements (e.g., improper wiring, no heat, or no running water);
• unsanitary and unclean living conditions (e.g. dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing); and
• an elder's report of being mistreated.

Abandonment is defined as the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.

• the desertion of an elder at a hospital, a nursing facility, or other similar institution;
• the desertion of an elder at a shopping center or other public location; and
• an elder's own report of being abandoned.

Financial or material exploitation is defined as the illegal or improper use of an elder's funds, property, or assets. Examples include but are not limited to cashing an elderly person's checks without authorization/permission; forging an older person's signature; misusing or stealing an older person's money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney.

• sudden changes in bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the elder;
• the inclusion of additional names on an elder's bank signature card;
• unauthorized withdrawal of the elder's funds using the elder's ATM card;
• abrupt changes in a will or other financial documents;
• unexplained disappearance of funds or valuable possessions;
• substandard care being provided or bills unpaid despite the availability of adequate financial resources;
• discovery of an elder's signature being forged for financial transactions or for the titles of his/her possessions;
• sudden appearance of previously uninvolved relatives claiming their rights to an elder's affairs and possessions;
• unexplained sudden transfer of assets to a family member or someone outside the family;
• the provision of services that are not necessary; and
• an elder's report of financial exploitation.

Self-neglect is failure to provide for one's own essential needs.  Self-neglect is characterized as the behavior of an elderly person that threatens his/her own health or safety. Self-neglect generally manifests itself in an older person as a refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions. The definition of self-neglect excludes a situation in which a mentally competent older person, who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety as a matter of personal choice.

1. dehydration, malnutrition, untreated or improperly attended medical conditions, and poor personal hygiene;
2. hazardous or unsafe living conditions/arrangements (e.g., improper wiring, no indoor plumbing, no heat, no running water);
3. unsanitary or unclean living quarters (e.g., animal/insect infestation, no functioning toilet, fecal/urine smell);
4. inappropriate and/or inadequate clothing, lack of the necessary medical aids (e.g., eyeglasses, hearing aids, dentures); and
5. grossly inadequate housing or homelessness.

Risk Factors:

Domestic Violence Grown Old
Personal Problems of Abusers
Living with Others and Isolation

Substance abuse

Frailty

Greater than 60 years old

Social isolation

Disability

Impairment Physical or mental

Dependency

Issues:

The role of culture in elder abuse and neglect. Culture influences how abuse is manifested, perceived, and responded to. It dictates victims' willingness to accept help and determines who they will turn to in times of need. Learn more about the critical role culture plays.

Mental capacity, consent, and undue influence. Effectively assessing and responding to elder abuse frequently requires an understanding of what vulnerable persons understand, their capacity to exercise informed consent, and their ability to withstand undue influence. Learn more about these issues and how they come into play in elder abuse cases.

The relationship between elder abuse and substance abuse. Substance abuse is the most frequently cited risk factor associated with elder abuse, affecting both victims and perpetrators. Learn more about the complex relationship between substance abuse and elder abuse.

Autonomy, self-determination, and least restrictive alternatives. Those who work with victims of abuse are committed to preserving clients' freedom and civil liberties even when doing so may jeopardize clients health and safety. Learn more about these fundamental principles.

Restitution. Requiring perpetrators to compensate victims for their losses can help victims heal financially and emotionally. It further holds perpetrators accountable to victims and their communities. As more cases of financial elder abuse are prosecuted, those who work with elderly victims need to understand this fundamental victims' right and challenges to protecting it.

Professionals and concerned citizens:

Adult protective service workers are the "front line" workers in elder abuse prevention. APS programs are designated as the primary agencies in most states to receive and investigate reports.

Professionals in the field of aging are often the first to discover abuse. For that reason, they provide a critical link between victims and protective service. They can provide encouragement and support to victims as they seek help and they can play an important role in educating other professionals about the special needs of the elderly.

Health and medical professionals play a key role in the identification and treatment of abuse. The trust and respect that patients often have for their health care providers places these professionals in a key position to help.

Law enforcement personnel ensure victims' safety and hold perpetrators accountable for their actions.

Researchers provide insight into the etiology, incidence, and risk factors associated with abuse - information that is critical in designing effective interventions and services.

The media plays a fundamental role in educating the public and shaping its perceptions about abuse. It can enlist the public's help in identifying abuse, educate policy makers about the need for improved services and public policy, direct victims to needed services, and warn abusers about the consequences of their actions.

Concerned citizens can play a vital role in preventing abuse by reporting cases, helping to raise awareness about the problem, volunteering at agencies, and advocating for needed services and policy.

Investigators:

• Adult protective services (APS) is the primary agency to accept reports in most states. Check your phone directory for the APS program in your community. In most communities, it is listed under the Department of Human Services or Social Services.
• Law enforcement is responsible for investigating abuse when it is criminal.
• Long-term care ombudsman programs are federally funded programs that investigate reports of abuse in nursing homes and residential care facilities.
• Medicaid fraud and control units: Under federal law, state Attorneys General are required to investigate and prosecute fraud and patient abuse or neglect in health care facilities that participate in Medicaid.

Services:

Mental health

Counseling 

Legal assistance

Support Services

• Support groups for caregivers address the emotional demands and stresses of providing care. They also provide instruction and guidance in meeting the older person's needs and handling difficult behaviors. They may relieve the tensions, resentments, and stresses that give rise to abuse and neglect.
• Respite programs give caregivers a break. Respite care comes in many forms. Attendants, professionals, or volunteers may come to the older person's home to provide a few hours of relief to the caregiver, or the older person may come to an agency. Some communities offer extended respite care of several days or longer.
• Home delivered meal programs. Programs deliver nutritious meals to seniors in their homes.
• Attendants assist vulnerable people with their daily activities, including bathing, shopping, and preparing meals.
• Adult day health centers provide an array of services, including nursing care; physical, occupational, and speech therapy; and socialization to frail seniors.
• Friendly visitors make home visits to isolated seniors.
• Telephone reassurance programs can make routine "check in" calls to isolated seniors or provide telephone counseling to seniors who are in emotional distress.

Case management

Victim witness assistance programs

Domestic violence programs

Services for Abusers

The following were transcribed form someone's class notes:

Dementia and Delirium

Delirium - altered state of consciousness, out of touch with reality 

Hallucination

sx

1. acute onset
2. memory deficit
3. hyperactivity, or hypoactivity
4. difficulties concentrating
5. changes of cognitive activity
6. paranoia
7. hallucinations
8. tremors
9. hallucinations
10. changes in sleep cycle
11. drug and alcohol withdrawal (medical emergency)

Risk factors

• age
• surgery, illness, infections, fever, HIV dehydration, UTI
• stroke
• emontional stress
• drug/alcohol withdrawal
• deprivations
• metabolic conditions
• vascular disease
• Parkinson's
• PTSB
• malnutrition
• dementia
• use of physical restraints
• use of bladder catheters
• use of 3 or more medications

Conditions that precipitate delirium

            MI, CHA, hypertension encephalopathy can cause delirium

            Also pneumonia, COPD, PE, fecal impaction

            Hypothyroidism, antipsychotics

In bedrest patients watch for delirium you take away independence.

By taking away glasses, hearing aids, they get delirium/confusions

-also moving bed position can cause it as well

Features of delirium

• can't maintain attention/disorientation
• hallucination
• see things that are there, but can't ID it (misperception)

Things that can happen to them (elders)

• can create the possibility of getting missed out of home

delirium can be a cause of dementia.

what is the cause of their delirium?

review medications is first thing you would check

to no precipitate delirium

• don't move pt
• well lighted room
• have someone sit with pt (24hrs)
• same support staff (continuity)
• same providers.  Need familiarity
• church representative (friends) are helpful as well (support)

Medications is top 3 causes of delirium

need support staff and limited changes to prevent delirium

make sure they have glasses, dentures, hearing aids

good nutrition, no restraints or catheters

prevent dehydration or constipation

In informed consent for surgery (elective surgery

will pt experience delirium after surgery,  because there can be long term cognitive impairments.  So you or pt should ask.

medical emergency origin/etiology, why you have it

Dementia

neuro ROS       \

Gen ROS         -------> in any cognitive change including delirium

Resp ROS        /

general appearance can tell you the most

types of dementia (4)

1. Alzheimer's 50%
2. vascular 10%
3. mixed 15%
4. Louis Body ?

drugs, delirium depression can cause dementia.

Alzheimer is higher with increasing age, women>men, FH, lower education

• anti-inflammatory used gives ↓ incidence of A.D.
• moderate alcohol consumption  ↓ incidence of A.D.
• hormone replacement ↓ incidents of A.D.

• insidious
• cognitive impairment
• short term and long memory loss
• difficulty with decisions
• ataxia (not able to move muscle to do tasks)

amnesia, agnosia (Loss of the ability to interpret sensory stimuli, such as sounds or images.), aphasia, apraxia (Total or partial loss of the ability to perform coordinated movements or manipulate objects in the absence of motor or sensory impairment.)

*-must have impairment and one of the A's

• personality change
• more alert and aware than is delirium
• decease awareness
• aphasia

Agnosia - can't recognize things

mild - can't balance checkbook

moderate - simple tasks (housework)

severe - personal grooming, restroom, department can care grutcs(can't read handwriting)

top three causes is delirium

1. infections
2. metabolism changes
3. meds

asserting dementia

• determine state of mind
• safety for themselves and others
• underlying cause (what's the reason)
• do neuro exam
• level of impairment
• co-existing condition (HTN, Gallbladder problems

Differential diagnosis  you need to think about

• medications with delirium
• infection, medical illness
• delirium
• stroke
• FH (guess at handwriting)
• syphilis can cause delirium and dementia

page 129 - workup for dementia and delirium

How would you screen cognition?

• Mini mental status
  • day, time, month year
  • mathematical equation
• ask patient family about any change in behavior personality change, irritability? change of appearance? Memory loss?  Social changes, bercasement (can't read writing)
• Time change exam (tool)  draw clock and time or 11:10 ask person what time is it
• Make change test - give pt 3 quarters 7 dimes, 7 nickels ask them to make that change $1.00
  • failing both tests is considered dementia.  The get 3 seconds for time and 10 seconds for change

Diagnostic test to do, to

            CBC, electrolyte, glomerular renal test, Lft, thyroid, B₁₂. folate.  Brain imaging (CAT) for brain infarcts, enlargement

Difference between D and D

• onset is quicker in delirium
• dementia not medical emergency
• dementia is progressive (you can slow, but can stop)

factors that effect behavior in negative way in dementia.

• change in environment
• confusion
• cancer, infections, medication, dehydration, constipation poor diet, MIs (silent), arrhythmias, surgery, skin breakdown from injuries, change in care giver lack of continuity

ethical issues with dementia because it's progressive

1. preserve pt autonomy
2. perform serial assessment of precision making ability
3. presentation of identity and family relationships
4. manage ethical conflicts
5. advanced directive, set process for their issues

Updated 7 Dec 2003