Gibbs Medical Implications of Elder Abuse and Neglect, An Issue of Clinics in Geriatric Medicine

1. Auflage 2014
ISBN: 978-0-323-32374-1
Verlag: Elsevier HealthScience EN
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, Band Volume 30-4, 100 Seiten

Reihe: The Clinics: Internal Medicine

This issue of Clinics in Geriatric Medicine, devoted to Medical Implications of Elder Abuse and Neglect, is edited by Drs. Lisa Gibbs and Laura Mosqueda. Articles in this issue include: Physiology of Aging; Understanding the Medical Markers of Elder Abuse and Neglect: Physical Exam Findings; Medical Markers of Elder Abuse and Neglect: Laboratory Findings; Common Presentations of Elder Abuse in Healthcare Settings; Physical Abuse; Elder Abuse and Neglect by Others; Geriatric Sexual Abuse; Emotional Abuse in Geriatrics; Self- Neglect in Geriatrics; Capacity Assessment in Elder Abuse and Neglect; Geriatric Dementia and Abuse; Mental Health/ Psychiatric Issues in Elder Abuse and Neglect; Care of the Victim in Elder Abuse and Neglect; Prevention and Early Identification of Elder Abuse and Neglect; and Doctors Roles and Relationships with other Agencies in Elder Abuse and Neglect.

Autoren/Hrsg.

Gibbs, Lisa

Leseproben

Aging
Physiology, Disease, and Abuse
Diana Homeier, [e-mail],     Division of Geriatrics, Keck School of Medicine of USC, 2020 Zonal Avenue, IRD 620, Los Angeles, CA 90033, USA There are physiologic changes associated with aging. There are also medical conditions that occur more commonly with advancing age. These changes and conditions increase an older adult’s vulnerability to and injuries from abuse or neglect. An older adult may have more difficulty recovering from an abuse incident. The investigation of abuse or neglect may be more difficult because of aging changes. Keywords Aging Physiology Disease Abuse Key points
• There are physiologic changes associated with aging. • There are medical conditions that occur more commonly with advancing age. • These physiologic changes and medical conditions increase an older adult’s vulnerability to and injuries from abuse or neglect. • An older adult may have more difficulty recovering from an abuse incident. • The investigation of abuse or neglect may be more difficult because of aging changes. With advancing age, an interplay of multiple factors places the older adult at increased risk for abuse and neglect. Consider the following scenario: A 70-year-old man was brought to the emergency room by paramedics after his daughter called 911 when she found him on the floor in his home without his caregiver. The emergency room doctor reported that the patient was dehydrated and confused; he could not provide his own medical history and did not know the date. You were the admitting physician; you were told that the patient had probably fallen at home. As you examined this patient’s injuries, you began to wonder if the injuries were consistent with a fall. When you met the patient, he was receiving a fluid bolus and was still confused. On review of his chart, you found that he had a history of macular degeneration, hypertension, coronary artery disease, severe arthritis, depression, incontinence, and mild Alzheimer disease. His medications included donepezil, aspirin, clopidogrel, hydrochlorothiazide, metoprolol, and sertraline. On examination, he had multiple bruises along his right shoulder, a large bruise on his left upper arm, and a large confluence of bruises scattered across his chest. There was also an unusual linear pattern bruise on the left side of his chest (Figs. 1 and 2). After seeing him and reviewing the chart, you considered the following questions: were these injuries consistent with the history of a fall? Where was the patient’s caregiver when he fell? Was the severity of the bruising caused by aspirin and clopidogrel? Could these injuries have been caused by physical abuse?
Fig. 1 Right shoulder.
Fig. 2 Chest. The proportion of the population in the United States that is considered elderly (aged =65 years) has increased dramatically in the past 50 years and will continue to do so in the next 50 years as the baby boomers age. According to US Census bureau data, in 2010, 40 million Americans were 65 years or older. This number is expected to increase to more than 80 million by 2050.1 This demographic imperative means that health care providers must understand the medical conditions that occur commonly with age as well as the psychological issues, social factors, and changes in function that may accompany these conditions. Aging is associated with many physiologic changes that are common to all persons. In addition to these changes, there are medical conditions (diseases) that occur more commonly with age. These changes and conditions increase an older adult’s vulnerability to abuse or neglect. Overview of aging physiology
As a human body ages, there is a progressive decline in physiologic functioning, which affects all organ systems. These changes place an older adult at increased susceptibility to illness; they also create a disadvantage in recovering from illness. Although these changes are common to everyone, they progress at different rates in each individual and, even in the same person, progress at different rates in each organ system. Table 1 denotes the physiologic changes that can be significant in considering a diagnosis or even a suspicion of elder abuse. Table 1 Physiologic changes that occur with normal aging; considerations for elder abuse System Physiologic Change Considerations for Elder Abuse Body composition Increased fat
Decreased water and muscle mass Increased side effects of lipophilic medications Skin Thinning epidermis
Decreased elasticity
Decreased subdermal fat tissue Increased bruising, skin tears, pressure sores Bone Decreased bone mineral density
Stiffer joints Increased fragility and fracture risk
More prone to musculoskeletal injuries from minor trauma Eyes Decreased tear production
Presbyopia
Miosis Increased risk for falls
Difficulty reading documents
Difficulty identifying abuser Ears Cerumen more tenacious
Sensorineural hearing loss Impaired ability to understand surrounding circumstances
Difficulty communicating in investigation Cardiovascular Decreased carotid baroreceptor sensitivity
Decreased maximal heart rate
Arterial wall stiffness
Increased left ventricle thickness Difficulty recovering from illness/trauma
More severe outcome from injuries Pulmonary Increased residual volume
Decreased FEV1, vital capacity
Weaker respiratory muscles
Stiffer chest wall Increased likelihood of respiratory failure
Increased risk for pneumonia Muscle Decreased muscle mass and strength
Increased stiffness of tendons and ligaments Loss of independence
Difficulty rising from the floor
Difficulty regaining independence after an injury Renal Decreased functioning glomeruli
Decreased renal blood flow
Glomerular filtration rate declines Increased susceptibility to medications Gastrointestinal Decreased salivation
Slowed esophageal peristalsis
Delayed colonic transit time   Neurologic Decreased white matter
Loss of synapses
Mild cognitive changes
Decreased proprioception and vibratory sense Slower information processing
Balance problems
Increased risk for falls Reproductive Vaginal atrophy
Narrowing of the vaginal introitus Increased risk for injury from sexual assault
More difficult sexual assault examination Body Composition
From young adulthood to old age, the percentage of body fat increases from 15% to 30%. This increase is accompanied by a decrease in muscle mass, total body water, and bone mass. These changes are important when considering the metabolism of medications and are part of the reason that some medications (eg, benzodiazepines) are more dangerous in older adults than younger adults. Skin
Skin is an important organ, which provides a protective, thermoregulatory, and sensory function. The effects of aging on the skin can be divided into intrinsic and extrinsic changes.2 The epidermal cells have a slower turnover rate, causing thinning of the epidermis. This thinner epidermis also has fewer melanocytes and Langerhans cells, decreasing the barrier and immune function of the skin and increasing risk for sunburn and cancer. In the dermis, there is a decrease in fibroblasts, collagen, and elastin, causing skin wrinkling and a loss of elasticity. A diminution of subdermal fat tissue in combination with capillary fragility leaves an elder more prone to bruising from seemingly minor trauma. In addition, several medications and conditions could increase an older adult’s risk for bruising. For example, aspirin, clopidogrel, and warfarin may increase bleeding time and propensity for bruising. Diseases such as cirrhosis or myelodysplasia could cause disruptions in the clotting mechanism and predispose to bruising or bleeding. Chronic sun exposure, the predominant extrinsic factor in age-related changes, contributes to wrinkling and loss of tone in the skin. Bone
With aging, there are changes in the architecture of both trabecular and cortical bone, as well as changes in the bone marrow. There is a reduction in trabecular and cortical bone volume, caused by an imbalance between bone formation and resorption. There is also an increase in adiposity of the bone marrow.3 These changes...