Geriatric assessment is complicated by several factors, regardless of whether abuse is suspected or known to exist. Dementia or impairment of cognitive function may make it impossible for the patient to recall and/or communicate about recent and past events. The patient may conflate multiple past experiences into a single event, and his inaccurate recall of medical history, medications and history of present illness may cast suspicion on any other reporting by him.
Worsening dementia ("I am not as sharp as I used to be") puts geriatric patients at greater risk of financial exploitation. Complex insurance, housing assistance and financial issues force many geriatric patients to trust others to look out for their best interests. You have probably heard, "I don't know those details. My son/daughter handles those things for me."
Geriatric patients are more likely to have impaired senses of sight, taste, hearing and vision, and may not be able to recognize a dangerous situation, like spoiled food, or be aware of an attacker.
Multiple medications and other medical problems provide ready excuses. Falls are a risk for all geriatric patients. Blaming physical wounds, even facial trauma, on a simple fall is possible for an older patient. In younger patients, we expect them to brace a fall with their hands and have upper extremity injuries. When the elderly fall, they may not have the reaction time to raise their hands, resulting in facial wounds much like those received from a slap to the head or face.
When responding to any geriatric medical or trauma emergency, follow the patient assessment process to identify and treat life threats. If the patient is in immediate physical danger from an abuser, request law enforcement assistance, and, if you can, evacuate the patient to an area of relative safety.
Use the secondary assessment to identify and prioritize problems for treatment. A systematic approach to patient assessment will help you identify things that are abnormal. If you suspect that there is more to a problem than a simple fall, instead of doing a detailed focused exam, do a full head-to-toe exam.
Follow your agency's treatment protocols. Treat what you find with the tools and training you have. If abuse is known or suspected, the most important treatment you may be able to administer is providing the patient a safe and respectful environment.
During the assessment and treatment process, don't confront the abuser with allegations. Focus on data collection and treating current problems efficiently and safely. If time and patient condition allow, do a visual scan of the patient's living conditions and make objective observations to include in the patient care report.
Transport the patient to the most appropriate facility based on his request and/or receiving facility capabilities. Even if the patient does not have acute injuries, transport to a receiving facility will allow assessment of suspected or known abuse to continue in a neutral location with trained adult protective services professionals. Do not leave a suspected abuse victim at home alone with their suspected abuser or where they may be exposed to their suspected abuser without involving law enforcement or adult protective services.
Your patient care report will be a valuable component in the investigation of elder abuse. An objective and comprehensive report that factually reports the assessment findings and treatments provided is critical. When documenting known or suspected elder abuse, follow these general principles:
- Report your factual observations of things like physical exam findings, patient living conditions and patient hygiene.
- Withhold opinions about what you think or believe may have happened or who may be at fault.
- Attribute the patient's own words with quotation marks.
- Keep the patient's words in the context in which they were said.
- Include statements made by the caregiver or family members in quotation marks.
- Document family members, caregivers and other emergency responders present during the assessment.
- Don't speculate on the cause or age of injuries in the healing process.
- Include the names of any agencies, like law enforcement or adult protective services, that were contacted and when they were contacted.
- Include the names of receiving facility staff who received report of known or suspected elder abuse.
- Avoid the words abuse, abuser and victim, as these words suggest blame or fault.20