 Good afternoon, everyone, and welcome to our broadcast. I'm Doris McMillan, your host for today's program. Today's topic will be Medical Aspects of Neglect, and Dr. Laura Mosqueda is with us here in the studio. Now, for our viewers with questions, we'll be taking your calls and faxes throughout the show. There is no need to wait for an official Q&A period. Just go right ahead and call in. The lines are now open. To call in your question, you should dial 1-800-953-2233. If you'd like to fax in your question, the number to call is 1-410-786-0123. Again, the number to call in is 1-800-953-2233 and to fax us the numbers 410-786-0123. And now that the technical information is out of the way, we're going to get on with our program. Let me introduce you to Dr. Mosqueda. She is a board-certified family physician and geriatrician, and she is the medical director of the UCI Senior Health Center at UCI Medical Center in Orange, California. In addition, her efforts have led to the creation of the nation's first elder abuse forensic center, which brings together UCI medical experts and representatives of Orange County's Adult Protective Services, Sheriff's Department, Office of District Attorney, Public Guardian, and other agencies in a coordinated battle against elder abuse. Dr. Mosqueda has also testified before the U.S. Senate Special Committee on Aging regarding abuse, neglect, and exploitation of the elderly. She has extensive experience in developing, implementing, and teaching courses on elder abuse for physicians, law enforcement officers, and prosecutors. So, ladies and gentlemen, let me introduce to you Dr. Lauren Mosqueda. And thank you, Dr. Mosqueda, for being with us. Thank you. It's my pleasure, Doris. Now, what will you be talking about today? Well, I'm going to provide some information about the investigation of abuse and neglect, and I want to give some background on the problem, as well as some specific details on what we call red flags for abuse. Red flags, so you mean indicators of abuse? Well, not so much indicators as possible indicators. For example, a bruise isn't automatically an indicator of abuse, but it... If you see a bruise in an inaccessible location, it's something that you want to really be looking at more closely. Okay. Well, I see it sounds like that information will be of great value to surveyors, so we're going to take a look. Let's start by talking about the definition of abuse. Some have defined abuse as the willful inflection of injury, unreasonable confinement, intimidation, or punishment that causes harm, pain, or mental anguish. It's also important to realize with older adults that seemingly small incidents, such as a push or a shove, can result in very severe physical harm. You probably have seen people with Parkinson's disease who have very poor balance, and you can imagine that even a small shove can send them tumbling over backwards and causing significant harm. This is one of the reasons it's been interesting to look at a comparison between child abuse and elder abuse. Many people have compared the state of the art in terms of what we know regarding medical knowledge and forensic issues related elder abuse with where we were in child abuse about 30 years ago. There's a lot of difficulty with detection and diagnosis of elder abuse compared to child abuse. For one thing, the medical picture for older adults tends to be much more complicated than that of a typical child. Many older adults have multiple medical problems, whereas we don't tend to see that with children. We also expect older adults to die eventually. After all, if you're 90 years old and you're in poor health, it won't be that surprising if death is imminent. But we don't tend to expect bad outcomes and death for children. With children, we tend to see them out and about in the community. They're being seen at school. They're being seen at daycare programs. And so there are a lot of eyes on children in our community. And if there are signs of abuse and neglect, people might be observing them. This isn't true for our older adults. Many older adults remain hidden in the home or in the nursing home. And so abuse and neglect are rarely observed. Finally, with older adults, it can be very difficult to link physical signs with diagnoses. It will be spending quite a bit of time talking about that today. Let's move on now and talk about some of the types of abuse that we see with older adults. Some of the typical categories that we see are physical abuse, psychological or emotional abuse, neglect, abduction, sexual abuse, and financial abuse. Today, we'll really be concentrating on the first three that we just mentioned. We'll be really concentrating on physical abuse, neglect, and we'll also spend a little bit of time talking about emotional or psychological abuse. It might be helpful to talk about a few examples of abuse that I've actually seen in my own practice. My experience has occurred through a number of different avenues related to elder mistreatment. For one, I used to be the medical director of several different nursing homes. And so I have a pretty good understanding of what happens in the real life sort of a situation. And I'm now the medical director of a forensic center on elder abuse. And we have many referrals that come in. So the examples I'm about to give you are all based on real life issues that have occurred in the past several years in my own experience. Some examples of physical abuse we've seen have included pulling a resident's hair, slapping, hitting, or punching, throwing food or water on a person, or tightening a restraint to cause pain. Sometimes it's difficult for people to believe that these things actually happen to older adults. It's almost unimaginable that somebody would actually slap or punch an older adult, yet it does occur. Let's talk about a few examples of psychological abuse. This might include terrorizing or threatening a person with a word or a gesture. Something like shaking a fist at an older adult who doesn't agree with what it is that you're asking them to do. Or threatening them by telling them that if they don't behave properly, that you're going to do something to them. Inappropriately isolating a patient is another example. I recently was at a nursing home in another state and a person was just screaming inside of a room. And when we asked why this person was there, they said because she screams all the time. And nobody had stopped to think about why is she screaming? Instead, they just isolated her so she wouldn't bother other people. This really is a form of psychological abuse. Yelling at a patient in anger, denying them food or privileges are also examples that really can terrorize, threaten and frighten people to a very, very extensive degree. Let's talk about some examples and neglect. People who are lying in their urine in feces for extended periods of time. People who develop malnutrition, dehydration, pressure source because they're not receiving appropriate care. People who are really in filthy conditions, they may have elongated nails, they may be living in a very dirty environment. There's really no excuse for this and these are all signs of possible neglect. We will talk about how to differentiate neglect from other issues that might be going on related to an individual. I certainly don't think that every time you see a pressure sore that it's evidence of neglect. But as we'll discuss, it at least should be a marker that raises a red flag in your mind. Abuse can occur in a variety of patterns in licensed facilities. Sometimes the perpetrator of the abuse is working at the facility. Sometimes the perpetrator is actually another resident of the facility. And abuse can occur even in facilities that are really good and of course abuse occurs in facilities that are really bad. Let's start by talking about abuse that occurs at the person level. This might be one resident abusing another. It might be a resident abusing a staff member. It might be a family member who has come in to visit the resident who actually is there having them sign over documents of perpetrating financial abuse or is even physically abusive to them. There might be abuse going on from the staff to the resident which is often what folks like you and me are being asked to look at. I'm going to talk about CNAs and we'll talk more about them in a few minutes. But I don't want you to think I'm picking on CNAs. I really believe that CNAs are some of our unsung heroes in our society in terms of the care that they give to our older adults in licensed facilities and some of the abuse that they have to take in order to provide this care. Other staff members who might be perpetrators of abuse include nurses, physicians, outside or paid help people who might be hired by the family to quote help the CNAs, janitors, really anybody who works there might be a perpetrator of abuse. I'm going to talk about abuse among CNAs because there at least are some studies that have looked at this particular issue. A pretty shocking study done by Carl Pilmer where he asked CNAs to fill out an anonymous questionnaire showed surprising rates of abuse. He found that 10% of the CNAs had committed physically abusive acts in the recent past. That included things like use of excessive restraints, pushing, grabbing, shoving, pinching people, hitting or slapping. Interestingly, fully 40%, almost half of the CNAs admitted to having committed psychologically abusive acts. That included everything from yelling at people, to insulting and swearing at people, denying them food, privileges as a form of punishment or threatening physical violence. Predictors of abuse among CNAs were really quite interesting. It turns out that those who are having a very high level of job stress and burnout and who are dealing with aggressive patients were more likely to be abusive. Those who engaged in frequent verbal conflicts with patients were also likely to be more aggressive. This is important to remember because if we're aware of some of these stresses and triggers, we can actually work at preventing abuse or seeing when somebody's sort of on the edge and might be ready to be an abusive caregiver and to do something about it and to intervene at an early stage. There's also the phenomenon of what I refer to as the great facility, one bad egg. You can have a really terrific facility and a lot of then administrators, medical directors think it's not possible for abuse to occur here. We really work hard to do a good job. You have a reasonable staffing ratio. The administration is good. There's high quality care. And then unbeknownst to everybody, a sociopath gets hired. This can occur. We all know that criminal background checks ain't perfect. And even though you do your best to screen people, a bad egg can get hired and can really wreak havoc. There's also the phenomenon of a really terrific facility where you have an unusual circumstance. Again, providing good quality care. But you have a particularly difficult resident. They're very, very physically dependent so they need a lot of care, but they're verbally abusive. They're quite provocative toward the CNAs. They might be yelling racial apathets. And then you have a CNA who is usually good with residents but might be extra stressed out. They might be having marital troubles or some sort of extra stress. And they sort of get pushed over the edge and then end up really taking it out on a resident. And of course, this isn't acceptable, but you can begin to imagine that depending on the scenario of abuse, you're going to have very different reactions in terms of how you're going to take care of it and what sort of solutions you're going to offer people. Abuse can also occur at what I refer to as the facility level. So rather than necessarily just one person abusing one resident, we do have facilities where there's poor care and neglect going on. There's an atmosphere of threats and reprisals. Everybody knows that you're not allowed to make a report that you're really discouraged from talking about inappropriate or bad things that are occurring. You don't have an administration or medical director who are open to hearing about this. And these sorts of facilities are now inviting abuse. In these poor quality of facilities, many residents are receiving poor care. And so what I'm looking at there is you're beginning to see a pattern of poor care. Why are there so many pressure sores? Why are they being properly treated? Is there evidence of malnutrition? Again, there can be times when malnutrition is appropriate. For example, if you have somebody on hospice, but if malnutrition is occurring to a lot of people and it's not being properly addressed, you have to really worry facility-wide about bad care. You also tend to see a lack of leadership or administrative support of these facilities, employee morale tends to be poor. You have an absentee medical director. There's a case I'm working on right now with really horrendous types of abuse going on. And I keep looking at it saying, where's the medical director? Why hasn't he been in? Why isn't he addressing some of these issues? And the answer is, nobody ever sees him. And that's a very bad sign and a real setup for abuse. So we don't like surprises to happen. We particularly don't like surprises that are potentially bad for us. And we really need to think about what the circumstances are that led to abuse in that facility in order to address solutions. I like to think about abuse as sort of a recipe. And these are the ingredients for the recipe. You have a vulnerable person, such as a person typically who's living in a licensed care facility. Another ingredient is you have what I referred to as a high-risk caregiver. It might be that stressed out CNA. It might be that sociopath. You have the contextual issues that surround it. The right circumstance occurs. So just as an example, you might have a vulnerable adult who has Alzheimer's disease. And now you have a caregiver who is getting stressed at work, stressed at home, and this person with Alzheimer's disease is yelling at them and is very combative. And now you have a context where the CNA is trying to change the person from a dirty diaper that person is battling them. And finally, you have the right circumstance and the CNA hauls off and hits the person. That's what I mean about a recipe for abuse. And it's important to pay attention to each one of those ingredients as you're looking for abuse and as you're looking for solutions. Okay, we're back live in the studio. And we have Dr. Laura Mosqueda with us to answer some viewer questions. Again, that phone number is 1-800-953-2233. And if you'd like to fax this, it's 410-786-0123. And as we mentioned, we invite you to start calling in, faxing in right now. You don't have to wait until sometime later in the program. Dr. Mosqueda, let me ask you this. If and when you have a patient who goes to the doctor, are physicians really aware of the signs of neglect and abuse? No, it's a very good question and a very important point. Physicians really receive very little training in how to detect elder abuse. And there have been very few research studies that give us good, clear indicators. That's why we've talked about, we'll be talking about some of the indicators we will today. But physicians really are among the poorest of reporters of elder abuse. It's oftentimes nurses and nursing assistants who might help bring to our attention that there's a problem and we need to do a better job at paying attention to them. Do you think it's because they're too busy and they're trying to see too many people or are they just in denial? It's probably a combination of both. I guess I think that the too busy issue is really an inadequate excuse. We certainly would never excuse that if that was happening with children and we need to get to a point where we don't allow that as an excuse for adults either. Now, in the event we see somebody that we think could potentially be or go ballistic on a patient, what do you do? I mean, how do you stop that from happening? Well, we have to really look carefully at why this person might be having these behavioral problems and the sort of approaches we'll take will certainly be behavioral and environmental at first and at some point we might need to be working with staff as well. Is there anything you can do to better screen the staff? Screening staff is a huge issue. We know that background checks are done, but a lot of times they really don't identify people who have pretty serious criminal histories and I think also having a good sense of what's going on with the staff, having a good read on the staff and their stress levels is very important to do. Okay, thank you so much. And of course we'll have more questions later on, but let's get back to more of our presentation. Well, what is the problem with the problem? In other words, why is it so difficult to detect and diagnose and do something about elder abuse? It's a very complex issue. We have age-related changes. For example, older adults tend to have low bone density, so fractures tend to occur. We'll talk more in more detail about that in a moment. There's also the question of when does it cross the line? At what point do you call something abuse? Another issue in terms of the problem with the problem is impaired capacity. Many of the victims of abuse have dementia and we will spend several minutes talking about dementia because people who have dementia are at high risk of being abused. I know this is going to come as a shock to you, but there are mandated roles of multiple different agencies and I'm sure you've experienced this, so that whether you're with CMS or whether you're with the Department of Health Services or whether you're with the Sheriff's Office, everybody has a slightly different role, a slightly different viewpoint about abuse, and that can make it difficult to come together as a team to figure out what to do. And finally, I know this is going to come as a shock also, there's a lack of a coordinated comprehensive system for what to do once abuse is discovered. Even to figure out the proper assessment, the proper investigation can be difficult. And then the other issue is what do you do once you find it? We don't really have necessarily standardized methods of doing these sorts of things. It's good now to turn to some of the normal and common age-related changes that make older adults vulnerable to being victims of abuse. First, let's talk about the integument or the skin. As we get older, the top part of our skin, the epidermis becomes thinner, our capillaries become more fragile. And so what do you think happens? Hey, older adults might bruise more easily or they might get skin tears more easily. In the renal system or the kidney system, there's a decrease in what's called the creatinine clearance. Creatinine clearance is a marker for how your kidney function is doing. And for many older adults, creatinine clearance or kidney function declines as a normal age-related change. For older adults who might have illnesses such as hypertension, high blood pressure, or diabetes, they may even have more dramatic declines in their creatinine clearance. And this is important because our kidneys, one of our kidneys' main functions is to clear out medications. And so it's much easier for an older adult to become toxic on medications. It's also important to think about the sensory system changes that occur in older adults. Older adults have slower reaction times, maybe less able to defend themselves if they're getting pushed. They also have what's called presbacusis or low hearing. And so an older adult might startle more easily if a sudden noise occurs. They won't know what's going on in their environment. They might get knocked off balance more easily because they haven't seen something coming at them. They may have visual problems such as macular degeneration or cataracts. Just imagine for a minute if your hearing is down and your vision is down and you've become a victim of abuse, how hard is it going to be to actually identify who did this to you? How hard is it going to be to communicate with people when you're trying to describe what happens? Pretty hard. Well, the next picture isn't a graphic example of what can happen if you have severe visual problems. Other normal and common changes that occur with aging occur in the musculoskeletal system. There's a phenomenon called sarcopenia, which is just a loss of muscle mass that occurs as we get older. There's also osteopenia or osteoporosis. These are illnesses that occur as we get older that refer to a decrease in bone density. So imagine now if you're an older adult, you have lower muscle mass, you have lower bone density, how vulnerable you are to getting hit and losing your balance and then ending up with a fracture. In the cardiovascular system, there's a phenomenon called orthostatic hypotension. What that simply means is that every time you change position, you're more vulnerable to having a drop in your blood pressure. All of us have little receptors that live in our carotid arteries and in our necks are carotid arteries bifurcate into an internal and external carotid artery. And where it bifurcates, you have little receptors that actually measure pressure. So that when any of us change position, those little receptors send a very strong message to our heart saying, hey, listen, heart, start to pump harder because she's moving now. So that when we change position and stand up and gravity wants to pull blood down toward our legs, our brains don't get deprived of oxygen. That these receptors help keep our heart rate up and help keep our blood pressure up. In older adults, when there's less sensitivity to that with the receptors, older adults then become much more likely to fall. Another common cardiovascular change with older adults is an illness called congestive heart failure. And I'm sure that in a lot of the facilities you visit, many older adults have this CHF or congestive heart failure. Again, this is something that can make older adults quite lethargic, tired, dizzy, and has all sorts of consequences on function. I'm always thinking about function with older adults. In fact, when I'm talking with our medical departments, I tell them to think of function as the geriatric F word. They always need to think about function because that's so closely tied to independence and quality of life. So anything that any of us can do to help our patients or residents or clients maintain their function will really help them with their independence and quality of life. As people get older, we often become more dependent. We often have changes in our gait. We might be on what I refer to as a frequent forward program, even though you don't get mileage for that. And so if you have this loss of function, it makes it much more difficult to stay independent. It also makes you more likely to be a victim of abuse. It's also important to think about activities of daily living. I'm sure that many of you are familiar with this term, which basically means what is it a person needs to do in order to maintain themselves on a daily basis? Whether it's clothing, dressing, basic grooming and hygiene, feeding yourself, toileting. As somebody becomes more and more dependent for their ADLs and then need more and more help, your vulnerability for abuse increases. So if somebody is having to help you with toileting and bathing, that just puts you in more and more vulnerable situations with potential perpetrators. It's very difficult sometimes to figure out when care crosses the line and you say that now we're at an issue of neglect. Most of us know what really, really great care looks like. And we appreciate it when we see it. And then at some point, really great care becomes good, not great, but good. And then at some point it becomes sort of so-so. They could be doing a much better job, but we certainly wouldn't call it abuse. And then at some point it becomes poor. And then it starts to get into that great area where you say, this isn't just poor. This is neglect. This should never have happened. And this often puts people like you and me in a difficult situation because we have to take what's a fuzzy gray line and make it into black and white. I believe that if we really concentrated on finding those areas at the end of the line where we say this shouldn't happen, this is neglect. That we would go a long way toward improving the lives and the quality of life for many of the residents in skilled nursing facilities. Okay. We are live again here in the studio with Dr. Laura Mosqueda. And remember, if you'd like to give us a call or a faxes, the number to call is 1-800-953-2233. And if you would like to faxes, the number is 410-786-0123 for the fax. Okay. And it's question time again. Dr. Mosqueda, what's the difference then between normal age-related changes and common age-related changes? Normal age-related changes are those sorts of changes that are not pathologic. We expect them to occur in older adults. You don't really have to do anything to prevent them or treat them and they don't cause any problem with that big F word function. And so we don't have to worry about normal changes too much. They can make older adults more vulnerable to abuse but they're not pathologic. Whereas common changes are illnesses such as dementia which we'll be talking about more in a minute such as congestive heart failure which we mentioned earlier. And those are pathologic changes and many of those are either preventable or really amenable to treatment. It's important to recognize them when they occur because if you can treat them you can help improve function, you can help improve quality of life and you can lessen somebody's risk for abuse. We have a telephone call. We have Kathy calling from New York. Kathy, thank you for calling. Please go ahead. Thank you. My question has to do with the example that you gave of a caregiver being stressed out, being put in a situation with a demented resident and being put over the edge and maybe striking out at a resident. Can you talk a little bit about what willful is and if someone is reacting to maybe being grabbed or hit or spit at, how does one make that determination? If you can clarify that a little bit more for me, Kathy, do you mean if the CNA is being grabbed then how do you determine if they're just reacting to that person? Is that what you're asking? Yes. It's a great question because it's such a common scenario. The way I think about it is all of us really need to be trained professionals and as hard as it is we're really not allowed to react to people by hitting them back even though it's very tempting. Under those circumstances we usually can identify pretty quickly the residents who are hitting, spitting, sort of acting out and try to figure out why they're doing that. I often try to put myself in the resident shoes. If I have a lot of memory loss I can't see very well, I can't hear very well when I put my clothes. That can be a pretty frightening experience and I might react by trying to give you a slug as well. And so I think helping the CNAs understand where the resident might be coming from can be helpful. But frankly, sometimes people with dementia really have these severe behavioral problems and then we need to look at oftentimes medication management in order to help that be better. But the message has to be sent out to folks caring for older adults so that it's never okay to react that way. You need to get help and we need to understand who those older adults might be ahead of time. Are you still on the phone, Kathy? Does that answer you? It certainly does. Thank you very much. Kathy, thank you all. Thank you for calling. And for those of you who will call in make sure you turn the volume down on your television set so we don't get the feedback. I'm also wondering if you would be able to tell me a little bit about determining the origin of a bruise from normal aging activity and normal activities of the elderly like willing themselves through the hallways. And when you do your investigation it's very difficult sometimes when the resident can't give you a good history of how they got an injury. And the staff themselves seem to not be able to lead you down a path that would suggest abuse or not one way or the other. I'm just wondering if there's some way to determine one bruise of abuse versus the bruise of original activities that are normal for that resident. That's a very important question that Amy is asking. We'll actually be talking about bruising a little bit later as well. I'll give you a preview which is that my concern about bruising is where is the bruise located. We've just actually published a study that came out just a month or so ago in the Journal of the American Geriatric Society where we looked at bruising in older adults because I got kind of tired of hearing well they're just old and they got bruised when I really believed that somebody had been hit. What I believe and I think what we're beginning to show is that bruises that happen in unusual locations face neck jaw, back, buttock, areas where you don't really tend to bump yourselves a lot those should really raise some suspicion. It doesn't prove anything but it means questions need to be asked. Certainly some nursing home residents are on medications that make them more likely to have bleeding if they do have a bump. We need to take that into account. It makes them more likely to have multiple bruises but not more likely to have bruises in unusual locations. I'm at the location of the bruise and I'm looking back again at the context does the story make sense? As you said, the most often answer we get as to how that bruise occurred is I don't know. At some point when we see massive bruising in unusual locations we have to go beyond and say that's not an adequate answer. Perfect. Thank you very much for your time. And thank you for calling Amy. I guess that's the last question for this segment so we're going to move on again. We're going to now take a look at dementia. Well, let's turn our attention to a subject that's near and dear to my heart and that's the issue of dementia. I love working with patients who have dementia because I feel that there is so much that we can do in order to help their quality of life and their loved one's quality of life. And this is true whether they're living in the community or living in a nursing home or assisted living facility. It might help to remind ourselves what the definition of dementia is is the root D in men's. Dementia literally means going away from the mind. Dementia is a disease process and we have to underline the fact that it's a disease process. It's not a normal age-related change. So it's a disease process and it causes loss of intellectual abilities so you're not able to use or do your usual activities. There are basically three things to think about when we talk about somebody having a dementing illness. One is they have to have loss of memory. Another is they have loss in some other area of cognition or thinking so that they might have trouble with visual spatial skills. They may have trouble with word finding. They may have trouble with executive function and understanding high-level sorts of concepts. And that this loss of memory and loss of other form of cognitive function has to be severe enough so that you're not able to do your usual activities. There are many different reasons that people can have a dementia and we'll just talk about a few different types for a moment. The most common type is Alzheimer's disease. Many people ask me, what's the difference between dementia and Alzheimer's disease? And the analogy I like to use is that dementia is a very broad category that simply means this person has a loss of these intellectual abilities so that their function is impaired and that Alzheimer's disease is a type of dementia. It's a little bit like comparing how is fruit different than an apple? Apple is a type of fruit. Alzheimer's disease is a type of dementia. So while we talk about Alzheimer's disease a lot because it's the most common type of dementia in older adults, we have to remember that there are dozens of different reasons people can have a dementia. Some of the other common types are vascular dementia which is a dementia that's due to either low blood flow or just a frank stroke that may have occurred in an individual. Final temporal lobe dementia can be quite tricky because these people often have very significant behavioral problems that go along with the memory loss. There's a type of dementia that's called primary progressive aphasia and even though it's a mouthful, what it really means is that in addition to memory loss, the person has a great deal of difficulty expressing themselves and finding their words. A dementia that you'll probably be reading a lot more about because we're coming up with better understanding and better definitions for it now is dementia with Lewy bodies or some people call it Lewy body disease. This is an interesting type of dementia because people look very Parkinsonian, they have that sort of classical Parkinsonian shuffling gate, they might have a great deal of rigidity and at the same time they have a dementing process occurring. What's particularly difficult and interesting with this type of dementia particularly in facilities is that these people tend to have very vivid visual hallucinations and you can imagine that if you're hallucinating up a storm, you can imagine what some people would label as a behavior problem in a facility where you're trying to get along with other people. Well, dementia could really make you vulnerable to being a victim of abuse. As we've talked about earlier, some people with dementia may have very provocative behaviors. Imagine for a minute if you were demented and hopefully none of you are but just imagine that you are for a minute and somebody who you don't know comes up and starts to try and take your clothes off. You might react by hitting and then you might in turn get hit back or you might be yelling at people or you might have repetitive behaviors that just annoy the hell out of everybody. I want to go home, I want to go home, I want to go home. How many times can people listen to that without finally going a little bit crazy in a lot of the CNAs and staff at these facilities are trying to deal with that all the time. So provocative behaviors can occur but we have to remember that it's still abuse for abuse. People who have dementia might not even be able to recognize that they're being abused, particularly in the middle and end stages of dementia, they may be treated horribly and not even be able to understand that they're being abused. People with dementia might not be able to report that they're being abused, they might not know how to pick up a phone and notify somebody and they may not be believed if they do say that I'm being abused. When somebody has Alzheimer's disease if they make a statement like I'm being abused people will say, well, they have Alzheimer's disease so we can't trust anything they say. So it's very important when you're interviewing somebody who has a dementing illness to be aware of these sorts of issues. Let's talk for a minute about approaching interviewing people with dementia. I really think this takes a special touch and a special talent. First of all, it's important for you to understand the type of dementia somebody has mentioned they may be in. Is this a mild or moderate or severe stage? Is this an Alzheimer's disease or do they have this primary progressive aphasia where they're going to have a very difficult time in expressing themselves to you? Know the pattern of cognitive loss that they might be experiencing. Is this a person who's not only having trouble with memory but having trouble with concepts and so if you're giving them a lot of information and giving them a long question that there's no way that they'll be able to hold it in their mind and respond to appropriately. And finally, I think it's important to answer the question of the when do you take it seriously if somebody has a dementing illness and says that they've been abused? The answer is always. You always take it seriously. It doesn't mean that we're going to assume that abuse really occurred but I think that people deserve our protection and that we have to at least look into it. I've had many patients with dementing illnesses make some accusations about abuse and if I look into it and it doesn't make sense and I'm satisfied that everything is fine with them, then I won't necessarily make a report because I don't have a reasonable suspicion but we have to give people the benefit of the doubt and the dignity of taking a look. There are different types of memory that you can think about and they get impacted with different types of dementia. There's verbal memory, in other words being able to hear something and remember something. There's visual memory being able to see something and remember it and finally there's emotional memory and I want to spend a minute talking about emotional memory even though somebody might have Alzheimer's disease and they don't have a clue what you just told them three minutes ago they will often remember the emotion that they experienced related to you. In my office practice we try to make visits for our patients with dementia as nice and as pleasant as possible with lots of hugs and lots of positive sorts of emotions from all of the staff because we know that if the person has a bad experience their family member may never be able to get them in the door again. Similarly in nursing home situation or assisted living sort of situation if a person is reacting to a caregiver in a particular way it's important to pay attention to it. Let me give you an example of a patient that I see who lives in an assisted living facility. There's this one particular caregiver that she adores she doesn't know his name she wouldn't be able to tell you anything she's almost totally a phasic is able to say very few words she has a moderately advanced dementia but every time he walks into the room or interacts with her she just lights up he's just lovely with her and he's so loving and kind that she really responds to that and is aware of that. So similarly I think we need to pay attention if a person with dementia reacts in fear to somebody or starts screaming or trying to backpedal when they see somebody that should be a clue to us that they're concerned about that caregiver. I'm going to take a slight detour now and talk about a phenomenon called delirium. Delirium is very common particularly among people who have a dementing illness and delirium is an acute medical problem that's almost always reversible. People who are in a delirium have a lot of problems with attention they're sort of with you one minute and not with you the next. So they have this fluctuation in their cognition that might occur over just a period of a few minutes where they're really able to pay attention to you and then they're almost lethargic really sort of out of it. You can't even make a diagnosis of dementia when somebody is in a delirium and unless people recognize that a delirium is occurring it can go on for months and months and months. It's important to recognize the possibility that it's almost always reversible and it's almost always related to multiple different things such as a urinary tract infection and medicines that they're on and maybe they're a little dehydrated. Put that all together and somebody who has dementia and they can end up with a delirium. It's important when you think about how delirium relates to abuse. People who are in a delirium are at very high risk of being abused. Delirium actually might be a marker of abuse. People who have been neglected, over-medicated might be in a state of delirium. What's interesting is that delirium can interfere with a person's ability to recognize that they're being abused or even explain what happened to them and you will often see a long delay in seeking care. This might be a marker that somebody is being neglected. You expect that if somebody has a delirium a real change in their status that somebody has alerted the physicians about it. I had one patient who was kept in a state of delirium on purpose. She was given high doses of morphine and she was also given herbal supplements that contained once we got it translated from the Chinese with the help of a pharmacist we discovered that the first ingredient on this herbal supplement was something called cannabis sativa. She basically was kept in a state of delirium and then her daughter would go in and have her sign over papers taking all of the money away from her mother. When her delirium was cleared and it took a while to detox her she still had a very mild underlying dementia but she was able to look at some of the checks that she had written able to look at some of the documents she signed and say, my god, I never would have done this if I was in my right mind. Well, we're live again here in the studio with Dr. Laura Mosqueda. That's scary. Dr, is dementia a normal age related disease? No, that's one of those common age related changes but it's not a normal age related change and it's particularly important to be aware of that because many people think, well, if you get old you end up having a dementia and if you make that assumption you don't do anything about it. It's also important because lots of times even though you have something like Alzheimer's disease where we really can't treat the underlying illness itself you may have other things that you can treat and that once you treat those other issues you may then be less vulnerable to being abused. When you're talking about dementia what do you mean by visual spatial skills? Well, we were talking about how you make a diagnosis of dementia and we talked about three things. You have to have memory problems and you have to have problems in some other area of cognition and those things have to interfere with function. One of the common other is visual spatial skills and that's our ability to sort of navigate around the environment. It's not vision. You can have normal vision but still have trouble understanding where things are in space. The example I always use is whenever I have a map I need to turn it whatever direction I'm going and my husband likes to make fun of me about it but I don't have great visual spatial skills to start with. Some people with excellent visual spatial skills know exactly where they are and navigate around immediately. People with illnesses like Alzheimer's disease often have pretty severe impairments and so they'll misjudge things. They might think that dark lines on a floor are actually a whole. It seems like a behavior problem because you're taking them into a bathroom and the bathroom has dark grout lines and they're terrified of going in there and you think they're just acting up and screaming when in fact they think you're taking them into something but you really need sensitivity when you're dealing with folks who are in these conditions, don't you? And are we seeing that? Well, you're right. We do need sensitivity and that's why I said I think that a lot of CNAs are just some of the unsung heroes because the way they work so lovingly with so many of these older adults who have demanding illnesses is remarkable. They've really taught me a lot. I think anytime we can try and put ourselves in their shoes it helps increase our sensitivity. You know something, we're all going to get older if we live long enough. That's the plan. So we do need to be sensitive. Okay, Dr. Mosqueda is going to talk about what to do when abuse is suspected and then what kinds of things ought to be examined and thought about. Let's take a look. Well, when there's a suspicion of elder abuse there's sort of a framework that I use when I'm thinking about it. One, I want to understand the context in which it occurred. I want to have some information about the history that occurred as well as the medical history of the person involved. I want to do a physical examination, a mental status examination. We might be looking at issues related to laboratory tests and looking at cognitive behavioral changes. So let's take each of these in sequence now and first talk about context. When I talk about context, I want to know what were the circumstances or events that led up to this alleged abuse? What are some of the characteristics of the victim of the perpetrator? What are they like in terms of their personality? What do we know about the medical history of the victim? Do they have multiple medical problems? Do they have a dementing illness? What sort of medicines are they on? And I want to know about their cognitive capacity. Very often as you well know people who are living in nursing homes have cognitive impairments but they're not necessarily diagnosed or written clearly on the chart. So it's important to hunt for it because it's not there. Some of the red flags in a history if somebody comes in with a variety of wounds or you're aware that somebody has wounds I'd like to know what the explanation is. Do these explanations make sense or are they just vague or are they implausible? I was involved in one case related to a resident in a nursing home who had a fracture of her femur not way up at her hip but about midway between her knee and her hip which is not a common place to have a fracture and in addition she had a huge hematoma on her forehead that just really must have occurred from a fairly significant trauma and what the people in the nursing home told us that this was due to the fact that she rolled over in her bed and actually hit her head on the railing of the bed and that that's how she ended up with this. Well that's what I would call an implausible explanation for several reasons. One, this lady could barely move. She had severe contractures and couldn't really move herself well in bed and I'm a little embarrassed to admit it but I got into a nursing home bed myself and I tried to roll myself into the bed rail to see if I could hit my head and I couldn't even when I was trying. So that's what I mean by an implausible sort of an explanation. The other red flags I look at are delay and notification. Sure people can have stage 3 or stage 4 disorders but why wasn't anything noticed or done about it prior to that? Are there unexplained injuries? For example there's somebody who I recently saw who had a dislocated shoulder and when we took an X-ray and identified it we also found that there was an old fracture lower down on her arm that was just in the healing stages and nobody had ever sort of noticed this or done anything about it prior. Are the stories inconsistent? Is there a different story about how it occurred? And finally particularly with people who have a demanding illness I look for changes in behavior because that might be our best clue to the fact that something bad is going on. So somebody who is demented who usually is outgoing likes to participate in activities and now all of a sudden withdrawn I'm going to at least in my mind wonder if there has been any abuse. Again I'm not accusing anybody but it just sets off a red flag that I want to take a look at. Interviewing issues are really huge in older adults. It's important if you're going to interview somebody that you have some sense of what their cognitive ability is like before you start the interview process if at all possible because many older adults with Alzheimer's disease are wonderful at cocktail parties. They're very socially appropriate they can carry on a great conversation with you but they have no idea what the date is who the president is, who you are and what it is you were talking about just a few minutes ago. So this can be a real challenge when you're interviewing somebody. You also have to be aware for example if they have visual problems cataracts very common issue in older adults produces a lot of glare. So if you are interviewing an older adult and you're sitting right next to a window with a lot of light coming in behind you the person might not be able to see your face at all the glare and won't be able to make out your face and it might be important if they have trouble with hearing because they might need to do some lip reading as well. You need to be careful if you're interviewing somebody that you know if they're hard of hearing or not so that you're speaking at an appropriate level so that this doesn't become a hearing test and that you're really able to do an interview. If somebody has hearing aids make sure that they're in their ears. If they have them in their ears if they're on make sure that the batteries are working. All of these things are very important in basic issues that can become very important when you're doing a decent interview. Is the person comfortable? If they're in one of those wheelchairs that have the slings seats and they're very uncomfortable help them get into a comfortable position so because the greater the comfort they have the easier it will be to get a good interview. You also want to find out if there's a particular time of day that this person is at their best many older adults particularly with demanding illnesses have something called sundowning syndrome where they do okay during the day and then as it starts to get later in the afternoon they become really wacky really confused that's not the time you want to do an interview what's the best time of day for this person our job is to make sure that we're finding the resident or the patient at their best time we have to adapt to them. During your interview be a good Sherlock Holmes and do some careful observation about what's going on in the environment if the alleged victim and the alleged perpetrator together observe what their interactions are like are they sort of grinding away at each other does the older adult who might be a victim of abuse do they react in fear that's what I mean when I talk about behavioral indicators of state of mind I've actually seen a woman who was in a wheelchair who was very demented she was with her son a big guy and we were worried that he had been coming and abusing her and in her wheelchair she was actually completely curled over in her wheelchair and when he left the room she unfurled like a flower and then was able to sit up and talk to me and have direct eye contact when her son came back into the room she bent back over and really reacted with a fear of reaction of course the lady was still very demented we couldn't use it as absolute evidence that he was the perpetrator of the abuse but you better believe that I took it seriously and that it went into my report so those are the sorts of indicators we look at in terms of behavioral indicators issues of being withdrawn they seem to be reacting with fear that they get more confused when this alleged perpetrator comes into the room let's turn to a minute now for physical examination issues I'm often involved in doing injury assessments but I need to make sure that I'm looking beyond just the injury I want to do a functional status exam on the person I want to do a full skin exam that means looking everywhere and of course there have been any concerns about sexual assault pelvic examinations, rectal examinations need to be done a lot of people don't even like to confront the idea that this could have occurred in a facility for an older adult but it can and it does occur so we really have to be willing to do the exams that are necessary in order to prove it some of the clues that I look for in physical exam are wounds such as sores, bruises lacerations if the person has a very dirty and unkempt appearance if their hygiene is very poor people aren't caring for them as they should be if there's evidence of malnutrition or dehydration we really need to keep an eye on the possibility of abuse in addition to the sort of typical physical exam where you're listening in the heart listening in the lungs you're looking at the wounds functional assessment is very important and by that I mean looking at things like range of motion remember that person I talked to you about a few minutes ago where they said she rolled over in bed and hit her head when I looked at her functional status there was no possible way that could have occurred she didn't have the range of motion to even allow that action to happen are people in pain what is their gait and balance like somebody who's walking very very well and their balance seems to be good and I'm told that these injuries have occurred as a result of a fall I'm starting to wonder does the history fit with the physical examination do these explanations make sense I'm also of course looking at their senses such as hearing and vision as we discussed prior it can be quite a challenge to assess injuries in older adults older adults can have a variety of injuries pressure source fractures burns so you need to think about what to look for in all of these sorts of injuries first of all is the history consistent with the exam as I just talked about does it make sense when I hear this story and put it together with a physical exam is there evidence of old injuries was there a delay in seeking care again why wasn't this person brought in or brought to attention a long time ago and then location and I really want to emphasize the importance of location when we're looking at things like pressure source fractures, bruises, lacerations sure they can occur without any sort of evil intent or evil goings on but then we don't expect to see them in unusual locations so location to me is one of the most important issues that I look at when I'm examining wounds we're going to turn now a little bit about pressure source and a few other wounds so that you can get a visual idea of what I'm talking about so as you can see on this graphic decubitus ulcers or pressure source go through a series of changes in the first stage or stage one which is in the upper left hand corner of the screen you just have some damage being done to the very top layer of skin or the epidermis that's called a stage one pressure source that might be something as simple as just redness or a blister in the second stage there's actually has been a disruption of the epithelial layer so there's been a disruption of that outer layer of skin and it just barely is into the underlying tissue also called the dermis and that's a stage two pressure source if it becomes deeper and it goes into what we call the subcutaneous tissue for example into some of the fat that is called a stage three pressure sore and if it gets deeper yet to the point where the sore is down to muscle, tendon or bone that's a severe end stage which is called a stage four pressure sore now you have to recall that in some older adults who might be very very thin even emaciated the distance between a stage one and a stage four pressure sore the distance from the epithelium to the bone may be a very short distance in some people it can take a lot of tissue to go through to become a stage four pressure sore and in others it can't this is a picture of somebody who has a pressure sore on their heel and we all know that pressure sores on heels are fairly common but pay particular attention to why this one is suspicious see if you can figure out why this one is suspicious is this the typical location remember we're talking about location again that you see on a pressure sore on the heel it's not usually on the medial or the inside part of the heel where you see a pressure sore and why does this person have some sort of lesion up toward their big toe I wouldn't just accept that this is a pressure sore that occurred as a result of lying in bed this person had to be in an unusual position in order to get a pressure sore there and I'm going to be nagging people for an explanation on a wound like this this next slide is a picture of somebody who's been severely burned in the story they gave so the person got out of bed and went and got into scalding water on their own remember we talked about the importance of functional exam on our history well functional examination on this person showed that while this person was ambulatory there was no way that they had the ability to step over a tub and get into a scalding water this had to have been something that was done by somebody to this person so the history does not fit the physical examination here's an example of a wound on the bottom of somebody's foot for goodness sake how does somebody get a wound on the bottom of their foot somebody ought to know how this occurred and I would be all over this asking questions and trying to figure out how it might have occurred if you're good observers you'll also notice that this person's toenails are quite elongated as well so I would really be undressing this person completely to look for other evidence of abuse okay we're live in the studio with Dr. Laura Mosqueda and remember if you'd like to give us a call the number is 1-800-953-2233 and if you'd like to fax this please do so at 410-786-0123 Dr. Mosqueda what do you or how do you approach an elderly person to ask them about possible sexual abuse well if you think that sexual abuse has occurred it is important to ask the question I think we tend to avoid it because we tend not to even think of older adults as sexual beings at all and the idea that somebody might sexually assault an older adult is almost unthinkable yet it does occur one of the real issues that police officers have in the nursing home setting is that we forget to treat it like a crime scene so that if there's a suspicion of sexual assault and the person is able to give you a good history you certainly want somebody who knows how to take a history document it and then you want people who are experts there are a lot of nurses who are real experts in sexual assault exams doing the exam but it's important that things aren't being flushed down the toilet that the police are being called and that the place really is treated like a crime scene so that a good investigation can be done we have Jan on the line calling from Missouri thanks for calling Jan please go ahead with your question well I've noticed that many healthcare professionals are unfamiliar with skin assessments and people of color could you address bruises and stage 1 pressure sores and people other than Caucasians no I'm just kidding yeah it's a huge issue because we don't really we're not as good at identifying bruising and trying to figure out the color changes that occur and in fact when we were doing our bruising study I have to admit we chickened out and looked only at people of white skin in order to look at the color changes we're realizing just as you're saying that we really need to do some research now to understand what color changes you need to look at and people who have other skin tones it's very important but there's really very little in the literature on this even in kids so I don't have a good answer what we do look at though with the stage 1 pressure sores it doesn't matter what color skin you have if you see a change in color if you see some blistering occurring or some redness or again it might just look like a change in color that needs to be attended to very quickly especially if it's over a pressure point okay Jan thank you thank you let's go to Montana Julie is on the line thank you for calling Julie yes my question had to do with you know when you have residents that come in and maybe you know by history that there has been some prolonged time that they've maybe had been falling at home and that and it has to do with you know what they're now talking about in terms of deep tissue injuries and the fact that you can actually have more injury there than what you're seeing initially on admission of that person and how can you you know best document so that you're indicating that this isn't a matter of neglect this is something that probably was already there so you're saying that if somebody has been at home and they already have the beginnings of a pressure sore right well you're right I think really one of the keys especially for positions that you're all in in terms of going into nursing homes and looking at quality of care is is there good documentation and I would certainly expect at the nursing home that people have perhaps photographed it have documented size color you can't tell from a photograph if there's any edema or if there's any tenderness and those things need to be documented as well there's beginning to be a few reports here and there about pressure sores that sort of erupt overnight and this idea that you can end up having pressure sores pressure sores from the from deep and then coming out there isn't a lot of good documentation on this and we're beginning to look at that issue as well that might be a little bit about what you're talking about too is that right yes that's correct I'm not entirely convinced that this is as common as some people are claiming it to be and I think that lots of times it's that nobody has noticed the pressure sore documented appropriately and all of a sudden they're saying this massive stage 4 pressure sore occurred overnight I'm really not willing to buy that and I would have to have a whole lot of contextual information that tells me that's a plausible explanation before I believed it okay all right thank you for calling thank you for calling Julie Dr. Muscadette how do we encourage the CNA's and the other staff there to really to look more closely at the patients to look for signs of abuse well I think the CNA's in my opinion are often the first people who we should go to to ask to see if they see a change I know when I'm seeing patients in nursing homes they're the first people I go to to ask how somebody is doing because they have the most intimate relationships with a lot of the residents there and so they're the ones who might first notice changes in skin condition changes in behavior other changes that might make us concerned about abuse so I think we need to go to them and ask if on the other hand you have concerns that a CNA is actually abusing another resident there can really be a conspiracy of silence because tattling on another person when you're already in a low paying job that you really need could put you in a very difficult position and so you need to also look at patterns does it seem to be that there are particular shifts or particular group of residents that you're concerned about that might relate back to one particular CNA all right well that's all the questions we have for this particular segment we're going to move on now and Dr. Muscadette will talk about some of the research that's been done on bruises as well as cover the remainder of the investigative topics that she mentioned earlier let's talk for a minute about the issue of bruising I have heard so many times that people just are bruised because they're old and while it is true that being older might make you more vulnerable to being bruised there are people who are getting really beaten up and pummeled and it's just being excused because they're old so we actually did a study where we looked at age-related changes, medications whether or not you can tell them how old a bruise is by its color some people especially from the pediatric literature have said well if you see bruises that have multiple different colors on different parts of the body it means they've been bruised multiple times at different times of the week or different times of the day is that actually true and again the history consistent with the injury we were also of course very interested in the question of location let me tell you about a summary of our results this is a study that we just published and we looked at a hundred older adults who had bruises and these were all bruises that were not related to abuse so the best of our knowledge not one of these people was abused and about a fourth of our subjects in this study actually live in nursing homes what did we find well nearly 90% of the bruises occurred on the extremities there were absolutely no bruises on the neck ears genitalia buttocks or soles of the feet no bruises there if a subject had a bruise for example on their torso, on their front or on their back they were more likely to know the cause of the bruise than if they had it say just on the front of their hand we found that 16 of the bruises were predominantly yellow in color very quickly with the first 24 hours of onset so people who say well yellow bruises are old we're finding that not to be the case and finally people who are on medicines such as aspirin or cumin warfarin who are on these medicines that actually impact the coagulation pathways were more likely to have multiple bruises so let's talk about location of bruises for a minute let's talk about the graphic from our study what you can see here on the left hand side is a body diagram of a person looking at them from the back or a posterior view and on the right hand side is from the front or an anterior view and what you'll see is that the vast majority of bruises occurred on the lower parts of the extremities this of course makes common sense this is where people might get bumped quite easily they can bump into objects but you'll notice there were very few bruises on the upper parts of the arms upper parts of the back or on the trunk just a couple bruises on the face but again these people knew why and how it occurred so this is the pattern that we tend to see in bruises that are not related to abuse we're hoping to get funding in order to do a study now to look at bruising in older adults who have been victims of abuse but I'm sure all of you have seen people who have had bruises in multiple different areas I really want this to be a red flag for you we shouldn't be seeing that other thing we looked at in our study was the progression of color and it turns out that it's very hard to tell the age of a bruise by looking at its color and it's an important myth to this spell as you can see from this graph we saw all colors in almost every stage of a bruise because we went and we examined people every day for up to four weeks or up until the bruise healed and we looked at the color progression it went through and we saw all sorts of colors at all different stages of a bruise so this idea that you can actually tell the age of a bruise by its color is really a myth and you have to be very careful about it we can say in general that if it's yellow-brown that it's much more likely to be an old injury but I just want you to exercise some caution to make this whole concept these next three photographs are examples of some of the bruises that we have observed in residents or patients that we've cared for if you look at this first picture I don't know if you can make it out but what we're looking at is the inside part of somebody's leg, their thigh and then there's the bend in their knee why is this suspicious? well, do you expect to see bruises like this on the inside of somebody's leg? that or darn well get a good explanation as to why that occurred and I wouldn't accept the mysterious gosh, nobody knows how it happened this to me is a major red flag if I see a bruise here it would also probably lead me in doing at least a cursory pelvic exam to look for any evidence of sexual assault if we look at this next picture what you can see here is somebody's elbow that's where the bend is and you see bruising that's occurring in the upper inner part of their upper extremity of their arm and as we saw with some of the previous data I showed you from our slide this is a suspicious location and I would like to know how this person ended up with bruises in the upper inner part of their arm it's awfully hard to bump yourself there and this last photograph shows somebody who has bruises if you can make this out on her chin on the front part of her neck and on the side part of her neck I told you a minute ago that you can't tell the date of a bruise by its color and now I'm going to go and sort of break my own rule because this is kind of a yellow brown bruise that we see on her and the story we had was that she fell that morning well I don't buy it I don't buy it because to have that degree of yellow brown fading color occurring over a period of 12 hours is highly suspicious to me and I don't know about you but there are a few falls on my life and I've never once gotten a bruise on my neck particularly not a bruise in two planes on the anterior and lateral portion of the neck so this is a story that I absolutely wouldn't believe and this woman this is actually an autopsy photo she actually ended up dying as a result of her injuries so seeing these sorts of bruises and really taking an extra look not necessarily accepting the explanation that you're given is a very important thing in terms of looking at red flags and seeing if it makes sense let's turn our attention now to other evidence of abuse or other evidence that you can use if you have a suspicion of abuse one of the underutilized pieces of data is laboratory data that you can get laboratory data can be very helpful if you have a suspicion of abuse or neglect you can look for evidence of malnutrition dehydration if you have a story well just because they're incuminent you want to be sure that you're doing coagulation studies things called a pro-time or INR to let you know whether or not they're really even getting their medicine whether or not they really are being anti-coagulated medication levels can be very handy people sometimes think about looking for toxic medication levels but it can work both ways so for example if somebody is being overdosed with a medicine like digoxin you can detect that on a blood exam there isn't being given some of their medicine so if they're not being given their thyroid medicine you'll see that their thyroid function studies never normalize sometimes you might want to ask yourself is this because they're not being given their medicine because if we don't give them their medicine they're not as much of a bother radiographic evidence of fractures can be very helpful if you have a suspicion of abuse and neuroimaging studies as you can get with MRIs and CT scans they might help you detect something like a subdural hematoma if this person has just had a fall and they've had a blow particularly to the side of their head in the temple area and now they had a change in behavior they may have a bleed that's on the outside of their brain called a subdural hematoma and neuroimaging studies can help you detect that mental status exams are very important to do whenever there's a suspicion of abuse sometimes these mental status exams are documented beautifully in the chart but unfortunately a lot of times they're not so that if you have a client or patient or resident where there's a suspicion of abuse it's very important that somebody who knows how to do a good mental status exam has performed one if possible if somebody knows how to do it it's good to have a formal exam such as the fullsteen mini mental state exam and to document it carefully but recall that these exams don't test for everything they might tell you something about memory they might tell you a little bit about language skills but they might not tell you anything about judgment reasoning and other issues so they have a limited utility but an important utility if you're not dealing with a place that really knows how to do a mental status exam well at least get some observation about their cognitive status this is important for a few reasons one it'll help give you an idea as to whether the information you're getting is valid or questionable it'll help give you an idea about whether this is a change just a few days ago that they were very clear and now they're not very clear cognitively clear I mean and so something must have happened in that intervening time interval there are other things you can do when you're walking through a facility look to see if there are a lot of residents who are in restraints look to get a sense of what sort of mood people are in it's amazing to me and get an immediate vibe about what the mood is like do people seem depressed and that means the staff as well as the residents if so you're dealing with kind of a high risk situation where there's probably a higher likelihood of abuse are there high rates of medication errors in this facility are they doing a good job with infection control if people have pressure sores are the staff aware of it doing appropriate things to prevent it are there staffing levels appropriate from the residents and from family members all of these are very important things to look at when you walk into a facility that can give you a hint as to how hard you need to look for evidence of abuse well I hope that this review of abuse that occurs in licensed facilities has perhaps given you a different way to think about it I just want to thank you for the work that you're doing because very often folks like you are the only buffer zone only advocates that many older adults have who live in these facilities all right we're back in the studio for our final round of questions for Dr. Laura Mosqueda and as a reminder this is your opportunity to call the number is 1-800-953-2233 and of course if you'd like to fax us the number is 410-786-0123 and again this is our final segment we have a question that came to us from the Michigan Department of Community Health Bureau of Health Systems from Mary Hess and Mary asks as surveyors of nursing homes she says we have to identify when abuse has occurred so when would we call behaviors exhibited by a resident with dementia abusive i.e. with intent these are same behaviors may be self protective on the residents part versus intent to purposely harm another right that's a very good point and an important issue that comes up I usually like to go one step beyond that which is why do we care about the intent issue well we care about the intent issues with people like cna's or physicians because if you're intentionally abusing somebody you need to be out of there and somebody needs to be dealing with you on the other hand if you're another resident in a nursing home and you have a dementing illness it can be pretty hard to figure out what you understand and how much you don't understand the main point there I doubt we're going to be trying to prosecute this person as we might if it's a physician who's abusing somebody and trying to put them in jail what we're really trying to do then is to get the other people protected so getting to the intent what I would probably do is involve a mental health specialist such as an LCSW a psychologist, a gyro psychiatrist who really understands dementia very well to help sort it out and to try to figure out what approaches we need to take it can be very difficult and particularly we talked about different sorts of dementias one type of dementia is frontal temporal lobe dementia and when you have the frontal lobes involve you have lots of disruption of what we call executive reasoning people have a lot of problems with judgment and do very bizarre things that they normally would never do and lots of times their families try to attach intent to it and really what you have is such a massive disruption in the frontal part of their brain they can't control their behaviors very well at all and so I've seen sometimes people with frontal temporal dementia actually become abusive not because they're a bad person or that they were ever like that in the past but because now their brain is unable to inhibit them from doing inappropriate behavior so when you see someone acting so totally out of character that ought to be a warning sign absolutely and good medical evaluation is really important to do whenever there's a sudden change in behavior in anybody with dementia it's a medical problem until proven otherwise ok let's go back to the pressure sore issue cause we saw some pretty hairy pictures there of pressure sores where there shouldn't have been are pressure sores always a sign of neglect? I don't believe that they are now there are some people who are saying that anytime you see a pressure sore this is evidence of abuse or neglect and I don't agree with that I've had patients who I think were being cared for very well who despite our best efforts develop pressure sores but here's the difference we've documented what's going on we're aware that they're developing a skin problem we have documentation of what we're trying to do to prevent it or to correct it whereas in some of these people who develop pressure sores that we do think are related to abuse or neglect you don't have any of that documentation you don't have any of that awareness you just have people saying oh gosh I don't know how they develop the pressure sores so that we can actually see their bone now how do you get doctors to pay attention when you think there might be abuse well I've been advocating the use of a pepper spray but my colleagues have not been too happy with short of that I think that um surveyors or nurses administrators really need to get the doctor's attention and say hey I think there's a problem here we have to be honest about the fact that sometimes medical directors of nursing homes have financial interests in nursing homes as well and all of those factors can come into play when we talk about recognizing and reporting abuse but it clearly to me as the physician's responsibility to be at the forefront of examining people taking it seriously documenting concerns and talking to the staff there as well when abuse is a possibility and what do you do if you have a CNA who is abusing is not likely to report themselves right yeah they're not likely to report themselves what we really have to hope for is that there are advocates in the facility it might be other residents who live there other CNA's administration who recognize or the physician recognize that something bad is going on um and then here goes the investigation of course people are very likely to deny that they're doing anything bad the person who's being abused is often demented and so their ability to recall events might be pretty poor and so that's why paying attention to some of these things that we've talked about today are important looking at the location seeing if the story makes sense getting an idea about whether the functional status of the person really makes sense in view of the wound that you're seeing and then being able to question the CNA more carefully if things don't make sense it's amazing how stories can change once you confront them with some of those facts well in light of the fact that we're just about to wrap up uh are there any other words of wisdom that you would like to leave with our viewing audience well again I what I'd like to say is thank you to the folks who are working in nursing homes it's such an important job that they're doing um and I think we have to really recognize the vulnerability of the people who are living in nursing homes and other sorts of licensed facilities and we all have a responsibility in protecting them okay thank you so much um it seems like that's all the questions we have for this time but we'd like to say thanks to Dr. Mascata for being here with us today and to everyone who called or faxed in with questions and remember you can see this entire broadcast for up to one year from this date all you have to do is go to the website uh cms.internetstreaming.com for duplication purposes please contact the National Technical Information Services at 5285 Port Royal Road room 1008 the Sills Building uh in Springfield Virginia the zip is 22131 uh be sure to join us for our next broadcast on October 21st for the 2005 survey and certifications long-term care policy year in review uh we want to thank you so much for watching I'm Doris McMillan have a great day