Carmel Bitondo Dyer

The high prevalence of depression and dementia in elder abuse or neglect.

BACKGROUND: The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people.

Elder Self-neglect and Abuse and Mortality Risk in a Community-Dwelling Population

CONTEXT Both elder self-neglect and abuse have become increasingly prominent public health issues. The association of either elder self-neglect or abuse with mortality remains unclear. OBJECTIVE To examine the relationship of elder self-neglect or abuse reported to social services agencies with all-cause mortality among a community-dwelling elderly population. DESIGN, SETTING, AND PARTICIPANTS Prospective, population-based cohort study (conducted from 1993 to 2005) of residents living in a geographically defined community of 3 adjacent neighborhoods in Chicago, Illinois, who were participating in the Chicago Health and Aging Project (CHAP; a longitudinal, population-based, epidemiological study of residents aged > or = 65 years). A subset of these participants had suspected elder self-neglect or abuse reported to social services agencies. MAIN OUTCOME MEASURES Mortality ascertained during follow-up and by use of the National Death Index. Cox proportional hazard models were used to assess independent associations of self-neglect or elder abuse reporting with the risk of all-cause mortality using time-varying covariate analyses. RESULTS Of 9318 CHAP participants, 1544 participants were reported for elder self-neglect and 113 participants were reported for elder abuse from 1993 to 2005. All CHAP participants were followed up for a median of 6.9 years (interquartile range, 7.4 years), during which 4306 deaths occurred. In multivariable analyses, reported elder self-neglect was associated with a significantly increased risk of 1-year mortality (hazard ratio [HR], 5.82; 95% confidence interval [CI], 5.20-6.51). Mortality risk was lower but still elevated after 1 year (HR, 1.88; 95% CI, 1.67-2.14). Reported elder abuse also was associated with significantly increased risk of overall mortality (HR, 1.39; 95% CI, 1.07-1.84). Confirmed elder self-neglect or abuse also was associated with mortality. Increased mortality risks associated with either elder self-neglect or abuse were not restricted to those with the lowest levels of cognitive or physical function. CONCLUSION Both elder self-neglect and abuse reported to social services agencies were associated with increased risk of mortality.

Progress in elder abuse screening and assessment instruments.

The responsibility of identifying elder mistreatment (EM) often falls on the healthcare professional. Many different screening and assessment instruments have been developed to aid healthcare professionals in making determinations about EM. The purpose of this article is to review existing EM screening and assessment instruments to examine progress in this field. The value and limitations of these instruments with regard to their use in different clinical and healthcare settings are discussed. The settings in which EM screening and assessment are conducted are also considered. The authors conclude that there is much to be done in terms of achieving consensus on what constitutes an appropriate screen or assessment instrument for detecting EM. Effort must be focused on instruments that can be used for brief, rapid screenings and those that can be used for more‐detailed diagnostic assessments.

Self-Neglect Among the Elderly: A Model Based on More Than 500 Patients Seen by a Geriatric Medicine Team

OBJECTIVES We sought to identify the functional, cognitive, and social factors associated with self-neglect among the elderly to aid the development of etiologic models to guide future research. METHODS A cross-sectional chart review was conducted at Baylor College of Medicine Geriatrics Clinic in Houston, Tex. Patients were assessed using standardized comprehensive geriatric assessment tools. RESULTS Data analysis was performed using the charts of 538 patients; the average patient age was 75.6 years, and 70% were women. Further analysis in 460 persons aged 65 years and older showed that 50% had abnormal Mini Mental State Examination scores, 15% had abnormal Geriatric Depression Scale scores, 76.3% had abnormal physical performance test scores, and 95% had moderate-to-poor social support per the Duke Social Support Index. Patients had a range of illnesses; 46.4% were taking no medications. CONCLUSIONS A model of self-neglect was developed wherein executive dyscontrol leads to functional impairment in the setting of inadequate medical and social support. Future studies should aim to provide empirical evidence that validates this model as a framework for self-neglect. If validated, this model will impart a better understanding of the pathways to self-neglect and provide clinicians and public service workers with more effective prevention and intervention strategies.

Quantifying the Problem of Abuse and Neglect in Adults—Analysis of a Statewide Database

BACKGROUND: Mistreatment of adults, including abuse, neglect, and exploitation, affects more than 1.8 million older Americans. Presently, there is a lack of precise estimates of the magnitude of the problem and the variability in risk for different types of mistreatment depending on such factors as age and gender.

Unique pattern of complications in elderly trauma patients at a Level I trauma center.

Background: Trauma centers are caring for increased proportions of elderly patients. Although age and Injury Severity Score are independently associated with mortality, trauma centers were originally designed to care for seriously injured patients without age-specific guidelines. We hypothesized that elderly patients would have different complication patterns than their younger counterparts. Methods: The trauma registry of an American College of Surgeons -verified Level I trauma center was queried for all patients older than 14 years admitted between January 2005 and December 2008. Mechanism, mortality, and complications were evaluated after dividing patients into eight age groups. Results: Of the 15,223 patients, 13% were elderly (≥65), and 86% were injured via a blunt mechanism. Increasing age correlated with fatality (all Injury Severity Scores), end-organ failure, and thromboembolic complications (deep venous thrombosis and coagulopathy). Analysis revealed a significant breakpoint at 45 years of age for mortality, decubitus ulcer, and renal failure (all p values <0.05). Infectious complications (sepsis, wound infection, and abscess) all peaked between 45 years and 65 years and then declined with increasing age. Conclusions: We document that elderly trauma patients suffer the same complications as their younger counterparts, albeit at a different rate. More importantly, we identified a “breakpoint” of increased risk of complications and mortality at greater than 45 years. Although the mechanisms behind these observations remain unknown, understanding their unique patterns may allow appropriate allocation of resources and focus research efforts on interventions that should improve outcomes. Level of Evidence: II.

Elder abuse detection and intervention: A collaborative approach

* Dedication * Acknowledgments * Preface * Introduction Part One: Understanding Elder Abuse * Historical Context * Defining Elder Abuse * Dynamics of Elder Abuse Part Two: Responding to Elder Abuse * Systemic Responses to Elder Abuse * Additional Agencies That May Offer Useful Services for Elder Abuse Victims Part Three: Collaboration * Collaborative Efforts: Benefits and Obstacles * Effective Interventions and Informal Collaborations * Team Processes * The Work of a Case Management Team * Enhancing Victim Safety Through Collaboration * A Collaborative Model for Holding Abusers Accountable * Systemic Review and Change Through Multidisciplinary Collaborations Part Five: Where Do We Go From Here? * Strategies to End Elder Abuse.

Patient Autonomy for the Management of Chronic Conditions: A Two-Component Re-Conceptualization

The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic care. The purpose of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy.

Changing Patient Characteristics and Survival Experience in an Alzheimer’s Center Patient Cohort

Background:Large and diverse dementia patient cohorts can further a variety of research programs aimed at improving diagnosis, treatment, and meaningful survival in AD. Method: We recruited 1,502 dementia patients between 1989 and 2002, subclassified using standardized criteria and laboratory procedures, and treated according to established guidelines. Baseline clinical and psychometric measures were repeated annually, in person or by use of a multi-modal telephone follow-up program that included many of the measures obtained at in-person visits. We tracked vital status of all subjects at 6-month intervals and offered autopsies to all participants. We assessed for cohort effects in baseline characteristics by 2-year intervals, examined the characteristics and outcomes for those who remained active compared to those who were eventually lost to follow-up, examined survival times for demographic or diagnostic subgroups, and assessed the accuracy of clinical diagnoses versus neuropathology. Results: The average age at entry, average educational level, and baseline MMSE scores for subjects are increasing over time, and probable AD diagnoses are also increasing. Most (80.6%) subjects have remained active in our Center; those who did not were more likely to have a non-AD diagnosis. Survival averages 5.2 years (CI 4.98–5.37) and is influenced by age and gender, but not by diagnosis of probable versus possible AD. Our diagnostic accuracy is 89.6%, with high sensitivity to the presence of AD (96%). Conclusions: In a large and representative clinical cohort, the demographics of AD are changing over time. Careful analyses of those who continue and those who drop out from follow-up suggest that atypical diagnosis, rather than severity or demographic issues accounts for most of the attrition. Clinicians are likely to encounter increasingly older patients with milder disease, and these trends have implications for the design of clinical trials. Survival from the onset of first symptoms, similar for probable and possible AD cases, may be increasing over time.

Hurricane katrina : Medical response at the houston astrodome/reliant center complex

On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility—the Katrina Clinic—at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.