James G. O'Brien

Self-Neglect: An Overview

SUMMARY Initially described in 1953, the concept of self-neglect is complex. Definitional problems exist because it can be redefined by changes in context. This article examines the epidemiology, etiology, detection, ethical/legal issues, management/intervention, and outcome. Prevention is particularly difficult given the nature of the problem, the poorly understood etiology, and the slow insidious progression of the syndrome before it reaches public attention. This complexity is compounded by the fact that respect for autonomy and personal rights is given paramount importance over paternalism when an intervention at an earlier stage could potentially result in a better outcome.

National profiling of elder abuse referrals

BACKGROUND there is little consistent data on patterns of reporting of elder abuse in Europe. Between 2002 and 2007, the Irish Health Service Executive developed dedicated structures and staff to support the prevention, detection and management of elder abuse without mandatory reporting. Public awareness campaigns, staff training and management briefings heightened awareness regarding this new service. Central to this process is the development of a national database which could provide useful insights for developing coordinated responses to elder abuse in Europe. OBJECTIVE to report the rate of referrals of elder abuse, patterns of elder abuse and outcomes of interventions related to a dedicated elder abuse service in the absence of mandatory reporting. METHODS data on all referrals were recorded at baseline by a national network of Senior Case Workers dedicated to elder abuse, with follow-up conducted at 6 months and/or case closure. All cases were entered on a central database and tracked through the system. The study design was cross-sectional at two time points. RESULTS of 1,889 referrals, 381 related to self-neglect. Of the remaining 1,508, 67% (n = 1,016) were women. In 40% (n = 603) of cases, there was more than one form of alleged abuse. Over 80% of cases referred related to people living at home. At review 86% (n = 1,300) cases were closed, in 101 client had died, 10% of these clients had declined an intervention. Cases are more likely to be open longer than 6 months if substantiated 36 versus 21% in the closed cases. Consultation with the police occurred in 12% (n = 170) of cases. The majority of clients (84% n = 1,237) had services offered with 74% (n = 1,085) availing of them. Monitoring, home support and counselling were the main interventions. CONCLUSION the number of reported cases of abuse in Ireland indicates an under-reporting of elder abuse. The classification of almost half of the cases as inconclusive is a stimulus to further analysis and research, as well as for revision of classification and follow-up procedures. The provision of services to a wide range of referrals demonstrated a therapeutic added benefit of specialist elder abuse services. The national database on elder abuse referrals provides valuable insight into patterns of elder abuse and the nature of classification and response. The pooling of such data between European states would allow for helpful comparison in building research and services in elder abuse.

Initiating and Sustaining a Standardized Pain Management Program in Long-Term Care Facilities

OBJECTIVES To identify current pain management practices in the long-term care setting; and, implement and evaluate a comprehensive pain management program in the long-term care setting. DESIGN An interventional pilot study. SETTING Community-based long-term care facilities. METHODS This study was conducted in two phases. Phase I consisted of interviewing long-term care facility administrators to ascertain current pain management policies and practices. This information was used to develop the Phase II intervention that involved collecting benchmark data, creating or modifying pain policies and procedures, implementing a pain management program and presenting educational programs. MEASUREMENTS Interviews with long term care administrators; facility and resident demographic data; chart audits for pain assessment and management data; pharmacy audits; telephone surveys. RESULTS Pain management policies and practices were inadequate prior to the study intervention. No facilities had policies or procedures that required ongoing (daily, weekly, etc.) pain assessment. Only one facility had mechanisms in place for measuring the presence or intensity of pain in their non-verbal, cognitively-impaired residents. Following the pain management program intervention, pain assessment significantly increased. and treatment for pain was provided for the vast majority of those indicating pain. All sites had a standardized pain assessment program in place one-year post-study completion. CONCLUSIONS Standardized pain management programs are critical to improving pain management in long-term care settings. Improvement in long-term care pain management can be obtained through a comprehensive pain management program that involves staff education, changes in pain policies and procedures, and identifying pain management as a quality indicator.

A Physician's Perspective: Elder Abuse and Neglect Over 25 Years

Twenty-five years of involvement with elder abuse and neglect has yielded mixed results. The contribution by physicians to elder abuse, in contrast with child abuse, has been very limited. Physicians, despite being in an advantaged position to intervene, lag behind other professionals in reporting. Potential remedies include identification of abuse as a syndrome to allow for reimbursement, increased education and research funding, and a greater advocacy role by physician organizations.

Ethics and Aging: Confronting Abuse and Self-Neglect

SUMMARY Self-neglect inevitably poses ethical dilemmas for those involved in providing help. The balance between respect for the autonomy of the victim and the desire to act in a beneficent manner oftentimes results in disagreement and tension. The issue of refusal of treatment and the determination of decisional capacity are explored. Advocacy for the victim in the least intrusive manner is recommended.

Self‐Neglect and Elder Abuse: Related Phenomena?

LF/(LF + HF) ratio in the rooftop forest (0.50 ± 0.05) was 12% less than that of the control (0.57 ± 0.04). The HF values of the older adults determined in the present study were markedly lower than those of young adults in a previous study, although the LF/(LF + HF) ratios were not different. Numerous studies have demonstrated that LF and HF values for HRV attenuate with older age and that age does not affect the LF/HF ratio.8– 10 The results of the present study were in accordance with those of previous studies on the effect of aging on HRV. Thus, elderly women continued to exhibit autonomic sensitivity to the forest’s natural elements. Although the planted area was limited, the rooftop forest was sufficiently relaxing for elderly patients. In conclusion, elderly women requiring care entered a physiologically relaxed state in a rooftop forest in their healthcare institute. The hospital rooftop forest is an environment where they can experience natural stimulation and be restored, facilitating high-quality geriatric medicine.

Prevention of elder abuse

www.thelancet.com Vol 377 June 11, 2011 2005 which is used to monitor and assess service performance and quality. For example, 84–88% of patients who started ART in 2008 remain in the 12-month follow-up in all four countries. In Cambodia, the care for HIV, diabetes, and hypertension has been integrated in two public hospitals. In Vietnam, cancer hospitals are adapting the HIV care systems, including home-based care for cancer patients. Rather than reinventing the wheel to manage NCDs, southeast Asian countries can adapt and apply learning from chronic care HIV systems.

Screening for Elder Abuse and Neglect

The Affordable Care Act guarantees “from an individual perspective the recognition of an elder’s rights including the right to be free from abuse and neglect and exploitation.”Elder abuse constitutes a significant problem for older adults; an estimated 7.6% to 10% of people aged 60 and older experienced abuse in 2014. This incidence rate would appear to justify screening for such a problem that frequently goes unreported, but screening the general population is not justified. The focus of this article is on generalized screening for elder abuse in individuals who present for care in healthcare facilities, as opposed to active case-finding in situations in which abuse or neglect is more likely to occur, such as in older women who are vulnerable as a result of mental or physical infirmity. Screening for elder abuse in healthcare settings is a challenge given the low priority accorded to care of older individuals, as the lack of individuals willing to devote their careers to elder care indicates. Elder abuse is the orphan in terms of abuse when compared with domestic and child abuse. Of almost 54 million older people eligible for screening when visiting their physician, fewer than 1,500 were screened. This is also evident when comparison is made in terms of research support and general acceptance by the medical community. Federal funding for elder abuse prevention has remained static since the 1990s and is miniscule, specific for elder abuse services research, compared with funding for child abuse and domestic violence. Elder abuse contributes to morbidity and mortality and robs victims of quality of life during their final years. Does elder abuse qualify as a condition worthy of being screened? This can be examined using the Wilson and Jungner criteria to justify screening (Table 2). Consistent with the analysis in Table 2, the U.S. Preventive Services Task Force concludes that “the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional for abuse and neglect.” This conclusion is based on a variety of factors. Although a number of screening instruments are available, not all are appropriate in different settings, and there is inadequate evidence on their accuracy or that screening or early detection reduces exposure to abuse. Most communities lack resources and programs to alleviate an abusive situation that are acceptable to the victim, particularly because placement in a long-term care facility as a solution may be the least-desirable option for the victim, who may choose to remain in an abusive situation. Many other factors militate against screening. The elderly adults at highest risk include those with dementia who may be incapable of reporting or corroborating the presence of abuse. Similarly, individuals with dementia most of whom develop psychosis and paranoia may wrongfully accuse the caregiver of theft or abuse. Not infrequently, the individual with dementia is abusive toward the caregiver. Those who screen and report to an overstretched Adult Protective Services (APS) may be dissatisfied with the response and so may refuse to report in the future. Introducing screenings in medical settings is equally problematic in primary care settings, where already practitioners are pressured with meeting performance measures, and trying to cope with a distraction (the electronic health record) that may impede observation of signs or indicators of abuse. Even if staff are trained to screen, it falls on the physician to intervene. Most physicians have no training or expertise in intervening and may fear repercussions if they report to APS. In addition, definitions of abuse vary from state to state and are often difficult to interpret. Given all this, it is unlikely that physicians will embrace the notion of incorporating screening into busy practice sites without the benefit of a significant increase in reimbursement.

Elder abuse in residential care

Jean-Claude Monfort and colleagues (Jan 22, p 300) bring helpful attention to neglected aspects of elder abuse. Elder mistreatment in institutions is poorly catalogued, and is especially complex in consisting of both in stitutional abuse—towards all residents—and acts of elder abuse specifi cally towards a single resident. Monfort and colleagues’ Correspondence raises the further challenge of abuse by other residents, who, along with care staff , are recognised as the most common perpetrators of sexual abuse of nursing home residents. Most defi nitions of elder abuse are premised on their occurring within a relationship where there is an expectation of trust, and the precise nature of the relationship between residents, particularly when one or both might have cognitive impair ment, is not at all clear. More attention needs to be paid to developing techniques to prevent, detect, and manage resident-toresident abuse, and experienced care staff can provide helpful insights into how to develop these strategies. However, it would be important not to assume that only those with a past history of paedophilia are likely to be off enders, since vulnerability and inadequate vigilance about access might be more important factors than an agebased “gerontophilia”. Ad ditionally, we are as yet far from understanding how best to meet the sexual and emotional needs of residents in nursing homes. The expression of sexuality by nursing home residents often creates discomfort among care staff , and fresh thinking and multidisciplinary strategies are required to address the emotional and sexual wellbeing of older people in residential care.

Indirect Life-Threatening Behavior in Elderly Patients

SUMMARY Older adults frequently engage in such indirect life-threatening behaviors as extreme lack of self-care, refusal to eat, refusal to take medications, and failure to comply with an understood medical regimen. These behaviors are often classified as non-compliance or passive suicide. Analysis of such phenomena reveals that these actions can represent attempts by the person to gain control of and to ameliorate a negative life situation. A case is presented which demonstrates the ultimate outcome of engagement in such behavior when it is misinterpreted and left untreated. The functions of indirect life-threatening behavior are discussed.