When to Suspect Elder Abuse

March 1, 2007

In his "What's Your Diagnosis?" case of an 89-year-old woman with advanced Alzheimer disease who had injuries attributed to a fall in a nursing home (CONSULTANT, October 2006, page 1373), Dr Henry Schneiderman notes that "the fall was not observed" and that "many prior falls have been ascribed to her lack of safety awareness in negotiating the environment."

In his "What's Your Diagnosis?" case of an 89-year-old woman with advanced Alzheimer disease who had injuries attributed to a fall in a nursing home (CONSULTANT, October 2006, page 1373), Dr Henry Schneiderman notes that "the fall was not observed" and that "many prior falls have been ascribed to her lack of safety awareness in negotiating the environment."

In this setting, I would suspect abuse. Dr Schneiderman notes that "poor caregiver oversight with a false report about trauma" should be considered as a cause of the patient's injuries. However, the possibility of a more active role in the incident by the staff, another resident, or a visitor should have been mentioned. An investigation into this matter should have been initiated and the resultant findings reported in the article. We all need to keep in mind that elder abuse is not rare.

-Norman Wasserman, MD
  Plantation, Fla

I am grateful for Dr Wasserman's reminder that elder abuse can be active, deliberate, and malicious as well as simply neglectful. This is a message never to be forgotten. In fact, this patient's bruise and fracture were thoroughly investigated by our nursing department. Such an investigation takes place after any incident of unexplained bruising or injury, whether or not the patient is able to recount the story; many other skilled nursing facilities have a similar practice, and there is widespread regulatory and statutory requirement for the same. Why is it necessary? Because, among other reasons, consistent denial that anything took place is the usual verbal response of a frightened older person even when abuse has occurred; a "negative" history recounted by the patient cannot be given undue credence.

I enjoyed a close familiarity with this woman for years before, during, and after the events recounted. I knew the patient, her incredibly devoted daughter and extended family, and the wonderful certified nursing assistants who gave her personal care, as well as the professional nurses, recreation therapist, and rehabilitation and social work personnel who worked with her. Moreover, around the time of these injuries I was present on the nursing unit at least daily. I thus had the luxury of confidence. Another reason that I did not have to worry that I might have had my head in the sand and been ignoring elder abuse-which, as Dr Wasserman points out, is all too common-is that the director of nursing and her deputies conducted a thorough investigation. The conclusion of the investigators was that no abuse had occurred. I wish I had included a report of the same in the case discussion, and can only plead the constraints of space and the assurance that I personally possessed to explain (not excuse) my omission.

My observations of this patient in the years that followed, over the course of an awful disease, will be the subject of a future "What's Your Diagnosis?" column. All the later experiences underscored that she was treated with the utmost dignity, respect, and regard. Would that every aged demented person could count on the same.

-Henry Schneiderman, MD
  Vice President, Medical Services/Physician-in-Chief
  Hebrew Health Care
  West Hartford, Conn
  Professor of Medicine (Geriatrics)
  Associate Professor of Pathology
  University of Connecticut Health Center
  Farmington