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AAP backs zero tolerance for headfirst hits in football
WASHINGTON – Teaching young athletes to tackle with their heads up and enforcing rules against illegal headfirst hits can reduce the risks of concussions in youth football, according to a new policy statement by the American Academy of Pediatrics.
An emphasis on proper tackling technique and implementing strategies to reduce head hits maintains the integrity of the game while reducing the most serious injuries as well as subconcussive hits, Dr. Gregory L. Landry, Fellow of the American Academy of Pediatrics (FAAP), and professor of pediatrics and orthopedics at the University of Wisconsin–Madison, said in his plenary talk at the annual meeting of the American Academy of Pediatrics.
Dr. Landry, along with Dr. William P. Meehan III, FAAP, led the Council on Sports Medicine and Fitness in writing the AAP’s policy statement on tackling in youth football (Pediatrics 2015 Oct 25. doi: 10.1542/peds.2015-3282).
In response to growing calls to ban tackling entirely in youth football, and calls to eliminate football from high school sports, the council reviewed the evidence on youth tackling, concussions, and other injuries in football to reach the seven conclusions outlined in the policy statement, Dr. Landry said.
“Most injuries sustained during participation in youth football are minor, including injuries to the head and neck,” according to the policy statement. “The incidences of severe injuries, catastrophic injuries, and concussion, however, are higher in football than most other team sports and appear to increase with age.”
During his talk, Dr. Landry noted that catastrophic injuries occur more frequently in gymnastics and wrestling than in football. Among all youth football injuries, 3.4% are neurologic and 2.5% are fractures. Half are contusions, 16.7% are sprains, and 9.3% are strains.
Within football, young players tend to have far lower rates of concussions, compared to older players. In one 2-year observational study, the overall concussion rates of 7.4 per 1,000 athletic exposures broke down to 4.3 per 1,000 exposures for fourth- and fifth-graders and 14.4 per 1,000 exposures for eighth-graders. On the low end, another study found a concussion rate of 1.8 per 1,000 exposures, with a rate of 0.24 for practices and 6.2 for games.
“One of the common themes is that game rate is always higher than practice rates,” Dr. Landry said. “Running backs seem to be at the highest risk for injuries.”
In addition, tackling is the most common player activity at the time of the injury and at the time of severe injury. “The act of tackling is, in fact, risky business,” Dr. Landry said.
One reason for this relates to improvement in football safety equipment, he explained.
“As football helmets began to improve, football players began leading with their heads instead of their shoulders,” he said. “Leading with the head increases the risk of both concussion and spinal injury. The priority must be that the head must be up when a player tackles someone. The proper way to tackle is leading with the chest.”
A key study showing the effect that heads-up tackling instruction can have on concussion rates involved comparisons with teams taught Heads Up Football, “a comprehensive program developed by USA Football to advance player safety,” according to the program’s website. During the 2014 football season in Indiana, researchers compared teams that participated in the Heads Up program with teams that did not and with a third group of Pop Warner–affiliated teams that had reduced the number of full body contact practices.
Among 71,262 athletic exposures, the rate was lowest for the teams that were both Pop Warner affiliated and Heads Up affiliated, with a rate of 0.97 concussions per 1,000 athletic exposures. The teams involved in neither program had a rate of 7.32 concussions per 1,000 exposures, but even the Heads Up–only teams had a rate more than twice as low, with 2.73 per 1,000 exposures, revealing the importance of not tackling head first, Dr. Landry said.
“That’s the problem with American football – the whole game has changed,” he said, regarding the shift in tackling technique. “And you’re seeing this at the college level and at the professional level.”
In light of the way the game has changed and the risks it presented, the council offered seven conclusions and recommendations in its policy statement:
1. Officials and coaches must enforce the rules of the game, moving toward “zero tolerance of illegal, headfirst hits.” The statement notes a current “culture of tolerance” regarding headfirst tackling. “This culture has to change to one that protects the head for both the tackler and those players being tackled,” the committee stated. “Stronger sanctions for contact to the head, especially of a defenseless player, should be considered, up to and including expulsion from the game.”
2. Although eliminating tackling from football would likely cause a decrease in overall and severe or catastrophic injuries, it would also change essential aspects of the game. “Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling,” the committee stated. Dr. Landry compared the game to hockey. “In ice hockey, if you don’t check, it’s still ice hockey,” he said. “But with football, removing tackling fundamentally changes the game.”
3. Football leagues should consider expanding their options to include football teams without tackling, such as flag football, for those who want to play without the additional risks from tackling. But youth flag football has not been studied, Dr. Landry pointed out, and some adult studies have shown higher rates of injuries, so youth flag football requires more study.
4. Officials and coaches should look for and implement ways to reduce the number of hits to the head that players experience. “If subconcussive blows to the head result in negative long-term effects on health, then limiting impacts to the head should reduce the risk of these long-term health problems,” the committee stated while acknowledging the need for more research in this area.
5. A theoretical risk exists that delaying the age when athletes learn tackling could lead it to become more dangerous. “Once tackling is introduced, athletes who have no previous experience with tackling would be exposed to collisions for the first time at an age at which speeds are faster, collision forces are greater, and injury risk is higher,” the committee stated. “Lack of experience with tackling and being tackled may lead to an increase in the number and severity of injuries once tackling is introduced.” Dr. Landry acknowledged that the risk is theoretical and hasn’t been studied but perhaps needs to be.
6. Neck strengthening might lessen the risk of concussions with head hits, though little scientific evidence exists to support this hypothesis. “Physical therapists, athletic trainers, or strength and conditioning specialists with expertise in the strengthening and conditioning of pediatric athletes are best qualified to help young football players achieve the neck strength that will help prevent injuries,” the committee stated.
7. Football teams should have athletic trainers present at organized football games and practices since research supports a link between trainers’ presence and a lower incidence of sports-related injuries.
Dr. Landry’s overall message focused on ways to reduce risks without ending football. “Let’s not ban the game,” he said. “Let’s just make it safer.”
Dr. Landry has no financial disclosures but had his college tuition paid by playing football, served as team physician for the University of Wisconsin football team for many seasons, and grew up as the son of a high school football coach. Dr. Meehan is involved in researched partly funded by the National Football League Players Association, and he receives compensation from ABC-Clio Publishing, Wolters Kluwer, and Springer International Publishing for works he has authored.
WASHINGTON – Teaching young athletes to tackle with their heads up and enforcing rules against illegal headfirst hits can reduce the risks of concussions in youth football, according to a new policy statement by the American Academy of Pediatrics.
An emphasis on proper tackling technique and implementing strategies to reduce head hits maintains the integrity of the game while reducing the most serious injuries as well as subconcussive hits, Dr. Gregory L. Landry, Fellow of the American Academy of Pediatrics (FAAP), and professor of pediatrics and orthopedics at the University of Wisconsin–Madison, said in his plenary talk at the annual meeting of the American Academy of Pediatrics.
Dr. Landry, along with Dr. William P. Meehan III, FAAP, led the Council on Sports Medicine and Fitness in writing the AAP’s policy statement on tackling in youth football (Pediatrics 2015 Oct 25. doi: 10.1542/peds.2015-3282).
In response to growing calls to ban tackling entirely in youth football, and calls to eliminate football from high school sports, the council reviewed the evidence on youth tackling, concussions, and other injuries in football to reach the seven conclusions outlined in the policy statement, Dr. Landry said.
“Most injuries sustained during participation in youth football are minor, including injuries to the head and neck,” according to the policy statement. “The incidences of severe injuries, catastrophic injuries, and concussion, however, are higher in football than most other team sports and appear to increase with age.”
During his talk, Dr. Landry noted that catastrophic injuries occur more frequently in gymnastics and wrestling than in football. Among all youth football injuries, 3.4% are neurologic and 2.5% are fractures. Half are contusions, 16.7% are sprains, and 9.3% are strains.
Within football, young players tend to have far lower rates of concussions, compared to older players. In one 2-year observational study, the overall concussion rates of 7.4 per 1,000 athletic exposures broke down to 4.3 per 1,000 exposures for fourth- and fifth-graders and 14.4 per 1,000 exposures for eighth-graders. On the low end, another study found a concussion rate of 1.8 per 1,000 exposures, with a rate of 0.24 for practices and 6.2 for games.
“One of the common themes is that game rate is always higher than practice rates,” Dr. Landry said. “Running backs seem to be at the highest risk for injuries.”
In addition, tackling is the most common player activity at the time of the injury and at the time of severe injury. “The act of tackling is, in fact, risky business,” Dr. Landry said.
One reason for this relates to improvement in football safety equipment, he explained.
“As football helmets began to improve, football players began leading with their heads instead of their shoulders,” he said. “Leading with the head increases the risk of both concussion and spinal injury. The priority must be that the head must be up when a player tackles someone. The proper way to tackle is leading with the chest.”
A key study showing the effect that heads-up tackling instruction can have on concussion rates involved comparisons with teams taught Heads Up Football, “a comprehensive program developed by USA Football to advance player safety,” according to the program’s website. During the 2014 football season in Indiana, researchers compared teams that participated in the Heads Up program with teams that did not and with a third group of Pop Warner–affiliated teams that had reduced the number of full body contact practices.
Among 71,262 athletic exposures, the rate was lowest for the teams that were both Pop Warner affiliated and Heads Up affiliated, with a rate of 0.97 concussions per 1,000 athletic exposures. The teams involved in neither program had a rate of 7.32 concussions per 1,000 exposures, but even the Heads Up–only teams had a rate more than twice as low, with 2.73 per 1,000 exposures, revealing the importance of not tackling head first, Dr. Landry said.
“That’s the problem with American football – the whole game has changed,” he said, regarding the shift in tackling technique. “And you’re seeing this at the college level and at the professional level.”
In light of the way the game has changed and the risks it presented, the council offered seven conclusions and recommendations in its policy statement:
1. Officials and coaches must enforce the rules of the game, moving toward “zero tolerance of illegal, headfirst hits.” The statement notes a current “culture of tolerance” regarding headfirst tackling. “This culture has to change to one that protects the head for both the tackler and those players being tackled,” the committee stated. “Stronger sanctions for contact to the head, especially of a defenseless player, should be considered, up to and including expulsion from the game.”
2. Although eliminating tackling from football would likely cause a decrease in overall and severe or catastrophic injuries, it would also change essential aspects of the game. “Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling,” the committee stated. Dr. Landry compared the game to hockey. “In ice hockey, if you don’t check, it’s still ice hockey,” he said. “But with football, removing tackling fundamentally changes the game.”
3. Football leagues should consider expanding their options to include football teams without tackling, such as flag football, for those who want to play without the additional risks from tackling. But youth flag football has not been studied, Dr. Landry pointed out, and some adult studies have shown higher rates of injuries, so youth flag football requires more study.
4. Officials and coaches should look for and implement ways to reduce the number of hits to the head that players experience. “If subconcussive blows to the head result in negative long-term effects on health, then limiting impacts to the head should reduce the risk of these long-term health problems,” the committee stated while acknowledging the need for more research in this area.
5. A theoretical risk exists that delaying the age when athletes learn tackling could lead it to become more dangerous. “Once tackling is introduced, athletes who have no previous experience with tackling would be exposed to collisions for the first time at an age at which speeds are faster, collision forces are greater, and injury risk is higher,” the committee stated. “Lack of experience with tackling and being tackled may lead to an increase in the number and severity of injuries once tackling is introduced.” Dr. Landry acknowledged that the risk is theoretical and hasn’t been studied but perhaps needs to be.
6. Neck strengthening might lessen the risk of concussions with head hits, though little scientific evidence exists to support this hypothesis. “Physical therapists, athletic trainers, or strength and conditioning specialists with expertise in the strengthening and conditioning of pediatric athletes are best qualified to help young football players achieve the neck strength that will help prevent injuries,” the committee stated.
7. Football teams should have athletic trainers present at organized football games and practices since research supports a link between trainers’ presence and a lower incidence of sports-related injuries.
Dr. Landry’s overall message focused on ways to reduce risks without ending football. “Let’s not ban the game,” he said. “Let’s just make it safer.”
Dr. Landry has no financial disclosures but had his college tuition paid by playing football, served as team physician for the University of Wisconsin football team for many seasons, and grew up as the son of a high school football coach. Dr. Meehan is involved in researched partly funded by the National Football League Players Association, and he receives compensation from ABC-Clio Publishing, Wolters Kluwer, and Springer International Publishing for works he has authored.
WASHINGTON – Teaching young athletes to tackle with their heads up and enforcing rules against illegal headfirst hits can reduce the risks of concussions in youth football, according to a new policy statement by the American Academy of Pediatrics.
An emphasis on proper tackling technique and implementing strategies to reduce head hits maintains the integrity of the game while reducing the most serious injuries as well as subconcussive hits, Dr. Gregory L. Landry, Fellow of the American Academy of Pediatrics (FAAP), and professor of pediatrics and orthopedics at the University of Wisconsin–Madison, said in his plenary talk at the annual meeting of the American Academy of Pediatrics.
Dr. Landry, along with Dr. William P. Meehan III, FAAP, led the Council on Sports Medicine and Fitness in writing the AAP’s policy statement on tackling in youth football (Pediatrics 2015 Oct 25. doi: 10.1542/peds.2015-3282).
In response to growing calls to ban tackling entirely in youth football, and calls to eliminate football from high school sports, the council reviewed the evidence on youth tackling, concussions, and other injuries in football to reach the seven conclusions outlined in the policy statement, Dr. Landry said.
“Most injuries sustained during participation in youth football are minor, including injuries to the head and neck,” according to the policy statement. “The incidences of severe injuries, catastrophic injuries, and concussion, however, are higher in football than most other team sports and appear to increase with age.”
During his talk, Dr. Landry noted that catastrophic injuries occur more frequently in gymnastics and wrestling than in football. Among all youth football injuries, 3.4% are neurologic and 2.5% are fractures. Half are contusions, 16.7% are sprains, and 9.3% are strains.
Within football, young players tend to have far lower rates of concussions, compared to older players. In one 2-year observational study, the overall concussion rates of 7.4 per 1,000 athletic exposures broke down to 4.3 per 1,000 exposures for fourth- and fifth-graders and 14.4 per 1,000 exposures for eighth-graders. On the low end, another study found a concussion rate of 1.8 per 1,000 exposures, with a rate of 0.24 for practices and 6.2 for games.
“One of the common themes is that game rate is always higher than practice rates,” Dr. Landry said. “Running backs seem to be at the highest risk for injuries.”
In addition, tackling is the most common player activity at the time of the injury and at the time of severe injury. “The act of tackling is, in fact, risky business,” Dr. Landry said.
One reason for this relates to improvement in football safety equipment, he explained.
“As football helmets began to improve, football players began leading with their heads instead of their shoulders,” he said. “Leading with the head increases the risk of both concussion and spinal injury. The priority must be that the head must be up when a player tackles someone. The proper way to tackle is leading with the chest.”
A key study showing the effect that heads-up tackling instruction can have on concussion rates involved comparisons with teams taught Heads Up Football, “a comprehensive program developed by USA Football to advance player safety,” according to the program’s website. During the 2014 football season in Indiana, researchers compared teams that participated in the Heads Up program with teams that did not and with a third group of Pop Warner–affiliated teams that had reduced the number of full body contact practices.
Among 71,262 athletic exposures, the rate was lowest for the teams that were both Pop Warner affiliated and Heads Up affiliated, with a rate of 0.97 concussions per 1,000 athletic exposures. The teams involved in neither program had a rate of 7.32 concussions per 1,000 exposures, but even the Heads Up–only teams had a rate more than twice as low, with 2.73 per 1,000 exposures, revealing the importance of not tackling head first, Dr. Landry said.
“That’s the problem with American football – the whole game has changed,” he said, regarding the shift in tackling technique. “And you’re seeing this at the college level and at the professional level.”
In light of the way the game has changed and the risks it presented, the council offered seven conclusions and recommendations in its policy statement:
1. Officials and coaches must enforce the rules of the game, moving toward “zero tolerance of illegal, headfirst hits.” The statement notes a current “culture of tolerance” regarding headfirst tackling. “This culture has to change to one that protects the head for both the tackler and those players being tackled,” the committee stated. “Stronger sanctions for contact to the head, especially of a defenseless player, should be considered, up to and including expulsion from the game.”
2. Although eliminating tackling from football would likely cause a decrease in overall and severe or catastrophic injuries, it would also change essential aspects of the game. “Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling,” the committee stated. Dr. Landry compared the game to hockey. “In ice hockey, if you don’t check, it’s still ice hockey,” he said. “But with football, removing tackling fundamentally changes the game.”
3. Football leagues should consider expanding their options to include football teams without tackling, such as flag football, for those who want to play without the additional risks from tackling. But youth flag football has not been studied, Dr. Landry pointed out, and some adult studies have shown higher rates of injuries, so youth flag football requires more study.
4. Officials and coaches should look for and implement ways to reduce the number of hits to the head that players experience. “If subconcussive blows to the head result in negative long-term effects on health, then limiting impacts to the head should reduce the risk of these long-term health problems,” the committee stated while acknowledging the need for more research in this area.
5. A theoretical risk exists that delaying the age when athletes learn tackling could lead it to become more dangerous. “Once tackling is introduced, athletes who have no previous experience with tackling would be exposed to collisions for the first time at an age at which speeds are faster, collision forces are greater, and injury risk is higher,” the committee stated. “Lack of experience with tackling and being tackled may lead to an increase in the number and severity of injuries once tackling is introduced.” Dr. Landry acknowledged that the risk is theoretical and hasn’t been studied but perhaps needs to be.
6. Neck strengthening might lessen the risk of concussions with head hits, though little scientific evidence exists to support this hypothesis. “Physical therapists, athletic trainers, or strength and conditioning specialists with expertise in the strengthening and conditioning of pediatric athletes are best qualified to help young football players achieve the neck strength that will help prevent injuries,” the committee stated.
7. Football teams should have athletic trainers present at organized football games and practices since research supports a link between trainers’ presence and a lower incidence of sports-related injuries.
Dr. Landry’s overall message focused on ways to reduce risks without ending football. “Let’s not ban the game,” he said. “Let’s just make it safer.”
Dr. Landry has no financial disclosures but had his college tuition paid by playing football, served as team physician for the University of Wisconsin football team for many seasons, and grew up as the son of a high school football coach. Dr. Meehan is involved in researched partly funded by the National Football League Players Association, and he receives compensation from ABC-Clio Publishing, Wolters Kluwer, and Springer International Publishing for works he has authored.
AT THE AAP NATIONAL CONFERENCE
New Warfarin Measure Aids in Anticoagulation Ranking
NEW YORK - A novel warfarin composite measure (WCM) that combines percent time in therapeutic range (TTR) and international normalized ratio (INR) variability might be useful in comparing anticoagulation clinic performance rankings, researchers report.
TTR reflects the intensity of anticoagulation, whereas INR variability reflects its stability. Both are important measures of anticoagulation quality, and previous studies have suggested their combination provides added value.
Dr. Zayd Razouki from Durham VA Medical Center in North Carolina and colleagues developed the WCM, which combines standardized TTR and standardized log INR variability, and examined its feasibility for profiling anticoagulation clinics in the Veterans Health Administration.
WCM's hazard ratios for fatal bleeding and ischemic stroke were greater with very poor control or poor control, compared with those with TTR or INR variability, the researchers report in Circulation Cardiovascular Quality and Outcomes, online September 29.
In contrast, WCM's hazard ratios for major bleeding were larger than those with INR variability but not significantly different from those with TTR.
As for patient level outcomes, WCM was no better than TTR or INR variability.
At the anticoagulation clinic level, WCM reconciled moderately well the discordance in rankings that occurred when using TTR or INR variability separately.
"We would recommend the use of WCM as a performance measure for clinic profiling, as it seems to identify different clinics as outliers," the researchers conclude. "Both on an empirical and a theoretical basis, WCM captures more completely relevant dimensions of anticoagulation control than its component measures."
Dr. Gabriel Vanerio from CASMU Arrhythmia Service in Montevideo, Uruguay, recently demonstrated the usefulness of INR variability for assessing anticoagulation quality. While admitting that the WCM is "very well constructed," he said by email, "I do not believe that this new measurement will be clinically useful."
Instead, Dr. Vanerio suggested that physicians should take home "the importance of anticoagulation quality control" as the main message of this report.
Dr. Razouki did not respond to a request for comments.
NEW YORK - A novel warfarin composite measure (WCM) that combines percent time in therapeutic range (TTR) and international normalized ratio (INR) variability might be useful in comparing anticoagulation clinic performance rankings, researchers report.
TTR reflects the intensity of anticoagulation, whereas INR variability reflects its stability. Both are important measures of anticoagulation quality, and previous studies have suggested their combination provides added value.
Dr. Zayd Razouki from Durham VA Medical Center in North Carolina and colleagues developed the WCM, which combines standardized TTR and standardized log INR variability, and examined its feasibility for profiling anticoagulation clinics in the Veterans Health Administration.
WCM's hazard ratios for fatal bleeding and ischemic stroke were greater with very poor control or poor control, compared with those with TTR or INR variability, the researchers report in Circulation Cardiovascular Quality and Outcomes, online September 29.
In contrast, WCM's hazard ratios for major bleeding were larger than those with INR variability but not significantly different from those with TTR.
As for patient level outcomes, WCM was no better than TTR or INR variability.
At the anticoagulation clinic level, WCM reconciled moderately well the discordance in rankings that occurred when using TTR or INR variability separately.
"We would recommend the use of WCM as a performance measure for clinic profiling, as it seems to identify different clinics as outliers," the researchers conclude. "Both on an empirical and a theoretical basis, WCM captures more completely relevant dimensions of anticoagulation control than its component measures."
Dr. Gabriel Vanerio from CASMU Arrhythmia Service in Montevideo, Uruguay, recently demonstrated the usefulness of INR variability for assessing anticoagulation quality. While admitting that the WCM is "very well constructed," he said by email, "I do not believe that this new measurement will be clinically useful."
Instead, Dr. Vanerio suggested that physicians should take home "the importance of anticoagulation quality control" as the main message of this report.
Dr. Razouki did not respond to a request for comments.
NEW YORK - A novel warfarin composite measure (WCM) that combines percent time in therapeutic range (TTR) and international normalized ratio (INR) variability might be useful in comparing anticoagulation clinic performance rankings, researchers report.
TTR reflects the intensity of anticoagulation, whereas INR variability reflects its stability. Both are important measures of anticoagulation quality, and previous studies have suggested their combination provides added value.
Dr. Zayd Razouki from Durham VA Medical Center in North Carolina and colleagues developed the WCM, which combines standardized TTR and standardized log INR variability, and examined its feasibility for profiling anticoagulation clinics in the Veterans Health Administration.
WCM's hazard ratios for fatal bleeding and ischemic stroke were greater with very poor control or poor control, compared with those with TTR or INR variability, the researchers report in Circulation Cardiovascular Quality and Outcomes, online September 29.
In contrast, WCM's hazard ratios for major bleeding were larger than those with INR variability but not significantly different from those with TTR.
As for patient level outcomes, WCM was no better than TTR or INR variability.
At the anticoagulation clinic level, WCM reconciled moderately well the discordance in rankings that occurred when using TTR or INR variability separately.
"We would recommend the use of WCM as a performance measure for clinic profiling, as it seems to identify different clinics as outliers," the researchers conclude. "Both on an empirical and a theoretical basis, WCM captures more completely relevant dimensions of anticoagulation control than its component measures."
Dr. Gabriel Vanerio from CASMU Arrhythmia Service in Montevideo, Uruguay, recently demonstrated the usefulness of INR variability for assessing anticoagulation quality. While admitting that the WCM is "very well constructed," he said by email, "I do not believe that this new measurement will be clinically useful."
Instead, Dr. Vanerio suggested that physicians should take home "the importance of anticoagulation quality control" as the main message of this report.
Dr. Razouki did not respond to a request for comments.
The fellowship of motherhood
I expected that having a baby as a pediatric subspecialty fellow was going to be a challenge. But I could never have anticipated how scary it would feel to step into the world on the other side of the clinic door. My friends invited me to join a breastfeeding support group on social media “so that I knew I wasn’t the only one up with my baby at 3 a.m.” I learned a lot more than that.
I learned that some mothers trust anecdotes from strangers more than advice from their pediatricians. They recount unsatisfying visits with their pediatricians and then ask other mothers to comment on the advice. As I sifted through a lot of nonscientific and sometimes medically dangerous advice, I also was offered a new perspective. Many mothers will lie to their pediatricians about sleeping and feeding habits because they don’t want to be judged or don’t want another canned answer. Instead of engaging in discussion, they nod, smile, and return to their online support groups.
Very little literature exists on how to partner with mothers to guide them through the breastfeeding journey. These are intimate and individual journeys for each mother and often for each new child. For most mothers who choose to breastfeed, their infant is asking them to learn a new endurance sport, and the body and mind have to start running a marathon on day 1. Breastfeeding consumes nearly every waking moment of at least the first 6 weeks of the infant’s life. It is the most important, stressful, and wonderful part of their young child’s life to date. Pediatricians need to understand and offer advice that reflects this struggle.
So how do we expect pediatricians to help new mothers when our pediatrics residencies lack a basic breastfeeding curriculum? We need to fix it soon because breastfeeding mothers expect evidence-based breastfeeding advice, and as I learned online, they may even fire you if they don’t like what they hear. Although many pediatricians may feel uncomfortable with counseling an adult woman about her body or even treating her, the American Academy of Pediatrics recommends that we do so (Pediatrics 2012 Mar;129[3]:e827-41). There are even resources available to guide billing of extended breastfeeding visits.
The basic science of breastfeeding and how to counsel on common concerns need to be represented in our residency curriculums, as a lack of training early on can perpetuate itself in practice, leading to pediatricians who give outdated advice, reassure when they should counsel further, or give the mother the impression her concerns are irrelevant. Mothers expect more of us when it comes to breastfeeding, and we should expect it of ourselves.
In the meantime, some resources I found helpful were:
• “The Nursing Mother’s Companion,” by Kathleen Huggins (Boston: Harvard Common Press, 2010). This is a great book to help those in training really understand the stresses and common concerns of breastfeeding moms.
• newborns.stanford.edu/Breastfeeding. This is a good online source for those who want a quick tutorial about the early days of breastfeeding.
• AAP Breastfeeding Residency Curriculum (www2.aap.org/breastfeeding/curriculum/medical_knowledge.html). These are learning modules to build knowledge of lactation pathophysiology and how to address mothers’ common concerns.
• www.drmilk.org. This is a support group for breastfeeding moms who are doctors.
Dr. Fricchione is a pediatric infectious diseases fellow at McGaw Medical Center of Northwestern University and the Ann and Robert H. Lurie Children’s Hospital of Chicago.
I expected that having a baby as a pediatric subspecialty fellow was going to be a challenge. But I could never have anticipated how scary it would feel to step into the world on the other side of the clinic door. My friends invited me to join a breastfeeding support group on social media “so that I knew I wasn’t the only one up with my baby at 3 a.m.” I learned a lot more than that.
I learned that some mothers trust anecdotes from strangers more than advice from their pediatricians. They recount unsatisfying visits with their pediatricians and then ask other mothers to comment on the advice. As I sifted through a lot of nonscientific and sometimes medically dangerous advice, I also was offered a new perspective. Many mothers will lie to their pediatricians about sleeping and feeding habits because they don’t want to be judged or don’t want another canned answer. Instead of engaging in discussion, they nod, smile, and return to their online support groups.
Very little literature exists on how to partner with mothers to guide them through the breastfeeding journey. These are intimate and individual journeys for each mother and often for each new child. For most mothers who choose to breastfeed, their infant is asking them to learn a new endurance sport, and the body and mind have to start running a marathon on day 1. Breastfeeding consumes nearly every waking moment of at least the first 6 weeks of the infant’s life. It is the most important, stressful, and wonderful part of their young child’s life to date. Pediatricians need to understand and offer advice that reflects this struggle.
So how do we expect pediatricians to help new mothers when our pediatrics residencies lack a basic breastfeeding curriculum? We need to fix it soon because breastfeeding mothers expect evidence-based breastfeeding advice, and as I learned online, they may even fire you if they don’t like what they hear. Although many pediatricians may feel uncomfortable with counseling an adult woman about her body or even treating her, the American Academy of Pediatrics recommends that we do so (Pediatrics 2012 Mar;129[3]:e827-41). There are even resources available to guide billing of extended breastfeeding visits.
The basic science of breastfeeding and how to counsel on common concerns need to be represented in our residency curriculums, as a lack of training early on can perpetuate itself in practice, leading to pediatricians who give outdated advice, reassure when they should counsel further, or give the mother the impression her concerns are irrelevant. Mothers expect more of us when it comes to breastfeeding, and we should expect it of ourselves.
In the meantime, some resources I found helpful were:
• “The Nursing Mother’s Companion,” by Kathleen Huggins (Boston: Harvard Common Press, 2010). This is a great book to help those in training really understand the stresses and common concerns of breastfeeding moms.
• newborns.stanford.edu/Breastfeeding. This is a good online source for those who want a quick tutorial about the early days of breastfeeding.
• AAP Breastfeeding Residency Curriculum (www2.aap.org/breastfeeding/curriculum/medical_knowledge.html). These are learning modules to build knowledge of lactation pathophysiology and how to address mothers’ common concerns.
• www.drmilk.org. This is a support group for breastfeeding moms who are doctors.
Dr. Fricchione is a pediatric infectious diseases fellow at McGaw Medical Center of Northwestern University and the Ann and Robert H. Lurie Children’s Hospital of Chicago.
I expected that having a baby as a pediatric subspecialty fellow was going to be a challenge. But I could never have anticipated how scary it would feel to step into the world on the other side of the clinic door. My friends invited me to join a breastfeeding support group on social media “so that I knew I wasn’t the only one up with my baby at 3 a.m.” I learned a lot more than that.
I learned that some mothers trust anecdotes from strangers more than advice from their pediatricians. They recount unsatisfying visits with their pediatricians and then ask other mothers to comment on the advice. As I sifted through a lot of nonscientific and sometimes medically dangerous advice, I also was offered a new perspective. Many mothers will lie to their pediatricians about sleeping and feeding habits because they don’t want to be judged or don’t want another canned answer. Instead of engaging in discussion, they nod, smile, and return to their online support groups.
Very little literature exists on how to partner with mothers to guide them through the breastfeeding journey. These are intimate and individual journeys for each mother and often for each new child. For most mothers who choose to breastfeed, their infant is asking them to learn a new endurance sport, and the body and mind have to start running a marathon on day 1. Breastfeeding consumes nearly every waking moment of at least the first 6 weeks of the infant’s life. It is the most important, stressful, and wonderful part of their young child’s life to date. Pediatricians need to understand and offer advice that reflects this struggle.
So how do we expect pediatricians to help new mothers when our pediatrics residencies lack a basic breastfeeding curriculum? We need to fix it soon because breastfeeding mothers expect evidence-based breastfeeding advice, and as I learned online, they may even fire you if they don’t like what they hear. Although many pediatricians may feel uncomfortable with counseling an adult woman about her body or even treating her, the American Academy of Pediatrics recommends that we do so (Pediatrics 2012 Mar;129[3]:e827-41). There are even resources available to guide billing of extended breastfeeding visits.
The basic science of breastfeeding and how to counsel on common concerns need to be represented in our residency curriculums, as a lack of training early on can perpetuate itself in practice, leading to pediatricians who give outdated advice, reassure when they should counsel further, or give the mother the impression her concerns are irrelevant. Mothers expect more of us when it comes to breastfeeding, and we should expect it of ourselves.
In the meantime, some resources I found helpful were:
• “The Nursing Mother’s Companion,” by Kathleen Huggins (Boston: Harvard Common Press, 2010). This is a great book to help those in training really understand the stresses and common concerns of breastfeeding moms.
• newborns.stanford.edu/Breastfeeding. This is a good online source for those who want a quick tutorial about the early days of breastfeeding.
• AAP Breastfeeding Residency Curriculum (www2.aap.org/breastfeeding/curriculum/medical_knowledge.html). These are learning modules to build knowledge of lactation pathophysiology and how to address mothers’ common concerns.
• www.drmilk.org. This is a support group for breastfeeding moms who are doctors.
Dr. Fricchione is a pediatric infectious diseases fellow at McGaw Medical Center of Northwestern University and the Ann and Robert H. Lurie Children’s Hospital of Chicago.
An under-recognized epidemic of elder abuse needs your awareness and action
In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.
Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.1
There are 2 main components to this definition:
• an older adult has suffered injury or deprivation
• another person is responsible for causing or failing to prevent it.2
Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.3
An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.4
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.6 Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year2; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.7
Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.8 The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.9
Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities10; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.11 A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,2 yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories12:
• neglect (58.5% of cases)
• physical (15.7%)
• financial (12.3%)
• psychological and emotional (7.3%)
• sexual (0.04%).
Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.12
Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.3 This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).4 The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).4 Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources3—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.15 There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.16 In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.17 Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.18
Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.3 Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.4 This type of abuse also is prevalent in nursing homes and other long-term care facilities.19
Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.16 Sexual abuse is more common in frail or dependent persons.3 Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections4—are required to identify sexual abuse, along with signs of depression and display of fear.
Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”20 Intentionally embarrassing an older adult in front of others also can be considered social abuse.
Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
• In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.21
• In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.22
• In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,23 in which images disappear 10 seconds after they are viewed.
As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),3 although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.
As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.4 Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.3
Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.15 One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.7
Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors2; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.
More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.24 Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.
Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”25 Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.25
In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.
Approximately 75% of caregivers of older adults are family members; 70% are female26; and most are adult children, spouses, and partners of those receiving care.27 Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.2 In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.2
From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,28 family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,2 often secondary to the stress of caring for an older adult.
Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,29 and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.30 They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.
The reason for shortened lifespan is multifactorial30:
• Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
• Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
• Injury from abuse can exacerbate an underlying illness.
• Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.31
Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.31 A study found that victims of
elder abuse are significantly more depressed than non-victims.32
In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.32 Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.33 According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.32
Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.2
Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.
To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.4 In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.4
In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.34 To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.35 According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.36
Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.
A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors37—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.38 Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.
Brandi et al37 provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).
Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.4 Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts16; make note of warning signs such as fear, silence, and inability to interview the patient alone.
In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.4
Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.39 A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.40 At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.41
After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.16 In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.16
No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.42 Older adults might choose not to report abuse because of shame, intimidation, or fear,43 or to protect a caregiver, who often is a family member.
Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.11 Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.44
There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.4 Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
• subtlety of signs
• victim denial
• ignorance of reporting procedures
• inadequate training
• lack of information about resources
• concern about losing physician–patient rapport
• concern about involvement in the legal system
• time limitations
• doubt about the effectiveness of APS.16
Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.16
How is capacity evaluated? A capacity evaluation has 3 components:
• Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
• Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
• Reliability is a person’s ability to provide a consistent choice over time.45
Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.45 Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment45; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.46 Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.47
If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.47 Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.47
If the older adult is found to lack capacity, a substitute decision-maker must be sought.47 Many states have statutes specifying the order in which family members are contacted.48 The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”49 Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.50,51
Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.4 However, screening in the office setting often involves short, directly administered questionnaires.49 For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions52:
• Has anyone close to you called you names or insulted you recently?
• Are you afraid of anyone in your life?
• Are you able to use the telephone anytime you want to?
• Has anyone forced you to do things you didn’t want to do?
• Has anyone taken things or money that belong to you without your OK?
• Has anyone close to you tried to hurt you or harm you recently?
Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients4 (Figure).
• New York City Elder Abuse Center encourages collaboration among health, mental health, and community justice organizations.28 The program involves a number of resources for addressing elder abuse, such as promoting staff awareness of risk factors for, and signs of, abuse, and screening for mental health problems in the abused.
• The Elder Justice Act, enacted in 2010 to combat elder abuse, provides federal funds and resources to prevent, detect, treat, and intervene to stop abuse and, when appropriate, to prosecute abusers.53
This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.
BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.
Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.
Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.
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65801372893020. Published July 3, 2013. Accessed June 24, 2015.
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NEWS/140507587. Updated May 7, 2014. Accessed June 24, 2015.
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31. Dyer CB, Pavlik VN, Murphy KP, et al. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48(2):205-208.
32. Pillemer K, Prescott D. Psychological effects of elder abuse: a research note. J Elder Abuse Negl. 1988;1(1):65-73.
33. Elder abuse: consequences. Centers for Disease Control and Prevention. http://www.cdc.gov/violenceprevention/elderabuse/consequences.html. Updated June 22, 2015.Accessed August 20, 2015.
34. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196.
35. Peck MD. Epidemiology of burns throughout the World. Part II: intentional burns in adults. Burns. 2012;38(5):630-637.
36. 2014 National Burn Repository; report of data between 2004-2013. American Burn Association. http://www.ameriburn.org/2014NBRAnnualReport.pdf. Published 2014. Accessed June 26, 2015.
37. Brandi B, Dyer CB, Heisler CJ, et al. Systemic responses to elder abuse. In: Brandi B, Dyer CB, Heisler CJ, eds. Elder abuse detection and intervention: a collaborative approach. New York, NY: Spring Publishing Company; 2007:79-100.
38. Welner M. Guardianship. The Forensic Panel. http://www.forensicpanel.com/expert_services/psychiatry/civil_law/guardianship.html. Accessed August 20, 2015.
39. Watson E. Elder abuse: definition, types and statistics, and elder abuse (mistreatment and neglect) laws. Journal of Legal Nurse Consulting. 2013;24(2):40-42.
40. National Center on Elder Abuse Administration on Aging. Reporting abuse. http://www.ncea.aoa.gov/Stop_Abuse/Get_Help/Report/index.aspx. Accessed August 18, 2015.
41. Mukherjee D. Organizational structures of elder abuse reporting systems. Administration in Social Work. 2011;35(5):517-531.
42. Costin LB, Karger HJ, Stoesz H. The politics of child abuse in America. New York, NY: Oxford University Press; 1996.
43. Thomson MJ, Lietzau LK, Doty MM, et al. An analysis of elder abuse rates in Milwaukee County. WMJ. 2011;110(6):271-276.
44. Teaster PB, Dugar TA, Mendiondo MS, et al; The National Committee for the Prevention of Elder Abuse; The National Adult Protective Services Association. The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years and Older. http://www.ncea.aoa.gov/Resources/Publication/docs/APS_2004NCEASurvey.pdf. Published March 2007. Accessed October 19, 2015.
45. Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.
46. Grisso T, Appelbaum PS. MacArthur competence assessment tool for treatment (MacCAT-T). Sarasota, FL: Professional Resources Press; 1998.
47. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;35(18):1834-1840.
48. Wynn S. Decision by surrogates: An overview of surrogate consent laws in the United States. Bifocal: A Journal of the ABA Commission on Bar and Aging. 2014;36(1). http://www.americanbar.org/publications/bifocal/vol_36/
issue_1_october2014/default_surrogate_consent_statutes.html. Accessed October 22, 2015.
49. American Medical Association. Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: American Medical Association; 1992.
50. Harrell R, Toronjo C, McLaughlin J, et al. How geriatricians identify elder abuse and neglect. Am J Med Sci. 2002;323(1):34-38.
51. Ahmad M, Lachs MS. Elder abuse and neglect: what physicians can and should do. Cleve Clin J Med. 2002; 69(10):801-808.
52. Elder abuse screening protocol for physicians: lessons learned from the Maine Partners for Elder Protection Pilot Project. University of Maine Center on Aging. http://umcoa.siteturbine.com/uploaded_files/mainecenteronaging.umaine.edu/files/elderabusescreeningmanual.pdf. Published May 2, 2007. Accessed August 20, 2015.
53. What is the Elder Justice Act? USC Davis School of Gerontology. http://gerontology.usc.edu/resources/articles/what-is-the-elder-justice-act/. Published 2015. Accessed October 20, 2015.
In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.
Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.1
There are 2 main components to this definition:
• an older adult has suffered injury or deprivation
• another person is responsible for causing or failing to prevent it.2
Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.3
An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.4
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.6 Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year2; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.7
Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.8 The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.9
Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities10; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.11 A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,2 yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories12:
• neglect (58.5% of cases)
• physical (15.7%)
• financial (12.3%)
• psychological and emotional (7.3%)
• sexual (0.04%).
Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.12
Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.3 This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).4 The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).4 Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources3—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.15 There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.16 In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.17 Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.18
Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.3 Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.4 This type of abuse also is prevalent in nursing homes and other long-term care facilities.19
Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.16 Sexual abuse is more common in frail or dependent persons.3 Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections4—are required to identify sexual abuse, along with signs of depression and display of fear.
Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”20 Intentionally embarrassing an older adult in front of others also can be considered social abuse.
Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
• In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.21
• In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.22
• In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,23 in which images disappear 10 seconds after they are viewed.
As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),3 although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.
As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.4 Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.3
Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.15 One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.7
Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors2; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.
More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.24 Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.
Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”25 Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.25
In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.
Approximately 75% of caregivers of older adults are family members; 70% are female26; and most are adult children, spouses, and partners of those receiving care.27 Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.2 In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.2
From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,28 family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,2 often secondary to the stress of caring for an older adult.
Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,29 and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.30 They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.
The reason for shortened lifespan is multifactorial30:
• Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
• Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
• Injury from abuse can exacerbate an underlying illness.
• Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.31
Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.31 A study found that victims of
elder abuse are significantly more depressed than non-victims.32
In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.32 Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.33 According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.32
Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.2
Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.
To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.4 In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.4
In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.34 To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.35 According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.36
Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.
A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors37—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.38 Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.
Brandi et al37 provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).
Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.4 Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts16; make note of warning signs such as fear, silence, and inability to interview the patient alone.
In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.4
Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.39 A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.40 At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.41
After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.16 In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.16
No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.42 Older adults might choose not to report abuse because of shame, intimidation, or fear,43 or to protect a caregiver, who often is a family member.
Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.11 Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.44
There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.4 Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
• subtlety of signs
• victim denial
• ignorance of reporting procedures
• inadequate training
• lack of information about resources
• concern about losing physician–patient rapport
• concern about involvement in the legal system
• time limitations
• doubt about the effectiveness of APS.16
Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.16
How is capacity evaluated? A capacity evaluation has 3 components:
• Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
• Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
• Reliability is a person’s ability to provide a consistent choice over time.45
Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.45 Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment45; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.46 Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.47
If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.47 Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.47
If the older adult is found to lack capacity, a substitute decision-maker must be sought.47 Many states have statutes specifying the order in which family members are contacted.48 The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”49 Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.50,51
Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.4 However, screening in the office setting often involves short, directly administered questionnaires.49 For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions52:
• Has anyone close to you called you names or insulted you recently?
• Are you afraid of anyone in your life?
• Are you able to use the telephone anytime you want to?
• Has anyone forced you to do things you didn’t want to do?
• Has anyone taken things or money that belong to you without your OK?
• Has anyone close to you tried to hurt you or harm you recently?
Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients4 (Figure).
• New York City Elder Abuse Center encourages collaboration among health, mental health, and community justice organizations.28 The program involves a number of resources for addressing elder abuse, such as promoting staff awareness of risk factors for, and signs of, abuse, and screening for mental health problems in the abused.
• The Elder Justice Act, enacted in 2010 to combat elder abuse, provides federal funds and resources to prevent, detect, treat, and intervene to stop abuse and, when appropriate, to prosecute abusers.53
This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.
BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.
Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.
Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.
In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.
Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.1
There are 2 main components to this definition:
• an older adult has suffered injury or deprivation
• another person is responsible for causing or failing to prevent it.2
Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.3
An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.4
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.6 Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year2; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.7
Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.8 The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.9
Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities10; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.11 A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,2 yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories12:
• neglect (58.5% of cases)
• physical (15.7%)
• financial (12.3%)
• psychological and emotional (7.3%)
• sexual (0.04%).
Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.12
Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.3 This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).4 The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).4 Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources3—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.15 There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.16 In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.17 Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.18
Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.3 Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.4 This type of abuse also is prevalent in nursing homes and other long-term care facilities.19
Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.16 Sexual abuse is more common in frail or dependent persons.3 Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections4—are required to identify sexual abuse, along with signs of depression and display of fear.
Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”20 Intentionally embarrassing an older adult in front of others also can be considered social abuse.
Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
• In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.21
• In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.22
• In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,23 in which images disappear 10 seconds after they are viewed.
As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),3 although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.
As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.4 Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.3
Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.15 One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.7
Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors2; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.
More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.24 Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.
Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”25 Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.25
In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.
Approximately 75% of caregivers of older adults are family members; 70% are female26; and most are adult children, spouses, and partners of those receiving care.27 Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.2 In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.2
From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,28 family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,2 often secondary to the stress of caring for an older adult.
Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,29 and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.30 They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.
The reason for shortened lifespan is multifactorial30:
• Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
• Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
• Injury from abuse can exacerbate an underlying illness.
• Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.31
Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.31 A study found that victims of
elder abuse are significantly more depressed than non-victims.32
In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.32 Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.33 According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.32
Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.2
Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.
To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.4 In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.4
In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.34 To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.35 According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.36
Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.
A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors37—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.38 Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.
Brandi et al37 provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).
Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.4 Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts16; make note of warning signs such as fear, silence, and inability to interview the patient alone.
In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.4
Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.39 A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.40 At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.41
After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.16 In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.16
No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.42 Older adults might choose not to report abuse because of shame, intimidation, or fear,43 or to protect a caregiver, who often is a family member.
Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.11 Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.44
There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.4 Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
• subtlety of signs
• victim denial
• ignorance of reporting procedures
• inadequate training
• lack of information about resources
• concern about losing physician–patient rapport
• concern about involvement in the legal system
• time limitations
• doubt about the effectiveness of APS.16
Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.16
How is capacity evaluated? A capacity evaluation has 3 components:
• Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
• Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
• Reliability is a person’s ability to provide a consistent choice over time.45
Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.45 Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment45; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.46 Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.47
If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.47 Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.47
If the older adult is found to lack capacity, a substitute decision-maker must be sought.47 Many states have statutes specifying the order in which family members are contacted.48 The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”49 Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.50,51
Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.4 However, screening in the office setting often involves short, directly administered questionnaires.49 For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions52:
• Has anyone close to you called you names or insulted you recently?
• Are you afraid of anyone in your life?
• Are you able to use the telephone anytime you want to?
• Has anyone forced you to do things you didn’t want to do?
• Has anyone taken things or money that belong to you without your OK?
• Has anyone close to you tried to hurt you or harm you recently?
Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients4 (Figure).
• New York City Elder Abuse Center encourages collaboration among health, mental health, and community justice organizations.28 The program involves a number of resources for addressing elder abuse, such as promoting staff awareness of risk factors for, and signs of, abuse, and screening for mental health problems in the abused.
• The Elder Justice Act, enacted in 2010 to combat elder abuse, provides federal funds and resources to prevent, detect, treat, and intervene to stop abuse and, when appropriate, to prosecute abusers.53
This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.
BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.
Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.
Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.
1. The Elder Abuse Prevention, Identification, and Treatment Act of 1985, HR 1674, 99th Cong (1985).
2. Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272.
3. Johannesen M, LoGiudice D. Elder abuse: a systematic review of risk factors in community-dwelling elders. Age Ageing. 2013;42(3):292-298.
4. Gibbs LM, Mosqueda L, eds. Medical implications of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):xv-xvi. doi: 10.1016/j.cger.2014.08.015.
5. Werner CA. The Older Population: 2010. U.S. Census Bureau. http://webcache.googleusercontent.com/search?q=cache:hCCb_pcnO6QJ :ht tps://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf+&cd=1&hl=en&ct=clnk&gl=uss. Issued November 2011. Accessed October 10, 2015.
6. Himes CL. Elderly Americans. Population Bulletin. 2002;56(4):1-41.
7. Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: a systematic review. Age Ageing. 2008;37(2):151-60.
8. Teaster PB. A response to the abuse of vulnerable adults: the 2000 Survey of State Adult Protective Services. The National Center on Elder Abuse. http://www.ncea.aoa.gov/Resources/Publication/docs/apsreport030703.pdf. 2003.
Accessed October 22, 2015.
9. Mouton CP, Rodabough RJ, Rovi SL, et al. Prevalence and 3-year incidence of abuse among postmenopausal women. Am J Public Health. 2004;94(4):605-612.
10. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292-297.
11. Kennedy RD. Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians. Fam Med. 2005;37(7):481-485.
12. Statistic Brain Research Institute. Elderly abuse statistics. http://www.statisticbrain.com/elderly-abuse-statistics. Accessed June 22, 2015.
13. Lachs MS, Bachman R, Williams CS, et al. Resident-to-resident elder mistreatment and police contact in nursing homes: findings from a population-based cohort. J Am Geriatr Soc. 2007;55(6):840-845.
14. Lachs M, Bachman R, Williams C, et al. Older adults as crime victims, perpetrators, witnesses, and complainants: a population-based study of police interactions. J Elder Abuse Negl. 2005;16(4):25-40.
15. Acierno R, Hernandez-Tejada M, Muzzy W, et al. National Elder Mistreatment Study. Washington, DC: National Institute of Justice; 2009.
16. Dong XQ. Elder abuse: systematic review and implications for practice. J Am Geriatr Soc. 2015;63(6):1214-1238.
17. Freedman M. The growing epidemic of financial elder abuse. The Tax Advisor. http://www.cpa2biz.com/Content/media/PRODUCER_CONTENT/Newsletters/
Articles_2007/Tax/Financial_Elder_Abuse.jsp. Published November 2007. Accessed June 24, 2015.
18. Consumer Financial Protection Bureau. Protection for older Americans. http://www.consumerfinance.gov/olderamericans. Accessed June 22, 2015.
19. Castle NG. Nursing home deficiency citations for abuse. J Appl Gerontol. 2011;30(6):719-743.
20. Elder Abuse Prevention Unit. Social abuse. http://www.eapu.com.au/elder-abuse/social-abuse. Published 2014. Accessed June 24, 2015.
21. Former nursing home employees allegedly photographed naked resident. United Press International. http://www.upi.com/Top_News/US/2013/07/03/Former-nursinghome-employees-allegedly-photographed-nakedresidents/
65801372893020. Published July 3, 2013. Accessed June 24, 2015.
22. Miller N. Two charged with elder assault at an assisted living facility. MetroWest Daily News. http://www.metrowestdailynews.com/article/20140506/
NEWS/140507587. Updated May 7, 2014. Accessed June 24, 2015.
23. Jorgensen J. New charges filed in nursing home case.WHAS11. http://www.whas11.com/story/news/local/2015/06/24/new-charges-filed-in-nursing-homecase/29243183/. Published June 24, 2015. Accessed June 27, 2015.
24. Hermandez-Tejada MA, Amstadter A, Muzzy W, et al. The National Elder Mistreatment Study: race and ethnicity findings. J Elder Abuse Negl. 2013;25(4):281-293.
25. Cooks-Daniels L. Lesbian, gay male, bisexual and transgendered elders: elder abuse and neglect issues. J Elder Abuse Negl. 1998;9(2):35-49.
26. Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: correlates of feelings of burden. Gerontologist. 1980;20(6):649-655.
27. Tatara T, Blumerman Kuzmeskus L, Duckhorn E, et al. The National Center on Elder Abuse Incidence Study: final report. http://aoa.gov/AoA_Programs/Elder_Rights/Elder_Abuse/docs/ABuseReport_Full.pdf. Published September 1998. Accessed October 19, 2015.
28. Rosen AL. Where mental health and elder abuse intersect. Generations. 2014;38(3):75-79.
29. LoFaso V. The role of the primary physician in assessing and treating the mental health concerns of elder abuse victims. NYC Elder Abuse Center eNewsletter.nyceac.com/wp-content/uploads/2013/03/Exploring-the-IntersectionofElder-Abuse-and-Mental-Health_eNewsletter.pdf. Published March 12, 2013. Accessed August 20, 2015.
30. Lachs MS, Williams CS, O’Brien S, et al. The mortality of elder mistreatment. JAMA. 1998;280(5):428-432.
31. Dyer CB, Pavlik VN, Murphy KP, et al. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48(2):205-208.
32. Pillemer K, Prescott D. Psychological effects of elder abuse: a research note. J Elder Abuse Negl. 1988;1(1):65-73.
33. Elder abuse: consequences. Centers for Disease Control and Prevention. http://www.cdc.gov/violenceprevention/elderabuse/consequences.html. Updated June 22, 2015.Accessed August 20, 2015.
34. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196.
35. Peck MD. Epidemiology of burns throughout the World. Part II: intentional burns in adults. Burns. 2012;38(5):630-637.
36. 2014 National Burn Repository; report of data between 2004-2013. American Burn Association. http://www.ameriburn.org/2014NBRAnnualReport.pdf. Published 2014. Accessed June 26, 2015.
37. Brandi B, Dyer CB, Heisler CJ, et al. Systemic responses to elder abuse. In: Brandi B, Dyer CB, Heisler CJ, eds. Elder abuse detection and intervention: a collaborative approach. New York, NY: Spring Publishing Company; 2007:79-100.
38. Welner M. Guardianship. The Forensic Panel. http://www.forensicpanel.com/expert_services/psychiatry/civil_law/guardianship.html. Accessed August 20, 2015.
39. Watson E. Elder abuse: definition, types and statistics, and elder abuse (mistreatment and neglect) laws. Journal of Legal Nurse Consulting. 2013;24(2):40-42.
40. National Center on Elder Abuse Administration on Aging. Reporting abuse. http://www.ncea.aoa.gov/Stop_Abuse/Get_Help/Report/index.aspx. Accessed August 18, 2015.
41. Mukherjee D. Organizational structures of elder abuse reporting systems. Administration in Social Work. 2011;35(5):517-531.
42. Costin LB, Karger HJ, Stoesz H. The politics of child abuse in America. New York, NY: Oxford University Press; 1996.
43. Thomson MJ, Lietzau LK, Doty MM, et al. An analysis of elder abuse rates in Milwaukee County. WMJ. 2011;110(6):271-276.
44. Teaster PB, Dugar TA, Mendiondo MS, et al; The National Committee for the Prevention of Elder Abuse; The National Adult Protective Services Association. The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years and Older. http://www.ncea.aoa.gov/Resources/Publication/docs/APS_2004NCEASurvey.pdf. Published March 2007. Accessed October 19, 2015.
45. Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.
46. Grisso T, Appelbaum PS. MacArthur competence assessment tool for treatment (MacCAT-T). Sarasota, FL: Professional Resources Press; 1998.
47. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;35(18):1834-1840.
48. Wynn S. Decision by surrogates: An overview of surrogate consent laws in the United States. Bifocal: A Journal of the ABA Commission on Bar and Aging. 2014;36(1). http://www.americanbar.org/publications/bifocal/vol_36/
issue_1_october2014/default_surrogate_consent_statutes.html. Accessed October 22, 2015.
49. American Medical Association. Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: American Medical Association; 1992.
50. Harrell R, Toronjo C, McLaughlin J, et al. How geriatricians identify elder abuse and neglect. Am J Med Sci. 2002;323(1):34-38.
51. Ahmad M, Lachs MS. Elder abuse and neglect: what physicians can and should do. Cleve Clin J Med. 2002; 69(10):801-808.
52. Elder abuse screening protocol for physicians: lessons learned from the Maine Partners for Elder Protection Pilot Project. University of Maine Center on Aging. http://umcoa.siteturbine.com/uploaded_files/mainecenteronaging.umaine.edu/files/elderabusescreeningmanual.pdf. Published May 2, 2007. Accessed August 20, 2015.
53. What is the Elder Justice Act? USC Davis School of Gerontology. http://gerontology.usc.edu/resources/articles/what-is-the-elder-justice-act/. Published 2015. Accessed October 20, 2015.
1. The Elder Abuse Prevention, Identification, and Treatment Act of 1985, HR 1674, 99th Cong (1985).
2. Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272.
3. Johannesen M, LoGiudice D. Elder abuse: a systematic review of risk factors in community-dwelling elders. Age Ageing. 2013;42(3):292-298.
4. Gibbs LM, Mosqueda L, eds. Medical implications of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):xv-xvi. doi: 10.1016/j.cger.2014.08.015.
5. Werner CA. The Older Population: 2010. U.S. Census Bureau. http://webcache.googleusercontent.com/search?q=cache:hCCb_pcnO6QJ :ht tps://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf+&cd=1&hl=en&ct=clnk&gl=uss. Issued November 2011. Accessed October 10, 2015.
6. Himes CL. Elderly Americans. Population Bulletin. 2002;56(4):1-41.
7. Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: a systematic review. Age Ageing. 2008;37(2):151-60.
8. Teaster PB. A response to the abuse of vulnerable adults: the 2000 Survey of State Adult Protective Services. The National Center on Elder Abuse. http://www.ncea.aoa.gov/Resources/Publication/docs/apsreport030703.pdf. 2003.
Accessed October 22, 2015.
9. Mouton CP, Rodabough RJ, Rovi SL, et al. Prevalence and 3-year incidence of abuse among postmenopausal women. Am J Public Health. 2004;94(4):605-612.
10. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292-297.
11. Kennedy RD. Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians. Fam Med. 2005;37(7):481-485.
12. Statistic Brain Research Institute. Elderly abuse statistics. http://www.statisticbrain.com/elderly-abuse-statistics. Accessed June 22, 2015.
13. Lachs MS, Bachman R, Williams CS, et al. Resident-to-resident elder mistreatment and police contact in nursing homes: findings from a population-based cohort. J Am Geriatr Soc. 2007;55(6):840-845.
14. Lachs M, Bachman R, Williams C, et al. Older adults as crime victims, perpetrators, witnesses, and complainants: a population-based study of police interactions. J Elder Abuse Negl. 2005;16(4):25-40.
15. Acierno R, Hernandez-Tejada M, Muzzy W, et al. National Elder Mistreatment Study. Washington, DC: National Institute of Justice; 2009.
16. Dong XQ. Elder abuse: systematic review and implications for practice. J Am Geriatr Soc. 2015;63(6):1214-1238.
17. Freedman M. The growing epidemic of financial elder abuse. The Tax Advisor. http://www.cpa2biz.com/Content/media/PRODUCER_CONTENT/Newsletters/
Articles_2007/Tax/Financial_Elder_Abuse.jsp. Published November 2007. Accessed June 24, 2015.
18. Consumer Financial Protection Bureau. Protection for older Americans. http://www.consumerfinance.gov/olderamericans. Accessed June 22, 2015.
19. Castle NG. Nursing home deficiency citations for abuse. J Appl Gerontol. 2011;30(6):719-743.
20. Elder Abuse Prevention Unit. Social abuse. http://www.eapu.com.au/elder-abuse/social-abuse. Published 2014. Accessed June 24, 2015.
21. Former nursing home employees allegedly photographed naked resident. United Press International. http://www.upi.com/Top_News/US/2013/07/03/Former-nursinghome-employees-allegedly-photographed-nakedresidents/
65801372893020. Published July 3, 2013. Accessed June 24, 2015.
22. Miller N. Two charged with elder assault at an assisted living facility. MetroWest Daily News. http://www.metrowestdailynews.com/article/20140506/
NEWS/140507587. Updated May 7, 2014. Accessed June 24, 2015.
23. Jorgensen J. New charges filed in nursing home case.WHAS11. http://www.whas11.com/story/news/local/2015/06/24/new-charges-filed-in-nursing-homecase/29243183/. Published June 24, 2015. Accessed June 27, 2015.
24. Hermandez-Tejada MA, Amstadter A, Muzzy W, et al. The National Elder Mistreatment Study: race and ethnicity findings. J Elder Abuse Negl. 2013;25(4):281-293.
25. Cooks-Daniels L. Lesbian, gay male, bisexual and transgendered elders: elder abuse and neglect issues. J Elder Abuse Negl. 1998;9(2):35-49.
26. Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: correlates of feelings of burden. Gerontologist. 1980;20(6):649-655.
27. Tatara T, Blumerman Kuzmeskus L, Duckhorn E, et al. The National Center on Elder Abuse Incidence Study: final report. http://aoa.gov/AoA_Programs/Elder_Rights/Elder_Abuse/docs/ABuseReport_Full.pdf. Published September 1998. Accessed October 19, 2015.
28. Rosen AL. Where mental health and elder abuse intersect. Generations. 2014;38(3):75-79.
29. LoFaso V. The role of the primary physician in assessing and treating the mental health concerns of elder abuse victims. NYC Elder Abuse Center eNewsletter.nyceac.com/wp-content/uploads/2013/03/Exploring-the-IntersectionofElder-Abuse-and-Mental-Health_eNewsletter.pdf. Published March 12, 2013. Accessed August 20, 2015.
30. Lachs MS, Williams CS, O’Brien S, et al. The mortality of elder mistreatment. JAMA. 1998;280(5):428-432.
31. Dyer CB, Pavlik VN, Murphy KP, et al. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48(2):205-208.
32. Pillemer K, Prescott D. Psychological effects of elder abuse: a research note. J Elder Abuse Negl. 1988;1(1):65-73.
33. Elder abuse: consequences. Centers for Disease Control and Prevention. http://www.cdc.gov/violenceprevention/elderabuse/consequences.html. Updated June 22, 2015.Accessed August 20, 2015.
34. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196.
35. Peck MD. Epidemiology of burns throughout the World. Part II: intentional burns in adults. Burns. 2012;38(5):630-637.
36. 2014 National Burn Repository; report of data between 2004-2013. American Burn Association. http://www.ameriburn.org/2014NBRAnnualReport.pdf. Published 2014. Accessed June 26, 2015.
37. Brandi B, Dyer CB, Heisler CJ, et al. Systemic responses to elder abuse. In: Brandi B, Dyer CB, Heisler CJ, eds. Elder abuse detection and intervention: a collaborative approach. New York, NY: Spring Publishing Company; 2007:79-100.
38. Welner M. Guardianship. The Forensic Panel. http://www.forensicpanel.com/expert_services/psychiatry/civil_law/guardianship.html. Accessed August 20, 2015.
39. Watson E. Elder abuse: definition, types and statistics, and elder abuse (mistreatment and neglect) laws. Journal of Legal Nurse Consulting. 2013;24(2):40-42.
40. National Center on Elder Abuse Administration on Aging. Reporting abuse. http://www.ncea.aoa.gov/Stop_Abuse/Get_Help/Report/index.aspx. Accessed August 18, 2015.
41. Mukherjee D. Organizational structures of elder abuse reporting systems. Administration in Social Work. 2011;35(5):517-531.
42. Costin LB, Karger HJ, Stoesz H. The politics of child abuse in America. New York, NY: Oxford University Press; 1996.
43. Thomson MJ, Lietzau LK, Doty MM, et al. An analysis of elder abuse rates in Milwaukee County. WMJ. 2011;110(6):271-276.
44. Teaster PB, Dugar TA, Mendiondo MS, et al; The National Committee for the Prevention of Elder Abuse; The National Adult Protective Services Association. The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years and Older. http://www.ncea.aoa.gov/Resources/Publication/docs/APS_2004NCEASurvey.pdf. Published March 2007. Accessed October 19, 2015.
45. Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.
46. Grisso T, Appelbaum PS. MacArthur competence assessment tool for treatment (MacCAT-T). Sarasota, FL: Professional Resources Press; 1998.
47. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;35(18):1834-1840.
48. Wynn S. Decision by surrogates: An overview of surrogate consent laws in the United States. Bifocal: A Journal of the ABA Commission on Bar and Aging. 2014;36(1). http://www.americanbar.org/publications/bifocal/vol_36/
issue_1_october2014/default_surrogate_consent_statutes.html. Accessed October 22, 2015.
49. American Medical Association. Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: American Medical Association; 1992.
50. Harrell R, Toronjo C, McLaughlin J, et al. How geriatricians identify elder abuse and neglect. Am J Med Sci. 2002;323(1):34-38.
51. Ahmad M, Lachs MS. Elder abuse and neglect: what physicians can and should do. Cleve Clin J Med. 2002; 69(10):801-808.
52. Elder abuse screening protocol for physicians: lessons learned from the Maine Partners for Elder Protection Pilot Project. University of Maine Center on Aging. http://umcoa.siteturbine.com/uploaded_files/mainecenteronaging.umaine.edu/files/elderabusescreeningmanual.pdf. Published May 2, 2007. Accessed August 20, 2015.
53. What is the Elder Justice Act? USC Davis School of Gerontology. http://gerontology.usc.edu/resources/articles/what-is-the-elder-justice-act/. Published 2015. Accessed October 20, 2015.
Painful Lesion Hasn’t Responded to Antibiotics
ANSWER
The correct answer is erythema nodosum (EN; choice “c”), a reactive form of septal panniculitis with many potential triggers.
Erythema induratum (choice “a”) is a manifestation of lobular panniculitis, which affects the fat lobules but not the septae. It too has numerous triggers, but it tends to manifest with more discrete nodules, which eventually open and drain. It is far less common than EN.
Urticaria (choice “b”), also known as hives, presents as itchy, stingy wheals that are typically evanescent (eg, they appear suddenly, within seconds, and disappear within hours). Despite the itching and stinging, urticaria rarely hurts when it presents on the skin.
Erysipelas (choice “d”) is a superficial form of skin infection. More superficial than cellulitis, it usually is caused by a member of the Streptococcus family. It has a bright red appearance and sharply demarcated margins, with a peau d’orange (dimpled, like an orange peel) effect on its surface. It is acute in origin and responds readily to most common antibiotics.
DISCUSSION
Erythema nodosum, a reactive process involving fibrous septae that support and separate subcutaneous adipocytes, is notable for the complete lack of epidermal change (eg, scaling, broken skin, pointing, draining). The incidence is about 2 in 10,000 population, with women outnumbering men at a rate of 4:1 and the 18-to-34 age-group most affected. The anterior leg is involved in the vast majority of cases.
EN often starts with flulike symptoms, followed by the appearance of discrete, bright red nodules, measuring 2 to 4 cm, on the anterior legs; these darken and coalesce over a period of seven to 10 weeks. New lesions can continue to appear for up to six weeks. As they progress, the lesions often become ecchymotic. Idiopathic cases (at least 20%) can last months.
Notable triggers include Crohn disease flares and use of drugs such as sulfa, gold salts, and oral contraceptives. Several infections have been identified as triggers, including strep, mycoplasma, and campylobacter, as well as deep fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis). More unusual causes include pregnancy and diseases such as sarcoidosis, tuberculosis, Behçet disease, and leukemia/lymphoma.
The diagnostic workup for EN includes punch biopsy of deep adipose tissue and throat culture, and when indicated, ASO titer (if strep is suspected) and chest films (to rule out tuberculosis and sarcoid). In most cases, the diagnosis can be made on clinical grounds alone, although the triggering entity may be difficult to identify. The identification and elimination of the underlying trigger is nonetheless crucial for diagnosis and treatment.
That issue aside, most cases of EN resolve with minimal treatment; this can include the use of NSAIDs and elevation of the limbs when possible. In this particular case, the intense pain the patient was experiencing called for stronger therapy (ibuprofen 800 mg tid, plus a two-week taper of prednisone 40 mg). She responded quite well, and the problem was almost totally resolved at a follow-up visit several weeks later.
In the absence of findings to the contrary, it is likely that the trigger for this patient’s EN was strep, given the timing of its manifestation after a sore throat.
ANSWER
The correct answer is erythema nodosum (EN; choice “c”), a reactive form of septal panniculitis with many potential triggers.
Erythema induratum (choice “a”) is a manifestation of lobular panniculitis, which affects the fat lobules but not the septae. It too has numerous triggers, but it tends to manifest with more discrete nodules, which eventually open and drain. It is far less common than EN.
Urticaria (choice “b”), also known as hives, presents as itchy, stingy wheals that are typically evanescent (eg, they appear suddenly, within seconds, and disappear within hours). Despite the itching and stinging, urticaria rarely hurts when it presents on the skin.
Erysipelas (choice “d”) is a superficial form of skin infection. More superficial than cellulitis, it usually is caused by a member of the Streptococcus family. It has a bright red appearance and sharply demarcated margins, with a peau d’orange (dimpled, like an orange peel) effect on its surface. It is acute in origin and responds readily to most common antibiotics.
DISCUSSION
Erythema nodosum, a reactive process involving fibrous septae that support and separate subcutaneous adipocytes, is notable for the complete lack of epidermal change (eg, scaling, broken skin, pointing, draining). The incidence is about 2 in 10,000 population, with women outnumbering men at a rate of 4:1 and the 18-to-34 age-group most affected. The anterior leg is involved in the vast majority of cases.
EN often starts with flulike symptoms, followed by the appearance of discrete, bright red nodules, measuring 2 to 4 cm, on the anterior legs; these darken and coalesce over a period of seven to 10 weeks. New lesions can continue to appear for up to six weeks. As they progress, the lesions often become ecchymotic. Idiopathic cases (at least 20%) can last months.
Notable triggers include Crohn disease flares and use of drugs such as sulfa, gold salts, and oral contraceptives. Several infections have been identified as triggers, including strep, mycoplasma, and campylobacter, as well as deep fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis). More unusual causes include pregnancy and diseases such as sarcoidosis, tuberculosis, Behçet disease, and leukemia/lymphoma.
The diagnostic workup for EN includes punch biopsy of deep adipose tissue and throat culture, and when indicated, ASO titer (if strep is suspected) and chest films (to rule out tuberculosis and sarcoid). In most cases, the diagnosis can be made on clinical grounds alone, although the triggering entity may be difficult to identify. The identification and elimination of the underlying trigger is nonetheless crucial for diagnosis and treatment.
That issue aside, most cases of EN resolve with minimal treatment; this can include the use of NSAIDs and elevation of the limbs when possible. In this particular case, the intense pain the patient was experiencing called for stronger therapy (ibuprofen 800 mg tid, plus a two-week taper of prednisone 40 mg). She responded quite well, and the problem was almost totally resolved at a follow-up visit several weeks later.
In the absence of findings to the contrary, it is likely that the trigger for this patient’s EN was strep, given the timing of its manifestation after a sore throat.
ANSWER
The correct answer is erythema nodosum (EN; choice “c”), a reactive form of septal panniculitis with many potential triggers.
Erythema induratum (choice “a”) is a manifestation of lobular panniculitis, which affects the fat lobules but not the septae. It too has numerous triggers, but it tends to manifest with more discrete nodules, which eventually open and drain. It is far less common than EN.
Urticaria (choice “b”), also known as hives, presents as itchy, stingy wheals that are typically evanescent (eg, they appear suddenly, within seconds, and disappear within hours). Despite the itching and stinging, urticaria rarely hurts when it presents on the skin.
Erysipelas (choice “d”) is a superficial form of skin infection. More superficial than cellulitis, it usually is caused by a member of the Streptococcus family. It has a bright red appearance and sharply demarcated margins, with a peau d’orange (dimpled, like an orange peel) effect on its surface. It is acute in origin and responds readily to most common antibiotics.
DISCUSSION
Erythema nodosum, a reactive process involving fibrous septae that support and separate subcutaneous adipocytes, is notable for the complete lack of epidermal change (eg, scaling, broken skin, pointing, draining). The incidence is about 2 in 10,000 population, with women outnumbering men at a rate of 4:1 and the 18-to-34 age-group most affected. The anterior leg is involved in the vast majority of cases.
EN often starts with flulike symptoms, followed by the appearance of discrete, bright red nodules, measuring 2 to 4 cm, on the anterior legs; these darken and coalesce over a period of seven to 10 weeks. New lesions can continue to appear for up to six weeks. As they progress, the lesions often become ecchymotic. Idiopathic cases (at least 20%) can last months.
Notable triggers include Crohn disease flares and use of drugs such as sulfa, gold salts, and oral contraceptives. Several infections have been identified as triggers, including strep, mycoplasma, and campylobacter, as well as deep fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis). More unusual causes include pregnancy and diseases such as sarcoidosis, tuberculosis, Behçet disease, and leukemia/lymphoma.
The diagnostic workup for EN includes punch biopsy of deep adipose tissue and throat culture, and when indicated, ASO titer (if strep is suspected) and chest films (to rule out tuberculosis and sarcoid). In most cases, the diagnosis can be made on clinical grounds alone, although the triggering entity may be difficult to identify. The identification and elimination of the underlying trigger is nonetheless crucial for diagnosis and treatment.
That issue aside, most cases of EN resolve with minimal treatment; this can include the use of NSAIDs and elevation of the limbs when possible. In this particular case, the intense pain the patient was experiencing called for stronger therapy (ibuprofen 800 mg tid, plus a two-week taper of prednisone 40 mg). She responded quite well, and the problem was almost totally resolved at a follow-up visit several weeks later.
In the absence of findings to the contrary, it is likely that the trigger for this patient’s EN was strep, given the timing of its manifestation after a sore throat.
A 57-year-old woman is referred to dermatology for “cellulitis” that has persisted despite several courses of oral antibiotics (including cephalexin and trimethoprim/sulfamethoxazole). She denies taking any other medications and has no significant medical history. She states that the problem manifested as discrete red nodules, which eventually coalesced into a single large patch. At the time, she had just recovered from a sore throat and still felt a bit ill, although she denies cough, fever, and shortness of breath. Examination reveals a large (12 x 14 cm) red edematous plaque in the skin over her right anterior tibia. The deep intradermal and subdermal edema is exquisitely tender to touch, considerably warmer than the surrounding skin, and highly blanchable. No other changes are noted on the epidermal surface. A deep 5-mm punch biopsy is performed. Results show a dense lymphohistiocytic infiltrate in the pannicular septae.
Is monitoring of plasma antipsychotic levels useful?
Although there has been success in defining the minimum therapeutic response threshold for certain antipsychotics—for example, clozapine (350 to 450 ng/mL), haloperidol (3 to 5 ng/mL), and fluphenazine (0.8 ng/mL)—one aspect of antipsychotic plasma levels not widely discussed is their value as a marker of adherence.
Many schizophrenia patients achieve an optimal response to agents for which there is no depot formulation. For them, maintenance of symptom control depends wholly on oral medication adherence.1 Regrettably, nonadherence with oral antipsychotic treatment is prevalent among patients with schizophrenia; yet, in routine clinical practice, the extent of nonadherence rarely is measured.
Studies have been able to quantify oral medication nonadherence using monitoring devices, such as the Medication Event Monitoring System (MEMS) that electronically records opening of the medication container and strongly correlates with pill count. Although patients knew they were participating in a trial using MEMS technology, only 48% were able to take their medication at least 80% of the time in a 4-week study,2 and only 43% met the 70% adherence threshold in a 6-month trial.3
Clinicians, patients: Unreliable indicators of adherence
Neither clinician rating nor patient self-reporting is a reliable predictor of adherence with an oral medication regimen. In the 6-month adherence trial,3 clinicians estimated that 95% of their patients met the 70% adherence threshold (the actual percentage was 43%); in a 12-week study, clinician ratings correlated weakly with adherence (r = 0.32; P = .001), but patient self-reporting showed no significant correlation (r = 0.18; P = .08) with pill count.4
Clinicians underestimate not only the extent of nonadherence but also the impact that even a brief period of modest nonadherence has on the risk of relapse. In an 18-month prospective study of patients who recently had been given a diagnosis of schizophrenia, and in whom clinician and patient reports were supplemented with a pill count every 1 to 2 weeks and plasma antipsychotic levels every 4 weeks, any period of at least mild nonadherence was significantly predictive of symptom exacerbation or relapse (hazard ratio [HR], 3.4; 95% CI, 1.4–8.4; P < .002).1 Moreover, 50% to 75% adherence for ≥ 2 consecutive weeks increased the HR to 5.8, and moderate nonadherence (<50% for 2.0 to 3.9 weeks) to an HR of 28.5.
There might be a better method already available
Given the poor correlation between a clinician’s judgment and a patient’s actual pill-taking, it is clear that more accurate methods of tracking adherence must be devised. Because MEMS technology is not widely available, and because pill counts require a home visit or a cooperative patient who brings medications to office visits, plasma antipsychotic monitoring potentially is an appealing method of tracking adherence.
Correlation between the plasma antipsychotic level and relapse is not consistently seen in the literature,4 but plasma levels obtained during periods of clinical stability offer the opportunity to define, for the individual patient, a range of drug exposure that is associated with clinical response. The ideal plasma level baseline is obtained at steady state during a presumed period of observed adherence, such as during a hospital stay. Although patients can be nonadherent in the hospital, this setting offers the best proxy for an acute clinical response to a given plasma level. The alternative is to obtain several plasma levels during a period of outpatient clinical stability.
Clinicians must be mindful that changes in the plasma antipsychotic level after hospital discharge might not reflect poor adherence; environmental factors (eg, exposure to cytochrome P450 or P-glycoprotein inducers) can have a significant impact on results. Resumption of smoking is a classic example, and routinely is associated with a 50% reduction in plasma clozapine levels.5
There also is expected variability in plasma antipsychotic levels based on (1) the timing of prior doses with regard to trough levels, and (2) the effects of an occasional missed dose. Nevertheless, in a sample of adherent clozapine-treated patients, investigators found that 98% of patients had a coefficient of variability (CV) of 30% for sequential plasma concentrations (mean CV, 14%).6
Clinicians should inform patients that the plasma antipsychotic level is a tool for helping track treatment engagement before relapse—the same way metabolic monitoring helps track abnormalities that can be associated with future cardiovascular events. (Clinicians also must be charitable with their patients when discussing a significant drop in the plasma antipsychotic level [eg, >30%], acknowledging that many patients often miss doses.)
Using the patient’s input about specific difficulties with a medication regimen, clinicians should strive to find ways to improve oral medication adherence. In many cases, the clinician can assist through medication simplification, consolidation of multiple daily doses, provision of pill boxes, and discussions about long-acting injectable (LAI) antipsychotics.
In short, plasma antipsychotic levels offer an opportunity to have a richer, evidence-based discussion about adherence, beyond the trite, ineffective question “Did you take your medication?” Use of an objective measure can (1) serve as a benchmark for the patient (eg, “You seemed to do better when your clozapine level was above 400 ng/mL”), and (2) remind clinicians of the variable adherence inherent with oral medication regimens.
A note about long-acting injectable antipsychotics
Because nonadherence is seen throughout the course of schizophrenia, discussion of LAI therapy should not be limited to patients with chronic illness. Results of recent naturalistic7 and randomized studies8 show significant reduction in the rate of psychotic relapse and improved symptom control8 among first-episode patients who are taking an LAI. Moreover, compelling data show that most first-episode patients who are taking an oral antipsychotic will accept a recommendation for treatment with an LAI.9
Summing up: 2 Tools for achieving therapeutic success
Monitoring plasma levels of antipsychotics offers a method for quantifying the problem of nonadherence. For many patients, an LAI antipsychotic provides a solution to nonadherence, and the increasing variety of LAI preparations means more options with which to match individual patients.
Clinicians have a limited amount of time to spend with patients in the office, but time spent discussing LAIs is an investment in the patient’s stability and functional outcome. Minutes once spent managing nonadherence can be devoted to understanding the patient’s aspirations and to developing strategies to achieve those goals.
In the end, isn’t that what we’d rather be talking about with our patients?
1. Subotnik KL, Nuechterlein KH, Ventura J, et al. Risperidone nonadherence and return of positive symptoms in the early course of schizophrenia. Am J Psychiatry. 2011;168(3):286-292.
2. Remington G, Teo C, Mann S, et al. Examining levels of antipsychotic adherence to better understand nonadherence. J Clin Psychopharmacol. 2013;33(2):261-263.
3. Byerly MJ, Thompson A, Carmody T, et al. Validity of electronically monitored medication adherence and conventional adherence measures in schizophrenia. Psychiatr Serv. 2007;58(6):844-847.
4. Velligan DI, Wang M, Diamond P, et al. Relationships among subjective and objective measures of adherence to oral antipsychotic medications. Psychiatr Serv. 2007;58(9):1187-1192.
5. Meyer JM. Individual changes in clozapine levels after smoking cessation: results and a predictive model. J Clin Psychopharmacol. 2001;21(6):569-574.
6. Dugan DJ, Ereshefsky L, Toney GB, et al. Dose and interval adherence among stabilized clozapine-treated patients measured by medication event monitoring. Presented at: Meeting of the New Clinical Drug Evaluation Unit; May 30-June 2, 2000; Boca Raton, FL.
7. Tiihonen J, Haukka J, Taylor M, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. [Erratum in Am J Psychiatry. 2012;169(2):223]. Am J Psychiatry. 2011;168(6):603-609.
8. Subotnik KL, Casaus LR, Ventura J, et al. Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia: a randomized clinical trial. JAMA Psychiatry. 2015;72(8):822-829.
9. Weiden PJ, Schooler NR, Weedon JC, et al. A randomized controlled trial of long-acting injectable risperidone vs continuation on oral atypical antipsychotics for first-episode schizophrenia patients: initial adherence outcome. J Clin Psychiatry. 2009;70(10):1397-1406.
Although there has been success in defining the minimum therapeutic response threshold for certain antipsychotics—for example, clozapine (350 to 450 ng/mL), haloperidol (3 to 5 ng/mL), and fluphenazine (0.8 ng/mL)—one aspect of antipsychotic plasma levels not widely discussed is their value as a marker of adherence.
Many schizophrenia patients achieve an optimal response to agents for which there is no depot formulation. For them, maintenance of symptom control depends wholly on oral medication adherence.1 Regrettably, nonadherence with oral antipsychotic treatment is prevalent among patients with schizophrenia; yet, in routine clinical practice, the extent of nonadherence rarely is measured.
Studies have been able to quantify oral medication nonadherence using monitoring devices, such as the Medication Event Monitoring System (MEMS) that electronically records opening of the medication container and strongly correlates with pill count. Although patients knew they were participating in a trial using MEMS technology, only 48% were able to take their medication at least 80% of the time in a 4-week study,2 and only 43% met the 70% adherence threshold in a 6-month trial.3
Clinicians, patients: Unreliable indicators of adherence
Neither clinician rating nor patient self-reporting is a reliable predictor of adherence with an oral medication regimen. In the 6-month adherence trial,3 clinicians estimated that 95% of their patients met the 70% adherence threshold (the actual percentage was 43%); in a 12-week study, clinician ratings correlated weakly with adherence (r = 0.32; P = .001), but patient self-reporting showed no significant correlation (r = 0.18; P = .08) with pill count.4
Clinicians underestimate not only the extent of nonadherence but also the impact that even a brief period of modest nonadherence has on the risk of relapse. In an 18-month prospective study of patients who recently had been given a diagnosis of schizophrenia, and in whom clinician and patient reports were supplemented with a pill count every 1 to 2 weeks and plasma antipsychotic levels every 4 weeks, any period of at least mild nonadherence was significantly predictive of symptom exacerbation or relapse (hazard ratio [HR], 3.4; 95% CI, 1.4–8.4; P < .002).1 Moreover, 50% to 75% adherence for ≥ 2 consecutive weeks increased the HR to 5.8, and moderate nonadherence (<50% for 2.0 to 3.9 weeks) to an HR of 28.5.
There might be a better method already available
Given the poor correlation between a clinician’s judgment and a patient’s actual pill-taking, it is clear that more accurate methods of tracking adherence must be devised. Because MEMS technology is not widely available, and because pill counts require a home visit or a cooperative patient who brings medications to office visits, plasma antipsychotic monitoring potentially is an appealing method of tracking adherence.
Correlation between the plasma antipsychotic level and relapse is not consistently seen in the literature,4 but plasma levels obtained during periods of clinical stability offer the opportunity to define, for the individual patient, a range of drug exposure that is associated with clinical response. The ideal plasma level baseline is obtained at steady state during a presumed period of observed adherence, such as during a hospital stay. Although patients can be nonadherent in the hospital, this setting offers the best proxy for an acute clinical response to a given plasma level. The alternative is to obtain several plasma levels during a period of outpatient clinical stability.
Clinicians must be mindful that changes in the plasma antipsychotic level after hospital discharge might not reflect poor adherence; environmental factors (eg, exposure to cytochrome P450 or P-glycoprotein inducers) can have a significant impact on results. Resumption of smoking is a classic example, and routinely is associated with a 50% reduction in plasma clozapine levels.5
There also is expected variability in plasma antipsychotic levels based on (1) the timing of prior doses with regard to trough levels, and (2) the effects of an occasional missed dose. Nevertheless, in a sample of adherent clozapine-treated patients, investigators found that 98% of patients had a coefficient of variability (CV) of 30% for sequential plasma concentrations (mean CV, 14%).6
Clinicians should inform patients that the plasma antipsychotic level is a tool for helping track treatment engagement before relapse—the same way metabolic monitoring helps track abnormalities that can be associated with future cardiovascular events. (Clinicians also must be charitable with their patients when discussing a significant drop in the plasma antipsychotic level [eg, >30%], acknowledging that many patients often miss doses.)
Using the patient’s input about specific difficulties with a medication regimen, clinicians should strive to find ways to improve oral medication adherence. In many cases, the clinician can assist through medication simplification, consolidation of multiple daily doses, provision of pill boxes, and discussions about long-acting injectable (LAI) antipsychotics.
In short, plasma antipsychotic levels offer an opportunity to have a richer, evidence-based discussion about adherence, beyond the trite, ineffective question “Did you take your medication?” Use of an objective measure can (1) serve as a benchmark for the patient (eg, “You seemed to do better when your clozapine level was above 400 ng/mL”), and (2) remind clinicians of the variable adherence inherent with oral medication regimens.
A note about long-acting injectable antipsychotics
Because nonadherence is seen throughout the course of schizophrenia, discussion of LAI therapy should not be limited to patients with chronic illness. Results of recent naturalistic7 and randomized studies8 show significant reduction in the rate of psychotic relapse and improved symptom control8 among first-episode patients who are taking an LAI. Moreover, compelling data show that most first-episode patients who are taking an oral antipsychotic will accept a recommendation for treatment with an LAI.9
Summing up: 2 Tools for achieving therapeutic success
Monitoring plasma levels of antipsychotics offers a method for quantifying the problem of nonadherence. For many patients, an LAI antipsychotic provides a solution to nonadherence, and the increasing variety of LAI preparations means more options with which to match individual patients.
Clinicians have a limited amount of time to spend with patients in the office, but time spent discussing LAIs is an investment in the patient’s stability and functional outcome. Minutes once spent managing nonadherence can be devoted to understanding the patient’s aspirations and to developing strategies to achieve those goals.
In the end, isn’t that what we’d rather be talking about with our patients?
Although there has been success in defining the minimum therapeutic response threshold for certain antipsychotics—for example, clozapine (350 to 450 ng/mL), haloperidol (3 to 5 ng/mL), and fluphenazine (0.8 ng/mL)—one aspect of antipsychotic plasma levels not widely discussed is their value as a marker of adherence.
Many schizophrenia patients achieve an optimal response to agents for which there is no depot formulation. For them, maintenance of symptom control depends wholly on oral medication adherence.1 Regrettably, nonadherence with oral antipsychotic treatment is prevalent among patients with schizophrenia; yet, in routine clinical practice, the extent of nonadherence rarely is measured.
Studies have been able to quantify oral medication nonadherence using monitoring devices, such as the Medication Event Monitoring System (MEMS) that electronically records opening of the medication container and strongly correlates with pill count. Although patients knew they were participating in a trial using MEMS technology, only 48% were able to take their medication at least 80% of the time in a 4-week study,2 and only 43% met the 70% adherence threshold in a 6-month trial.3
Clinicians, patients: Unreliable indicators of adherence
Neither clinician rating nor patient self-reporting is a reliable predictor of adherence with an oral medication regimen. In the 6-month adherence trial,3 clinicians estimated that 95% of their patients met the 70% adherence threshold (the actual percentage was 43%); in a 12-week study, clinician ratings correlated weakly with adherence (r = 0.32; P = .001), but patient self-reporting showed no significant correlation (r = 0.18; P = .08) with pill count.4
Clinicians underestimate not only the extent of nonadherence but also the impact that even a brief period of modest nonadherence has on the risk of relapse. In an 18-month prospective study of patients who recently had been given a diagnosis of schizophrenia, and in whom clinician and patient reports were supplemented with a pill count every 1 to 2 weeks and plasma antipsychotic levels every 4 weeks, any period of at least mild nonadherence was significantly predictive of symptom exacerbation or relapse (hazard ratio [HR], 3.4; 95% CI, 1.4–8.4; P < .002).1 Moreover, 50% to 75% adherence for ≥ 2 consecutive weeks increased the HR to 5.8, and moderate nonadherence (<50% for 2.0 to 3.9 weeks) to an HR of 28.5.
There might be a better method already available
Given the poor correlation between a clinician’s judgment and a patient’s actual pill-taking, it is clear that more accurate methods of tracking adherence must be devised. Because MEMS technology is not widely available, and because pill counts require a home visit or a cooperative patient who brings medications to office visits, plasma antipsychotic monitoring potentially is an appealing method of tracking adherence.
Correlation between the plasma antipsychotic level and relapse is not consistently seen in the literature,4 but plasma levels obtained during periods of clinical stability offer the opportunity to define, for the individual patient, a range of drug exposure that is associated with clinical response. The ideal plasma level baseline is obtained at steady state during a presumed period of observed adherence, such as during a hospital stay. Although patients can be nonadherent in the hospital, this setting offers the best proxy for an acute clinical response to a given plasma level. The alternative is to obtain several plasma levels during a period of outpatient clinical stability.
Clinicians must be mindful that changes in the plasma antipsychotic level after hospital discharge might not reflect poor adherence; environmental factors (eg, exposure to cytochrome P450 or P-glycoprotein inducers) can have a significant impact on results. Resumption of smoking is a classic example, and routinely is associated with a 50% reduction in plasma clozapine levels.5
There also is expected variability in plasma antipsychotic levels based on (1) the timing of prior doses with regard to trough levels, and (2) the effects of an occasional missed dose. Nevertheless, in a sample of adherent clozapine-treated patients, investigators found that 98% of patients had a coefficient of variability (CV) of 30% for sequential plasma concentrations (mean CV, 14%).6
Clinicians should inform patients that the plasma antipsychotic level is a tool for helping track treatment engagement before relapse—the same way metabolic monitoring helps track abnormalities that can be associated with future cardiovascular events. (Clinicians also must be charitable with their patients when discussing a significant drop in the plasma antipsychotic level [eg, >30%], acknowledging that many patients often miss doses.)
Using the patient’s input about specific difficulties with a medication regimen, clinicians should strive to find ways to improve oral medication adherence. In many cases, the clinician can assist through medication simplification, consolidation of multiple daily doses, provision of pill boxes, and discussions about long-acting injectable (LAI) antipsychotics.
In short, plasma antipsychotic levels offer an opportunity to have a richer, evidence-based discussion about adherence, beyond the trite, ineffective question “Did you take your medication?” Use of an objective measure can (1) serve as a benchmark for the patient (eg, “You seemed to do better when your clozapine level was above 400 ng/mL”), and (2) remind clinicians of the variable adherence inherent with oral medication regimens.
A note about long-acting injectable antipsychotics
Because nonadherence is seen throughout the course of schizophrenia, discussion of LAI therapy should not be limited to patients with chronic illness. Results of recent naturalistic7 and randomized studies8 show significant reduction in the rate of psychotic relapse and improved symptom control8 among first-episode patients who are taking an LAI. Moreover, compelling data show that most first-episode patients who are taking an oral antipsychotic will accept a recommendation for treatment with an LAI.9
Summing up: 2 Tools for achieving therapeutic success
Monitoring plasma levels of antipsychotics offers a method for quantifying the problem of nonadherence. For many patients, an LAI antipsychotic provides a solution to nonadherence, and the increasing variety of LAI preparations means more options with which to match individual patients.
Clinicians have a limited amount of time to spend with patients in the office, but time spent discussing LAIs is an investment in the patient’s stability and functional outcome. Minutes once spent managing nonadherence can be devoted to understanding the patient’s aspirations and to developing strategies to achieve those goals.
In the end, isn’t that what we’d rather be talking about with our patients?
1. Subotnik KL, Nuechterlein KH, Ventura J, et al. Risperidone nonadherence and return of positive symptoms in the early course of schizophrenia. Am J Psychiatry. 2011;168(3):286-292.
2. Remington G, Teo C, Mann S, et al. Examining levels of antipsychotic adherence to better understand nonadherence. J Clin Psychopharmacol. 2013;33(2):261-263.
3. Byerly MJ, Thompson A, Carmody T, et al. Validity of electronically monitored medication adherence and conventional adherence measures in schizophrenia. Psychiatr Serv. 2007;58(6):844-847.
4. Velligan DI, Wang M, Diamond P, et al. Relationships among subjective and objective measures of adherence to oral antipsychotic medications. Psychiatr Serv. 2007;58(9):1187-1192.
5. Meyer JM. Individual changes in clozapine levels after smoking cessation: results and a predictive model. J Clin Psychopharmacol. 2001;21(6):569-574.
6. Dugan DJ, Ereshefsky L, Toney GB, et al. Dose and interval adherence among stabilized clozapine-treated patients measured by medication event monitoring. Presented at: Meeting of the New Clinical Drug Evaluation Unit; May 30-June 2, 2000; Boca Raton, FL.
7. Tiihonen J, Haukka J, Taylor M, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. [Erratum in Am J Psychiatry. 2012;169(2):223]. Am J Psychiatry. 2011;168(6):603-609.
8. Subotnik KL, Casaus LR, Ventura J, et al. Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia: a randomized clinical trial. JAMA Psychiatry. 2015;72(8):822-829.
9. Weiden PJ, Schooler NR, Weedon JC, et al. A randomized controlled trial of long-acting injectable risperidone vs continuation on oral atypical antipsychotics for first-episode schizophrenia patients: initial adherence outcome. J Clin Psychiatry. 2009;70(10):1397-1406.
1. Subotnik KL, Nuechterlein KH, Ventura J, et al. Risperidone nonadherence and return of positive symptoms in the early course of schizophrenia. Am J Psychiatry. 2011;168(3):286-292.
2. Remington G, Teo C, Mann S, et al. Examining levels of antipsychotic adherence to better understand nonadherence. J Clin Psychopharmacol. 2013;33(2):261-263.
3. Byerly MJ, Thompson A, Carmody T, et al. Validity of electronically monitored medication adherence and conventional adherence measures in schizophrenia. Psychiatr Serv. 2007;58(6):844-847.
4. Velligan DI, Wang M, Diamond P, et al. Relationships among subjective and objective measures of adherence to oral antipsychotic medications. Psychiatr Serv. 2007;58(9):1187-1192.
5. Meyer JM. Individual changes in clozapine levels after smoking cessation: results and a predictive model. J Clin Psychopharmacol. 2001;21(6):569-574.
6. Dugan DJ, Ereshefsky L, Toney GB, et al. Dose and interval adherence among stabilized clozapine-treated patients measured by medication event monitoring. Presented at: Meeting of the New Clinical Drug Evaluation Unit; May 30-June 2, 2000; Boca Raton, FL.
7. Tiihonen J, Haukka J, Taylor M, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. [Erratum in Am J Psychiatry. 2012;169(2):223]. Am J Psychiatry. 2011;168(6):603-609.
8. Subotnik KL, Casaus LR, Ventura J, et al. Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia: a randomized clinical trial. JAMA Psychiatry. 2015;72(8):822-829.
9. Weiden PJ, Schooler NR, Weedon JC, et al. A randomized controlled trial of long-acting injectable risperidone vs continuation on oral atypical antipsychotics for first-episode schizophrenia patients: initial adherence outcome. J Clin Psychiatry. 2009;70(10):1397-1406.
BEST-CLI: New Initiatives, Upcoming Meetings
A number of new initiatives have recently been incorporated into the Best Endovascular versus best Surgical Therapy in patients with Critical Limb Ischemia (BEST-CLI) trial. It is hoped the additions and changes, including a modification of the protocol exclusion criteria, will facilitate subject accrual, an expansion to 140 trial sites and distribution of additional funds to all participating and enrolling centers.
The landmark BEST-CLI trial is a prospective, randomized, pragmatic, open-label superiority trial that is currently enrolling patients at 120 active sites in the United States and Canada. The trial will compare treatment efficacy, functional outcomes and cost in patients with critical limb ischemia who are candidates for both infrainguinal bypass and endovascular therapy and who are randomly assigned to one of the two treatments. Of the target number of 2,100 patients, 295 have been assigned treatments.
Changes include:
- The presence of >50% stenosis of the ipsilateral common femoral artery (CFA) will no longer be an exclusion. Treatment of a severe stenosis or an occlusion of the CFA either by open (surgical endarterectomy and patch angioplasty) or endovascular means will now be allowed and will be irrespective of the randomized treatment of the more distal occlusive disease.
- Immnosuppressive medication, a femoropopliteal TASC II A pattern of disease and hypercoaguagility will no longer be exclusions.
- The required delay following a previous open vascular or endovascular procedure (surgical bypass, balloon angioplasty, atherectomy or stenting) performed on the index limb has been reduced from six to three months. The required delay following a previous surgical inflow procedures performed on the index limb has been reduced from six months to six weeks.
- Treatment of an aortic or ipsilateral iliac artery occlusion will now be allowed.
- The protocol changes serve to bring the trial criteria more in line with common practice, while not altering to any significant degree the study aims.
The National Heart Lung and Blood Institute is sponsoring the trial, designed to address a number of questions of ongoing clinical interest. It aspires to significantly impact clinical practice by defining an evidence-based standard of care for patients with CLI. Recent changes in the trial design should serve to facilitate patient enrollment. Vascular surgeons participating are asked to continue their efforts to achieve current enrollment targets. Those not participating who wish to do so are asked to email BEST@neriscience.com.
Drs. Alik Farber (Boston Medical Center), Matthew Menard (Brigham and Women’s Hospital) and Kenneth Rosenfield (Massachusetts General Hospital) are leading the BEST-CLI Trial.
All are invited to upcoming BEST-CLI Trial Investigators Meetings at VIVA (3 to 4:30 p.m. PST on Tuesday, Nov. 3) and VEITH (3 to 4:30 p.m. EST on Friday, Nov 20).
For more information visit www.bestcli.com
A number of new initiatives have recently been incorporated into the Best Endovascular versus best Surgical Therapy in patients with Critical Limb Ischemia (BEST-CLI) trial. It is hoped the additions and changes, including a modification of the protocol exclusion criteria, will facilitate subject accrual, an expansion to 140 trial sites and distribution of additional funds to all participating and enrolling centers.
The landmark BEST-CLI trial is a prospective, randomized, pragmatic, open-label superiority trial that is currently enrolling patients at 120 active sites in the United States and Canada. The trial will compare treatment efficacy, functional outcomes and cost in patients with critical limb ischemia who are candidates for both infrainguinal bypass and endovascular therapy and who are randomly assigned to one of the two treatments. Of the target number of 2,100 patients, 295 have been assigned treatments.
Changes include:
- The presence of >50% stenosis of the ipsilateral common femoral artery (CFA) will no longer be an exclusion. Treatment of a severe stenosis or an occlusion of the CFA either by open (surgical endarterectomy and patch angioplasty) or endovascular means will now be allowed and will be irrespective of the randomized treatment of the more distal occlusive disease.
- Immnosuppressive medication, a femoropopliteal TASC II A pattern of disease and hypercoaguagility will no longer be exclusions.
- The required delay following a previous open vascular or endovascular procedure (surgical bypass, balloon angioplasty, atherectomy or stenting) performed on the index limb has been reduced from six to three months. The required delay following a previous surgical inflow procedures performed on the index limb has been reduced from six months to six weeks.
- Treatment of an aortic or ipsilateral iliac artery occlusion will now be allowed.
- The protocol changes serve to bring the trial criteria more in line with common practice, while not altering to any significant degree the study aims.
The National Heart Lung and Blood Institute is sponsoring the trial, designed to address a number of questions of ongoing clinical interest. It aspires to significantly impact clinical practice by defining an evidence-based standard of care for patients with CLI. Recent changes in the trial design should serve to facilitate patient enrollment. Vascular surgeons participating are asked to continue their efforts to achieve current enrollment targets. Those not participating who wish to do so are asked to email BEST@neriscience.com.
Drs. Alik Farber (Boston Medical Center), Matthew Menard (Brigham and Women’s Hospital) and Kenneth Rosenfield (Massachusetts General Hospital) are leading the BEST-CLI Trial.
All are invited to upcoming BEST-CLI Trial Investigators Meetings at VIVA (3 to 4:30 p.m. PST on Tuesday, Nov. 3) and VEITH (3 to 4:30 p.m. EST on Friday, Nov 20).
For more information visit www.bestcli.com
A number of new initiatives have recently been incorporated into the Best Endovascular versus best Surgical Therapy in patients with Critical Limb Ischemia (BEST-CLI) trial. It is hoped the additions and changes, including a modification of the protocol exclusion criteria, will facilitate subject accrual, an expansion to 140 trial sites and distribution of additional funds to all participating and enrolling centers.
The landmark BEST-CLI trial is a prospective, randomized, pragmatic, open-label superiority trial that is currently enrolling patients at 120 active sites in the United States and Canada. The trial will compare treatment efficacy, functional outcomes and cost in patients with critical limb ischemia who are candidates for both infrainguinal bypass and endovascular therapy and who are randomly assigned to one of the two treatments. Of the target number of 2,100 patients, 295 have been assigned treatments.
Changes include:
- The presence of >50% stenosis of the ipsilateral common femoral artery (CFA) will no longer be an exclusion. Treatment of a severe stenosis or an occlusion of the CFA either by open (surgical endarterectomy and patch angioplasty) or endovascular means will now be allowed and will be irrespective of the randomized treatment of the more distal occlusive disease.
- Immnosuppressive medication, a femoropopliteal TASC II A pattern of disease and hypercoaguagility will no longer be exclusions.
- The required delay following a previous open vascular or endovascular procedure (surgical bypass, balloon angioplasty, atherectomy or stenting) performed on the index limb has been reduced from six to three months. The required delay following a previous surgical inflow procedures performed on the index limb has been reduced from six months to six weeks.
- Treatment of an aortic or ipsilateral iliac artery occlusion will now be allowed.
- The protocol changes serve to bring the trial criteria more in line with common practice, while not altering to any significant degree the study aims.
The National Heart Lung and Blood Institute is sponsoring the trial, designed to address a number of questions of ongoing clinical interest. It aspires to significantly impact clinical practice by defining an evidence-based standard of care for patients with CLI. Recent changes in the trial design should serve to facilitate patient enrollment. Vascular surgeons participating are asked to continue their efforts to achieve current enrollment targets. Those not participating who wish to do so are asked to email BEST@neriscience.com.
Drs. Alik Farber (Boston Medical Center), Matthew Menard (Brigham and Women’s Hospital) and Kenneth Rosenfield (Massachusetts General Hospital) are leading the BEST-CLI Trial.
All are invited to upcoming BEST-CLI Trial Investigators Meetings at VIVA (3 to 4:30 p.m. PST on Tuesday, Nov. 3) and VEITH (3 to 4:30 p.m. EST on Friday, Nov 20).
For more information visit www.bestcli.com
PTSD in Women and Men
Beginning in September, Federal Practitioner will focus on female health and women service members, including interviews with authors of chapters from Women at War. For more, visit www.fedprac.com/articles/women-at-war.html.
In addition to coediting the Women at War volume, Dr. Ritchie authored the chapter, “Female Soldiers and Post-Traumatic Stress Disorder” (PTSD). In this interview, she discusses the evolving definition of PTSD, military and civilian research into the condition, its stressors, and how PTSD may differ in women and men.
For a limited time, a discount is being offered to Federal Practitioner readers. Click here and use the promo code AMPROMD9 at checkout.
Beginning in September, Federal Practitioner will focus on female health and women service members, including interviews with authors of chapters from Women at War. For more, visit www.fedprac.com/articles/women-at-war.html.
In addition to coediting the Women at War volume, Dr. Ritchie authored the chapter, “Female Soldiers and Post-Traumatic Stress Disorder” (PTSD). In this interview, she discusses the evolving definition of PTSD, military and civilian research into the condition, its stressors, and how PTSD may differ in women and men.
For a limited time, a discount is being offered to Federal Practitioner readers. Click here and use the promo code AMPROMD9 at checkout.
Beginning in September, Federal Practitioner will focus on female health and women service members, including interviews with authors of chapters from Women at War. For more, visit www.fedprac.com/articles/women-at-war.html.
In addition to coediting the Women at War volume, Dr. Ritchie authored the chapter, “Female Soldiers and Post-Traumatic Stress Disorder” (PTSD). In this interview, she discusses the evolving definition of PTSD, military and civilian research into the condition, its stressors, and how PTSD may differ in women and men.
For a limited time, a discount is being offered to Federal Practitioner readers. Click here and use the promo code AMPROMD9 at checkout.
How a cancer diagnosis affects income
receiving treatment
Photo by Rhoda Baer
A new study indicates that when American adults are diagnosed with
cancer, they experience significant decreases in the probability of
working, in the number of hours they work, and correspondingly, in their
incomes.
Additionally, these effects appear to be more pronounced among men than women.
Anna Zajacova, PhD, of the University of Wyoming in Laramie, and her colleagues reported these findings in Cancer.
The researchers analyzed data from the Panel Study of Income Dynamics, a nationally representative, prospective, population-based, observational study with individual and family level economic information. The data spanned the period from 1999 to 2009.
The team used models to estimate the impact of cancer on employment, hours worked, individual income, and total family income.
The results showed that, after a cancer diagnosis, the probability of a patient being employed dropped by almost 10 percentage points, and hours worked declined by up to 200 hours, or about 5 weeks of full-time work, in the first year.
Annual labor market earnings dropped almost 40% within 2 years of diagnosis, and they remained lower than before diagnosis. Total family income declined by 20%, although it recovered within 4 years of cancer diagnosis.
These effects were primarily driven by losses among male cancer survivors. For women diagnosed with cancer, the losses were largely not statistically significant.
“Fifteen million American adults are cancer survivors, and American families need economic support while they are dealing with the rigors of cancer treatment,” Dr Zajacova said.
“Our paper suggests that families where an adult—especially a working-age male—is diagnosed with cancer suffer short-term and long-term declines in their economic well-being. We need to improve workplace and insurance safety nets so families can focus on dealing with the cancer treatment rather than deal with the financial and employment fallout.” 
receiving treatment
Photo by Rhoda Baer
A new study indicates that when American adults are diagnosed with
cancer, they experience significant decreases in the probability of
working, in the number of hours they work, and correspondingly, in their
incomes.
Additionally, these effects appear to be more pronounced among men than women.
Anna Zajacova, PhD, of the University of Wyoming in Laramie, and her colleagues reported these findings in Cancer.
The researchers analyzed data from the Panel Study of Income Dynamics, a nationally representative, prospective, population-based, observational study with individual and family level economic information. The data spanned the period from 1999 to 2009.
The team used models to estimate the impact of cancer on employment, hours worked, individual income, and total family income.
The results showed that, after a cancer diagnosis, the probability of a patient being employed dropped by almost 10 percentage points, and hours worked declined by up to 200 hours, or about 5 weeks of full-time work, in the first year.
Annual labor market earnings dropped almost 40% within 2 years of diagnosis, and they remained lower than before diagnosis. Total family income declined by 20%, although it recovered within 4 years of cancer diagnosis.
These effects were primarily driven by losses among male cancer survivors. For women diagnosed with cancer, the losses were largely not statistically significant.
“Fifteen million American adults are cancer survivors, and American families need economic support while they are dealing with the rigors of cancer treatment,” Dr Zajacova said.
“Our paper suggests that families where an adult—especially a working-age male—is diagnosed with cancer suffer short-term and long-term declines in their economic well-being. We need to improve workplace and insurance safety nets so families can focus on dealing with the cancer treatment rather than deal with the financial and employment fallout.”
receiving treatment
Photo by Rhoda Baer
A new study indicates that when American adults are diagnosed with
cancer, they experience significant decreases in the probability of
working, in the number of hours they work, and correspondingly, in their
incomes.
Additionally, these effects appear to be more pronounced among men than women.
Anna Zajacova, PhD, of the University of Wyoming in Laramie, and her colleagues reported these findings in Cancer.
The researchers analyzed data from the Panel Study of Income Dynamics, a nationally representative, prospective, population-based, observational study with individual and family level economic information. The data spanned the period from 1999 to 2009.
The team used models to estimate the impact of cancer on employment, hours worked, individual income, and total family income.
The results showed that, after a cancer diagnosis, the probability of a patient being employed dropped by almost 10 percentage points, and hours worked declined by up to 200 hours, or about 5 weeks of full-time work, in the first year.
Annual labor market earnings dropped almost 40% within 2 years of diagnosis, and they remained lower than before diagnosis. Total family income declined by 20%, although it recovered within 4 years of cancer diagnosis.
These effects were primarily driven by losses among male cancer survivors. For women diagnosed with cancer, the losses were largely not statistically significant.
“Fifteen million American adults are cancer survivors, and American families need economic support while they are dealing with the rigors of cancer treatment,” Dr Zajacova said.
“Our paper suggests that families where an adult—especially a working-age male—is diagnosed with cancer suffer short-term and long-term declines in their economic well-being. We need to improve workplace and insurance safety nets so families can focus on dealing with the cancer treatment rather than deal with the financial and employment fallout.”
How a cancer diagnosis affects income
receiving treatment
Photo by Rhoda Baer
A new study indicates that when American adults are diagnosed with cancer, they experience significant decreases in the probability of working, in the number of hours they work, and correspondingly, in their incomes.
Additionally, these effects appear to be more pronounced among men than women.
Anna Zajacova, PhD, of the University of Wyoming in Laramie, and her colleagues reported these findings in Cancer.
The researchers analyzed data from the Panel Study of Income Dynamics, a nationally representative, prospective, population-based, observational study with individual and family level economic information. The data spanned the period from 1999 to 2009.
The team used models to estimate the impact of cancer on employment, hours worked, individual income, and total family income.
The results showed that, after a cancer diagnosis, the probability of a patient being employed dropped by almost 10 percentage points, and hours worked declined by up to 200 hours, or about 5 weeks of full-time work, in the first year.
Annual labor market earnings dropped almost 40% within 2 years of diagnosis, and they remained lower than before diagnosis. Total family income declined by 20%, although it recovered within 4 years of cancer diagnosis.
These effects were primarily driven by losses among male cancer survivors. For women diagnosed with cancer, the losses were largely not statistically significant.
“Fifteen million American adults are cancer survivors, and American families need economic support while they are dealing with the rigors of cancer treatment,” Dr Zajacova said.
“Our paper suggests that families where an adult—especially a working-age male—is diagnosed with cancer suffer short-term and long-term declines in their economic well-being. We need to improve workplace and insurance safety nets so families can focus on dealing with the cancer treatment rather than deal with the financial and employment fallout.”
receiving treatment
Photo by Rhoda Baer
A new study indicates that when American adults are diagnosed with cancer, they experience significant decreases in the probability of working, in the number of hours they work, and correspondingly, in their incomes.
Additionally, these effects appear to be more pronounced among men than women.
Anna Zajacova, PhD, of the University of Wyoming in Laramie, and her colleagues reported these findings in Cancer.
The researchers analyzed data from the Panel Study of Income Dynamics, a nationally representative, prospective, population-based, observational study with individual and family level economic information. The data spanned the period from 1999 to 2009.
The team used models to estimate the impact of cancer on employment, hours worked, individual income, and total family income.
The results showed that, after a cancer diagnosis, the probability of a patient being employed dropped by almost 10 percentage points, and hours worked declined by up to 200 hours, or about 5 weeks of full-time work, in the first year.
Annual labor market earnings dropped almost 40% within 2 years of diagnosis, and they remained lower than before diagnosis. Total family income declined by 20%, although it recovered within 4 years of cancer diagnosis.
These effects were primarily driven by losses among male cancer survivors. For women diagnosed with cancer, the losses were largely not statistically significant.
“Fifteen million American adults are cancer survivors, and American families need economic support while they are dealing with the rigors of cancer treatment,” Dr Zajacova said.
“Our paper suggests that families where an adult—especially a working-age male—is diagnosed with cancer suffer short-term and long-term declines in their economic well-being. We need to improve workplace and insurance safety nets so families can focus on dealing with the cancer treatment rather than deal with the financial and employment fallout.”
receiving treatment
Photo by Rhoda Baer
A new study indicates that when American adults are diagnosed with cancer, they experience significant decreases in the probability of working, in the number of hours they work, and correspondingly, in their incomes.
Additionally, these effects appear to be more pronounced among men than women.
Anna Zajacova, PhD, of the University of Wyoming in Laramie, and her colleagues reported these findings in Cancer.
The researchers analyzed data from the Panel Study of Income Dynamics, a nationally representative, prospective, population-based, observational study with individual and family level economic information. The data spanned the period from 1999 to 2009.
The team used models to estimate the impact of cancer on employment, hours worked, individual income, and total family income.
The results showed that, after a cancer diagnosis, the probability of a patient being employed dropped by almost 10 percentage points, and hours worked declined by up to 200 hours, or about 5 weeks of full-time work, in the first year.
Annual labor market earnings dropped almost 40% within 2 years of diagnosis, and they remained lower than before diagnosis. Total family income declined by 20%, although it recovered within 4 years of cancer diagnosis.
These effects were primarily driven by losses among male cancer survivors. For women diagnosed with cancer, the losses were largely not statistically significant.
“Fifteen million American adults are cancer survivors, and American families need economic support while they are dealing with the rigors of cancer treatment,” Dr Zajacova said.
“Our paper suggests that families where an adult—especially a working-age male—is diagnosed with cancer suffer short-term and long-term declines in their economic well-being. We need to improve workplace and insurance safety nets so families can focus on dealing with the cancer treatment rather than deal with the financial and employment fallout.”