Case history
Case history #1
An 85-year-old man who lives in a long-term care facility is seen for a routine health check. He is noted to have a history of hypertension, mild cognitive impairment, and hyperlipideamia. Follow-up has been erratic over the past year, with a number of missed appointments, and the control of blood pressure (BP) and lipids that was established has worsened. His BP is 190/110 mmHg, and he has lost 15 lb (7 kg) in weight. He is not forthcoming with information and is generally quiet during the interview. Physical exam is otherwise unremarkable. On questioning he reveals that his medications are not always given and that one of the members of staff is mean and verbally abusive to him.
Case history #2
An 76-year-old woman who lives with her daughter is brought to her primary care physician’s office for regular follow-up. Her history is significant for Alzheimer’s dementia with mood lability and hospitalisation for a fall 3 months ago. Since her last hospitalisation she is incontinent but refuses to wear adult diapers. Her daughter, who is her sole caregiver, reports concerns that she has been up at night and attempts to use the stove. During the visit, the daughter appears tired, frustrated, and repeatedly contradicts her mother’s report of events; she refuses to let her mother be interviewed by herself. On examination the older woman has multiple bruises of different ages and a minor burn on her right arm.
Other presentations
The presentation of older adult abuse is often subtle, and the course prolonged, which makes the diagnosis difficult during a single encounter. While obvious signs of injury (e.g., bruises or other wounds) suggest physical abuse, the diagnosis of other forms of abuse is often complicated by the presence of comorbidities, such as dementia or stroke. New onset issues such as sleep concerns, anxiety and depression may be due to the older person being a victim of financial fraud, an increasingly common problem. Certain signs can assist the healthcare provider to diagnose abuse. They include: the presence of restraint marks; the older adult being over- or under-medicated; refusal of the carer to let the patient answer any of the questions during an interview; refusal of the carer to let the older patient be interviewed separately; a withdrawn patient who does not make any eye contact; presence of agitation or other behaviour not appropriate for the level of dementia; multiple pressure ulcers; a patient smelling of urine or faeces; malnutrition and volume depletion; and an overall neglected or unkempt appearance.[6][7]
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