On Elder Abuse Awareness Day, California Attorney General Rob Bonta provided Californians with tips to identify and report elder abuse. Elder Abuse is a national issue that threatens some of the most vulnerable members of our communities — according to figures by the U.S. Department of Justice, at least 10% of adults age 65 and older will be a victim of elder abuse in a given year. Here are some common warning signs to help the families and caretakers of elderly individuals identify abuse.
“Sadly, whether it’s due to fear of retaliation, or worse, many of our elders don’t talk about the abuse they’ve endured” said Attorney General Bonta. “Elder abuse can take many insidious forms, including the neglect of a caregiver, financial exploitation and sexual, physical, and mental abuse. Too often, the perpetrators of these egregious actions are those we trust the most to take care of our loved ones. Our elders should never suffer, especially in silence. I urge Californians to look at the warning signs, and to report confirmed or suspected mistreatment to our Division of Medi-Cal Fraud and Elder Abuse at oag.ca.gov/dmfea/reporting.”
What is Elder Abuse?
Acts that may constitute abuse or neglect of elders and dependents under the law are defined broadly. Abusive conduct may include the infliction of injury, inappropriate sexual contact or conduct, theft and/or financial exploitation, unreasonable confinement, intimidation, or punishment with resulting physical or financial harm, pain, or mental anguish. Neglect can include the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.
What are Common Signs of Elder Abuse?
Here are important warning signs for elders, their families, friends, and caregivers to help identify and prevent abuse:
- Neglect and Abandonment: Dehydration, malnutrition, untreated bed sores, and poor personal hygiene. Hazardous or unsafe living condition/arrangements. Unsanitary and unclean living conditions.
- Financial Exploitation: Sudden changes in bank accounts or banking practices. Unauthorized withdrawal of the elder’s funds using the elder’s ATM card. Abrupt changes in a will or other financial documents.
- Psychological: Being emotionally upset or agitated, extremely withdrawn, non communicative or non responsive. Exhibiting a change in sleeping patterns or eating habits. Personality changes, such as apologizing excessively, or depression or anxiety.
- Sexual Abuse: Bruises around the breasts or genital area, unexplained venereal disease, or genital infections. Changes in a senior’s demeanor, such as showing fear or becoming withdrawn when a specific person is near. Blood found on sheets, linens or a senior’s clothing.
- Physical Abuse: Bruises, black eyes, welts, lacerations, sprains, dislocations, fractures, broken bones, or internal injuries/bleeding. Broken eyeglasses or frames, physical signs of being subjected to punishment, or signs of being restrained. Laboratory findings of medication overdose or underutilization of prescribed drugs.
What Are Pressure Injuries (also known as Bedsores)?
A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs because of intense and/or prolonged pressure, or pressure in combination with shear. The tolerance of soft tissue for pressure and shear also may be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin – Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis – Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage cannot be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Injury: Full-thickness skin loss – Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical locations; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscure the extent of tissue loss, this is an unstageable pressure injury.
Stage 4 Pressure Injury: Full-thickness skin and tissue loss – Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar maybe visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscure the extent of tissue loss, this is unstageable pressure injury.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss – Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration – Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
Preventing Pressure Injuries and Bedsores
Preventing pressure ulcers can be nursing intensive. The challenge is more difficult when there is nursing staff turnover and shortages. Studies have suggested that pressure ulcer development can be directly affected by the number of registered nurses and time spent at the bedside.46, 47 Given that the cost of treatment has been estimated as 2.5 times that of prevention, implementing a pressure ulcer prevention program remains essential.
A growing level of evidence suggests that pressure ulcer prevention can be effective in all health care settings. One study examined the efficacy of an intensive pressure ulcer prevention protocol to decrease the incidence of ulcers in a 77-bed long-term care facility.50 The pressure ulcer prevention protocol consisted of preventive interventions stratified on risk level, with implementation of support surfaces and turning/repositioning residents. The sample included 132 residents (69 prior to prevention intervention and 63 after prevention intervention). The 6-month incidence rate of pressure ulcers prior to the intensive prevention intervention was 23 percent. For the 6-months after intensive prevention intervention, the pressure ulcer incidence rate was 5 percent. This study demonstrated that significant reductions in the incidence of pressure ulcers are possible to achieve within a rather short period of time (6 months) when facility-specific intensive prevention interventions are used. https://www.ncbi.nlm.nih.gov/books/NBK2650/
Mechanical Loading / Repositioning and Turning
One of the most important preventive measures is decreasing mechanical load. If patients cannot adequately turn or reposition themselves, this may lead to pressure ulcer development. It is critical for nurses to help reduce the mechanical load for patients. This includes frequent turning and repositioning of patients.
Very little research has been published related to optimal turning schedules. The first such nursing study was an observational one that divided older adults into three turning treatment groups (every 2 to 3 hours [n = 32], every 4 hours [n = 27], or turned two to four times/day [n = 41]).59 These researchers found that older adults turned every 2 to 3 hours had fewer ulcers. This landmark nursing study created the gold standard of turning patients at least every 2 hours. Some researchers would suggest that critically ill patients should be turned more often. However, one survey study investigating body positioning in intensive care patients found that of 74 patients observed, 49.3 percent were not repositioned for more than 2 hours.60 Only 2.7 percent of patients had a demonstrated change in body position every 2 hours. A total of 80–90 percent of respondents to the survey agreed that turning every 2 hours was the accepted standard and that it prevented complications, but only 57 percent believed it was being achieved in their intensive care units. https://www.ncbi.nlm.nih.gov/books/NBK2650/
The use of support surfaces is an important consideration in pressure redistribution. The concept of pressure redistribution has been embraced by the NPUAP.66 You can never remove all pressure for a patient. If you reduce pressure on one body part, this will result in increased pressure elsewhere on the body. Hence, the goal is to obtain the best pressure redistribution possible.
A major method of redistributing pressure is the use of support surfaces. Much research has been conducted on the effectiveness of the use of support surfaces in reducing the incidence of pressure ulcers. A comprehensive literature review by Agostini and colleagues67 found that there was adequate evidence that specially designed support surfaces effectively prevent the development of pressure ulcers.
Controversy remains on how best to do nutritional assessment for patients at risk for developing pressure ulcers. The literature differs about the value of serum albumin; some literature reports that low levels are associated with increased risk.70 While the AHRQ pressure ulcer prevention guideline suggests that a serum albumin of less than 3.5 gm/dl predisposes a patient for increased risk of pressure ulcers, one study reveals that current dietary protein intake is a more independent predictor than this lab value.8, 42 In the revised Tag F-314 guidance to surveyors in long-term care, CMS recommends that weight loss is an important indicator.40 Evaluation of the patient’s ability to chew and swallow may also be warranted.
The literature is unclear about protein-calorie malnutrition and its association with pressure ulcer development.70 Reddy and colleagues62 suggested that the widely held belief of a relationship between nutrition intake and pressure ulcer prevention was not always supported by randomized controlled trials. Some research supported the finding that undernourishment on admission to a health care facility increases a person’s likelihood of developing a pressure ulcer. In one prospective study, high-risk patients who were undernourished on admission to the hospital were twice as likely to develop pressure ulcers as adequately nourished patients (17 percent and 9 percent, respectively).71 In another study, 59 percent of residents were undernourished and 7.3 percent were severely undernourished on admission to a long-term care facility. Pressure ulcers occurred in 65 percent of the severely undernourished residents, while no pressure ulcers developed in the mild-to-moderately undernourished or well-nourished residents.15
These studies show that pressure ulcers and injuries are preventable in most circumstances, and preventive measures proven to reduce the frequency and severity of bedsores are not being employed in enough clinical settings. At Bedsore.Law, we specialize in advising and assisting residents and their families when having to navigate the presence of a bedsore. Visit us online for more information.
Contact Jeff Aidikoff, Bedsore Lawyer and Founding Partner, for more info.