What Does Neglect Look Like in the Geriatric ED?
An older man brings his wife who has dementia to an ED in the middle of the night because “she’s having pain.” An hour later, still not seen by the doctor, he tells the nurse they are leaving. That seems reasonable, right? He’s an adult and can make his own decisions. Fortunately, in this situation, the astute nurse notices that something “didn’t seem quite right” and asked me, the doctor, to see them promptly. What became clear quite quickly (what the nurse had noticed) was that the husband also had significant dementia although he was the principal caregiver and decision-maker for his wife.
This case started me thinking about the “N” in EAN – elder abuse and neglect. As ED clinicians we know that abuse of all kinds is common – child abuse, domestic or intimate partner abuse, sexual abuse, even elder abuse – and that we have a role to play in identifying it and supporting the victim. And typically, when we think about elder abuse (which isn’t often enough anyhow), it is usually with images of wilful assault, usually violent, perpetrated by malign contacts with malevolent intention. We conjure up images of bruises and fractures and untended wounds, stolen pension checks, and banking fraud. It is true that those perpetrators do exist, and those awful events do happen. However, it is also true that much of the elder abuse and neglect that we see is much more “banal” and routine – so much so that we don’t even notice it or think we in the ED can do anything about it.
A lot of work by some EDs and organisations like the National Collaboratory on Elder Mistreatment has gone into highlighting the neglect that all vulnerable patient groups suffer, including older people. Examples of this would be inadequate attention to basic care needs – clean clothes, food and drink, adequate housing, support with ADLs and iADLS like medication management. One way of re-thinking our response to this form of neglect is “how can EDs help to identify and address unmet social needs”? Perhaps the frail person seen in the ED is not getting adequate nutrition simply because they are no longer able to shop and cook for themselves. Linking that person with a meal delivery service may address what looks like “neglect” but may simply be a lack of information about available resources. Perhaps the reason that a person is taking the wrong medications or too many of the right ones is that they have mild cognitive impairment and simply need to have their pharmacist blister pack their medications on a weekly basis. A more complex example might be the patient who keeps falling because there is no one around to assist them to the bathroom regularly because their low-income family member is working two jobs to ensure they are not both homeless. Perhaps if an astute ED clinician asked, “who helps you at home?”, that person could be linked to some additional supports such as a community-based care service, a friendly visitor, or even getting access to a bedside commode or a walker.
It is valuable to be ever attentive to the most grievous forms of abuse, assault, and financial exploitations. It is also true that, without dismissing their importance, almost no older person ever died because of those more gross forms of abuse. However older people often sicken and die because of preventable poor nutrition, medication problems, and frequent falls. Perhaps by being more attentive to the everyday forms of neglect – and ways that we can intervene to address – we can make a big difference in the lives of vulnerable older people. And perhaps save a life.
Dr. Don Melady is an emergency physician at Mount Sinai Hospital in Toronto, Canada and a founding member of the Geriatric Emergency Department Collaborative. He is the author of the website www.geri-EM.com – a CME accredited program for geriatric emergency medicine education – and the chair of the Geriatric EM committee of the International Federation of Emergency Medicine.