The Essential Medicine of Elder Abuse

The United States currently has a shortage of 200,000 nurses. In 13 years, year 2020, the shortage is projected to be over 800,000. At that time, nursing homes will need 66 percent more nurses than they have today. The most common areas of elder abuse are directly related to nurse staffing issues. The essential medicine of elder abuse revolves around nursing care.

Understanding how normal aging affects the most common areas of elder abuse is important in discerning neglect by an administrator, employee, professional or non-professional staff member providing care and services for elder or dependant adults. Understanding how the nursing care process involves custodial care, attending to basic needs, and the supervision of non-professional staff is important in determining elder abuse.

The elderly and dependent adults are obviously an at-risk population. Dementia puts this group at an even greater risk for abuse and neglect because of a greater degree of dependency and associated behavior problems. As a progressive brain dysfunction, dementia presents with a functional decline in cognitive and physical abilities which worsens over time. Advanced dementia is a common cause for nursing home placement. Studies have shown that aggressive behavior may be seen in over 65 percent of patients with dementia. Because of this, physical restraints are routinely used in this population, making it necessary to pay special attention to these patients to ensure that pressure sores do not result. The natural course of dementia can make it difficult to interpret sudden declines in health. Malnutrition, dehydration, poor personal hygiene, pressure ulcers, and falls may be indicators of abuse and neglect.

Malnutrition

Malnutrition is a common threat not only to dementia patients, but all elderly and dependent adults in health care facilities. The clinical signs of malnutrition include a decrease in body weight of more than 15 percent, low serum albumin levels, and a low total lymphocyte count. There are a number of conditions which can pre-dispose patients to malnutrition ranging from restricted diet and dental issues, to depression, confusion, and cancer. Unintended weight loss occurs during the normal aging process as we lose muscle mass. It also often occurs with patients who require help with eating. Studies have shown that staff members take only 5-10 minutes to feed patients who are unable to feed themselves. Severe malnutrition causes a drop in the albumin level and lymphocyte count. Poor nutritional status impacts tissue healing in bed sores. Also, dehydration can cause a pressure sore to develop.

Dehydration

Patients require a minimum of six eight-ounce glasses of water per day, or, as documented in medical records, 1500 to 2500 milliliters per day. At a minimum, intake must equal the fluid loss through urine, feces, skin, and lungs. When fluid is not replaced to cover the amount lost, then a loss of total body water content occurs. Clinically, this will present as an increased serum osmolality coupled with a rapid weight loss of greater than three percent of body weight. The physical signs and symptoms include concentrated urine, dry skin, dry mucous membranes, thirst, skin tenting, sunken eyes, rapid heart beat, low blood pressure, and mental confusion.

There are many conditions which pre-dispose patients to dehydration, which are taken into account by medical and nursing staff when managing the fluid requirements: Certain chronic conditions, decreased renal functions, neurological impairments, diarrhea, and fever. The nursing staff should implement care to address the problem of a natural blunted thirst mechanism in the elderly, or a patient with dementia who needs to be reminded to drink. Additionally, certain medications will cause fluid loss, such as diuretics, tranquilizers, and sedatives.

The management of adequate fluid intake requires diligent adherence to the nursing process of assessment, planning, implantation, and evaluation to assure that dehydration is avoided. The consequences of which can be wide ranging, from urinary tract infections, pneumonia, pressure ulcers, and even death if undetected.

Poor Personal Hygiene

Poor dentitions can affect a patient’s ability to eat, contributing to malnutrition. 30 percent of people over 65 have no natural teeth. Personal hygiene is the most basic expectation of custodial care to maintain a person’s comfort. Oral care is challenging and time consuming for a caregiver, as it requires daily attention to brush the teeth and dentures. If the patient is compliant and the caregiver does not provide adequate care, neglect is often related to poor staffing. Elderly patients and those with aggressive dementia can be non-compliant regarding personal hygiene by refusing to bathe and/or refusing to allow the caregiver to complete tasks of hygiene. In the extreme, there is a behavior disorder of extreme self neglect called Diogenes syndrome. The non-compliant situation requires good documentation and notification of the doctor and nursing supervisor.

Pressure Ulcers

Pressure ulcers, also called decubitus ulcers or bedsores, are the most common issue involved in elder abuse cases. They are called pressure ulcers because pressure is the single most important factor in ulcer formation. Normal capillary pressure usually ranges between 12 and 32 millimeters of mercury. Pressure sores develop when the outside pressure on the skin exceeds the mean capillary pressure, which reduces the blood flow and tissue oxygenation. When the skin is starved of nutrients and oxygen for too long, the tissue dies and a pressure ulcer forms. The most common sites of ulcers are areas of skin overlying bony prominences because one forms when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time. 95 percent of all pressure ulcers develop on the lower portion of the body. The National Pressure Advisory Board developed a classification system for staging ulcers. There are four stages:

Stage One: A redden area of the skin that does not turn white when you press it.

Stage Two: Partial thickness skin loss involving the top to layers of the skin: the dermis and epidermis. This looks like a blister or abrasion.

Stage Three: Full thickness skin loss involving the subcutaneous tissue and maybe the
underlying facia. This presents as a deep crater and might involve adjacent tissue.

Stage Four: Full thickness skin loss with extensive destruction, tissue death, muscle, tendon damage, or damage to bone.

A constant pressure of 70 mm of mercury for more than two hours leads to tissue death. If pressure is intermittently relieved, minimal changes occur. Thus, the standard of turning patients is every two hours. This traditional recommendation is a minimal requirement and actually is dependant on the degree of patient mobility and the support surface used. At-risk patients should be monitored closely for stage one pressure sores and have the turning plan revised for more frequent timing. To aid in monitoring the patient, a written re-positioning schedule should be used and posted in the patient’s room. The other factor to be aware of is that the highest interstitial pressure occurs at the bone and muscle interface, with less damage at the epidermal level, so deep tissue trauma can occur with very little superficial damage to alert caregivers to the extent of the injury.

Shearing forces are also a major contributor to pressure ulcers. Clinically, these occur when the head of a supine patient is raised 30 degrees. Friction reduces the amount of pressure needed to produce ulcers. This happens when a bedridden patient is dragged across the bed sheets. A long-term moist environment from urine, perspiration, or fecal material will increase the risk of an ulcer five times. These are all significant on there own, but when combined, ulcer formation becomes almost inevitable.

In addition to these factors, several other conditions pre-dispose a person to pressure ulcers:

Prolonged immobilization, sensory, and circulatory deficits.
Poor nutrition.
Smoking.
Medications.

Upon admission, a complete assessment should be done to identify at-risk patients. A scale, called the Braden Scale, is used to assess the risk factors aforementioned: Sensory perception, moisture, activity, mobility, nutrition, friction, and shear. On the Braden Scale, scores less than 12 indicate a high risk for development of ulcers, whereas a score between 13 and 15 reflects moderate risk, and a score of 16 or 17 indicates mild risk. This assessment forms the basis for medical and nursing care plans.

As is true of most ailments, the key to treatment of pressure ulcers is prevention. The key to prevention of pressure ulcers is pressure reduction. A pressure-reducing surface should be used for all patients at risk; there are many types of mattresses and mattress over-lays that can be used to reduce pressure. Patient positioning is also key to pressure reduction. A right or left 30 degree oblique position is recommended because it avoids direct pressure on 80 percent of the most common sites for ulcers. Maintaining the head of the bed at less than 30 degrees is optimal because greater than 30 degrees increases sheering force, as was previously stated. Patients in chairs for longer than one to two hours should have pressure reducing cushions such as mattress overlays.

If prevention is unsuccessful and an ulcer develops, the treatment proceeds initially with a carefully recorded assessment of all ulcers at the initiation of therapy. This is mandatory as a baseline against which to judge improvement or deterioration. A complete description of each sore should include location, stage, and size; necrotic tissue, odor, and drainage; and serial photos. If surgical treatment is required, it usually includes direct closure, skin graft, and skin flaps.

Pressure ulcers are common in elderly patients with reduced mobility, but they can often be avoided if the appropriate measures are taken. If they are unavoidable, pressure ulcers can be monitored and treated to cease or stunt their progression.

Falls and Fractures

Falls and the injuries sustained occur in three phases. These are important to understand because each phase is evaluated both during a fall risk assessment and a post fall assessment for determining what caused the fall. Phase one is the event that displaces the base of support, phase two is the failure of the motor and sensory system to correct the imbalance, and phase three is the impact itself. Upon facility admission, all patients are assessed for risk of falls. If there is a history of falls, the prior three months are evaluated to obtain a history and identification of causative factors. If dementia is a factor, it is assessed if the patient has an awareness of their limitations. Medical facilities will have fall prevention and restraint avoidance programs already in place. Nursing care plans will focus on preventative measures such as environmental changes, assistive walking devises, and physical therapy.

If a fall and injury does occur, a post fall assessment is done to identify the exact cause of the fall. This requires not only a thorough physical examination but a review of the medical records including current medical problems and medications. Once the cause is isolated, medical and nursing treatment can be initiated specifically for the modifiable factors. All falls require an Incident Report to be completed. There are several questions surrounding facility falls that must be addressed. Did the staff understand the patient’s risk factors and fall history? What measures were implemented to prevent a fall? How did the fall occur? Was a complete post fall assessment done to determine injuries, and was the medical treatment timely and appropriate?

It is important to identify when the abuse occurred, as sometimes patients will arrive at a new facility having already been neglected. Conditions such as malnutrition, dehydration, and pressure ulcers may have already developed at a previous facility or in the care of family, and despite all efforts, the facility in question could do nothing to prevent further decay or to reverse the condition. All elder abuse cases are different, but with a clear understanding of the guidelines for practice and the common indicators of abuse, you will have the foundation for building any case.

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