Vai trò của các bác sĩ phẫu thuật chỉnh hình docx

Vol 10, No 1, January/February 2002 25 Elder abuse is a pervasive social and medical problem that is suspected to be a major source of morbidity and mortality. In recent years, the num- ber of reports of elder abuse has risen as a result of greater family involvement in caregiving relation- ships with the elderly as well as the increase in the number of elderly persons with chronic debilitating diseases. 1 Because of the increasing public outcry about the widespread public health problem of elder abuse, all states now have abuse laws that are specific for older adults, and most states mandate reporting of elder abuse by health- care professionals. However, physi- cians infrequently report elder abuse for a number of reasons, among them lack of familiarity with the reporting laws, fear of offending pa- tients or infringing on the autonomy of competent individuals, concerns about time limitations and paper- work, or the belief that they do not have the appropriate evaluation skills. 2 Approximately 2.5 million cases of elder abuse are reported annual- ly, and as the population grows, this number will likely increase. As this number represents only reported cases, it is undoubtedly an underes- timation of the actual incidence. 3 A recent investigation reported the results of the first nationwide inci- dence study of abuse and neglect in noninstitutionalized elderly per- sons, estimating that 1% to 2% of older persons living in their homes are abused physically, emotionally, sexually, and/or financially, and that as many as five times more incidents go unreported. 4 The exact magnitude of the problem is not easily quantifiable, although the most frequently cited estimate of community prevalence of elder abuse is 32 cases per 1,000 persons. 3 Dr. Chen is Resident, Department of Ortho- paedic Surgery, New York University–Hospital for Joint Diseases Orthopaedic Institute, New York, NY. Dr. Koval is Associate Professor and Chief, Fracture Service, Department of Orthopaedic Surgery, New York University– Hospital for Joint Diseases Orthopaedic Institute. Reprint requests: Dr. Koval, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17th Street, New York, NY 10003. Copyright 2002 by the American Academy of Orthopaedic Surgeons. Abstract Increased awareness of elder abuse has led to the recognition that mistreatment of individuals over the age of 65 years is a widespread public health problem. It is estimated that the prevalence of elder abuse is 32 cases per 1,000 persons and is increasing with the growing elderly population. Elder abuse is suspected to be a major source of morbidity and mortality, representing a high economic burden to society. The diagnosis of elder abuse is seldom straightforward due to social issues, cognitive impairment, and comorbid conditions, and requires careful cor- relation of historical and clinical findings. Comprehensive evaluation, including a detailed history, systematic physical examination, and appropriate laboratory and radiographic assessment, is essential. The orthopaedic surgeon consulted to evaluate an elderly individual with musculoskeletal injuries must be cognizant of the potential for elder abuse, especially when circumstances are suspect. The role of the orthopaedic surgeon is often fundamental to establishing whether musculoskeletal injuries are consistent with the stated mechanism of injury. Due to the variety of presentations, there are no fracture patterns considered pathognomonic of elder abuse. Rather, the nature and pattern of injury must be viewed in the context of the general health and psychosocial environment of the patient to determine whether abuse has occurred. Once the diagnosis of elder abuse has been made, a comprehensive, multidisciplinary long-term care plan must be formulated to ensure patient safety while respecting the autonomy of a competent individual. Physicians have an ethical and legal responsibility to pro- tect patients from suspected abuse, and most states mandate reporting by health- care personnel. J Am Acad Orthop Surg 2002;10:25-31 Elder Abuse: The Role of the Orthopaedic Surgeon in Diagnosis and Management Andrew L. Chen, MD, MS, and Kenneth J. Koval, MD The difficulty of collecting more accurate statistics is likely related to underrecognition or denial of abuse by community members and health professionals. This is compounded by a poor understanding of the signs and symptoms associated with elder abuse, which may be mistaken for age-related changes or signs of dis- ease. 5 Elderly persons may be reluc- tant to report abuse because of fear of family embarrassment, fear of iso- lation from caregivers, or stoicism. 6 Furthermore, negative stereotyping of the elderly and age-related dis- crimination may result in the unjus- tified labeling of elderly persons as demented, thus diminishing the credibility of abuse reports. Definition of Abuse The precise definition varies by state agency, but in general the term “elder abuse” refers to the in- fliction of physical pain, injury, mental anguish, or deprivation by a caretaker who performs services necessary for the physical and men- tal well-being of an individual over the age of 65 years. Elder mistreat- ment may occur as a result of abu- sive behavior, in which purposeful acts of harm or injury are inflicted by the abuser, or neglectful behav- ior, in which attention to specific needs is withheld or delayed. Ac- tive neglect occurs when the re- sponsible party is cognizant of his or her neglectful actions. Passive neglect implies a lack of awareness of the mistreatment and what spe- cific needs are not being met. 5 For example, the intentional withhold- ing of necessary medications from an elderly individual constitutes active neglect, but unintentional failure to provide adequate nutri- tion to an elderly individual may constitute passive neglect. Abuse extends to any violation of the individual’s sphere of well-being and includes physical, psychologi- cal, financial, and material forms. Physical abuse refers to any unwanted physical contact, including the inflic- tion of bodily injury, physical pain, or unsolicited sexual contact. Psy- chological abuse refers to the inflic- tion of mental or emotional anguish. Financial or material abuse involves the exploitation of an individual for financial or material gain. 7 Abuse that occurs in a medical, long-term care, or board-and-care facility is referred to as “institutional abuse.” Although a minority of physicians provide care in that set- ting, patients living in such facilities may be encountered in outpatient offices, inpatient facilities, or emer- gency settings, thus providing op- portunities for physicians to recog- nize sequelae of abuse. Abuse in the institutional setting may be perpe- trated by visitors, other residents of the institution, or members of the staff. In a random-sample survey of nursing home staff members, 10% of nurses’ aides reported that they had committed at least one act of physi- cal abuse in the preceding year, and 40% reported at least one act of psy- chological abuse. 8 Institutional abuse may also include unreason- able restraint, isolation from other re- sidents, failure to respect the wishes of a competent individual, and fail- ure to devise or implement a goal- oriented extended-care plan. 9 Risk Factors for Abuse Approximately 1% to 2% of elderly persons living in their own homes are abused. 10 The term “victim char- acteristics” refers to a constellation of psychosocial traits, conditions, and behaviors that may increase the risk of abuse. These include dementia, poor physical and emotional health, disruptive or aggressive behavior, social dysfunction, and prior vio- lence or abusive acts by the victim toward the abuser. 11 Other risk fac- tors are listed in Table 1. Gender has not been identified as an indepen- dent risk factor. Pooled logistic regression analysis has identified increasing age, race, poverty, func- tional disability, and cognitive im- pairment as additional risk factors for elder mistreatment. 10 A strong association between reported child abuse and reported elder abuse with- in a regional population has been reported, suggesting a correlation between geographic demographics and risk of elder abuse. 12 Abusers are predominantly adult children, spouses, and other rela- tives, and are often financially de- pendent on the abused person. 10 A caregiver history of psychiatric ill- ness, including depression, person- ality disorder, social dysfunction, or alcohol abuse, may increase the risk of elder abuse. The “caregiver stress hypothesis,” which maintains that elder abuse is the result of resent- ment and frustration engendered by the long-term responsibility for care of dependent elders, is controver- sial. 2,9 Stress for the caregiver arises from social isolation, especially when the elderly person needs full- time care; the frustration of dealing with declining health or terminal ill- ness; the possible strain of financial resources; and a lack of understand- ing of the patient’s needs. This may be compounded by the lack of in- volvement of other family members or by a sense of ingratitude. Among institutional caregivers, risk factors for abuse include a history of previ- ous abuse, job dissatisfaction, de- pression, burnout, a tendency to in- fantilize the elderly, and a stressful personal life. History and Clinical Features A detailed history is essential when elder abuse is suspected. The pa- tient, caregiver, and any other rele- vant persons should all be inter- viewed individually. Any conflicting Elder Abuse Journal of the American Academy of Orthopaedic Surgeons 26 information should be noted and investigated. Patients typically are reluctant to discuss the abuses they have received because of a fear of reprisal, a sense of being thought ungrateful, or unwillingness to im- plicate a friend or relative. The in- terview must, therefore, be comfort- able and psychologically supportive; an accusatory or probing tone may result in disinclination on the pa- tient’s part to reveal any abuse that has occurred. The interview should be initiated with general questions concerning the patient’s perceptions about his or her own care within the house (or institution) and should progress to more specific questions about feelings of safety, disagreements, delayed meals or medication, and any aggressive behavior or unso- licited contact on the part of anyone toward the patient. Early con- frontation is likely to be counter- productive in terms of disclosure of information; a nonaggressive, im- partial approach that is cognizant of the suspected abuser’s feelings and stresses is more conducive to an effective informational interview. 5 Elderly persons suffer a variety of chronic diseases that can mimic the signs and symptoms of abuse. Dramatic cases of abuse are typically not difficult to diagnose, but subtle or contradictory physical and psy- chological signs and symptoms may require high-level clinical investiga- tion or diagnostic testing. Common physical findings consistent with abuse include bodily injury without reasonable cause or explanation and multiple wound sites in various stages of healing. Evidence of dehy- dration, long-standing malnutrition, poor hygiene, and unmet medical needs are pertinent findings if they are inconsistent with the patient’s standard of living. Finally, with- drawal, refusal to make eye contact, and wariness of contact with the suspected abuser are also warning signs. Other presentations that are suggestive of abuse or neglect are listed in Table 2. Physical Examination When elder abuse is suspected, a de- tailed, systematic, multidisciplinary Andrew L. Chen, MD, MS, and Kenneth J. Koval, MD Vol 10, No 1, January/February 2002 27 Table 1 Risk Factors for Abuse of the Elderly * Risk Factor Mechanism Poor health and functional - Disability reduces the elderly impairment person’s ability to seek help and defend himself or herself. Cognitive impairment Aggression toward the caregiver and disruptive behavior resulting from dementia may precipitate abuse. Higher rates of abuse have been found among patients with dementia. Substance abuse or mental illness on Abusers are likely to abuse alcohol the part of the abuser or drugs and to have serious mental illness, which in turn leads to abusive behavior. Dependence of the abuser on the Abusers are very likely to depend on victim the victim financially, for housing, and in other areas. Abuse results from attempts by a relative (espe- cially an adult child) to obtain resources from the elderly person. Shared living arrangements Abuse is much less likely among elderly people living alone. A shared living situation provides greater opportunities for tension and conflict, which generally pre- cede incidents of abuse. External factors causing stress Stressful life events and continuing financial strain decrease the family’s resistance and increase the likeli- hood of abuse. Social isolation Elderly people with fewer social con- tacts are more likely to be victims. Isolation reduces the likelihood that abuse will be detected and stopped. In addition, social support can buffer the effects of stress. History of violence Particularly among spouses, a history of violence in the relationship may predict abuse in later life. * Reprinted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly persons. N Engl J Med 1995;332:437-443. Copyright 1995 by the Massachusetts Medical Society. All rights reserved. evaluation is required (Table 3). An informal mental status examination should be performed initially, and risk factors for abuse, such as cogni- tive impairment, noted. A compre- hensive physical examination should also be performed, with close atten- tion paid to the interaction of the patient with the suspected abuser. The general appearance of the patient should be noted, including the man- ner in which the patient is dressed and the level of cleanliness. The skin should be scrutinized for evidence of old injuries. The head and scalp should be examined for evidence of trauma, lacerations, or alopecia, which may be suggestive of hair- pulling. The oral cavity and nares should be carefully examined for evi- dence of dental or mucosal injury that may otherwise go unrecognized on an external examination. 13 Frequent manifestations of phy- sical abuse include bruises, sprains, abrasions, lacerations (particularly evidence of old lacerations that healed by secondary intention), head injuries, burns, and unexplained frac- tures. 9 With musculoskeletal inju- ries, the role of the orthopaedist is to determine the age and nature of the injury, whether the injury is associ- ated with other injuries that may be suggestive of abuse, and whether there are other fractures in various stages of healing or healed but mal- aligned. Musculoskeletal injuries must be carefully evaluated, with correlation of soft-tissue and overly- ing skin injuries (e.g., lacerations, contusions, ecchymoses). Cogni- tively impaired patients require examination and palpation of all extremities. The orthopaedist must decide whether the injury is consis- tent with the mechanism of injury, and must remain cognizant of the possibility of an underlying disorder, such as a malignant condition, that may explain a fracture after seem- ingly minor trauma. Diagnostic Evaluation Laboratory tests may be indicated, depending on the index of suspicion of abuse and the results of the physi- cal examination. Laboratory tests should include (1) a complete blood cell count with platelet count; (2) serum electrolyte, blood urea nitro- gen, and serum creatinine levels (to assess dehydration and diabetic control); (3) prothrombin and partial thromboplastin times (to rule out coagulopathy); (4) liver function tests (to identify alcohol abuse and other metabolic problems); (5) serum albu- min level (to assess nutritional sta- tus); (6) thyroid function tests (to rule out hyperthyroidism as a cause of weight loss); and (7) urinalysis (to assess the source of fever). Toxico- logic screening may be used to demonstrate the presence of drugs or other substances that were not pre- scribed for the patient or that were prescribed at a subtherapeutic level. Elder Abuse Journal of the American Academy of Orthopaedic Surgeons 28 Table 2 Presentations That Suggest Abuse or Neglect of an Elderly Patient * Presentation † Example Delays between an injury or illness Lacerations healing by secondary and the seeking of medical atten- intention, radiographic evidence of tion healed but misaligned fractures, presentation in extremis with decompensated chronic disease when caregiver has been monitor- ing patient Disparity in histories from the Different mechanisms of injury patient and the suspected abuser offered, different chronology of or a history that is given solely injuries by the caregiver Implausible or vague explanations Fractures that are not explained by provided by either party the purported mechanisms of injury Frequent visits to the emergency Exacerbations of chronic obstructive room for exacerbations of chronic pulmonary disease or congestive disease despite a plan for medical heart failure due to lack or misad- care and adequate resources ministration of medicines Presentation of a functionally im- Patient with advanced dementia paired patient without his or her who presents to the emergency designated caregiver room alone Laboratory findings that are incon- Subtherapeutic levels of drugs (e.g., sistent with the history provided digoxin) despite compliance reported by caregiver, toxicologic evidence of psychotropic agents that have not been prescribed * Adapted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly persons. N Engl J Med 1995;332:437-443. Copyright 1995 by the Massachusetts Medical Society. All rights reserved. † The indicators of possible abuse or neglect are derived from Jones JS: Geriatric abuse and neglect, in Bosker G, Schwartz GR, Jones JS, Sequeira M (eds): Geriatric Emergency Medicine. St Louis: CV Mosby, 1990, pp 533-542. Andrew L. Chen, MD, MS, and Kenneth J. Koval, MD Vol 10, No 1, January/February 2002 29 Table 3 Clinical Procedures for the Detection of Abuse of an Elderly Patient * Focus Procedure or Item to Be Noted History Interview the patient and the suspected abuser separately and alone. Make direct inquiries about physical violence, restraints, or neglect. Request precise details about nature, frequency, and severity of events. Assess the patient’s functional status (independence, activities of daily living). Inquire who is the designated caregiver if impairment in activities of daily living is present. Assess recent psychosocial factors (e.g., bereavement, financial stress). Elicit caregiver’s understanding of patient’s illness (e.g., care needs, prognosis). Behavioral observation Withdrawal Infantilizing of patient by caregiver Caregiver who insists on providing the history General appearance Hygiene Cleanliness and appropriateness of dress Skin and mucous Skin turgor, other signs of dehydration membranes Multiple skin lesions in various stages of evolution Bruises, decubitus ulcers Evaluate care of skin lesions Head and neck Traumatic alopecia (distinguishable from male-pattern alopecia on the basis of distribution) Scalp hematomas Lacerations, abrasions Trunk Bruises, welts (the shape may suggest an implement, such as an iron or belt) Genitourinary tract Rectal bleeding Vaginal bleeding Decubitus ulcers, infestations Extremities Wrist or ankle lesions suggesting the use of restraints or an immersion burn (stocking-glove distribution) Musculoskeletal system Examine for occult fracture, pain Observe gait Neurologic-psychiatric status Conduct a thorough evaluation to assess focality Depressive symptoms, anxiety Other psychiatric symptoms, including delusions and hallucinations Formal mental-status testing Cognitive impairment suggesting delirium or dementia has a role in assessing decision-making capacity Imaging and laboratory tests As indicated from the clinical evaluation (serum albumin, blood urea nitrogen, and serum creatinine levels, toxicologic screening [assess caregiver’s compliance with medical regimen]) Social and financial resources Inquire about other members of the social network available to assist the elderly person and about financial resources (this information is crucial in considering interventions that include alternative living arrangements and home services) * Adapted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly persons. N Engl J Med 1995;332:437-443. Copyright 1995 by the Massachusetts Medical Society. All rights reserved. Radiographic evaluation should include plain films of the chest, as well as any area in which a suspected injury was noted during the phy- sical examination. If there is evi- dence of fracture, one should assess whether the stated history of injury is consistent with the radiographic picture. The presence of multiple healed fractures, especially if mal- aligned, should raise suspicion of abuse in the absence of a plausible explanation, such as severe osteope- nia. A skeletal survey may be indi- cated if the patient has multiple sites of injury or a severe cognitive impairment and the examiner has a strong suspicion of abuse. The pos- sibility of pathologic fracture (e.g., due to malignancy or osteomalacia) must be ruled out with further eval- uation if the radiographic presen- tation is suggestive of underlying disease. If cognitive problems that are new, unexplained, or correlated with head injury are identified dur- ing mental status testing, computed tomography of the head may be indicated. If a significant weight loss cannot be attributed to stress, drug use, or abuse, a metastatic workup should be initiated. Appro- priate consultation should be sought as dictated by the results of evalu- ation. Differential Diagnosis The presentation of elder abuse is extremely variable. Acute and chronic disease states that may mimic elder abuse include delirium, dementia, clotting disorder (which may be manifested by bruises), depression (malnourishment, poor hygiene, apathy), alcoholism (falls, bruises, malnourishment), anorexia, malignancy (cachexia, malnourish- ment, fractures), and gait disorders (falls). An increased propensity toward fractures may reflect a dis- ruption of normal bone homeosta- sis, such as may occur with osteo- porosis, osteomalacia, renal disor- ders, or a malignant condition. Various reports have demonstrated that prolonged bed rest, malnour- ishment, and lack of exposure to sunlight may result in “sponta- neous” long-bone fractures in the absence of obvious trauma. 14-16 This emphasizes the need for thorough evaluation and consultation, if nec- essary, before interpretation of a case of suspected elder abuse. Management After appropriate treatment of injuries, the safety of the patient must be ensured. This requires a multidisciplinary approach, with coordination between the treating medical personnel and social work- ers. The patient’s autonomy must be respected during this process of establishing a secure environment. Some patients lack decision-making ability, and others will not permit an intervention on their behalf. In either case, if the physician suspects abuse and perceives that the indi- vidual is in continued danger, every alternative must be explored to maximize the safety of the patient, including removal from the care of the suspected abuser or the abusive environment. The reluctance to remove an elderly person from a functional living arrangement, par- ticularly from a family member’s home, must be superseded by the ensured safety of the individual. The physician’s authority to pre- scribe hospitalization can be upheld on the basis of documented injury or continuing medical problems. 17 The wishes of a competent elder- ly individual who refuses to leave a confirmed abusive environment must be respected. Physicians must detail all possible options of inter- vention to maximize acceptance of a positive treatment plan and empha- size to the patient that the current situation can be improved. Every effort must be made to ensure a safe environment while preserving pa- tient autonomy. A court-appointed guardian or conservator may be required for patients without deci- sion-making capacity. A thorough evaluation is necessary to optimize living arrangements to ensure a safe environment. 5 Reporting Requirements The Omnibus Budget Reconciliation Act of 1987 established standards for the quality of nursing home care. The Older Americans Act of 1976 requires that access to nursing home ombudsmen must be provided for residents and that physicians must report elder abuse to the state om- budsman. As a result, most states have laws that require health-care workers to report suspected cases of elder abuse to government or offi- cial state agencies, such as the Department of Adult Protective Ser- vices. Each state, however, has de- veloped its own definition of abuse and neglect as well as mandatory- reporting regulations. According to a recent US Government Account- ing Office study, the interstate vari- ability of abuse definition and re- porting requirements obfuscates meaningful analysis and compari- son of state reporting data, although enhanced public awareness of abuse of the elderly was likely a signifi- cant factor in the disclosure of new elderly abuse cases. 14 In most states, suspicion of elder abuse by the physician is sufficient cause to initiate an information- gathering inquiry without absolute proof. Many states offer immunity and anonymity to physicians who file reports of suspected abuse. If evidence of abuse is established, however, the physician has a moral and legal obligation to ensure the safety of the abused individual and to solicit permission from the pa- Elder Abuse Journal of the American Academy of Orthopaedic Surgeons 30 tient for family or professional inter- vention. Summary Abuse of individuals over the age of 65 years is a widespread public health problem that appears to be increasing with the growing elderly population. Although elder abuse is suspected to be a major source of morbidity and mortality, the diagno- sis of elder abuse is seldom straight- forward. The orthopaedist is fre- quently consulted to manage mus- culoskeletal injuries sustained dur- ing such abuse, and therefore must be cognizant of the potential for elder abuse, especially when circum- stances are suspect. Although there are no fracture patterns considered pathognomonic of elder abuse, the nature and pattern of injury must be considered in the context of the gen- eral health and psychosocial envi- ronment of the patient. Once elder abuse has been established and appropriate treatment rendered, a long-term care plan must be formu- lated to ensure continued patient safety while respecting the autono- my of a competent individual. Andrew L. Chen, MD, MS, and Kenneth J. Koval, MD Vol 10, No 1, January/February 2002 31 References 1. Schiamberg LB, Gans D: Elder abuse by adult children: An applied ecologi- cal framework for understanding con- textual risk factors and the intergener- ational character of quality of life. Int J Aging Hum Dev 2000;50:329-359. 2. Kleinschmidt KC: Elder abuse: A re- view. Ann Emerg Med 1997;30:463-472. 3. Pillemer K, Finkelhor D: The preva- lence of elder abuse: A random sample survey. Gerontologist 1988;28:51-57. 4. Dolan VF: Risk factors for elder abuse. J Insur Med 1999;31:13-20. 5. Koval KJ: Elder abuse. Arch Am Acad Orthop Surg 1998;2:45-51. 6. Otiniano ME, Herrera CR: Abuse of Hispanic elders. Tex Med 1999;95: 68-71. 7. Marshall CE, Benton D, Brazier JM: Elder abuse: Using clinical tools to iden- tify clues of mistreatment. Geriatrics 2000;55:42-44, 47-50, 53. 8. Pillemer K, Moore DW: Abuse of pa- tients in nursing homes: Findings from a survey of staff. Gerontologist 1989;29: 314-320. 9. Lachs MS, Pillemer K: Abuse and ne- glect of elderly persons. N Engl J Med 1995;332:437-443. 10. Lachs MS, Williams C, O’Brien S, Hurst L, Horwitz R: Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. Gerontologist 1997;37:469-474. 11. Anetzberger GJ, Palmisano BR, San- ders M, et al: A model intervention for elder abuse and dementia. Geron- tologist 2000;40:492-497. 12. Jogerst GJ, Dawson JD, Hartz AJ, Ely JW, Schweitzer LA: Community char- acteristics associated with elder abuse. J Am Geriatr Soc 2000;48:513-518. 13. Fenton SJ, Bouquot JE, Unkel JH: Oro- facial considerations for pediatric, adult, and elderly victims of abuse. Emerg Med Clin North Am 2000;18:601-617. 14. Kane RS, Goodwin JS: Spontaneous fractures of the long bones in nursing home patients. Am J Med 1991;90:263-266. 15. Horiuchi T, Igarashi M, Karube S, et al: Spontaneous fractures of the hip in the elderly. Orthopedics 1988;11:1277-1280. 16. Lourie H: Spontaneous osteoporotic fracture of the sacrum: An unrecog- nized syndrome of the elderly. JAMA 1982;248:715-717. 17. Clarke ME, Pierson W: Management of elder abuse in the emergency de- partment. Emerg Med Clin North Am 1999;17:631-644. . medical regimen]) Social and financial resources Inquire about other members of the social network available to assist the elderly person and about financial resources (this information is crucial