investigation of abuse: use of science, technology and law in detection and resolution laura...
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Investigation of Abuse:Investigation of Abuse:Use of Science, Technology and Use of Science, Technology and Law in Detection and ResolutionLaw in Detection and Resolution
Laura Mosqueda, M.D.Laura Mosqueda, M.D.Director of GeriatricsDirector of Geriatrics
Professor of Family MedicineProfessor of Family MedicineUniversity of California, Irvine School of MedicineUniversity of California, Irvine School of Medicine
Normal & Common ChangesNormal & Common Changes
• Musculoskeletal– sarcopenia– osteopenia/osteoporosis
• Cardiovascular– orthostatic hypotension– peripheral vascular disease
• Function– gait/falls– ADLs
Normal & Common ChangesNormal & Common Changes
• Integument– thinner epidermis– capillary fragility
• Renal – decrease in creatinine clearance
• Sensory system– presbycussis– slower reaction time– macular degeneration, cataracts
Injury Assessment:Injury Assessment:The Challenge in EldersThe Challenge in Elders
• Normal changes of aging
• Medication effects
• Multiple co-morbidities
• Cognitive impairment
Are there ways to improve Are there ways to improve what we are doing through what we are doing through collaborative efforts?collaborative efforts?
O.C. V.A.S.T.O.C. V.A.S.T.O.C. Vulnerable Adult Specialist TeamO.C. Vulnerable Adult Specialist Team
• Integrates geriatricians and psychologists into the “system”
• Consultation: APS, law enforcement, district attorney
• Original funding: Archstone Foundation
• Current funding: Orange County
O.C. VASTO.C. VAST
• Case presentations at weekly team meetings
• Telephone and email consultations
• Record review (written, photographs, videotapes)
• Examinations (cognitive and/or physical) in appropriate location
Team Home VisitTeam Home Visit
• Living conditions – Physical environment– Emotional environment– Social environment
• Functional capacity
• Caregiver/family dynamics
• Mental status exam
• Limited physical exam
Outgrowths of VASTOutgrowths of VAST• Research: bruising, capacity, dementia • Pocket Doc• Publications in medical journals• Interest in reproducing VAST • Elder Abuse training institute• Orange County Coalition for the Prevention of
Elder Abuse• Orange County Elder Death Review Team• Forensic Center
Orange County Elder Abuse Orange County Elder Abuse Forensic CenterForensic Center
• The Need: coordinated effort among many agencies that deal with criminal justice aspects of mistreatment
Elder Abuse Forensic Elder Abuse Forensic CenterCenter
Elder Abuse Forensic CenterElder Abuse Forensic Center
A collaboration between 9 agencies:Program in Geriatrics, UCI School of MedicineAdult Protective ServicesDistrict Attorney’s OfficeSheriffPublic Administrator/Public GuardianHuman Options (domestic violence experts)Community Service ProgramsLong-Term Care OmbudsmanHCA Older Adult Services (county mental health
agency)
Elder Abuse Forensic CenterElder Abuse Forensic CenterMission StatementMission Statement
Identify and promote the appropriate legal remedies for vulnerable adult mistreatment through collaborative evaluation, research, education, and consultation
The Hard Part About The Hard Part About CollaborationCollaboration
• May take more time, especially in early
phase
• Always takes more effort
• Frustration with the other party
• Cultural differences
Cultural DifferencesCultural Differences
• Victim Advocate has victims
• Adult Protective Services have clients
• Regional Center has consumers
• Geriatricians/Psychologists have patients
• Law Enforcement has suspects
• District Attorney has defendants
Benefits of CollaborationBenefits of Collaboration
• Communication/inclusion– Team approach
– Creative solutions
• Time efficiency
• Improved risk assessment
• Support for each other
• Education
Bruising Study: ObjectiveBruising Study: Objective
To summarize the occurrence, progression, and To summarize the occurrence, progression, and resolution of accidentally acquired bruises in a resolution of accidentally acquired bruises in a sample of adults aged 65 and older. sample of adults aged 65 and older.
Our Hope: The systematic documentation of accidentally occurring bruises in older adults will provide a foundation for comparison when considering suspicious bruising in older adults.
Study ProcedureStudy Procedure
A subject was enrolled in the study if they
developed a bruise during a two week period
of daily observation.
If a new bruise appeared, we knew that it had
occurred during the prior 24 hours.
The bruise was then documented everyday until resolution or up
till 6 weeks.
Bruises present at the first visit were documented and not included in the
study.
Location of BruisesLocation of Bruises
(108 bruises at Day 1)
Progression of color
Day Number
54
51
48
45
42
39
36
33
30
27
24
21
18
15
12
9
6
3
0
Su
m300
200
100
0
Red
Purple
Blue
Yellow
Black
Green
Summary of ResultsSummary of Results
Nearly 90% of the bruises were on the extremities.
There were no bruises on the neck, ears, genitalia, buttocks, or soles of the feet.
Subjects were more likely to know the cause of the bruise if the bruise was on the trunk.
Contrary to the common perception that yellow coloration indicates an older bruise, 16 bruises were predominately yellow within the first 24 hours of onset.
Those people on medications known to impact coagulation pathways and those with compromised function were more likely to have multiple bruises.
Abuse of Elders With Dementia: Abuse of Elders With Dementia:
Toward a Model of PredictionToward a Model of Prediction
UC Irvine Program in GeriatricsUC Irvine Program in GeriatricsUC Irvine Institute for Brain Aging and Dementia (IBAD)UC Irvine Institute for Brain Aging and Dementia (IBAD)
Alzheimer’s Association of Orange County (AAOC)Alzheimer’s Association of Orange County (AAOC)County of Orange, Adult Protective Services (APS)County of Orange, Adult Protective Services (APS)
Research DesignResearch Design
• Pilot, cross-sectional study• Goal is development and testing of a model for
assessing risk factors associated with mistreatment of elders with dementia
• Two cohorts being recruited:– UCI ARCC/ADRC-based– AAOC community-based
• Home visit methodology• Future goal – longitudinal study
Flowchart of The System
It is time for people who work in It is time for people who work in the fields of Science, the fields of Science, Technology, and Law to Technology, and Law to wake wake up and take this seriouslyup and take this seriously..
Common QuestionsCommon Questions
• How long did it take for that pressure sore to develop?
• She has dementia: can we trust anything she tells us?
• His daughter told us “I was doing the best I could”; why should we prosecute her?
• Has this crossed the line from poor care to criminal neglect?
• Isn’t this inevitable when you’re old?
