An 80-year-old woman comes to the office accompanied by her nephew, who helps take care of her. The patient lives alone and rarely leaves the house. She has a history of hypertension, osteoporosis, type 2 diabetes mellitus, and cognitive impairment (Mini-Mental Status Exam score of 23 out of 30) . She received treatment for a spiral fracture of the humerus a year ago. The patient performs most of her activities of daily living unassisted but needs help with cooking, cleaning, and shopping. She reports no new problems today. Medications include metoprolol, hydrochlorothiazide, glipizide, calcium, and vitamin D.
On examination, she is quiet and appears frail. Blood pressure is 170/94 mm Hg and pulse is 90/min. BMI is 18 kg/m². There is a 2×4 cm, Stage 2 pressure ulcer in her presacral area. Fingerstick blood glucose level is 250 mg/dL.
On further questioning, the patient states that she is now unable to pay for her prescription refills.
Which of the following is the most appropriate course of action?

Question

Quizplus · Accepted Answer

11ec193a_9944_e79e_853d_e9d05d81507f_MD0002_00 Elder abuse is common and often goes unrecognized. This patient has many risk factors for elder abuse, including female gender, advanced age, social isolation, and cognitive impairment. There are several red flags that strongly suggest the possibility of elder abuse in this patient, including a spiral fracture of a long bone, a change in ability to pay (possible financial exploitation), malnutrition, and signs of neglect (pressure ulcer). Although all patients with suspected abuse should be interviewed alone and asked directly about abuse, many elders are either cognitively impaired and/or reluctant to report abuse. Given the history and signs of neglect on physical examination, assuring this patient's safety is the priority and a formal evaluation by experienced personnel is urgently needed. Contacting adult protective services directly to report this patient's circumstances and the possibility of abuse is appropriate and, in many states, mandated. An experienced senior's social worker could facilitate information-gathering and make the necessary contacts and arrangements. The site and extent of safe and supportive care for this patient will need to be determined based on further evaluation, comprehensive geriatric assessment, and availability of resources. (Choices A, B, C, and D) These interventions may be appropriate depending on the outcome of further evaluation by adult protective services. Reporting the suspected abuse takes priority. Educational objective: Unexplained traumatic injuries, signs of neglect (eg, pressure ulcers), and abrupt changes in financial status or ability to pay are red flags for elder abuse. When elder abuse is suspected, adult protective services should be contacted immediately. __________ References: Elder abuse: systematic review and implications for practice. (http://www.ncbi.nlm.nih.gov/pubmed/26096395) Elder abuse. (http://www.ncbi.nlm.nih.gov/pubmed/26559573) Understanding the medical markers of elder abuse and neglect: physical examination findings. (http://www.ncbi.nlm.nih.gov/pubmed/25439636)

An 80-Year-Old Woman Comes to the Office Accompanied by Her