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Year : 2021  |  Volume : 24  |  Issue : 4  |  Page : 178-184

Hospitalization and discharge against medical advice underpinned by elder mistreatment

1 Department of Medicine, University of Benin Teaching Hospital; Department of Medicine, College of Medical Sciences, University of Benin, Benin City, Nigeria
2 Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria

Date of Submission08-Mar-2017
Date of Decision11-May-2017
Date of Acceptance06-Jun-2017
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Obehi Aituaje Akoria
Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria and Department of Medicine, College of Medical Sciences, University of Benin, Benin City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/smj.smj_16_17

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This clinical vignette is that of an 82-year-old woman who was admitted into a geriatrics unit in Nigeria, with acute heart failure and multiple decubitus ulcers. She was subsequently discharged against medical advice after 27 days on account of financial constraints and her children's inability to achieve a unified front for her care provision. The clinical scenario illustrates that medical presentation of disease may be a manifestation of elder mistreatment. It also highlights how discharge against medical advice may be the culmination of mistreatment of hospitalized older adults. We review the literature on types and important features of elder mistreatment and how it may be diagnosed in clinical settings. We also discuss challenges that clinicians in Nigeria may face in diagnosing and managing elder mistreatment as a result of a dearth of training in geriatrics and the absence of a national framework to tackle elder mistreatment.

Keywords: Agism, discharge against medical advice, elder mistreatment, geriatrics, Nigeria

How to cite this article:
Akoria OA, Edeki IR, Dawodu EA. Hospitalization and discharge against medical advice underpinned by elder mistreatment. Sahel Med J 2021;24:178-84

How to cite this URL:
Akoria OA, Edeki IR, Dawodu EA. Hospitalization and discharge against medical advice underpinned by elder mistreatment. Sahel Med J [serial online] 2021 [cited 2022 May 22];24:178-84. Available from: https://www.smjonline.org/text.asp?2021/24/4/178/337487

  Introduction Top

Elder mistreatment has been described as “a serious public health challenge for the 21st century.”[1] The definition of who is an “elder” or “older adult” is largely contextual. In some countries, for example, Australia, an elder is statutorily someone aged 70 years or older because this is the age at which pension and aged care services can be accessed.[2] “Older” adult for the Aborigines and people of the Torres Strait Islands is 45-50 years of age because of the lower life expectancy. The United Nations' cut off for older adult is 60 years.[3]

Elder abuse has been described as “any action, single, or repeated that causes harm or creates serious risk of harm to a vulnerable elder by a caregiver or trusted individual.”[4] When a caregiver fails “to satisfy basic needs for survival” or when action that is needed to “protect the elder from harm”[4] is not taken, this constitutes elder abuse.[4],[5] Acts of omission are categorized as neglect, whereas acts of commission are categorized as abuse.[6] Elder mistreatment may be intentional or unintentional and may be perpetrated by a caregiver or self. In a systematic review of 4, 627 older adults, the older black men were 3 times as likely as the white men to experience self-neglect.[7]

The prevalence of elder mistreatment varies between countries and between types of mistreatment.[2] There are also gender disparities in prevalence, with older females more likely to be abused than males. In the 1970s, when elder mistreatment was first recognized, it was described as “granny battering.”[8] Synonyms for this social and societal ill are elder maltreatment, elder abuse, battered elder syndrome, granny bashing, old age abuse, and granny abuse.[6],[9]

Physical abuse refers to situations in which older persons are intentionally subjected to bruising, force feeding, pinching, pushing, shoving, and slappings.[8] Incorrect positioning and inappropriate use of physical or pharmacological restraints also constitute physical abuse. Verbal or nonverbal activities which cause agony, mental stress, or pain to an older person constitute psychological (or emotional) abuse.[8] Infantilizing (i.e., treating an older adult like a child) and bullying are examples of psychological abuse.[8] Financial or material mistreatment refers to acts against older persons that deny them access to their legitimate funds or putting older persons' financial or other personal resources to use not approved by them.[6] Sexual exposure or sexual contact that occurs without an older person's consent constitutes sexual abuse. Ignoring or failing to accord an older person the right to make personal decisions constitutes a violation of their personal rights and demonstrates disrespect for the older person's autonomy and dignity. Medical neglect of older persons manifests in treatment of symptoms without appropriate evaluation or referral. These are often brushed aside as being due to “old age.” It also manifests in “objectification” of older persons, i.e. treating them as objects, e.g. of disease, rather than full-fledged human beings.[10]

Perpetrators of elder mistreatment may be family members or other caregivers working in formal or informal settings.[6] No ethnicity, culture, or race is spared in this global public health and human rights challenge.[11],[12] The scale of the problem is expected to increase as the numbers of persons who survive into older adult life increase.[13] Older persons living in rural and urban communities in Southwest Nigeria identified disrespect, name calling, and lack of recognition as some of the injustices or unfair treatment meted to them. Their adult children were also identified as the main perpetrators of mistreatment.[14]

Within Nigeria, the perception of what constitutes elder mistreatment varies from one part of the country to another.[15] We have no national data about the prevalence of elder mistreatment, and studies from different parts of the country have reported different prevalence rates. Curiously, overall prevalence of elder mistreatment is higher in Egypt (43.7%) and Nigeria (30%) than in countries with similar economies such as India (21%), Iran (14.7%), and Thailand (14.6%).[8] The variability of reported prevalence rates of elder mistreatment between different studies has been attributed to differences in the definition of mistreatment and in the validity of instruments used.

We report a presentation of elder mistreatment which occurred in our geriatrics unit. Our goal is to enable a discussion of the dimensions of elder mistreatment and to highlight some of the challenges that clinicians who care for mistreated older adults in Nigeria may face. In this paper, we will use the term “elder mistreatment” for actions or inactions that cause harm or have the potential to do so, which are attributable to anyone in caregiving or trusting relationships with older persons.

  Case Report Top

An 82-year-old woman was admitted into our geriatrics unit for treatment of acute heart failure secondary to hypertensive heart disease, in New York Heart Association Class III. There was also sepsis, with bronchopneumonia. The patient had been diagnosed with hypertension four years before this presentation but had not been adherent to her prescribed medications. She had multiple decubitus ulcers at the time of admission.

Baseline geriatric assessment at admission revealed a mini nutritional assessment score of 2/14, which indicated that she was malnourished.[16] Her Modified Barthel Index Score was 3/20 (she was functionally dependent)[17] and the Braden score was 10, which placed her at high risk for developing more pressure ulcers.[18] Using the Confusion Assessment Method for delirium screening, she was not delirious.[19],[20]

A widow with eight children, she was a retired farmer with no health insurance, so all payments for all her healthcare were made out of pocket by her children. There were challenges with meeting the financial demands of her hospitalization throughout the period of her stay. An initial request for discharge was made by one of her children on the 4th day of hospitalization on account of financial constraints. With counseling, however, he consented to his mother's continued in-hospital care.

As a unit that encourages family presence with active participation of significant others (e.g. spouses, children, and other designated caregivers) in patient care, the absence of this patient's children during the period of hospitalization was a concern. When they visited, there were often family conflicts which played out with the children quarreling in the patient's presence. There were also extended periods when the patient did not receive some of her medications (e.g., antibiotics) because they had not been purchased.

After about 2 weeks on admission, the patient became withdrawn and refused meals. The Short Geriatric Depression Scale was administered and she scored 10/15 suggesting depression.[21] This necessitated a consult to Mental Health physicians. After a total of 27 days on admission, the patient was discharged against medical advice by one of her children. On the discharge day, there was a physical combat between siblings, during which the patient was called names by one of them, who pointed menacingly at her and would have hit her but for intervention of the geriatrics unit staff.

The findings on assessment of this patient using the Elder Assessment Instrument[22] are depicted in [Table 1], [Table 2], [Table 3], [Table 4]. Clothing was poor; nutrition and skin integrity were very poor [Table 1]. There was no evidence of physical abuse [Table 1]. Depression was probable, going by her score on the Geriatric Depression Scale. The patient had not received medications as prescribed and there was evidence of delay in responding to signs of disease [Table 2]. Discharge against medical advice (DAMA) was evidence that care had been withdrawn precipitously. The assessment summary is depicted in [Table 4], which indicates that there was definite evidence of abuse and neglect and probable evidence of abandonment in this patient. Objective assessment for elder mistreatment was done on the last day of patient's hospitalization, thus some of the findings [e.g., good hygiene in [Table 1]] reflect improvements that had occurred in the course of in-hospital care. Important tell-tale signs of elder mistreatment are illustrated in [Table 5].
Table 1: Findings in the 82-year-old patient using the Elder Assessment Instrument[22]: General assessment and possible abuse indicators

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Table 2: Findings in the 82-year-old patient using the Elder Assessment Instrument[22]: Possible neglect indicators

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Table 3: Findings in the 82-year-old patient using the Elder Assessment Instrument[22]: Possible exploitation and abandonment indicators

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Table 4: Findings in the 82-year-old patient using the elder assessment instrument[22]: Summary of evidence

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Table 5: Physical signs of elder mistreatment

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  Discussion Top

We have presented one example of several similar clinical scenarios which we frequently encounter. In traditional medical practice, the focus is usually on medical diagnoses and treatment, and elder mistreatment which may underlie disease manifestation is hardly, if ever, diagnosed.

In societies such as Nigeria, where respect for elders is a central tenet in the culture,[8] older persons are (or used to be) seen as repositories of wisdom who command respect and admiration.[8] There may thus be an assumption among some that older persons are unlikely to be victims of mistreatment. Unfortunately, this is not always the case. Marginalization of older persons has been identified as one of the downsides of westernization.[10] Discussions on elder mistreatment are considered taboo in Nigeria, and the subject is yet to receive national attention.[15] Many erroneously assert that extended family ties shield older adults from mistreatment whereas the reality today is that children and relatives of older persons are largely unable to fulfill their filial obligations because of pervasive poverty, urbanization, and migration.

It could be disheartening for a managing physician when a patient or her/his legal guardian opts for DAMA.[23] Even more disheartening is a situation where there is evidence of elder mistreatment and the managing physician is handicapped in terms of recourses to protect the older person from further harm. Poor medication adherence and the presence of decubitus ulcers were pointers to elder mistreatment in the clinical vignette reported here. The request for DAMA 4 days into the patient's hospitalization was another “red flag,” especially because it was not at the patient's instance. In many developed countries, there are state policies and services for handling elder mistreatment. We do not have these in Nigeria.

Elder mistreatment is usually not a one-off event. Older adults who suffer mistreatment are likely to be chronically exposed to one or more forms of mistreatment.[24] We were concerned about the blatant neglect and abuses meted to the patient in this report and we could reasonably guess that she might get even worse treatment after her precipitous discharge from hospital, but we were handicapped. There is no policy or legislation in Nigeria upon which we could have leveraged any intervention to mitigate the negative outcomes of mistreatment in this patient.

In situations of DAMA, there is often a conflict between the ethical principles of beneficence – the physician doing what he or she thinks is the best for the patient and that of autonomy – patients or their legal proxies exercising their right to choose what they consider best for themselves. An older person with no personal income or health insurance may be vulnerable to mistreatment. The elderly woman in focus had no say in the decision to DAMA. This was an infringement on her rights as a human being and itself constitutes mistreatment.

Elder mistreatment has been explained using different models, for example, the vulnerability and risk model.[25] Vulnerability factors apply to the older person who is at the receiving end of care and include dementia and functional impairment (among others) while risk factors relate to persons who provide care and include alcohol abuse, burden of care, and burn out.[25] Elder mistreatment has also been strongly linked with caregiver stress and burden, with the likelihood of mistreatment being higher in situations where there is dependency and increasing demands of caregiving. Proponents of the family caregiving dynamics model hold the view that caregiver burden and elder mistreatment are driven by the caregiver's perceptions of the older adult's history and behaviors.[26]

It is important to note that elder mistreatment does not occur only in situations of dependency on the part of the older person. An adult child who depends on a parent, for example, for accommodation, financial support, and other needs may become abusive or mete out other forms of mistreatment as a means of addressing her/his perceived dependency and the relational power imbalances. This is the family-power-dependent relationships model for explaining elder mistreatment.[26] Family conflict, quality of previous relationships, and past abuse are some relationship factors that have been associated with elder mistreatment.[25] Individual and social values that do not accord older adults their due human rights also foster mistreatment. So do social norms that relegate female gender to certain roles.[2]

Several studies have reported associations between income, occupation, accommodation type, and the risk of mistreatment in developed countries. Low-income earners, persons with “blue collar” jobs, and persons living in rented accommodation are more likely to be mistreated than others.[27] Elder mistreatment was also found to be more prevalent in women in separated relationships, women who had ever been in abusive relationships, and those who had need for multiple visits to specialists.[1]

Societal or cultural abuse has been described in Nigeria.[15] This refers to a situation in which an older person is ostracized, stigmatized, punished, and/or labeled as a “witch” because of physical attributes such as frailty, a stooped posture, and/or the use of a stick as a walking aid.[15] Females are more at risk of this form of mistreatment. Some have been beaten to death in parts of Nigeria, as a result of this societal perception of older women.[14],[15] Mistreatment of older persons in Nigeria, who queue for days, weeks, sometimes months, in the hope of receiving their government pensions has been described as “structural abuse.”[15] Older persons also suffer mistreatment in conflict situations because their needs are not prioritized.[15]

The assessment instrument that was used in this case report is one of the most recently developed tools for assessing elder mistreatment.[11] Its strengths include rapidity of use: the 41-item checklist can be completed in 15 min in clinical settings.[11] It also covers multiple domains in elder mistreatment such as abuse and neglect.[11] However, the section on abuse focuses on physical and sexual abuse and does not include psychological (emotional) abuse, which was evident in the situation of the 82-year-old woman reported here.

Elder mistreatment always occurs in caregiving relationships in which there is some trust. “Domestic violence against women” is a broader concept which could occur in or outside caregiving relationships.[28] Detection of elder mistreatment may be difficult because of denial by victims, which may be underpinned by fear of reprisal. The woman in this clinical vignette was in a caregiving relationship with the identified perpetrators of her mistreatment – her own adult children. An older adult from one culture may view as “normal” what may be understood as abuse in a different culture.[29] Reporting practices are also driven by ethnic and cultural perspectives about elder mistreatment.[29]

Elder mistreatment can lead to physical and emotional pain, injury, and increased risk of depression and other illnesses. It also increases the risk of hospitalization and death.[2],[30] A nationally representative study of young, middle-aged, and older women in Australia, who were followed prospectively for 12 years demonstrated that elder mistreatment predicted disability and mortality.[2] Elder mistreatment is significantly associated with reduced lifespans, after adjusting for other causes of mortality.[2]

Treated differently, the 82-year-old woman presented in this report may have received her prescribed medications and other care, and she may not have developed overt heart failure and decubitus ulcers. She may also have got a chance to receive in-hospital care for the required duration, and she may have recovered.

Elder mistreatment is fundamentally linked to agism. Understanding the reality of elder mistreatment means that no one can take it for granted that they will be protected against mistreatment in their old age.[31] Agism has been described as “systematic discrimination” against older persons, “viewing them as senile, a burden, useless, and invisible.”[10] Agism can occur at individual, institutional, and societal levels. Manifestations of agism in healthcare include the reluctance of health-care staff to work with older adults and poor rating – in terms of prestige – of health-care personnel who choose careers with older persons.[10] Agism in healthcare also manifests in paternalistic behaviors toward older adults, failure to refer elderly persons for appropriate specialist care, and the equation of older age with “senility.”[10] Agism may also underlie the negative connotations associated with the term “geriatric.”

Elder mistreatment cannot be tackled without tackling agism and agist tendencies with health-care professionals and the larger society.[11] Professional work with older persons should be guided by the United Nations Principles for Older Persons,[32] which include affording older people care, dignity, independence, participation, and self-fulfillment.[32]

Health-care staff should be encouraged to engage in self-reflection on their work with older persons. Thinking through how we have approached our work and reminding ourselves that we too could be victims of mistreatment could be sobering and may change some of our implicit agist tendencies.[10] Working in multidisciplinary teams (a core value in geriatrics) can reduce institutional neglect which is often driven by agism.[10]

Studies undertaken to explore the perspectives of health professionals about elder mistreatment indicate that there is need for education and reeducation to achieve the knowledge and attitude changes that will be required to prevent and manage elder mistreatment. Physicians need to be trained to interview patients and their caregivers in ways that can identify elder mistreatment. Training is also required to enable physicians distinguish signs of elder mistreatment from signs of aging-related and psychiatric diseases with which there could be overlaps.[33] Health-care professionals in Nigeria are pivotally placed to identify and manage this covert public health scourge, in spite of our current limitations. The mistreated older adult may have no other contact with the outside world except with a health-care professional, during visits to the emergency room, outpatient clinic, or during episodes of hospitalization.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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