OASIS Alert

Most elder abuse takes place at home -- not in nursing homes.

Add a Sherlock Holmes deerstalker cap to the hats you already wear in your role as assessing clinician. The answers to the OASIS questions may point to possible elder abuse and neglect.

Besides the obvious human suffering, abuse or neglect can keep your patient from following the plan of care, achieving the expected outcomes and being cared for successfully at home.

Patients needing home care are often vulnerable to mistreatment by their caregivers and family members. The count of older persons abused, neglected or exploited reaches hundreds of thousands each year -- two-thirds of them by family members -- according to the Depart-ment of Health & Human Services' Admin-istration on Aging. Clinicians providing home care have the best opportunity to assess both the patient and the home environment.

Reality: This is a complex problem that most often occurs at home, not in nursing homes, warns the American Psychological Association. And for every reported case, there are probably five that are not reported, the APA predicts.

Your comprehensive assessment, in-cluding the OASIS questions, addresses many aspects of a patient's physical and emotional condition that offer a glimpse into the patient's life when the clinician is not there. For example, M0560 (Cognitive functioning) checks the patient's ability to follow commands and looks for disorientation and delirium. M0610 (Be-haviors demonstrated at least once a week) and M0620 (Frequency of behavior problems reported or observed) can uncover a patient's physical or verbal aggression, socially inappropriate behavior and other problems that may be stressing the caregiver.

Warning: Risk of abuse and neglect increase when the patient is physically aggressive, refuses to eat or take medicine, is noisy, invades the caregiver's privacy, exhibits disruptive behavior or embarrassing public displays or has what the caregiver considers "vulgar habits," reports the National Center on Elder Abuse (NCEA) in Washington, DC.

Another use for M0610: Besides looking at stresses on the caregiver, M0610 can detect signs of abuse in patients, such as impaired decision-making. M0580 (When anxious) helps you evaluate the level of anxiety and M0590 (Depressive feelings reported or ob-served) addresses the patient's mood. These are important clues to abuse and neglect.

"A person who is being neglected or abused may show increasing indicators of cognitive problems, including daily decision-making, mood and anxiety," says Gail Robison, a registered nurse and consultant with Boyer and Associates in Brookfield, WI.

Look at M0370 (How often does the pa-tient receive assistance from the primary caregiver?) and M0380 (Type of primary caregiver assistance) to determine the amount and type of assistance the patient requires. The more basic the assistance and the more frequently the patient needs help, the more stressed the caregiver is likely to be, experts say.

Heads up: If the patient needs assistance with eating and you see significant weight loss, there could be "some measure of neglect" or the caregiver may "lack knowledge about how best to provide feeding assistance," says Barbara Bates-Jensen, a nursing professor at the UCLA School of Nursing and School of Medicine and the VA GLA Geriatric Research Education Clinical Center.

Answering "yes" on M0445 (Pressure ulcer) should trigger an evaluation of possible causes of this problem, experts agree. Remem-ber that one cause can be caregiver neglect of the patient's medical needs and hygiene, the NCEA points out on its Web site.

M0440 (Does this patient have a skin lesion or open wound?) may seem like a frustratingly inclusive question. As defined by the Centers for Medicare & Medicaid Services, almost everyone has some kind of skin lesion. But if you note bruises or skin tears, you need to look further.

Obvious causes: "Someone taking Coumadin is more likely to bruise with minimal trauma," Bates-Jensen says. Elevated prothrombin times or chemotherapy-induced anemia can also increase chances of bruising, she adds.

Dialysis patients have more fragile skin and are more likely to get skin tears and bruising, Robinson notes. And osteoporosis can result in unexplained fractures. "Twisting motions, such as pivoting in a transfer, can cause fractures in severely osteoporotic individuals," says St. Louis, MO-based physician Charles Crecelius.

Don't stop there: Look closely for a pattern of fractures that may indicate rough handling or abuse, Robison says. Look at abrasions, bruises, burns and skin tears, she advises. Skin tears do occur in someone with fragile skin. But if skin tears suddenly pop up on an assessment -- or if there's an erratic pattern where they are noted on one assessment but not others -- take a closer look. It could be an assessment accuracy issue or it could be due to abuse or rough handling, she suggests.

Note: The NCEA site contains extensive resources about elder abuse at http://www.ncea.aoa.gov. The APA report Elder Abuse and Neglect: In Search of Solutions, at http://www.apa.org/pi/aging/eldabuse.html, contains a list of signs to look for and case examples. To locate help in your state, call 1-800-677-1116.