Manasvi Khullar and Reema Navalurkar: Elders need more robust protections from abuse and neglect

By Manasvi Khullar and Reema Navalurkar

The chatter of our medical team abruptly quieted as we arrived at the bedside of our new patient, who we’ll call Harold. We were told this 80-year-old had an eye infection, but one glance around the curtain made his eye the least of our concerns. Under the fluorescent lights lay a man so emaciated we could easily make out the grooves of his skull. He was curled into a ball, staring mutely at the ceiling.

Our exam revealed that Harold’s limbs were contracted into the fetal position. He had gruesome pressure injuries along his bottom, suggesting prolonged immobility. His eye infection was so advanced, it had likely been present for days, if not weeks. Once over 6 feet tall, he now weighed 93 pounds.

As physicians, we choose to work at a Level I trauma center serving the region’s most vulnerable adults, but witnessing suffering up close never gets easier. The most difficult cases to stomach are those of abuse.

June is Elder Abuse Awareness Month. We are using Harold’s story to illustrate the need for all of us to be informed and ready to act.

We treated Harold’s dehydration, wounds and eye infection. We learned that he had lived in his Seattle home for decades. Due to lifelong disability, his family had hired caregivers to help with daily chores. His closest family was a nephew in Wyoming. Six months ago, his family requested increased caregivers’ hours so that Harold would have 24/7 supervision due to increasingly frequent injurious falls. Despite this, Harold had several more falls, including one that resulted in multiple broken ribs.

Harold’s caregiving agency had designated one of its own administrators as his durable power of attorney for healthcare, granting them authority to make medical decisions on his behalf. Alarmingly, though Harold’s nephew was willing to serve in this role, this administrator had met him only once. More importantly, a DPOA-HC cannot legally be a part of one’s care team. Though this document was signed eight weeks ago and bears Harold’s signature, medical records suggest he lacked capacity to make this decision.

Last month, an emergency physician, astutely worried about his safety, submitted a report to Adult Protective Services. APS is a state and federally funded agency that investigates reports of maltreatment involving vulnerable adults. Risk factors include older age, cognitive impairment and lack of social support. After the initial report is filed, APS conducts a formal investigation, which usually concludes with offering medical care, legal aid, and counseling.

Harm is not necessarily due to malicious intent; it may also be the unfortunate result of adverse circumstances. In this case, Harold’s family did their best to navigate a system ill-equipped to meet the evolving needs of an aging population. This caregiving agency then took advantage of their desperation. Our community relies on APS to uncover harm and catalyze necessary change. We wish that our country invested more in APS and social services for adults at risk, especially for those who cannot advocate for themselves.

As seen in Harold’s case, investigations can move painfully slowly, while neglect and abuse continue unchecked. APS must balance autonomy with an individual’s physical and psychosocial safety. And yet, it is impossible to ignore the fact that if Harold were younger than 18, the more resourced Child Protective Services likely could have intervened sooner and more effectively. Unlike CPS, APS cannot forcibly remove adults from their home, even in the most dangerous situations.

Despite our best efforts, it was too late to save Harold’s life. We transferred him to a hospice facility to keep him safe and comfortable in his final days. His nephew visited but was heartbroken when Harold passed away two days later. If APS were equipped to swiftly provide food and a safer environment, would Harold’s story have ended differently?

Healthcare providers are legally required to report to APS whenever there is “reasonable suspicion” of harm, which can take many forms: physical, psychological, financial or even self-neglect. In 2023, APS received more than 1.5 million cases nationally, more than half of which were submitted by medical professionals. Still, studies estimate that only 1 in 24 cases of adult abuse are reported.

As our population ages, these numbers will only grow. We are haunted by patients like Harold who were failed by the inadequacies of infrastructure meant to protect them. We hope you speak up for the vulnerable adults in our community.

If you or a loved one are experiencing abuse, neglect, or exploitation, you can contact Adult Protective Services 877-734-6277 or apscentralintake@dshs.wa.gov.

Manasvi Khullar, DO, is a neurology resident at the University of Washington. Reema Navalurkar, MD, is a geriatrician at the University of Washington. Both live in Seattle. The views expressed in this column are their own.