Pulmonary Embolism (Blood Clot)

WHAT IS A PULMONARY EMBOLISM?

Pulmonary embolism is the sudden blockage of a major blood vessel (artery) in the lung, usually by a blood clot.  In most cases, the clots are small and are not deadly, but they can damage the lung.  If the clot is large and stops blood flow to the lung, it can be deadly.  Quick treatment could save your life or reduce the risk of future problems.

WHAT ARE THE SYMPTOMS?

The most common symptoms are:

• Sudden shortness of breath.
• Sharp chest pain that is worse when you cough or take a deep breath.
• A cough that bring up pink, foamy mucus.

Pulmonary embolism can also cause more general symptoms. For example, you may feel anxious or on edge, sweat a lot, feel lightheaded or faint, or have a fast heart rate or palpitations.

If you have symptoms like these, you need to see a doctor right away, especially if they are sudden and severe.

WHAT CAUSES PULMONARY EMBOLISM?

In most cases, pulmonary embolism is caused by a blood clot in the leg that breaks loose and travels to the lungs.  A blood clot in a vein close to the skin is not likely to cause problems.  But having blood clots in deep veins (deep vein thrombosis) can lead to pulmonary embolism.  More than 300,000 people each year have deep vein thrombosis or a pulmonary embolism.

Other things can block an artery, such as tumors, air bubbles, amniotic fluid, or fat that is released into the blood vessels when a bone is broken.  Most of these are very rare.

WHAT INCREASES YOUR RISK OF PULMONARY EMBOLISM?

Anything that makes you more likely to form blood clots increases your risk of pulmonary embolism.  Some people are born with blood that clots too quickly.  Other things that can increase your risk include:

• Being inactive for long periods.  This can happen when you have to stay in bed after surgery or a serious illness or when you sit for a long time on a flight or car trip.
• Recent surgery that involved the legs, hips, belly, or brain.
• Some diseases, such as cancer, heart failure, stroke, or a severe infection.
• Pregnancy and childbirth (especially if you had a cesarean section).
• Taking birth control pills or hormone therapy.
• Smoking.

You are also at higher risk for blood clots if you are an older adult (especially older than 70) or extremely overweight (obese).

HOW IS PULMONARY EMBOLISM DIAGNOSED?

It may be hard to diagnose pulmonary embolism, because symptoms are like those of many other problems, such as a heart attack, a panic attack, or pneumonia.  A doctor will start by doing a physical exam and asking questions about our past health and your symptoms.  This helps the doctor decide if you are at high risk for pulmonary embolism.  Based on your risk, you might have tests to look for blood clots or rule out other causes of your symptoms.  Common tests include blood tests, ultrasound, spiral CT scan, electrocardiogram (EKG, ECG), and MRI. 

HOW IS IT TREATED?

Doctors usually treat pulmonary embolism with medicines called anticoagulants.  They are often called blood thinners, but they don't really thin the blood.  They help prevent new clots and keep existing clots from growing.  At first, the doctor may give you a shot of heparin, a blood thinner that works quickly.  Then you may take warfarin (such a Coumadin), a blood thinner that you take as a pill.  Most people take warfarin for a few months.  People at high risk for blood clots may need it for the rest of their lives.

If symptoms are severe and life-threatening, "clot busting" drugs called thrombolytics may be used.  These medicines can dissolve clots quickly, but they increase the risk of serious bleeding.  Another option is surgery to remove the clot (embolectomy).

Some people can't take blood thinners, or they form clots in spite of taking the medicine.  To prevent future problems, they may have a filter put into the large vein (vena cava) that carries blood from the lower body to the heart.  a vena cava filter helps keep blood clots from reaching the lungs.

If you have had pulmonary embolism once, you are more likely to have it again.  Blood thinners can help reduce your risk, but they increase your risk of bleeding.  If your doctor prescribes blood thinners, be sure you understand how to take your medicine safely, and see our doctor for regular blood tests.  You can reduce your risk of pulmonary embolism by doing things that help prevent blood clots in your legs.

• Avoid sitting for long periods.  Get up and walk around every hour or so, or flex your feet often.
• Get moving as soon as you can after surgery.
• Wen you travel, drink extra fluids. Avoid drinks with alcohol or caffeine.
• Wear compression stocking if you are at high risk.
• If you take blood thinners, take them just the way your doctor tell you to.

Leg and Skin Ulcers

The word "ulcer" means a break in the layer of cells forming a surface. Ulcers can occur on any area of the body and have many causes. Ulcers occur when the skin breaks down allowing air and bacteria to get into the underlying tissue. They usually form as scabs or open wounds with redness and swelling of the surrounding area, most commonly on the lower legs and/or feet.

What are the Symptoms of Leg Ulcers?
Associated symptoms of a venous leg ulcer are caused by blood not flowing properly through your veins. This is known as venous insufficiency.   Symptoms of leg ulcers may include:

• Stinging Leg pain, which can be continuous, or intermittent
• Pitting edema, where swollen ankles are filled with fluid that temporarily holds the imprint of your finger when pressed
•  Hyperpigmentation, or discoloration and darkening of your skin around the ulcer 
• Hardened skin around the ulcer, which may make your leg feel rigid 
• Atrophy blanche, or small, smooth areas of white skin, which may have tiny red spots
•  A 'heavy' feeling in the affected leg 
•  Aching
• Itching
• Swelling 
• Itchy, irritated skin which is caused by high blood pressure in the veins of your leg

What Causes Leg Ulcers?
Years of research have shown that the usual causes of leg ulcers are not a problem with the skin itself, but rather with the underlying blood supply to the skin. Therefore successful prevention for leg ulcers and successful treatment for leg ulcers must be directed at correcting the underlying cause, not the ulcer itself.

Because blood supply to the skin is crucial, ulcers can occur as a result of poor circulation and so it is also mostly associated with disorders that affect circulation, such as diabetes, rheumatoid arthritis and hypertension. Leg and foot ulcers can also be worsened by secondary bacterial and viral infections and be associated with surrounding eczema. Ulcers are also commonly associated with depressed or lowered immune systems.

Diagnosing Leg Ulcers
Diagnosis is usually made based on symptoms, location and the way the surrounding skin of the ulcer looks. A diagnosis is determined by the patient’s medical history, a thorough physical examination by a wound specialist or physician, and laboratory tests, which may include X-rays, MRIs, CT scans and noninvasive vascular studies to help develop a treatment plan.

Leg Ulcers in the Elderly
Leg ulcers usually occur in the elderly more so than any other age group, due to poor circulation in aging limbs. Ulcers in the elderly affect their quality of life, especially if they are affected by them chronically. Many elderly individuals are inactive, making it very hard to treat ulcers in a traditional manner.   Two conditions that add to the complications of leg ulcers in the elderly are obesity and diabetes. Since many elderly individuals spend a majority of their time sitting, one of the best remedies is to keep their legs elevated, preferably above the heart.

Most Common Types of Leg Ulcers

• Venous (Varicose) Ulcers mostly occur due to improper functioning of the valves connecting the superficial and deep veins. The failure of these valves causes blood to improper flow of the veins, causing varicose veins. 
• Arterial (Ischemic) Ulcers are caused by poor blood circulation as a result of narrowed arteries or by damage to the small blood vessels from diabetes. 
• Neurotrophic (Diabetic) Ulcers occur in those diagnosed with diabetes.  Decreased circulation from diabetes is the main reason for the development of diadetic leg ulcers.

Treatments for Leg Ulcers
Treatment for leg ulcers should include weight loss if you are overweight and regular exercise to promote good circulation. Body detox can also help to purify the blood and cleanse the system. Treatment for leg ulcers greatly depends on the factors that cause the ulcer or have prevented healing.

Once the causes of leg ulcers are under control, (for example the blood sugar level in diabetes) the ulcer should heal by itself. Treatment may involve wound cleansing, anti-inflammatory treatment and application of dressings. So long as there is no arterial disease, venous leg and foot ulcers will benefit from elevation and compression dressings.

If an underlying disease is one of the causes of leg ulcers, it's important that it is treated - for example hardening of the arteries. Leg and foot ulcers have a tendency to recur in elderly people, and sometimes may require years of therapy.

Tips for the Prevention of Leg Ulcers

• Activate your calf muscles regularly by walking and exercising.
• Reduce the amount of fat in your food. Eat more fruit and vegetables. 
• Sit with your legs raised whenever you have the opportunity - above heart level if possible. 
• Avoid sitting with your legs crossed. This impairs blood circulation.
• If your work requires a lot of standing or sitting, try to vary your stance as much as possible. Walk about from time to time, if you can. 
• If you have to stay seated for a long time, move your feet up and down occasionally. 
• Support stockings may be useful, but talk to your doctor or practice nurse first. 
• Massaging the legs to improve circulation can also prevent leg ulcers. 
• Reduce alcohol consumption, as this increases your risk of getting leg ulcers.

Peripheral Artery Disease - PAD

Definition

Peripheral artery disease is a common circulatory problem in which narrowed arteries reduce blood flow to your limbs.

When you develop peripheral artery disease (PAD), your extremities — usually your legs — don't receive enough blood flow to keep up with demand. This causes symptoms, most notably leg pain when walking (intermittent claudication).

Peripheral artery disease is also likely to be a sign of a more widespread accumulation of fatty deposits in your arteries (atherosclerosis). This condition may be reducing blood flow to your heart and brain, as well as your legs.

Often, you can successfully treat peripheral artery disease by quitting tobacco, exercising and eating a healthy diet.

Symptoms

While many people with peripheral artery disease have mild or no symptoms, some people have leg pain when walking (intermittent claudication).

Intermittent claudication symptoms include muscle pain or cramping in your legs or arms that's triggered by activity, such as walking, but disappears after a few minutes of rest. The location of the pain depends on the location of the clogged or narrowed artery. Calf pain is most common.

The severity of intermittent claudication varies widely, from mild discomfort to debilitating pain. Severe intermittent claudication can make it hard for you to walk or do other types of physical activity.

Peripheral artery disease symptoms include:

v  Painful cramping in your hip, thigh or calf muscles after activity, such as walking or climbing stairs (intermittent claudication)

v  Leg numbness or weakness

v  Coldness in your lower leg or foot, especially when compared with the other leg

v  Sores on your toes, feet or legs that won't heal

v  A change in the color of your legs

v  Hair loss or slower hair growth on your feet and legs

v  Slower growth of your toenails

v  Shiny skin on your legs

v  No pulse or a weak pulse in your legs or feet

v  Erectile dysfunction in men

If peripheral artery disease progresses, pain may even occur when you're at rest or when you're lying down (ischemic rest pain). It may be intense enough to disrupt sleep. Hanging your legs over the edge of your bed or walking around your room may temporarily relieve the pain.

When to see a doctor

If you have leg pain, numbness or other symptoms, don't dismiss them as a normal part of aging. Call your doctor and make an appointment.

Even if you don't have symptoms of peripheral artery disease, you may need to be screened if you are:

v  Over age 70

v  Over age 50 and have a history of diabetes or smoking

v  Under age 50 but have diabetes and other peripheral artery disease risk factors, such as obesity or high blood pressure

Causes

Peripheral artery disease is often caused by atherosclerosis. In atherosclerosis, fatty deposits (plaques) build up in your artery walls and reduce blood flow.  Although the heart is usually the focus of discussion of atherosclerosis, this disease can and usually does affect arteries throughout your body. When it occurs in the arteries supplying blood to your limbs, it causes peripheral artery disease.  Less commonly, the cause of PAD may be blood vessel inflammation, injury to your limbs, unusual anatomy of your ligaments or muscles, or radiation exposure.

Risk factors

Factors that increase your risk of developing peripheral artery disease include:

v  Smoking

v  Diabetes

v  Obesity (a body mass index over 30)

v  High blood pressure (140/90 millimeters of mercury or higher)

v  High cholesterol (total blood cholesterol over 240 milligrams per deciliter, or 6.2 millimoles per liter)

v  Increasing age, especially after reaching 50 years of age

v  A family history of peripheral artery disease, heart disease or stroke

v  Excess levels of homocysteine, a protein component that helps build and maintain tissue

v  People who smoke or have diabetes have the greatest risk of developing peripheral artery disease due to reduced blood flow.

Complications

If your peripheral artery disease is caused by a buildup of plaques in your blood vessels (atherosclerosis), you're also at risk of developing:

v  Critical limb ischemia. This condition begins as open sores that don't heal, an injury, or an infection of your feet or legs. Critical limb ischemia (CLI) occurs when such injuries or infections progress and can cause tissue death (gangrene), sometimes requiring amputation of the affected limb.

v  Stroke and heart attack. The atherosclerosis that causes the signs and symptoms of peripheral artery disease isn't limited to your legs. Fat deposits also build up in arteries supplying your heart and brain.

Preparing for your appointment

You're likely to start by seeing your family doctor or a general practitioner. However, you may then be referred to a doctor who specializes in disorders of blood vessels (vascular specialist) or a doctor who specializes in the heart and circulatory system (cardiologist).

Because appointments can be brief, and there's often a lot of ground to cover, it's a good idea to arrive well prepared. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

v  What you can do

v  Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

v  Make a list of all medications, vitamins or supplements that you're taking, and include dosage information.

v  Write down questions to ask your doctor.

Your time with your doctor may be limited, so preparing a list of questions can help you make the most of your time together. For peripheral artery disease, some basic questions to ask your doctor include:

v  What's the most likely cause of my symptoms?

v  Are there other possible causes for my symptoms?

v  What kinds of tests do I need? Do these tests require any special preparation?

v  Is peripheral artery disease temporary or long lasting?

v  What treatments are available, and which do you recommend?

v  What types of side effects can I expect from treatment?

v  Are there any alternatives to the primary approach that you're suggesting?

v  What can I do on my own that might help me get better?

v  I have other health conditions. How can I best manage these conditions together?

v  Is there a generic alternative to the medicine you're prescribing me?

v  Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment anytime you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

v  When did you first begin experiencing symptoms?

v  Are your symptoms continuous or occasional?

v  Do your symptoms get worse when you exercise?

v  How severe are your symptoms?

v  Do your symptoms get better when you're resting?

v  Do you use tobacco products? If yes, how much?

What you can do in the meantime
It's never too soon to quit smoking if you're a smoker. Smoking increases the risk of peripheral artery disease and can make existing PAD worse. Other healthy lifestyle habits you can immediately adopt are eating less saturated fat and adding more fruits and vegetables to your diet.

Elder Abuse Information

Elder abuse is a general term used to describe certain types of harm to older adults. Other terms commonly used include: "elder mistreatment", "senior abuse", "abuse in later life", "abuse of older adults", "abuse of older women", and "abuse of older men".

One of the more commonly accepted definitions of elder abuse is "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person."^[1]This definition has been adopted by the World Health Organizationfrom a definition put forward by Action on Elder Abuse in the UK.

The core feature of this definition is that it focuses on harms where there is "expectation of trust" of the older person toward their abuser. Thus it includes harms by people the older person knows or with whom they have a relationship, such as a spouse, partner or family member, a friend or neighbor, or people that the older person relies on for services. Many forms of elder abuse are recognized as types of domestic violence or family violence.

The term elder abuse does not include general criminal activity against older persons, such as home break ins, "muggings" in the street or "distraction burglary", where a stranger distracts an older person at the doorstep while another person enters the property to steal.

In 2006 the International Network for Prevention of Elder Abuse (INPEA) designated June 15 as World Elder Abuse Awareness Day(WEAAD) and an increasing number of events are held across the globe on this day to raise awareness of elder abuse, and highlight ways to challenge such abuse.^[2]
Types
Although there are common themes of elder abuse across nations, there are also unique manifestations based upon history, culture, economic strength and societal perceptions of older people within nations themselves. The fundamental common denominator is the use of power and control by one individual to affect the well-being and status of another, older, individual.
There are several types of abuse of older people that are generally recognized as being elder abuse, including:

1. Physical: e.g. hitting, punching, slapping, burning, pushing, kicking, restraining, false imprisonment/confinement, or giving excessive or improper medication
2. Psychological/Emotional: e.g. shouting, swearing, frightening, or humiliating a person. A common theme is a perpetrator who identifies something that matters to an older person and then uses it to coerce an older person into a particular action. It may take verbal forms such as name-calling, ridiculing, constantly criticing, accusations, blaming, and general disrespect, or non verbal forms such as ignoring, silence or shunning.
3. Financial abuse: also known as financial exploitation. e.g. illegal or unauthorized use of a person’s property, money, pension book or other valuables (including changing the person's will to name the abuser as heir). It may be obtained by deception, coersion, misrepresentation, undue influence, or theft. The term includes fraudulently obtaining or use of a power of attorney. Other forms include deprivation of money or other property, or by eviction from own home
4. Sexual: e.g. forcing a person to take part in any sexual activity without his or her consent, including forcing them to participate in conversations of a sexual nature against their will; may also include situations where person is no longer able to give consent (dementia)
5. Neglect: e.g. depriving a person of food, heat, clothing or comfort or essential medication and depriving a person of needed services to force certain kinds of actions, financial and otherwise. The deprivation may be intentional (active neglect) or happen out of lack of knowledge or resources (passive neglect).

In addition, some U.S. state laws ^[3]also recognize the following as elder abuse:

1. Rights abuse: denying the civil and constitutional rights of a person who is old, but not declared by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being recognized and adopted by nations
2. Self-neglect: elderly persons neglecting themselves by not caring about their own health or safety. Self neglect (harm by self) is treated as conceptually different than abuse (harm by others).
3. Abandonment : deserting a dependent person with the intent to abandon them or leave them unattended at a place for such a time period as may be likely to endanger their health or welfare.^[4]
4. Institutional abuse to physical or psychological harms, as well as rights violations in settings where care and assistance is provided to dependent older adults or others.

Signs
The signs of abuse vary considerably among older people and with the type of harm being experienced. An older person who is being abused may:

• Say she or he is being harmed
• Seem depressed and withdrawn; signs of depression in elders are not getting dressed, not performing basic care of themselves that they are able to do, never going out even if they can, inability to sleep or sleeping too much
• Not accepting invitations to spend time away from their family or a caregiver
• Seem afraid to make their own decisions
• Seem to be hiding something about a caregiver
• Not have any spending money
• Put off going to the doctor
• Feel anxious and fearful
• Try to "run away," leaving their place of residence and not wishing to return
• Seem to have too many household "accidents"^[5]

Any of these potential signs can indicate problems other than abuse or neglect, and none of these "proves" there is harms occurring. The presence of the signs simply indicates that further inquiry may be necessary.

Common abusers of older people
An abuser can be a spouse, partner, relative, a friend or neighbor, a volunteer worker, a paid worker, practitioner, solicitor or any other individual with the intent to deprive a vulnerable person of their resources. Relatives include adult children and their spouses or partners, their offspring and other extended family members. Children and living relatives who have a history of substance abuse or have had other life troubles are of particular concern.

Perpetrators of elder abuse can include anyone in a position of trust, control or authority. Family relationships, neighbors and friends, are all socially considered as relationships of trust, whether or not the older adult actually thinks of the people as "trustworthy". Some perpetrators may "groom" an older person (befriend or build a relationship with them) in order to establish a relationship of trust. Older people living alone who have no adult children living nearby are particularly vulnerable to "grooming" by neighbors and friends who would hope to gain control of their estates.

The majority of abusers are relatives, typically the older adult's spouse/partner or sons and daughters, although the type of abuse differs according to the relationship. In some situations the abuse is "domestic violence grown old", a situation in which the abusive behavior of a spouse or partner continues into old age.
In some situations, an older couple may be attempting to care and support each other and failing, in the absence of external support. With sons and daughters it tends to be financial abuse, justified by a belief that it is nothing more than the "advance inheritance" of property, valuables and money.

Within paid care environments, abuse can occur for a variety of reasons. Some abuse is the willful act of cruelty inflicted by a single individual upon an older person. In fact, a case study in Canada suggests that the high elder abuse statistics are from repeat offenders.

With the aging of today's population, there is the potential that elder abuse will increase unless it is more comprehensively recognized and addressed.

Abuse statistics
There has been a general lack of reliable data in this area and it is often argued that the absence of data is a reflection of the low priority given to work associated with older people. However, over the past decade there has been a growing amount of research into the nature and extent of elder abuse. The research still varies considerably in the definitions being used, who is being asked and what is being asked. As a result, the statistics used in this area vary considerably.

One study suggests that around 25% of vulnerable older adults will report abuse in the previous month, totaling up to 6% of the general elderly population.^[6]However, some consistent themes are beginning to emerge from interaction with abused elders, and through limited and small scale research projects. Work undertaken in Canada suggests that approximately 70% of elder abuse is perpetrated against women, and this is supported by evidence from the AEA helpline in the UK which identifies women as victims in 67% of calls. Also domestic violence in later life may be a continuation of long term partner abuse and, in some cases, abuse may begin with retirement or the onset of a health condition.^[7]Certainly, abuse increases with age, with 78% of victims being over 70 years of age.^[8]

The higher proportion of spousal homicides supports the suggestion that abuse of older women is often a continuation of long term spousal abuse against women. In contrast, the risk of homicide for older men was far greater outside the family than within.^[9]This is an important point because the domestic violence of older people is often not recognized, and consequently strategies which have proved effective within the domestic violence arena have not been routinely transferred into circumstances involving the family abuse of older people.

According to the AEA helpline in the UK, abuse occurs primarily in the family home (64%), followed by residential care (23%) and then hospitals (5%), although a helpline does not necessarily provide a true reflection of such situations as it is based upon the physical and mental ability of people to utilize such a resource.^[8]

Abandonment
Elder abuse can also include deserting an elderly, dependent person with the intent to abandon them or leave them unattended at a place for such a time period as may be likely to endanger their health or welfare.^[4]

Self-abuse and neglect
Older adults may neglect themselves by not taking care of or caring about their own personal health and well-being.^[10]Elder self-neglect can lead to illness, injury or even death. Common needs that the older adult may deny themselves or ignore are the following:

• Sustenance (food or water)
• Cleanliness (bathing and personal hygiene)
• Adequate clothing for climate protection
• Proper shelter
• Adequate safety
• Clean and healthy surroundings
• Medical attention for serious illness
• Essential medications

Self neglect is often created by an individual's declining mental awareness or capability.
Some older adults may choose to deny themselves some health or safety benefits, which may not be self-neglect. This may simply be their personal choice. Caregivers and other responsible individuals must honor these choices if the older adult is sound of mind. In other instances, the older adult may lack the needed resources, as a result of poverty or other social condition. This is also not considered as "self neglect".

References

1. ^[1], Action on Elder Abuse, accessed October 12, 2007.
2. ^International Network for the Prevention of Elder Abuse, accessed June 26, 2007.
3. ^Nursing Home Abuse Laws (NHAL), http://www.nursinghomeabuselaws.org/elders/
4. ^ ^abOregon Revised Statutes.
5. ^ ^abInstitute for Good Medicine at the Pennsylvania Medical Society, http://www.myfamilywellness.org/MainMenuCategories/FamilyHealthCenter/DomesticViolence/ElderAbuse.aspx
6. ^Cooper C, Selwood A, Livingston G (March 2008). "The prevalence of elder abuse and neglect: a systematic review". Age Ageing 37 (2): 151–60. doi:10.1093/ageing/afm194. PMID18349012. http://ageing.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18349012.
7. ^Silent and Invisible: A Report on Abuse and Violence in the Lives of Older Women in British Columbia and Yukon, 2001.
8. ^ ^abHidden Voices, Action on Elder Abuse, 2005.
9. ^Statistics Canada, 1999, 38.
10. ^Tina de Benedictis, Ph.D., Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., (2007) Elder Abuse Types, Signs, Symptoms, Causes, and Help. Helpguide, helpguide.org.
11. ^ ^abAge Concern Elder Abuse and Neglect Prevention Services: An Analysis of Referrals for the period 1 July 2002 to 30 June 2004. Age Concern New Zealand, November 2005.

Further reading

• Nerenberg, Lisa Elder Abuse Prevention: Emerging Trends and Promising Strategies (2007)

External links

1. Action on Elder Abuse website
2. Canadian Network for the Prevention of Elder Abuse
3. Elder Abuse Prevention Video Training
4. International Network for the Prevention of Elder Abuse website (INPEA)
5. National Adult Protective Services Association
6. National Center For Elder Abuse (NCEA)
7. The National Committee for the Prevention of Elder Abuse (NCPEA)
8. World Health Organization website

Website of European project for the Prevention of Elder Abuse, funded by the European Commission

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