Transcript Elder Abuse

Elder Abuse
Module 3
The Health Care Provider’s Role
in Intervention
Debra Mostek, M.D
Asst. Professor
Section of Geriatrics
UNMC, 981320
Omaha, NE 68198-1320
[email protected]
April 2006
PROCESS
Series of modules and questions
Step #1: Power point module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
Objectives
• Discuss the health care provider’s role in
developing interventions to aid victims of
elder mistreatment
• Discuss the limitations of interventions
Elder mistreatment and the health
care provider
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Recognize elder mistreatment
Report EM
Barriers
Advantages of reporting
The at-risk elder may qualify for additional
services
• Improves APS access to the elder’s medical
information
• May report anonymously/No liability
• Report even if just suspicion of abuse
(the clinician does NOT have to prove the
abuse)
The health care provider’s role
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Documenting elder mistreatment
Cognitive evaluation
Determine decision-making capacity
Assess safety: is inpatient admission
necessary to protect elder from immediate
danger?
• Home health care
The health care provider’s role (2)
• Treat medical illness
• Increased mortality
– Individuals never reported to APS 17.3%
– Physical abuse or caregiver neglect 53.2%
– Self-neglect 40.3%
Lachs et al
• Educate patient
• Caregiver education
• Treat psychiatric symptoms that are interfering
with elder’s function/safety
The health care provider’s role 3
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Interdisciplinary team approach
Cooperating with social agencies
Communicating with APS
Substance abuse treatment
Serve on a community elder abuse task
force
• Participate in continuing education on
elder mistreatment
Ethical Issues and Interventions
• Is the plan focused on safety or autonomy?
• Are the elder’s choices being considered?
• Does the intervention cut off the elder from
his/her social support system or family?
• Cultural considerations
Dyer CB: The Medical Management of Elder Abuse:
A Practical Approach. Presentation. August, 2003
APS Interventions
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Advocating for the elder
Develop natural support systems
Coordinate services
Helps client obtain benefits for which
he/she is eligible
• Refer for medical evaluation
“Interventions” from The Medical Management of Elder Abuse: A Practical
Approach. Program Director: Carmel Bitondo Dyer, MD
APS Interventions
• Confront perpetrators
• Protection order to shield the elder from
perpetrator
• One time clean up of house/apartment
• One time payment of rent or utilities
• Emergency shelter, food, clothing,
medication, adaptive equipment,
transportation
Nebraska Adult Protective Services
APS Interventions
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Referrals for family violence programs
Protect client assets
Alternative placement
Guardianship, conservatorship
Legal interventions
(less than 1 in 10 cases)
Dyer CB: The Medical Management of Elder Abuse: A Practical
Approach. Presentation. August, 2003.
APS use and nursing home
placement
• 2812 community-dwellers followed for 9 years
(New Haven EPESE)
• 202 referred to APS;
Nursing Home Placement rates:
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Self-neglect 69.2% (83 of 120)
Mistreated elders 52.3% (23 of 44)
No contact with APS 31.8%
Included other demographic, medical, functional, and
social factors assoc with NHP
Lachs MS et al. The Gerontologist 2002; 42(6), 734-739
Key Issues
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Capacity evaluation
Patient’s culture and previous standards
Risk assessment
HCP needs to be aware that; own beliefs,
values, and attitudes affect intervention
decisions
• Risk tolerance increased with experience
• Protect clients from unnecessary interference
Gunstone S. J Psych and Mental Health Nursing, 2003. 10:287-296
Limitations of APS Interventions
• Immediate danger: Call 911
• Individuals with intact decision-making
capacity are “allowed to make bad
decisions”
• Case is investigated and usually has to be
closed after 6 months unless ongoing
concern
“At Risk” Patients
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Consult Home Health Care Agency
In home services
Meals on Wheels
Housekeeping services
Home health aide
House calls
Respite care to lessen caregiver burden
Legal Interventions
• Letters outlining medical and
recommendations for interventions
• Rarely testify in court
Testifying in Court
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Review documents ahead of time
Know what evidence will be introduced
Know your role
Review with prosecutor
May use notes
Answer with brief, clear statements (don’t
speculate)
Tronetti PS; AGS Meeting May 2002
Testifying in Court
• OK to say “I don’t know” or “that was
beyond the scope of my exam”
• Suggest interventions if asked
• Dress conservatively
• Address attorney’s as “Sir”, “Ma’am”,
“Councilor”
• Avoid humor in court
Tronetti PS; AGS Meeting May 2002
Web Based Resources
• Texas Elder Abuse and Mistreatment
Institute. teaminstitute.org
• American Medical Association. Diagnostic
and treatment guidelines on elder abuse
and neglect. www.amaassn.org/ama1/pub/upload/mm/386/elderabuse.
pdf
• National Center on Elder Abuse
http://www.elderabusecenter.org
Summary
• Screen all elders
• Report all suspected elder abuse
• Adults who have decision-making capacity have
the right to refuse treatment/service
• Utilize least restrictive interventions
• Engage interdisciplinary team to enhance and
individualize intervention plan
Sources
• The Medical Management of Elder Abuse: A Practical
Approach. Program Director: Carmel Bitondo Dyer
Sponsored by Baylor College of Medicine Geriatrics
Program. Presented August 22, 2003. Omaha, NE.
• Pompei P, Murphy JB, eds. Geriatrics Review Syllabus:
A Core Curriculum in Geriatric Medicine. 6th ed. New
York: American Geriatrics Society; 2006. 86-90
• Lachs MS, Pillemer. Elder Abuse. The Lancet. 2004.
364:1263-1272.
• Heath JM, Kobylarz FA, et al. Interventions from HomeBased Geriatric Assessment of Adult Protective Services
Clients Suffering Elder Mistreatment. Journal of the
American Geriatrics Society. 2005. 53:1538-1542.
• Tronetti PS; The Ten Commandments of Testimony:
Presented at AGS Meeting, May 2002
Sources
• Lachs MS, Williams CS, et al. Adult Protective Service
Use and Nursing Home Placement. The Gerontologist
2002; 42(6):734-739.
• Friedman SM, Williamson JD, et al. Increased Fall Rates
in Nursing Home Residents After Relocation to a New
Facility. Journal of the American Geriatrics Society. 1995;
43:1237-1242.
• Daly, JM. Evidence-Based Protocol Elder Abuse
Prevention. Gerontological Nursing Interventions
Research Center. 2004; 1-68.
• Levine JM. Elder Neglect and Abuse; A Primer for
Primary Care Physicians. Geriatrics. 2003;58(10):37-44.
• Gunstone S. Risk assessment and management of
patients whom self-neglect: a ‘grey area’ for mental
health workers. Journal of Psychiatric and Mental Health
Nursing. 2003;10:287-296.
Post-test
• An 86-year-old man is brought to the emergency department
because of shortness of breath. He is inattentive, combative, and
unable to speak in full sentences. Pulse rate is 128 per minute, and
respirations are 28 per minute; blood pressure is 180/100 mm Hg.
Physical examination reveals audible wheezes, bilateral crackles,
jugular venous distention, an S3, and pitting 2+ pedal edema. The
patient lives with his son, who tells you that his father has heart
failure and was in the hospital last week for a similar episode.
Current medications are digoxin, furosemide, and captopril. The son
administers these, supervises his father, and runs a lucrative family
business. Electrocardiogram shows sinus tachycardia but no new
ischemic changes. Chest radiograph shows pulmonary edema and
several old rib fractures. Complete blood cell count and other routine
laboratory studies are normal, but serum digoxin level is zero. A
recent echocardiogram revealed an ejection fraction of 42%. The
patient has been in the emergency department nine times in the
past year with similar presentations. Which of the following
statements is correct?
Which of the following statements is correct?
A. You should confront the son immediately
about abuse or neglect of his father.
B. A toxicology screen would not be useful.
C. A high socioeconomic level makes elder
mistreatment unlikely.
D. Frequent emergency department visits
are rare in elder mistreatment.
E. Evidence of physical abuse, such as rib
fractures, may coexist with neglect.
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Correct Answer: E. Evidence of physical abuse,
such as rib fractures, may coexist with neglect.
Feedback:
Abuse and neglect affect 3% to 6% of patients aged 65 and
over. A clinician may be the only person an abused
elderly person sees, other than the perpetrator of
mistreatment; thus, the role of physicians in identifying
and managing mistreatment is critical. Different forms of
mistreatment (eg, physical abuse, verbal abuse, neglect,
exploitation) often coexist. Several studies point to the
frequent concurrence of abuse and neglect. This patient
may have been physically abused, but other findings (ie,
emergency department recidivism, nonadherence with
medications, and an increase in caregiver burden)
suggest that neglect also is occurring. Confrontation with
a suspected abuser in the information-gathering phase
of an evaluation may result in sequestration of the victim.
Loss of access to a vulnerable patient is worrisome.
• Abusers often are the primary caregivers for victims.
Strategies to engage and support suspected
perpetrators, rather than confront and punish them, may
be appropriate. Digoxin has an extremely long half-life,
so several doses must be missed for the level to be zero.
The patient’s altered mental status may reflect hypoxia
from pulmonary edema but could reflect restraint with
unprescribed sedatives. Toxicology screening is
indicated. High socioeconomic level should not foster
complacency in cases of suspected mistreatment. This
problem crosses all ethnic groups, income levels, and
geographic regions. A higher prevalence of nonwhite
persons in Adult Protective Service databases probably
reflects a reporting bias for disenfranchised minority
patients. Abused elderly persons often have substantial
contact with emergency departments before
mistreatment is finally diagnosed, a pattern that
represents missed opportunities for detection of
mistreatment. End