Transcript Slide 1

Elder Abuse and Mistreatment:
Screening and Intervening
Module 2 of 2
in Cases of Abuse
Barbara A. Reilley, PhD, Sabrina Pickens, PhD, MSN, GNP, ANP, Carmel B. Dyer, M.D.
nd Kathleen Pace Murphy, PhD, GNP
he University of Texas Health Science Center at Houston (UTHealth)
Module 2 of 2
Learning Objectives
Successful students will be able to :
• Determine the steps to screen for elder abuse.
• Describe three interventions for victims of elder abuse.
• Discuss three interventions for stressed caregivers.
• List common community resources available to elders and their families.
Elder Abuse Intervention
For the purposes of this module, elder abuse
refers broadly to all forms of elder abuse, also
referred to as mistreatment, including:
Physical abuse
Neglect, including self-neglect
Emotional or psychological abuse
Verbal abuse and threats
Financial abuse and exploitation
Sexual abuse
Abandonment
Why Should I Identify Cases of Elder Abuse?
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American Medical Association,
American Academy of Family Physicians,
American College of Obstetricians and Gynecologists,
American Nurses Association, and the
American College of Emergency Physicians
recommend
physician involvement in identifying,
intervening and reporting elder
abuse.
Only 2% of
physicians
report elder
abuse and
neglect to
Protective
Service
Agencies.
Why Should I Identify Cases of Elder Abuse?
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The Joint Commission recognizes physician involvement as
part of the protocol for identifying elder abuse in all
ambulatory care settings.
Elder abuse is common and a growing public health concern
(11% of adults age 60 years or older reported abuse).
Intervention, especially using an interprofessional
approach, can be very effective.
How to Screen for Elder Abuse
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Physicians can screen for elder abuse.
1. Make questions about abuse a routine part
of clinical practice.
2. Speak to patient at eye level.
3. Keep questions simple,
direct and
nonjudgmental.
4. Assure that all discussions are private.
5. The primary focus is on patient
safety.
How to Screen for Elder Abuse
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Elder persons usually will not admit
to abuse or neglect unless probed.
A non-threatening manner, keeping the patient comfortable,
assuring privacy, attending to hearing, vision needs,
demonstrating empathy but being direct and honest with the
patient will usually elicit more forthright responses.
Patient safety is
paramount in
intervention efforts.
How to Screen for Elder Abuse
Page 3 of 3
Safety planning is the process of the protector/helper
and the victim jointly creating a plan to minimize victim
risk.
Safety plans include:
• Prevention strategies – relocating to a shelter or
moving, restraining or protective orders, hiding
• Protection strategies – escape routes, shelters, locking
in oneself
• Notification strategies – cell phones, easily accessible
emergency numbers, alarm pendants, security systems,
code words, faith and community organizations
Screening Questions to Ask of Elders
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Has anyone at home ever hurt you?
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Has anyone ever made you do things you did not want to do?
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Has anyone taken something that belongs to you without asking?
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Does anyone scold or threaten you, recently or in the last few
years?
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Have you ever signed documents you do not understand?
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Are you afraid of anyone that lives with or cares for you?
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Are you alone often?
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Has anyone ever failed to assist you when you needed help?
Acceptable Question
It is acceptable to simply ask,
“Have you been abused?”
Physician Best Practices
Be alert for unusual behavior and clues to possible abuse.
Does the caregiver have
little or no knowledge
of the patient’s medical
conditions?
Does the caregiver
allow the physician to
interview the patient
alone?
Has the patient changed
his or her caregiver?
Has the patient had
frequent visits to the
ER?
Physician Best Practices
Be alert for unusual behavior and clues to possible abuse.
Physical findings or
discrepancies in labs
and x-rays that differ
from caregiver reports.
The patient and/or
caregiver does a large
amount of “doctor
shopping.”
Does the caregiver have
a mental or physical
impairment?
The patient has
unexplained or unusual
injuries.
Physician Best Practices
Be alert for unusual behavior and clues to possible abuse.
Relationships between the caregiver and the elder should be taken in context of the
ongoing relationship. For example, if a couple has always disagreed and been
argumentative, does that constitute psychological abuse as they get older?
Patients may also be reluctant to relate events (either through fear of the caregiver
or of being removed). If a patient is demented, the physician quite often has to rely
on caregiver statements which may or may not be true. It is incumbent on the
physician to match the verbal narrative of the patient and the caregiver with the
objective findings of the examination, laboratory and x-ray results, and use his/her
best clinical judgment in reaching a conclusion.
When interviewing the patient and the caregiver (preferably separately), it is
important for the physician to be as specific as possible about the patient-caregiver
relationship.
Physician Best Practices
Be alert for physical signs such as:
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Patient’s general appearance that is slovenly, dirty, or disheveled.
Patient shows signs of dehydration, blood loss, low blood
pressure, rapid pulse, or abnormal laboratory work.
Oral bruising, poor dentition, loose fitting or no dentures,
venereal lesions.
Trauma to the nose, marks indicating object pressure on the ears,
nose or throat (finger prints, rope, wire or other signs of choking
or physical abuse).
see more of the “be alert for physical signs” list
Physician Best Practices
Be alert for physical signs such as:
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Burns on the skin, skin bruising in various stages of healing,
lacerations, decubitus ulcers, signs of restraint use.
Fractured ribs, old fractures, pneumothorax, splenic rupture,
hemorrhage.
Impaired mental status, impaired functioning in ADLs and IADLs,
depression, anxiety, mental illness.
Unusual or impaired gait, or evidence of old, untreated fractures.
Intervention Strategies
A patient diagnosed with
dementia and having
behavioral problems.
Caregiver abuse of a patient
with dementia.
A mentally ill patient who
assaults his or her parents.
A patient with decisional
capacity refusing treatment.
A patient diagnosed with dementia and
having behavioral problems.
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An abused elderly patient
without the capacity for
decision-making.
Rule out other medical conditions.
Request psychiatric evaluation and possible
medication.
Maintain the continuity of care.
Repeatedly orient the patient to his or her
surroundings.
Request referral for home services, respite
care or possible institutional placement.
Assess patient’s capacity.
Intervention Strategies
A patient diagnosed with
dementia and having
behavioral problems.
Caregiver abuse of a patient
with dementia.
A mentally ill patient who
assaults his or her parents.
Caregiver abuse of a patient with dementia.
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A patient with decisional
capacity refusing treatment.
An abused elderly patient
without the capacity for
decision-making.
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Provide a referral for respite services.
Provide a referral for counseling or domestic
services.
Provide information on social service agencies
and/or support groups.
Recommend the placement of a family
member, if indicated.
When possible, encourage social and/or
religious support.
Intervention Strategies
A patient diagnosed with
dementia and having
behavioral problems.
Caregiver abuse of a patient
with dementia.
A mentally ill patient who
assaults his or her parents.
A patient with decisional
capacity refusing treatment.
An abused elderly patient
without the capacity for
decision-making.
A mentally ill patient who assaults his or
her parents.
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Provide a psychiatric referral for the abuser.
Suggest mental health counseling for the
victim.
Suggest alternative living arrangements.
Intervention Strategies
A patient diagnosed with
dementia and having
behavioral problems.
Caregiver abuse of a patient
with dementia.
A patient with decisional capacity
refusing treatment.
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A mentally ill patient who
assaults his or her parents.
A patient with decisional
capacity refusing treatment.
An abused elderly patient
without the capacity for
decision-making.
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Contact Adult Protective Services.
Educate the patient about possible dangers.
Provide emergency contact numbers.
Follow-up.
Develop a safety plan.
Intervention Strategies
A patient diagnosed with
dementia and having
behavioral problems.
Caregiver abuse of a patient
with dementia.
A mentally ill patient who
assaults his or her parents.
A patient with decisional
capacity refusing treatment.
An abused elderly patient
without the capacity for
decision-making.
An abused elderly patient without
the capacity for decision-making.
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Contact Adult Protective Services.
Assist agencies with guardianship and/or
conservatorship recommendations.
Provide referrals and resources for
financial management.
Reporting Abuse: The Physician’s Role
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All but six states have
mandatory elder abuse
reporting laws.
 Exceptions are: CO, NJ, NY, ND, SD, and WI
Laws vary on penalties for not reporting, the age of the
person covered under reporting requirements, classification
of the abuse as criminal or civil, investigative procedures, and
remedies.
Physicians should be familiar with the criteria
for reporting in their state.
Barriers to Physician Reporting of Elder Abuse
Disparities in definitions
Impairs the ability to ascertain and compare data across studies.
Current databases are inadequate to meet reporting requirements.
Regulatory requirements.
Research, evaluation and policy
Minimal potential for innovation or discovery on the topic.
Barriers to Physician Reporting of Elder Abuse
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International Statistical Classification of Diseases (ICD) and
Diagnosis Related Group (DRG) codes for abuse are rarely used
by physicians.
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Why? Because:
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Reimbursement is low.
Physicians and coding personnel are unaware of the correct codes.
Lack of physician training in elder abuse recognition.
Concern of mandatory reporting and possible appearance in court
due to report.
Fear of causing further harm to the patient.
Adult Protective Services
Adult Protective Services (APS) insures
the safety and well-being of elders and
adults with disabilities who are in danger
of being mistreated or neglected, are
unable to take care of themselves or
protect themselves from harm, and have
no one to assist them.
Adult Protective Services
APS Interventions
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Receiving reports of elder/vulnerable adult abuse, neglect, and/or
exploitation and investigation of the reports.
Assessing victim's risk
Assessing victim's capacity to understand his/her risk and ability
to give informed consent
Developing a case plan
Arranging for emergency shelter, medical care, legal assistance,
and supportive services
Evaluation
Adult Protective Services
APS Limitations
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An APS client’s wishes and interest supersedes the wishes and
interests of the family and the community.
The plan to manage the case must maximize self-determination of
the elder.
A client has the right to live in unsafe surroundings or engage in
unsafe behaviors.
A client has the right to refuse services and/or treatment unless
life is threatened or he or she has no mental capacity available.
The Interprofessional Approach
An
interprofessional
team approach
uses formal
and informal
relationships
with:
A Model of the Interprofessional TEAM Approach
The Texas Elder Abuse and
Mistreatment (TEAM)
Institute
is a collaboration between:
The University of Texas Health Science
Center at Houston Medical School,
Texas Department of Family and
Protective Services,
Harris County Hospital District, and
Baylor College of Medicine.
Includes: Physicians, Social Worker, Nurse Practitioners
Psychiatrist, Adult Protective Service Case Workers, Other disciplines as
needed: law enforcement, elder law attorney, district attorney, Better
Business Bureau (financial abuse), Attorney General Medicare Fraud Division.
TEAM Approach
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The client is referred by APS or other parties for
physical and/or capacity assessment.
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Clinicians conduct a comprehensive geriatric assessment and
assess capacity, if needed.
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The interprofessional team meets and formulates a care plan for
the abused elder.
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The care plan is implemented, and follow-up
is provided as necessary.
Where and How to Report
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In most states, a person who knows or suspects elder abuse is
required to report the abuse. Some states also require reporting
an elder who is self-neglecting.
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Report even if it is not required in a specific state of practice.
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Visit the State Directory of Help lines, Hotlines, and Elder Abuse
Prevention Resources at
http://www.ncea.aoa.gov/NCEAroot/Main_Site/Find_Help/State_
Resources.aspx
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Or Call the Eldercare Locator at 1-800-677-1116
Case Study
Patient Presentation:
patient presentation
Mary Jones is an 80-year-old female living with her single, working daughter.
She uses a walker for mobility and needs assistance with grooming and
dressing, but she can toilet and feed herself.
Her daughter reports that Mary is irritable, has been falling more often and is
becoming obstinate. Mary has lost 15 pounds in the last two months. She does
not currently take any medications.
There is indication of bruising on her forearms and left hip; a small bruise on
her forehead; numerous abrasions on her arms and legs; and, she complains
of pain in her left forearm.
Mary’s daughter was irritable while with Mary at her medical appointment.
She was impatient with Mary, belittling Mary and speaking sharply with a
raised voice.
Next: Questions to consider
Case Study
Mary’s Comprehensive Geriatric Assessment
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comprehensive geriatric
assessment
Lab work (rule out malnutrition, dehydration, some form of
cancer; coagulapathies, other illnesses)
X-rays-left forearm
Confusions Assessment Method rule out delirium
Medication review
Separate interviews with Mary and her daughter
Screening examinations for possible dementia and/or depression
Next: Mary’s Outcomes
Case Study
Physician Recommendations:
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physician
recommendations
In-home services were recommended, with respite care.
Nutritional supplements were ordered for Mary.
A report was made to APS.
Another appointment was scheduled in two weeks, and the nurse
was asked to follow-up with Mary by phone within one week.
Next: Recap of Case
Case Study: Is this Abuse?
It is possible abuse.
The physician recognized that Mary’s daughter was under extreme
pressure, a risk factor for elder abuse. He referred Mary to APS for
determination of abuse, but also to provide Mary’s daughter access
to resources and services to keep Mary safe.
Physicians are often fearful that the patient/doctor relationship could
be compromised if they question whether abuse exists.
Physicians can put the need to refer in the context of assisting with
referrals and needed services for the patient and the caregiver.
Conclusions
• Physicians and other clinicians will see cases of elder abuse in their
practice.
• Know how to recognize the problem and screen for abuse.
• Document, assess and refer for appropriate care.
The steps taken in the clinic can make
a significant impact on the life of an elder.
References
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Acierno, R., Hernandez, M.A., Amstadter, A.B., et al. 2010. Prevalence and correlates of
emotional, physical, sexual and financial abuse and potential neglect in the United States:
the National Elder Mistreatment Study. American Journal of Public Health, 100(2), pgs.
292-297.
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Ahmad M, Lachs MS: “Elder abuse and neglect: What physicians can and should do.”
Cleveland J of Med. 69(10). October 2002.
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American Medical Association, Diagnostic and Treatment Guidelines on Elder Abuse and
Neglect. Chicago, IL: American Medical Association, 1992. www.amaassn.or/ama1/pub/upload/mm/386/elderabuse.pdf

Brandl B, Dyer CB, Heisler C, Otto JM, Stiegel L, Thomas, TW. Enhancing victim safety
through collaboration. Care Management Journals 7(2), Summer 2006. 64-72
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Harrell R, Toronjo C, Pavlik VN, Hyman DJ, McLaughlin J, Dyer CB: “How geriatricians
identify elder abuse and neglect.” Am J of Med Sci, 323(1):34-38, 2002.
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McGreevey JF. Elder Abuse: the Physician’s Perspective. Clinical Gerontologist. 28(12)2005.
pp 83-103.
References (cont.)
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McGuire P, FulmerT: Elder abuse. In Cassel CK et al.(Ed). Geriatric Medicine, 3rd ed., 855859. New York: Springer-Verlag., 1997.
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National Center on Elder Abuse (2006).
http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx
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National Center on Elder Abuse.
http://www.ncea.aoa.gov/ncearoot/Main_Site/Find_Help/APS/About_APS.aspx
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National Center on Elder Abuse. http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx
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National Center on Elder Abuse.
http://www.ncea.aoa.gov/ncearoot/Main_Site/pdf/publication/NCEA_WhatIsAbuse2010.pdf
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Texas Elder Abuse and Mistreatment (TEAM) Institute website is located at
http://www.uth.tmc.edu/schools/med/imed/divisions/geriatrics/team-institute.html
Photographs used for the cover slide are allowed by the MorgueFile free photo agreement and the
Royalty Free usage agreement at Stock.xchng. They appear on the cover slide in this order:
Wallyir at morguefile.com/archive/display/221205
Mokra at www.sxc.hu/photo/572286
Clarita at morguefile.com/archive/display/33743
The Training Excellence in Aging Studies (TEXAS) program
promotes geriatric training from medical school through the
practicing physician level. This project is funded by the Donald
W. Reynolds Foundation to the division of Geriatrics and
Palliative Medicine within the department of Internal Medicine
at The University of Texas Health Science Center at Houston
(UTHealth)
TEXAS would also like to recognize the following for contributions:
Houston Geriatric Education Center
Harris County Hospital District
Memorial Hermann Foundation
The TEXAS Advisory Board
Othello "Bud" and Newlyn Hare
UTHealth Medical School Office of the Dean
UTHealth Medical School Office of Educational Programs
UTHealth School of Nursing
UTHealth Consortium on Aging