Transcript Slide 1

Identifying and
Intervening in Cases of
Elder Abuse
Part 2 of 3: Screening
and Intervening
Barbara A. Reilley, PhD,
Sabrina Pickens, MSN, and
Carmel B. Dyer, M.D.
The University of Texas Health Science Center
at Houston
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
National Center on Elder Abuse: http://www.ncea.aoa.gov/NCEAroot/Main_Site/pdf/publication/NCEA_WhatIsAbuse-2010.pdf
Why Should I
Identify Cases of Elder Abuse?
Page 1 of 2
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.
(Ahmad M, Lachs
MS: Elder abuse and
neglect: What
physicians can and
should do. Cleveland
J of Med. 69(10).
October 2002)
Why Should I
Identify Cases of Elder Abuse?
Page 2 of 2
• 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
interdisciplinary approach, can be very
effective.
11% reported abuse:
Acierno, R.,
Hernandez, M.A.,
Amstadter, A.B., et al.
2010. Prevalence and
correlates of
emotional, physical,
sexual and financial
abuse and potential
neglect n the United
States: the National
Elder Mistreatment
Study. American
Journal of Public
Health, 100(2), pgs.
292-297.
How to Screen for Elder Abuse
Page 1 of 3
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.
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.
Ahmad M, Lachs MS: “Elder abuse and neglect: What
physicians can and should do.” Cleveland J of Med. 69(10).
October 2002.
How to Screen for Elder Abuse
Page 2 of 3
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.
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
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
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
Screening Questions to Ask of Elders
•
Has anyone at home ever hurt you?
•
Has anyone ever made you do things you did not want to do?
•
Has anyone taken something that belongs to you without asking?
•
Does anyone scold or threaten you, recently or in the last few
years?
•
Have you ever signed documents you do not understand?
•
Are you afraid of anyone that lives with or cares for you?
•
Are you alone often?
•
Has anyone ever failed to assist you when you needed help?
American Medical Association, Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. www.amaassn.or/ama1/pub/upload/mm/386/elderabuse.pdf
Acceptable Question
It is acceptable to simply ask,
“Have you been abused?”
Physician Best Practices
Page 1 of 2
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?
McGuire P, FulmerT: Elder abuse. In Cassel CK et al.(Ed). Geriatric Medicine, 3rd ed., 855-859. New York: Springer-Verlag.,
1997.
American Medical Association Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago, IL: American
Medical Association, 1992.
Physician Best Practices
Page 2 of 2
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 of physical
impairment?
The patient has
unexplained or unusual
injuries.
McGreevey JF. Elder Abuse: the Physician’s Perspective.
Clinical Gerontologist. 28(12)2005. pp 83-103.
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.
McGreevey JF. Elder Abuse: the Physician’s Perspective. Clinical Gerontologist. 28(12)2005. pp 83-103.
Physician Best Practices
Page 1 of 2
Be alert for physical signs such as:
– 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).
Physician Best Practices
Page 2 of 2
Be alert for physical signs such as:
– 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.
An abused elderly patient
without the capacity for
decision-making.
A patient diagnosed with dementia
and having behavioral problems.
 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.
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.

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 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.

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.
A patient with decisional capacity
refusing treatment.
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.
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.



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
• 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.
National Center on Elder Abuse (2006) http://1.usa.gov/ElderAbuseResources
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
• International Statistical Classification of Diseases (ICD) and
Diagnosis-Related Group (DRG) codes for abuse are rarely
used by physicians.
• Why? Because:
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.
http://www.ncea.aoa.gov/ncearoot/Main_Site/Find_Help/APS/About_APS.aspx
Adult Protective Services
APS Interventions:
• 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
http://www.ncea.aoa.gov/ncearoot/Main_Site/Find_Help/APS/About_APS.aspx
Adult Protective Services
APS Limitations
• An APS client’s wishes and interest supercedes the wishes
and interests of the family and the community.
• The plan to manage the case must maximize selfdetermination 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 Interdisciplinary Approach
Physicians may
take an
interdisciplinary
team approach
using formal
and informal
relationships
with:
A Model of the Interdisciplinary
TEAM Approach
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.
more info
The Texas Elder Abuse and
Mistreatment (TEAM)
Institute
Click for
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
• The client is referred by APS or other parties for
physical and/or capacity assessment.
• Clinicians conduct a comprehensive geriatric
assessment and assess capacity, if needed.
• The care plan is implemented, and
follow-up is provided as necessary.
Click for
http://www.uth.tmc.edu/schools/med/imed/divisions/geriatrics/team-institute.html
more info
• The interdisciplinary team meets and
formulates a care plan for the abused elder.
Where and How to Report
• 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.
• Report even if it is not required in a specific state of practice.
• 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_Res
ources.aspx
• Or Call the Eldercare Locator at 1-800-677-1116
National Center on Elder Abuse: http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx
Case Study
• On the next few screens you will be presented with a
case. Consider the patient and the caregiver, and
their needs as you review the content.
• After you are given the case’s Patient Presentation,
you will find images on the top of the screen, click
through them to learn more or just click the button at
the bottom of each screen to go through the case.
Case Study
patient presentation
questions to consider
comprehensive geriatric
assessment
assessment outcomes
physician
recommendations
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
Next, let’s consider some questions.
speaking sharply with a raised voice.
Case Study
patient presentation
questions to consider
comprehensive geriatric
assessment
assessment outcomes
physician
recommendations
Questions to Consider
Thinking about Mary’s case, how would you answer these questions:
• Is this abuse and/or neglect?
• Is Mary’s daughter’s behavior consistent with caregiver stress?
• What are some alternatives for Mary and her daughter?
• Should the physician make a referral to APS?
Let ‘s look at Mary’s Comprehensive Geriatric Assessment next.
Case Study
patient presentation
questions to consider
comprehensive geriatric
assessment
assessment outcomes
physician
recommendations
Mary’s 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
Let’s look at the assessment.
Case Study
patient presentation
questions to consider
comprehensive geriatric
assessment
assessment outcomes
physician
recommendations
Mary’s Assessment Outcomes
Labs were essentially normal.
• Mary was moderately demented.
• The left forearm was negative for fracture.
• No indication of delirium.
The physician ascertained that the daughter had recent medical
problems, but continued to work and care for Mary. She was also having
financial difficulties.
Next, physician recommendations.
Case Study
patient presentation
questions to consider
comprehensive geriatric
assessment
assessment outcomes
physician
recommendations
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.
Recap of case
Case Study
patient presentation
questions to consider
comprehensive geriatric
assessment
assessment outcomes
physician
recommendations
Is this a case of abuse?
Considering all that you have learned about Mary and her case, is this
a case of abuse or not?
•
•
select any of the case buttons at the top to review the case
or complete the case by choosing one option below:
– Yes, this is a case of abuse, as a physician, I should take steps to help protect
Mary and her caregiver.
– No , it is not a case of abuse.
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.
Learn More
See more on the 3 part series
Identifying and
Intervening in Cases of
Elder Abuse
• Part 1 of 3: Evidence and Identification
• Part 3 of 3: Assessment of Mental Capacity