Barbara A. Reilley, PhD, Sabrina Pickens, MSN, and Carmel B. Dyer, M.D. The University of Texas Health Science Center

1. Identifying and Intervening in Cases of Elder Abuse Part 2 of 3: Screeningand Intervening Barbara A. Reilley, PhD, Sabrina Pickens, MSN, and Carmel B. Dyer, M.D. The University of Texas Health Science Center at Houston

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.

3. 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

4. Why Should I Identify Cases of Elder Abuse? Page 1 of 2 • 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) • 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.

5. Why Should I Identify Cases of Elder Abuse? Page 2 of 2 • 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. • 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.

6. 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.

7. 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

8. 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

9. 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.ama-assn.or/ama1/pub/upload/mm/386/elderabuse.pdf

10. Acceptable Question It is acceptable to simply ask,“Have you been abused?”

11. Physician Best Practices Page 1 of 2 Be alert for unusual behavior and clues to possible abuse. 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.

12. Physician Best Practices Page 2 of 2 Be alert for unusual behavior and clues to possible abuse. McGreevey JF. Elder Abuse: the Physician’s Perspective. Clinical Gerontologist. 28(12)2005. pp 83-103.

13. 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 throughfear 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.

14. Physician Best Practices Page 1 of 2 • 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). Be alert for physical signs such as:

15. Physician Best Practices Page 2 of 2 • 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. Be alert for physical signs such as:

16. Intervention Strategies A patient diagnosed with dementia and having behavioral problems. 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. 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.

17. Intervention Strategies A patient diagnosed with dementia and having behavioral problems. Caregiver abuse of a patient with dementia. • 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. 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.

18. Intervention Strategies A patient diagnosed with dementia and having behavioral problems. A mentally ill patient who assaults his or her parents. • Provide a psychiatric referral for the abuser. • Suggest mental health counseling for the victim. • Suggest alternative living arrangements. 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.

19. Intervention Strategies A patient diagnosed with dementia and having behavioral problems. A patient with decisional capacity refusing treatment. • Contact Adult Protective Services. • Educate the patient about possible dangers. • Provide emergency contact numbers. • Follow-up. • Develop a safety plan. 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.

20. Intervention Strategies A patient diagnosed with dementia and having behavioral problems. 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. 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.

21. 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

22. 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.

23. 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.

24. 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

25. 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

26. APS Limitations Adult Protective Services • 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 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.

27. The Interdisciplinary Approach Physicians may take an interdisciplinary team approach using formal and informal relationships with:

28. A Model of the Interdisciplinary 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. more info 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.

29. 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 interdisciplinary team meets and formulates a care plan for the abused elder. • The care plan is implemented, and follow-up is provided as necessary. • Texas Elder Abuse and Mistreatment Institute more info Click for • http://www.uth.tmc.edu/schools/med/imed/divisions/geriatrics/team-institute.html

30. 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_Resources.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

31. 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.

32. Case Study 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. patient presentation questions to consider comprehensive geriatric assessment assessment outcomes physicianrecommendations Patient Presentation: Next, let’s consider some questions.

33. Case Study 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? patient presentation questions to consider comprehensive geriatric assessment assessment outcomes physicianrecommendations Let ‘s look at Mary’s Comprehensive Geriatric Assessment next.

34. Case Study 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 patient presentation questions to consider comprehensive geriatric assessment assessment outcomes physicianrecommendations Let’s look at the assessment.

35. Case Study 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. patient presentation questions to consider comprehensive geriatric assessment assessment outcomes physicianrecommendations Next, physician recommendations.

36. Case Study 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. patient presentation questions to consider comprehensive geriatric assessment assessment outcomes physicianrecommendations Recap of case

37. Case Study 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. patient presentation questions to consider comprehensive geriatric assessment assessment outcomes physicianrecommendations

38. 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.

39. 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.

40. 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