Elder Abuse Module 3 The Health Care Provider’s Role in Intervention

1. Elder AbuseModule 3The Health Care Provider’s Role in Intervention Debra Mostek, M.D Asst. Professor Section of Geriatrics UNMC, 981320 Omaha, NE 68198-1320 demostek@unmnc.edu April 2006

2. 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

3. Objectives • Discuss the health care provider’s role in developing interventions to aid victims of elder mistreatment • Discuss the limitations of interventions

4. Elder mistreatment and the health care provider • 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)

5. The health care provider’s role • Documenting elder mistreatment • Cognitive evaluation • Determine decision-making capacity • Assess safety: is inpatient admission necessary to protect elder from immediate danger? • Home health care

6. 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

7. The health care provider’s role 3 • 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

8. 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

9. APS Interventions • 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

10. 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

11. APS Interventions • 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.

12. APS use and nursing home placement • 2812 community-dwellers followed for 9 years (New Haven EPESE) • 202 referred to APS; Nursing Home Placement rates: • 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

13. Key Issues • 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

14. 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

15. “At Risk” Patients • Consult Home Health Care Agency • In home services • Meals on Wheels • Housekeeping services • Home health aide • House calls • Respite care to lessen caregiver burden

16. Legal Interventions • Letters outlining medical and recommendations for interventions • Rarely testify in court

17. Testifying in Court • 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

18. 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

19. Web Based Resources • Texas Elder Abuse and Mistreatment Institute. teaminstitute.org • American Medical Association. Diagnostic and treatment guidelines on elder abuse and neglect. www.ama-assn.org/ama1/pub/upload/mm/386/elderabuse.pdf • National Center on Elder Abuse http://www.elderabusecenter.org

20. 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

21. 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 Home-Based 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

22. 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.

23. 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?

24. 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.

25. 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.

26. 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