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

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. American Medical Association, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American Nurses Association, and the American College of Emergency Physicians Page 1 of 2 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?

5. Elder abuse is common and a growing public health concern (11% of adults age 60 years or older reported 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. 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.

6. How to Screen for Elder Abuse 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. 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. Page 1 of 3

7. How to Screen for Elder Abuse 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 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. Elder persons usually will not admit to abuse or neglect unless probed. Patient safety is paramount in intervention efforts. Page 2 of 3

8. How to Screen for Elder Abuse 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 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 Page 3 of 3

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

11. 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 had frequent visits to the ER? Has the patient changed his or her caregiver? McGuire P, FulmerT: Elder abuse. In Cassel CK et al.(Ed). Geriatric Medicine, 3 rd 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. Page 1 of 2

12. 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.” The patient has unexplained or unusual injuries. Does the caregiver have a mental of physical impairment? McGreevey JF. Elder Abuse: the Physician’s Perspective. Clinical Gerontologist. 28(12)2005. pp 83-103. Page 2 of 2

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 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.

14. Physician Best Practices – 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: Page 1 of 2

15. Physician Best Practices – 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: Page 2 of 2

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

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

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

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

20.  Contact Adult Protective Services.  Assist agencies with guardianship and/or conservatorship recommendations.  Provide referrals and resources for financial management. An abused elderly patient without the capacity for decision-making. Caregiver abuse of a patient with dementia. Caregiver abuse of a patient with dementia. A patient diagnosed with dementia and having behavioral problems. A patient diagnosed with dementia and having behavioral problems. 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. 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. Intervention Strategies

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. 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. Barriers to Physician Reporting of Elder Abuse

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 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. Adult Protective Services

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

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. 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. more info Click for

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. m o r e i n f o 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_Res ources.aspx 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

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. 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, let’s consider some questions. patient presentationassessment outcomesphysician recommendations questions to considercomprehensive geriatric assessment Case Study

33. 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. patient presentationassessment outcomesphysician recommendations questions to considercomprehensive geriatric assessment Case Study

34. 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. patient presentationassessment outcomesphysician recommendations questions to considercomprehensive geriatric assessment Case Study

35. 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. patient presentationassessment outcomesphysician recommendations questions to considercomprehensive geriatric assessment Case Study

36. 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 patient presentationassessment outcomesphysician recommendations questions to considercomprehensive geriatric assessment Case Study

37. 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. Yes, this is a case of abuse – No, it is not a case of abuse. No, it is not a case of abuse patient presentationassessment outcomesphysician recommendations questions to considercomprehensive geriatric assessment Case Study

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. 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. Conclusions The steps taken in the clinic can make a significant impact on the life of an elder.

40. 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 Learn More