ELDER AND VULNERABLE PERSON ABUSE, NEGLECT, AND …



6. Screening and Assessment for Elder Mistreatment

Purpose

In 1992, the American Medical Association (AMA) recommended that health care assessment for elder mistreatment follow a routine pattern.[i] The first step is screening for elder mistreatment. If mistreatment is suspected, the next step is to conduct an assessment to identify, evaluate and document any signs of mistreatment and, ultimately, decide if there is reason to believe that mistreatment has occurred.

The purpose of Module 6 is to introduce participants to nursing practices related to screening and assessment of elder mistreatment. It examines the process of asking screening and assessment questions, as well as techniques for enhancing communications with patients and their family members and caregivers. Responses to screening and assessment questions, in conjunction with clinical observation of patients, can help nurses rule out or detect elder mistreatment.

Topics

• Screening and assessment for elder mistreatment: why, when, where, with whom and how.

• Steps in asking screening and assessment questions.

• Enhancing communication with patients and families/caregivers.

Learning Objectives

By the end of this module, participants will be able to:

• Discuss why, when, where, with whom and how screening and assessment with older patients for elder mistreatment should occur;

• Identify steps in interviewing older patients to screen and assess for elder mistreatment;

• Discuss appropriate questions to ask during the screening and assessment process; and

• Describe methods and techniques to communicate with patients, as well as their caregivers and family members, when screening and assessing for elder mistreatment.

Instructor Preparation

Clarify instructor roles in teaching this module. A nurse educator should take the lead, with an elder mistreatment expert and legal expert available to answer questions as they arise.

Preview activities, sequence and time allotments:

1. Small and large group discussions of case study. (30 minutes) (Slides 2-10)

2. Large group discussion of steps in interviewing, as well as screening and assessment questions. (25 minutes) (Slides 11-18)

3. Small and large group discussions using case study from Activity 1 on enhancing communication between nurses and patients. (30 minutes) (Slides 19-26)

4. Small and large group discussions of case study, focused on communications with families and caregivers. (30 minutes) (Slides 27-32)

5. Closing assessment. (5 minutes) (Slide 33)

6. Optional role play activity and debriefing to practice interviewing patients and others who accompany them. (add 75 minutes) (Slides 34-35)

Preview instruction materials for Module 6 in the Instructor’s Guide, Participant Materials and Slides. Note that information from the following key resources is interwoven into this module:

American Medical Association. (1992). Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: Author.

Aravanis, S., Adelman, R., Breckman, R., Fulmer, T., Holder, E., Lachs, M., O’Brien, J., & Sanders, A. (1993). Diagnostic and treatment guidelines on elder abuse and neglect. Archive of Family Medicine, 2, 371–388. Retrieved from .

Anetzberger, G. (Ed.) (2005). The clinical management of elder abuse. Binghamton, NY: Haworth Press.

Flattum Hamp, L. (2003). Appendix B: Analysis of elder abuse and neglect definitions under state law. In R. Bonnie & R. Wallace (Eds.). (2003). Elder mistreatment, abuse, neglect and exploitation in an aging America (pp. 181-237). Washington, DC: The National Academies Press. Retrieved from .

Fulmer, T. (n.d.). Elder mistreatment: Training manual and protocol. New York: New York University, College of Nursing. Retrieved from .

Fulmer, T. (2008). Elder mistreatment assessment. Try this: Best practices in nursing care to older adults. New York: New York University, College of Nursing. Retrieved from .

Levine, J. (2003). Elder neglect and abuse: A primer for primary care physicians. Geriatrics, 58, 37-44. Retrieved from .

Miller, C. (2008) Nursing wellness in older adults (5th ed.) (Chapters 9 and 10). Philadelphia, PA: Lippincott, Williams and Wilkins. Retrieved from .

To the extent possible, become familiar with relevant policy and procedures from participants’ practice settings. If the curriculum is used with participants from a specific facility or number of facilities in the same region, become familiar with their procedures related to screening and assessment for elder mistreatment. Consider developing a participant handout on features of policies/procedures.

Lesson Plan

Activity 1: Case Study Introduction

Briefly introduce the topic. Nurses need to know how to screen, assess and document known/suspected elder mistreatment. The process of screening, assessing and documenting is often referred to broadly as “assessment.” Among medical providers, nurses most often assume major responsibilities for assessing elder mistreatment situations.[ii] (5 minutes) (Slide 2)

• Screening older patients provides nurses a first opportunity to detect elder mistreatment. If there is a suspicion of mistreatment, it can trigger a full assessment. Screening and assessment typically closely follow one another. (Slide 2)

• Screening and assessment by nurses usually does not occur in isolation from other professionals. More typically, others will be involved within the practice setting (doctors, other nurses, social workers, etc.) and, subsequently, from outside the practice setting (law enforcement, APS, long-term care ombudsmen, domestic/sexual violence victim advocates, etc.).

• When referrals to more specialized health care providers experienced in elder mistreatment assessment are warranted (e.g., a forensic nurse examiner, geriatric nurse practitioner or a multidisciplinary team): whether a referral is warranted will depend on facility policy and/or the availability of specialized providers. For example, a nurse’s screening leads her to suspect sexual abuse and her facility has access to a sexual assault forensic examiner program and a policy to activate an examiner in that instance. Or, the facility may have a multidisciplinary team in place (e.g., geriatric nurse, physician and social worker) that takes referrals whenever elder mistreatment is suspected.

Ask participants if there are any specialized providers in their agencies who assess for elder mistreatment.

o Forensic examiner programs typically have their own assessment procedures and forms, often including a checklist of questions they ask patients. Initial screening and history taken by a nurse can inform the forensic nurse’s efforts to gather information.[iii]

Review learning objectives on page 1. (Slide 3)

Ask participants to review the case study and then discuss in small groups the questions below: (10 minutes)

Mr. Rodriguez is a 75-year-old male who has mild dementia and lives with his son. The son brought Mr. Rodriguez in for a routine quarterly appointment with the nurse practitioner to assess control of hypertension and diabetes. The son expressed concern that his father has been more confused, falling a lot and wandering away from their apartment lately. Upon initial examination, the nurse practitioner noticed what appeared to be circumferential abrasions on Mr. Rodriguez’s wrists and ankles and bruising on his chest. She also noted significant weight loss and unkempt appearance in the patient since his last visit. The nurse practitioner is new in her position and is unaware of the clinic’s protocols to deal with what she thinks may be elder mistreatment.

With a few adjustments, this scenario could play out in an emergency department (ED). For example, the patient could have been brought from his home or from a long-term care facility to an ED for any number of reasons. Instructors should feel free to adjust the scenarios as needed to increase the relevance of the scenario to nurses from specific practice settings.

Questions to consider: (Slide 4)

? What do you see as the presenting issues in this case?

? What additional information does the nurse practitioner need in order to proceed/respond effectively to these issues?

? What screening questions could the nurse practitioner ask in her initial conversation with Mr. Rodriguez? With the son?

? Do you foresee any screening/assessment challenges with the patient and the son?

Comments on questions to help guide discussions:

Due to her observation of wrist and ankle abrasions, bruising, weight loss (possible malnutrition) and poor hygiene, the nurse practitioner immediately suspects physical abuse and perhaps neglect of Mr. Rodriguez.

Since she does not have a protocol for what to do, she will have to rely on her clinical skills and experience.

She knows she is required by law to report suspected elder mistreatment.

It is important that she documents what she sees, questions both the patient and the caregiver son to get a better sense of what is going on and assesses immediate danger to Mr. Rodriguez.

She should talk with the patient in private, away from his son. Suggested questions to ask the patient include:

• Can you tell me where, when and how these abrasions and bruises occurred?

• You have lost __ pounds since I last saw you and you seem to be a bit disheveled. Can you talk with me about your weight loss and your appearance?

Away from the patient, the son can be asked how, when and where the injuries occurred and why his father has lost weight and is more disheveled than usual.

The nurse practitioner would also evaluate Mr. Rodriguez’s capacity to make reasonable judgments about his self-care and safety.

Potential challenges to the assessment include:

• Vague answers by Mr. Rodriguez and his son and reluctance to talk about how the injuries occurred;

• The son may not want to leave Mr. Rodriguez alone, as the son may be the perpetrator; and

• Mr. Rodriguez may or may not be cognitively impaired.

Follow the small group discussion with a large group discussion on the questions, weaving teaching points below to confirm what participants know about screening/assessment, identify what they still need to know, and offer information. (15 minutes)

Teaching Points

Screening/assessment: why, where, who, when, how (Slide 5)

? Why should nurses screen and assess?

? Where should screening and assessment take place?

? Who should be screened and assessed?

? When should screening and assessment take place?

? How should screening and assessment be conducted?

Why screen and assess? We discussed the “why” briefly during the introduction to this topic. Screening and assessment provide clinicians an opportunity to detect known or suspected elder mistreatment. Elder mistreatment is known if it is personally observed or reported by the victim or some other person capable of having that knowledge. It is suspected through the identification of signs which represent the consequence of mistreatment. Signs suggest the probability of elder mistreatment.[iv]

Where screening and assessment should occur: in community settings and long-term care facilities. There are many opportunities for nurses to screen in the community: hospitals, clinics, the client’s home, physician and dentist offices, health fairs, senior centers, adult day health programs and religious organizations; and during routine health screenings, such as yearly mammograms. Opportunities also exist in long-term care settings, such as continuing care retirement communities, assisted living facilities, board-and-care homes and nursing homes. (Slide 6)

Ask participants from different settings if they screen for elder mistreatment.

Who should be screened and assessed? Ideally, every vulnerable older adult with whom the nurse interacts should be screened for elder mistreatment. Note that not all health care settings screen every older patient for mistreatment. Rather, some promote or mandate screening and assessment of older adults only in instances where the health care provider identifies someone at high risk and/or hears or observes something that makes them suspicious of elder mistreatment.[v] (Slide 7)

When screening and assessment should occur? Initial clinical observations and a few simple questions to detect elder mistreatment can routinely be included in nurse interactions with older adults. If screening leads to a suspicion of mistreatment, an assessment should promptly follow. Screening and assessment questions—first simple, then more probing—allow health care providers to rule out rather than overlook mistreatment.[vi] (Slide 8)

Ask participants if they know what their practice setting policies are regarding whom to screen for elder mistreatment (all older vulnerable adults or just those who present with signs) and when screening should occur.

How screening and assessment should occur: A standardized plan for screening and assessment of vulnerable older adults for elder mistreatment should be incorporated into an agency’s written policies. It can be woven into patient history taking and the physical examination. (Slide 9)

If training is local or specific to a particular health care facility, review the facility’s screening procedures and forms and what to do with the information obtained.

• Screening and assessment of patients for risk of elder mistreatment can be facilitated through use of assessment tools which have been validated by research among this population. These tools typically require discussion with the patient or others presenting with the patient and examination of the patient. (Slide 10)

• Assessment instruments are tools for organizing information regarding elder mistreatment, ideally ensuring that all mistreatment types are covered. Numerous instruments and protocols are available and are usually tailored to individual settings and within the context of existing state regulations.[vii] There is not one universally accepted tool for all practice settings and disciplines. The Participant Materials offer additional material and resources on assessment tools.

Activity 2: Steps in Interviewing and Questions to Ask

This activity identifies simple steps for interviewing older patients to screen/assess for elder mistreatment. It also discusses questions to ask during screening and assessment, as screening flows naturally into assessment, in conjunction with clinical observations and statements by patients and others accompanying them.

In a large group setting, ask participants what screening and assessment questions they think would be useful to ask older patients to screen/assess for elder mistreatment. Instructors can list their questions and then add others as they present the teaching points below on (1) steps in interviewing, (2) general screening questions, (3) additional questions, and (4) what to do if affirmative answers are received. (25 minutes) (Slide 11)

Teaching Points

Steps for interviewing vulnerable older adults (Slide 12)

1. First ask general questions. Customize them if any initial observations or statements of patients or others suggest elder mistreatment.

2. Then ask more questions as necessary to probe for physical abuse, psychological abuse, sexual abuse, neglect, abandonment and/or exploitation.

3. If you received an affirmative answer regarding a possible incident of elder mistreatment, follow-up to determine: How did it occur? When did it occur? Where did it occur? Who was involved? Other contextual factors?

4. Document statements in the medical record. Document verbatim statements and behaviors/demeanor (e.g., crying or shaking) of patients and others, as well as excited utterances. An excited utterance is a spontaneous statement related to a startling or shocking event or condition, made while the person is under the stress of excitement from the event or condition.[viii] This documentation may have significance in legal proceedings.[ix] Be careful not to document opinions (e.g., “he’s drunk and obnoxious” or “she’s hysterical and overreacting”). See Module 11 for more on documentation.

Step1: Nine general screening questions specific to elder mistreatment were adapted from questions incorporated in the AMA’s Diagnostic and Treatment Guidelines on Elder Abuse and Neglect (1992), which in turn, were drawn from protocols such as those from the Mount Sinai Medical Center and Victim Services Agency Elder Abuse Project, New York, NY (1988).[x] Selection of questions should be adapted to specific population and setting. The nine questions are:[xi] (Slide 13-15)

1. Has anyone at home (or the long-term care facility) hurt you?

2. Has anyone at home (or the long-term care facility) ever touched you without your consent?

3. Has anyone at home (or the long-term care facility) ever made you do things you did not want to do?

4. Has anyone at home (or the long-term care facility) ever scolded or threatened you?

5. Are you afraid of anyone at home (or the long-term care facility)?

6. Are you often left alone at home (or the long-term care facility)?

7. Has anyone at home (or the long-term care facility) ever failed to help you take care of yourself when you needed help?

More specific questions may be asked of residents of long-term care facilities, such as:

8. Since you have been here, has any employee, resident, family member, volunteer or visitor hurt you? OR

9. Since you have been here, has any employee, resident, family member, volunteer or visitor hit, slapped or otherwise hurt you?

Step 2: Additional questions can be asked to probe for different types of mistreatment. Recognize that inconsistencies in responses may suggest the need for further questioning. For example: (Slide 16)

• Are you afraid of anyone at home (or the long-term care facility)?

• Have you been struck, slapped, pushed, choked, kicked or otherwise hurt by someone in your home (or the long-term care facility)?

• Have you been tied down or locked in a room?

• Can you tell me about a time recently when someone made you do things you didn’t want to do?

• Are you ever isolated from people for long periods of time?

• Have you been threatened with punishment or deprivation?

• Have you received the silent treatment?

• Do you routinely receive news or information?

• What happens when you and your caregiver disagree?

• Can you tell me about a time recently when someone talked to or yelled at you in a way that made you feel bad about yourself?

• Has anyone touched you without your permission?

• Has anyone forced you into a sexual activity?

• Do you lack assistive devices, such as eyeglasses, hearing aids, dentures or a walker?

• Have you been left alone for long periods?

• Has anyone failed to help you care for yourself when you needed assistance?

• Are you getting all the help you need?

• Has anyone at home (or the long-term care facility) taken anything that was yours without asking?

• Has anyone at home (or the long-term care facility) had you sign documents that you did not understand?

• Step 3: If YES, suggested responses are: (Slide 17)

• I’m glad you told me about this.

• When was the last time?

• Can you give me an example? How did it occur? When did it occur? Where did it occur? Who was involved?

It may feel uncomfortable to ask these questions in the clinical settings, but, when such questions are not asked, vulnerable older adults may perceive that the door to help is closed or does not exist.[xii] (Slide 18)

Activity 3: Enhancing Communications with Patients

Ask participants, in a small group setting, to discuss the following question (the case of Mr. Rodriguez from Activity 1 could be used as an example): (10 minutes) (Slide 19)

? What communication techniques during screening and assessment might increase the comfort level of the patient and elicit valuable information?

Then ask participants to report back in a large group discussion. During the discussion, incorporate the teaching points below. (20 minutes)

Teaching Points

Note that some of these elements have been explored in Module 5.

Seek informed consent from the patient and explain the scope and limits of confidentiality. Patients should understand that statements and examination findings are documented in their medical record. (Slide 20)

Clients should be aware that information they provide is confidential, except in cases where:

• The health care provider is required to report. Patients should be advised that disclosure of mistreatment might prompt mandatory reporting to law enforcement and/or APS.[xiii] In cases where reporting is not mandatory, health care providers should not report without the permission of the patient.

• Patient medical records may be accessed by legal guardians, APS and/or criminal justice agencies if the case is reported and information is subpoenaed. In the case that the guardian is a suspected perpetrator, guardian access should be denied according to facility/local policies.

Ask about safety and begin safety planning from the start of your interactions with the patient. Directly ask patients if they have any concerns about their safety. Follow best practices in addressing concerns about patient safety during the screening and assessment process. (Slide 20)

Questions should be first directed at patients rather than others who accompany them to promote patient autonomy and safety. (Slide 21)

• Even if a vulnerable older adult has a cognitive disability, it is reasonable to ask about mistreatment, since diminished cognitive capacity does not necessarily negate the person's ability to describe mistreatment. Follow best practice for evaluating the patient’s cognitive status. If the patient has a significant degree of dementia and cannot answer questions about mistreatment, seek out an appropriate respondent who is not likely to be a perpetrator.[xiv] (Slide 21)

Assume the patient is accurate even if there is possible cognitive dysfunction. For example, the patient may be disoriented about time, but accurate about who is doing what to them.

Nurses should assess patients initially in a private setting, away from caregivers and/or family members.[xv] The private setting might be the patient’s bedroom, hospital room or an office or family conference room that is not used by staff or residents on a daily basis. The presence of caregivers and/or family members may influence patient statements (e.g., patients may fear reprisal by abuser). Separate statements from individuals who accompany the vulnerable older adult should be obtained as needed in each case. See the below section on questioning family and caregivers. (Slide 22)

Keep questions simple and direct. Mistreated vulnerable older adults and caregivers rarely admit that abuse is taking place. Therefore, questions about mistreatment, injury and harm need to be asked directly.[xvi] This strategy is particularly important for patients with cognitive disabilities. Use open-ended, single-pointed questions and avoid leading questions. Leading questions are questions that can be answered with a yes or no and in some way suggest an answer.[xvii] (Slide 23)

Find out the patient’s preferred method of communication (e.g., oral language, whether English or another language; use of a translator or interpreter; American Sign Language; written language; body movements; sounds; communication boards or other computer assisted technology; augmentive communication devices; anatomically correct dolls or pictures; or drawing). (Slide 24)

Consider how circumstances of a patient might affect communications and make accommodations where possible (e.g., when a patient is taking certain medication or non-prescribed drugs/alcohol). (Slide 24)

• If the patient requires someone to assist her/him in communicating (e.g., an interpreter), speak directly to the patient, not the person assisting with communications.

• A certified medical interpreter should be available for patients for whom English is a second language or who have hearing impairments.[xviii] Document use of certified medical interpreters in the patient medical record. (Do not have a family member or caregivers serve as interpreters.)

• Some people with cognitive disabilities may come in with their medical records; these might include an individual service plan that indicates how to communicate with them.

• For non-verbal persons: Communicate with non-verbal adults through techniques, such as eye blinking or finger squeezing for yes or no answers.

o Be sure the patient has needed assistive devices, such as eye glasses and hearing aids.

o Allow adequate time for communication.

o Identify cognitive impairment.

o Monitor behaviors, such as restlessness, agitation or vocalizations when family members and/or caregivers are present.

Use communication strategies that encourage patients to talk openly and honestly with you. (Slide 24-25)

• Establish rapport by approaching patient in a warm, caring. and empathic manner:[xix]

o Use “I” messages: “I am concerned about you….”

o Be specific: “Because I see a bruise on your arm…”

o Be sensitive to other’s feelings.

o Be nonjudgmental and non-threatening: “Would you like to talk to me about it?”

o Empower rather than rescue: “Do you want to talk about some of the resources you might use?”

o Help remove any perceived stigma about being abused: “I have often seen people who are not receiving the care that they deserve….”

o With any YES response, state “Thank you for sharing that with me.”

• Anticipate and work to overcome reluctance to disclose mistreatment. Barriers to disclosure, seeking help and/or reporting have been discussed in previous modules. For example, the patient may not want to report abuse or the abuser because of shame or fear of abandonment or retaliation. The patient may be reluctant to undress and reveal injuries. To overcome reluctance, make a statement that paves the way for the patient to open up. For example, if you note bilateral bruising or other signs of physical abuse, you might say, "Injuries like this usually don't happen by accident. Perhaps someone else was involved." Ask the patient directly about the possibility of mistreatment.

o Believe the account of the mistreatment and assure the patient you take mistreatment seriously. Let the patient know that mistreatment can happen to anyone; the patient is not to blame.

o Offer options and information about resources.

o Allow the victim to make decisions about next steps as much as possible (returning power to the victim).

Particularly in family violence in later life situations, recognize that many patients may deny mistreatment or refuse to discuss it. Screening and assessment can still be a powerful tool to let patients know that there is support available if and when they are ready to use it. Even if they do not take action immediately, screening and assessment leave the door open for future discussion and intervention.[xx] (Slide 26)

Activity 4: Questioning Family and Caregivers

This activity examines techniques and methods for communicating with and/or interviewing family members and caregivers who accompany the vulnerable older adult to the health care setting (or those who alert others of suspicion within a home or long-term care facility if there is any suspicion of mistreatment.

Ask participants to review the case study below and then discussion the questions in a small group setting. (15 minutes)

Mr. Jones, an 83 year old male, is transported to the emergency department (ED) by ambulance. Mr. Jones lives in his own home and is cared for by employees of a local home health agency. This is the second time in one week that Mr. Jones has been brought to this ED. With the first visit, his primary live-in caregiver, Tom, came with Mr. Jones. With the current visit, Mr. Jones is accompanied by Rita, a caregiver who often works when Tom has scheduled time off. Mr. Jones’s nephew, Bob, has also arrived at the ED, as Rita notified Bob that Mr. Jones was again being transported to the ED.

Upon arrival, Mr. Jones is short of breath and has a tympanic membrane temperature of 101 degrees Fahrenheit. The triage nurse prioritizes Mr. Jones’s case; Mr. Jones is taken back for treatment by the emergency team.

Rita and Bob start talking in the waiting area within earshot of the triage nurse. Rita tells Bob that she found Mr. Jones alone and in his current condition in his room. She also says that, during handoff, Tom told her not to pay attention to “the old trouble-maker.”

Rita also related how Tom was angry after Mr. Jones’ last ED visit and hospital admission because a hospital social worker asked questions that insinuated that he might be abusing Mr. Jones. In addition, he was angry that an APS worker and a police detective came to the house “nosing around.” Rita seems nervous and says to Bob, “I’m not trying to get anyone into trouble; I’m only trying to help. I don’t want to lose my job.”

The nephew seems furious. He pushes Rita aside, confronts the triage nurse and yells, “I think they are trying to kill him at that place and you people don’t care! I’m not leaving him alone with you or that witch who brought him here! I want you to make sure that they get what they deserve! He’s my uncle and I’m warning you to take care of it!” He demands to be taken back to the bay where his uncle is being treated.

Questions to consider: (Slide 27)

? How will you, as the nurse, approach the situation given your suspicions of mistreatment?

? What challenges will you face with situations like this?

? What questions need to be asked of each person involved? What additional information would be useful to know?

? Does the nephew have the authority to tell you how to handle this case? What strategies will you use to talk with Mr. Jones in private?

Comments on questions to guide discussions:

Talking to the patient may be challenging, both because he may not be physically able and the nephew may not leave the area. However, an attempt should be made to get a history from the patient, away from the nephew. The nurse can use techniques listed below to deal with hovering family members.

Getting the nephew to calm down, stop issuing orders and provide his view of the situation will be a challenge.

The nurse will need to talk with Rita, but again, away from the nephew.

A social worker should find out the nephew’s role in caring for Mr. Jones—is he the legal guardian or holder of power of attorney? Are there any other immediate family?

Why has this patient reappeared when the hospital already contacted law enforcement and APS during his latest admissions? What was supposed to happen after this contact—with the patient, the nephew, the caregiver and the facility?

Then ask participants to report back as part of a large group discussion. Incorporate the teaching points below. (15 minutes)

Teaching Points

Get statements from others who accompany the patient. The likelihood of detecting or ruling out elder mistreatment increases as the net of observation and inquiry made by clinicians is widened.[xxi] Ideally, obtain statements from others after talking alone with the patient (even in instances where you feel the patient lacks decision-making capacity). Nurses should record verbatim statements made by others who accompany the patient to explain or support the patient’s statements or findings from the assessment. Discrepancies should be noted. (Slide 28)

• Recognize that others may be reluctant to disclose mistreatment for some of the same reasons as the patient. Nurses need to ask direct questions about mistreatment.

If a patient’s decision-making capacity is questionable, ask if there is a legal guardian or holder of power of attorney. (If the patient can’t tell you, those who accompany the patient may have this role or be aware of the situation). Follow related facility/practice setting policy, including what to do if that person is a suspected perpetrator. Ask participants about related policies they follow.

Module 5 discusses nursing response in instances where a patient does not have capacity to make health care decisions.

Some additional considerations:[xxii] (Slide 29)

• Adults who lack capacity to make decisions and, as a result, cannot protect themselves or their assets are at risk for mistreatment. Incapacitated vulnerable adults can be protected through a spectrum of interventions, ranging from advance directives to assignment of power of attorney and placement under guardianship/conservatorship (including limited guardianship/conservatorship).

o Advance directives, such as a living will, describe an individual's choices regarding medical care and end-of-life decisions. They are created "in advance" of an incapacitating event (e.g., a stroke).

o A durable power of attorney (DPOA), also created in advance of incapacitation, is a document that allows an individual (known as the principal) to name someone to act on his or her behalf (known as the agent) if circumstances warrant surrogate decision-making in the future.

o Guardianship/conservatorship, the most restrictive legal mechanism for protection of vulnerable adults, assigns responsibility for the incapacitated adult's welfare to a court- appointed individual. The court monitors such situations.

If the suspected perpetrator presents with the patient: Patient and staff safety are a priority. Do not hesitate to call for security personnel if a visitor or family member is threatening a patient or staff. If safety is not an issue, statements should be sought from the patient and suspect, separately and together as appropriate (be cautious about bringing them together if any information provided by the patient will be discussed/shared). Talking with them together allows clinicians to observe interaction. Separate discussions facilitate individual candor and enable comparison of accounts.[xxiii]

• If a caregiver is suspected of elder mistreatment:[xxiv] (Slide 30)

o It is important to observe the speech, tone and touch interaction between the patient and caregiver as it can reflect caring, tension, disrespect, blaming, confronting, arguing, correcting, etc.

o Indirect clues that can suggest mistreatment can include a caregiver who appears to lack concern about or interest in the medical visit, closely monitors the interaction between patient and provider, is overly protective or solicitous to the patient, treats the patient like an infant, answers questions directed to the patient, provides answers that conflict with those of the patient, refuses to leave the room when asked and/or is hostile or uncooperative.

o Some red flags that increase the vulnerability for or probability of mistreatment include: isolation of the vulnerable older adult, a history of elder mistreatment, caregiver dependence on the older adult for shelter and/or money, the caregiver’s perception of his or her stress, a vulnerable older adult and/or caregiver who has a mental illness or substance abuse problem, and a vulnerable older adult’s inability to defend herself/ himself.

A perpetrator of elder mistreatment can be charming and manipulative or disruptive and threatening, among other behaviors, to the older adult, responders or both.

• Nurses should not confront or accuse a caregiver they suspect is mistreating an older patient. It can place the nurse at risk and the patient at risk for additional abuse from retaliation. Non-judgmental ways to start a discussion with a caregiver suspected of mistreating a vulnerable older adult include:[xxv] (Slide 31)

o What does your _____ (e.g., father/mother) need help with every day?

o How do you and your ______ handle disagreements?

o What expectations does your ______ have of you?

o Is caring for your _____ different than you thought it would be? How?

o Sometimes providing care for a family member is challenging. What do you do or who do you tell when you are feeling stressed?

If others who accompany the patient do not want you to talk with the patient alone: Nurses may need to be creative in separating “hovering” family members or caregivers (including those who may be perpetrators) from patients to create a window of time to ask questions of patients, such as asking for time alone so the patient can give you a urine sample; explaining that it is clinic policy to have five minutes alone with each patient; taking the patient down the hall for a “procedure” or “test.” Trust your judgment regarding suspicions about mistreatment. (Slide 32)

Ask participants what strategies they have used to talk with patients alone.

Activity 5: Closing Assessment

Ask participants to write down one thing they have learned from this module that they can apply to their practice setting. Then ask them to share what they learned with the large group. (Slide 33)

Also share suggestions for additional reading as listed in the Participant Materials.

Activity 6 (Optional): Interviewing Patients, Family Members and Caregivers

Briefly introduce activity: In each of the following scenarios, participants will role play as nurses, patients and family/caregivers. The group must identify what information the nurse should gain from the patient. Then, others presenting with the patients in each scenario (e.g., family members, caregivers and staff) will be screened by the nurse. The scenarios offer varying amounts of information. In all scenarios, the patient has been physically examined to some degree and some explanation of what happened has been provided.

The purpose of these role plays is to allow nurse participants to practice interviewing those involved in different situations of potential elder mistreatment. In particular, the activity is intended to allow participants to practice using caring communications when interacting with patients and others; making accommodations appropriate for communicating with patients/others in each situation; asking questions that will elicit important information; and overcoming barriers to disclosure.

Ask participants to form groups of three and then identify who will be role player A, B and C. Put a chart on the wall that shows: (Slide 34)

• Round 1: A (Observer), B (Nurse), C (Patient/Other)

• Round 2: A (Nurse), B (Patient/Other), C (Observer)

• Round 3: A (Patient/Other), B (Observer); C (Nurse)

Participants’ letters stay the same for all three rounds; however, their roles will rotate based on the instructor’s assignments. There are three rounds so that each group has the opportunity to role play each of the three scenarios.

Give directions for the role play activity and a time allotment. Each round will have two 5-minute role plays, followed by a 15 minute debriefing, total 25 minutes each.

For each scenario, ask the nurse to role play (1) what she/he would do to maximize communication with the patient; and (2) how she/he would go about questioning the patient to detect or rule out elder mistreatment. Then, ask the nurse to role play questioning the other person who presents with the patient.

Debrief after each round with the questions below.

Case 1

A 78-year-old female patient is brought to the local urgent care center and taken to the treatment area accompanied by her 79-year-old husband. She is alert and oriented. She is holding a kitchen towel to her head where you observe a fresh two inch laceration to the top of head and bruising to her right forearm along the ulnar surface. You ask the husband to step out into the waiting room, but he states that she will want him to stay with her because she is afraid of doctors and nurses. He states his wife fell down in the garage and cried out for his help. Both state that she did not lose consciousness.

Case 2

An 83-year-old male is brought into the emergency department (ED) via non-emergency private ambulance from a skilled nursing facility. The patient is only minimally verbal secondary to a CVA (cerebrovascular accident, also referred to as a stroke) years ago, but appears to understand all verbal requests to transfer from the ambulance gurney to the ED bed. EMS personnel indicate that nursing facility staff said the patient had pulled out his Foley catheter again and needed a new one. While undressing the patient, you assess numerous bruises to his chest, arms and back in various stages of healing and long semi-circular shaped bruises to his anterior thighs. You ask what happened and the patient begins to cry.

Case 3

An 87-year-old female is brought to the emergency department (ED) by ambulance. She is accompanied by her neighbor who found her lying on the floor in her house and called 911. The patient is mentally alert, but physically frail and currently in a weakened condition. She has significant vision loss. She depends on her son, who lives with her, to help with her with most of daily living activities—meal preparation, cleaning/home maintenance, bathing, dressing, shopping and administering her medications. Upon initial examination, you find she has a fractured hip and is dehydrated, malnourished, hypertensive and short of breath. She has unwashed clothing and reports that she has not been bathed in over a week. She has been incontinent of urine and stool. When you ask what happened, the patient says she fell on her way to the bathroom yesterday and could not get up to call for help. She also said that, for a couple days prior to the fall, she had not been able to find her medications for high blood pressure and emphysema. You ask where her son was and the patient reluctantly admits she had not seen or heard from him for the last week. When asked how often these periods of absences on her son’s part occurred, the patient evasively replies that her son does his best to help her but he has his own problems to deal with. She mentions that he has difficulty holding a job and she writes him checks from “time to time” to help him financially.

Debriefing Process Questions: (Slide 35)

Ask the patient (if she/he was questioned):

? What did the nurse do that you found helpful (e.g., help you overcome reluctance to disclose mistreatment, address your communication challenges, etc.)?

? What would you like the nurse to do to further help you?

Ask the other person presenting with the patient (if she/he was questioned):

? What did the nurse do to gain information from you to detect any possible mistreatment of the patient or about any unexplained injuries?

? What else could the nurse have done?

Ask the nurse:

? What did you do that worked in this screening situation? What would you change?

? What did you do to address challenges?

Ask the observer:

? What behaviors did the nurse demonstrate that were effective in communicating with the patient and screening for elder mistreatment?

? What else could the nurse could have done?

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[i] American Medical Association, Diagnostic and treatment guidelines on elder abuse and neglect (Chicago, IL: Author, 1992).

[ii] C. Miller, Elder abuse: The nurse’s perspective, in G. Anetzberger (Ed.), The clinical management of elder abuse (New York: The Haworth Press, Inc., 2005), 105.

[iii] Questions and interviewing methods used by examiners may need to be adjusted, depending on the needs of the older adult.

[iv] Last three sentences in paragraph from Anetzberger, 28.

[v] American Medical Association, in Diagnostic and treatment guidelines on elder abuse and neglect, urged “every clinical setting” to use a protocol for detecting and assessing elder mistreatment, following a “routine pattern” in each case. Continued research is needed to explore what specific protocols and tools are suitable for detecting elder mistreatment in different clinical settings and for identifying different types of mistreatment. Drawn from R. Bonnie & R. Wallace (Eds.), Elder mistreatment, abuse, neglect and exploitation in an aging America (Washington, DC: National Academies Press, 2003), 104. See .

[vi] T. Fulmer, Elder mistreatment: Training manual and protocol (New York: College of Nursing, New York University, n.d.), 14, (2010).

[vii] Fulmer, 24.

[viii] Noted in W.J. Murphy, Admission of excited utterance to police officer in domestic violence case upheld (Indiana Court of Appeals, Fowler v. Indiana, June 14, 2004), .

[ix] Some states, e.g., California, do not use the term “excited utterance.” Other states, as well as federal rules of evidence, do use this term.

[x] P. Ansell & R. Breckman, Elder mistreatment guidelines for health care professionals: Detection, assessment and interventions (New York: Mount Sinai/Victim Service Agency, 1988).

[xi] Also see the Hwalek-Sengstock’s Elder abuse modified screening test (1986, modified 1999)—it offers six questions to do a simple screening for elder abuse: (1) Are you afraid of anyone in your family? (2) Has anyone close to you tried to hurt or harm you recently? (3) Has anyone close to you called you names or put you down or made you feel bad recently? (4) Does someone in your family make you stay in bed or tell you you're sick when you know you aren't? (5) Has anyone forced you to do things you didn't want to do? (6) Has anyone taken things that belong to you without your OK? Drawn from R. Wolf, Risk assessment instruments, National Center on Elder Abuse Newsletter (2000), .

[xii] T. Fuller, Try this: Elder mistreatment assessment (Online video) (New York: College of Nursing, New York University, 2008), go to .

[xiii] B. Brandl, Assessing abuse in later life (Madison, WI: National Clearinghouse on Abuse in Later Life, Wisconsin Coalition Against Domestic Violence, 2004), 5, .

[xiv] Bullet from S. Aravanis, R. Adelman, R. Breckman, T. Fulmer, E. Holder, M. Lachs, J. O’Brien & A. Sanders, Diagnostic and treatment guideline on elder abuse and neglect, Archive of Family Medicine, 2 (1993), 373, .

[xv] Aravanis, Adelman, Breckman, Fulmer, Holder, Lachs, O’Brien & Sanders, 373.

[xvi] K. Foland, Native American elders, health care series, South Dakota State University (Module 3), prevention and treatment of two critical health care issues: Substance abuse and elder abuse (Section 4) (Philadelphia, PA: University of Pennsylvania Institute of Aging, n.d.), .

[xvii] One resource is Office for Victims of Crime, Victims with disabilities: The forensic interview, techniques for interviewing victims of crime with communication or cognitive disabilities (Training DVD and trainer’s guide free except for DVD shipping costs) (Washington, DC: Office of Justice Programs, U.S. Department of Justice, 2007), .

[xviii] Brandl, 5.

[xix] Bulleted list from E. Siegel, Tips for caring communication, looking beyond the hurt (St John’s, Newfoundland, Canada: Senior Resource Centre of Newfoundland and Labrador, 2004), .

[xx] Brandl, 9.

[xxi] Anetzberger, 29.

[xxii] From National Center on Elder Abuse, Guardianship and other legal protections of vulnerable adults (Newark, DE: Author, last modified 2007), .

[xxiii] Anetzberger, 29.

[xxiv] Bulleted list from R. Chez, Elder Abuse: An Introduction for Clinicians (Slide presentation) (Washington, DC: American College of Obstetricians and Gynecologists, 2009), .

[xxv] Chez. Another resource is E.J. Lindbloom, How can we identify the physical and psychological markers of abuse and neglect? (Summary of presentation) (Elder Justice Roundtable: Medical Forensic Issues Concerning Abuse and Neglect, U.S. Department of Justice Nursing Home Initiative, 2000), .

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Total Time

2 hours

3.25 hours with optional activity

30 minutes total

Slides 2 -10

25 minutes total

Slides 11-18

30 minutes total

Slides 19-26

30 minutes total

Slides 27-32

5 minutes total

Slide 33

75 minutes total

Slides 34-35

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