Screening for Elder Abuse

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1 Screening for Elder Abuse Silvia Perel-Levin Fulda, 31 May 2012

2 Outline Screening: definitions and principles Existing tools for detecting elder abuse Should we screen? The debate Barriers Interventions and implications for practice

3 Screening - Definitions Different jargons among different professions Screening Population Screening Case finding Early detection Diagnostic evaluation Assessment

4 Screening - Definitions A public health service in which members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test, to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of a disease or its complications. (UK, NSC, 2005)

5 Screening - Definitions Screening for violence: Assessment of current harm or risk of harm from family and intimate partner violence in asymptomatic persons in a health care setting. Individuals presenting with injuries from family violence undergo a diagnostic, not screening, evaluation. Universal screening means assessing everyone; selective screening indicates that only those who meet specific criteria are assessed. (US Preventive Services Task Force 2004)

6 Screening principles Important health problem Valid, simple, safe, sensitive tool

7 Screening principles Important health problem Valid, simple, safe, sensitive tool

8 Risk factors ecological model Societal Community Relationship Relationship Individual Societal Community Individual Ageism Social isolation Financial Dementia Dependence Sexism and racism Concentration of poverty Emotional Depression dependence Socio-economic factors Weak police/criminal Justice Living Experienced arrangements abuse Long-term Agression conflict? Intergenerational Dependence or transmission? disability? Gender? Age?

9 Screening principles A double-edged sword?

10 Should primary health care workers screen for elder abuse? Practitioners using structured tools detect more cases of abuse than prevalence studies However Only a minority of doctors routinely ask older people about abuse

11 What kind of tools are used to identify/detect elder abuse? 1. Direct questioning or self-reports of the older adult 2. Inspecting for signs of abuse 3. Evaluating risk indicators of abuse

12 Examples of tools Tool Respondent Characteristics H-S/EAST Hwalek-Sengstock Elder Abuse Screening Test VASS Vulnerability to Abuse Screening Scale EASI Elder Abuse Suspicion Index + EASI SA Older person Older women Older person 15 items To identify situations likely to be abusive or neglectful. 12 items. Adapted from H- S/EAST. 6 items (5 questions and one observation by doctor).

13 Examples of tools Tool Respondent Characteristics BASE The Brief Abuse Screen for the Elderly CASE Caregiver Abuse Screen Trained practitioner Caregiver 5 items To assess likelihood of abuse by caregiver or elder. 8 items (worded to be non-blaming). To identify potentially abusive caregivers.

14 Examples of tools Tool Respondent Characteristics EAI Elder Assessment Instrument Older persons Trained nurses at clinical settings. 41 items in 7 categories Mostly used at emergency department. IOA Indicators of Abuse Screen Trained practitioner to assess caregiver and elder. Check list of 29 items To help identify abuse among health and social services clients.

15 Canadian pocket tools

16 Examples of tools EASI Originally in English and French Has been translated and culturally adapted (WHO project) in Australia, Brazil, Chile, Costa Rica, Kenya, Singapore, Spain, Switzerland. Germany, Israel, Japan

17 Durham Elder Abuse Network Assisted Communication Elder Abuse screening toolkit

18 Examples of tools

19 Examples of tools

20 Examples of tools

21 Examples of tools Recognize, Respond and Refer to Domestic Abuse.

22 Screening and assessment tools Summary Heavy influence of the caregiver model Many tools do not address the client directly Heavy emphasis on physical and psychological abuse Assumptions about dependency/frailty Rights violations/societal level missing

23 Diagnostic and treatment guideline on elder abuse and neglect AMA, 1992 S c r e e n i n g Mistreatment suspected Mistreatment not suspected Report to adult protective services and/or other public agencies Is there an imminent danger? No Can full, private assessment be done now? No Discuss safety issues. Schedule for full assessment, if possible Yes Create safety plan. Options include: hospital admissions, court protective order, safe home placement Yes Assessment: Safety Access Cognitive status Emotional status Health and functional status Social and financial resources Frequency, severity and intent Reason to believe that mistreatment has occurred: plan intervention No mistreatment found

24 Should we screen for elder abuse? The debate Lack of evidence No randomized trials on interventions - No evidence of effectiveness. No generalizability 2003 Canadian Preventive Health Care Task Force and 2004 US Preventive Services Task Force did not recommend one way or the other UK National Screening Committee recommended against screening for Domestic Violence. They did not address older women

25 Should we screen for elder abuse? The debate Primary Health Care PHC may be the only place of contact Abused persons visit PHC more often In the UK, over 90% of population comes into contact with PHC services within five years With higher risk of chronic diseases, PHC becomes a usual and natural point of contact implying an ongoing relationship of trust.

26 Safety Should we screen for elder abuse? The debate Ethical considerations False positives, false negatives Randomized controlled studies? Confidentiality Reporting Autonomy

27 Should we screen for elder abuse? The debate Acceptability Most women are in favour or do not mind Most doctors are against Most older persons have not been asked

28 Should we screen for elder abuse? The debate Routine screening or Routine enquiry?

29 Barriers to screening Both patient and practitioners fear retaliation Fear of offending and or labelling Tyranny of time

30 Barriers to screening Lack of knowledge and training Lack of effective interventions Language/culture/ generational gap Lack of support to PHC workers

31 Barriers to screening Confidentiality Reporting? Mandatory reporting? Lack of interdisciplinary communication PHC staff may experience themselves abuse

32 Barriers to screening Cognitive impairment Lack of trust Lack of privacy Opening Pandora s box

33 Interventions Screening is only a first step. Appropriate referrals Intervention does not mean FIX IT Ecological model

34 Interventions Safety Autonomy?

35 Implications for practice Formal and clear procedures in place Who should screen? More research is needed Participatory research that includes older persons

36 Implications for practice Education and Training Interdisciplinary training Raising awareness E-health and screening

37 Concluding remarks Scientific rigour humanistic model? Respect is better than food or drink An older respondent WHO, 2002 Missing Voices

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