The role of primary health care professionals in detecting abuse and neglect
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1 The role of primary health care professionals in detecting abuse and neglect Caribbean Conference on Ageing, Elder Abuse and the Rights of Older Persons Roseau, Dominica, 30 November 01 December 2015 Presented by: Douladel Tyndale Mona Ageing and Wellness Centre The University of the West Indies, Mona Campus, Jamaica
2 Presentation Outline Elder abuse and neglect Primary Health Care Settings PHC Encounters and identifying elder abuse Protocols for dealing with abuse and neglect Recommendations for future action
3 Elder Abuse and Neglect Single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person Physical Sexual Psychological Financial and material Abandonment Neglect Actions that result in loss of dignity and respect World Health Organization, 2015
4 Extent of the problem Difficult to quantify Underreporting Sparse data from developing countries Global estimate: 1 in 10 older people per month Type-specific prevalence* Physical abuse: % Sexual abuse: % Psychological abuse: % Financial abuse: % Neglect: % *High/middle-income countries-estimated from 1 study World Health Organization, 2015
5 Elder Abuse in the Caribbean Anecdote Occasional publicized incident of mistreatment in nursing homes Physical abuse
6 Financial abuse Trinidad and Tobago
7 Risk Factors for Elder Abuse Older adult characteristics Caregiver characteristics Law & Governance Institution Society Frail/physically dependent Highly stressed Absent or inadequate policy & legislation Poor training Low societal value for elders Cognitively impaired Substance abuse Ill-equipped facilities Financially dependent Socially isolated Bad relationship with care recipient Financially dependent on older person Weak enforcement of laws Poor monitoring systems Dis-satisfied and demotivated staff Low accountability No support system for caregivers
8 Addressing Elder Abuse United Nations Principles for Older Persons (1991) Madrid International Plan of Action on Ageing (2002) Work of the WHO Ageing and Life Course Programme and partners (2002- onward) Work of the WHO and the Centre for Interdisciplinary Gerontology UN ECLAC Policy and legislation Priority area for several ageing agencies within countries Public awareness initiatives Helplines
9 Primary Health Care Settings Doctor Doctor CHA^ Public Health Centre Public Health Nurse Doctor Private Sector Social Worker Nurse Home Visits (Public Sector) Nurse* CHA
10 Primary Health Care Encounters (Jamaica, 2012) Community dwelling older adults have frequent interactions with PHC professionals Majority have a routine source of care PHC facilities (public and private) most visited facility type by the 60 in preceding 3 years Average of 3 visits in previous 12 months Visits largely due to chronic conditions Home visits? What takes place during visit Public: registration (clerk); vitals and anthropometry (nurse or trained CHA); clinical assessment and management (doctor) Private: As above or see doctor for all checks, etc after registration (if no nurse)
11 Primary Health Care Encounters (Jamaica, 2012) Satisfaction with select services at most recent visit
12 Opportunities for detecting abuse and neglect PHC professionals are uniquely positioned to detect elder abuse and neglect Older adults are frequent visitors to health facilities Screening and in-depth examinations for signs of abuse and neglect can be incorporated into existing visit activities Nurse, CHA and/or any other trained member of the health team can be involved in some aspects of the assessment (eg. Preliminary screening)
13 Signs of possible abuse and neglect that can be identified in the PHC setting Depression/Depressive symptoms Anxiety Changes in behaviour Cuts and Bruises (un- or poorly explained) Repeated injuries Bruises and marks in areas like wrists, ankles, neck, genitalia STI Untreated bedsores Poor hygiene Weight loss (medically unexplained) Dehydration Poor control of medical problems despite access to medication
14 Detecting abuse and neglect in the PHC setting Physical examination Observant and alert PHC worker Observes interaction between caregiver and older adults Aware of the characteristics of older adult and caregiver that increase risk of abuse and neglect Knows the right questions to ask older adult Some instruments exist. Adaptations may be needed to make them culturally appropriate Willing to get involved Knows steps that should be taken on suspicion
15 Screening for abuse and neglect Age Friendly PHC toolkit: Some elder abuse indicators, risk factors Screens and Detailed/confirmatory assessments
16 Several tools for screening elder abuse Elder Abuse Suspicion Index (EASI) 6-item instrument For use in persons without cognitive impairment Queries dependency, screens for main types of abuse Includes physician opinion on manifestation of signs Further evaluation by relevant social services WHO and partners sought to develop and validate a tool (based on EASI) in different cultural and geographical contexts
17 Challenges and Best Practices in Care of Older Adults Challenges Heavy patient load limits consultation time Absence of a single, usual medical practitioner in the public sector can limit ability to build trust, get to know patient Inadequate geriatrics and gerontology competence among health care providers Limited knowledge of pertinent issues in elder health Limited expertise in dealing with older adults Inadequate monitoring of residential care facilities Absence of detailed/comprehensive standards and regulations for residential care facilities
18 Challenges and Best Practices in Care of Older Adults Best Practices (various Caribbean countries) Representation at the Governmental and/or national level Established national ageing councils Ageing policies and legislation which direct and influence care activities Measures to improve health care access and utilization Removal of user fees Health insurance Drug subsidies Subsidized bus fares
19 Protocols for dealing with elder abuse Jamaica Not actively screened for If abuse suspected in the PHC setting, doctor can report directly to police Doctor usually refers to social worker for case investigation Investigation can include interview with older adult, caregiver (separately), and home visits Psychosocial intervention Handled under broader legislation governing offences against the person, sexual offences and domestic violence
20 Recommendations Research Public education campaigns about the elder abuse and neglect In-service/continuing education for PHC workers which includes geriatrics and gerontology components Sensitization of PHC workers to the occurrence, risk factors and signs of elder abuse Consider incorporation of screening during routine PHC visit Develop/Identify suitable elder abuse screening tool Screen for abuse risk factors (Age Friendly tool kit) Train auxiliary health workers to conduct some of the screening Improvement in monitoring of residential care facilities Provision of caregiver support
21
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