Few doctors report abuse of elderly patients

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01:00 AM EDT on Sunday, August 10, 2008

By Tracy Breton

The Providence Journal
Doctors in almost every state are required by law to report suspected elder abuse of their patients. But hardly any of them do, even if they fear that their silence may subject an elderly person to continued abuse at the hands of a caregiver.

Physicians report just 2 percent of the elder abuse and neglect cases recorded each year by state protective service agencies, according to medical and legal experts and recent articles published in medical journals. One study, published in 2005 in a journal focusing on geriatric medicine, says that the actual figure may be even lower.

The lack of physician reporting is a huge problem, experts say, because as the elderly population continues to grow and doctors become ever more pressed for time in meeting the demands for care, more elder abuse will go undetected.

Doctors are often the only people outside an elderly victim’s home who have contact with the victim. If they don’t blow the whistle, who will?

“I think we have an ethical responsibility, a moral responsibility and we’re shirking it,” says Dr. Laura Mosqueda, director of geriatrics at the University of California, Irving College of Medicine, who is co-director of the school’s Elder Abuse Forensic Center. “If you see signs that a person may have been abused, you need to ask: ‘Has anybody hurt you? Are you afraid of anybody? How did this happen?’ If the explanation doesn’t fit with what you see, you need to probe further.”

Every year, an estimated 2.1 million older Americans are victims of physical, psychological or other forms of abuse, according to the American Psychological Association. Congress says the number could be closer to 5 million. Most of the abused or neglected elderly live in the community “” not in nursing homes or assisted-living facilities —— and 90 percent of the time, the perpetrator is a family member, most often an adult child or spouse, according to the National Center on Elder Abuse.

Roberta M. Hawkins, the executive director of The Alliance For Better Long-Term Care and Rhode Island’s ombudsman for the elderly, estimates that as many as 7 out of 10 of the state’s seniors are victims of abuse, neglect or self-neglect.

Since 1981, Rhode Island law has required anyone who believes that an elderly person is being abused, exploited, neglected or abandoned to make “an immediate report to the state Department of Elderly Affairs. Failure to make such a report is a crime punishable by up to a year in prison and/or a $1,000 fine.

Yet Corinne Calise Russo, director of the DEA, says that very few of the 800 to 900 abuse and neglect complaints filed each year with her office are made by physicians. The doctors who do report, she says, work mostly in nursing homes and hospitals.

Over the past several months, The Providence Journal made attempts to interview primary care physicians about their reporting of elder abuse. But those who were contacted said they were either too busy to talk or didn’t feel they had enough expertise to comment on the subject.

“Until I started looking into” the psychiatric implications of elder abuse, “the reporting issue didn’t cross my mind. I was ignorant myself,” says Dr. Robert Kohn, the director of geriatric psychiatry at Miriam Hospital who also runs the geriatric training program at the Warren Alpert School of Medicine at Brown University. “Physicians don’t view abuse toward the elderly the same way they view child abuse….” Although 44 states and the District of Columbia have laws that mandate physician reporting of suspected elder abuse, “nobody ever gets into trouble for not reporting it … at least in Rhode Island,” says Kohn.

THERE ARE a myriad of reasons why doctors don’t report elder abuse, say experts who have studied the issue.

“Sometimes physicians don’t know what they’re looking at because, historically, there has not been education on elder abuse provided in medical training,” says Candace Heisler, a lawyer who spent 25 years prosecuting domestic violence cases in San Francisco and now works as an elder abuse consultant. “There are relatively few medical schools that have any specialized geriatrics training and there are relatively few geriatricians.”

Says Kohn: “Elder abuse is often hidden. You don’t necessarily see the bruises or the broken ribs. Most elder abuse clients don’t have a bruise to show for it.” Those who do, he says, often won’t go to their doctor until after their wounds have healed.

“Primary care doctors don’t know how to probe and don’t have the time” to ask the appropriate questions, Kohn says. There are some doctors who will spend a half-hour or more with a patient. But many doctors have so many patients that an appointment may last less than 15 minutes.

Some doctors don’t report suspected abuse because their patients beg them not to. Patients generally don’t want to see an abusive family member sent to prison and fear, if a report is made, that they will be moved out of their homes into assisted living or a nursing home. Some doctors believe the patient will be worse off if they don’t adjust well to living in a nursing home, or that the abuse at home will escalate, as a form of retribution, if they notify authorities about mistreatment.

Richard W. Besdine, the director of the Center for Gerontology and Health Care Research at Brown, says that “as awful as it is,” many elderly people are “dependent on [an abuser] to meet needs that otherwise would be unmet. Sometimes the abusive nephew is the only person who will come to the house to get the elder out of bed so she can sit in front of the television set during the day.” Sometimes, says Besdine, an abusive daughter is the only person who will cook meals for the elder.

Dr. Carmel Dyer, director of geriatric and palliative medicine at the University of Texas Medical Center at Houston, says that “if the caregiver suspects the patient is talking to the doctor” about being abused, “they won’t take the patient to the doctor anymore.”

But Mosqueda says that it’s been her experience that doctors find it “easier not to ask and not to probe” if they suspect abuse of an elderly patient. They “don’t want to get involved with the legal system or the social service system. They tell me, ‘What’s the use of making a report? It’s all a black hole.'”‚”

In some studies, doctors say they fear that reporting suspected abuse of an elder may open them up to being sued by the abuser, if the complaint doesn’t turn into a successful prosecution “” even though in most cases, the doctor’s identity remains confidential and good-faith reporting makes one immune from liability.

Other doctors are simply reluctant to bring up the subject of elder abuse with their patients.

Dr. Michael Rodriguez, a professor at the David Geffen School of Medicine at UCLA who received a grant from the National Institute on Aging to interview primary care physicians about their low rate of reporting, says “the relationship issue” involving doctors, their patients and the patient’s family “is a double-edged sword. Alliances, friendships develop between patients and the patient’s family and caregivers. They [the doctors] don’t want to accept a different potential reality.”

“In some cases, primary care doctors feel torn about reporting because sometimes they feel reporting may do good with regards to the patient and their relationship with the patient” but it may undermine the rapport the doctor has with the patient.

Rodriguez says that some doctors told him that they’ve made a conscious decision not to report suspected elder abuse and neglect because they have no faith that overworked social workers who are assigned the task of investigating such cases will handle the situation appropriately or provide necessary services. While doctors feel that reporting sometimes “could improve an elder’s quality of life as it relates to safety, it could also adversely affect the patient’s quality of life.”

Doctors told Rodriguez that adult protective-services (APS) workers are “not always helpful but destructive. I interviewed one doctor who said that after he reported to APS, their patient almost got kicked out of their apartment” because the suspected abuser was the landlord who got very upset when a social worker came to question him. Nothing happened to the landlord and the doctor had to intervene to make sure the woman could remain living where she was.

Also, Rodriguez found that “some physicians tend to dismiss or not identify elder abuse as a problem … that they can do anything about.” They “tend to minimize the role of physicians in addressing elder abuse. Some of them feel if they do something, it’s not going to make any difference. Other physicians feel it’s more important to address the medical issues [the patient] comes in with rather than the elder abuse issues.”

One survey of 1,030 Iowa family physicians concluded that there was a greater likelihood of doctors reporting suspected abuse if they knew that they were required by law to do so “” something, experts say, many physicians are unaware of. The survey also concluded that if doctors asked their patients direct questions about elder mistreatment, they would find out about more cases and report them.

In another study, published in 2006 in The Journal of the National Medical Association, a majority of the Michigan doctors who were surveyed said they were unable to recognize key risk factors for elder abuse, were not routinely screening seniors for abuse and were unfamiliar with signs of family violence. They also said they were unclear about how to report suspected abuse.

Dyer, of the University of Texas, says that when doctors do report mistreatment of an elder, it is most often “actual physical abuse.” They are less likely to report elder neglect or financial exploitation. “Doctors need to be made aware that if they have a suspicion of financial exploitation, patient abuse or neglect, they must report,” she says.

EXPERTS SAY that more needs to be done to teach physicians. In 2006, Brown and Harvard universities each received $2-million grants from the Donald W. Reynolds Foundation to change their medical school curricula to incorporate teaching about gerontology into all of their courses.

“Doctors need to become better educated when dealing with elderly patients, to recognize that the bruises they see on an elderly person might not be from rolling over in bed,” says Brown’s Besdine, who has trained more than 90 doctors for careers in geriatrics. “Most of the abuse occurs in the process of giving care to needy, frail older people who are not easy to take care of.” Oftentimes, he says, the abuse is committed by a family member who is stressed out and strikes out verbally or physically out of exhaustion or frustration.

Heisler, the former prosecutor, says that the key to better physician reporting is making more time. Doctors need to take the time to ask questions that “will lead to a discussion of abuse, questions such as ‘How are things going at home? Is someone new living there? Are you getting out very much? If not, why not?'”‚” These are the “much more subtle questions” that will most often get elderly patients to open up about what is happening at home, she says.

“Reaching the point where you’re trusted as a health-care professional takes time, coaxing, building a lot of trust, creating a safe environment and having a skill set to talk….”

“Most people don’t walk into a doctor’s office because they are victims of elder abuse. They have depression, weight problems, nightmares, sleeping problems, GI problems, neck and muscle pain rather than bruises, and many times they are not asked questions about these things.”

Heisler says that if more doctors report abuse and neglect, more abusers will be held accountable and that may act as a deterrent. If health-care providers are reporting well … and evidence is properly collected,” she says, “I think the end point would be more prosecutions.”
Tracy Breton, a recipient of the Rosalynn Carter Mental Health Journalism Fellowship for 2006-2007, is writing an intermittent series of stories about elder abuse and exploitation.

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