Texas Elder Abuse and Mistreatment Institute

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Texas Elder Abuse and Mistreatment Institute
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Module 2 INTERVIEWING ELDERS, ELDERLY VICTIMS,
and PERPETRATORS Part A Geriatric Assessment
and Decision-making Capacity

• E. Lee Poythress, M.D.
• Baylor College of Medicine

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Module 2 Objectives

• Use general interviewing skills with the elderly.
• Review the clinical interview and describe how it
  pertains to geriatric assessment and
  intervention.
• Describe methods for determining mental capacity.
• Define neutralization and its various types.
• Demonstrate neutralization techniques.

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Pre-Test Questions

• 1. Which of the following is true regarding
  geriatric assessment and intervention (GAI)?
• a. It is best applied in the hospital
  setting.
• b. It can be performed by a licensed social
  worker.
• c. It has been shown to delay diagnosis at
• times.
• d. It involves a comprehensive
• multidimensional evaluation.
• e. It is a proven intervention for elder
• mistreatment.

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Pre-Test Questions

• In Texas, which of the following professionals
  can determine decision-making capacity?
• a. Social workers
• b. Police officers
• c. Prosecutors
• d. Physicians
• e. Psychologists

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General Approach to the Elderly Patient

• Elderly patients often present with complex,
  chronic issues.
• Elder mistreatment victims often live in
  precarious social situations.
• Initial assessment can be a significant
  undertaking.

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General Approach to the Elderly Patient

• Allow for extra time on a visit or consider
  breaking up the visit into two closely spaced
  meetings.
• 2. Geriatric Assessment Intervention (GAI)
  techniques are a structured way to evaluate the
  elderly.
• 3. Autonomic dysfunction set room temperature
  at 70-80 degrees Fahrenheit.

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General Approach (cont.)

• 4. Aid vision and communication by using bright
  light and large-print literature and by sitting
  face to face.
• 5. Presbycusis speak in a lower pitch without
  significantly raising the voice, sit face to
  face, and use headphones.
• 6. Central processing auditory deficit quiet
  rooms.
• 7. Privacy.

Cassel, 1997
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General Approach (cont.)

• 8. Normal aging comes with a slowing of
  performance, but not decreased cognition.
• 9. Family members or caregivers often accompany
  patients. Remember to respect autonomy.
• 10. Dementia or cognitive impairment does not
  mean incapacity.

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The Clinical Interview and Geriatric Assessment
and Intervention
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Clinical Evaluation GAI

• Geriatric Assessment and Intervention (GAI)
• Comprehensive history and physical.
• Assessment of cognitive and functional status.
• Full social evaluation.
• Tailored items (Physical Therapy -Occupational
  Therapy screen, audiovisual screen, other).

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Clinical Evaluation GAI

• Usually composed of a team Medical Doctor,
  Nurse Practitioner, Physicians Assistant,
  Physical Therapist/Occupational Therapist, Social
  Worker, nurse managers, etc.
• Shown in multiple care settings to improve
  outcomes, decrease readmission rates, and improve
  quality of life.
• Office-based adjustments can be made.

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Clinical Evaluation GAI

• Primary care physicians may be reluctant to get
  involved in all forms of family violence (AMA
  Guidelines, 1992).
• Time and reimbursement issues are real.
• GAI can help with these matters.
• Dont give up!

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Clinical Evaluation GAI

• Social History
• Important for all forms of abuse and neglect.
• Essential components
• Living arrangements?
• Home utilities working?
• History of family violence?
• Drug or alcohol use by patient or caregivers?

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Clinical Evaluation GAI

• Essential components
• Finances/monthly income Who manages money (pays
  bills, cashes checks, etc.)?
• Social contacts?
• Food supply Who buys it? Who prepares it?
• How did patient get to the clinic?

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Clinical Evaluation GAI

• Depression Screening and Cognitive and Functional
  Assessment
• Key component of GAI.
• Use of brief, accepted screening tools.

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Clinical Evaluation

• Other evaluations
• Complete blood count
• Serum chemistries
• X-rays
• Toxin screens
• Drug levels

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Conclusions

• Interviewing elderly patients requires some
  adjustments in approach.
• The theories and risk factors surrounding elderly
  mistreatment can act as important tools when
  evaluating patients.
• GAI is an efficient and reliable way to evaluate
  elderly patients.

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Decision-making Capacity
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Decision-making Capacity

• Competence refers to a persons capacity to
  make rational, informed decisions about his or
  her care. (Oyama O, 1999)
• Medical competence refers to a persons ability
  to understand medical information and make
  informed medical decisions.
• Competence legal term
• Decision-making capacity medical term

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Decision-making Capacity

• Formal competence assessment usually takes place
  after evidence calls a patients capacity into
  question (in a medical setting).
• Primary clinicians can perform assessment.

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Decision-making Capacity

• Competence is a legal determination based partly
  on a medical assessment.
• Final ruling is judicial.
• A person can have a mental health disorder, such
  as Alzheimers disease, and show signs of obvious
  impairment, and still be legally competent.

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Methods of Competency TestingMiller, S.S. and
Marin, D.B. (2000)

• Many instruments have been developed for
  assessing patients competence. There is no
  universal standard.
• Physicians are primarily focused on medical
  decision-making capacity.

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Methods of Competency Testing

• Basic tenets of assessing medical decision-making
  capacity can be used to assess a patients
  capacity to make rational, informed decisions in
  other areas of life.
• When filling out capacity assessment forms for
  court, you are asked to extrapolate.

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Applebaum and Grisso, 1988

• 1. Communicating choices.
• 2. Understanding relevant information.
• 3. Appreciating the situation and its
• consequences.
• 4. Manipulating information rationally.

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Annas and Densberger, 1984

• What is your present physical condition?
• What treatment is being recommended for you?
• 3. What do you and your doctor think might
  happen if you decide to accept the treatment?

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Annas and Densberger, 1984 (cont.)

• What do you and your doctor think might happen if
  you decide not to accept the treatment?
• 5. What alternatives are available? What are the
  probable consequences of each one?

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Documentation

• Document using either the Applebaum and Grisso
  method or the Annas and Densberger method and
  address each topic as it pertains to your
  patient.

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Conclusions

• Primary care physicians can assess competence in
  most clinical situations.
• There are no accepted standards for this.
• Primary care clinician focuses on medical
  decision-making capacity but, in competency
  situations, will be asked to extrapolate.

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Conclusions

• Both the Applebaum and Grisso method and the
  Annas and Densberger method provide a solid
  framework for discussing patients medical
  decision-making capacity and court-evaluated
  competency.

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Post-Test Questions

• 1. Which of the following is true regarding
  geriatric assessment and intervention?
• a. It is best applied in the hospital
  setting.
• b. It can be performed by a licensed social
  worker.
• c. It has been shown to delay early
  diagnosis
• at times.
• d. It involves a comprehensive
• multidimensional evaluation.
• e. It is a proven intervention for elder
  
• mistreatment.

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Post-Test Questions

• In Texas, which of the following professionals
  can determine decision-making capacity?
• a. Social workers
• b. Police officers
• c. Prosecutors
• d. Physicians
• e. Psychologists

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INTERVIEWING ELDERS AND ELDERLY VICTIMSPart B
Fine-tuning the Interview of Elderly Victims and
Perpetrators
Gregory Paveza, M.S.W., Ph.D. School of Social
Work University of South Florida
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Pre-Test Questions

• 1.      The 5 Ps of assessment are
•  
• a.  Privacy, Pacing, Planning, Pitch,
  Punctuality
• b.  Privacy, Pacing, Plumbing, Pitch,
  Personality
• c.  Personhood, Pacing, Personality, Planning,
  Pitch
• d. None of the above

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Pre-Test Questions

• 2. A classic neutralization technique is denying
  responsibility. The abuser
•  
• a. Makes the victim out to be the wrongdoer.
• b. Says all people are hypocrites.
• c. Suggests the abuse is the result of forces
• beyond his or her control.
• d. Believes that abuse is inconsequential if
  
• no one is physically injured.
• e.  Says that the abuse never happened.

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Discovering the Problem

• The problem may come to light when
• you discover it.
• the caregiver discloses it.
• the patient discloses it.

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Handling the Disclosure

• Let the discloser speak.
• Listen!
• Dont be distracted.
• Keep questions to a minimum.
• Watch for nonverbal clues.
• Accept natural silences.

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Encouraging the Disclosure

• Who?
• What?
• When?
• Where?
• How?

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Personally Dealing with the Disclosure

• Address confidentiality.
• Remember, your clients are adults.
• Respect your clients basic rights.
• Dont jump to conclusions.
• Avoid being judgmental.
• Avoid making accusations
• Observe the discloser.
• Avoid panic/keep calm.

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Personally Dealing with the Disclosure (cont.)

• Avoid expressing shock or horror verbally or
  nonverbally.
• Consult as needed.

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Monitor Yourself

• Pay attention to your own feelings of frustration
  or fatigue.
• If you get angry and upset because the person is
  confused and does not understand, ask someone
  else to be your mediator or to participate.
  Remember the confusion is not deliberate,
  regardless of how lucid the person was in the
  past.

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The 5 Ps of Assessment

• Privacy
• Pacing
• Planning
• Pitch
• Punctuality

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Interviewing the Suspected Abuser

• Begin by saying
• This is a standard part of the assessment.
• You want to get all of the information.
• Information is needed in order to provide
  services and help for the patient.

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Critical Information

• Is there a presence of
• psychological, drug, or alcohol problems?
• physical illness?
• Does the caregiver have help?
• Is there a perceived burden in care giving?
• What is the caregivers perspective?
• What is the level of dependence on the client
• for finances?
• for housing?
• Gather details about possible exploitation.

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Call the Question

• Based on the information collected, do you
  believe abuse, neglect, or financial exploitation
  is occurring?
• If so, what are the next steps?
• Finally, document, document, document.

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Neutralization

• Neutralization is when someone engaging in
  delinquent behavior tries to justify it or make
  it acceptable.
• The tendency to try to make unacceptable behavior
  neutral must be addressed.

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Neutralization Techniques and Counters

• Denial of Responsibility
• Claim Abuse is accidental or the result of
  forces beyond the persons control.
• Counter Confront the abuser with the truth the
  event could not have been an accident or caused
  by someone or something else.

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Neutralization Techniques and Counters (cont.)

• Denial of Injury
• Claim The abuse is inconsequential because no
  one was really injured.
• Counter Help the abuser to understand the nature
  of the injury in terms of emotional or financial
  consequences.

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Neutralization Techniques and Counters (cont.)

• Denial of the Victim
• Claim The victim is the real wrong-doer.
• Counter The victims behavior is not an issue.
  The abuser is responsible for harmful behavior
  over which he or she had control.

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Neutralization Techniques and Counters (cont.)

• Condemning the Condemners
• Claim All people are hypocrites. All people do
  things that are wrong. People shouldnt stick
  their noses in someone elses business.
• Counter Nobody is perfect. This does not lessen
  the seriousness of the offense or excuse it.

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Neutralization Techniques and Counters (cont.)

• Appealing to Higher Loyalties
• Claim The victims loyalties are with me. Blood
  is thicker than water.
• Counter Its still abuse, and the victim must be
  protected.

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Neutralization Techniques and Counters (cont.)

• Defense of Necessity
• Claim The abuse was necessary to prevent some
  greater evil.
• Counter The abuser could have chosen other ways
  to deal with the problem.

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Neutralization Techniques and Counters (cont.)

• Metaphor of the Ledger
• Claim I deserve to have this be excused because
  of everything Ive done for him/her.
• Counter No amount of bookkeeping justifies the
  abuse and the harm inflicted.

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Final Thoughts

• Working with disclosure is difficult. Make sure
  you have support.
• Neutralization is common. Be prepared to deal
  with it.

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Post-Test Questions

• 1. The 5 Ps of assessment are
•  
• a.  Privacy, Pacing, Planning, Pitch,
  Punctuality
• b.  Privacy, Pacing, Plumbing, Pitch,
  Personality
• c.  Personhood, Pacing, Personality, Planning,
  Pitch
• d. None of the above

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Post-Test Questions

• 2. A classic neutralization technique is the
  denial of responsibility. The abuser
•  
• a. Makes the victim out to be the wrong-
• doer.
• b. Says all people are hypocrites.
• c. Says the abuse is the result of forces
• beyond his or her control.
• d. Believes abuse is inconsequential if no
  one is
• physically injured.
• e. Asserts that the abuse never happened.

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Texas Elder Abuse and Mistreatment Institute
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