Detecting and managing elder abuse: challenges in primary care
Paul Krueger, PhD; Christopher Patterson, MD, for the Research Subcommittee of the Elder Abuse and Self-Neglect Task Force of HamiltonWentworth
CMAJ 1997;157:1095-100
[ résumé ]
Dr. Krueger is with the HamiltonWentworth Regional Public Health Department (a teaching health unit affiliated with McMaster University and the University of Guelph) and the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont., and Dr. Patterson is with the Department of Medicine, Faculty of Health Sciences, McMaster University, and the Hamilton Health Sciences Corporation, Hamilton, Ont.
Other members of the Research Subcommittee: Bryan Alton, MD, Geriatric Medicine, St. Peter's Hospital, Hamilton, Ont.; Christene Briks, MSW, CSW, HamiltonWentworth Home Care Program; Kim Eveleigh, MSc, Senior Peer Counselling, Catholic Family Services, HamiltonWentworth; Lynda Young, MA, Regional Municipality of HamiltonWentworth Advisory Committee on Services for Seniors; Judy Curran, BSN, MEd, Anne Stanziani, BScN, and Nancy LeMay, BScN, HamiltonWentworth Regional Public Health Department; and Amanda Beaman, BA, Gerontology Program, McMaster University.
This article has been peer reviewed.
Correspondence to: Dr. Paul Krueger, HamiltonWentworth Regional Public Health Department, 25 Main St. W, 4th Floor, PO Box 897, Hamilton ON L8N 3P6; fax 905 546-4075; kruegerp@fhs.csu.mcmaster.ca
© 1997 Canadian Medical Association (text and abstract/résumé)
Contents
Abstract
Objective: To determine family physicians' perceptions of barriers and strategies in the effective detection and appropriate management of abused elderly people.
Design: Questionnaire survey; the protocol included an advance notification letter and 3 follow-up mailings.
Setting: Regional Municipality of HamiltonWentworth, Ont.
Participants: All active nonspecialist physicians who reported seeing elderly patients in their practices were eligible for inclusion. Fifty health service organization (HSO) physicians were randomly selected from among those listed with the HSO Mental Health Program, and 200 fee-for-service physicians were randomly selected from the Canadian Medical Directory. Of the 189 eligible physicians 122 returned completed questionnaires, a response rate of 65%.
Outcome measures: Physicians' ratings of the importance of potential barriers in assisting older people experiencing abuse and of the usefulness of strategies for dealing with elder abuse.
Results: Physicians identified the following barriers as fairly or very important: denial of abuse, resistance to intervention, not knowing where to call for help, lack of protocols to assess and respond to abuse, lack of guidelines about confidentiality, fear of reprisal, and lack of knowledge of the prevalence and definition of elder abuse. Strategies deemed to be helpful included a single agency to call, a directory of services, a list of resource people, an educational package, guidelines for detection and management, reimbursement for time spent on legal matters, continuing education, revision of fee structure and a central library of resources on elder abuse.
Conclusion: Although the physicians perceived numerous barriers to their detection and management of elder abuse, they identified many strategies that could be implemented at a local level. Preparation of an algorithm to help physicians is the next phase of this work.
Résumé
Objectif : Déterminer les perceptions chez les médecins de famille des obstacles et des stratégies pour bien repérer les personnes âgées victimes de mauvais traitements et pour faire le nécessaire.
Conception : Sondage par questionnaire; le protocole prévoyait une lettre d'avis préliminaire et trois envois de suivi.
Contexte : Municipalité régionale de HamiltonWentworth (Ontario).
Participants : Tous les médecins non spécialistes actifs qui ont déclaré voir des patients âgés dans l'exercice de leur pratique pouvaient répondre au questionnaire. Cinquante médecins d'organismes de services de santé (OSS) ont été choisis au hasard parmi ceux qui figurent dans la liste du programme de santé mentale des OSS et 200 médecins rémunérés à l'acte ont été choisis au hasard dans le Répertoire des médecins canadiens. Des 189 médecins admissibles, 122 ont renvoyé le questionnaire rempli, soit un taux de réponse de 65 %.
Mesure de résultats : Évaluation par les médecins de l'importance des obstacles pouvant les empêcher d'aider les personnes plus âgées victimes de mauvais traitements et de l'utilité des stratégies à ce sujet.
Résultats : Les médecins ont indiqué que les obstacles ci-après sont assez ou très importants : refus de reconnaître qu'il y a mauvais traitements, résistance à l'intervention, ignorance des services d'aide, absence de protocoles pour évaluer les mauvais traitements et y réagir, absence de directives au sujet de la confidentialité, crainte de représailles et manque de connaissances au sujet de l'existence et de la définition des mauvais traitements infligés aux personnes âgées. Parmi les stratégies jugées utiles, mentionnons la désignation d'un seul organisme avec lequel communiquer, un répertoire des services, une liste des personnes-ressources, une trousse d'éducation, des directives pour le repérage et la gestion des cas, le remboursement des heures consacrées aux interventions juridiques, l'éducation continue, la révision de la structure tarifaire et une bibliothèque centrale sur les ressources au sujet des personnes âgées maltraitées.
Conclusion : Même si les médecins jugent qu'il leur est encore très difficile de repérer les personnes âgées victimes de mauvais traitements et de s'en occuper, ils ont mentionné de nombreuses stratégies qui pourraient être utiles à l'échelon local. La prochaine étape de ce travail consistera en la préparation d'une grille d'intervention visant à aider les médecins.
[ Contents ]
Introduction
Elder abuse is most simply defined as "mistreatment of older people by those in the position of trust, power or responsibility for their care."1 The best estimate of the prevalence of elder abuse in Canada, obtained by a telephone survey of 2000 randomly selected seniors stratified by geographic region, is 4%.2 The prevalence of material abuse (including financial or property) was 2.5%, chronic verbal aggression 1.4%, physical violence 0.5% and neglect 0.4%. Estimates in other jurisdictions have ranged as high as 10%.3 Health care and social service workers play a crucial role in the detection and treatment of abuse and neglect among older people.
Physicians, especially family physicians, are frequently in contact with older people and are well positioned to detect abuse and to initiate appropriate investigation and intervention. Unfortunately, elder abuse may be difficult to detect unless there are obvious signs of physical injury. As an offence against older people, particularly those who are isolated and vulnerable, abuse is frequently denied by its perpetrators and by those experiencing the abuse themselves. Many physicians, particularly those who did not graduate recently, were not exposed to the issue of elder abuse during undergraduate or postgraduate medical education. Without a high index of suspicion, abuse may be overlooked. Even when abuse is detected, management is often complex, and evidence of successful management is scarce.4
To determine family physicians' perceptions of barriers and strategies in the effective detection and appropriate management of abuse of elderly people, we carried out a survey of family physicians practising in the Regional Municipality of HamiltonWentworth, Ont.
[ Contents ]
Methods
The survey was conceived, developed and implemented by a multidisciplinary group of people who were part of the Elder Abuse and Self-Neglect Task Force of Hamilton Wentworth. The research group comprised nurses, physicians (including C.P.), an epidemiologist (P.K.), a social worker, a seniors' volunteer program coordinator, a seniors' advisory group member and a gerontology student, representing the HamiltonWentworth Regional Public Health Department, advocacy organizations, hospital geriatric programs and McMaster University.
For the purpose of this survey, "elderly" was defined as 60 years of age or older, and "elder abuse" as any action or inaction by a person in a position of trust -- a friend, family member, neighbour or paid caregiver -- that causes harm (physical, psychologic or financial or through neglect) to an elderly person.
Selection of physicians
The study group hypothesized that responses might differ according to the physician's method of reimbursement. Therefore, we decided to randomly select a sample of both health service organization (HSO) physicians and fee-for-service physicians. HSOs are alternative-payment programs funded on a capitation basis to provide primary health care services to roster members. The capitation payment method is intended to encourage a multidisciplinary approach so that the most appropriate and cost-effective care provider may be used in responding to patients' needs. To obtain a representative sample of HSO physicians in HamiltonWentworth we selected at random (using a computerized random-number generator) 50 of the 89 physicians registered with the HSO Mental Health Program. To obtain a representative sample of fee-for-service nonspecialist physicians (general practitioners, family physicians and family practice/emergency medicine physicians) in HamiltonWentworth we randomly selected 200 of the 377 physicians listed in the Canadian Medical Directory,5 after removing the 89 HSO physicians from the list. This sampling procedure resulted in a sample of 250 physicians, or about 54% of the 466 nonspecialist physicians in HamiltonWentworth.
Questionnaire
Using a framework described by Dillman,6 we spent about 2 years developing, pretesting and revising the questionnaire before mailing it to the physicians. (Copies of the questionnaire are available by request to the corresponding author.)
An advance notification letter and 3 follow-up mailings were used to maximize the response rate. All the participants were assured of complete confidentiality. The advance notification letter was sent on Oct. 28, 1996, to the 250 physicians to notify them that they had been selected to participate in a region-wide survey (the survey was sent by first class mail to physicians who provided home addresses for correspondence and by courier to those who provided office addresses). One week later the questionnaire, a return postage-paid envelope and a cover letter explaining the purpose of the study were sent to all the physicians. One week after that a thank you/reminder letter was sent to all the physicians. Two weeks later a duplicate package was sent to physicians who had not returned the questionnaire. On Dec. 17, 1996, a final package was sent by registered mail to physicians who had still not returned the questionnaire. Finally, in an attempt to identify the eligibility status of the nonrespondents, we called their offices to verify whether they saw elderly patients in their current practice.
Statistical analysis
Before statistical analyses were conducted, the data were weighted to adjust for the sampling strategy used to select HSO and fee-for-service physicians. Frequency counts and proportions were calculated and then ordered for responses related to potential barriers to and strategies for detecting and managing elder abuse. We used the *2 test or, when appropriate, Fisher's exact test to determine whether statistically significant differences existed in the proportions of responses according to physician characteristics such as method of reimbursement (fee-for-service v. HSO), year of graduation (before 1980 v. 1980 or later), sex, attendance at continuing medical education (CME) events on elder abuse and whether the physician had ever seen abused elderly patients in her or his current practice. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported as appropriate. A probability level of 0.05 was used to determine statistical significance. We used SPSS (version 6.1.3 for Windows, SPSS Inc., Chicago, 1995) and Epi-Info (version 6.04a, Centers for Disease Control and Prevention, Atlanta, 1995) for statistical computations.
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Results
During the course of the study it was discovered that 61 of the physicians selected were ineligible, and they were excluded from the analysis. The ineligible physicians were excluded because they were no longer in family practice, were no longer in HamiltonWentworth, were retired or did not see elderly patients, or because mail was returned and we were unable to locate a current address. Of the 189 eligible physicians 122 returned completed questionnaires, a response rate of 65%.
Characteristics of respondents
Of the 122 respondents 53 (43.4%) classified their type of practice as a solo practice, 50 (41.0%) as a group practice (with other physicians), 7 (5.7%) as a multidisciplinary group practice and 9 (7.4%) as another type of practice. Overall, 96 physicians (78.7%) reported their method of reimbursement as fee-for-service and 26 (21.3%) as HSO. Although little information was available for comparing the characteristics of the respondents to the overall population of nonspecialist physicians in HamiltonWentworth, we were able to find comparable data on year of graduation and sex.7 A total of 44.5% of the respondents (53/119) reported that they graduated from a program in medicine before 1980. This was not significantly different from the proportion of HamiltonWentworth physicians who graduated before 1980, 54% (p = 0.06). The proportion of male physicians in our study was 53%, compared with 61% of physicians in Hamilton Wentworth, again a nonsignificant difference (p = 0.10).
Barriers to assisting abused elderly patients
Physicians were asked to rate the importance of 14 potential barriers to assisting older people experiencing abuse. Table 1 lists the 9 barriers that were felt to be fairly or very important by more than 50% of the respondents.
To determine whether there were differences in perceived barriers according to the physicians' characteristics, each of the 14 potential barriers was analysed by method of reimbursement (fee-for-service or HSO), year of graduation from undergraduate medicine (before 1980, or 1980 or later), sex, attendance at CME events on elder abuse and whether the physician reported ever having seen older patients suspected of being abused in her or his current practice.
When the data were analysed by method of reimbursement, fee-for-service physicians were significantly more likely than HSO physicians to report lack of knowledge about where to call for help (OR 4.11, 95% CI 1.46 to 11.68) and fear of reprisal by the abuser toward the abused person (OR 3.08, 95% CI 1.12 to 8.65) as important barriers to assisting elderly people experiencing abuse. Female physicians were significantly more likely than their male colleagues to report lack of a professional protocol related to assessing elder abuse (OR 2.98, 95% CI 1.23 to 7.30) and lack of a professional protocol related to responding to elder abuse (OR 3.00, 95% CI 1.26 to 7.22) as important barriers. Physicians who graduated in 1980 or later were significantly more likely than those who graduated before 1980 to report lack of a professional protocol related to responding to elder abuse (OR 3.06, 95% CI 1.31 to 7.25), lack of knowledge about where to call for help (OR 2.42, 95% CI 1.00 to 6.08) and language or cultural barriers (OR 2.23, 95% CI 1.00 to 5.08) as important barriers. Physicians who had not attended CME events on elder abuse were more likely than those who had attended such events to report difficulty in determining what constitutes elder abuse as an important barrier (OR 2.82, 95% CI 1.00 to 8.25). No differences were found in the rating of barriers when the data were analysed by whether the physician had seen elderly patients suspected of being abused in his or her current practice.
Strategies to help deal with elder abuse
Physicians were also asked to rate the likelihood of their using 11 potential strategies to help deal with elder abuse. Table 2 lists the 10 strategies that more than 50% of the respondents indicated they were fairly or very likely to use in their practices. Each of the 11 potential strategies was analysed by method of reimbursement, year of graduation, sex, attendance at CME events on elder abuse and whether the physician reported having seen elderly patients suspected of being abused in his or her current practice.
Female physicians were significantly more likely than their male colleagues to report professional guidelines or protocols for detection and management of elder abuse (OR 3.26, 95% CI 1.01 to 12.28) and a single agency to call regarding cases of elder abuse (because one of the cells of the contingency table was 0, the OR was estimated at 13.0 by adding 0.5 to each cell, p = 0.03) as useful strategies. Physicians who graduated in 1980 or later were significantly more likely than those who graduated before 1980 to report an elder abuse resource package for use in the practice (OR 3.47, 95% CI 1.12 to 11.88) and elder abuse education provided in the physician's practice (OR 1.52, 95% CI 1.02 to 2.27) as useful strategies. Physicians who had not attended CME events on elder abuse were more likely than those who had attended such events to report a central, accessible library of elder abuse resources as a useful strategy (OR 3.92, 95% CI 1.31 to 13.15). No differences were found in the likelihood of use of each of the potential strategies when the data were analysed by method of reimbursement or whether the physician had seen elderly patients suspected of being abused in her or his current practice.
Types of service normally used
Of the 122 respondents 65 (53.3%) indicated that they had seen older patients suspected of being abused. These physicians were asked to identify which services they would normally use in a situation where elder abuse was suspected. Table 3 lists the services that more than 50% of the 65 respondents reported they would use. These physicians were also asked what they would normally do in cases in which the abused person would not agree to accept help (more than one response was allowed): 39 (60%) indicated they would seek advice from others, 26 (40%) would refer the patient for further assessment, 7 (11%) would take no further action, and 14 (22%) did not know what they would do.
Concern about the potential for elder abuse
When asked "How concerned are you about the potential for elder abuse in your practice?", 50 (41.0%) of the physicians reported that they were fairly or very concerned. When the data were analysed by physician characteristics, only one statistically significant finding appeared: physicians who reported having seen older patients suspected of being abused were more likely to be concerned about the potential for elder abuse in their practices than physicians who had not seen such patients (OR 2.74, 95% CI 1.21 to 6.29).
Confidence in assessing elder abuse
Fewer than half of the respondents (55, or 45.1%) indicated that they were fairly or very confident in assessing the existence of elder abuse in their practices. Physicians who reported never having seen a suspected case of elder abuse in their practices were significantly more likely to be confident in assessing elder abuse than those who had seen abused elderly patients (OR 4.04, 95% CI 1.77 to 9.31). Physicians who had attended CME events on elder abuse were 2.6 times more likely to be fairly or very confident in assessing elder abuse in their practices than those who had not attended such events; however, the association was not statistically significant (p = 0.06). None of the other physician characteristics were significantly associated with confidence in assessing elder abuse.
Knowledge of existing community services
Only 27 respondents (22.1%) indicated that they were fairly or very confident about their knowledge of existing community services to assist abused elderly people. Physicians who graduated before 1980 were significantly more likely than those who graduated in 1980 or later to be confident in their knowledge about such services (OR 2.99, 95% CI 1.11 to 8.21). Physicians who had attended CME events on elder abuse were more likely to be confident in their knowledge of existing services than physicians who had not attended such events (OR 3.62, 95% CI 1.23 to 10.73). None of the other physician characteristics were significantly associated with confidence in knowledge of community services to assist abused elderly people.
[ Contents ]
Discussion
The strengths of this survey were the carefully devised questionnaire, which was pretested and modified before distribution, the random selection of HSO and fee-for-service physicians, and the rigorous follow-up to ensure a high response rate.
One weakness of the study was the difficulty in obtaining an accurate list of practising physicians, which led to concern that those who responded may not have been representative of the overall population of nonspecialist physicians in HamiltonWentworth. Surprisingly, the Canadian Medical Directory and documents from the provincial medical organization and the local academy of medicine were not sufficient to provide completely accurate data, with the result that the chosen sample of physicians included 61 who were ineligible to participate. Despite our best efforts, a response rate of greater than 65% could not be achieved.
Potential barriers to the detection and management of abuse identified in our study included a lack of knowledge about the prevalence and definition of elder abuse, although the latter was less likely among physicians who had attended CME courses on abuse of elderly people. The implication is that CME courses may improve knowledge in this area. Dealing with denial and resistance and fear of reprisals were areas of concern, but the lack of knowledge about where to call for help is particularly disturbing, especially among fee-for-service physicians. Increasing awareness at the local level of resources to help assess and manage elder abuse is a high priority. Although lack of reimbursement for time spent on legal matters and the present fee structures were identified as barriers to effective management, the availability of local resources (e.g., a single agency to call, a directory of services for older people and a list of resource people to advise on elder abuse) were seen as important potential strategies. Elder abuse resource packages for use in practice and guidelines or protocols for detecting and managing elder abuse were also identified as potentially useful.
The development and evaluation of a convenient algorithm to assist Canadian physicians in detecting and managing elder abuse is considered a high priority. As a result of the findings of this survey, our group has undertaken a project to develop such an algorithm.
We gratefully acknowledge the help of the volunteers at Senior Peer Counselling, Catholic Family Services, Hamilton Wentworth, those who helped pretest the survey instrument and all the physicians who participated in this study.
This research was funded in part by the Education Centre on Aging and Health of McMaster University, the HamiltonWentworth Regional Public Health Department, the Division of Geriatric Medicine Research Fund of McMaster University and the Hamilton Community Foundation.
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References
- Toronto Mayor's Committee on Aging. Elder abuse. Report by the Crimes and Abuse Subcommittee to Toronto City Council. Toronto: City of Toronto; 1984.
- Podnieks E. National survey on abuse of the elderly in Canada. J Elder Abuse Neglect 1992;4:5-58.
- Clark CB. Geriatric abuse -- out of the closet. J Tenn Med Assoc 1984;77:470-1.
- Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1994 update: 4. Secondary prevention of elder abuse and mistreatment. CMAJ 1994;151:1413-20.
- Forty-first annual Canadian medical directory. Don Mills (ON): Southam Magazine and Information Group in association with Canadian Medical Association; 1995.
- Dillman DA. Mail and telephone surveys: the total design method. New York: John Wiley & Sons; 1978. p. 119-99.
- Physicians in Ontario. Hamilton (ON): Ontario Physician Human Resources Data Centre, McMaster University; 1996.
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