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| Vol. 22, No. 17 |
| Jun 15, 2000 |
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TEAM Institute: A Collaboration to Deal with Elder Neglect, Abuse by ROGER WIDMEYER Texas Medical Center News
"You can't imagine some of the things we have seen," says Dr. Carmel Dyer, director of the hospital district's geriatric services and associate professor of medicine at Baylor College of Medicine. The district's geriatric service - which includes a 24-bed inpatient unit and an outpatient clinic, both at Quentin Mease Community Hospital - has been in operation for seven years. The service has developed an exciting new partnership with the Texas Department of Protective and Regulatory Services - Adult Protective Service Division (APS) designed to help neglected and abused elderly citizens. The geriatric service has evaluated and medically treated about 200 clients so far. APS clients typically come from settings where there has been physical abuse, care giver neglect, exploitation or self-neglect. Most numerous is the last category because most clients have been living alone. Inherent in self neglect is medical neglect, notes Dr. Dyer. Representatives from the U.S. Department of Justice visited the TEAM Institute May 15-16 and came away impressed, according to Dr. Dyer. "The Justice Department is very interested in elder abuse and neglect, and they were encouraging about this program - the first of its kind in the U.S. that they have seen." Additionally, three other Texas cities and cities in five other states have asked the TEAM Institute to present findings to them. "The Texas Elder Abuse and Mistreatment (TEAM) Institute has the mission of improving the lives of abused or neglected elders through our clinical services, education and research," says Dr. Dyer. "That's the mission, but our first priority is to bring the patient back to good health and chart a course for good health maintenance. Once Adult Protective Services has made a referral to us, we assess the patient."
Medical Assessment and Care Plan Assessing the medical condition of an elderly person can be a complex task, says Dr. Dyer. Symptoms for a number of illnesses can be quite different in the elderly, as compared to younger persons. Medications can affect older people differently than people of middle age and younger; most older people are taking a number of prescribed medications, and this can further complicate the assessment. About 20 percent of the elderly are considered frail or have multiple illnesses. "Very frequently patients are diagnosed with memory loss and even dementia when, in fact, the cause for the memory impairment is depression, a fairly common complaint in the elderly," says Dr. Dyer. "Certain medications can cause side effects. And, of course, there are many illnesses almost exclusively seen in the elderly. Ideally, elderly patients should be evaluated by geriatricians." (There are about 9,500 geriatricians in the U.S., and medical experts at the American Geriatric Society feel that 20,000 geriatricians are necessary to fill the needs of the country's elderly.) The Baylor/Hospital District geriatric program is also staffed with nurse practitioners, social workers, dieticians, pharmacists, physical therapists and occupational therapists. The particular population of the TEAM collaboration is the neglected and abused geriatric population - and the number is larger than most people might suspect. Estimates are that between 3 and 7 percent of elders are mistreated; in 1996, there were 2.1 million reported cases. "There were 63,000 elder abuse cases reported in Texas in 1997," says Dr. Dyer. "And probably about only one in five is reported." Once the initial evaluation by Adult Protective Services and the medical evaluation by the geriatric team is completed, a course of treatment and follow-up is planned for each patient. The Hospital District geriatric care program includes the 24-inpatient unit at Quentin Mease as well as a 22-bed acute care unit at Ben Taub General Hospital, one of Baylor's primary teaching hospitals. The District also contracts for 10 beds in a local nursing home. Additionally, the geriatric program has a home care component. "With our `house call' program, homebound patients are seen in their homes by nurses and physicians for periodic assessment," says Dr. Dyer. "It's great for them, of course, but it also offers us the chance to evaluate the safety of the home and do some education with the patient and family." Dr. Dyer notes that there can be a great lack of knowledge in some families about supportive agencies and appropriate health care strategies for their elder family member. Area agencies are frequently utilized, especially for the elderly person living alone. The house may need a good cleaning, or an exterminator may be called in. Ramps may need to be built. Many of the clients utilize Meals on Wheels. The geriatric program's outpatient clinic is a model of total geriatric care. All appropriate services for an elder patient - including podiatry, urology, psychiatry, audiology and physical medicine and rehabilitation- are offered during the multi-service clinic that is held periodically. On a daily basis, the geriatric clinic at Quentin Mease offers specialty and primary care.
Education and Research The education core of the TEAM Institute is multi-faceted. TEAM members have many opportunities to educate their colleagues, medical professionals and social service agency staffs about elder neglect and abuse. Third-year medical students at Baylor rotate through the geriatric service and go on investigations with APS specialists. "Education is absolutely critical in this area of elder neglect and abuse," says Dr. Dyer. "There is not a good, established curriculum in this area. For too long, only social scientists have been truly involved in studying it. In the public perception, elder abuse is not nearly as recognized as a serious health issue as is child abuse. Public awareness has been a great part of the child abuse prevention efforts, and we need to do the same for our abused elderly." The TEAM Institute is seeking grants to support the creation of a Center for the Prevention of Elderly Victimization, a program that will help train primary care and emergency physicians in recognizing symptoms of neglect and abuse. The research that the TEAM Institute intends to carry out should provide valuable information for educating the public, as well as tracking successful treatment outcomes. "The state's data base is a great resource so we hope to contribute geriatric assessment data," says Dr. Dyer. "That will help us identify risk factors. Finally, we will be looking to find the absolute best ways to diagnose and manage these patients. We are developing an assessment tool to study our outcomes." The Team Institute is preparing a grant proposal to the National Institutes of Aging in order to conduct detailed studies of the cognitive, functional and medical status and needs of the cases reported to Adult Protective Services. The purpose of the research will be to assess the prevalence of conditions that can be treated effectively through geriatric intervention in cases of neglect. The TEAM Institute's work has occasionally brought families together. "We intervened with an elderly woman who'd gone off to live alone. She had some psychotic behavior," says Dr. Dyer. "After some B-12 injections and the appropriate anti-psychotic meds, she's doing really fine. She's reunited with her daughter, who wrote to us to say, `Thank you for giving me back my mother.'"
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