Elder Mistreatment Prevention and Solutions: Carrie Rubenstein, Julia Hiner, & Tony Rosen

Eric 00:16

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:19

This is Alex Smith.

Eric 00:20

And Alex, today we’re going to be talking about elder mistreatment prevention and solutions. Who do we have on with us to talk about this topic?

Alex 00:26

We are delighted to welcome Julia Hiner, who is a geriatrician and fellowship director at the University of Texas Health Science center in Houston. Julia, welcome to the GeriPal Podcast.

Julia 00:39

Thank you so much. I’m thrilled to be here.

Alex 00:41

And we’re delighted to welcome Carrie Rubenstein, who is a geriatrician and fellowship director at Swedish in Seattle. Carrie, welcome to GeriPal.

Carrie 00:51

Wonderful to be here. Longtime listener, first time guest.

Eric 00:55

Wow, this is the first time.

Alex 00:56

And Tony Rosen, emergency medicine doctor and researcher, and I know him from the Beeson meeting. He’s at Weill Cornell and New York Presbyterian Hospital in New York City. Tony, welcome to GeriPal.

Tony 01:11

Thanks very much. Really appreciate the invitation. Excited to talk to you guys.

Eric 01:15

So we got a lot to talk about. We did do a podcast on Elder mistreatment. Was it six years ago? Alex with Laura Mosqueda. Laura, that’s kind of an update where we are right now as far as prevention and solutions. But before we get into that topic, Tony, do you have a song request for Alex?

Tony 01:31

Yes, I’d like Alex, or we’d all like Alex to play Eleanor Rigby.

Eric 01:36

Why did you choose this song?

Tony 01:38

Well, I mean, Eleanor Rigby is obviously an amazing song, one that we’ve all kind of known the words to since we were kids. And I think we all sing along. In fact, I think I’ve actually sung along with Alex on this song many times over the years. But it’s really, it’s a course as a song about loneliness. It’s a song about loneliness for older adults with social isolation and even perhaps sort of societal neglect and folks who go unnoticed. And I think we’re hopefully going to discuss during the session.

But there are a lot of opportunities that we can prevent elder mistreatment by increasing social connectedness and social services. So really excited to hear Eleanor Rigby.

Alex 02:14

Love that. Here’s a snippet.

Alex 02:20

(singing)

Eric 02:54

Wonderful. We’ll have a little bit more of that song at the end of that podcast. Carrie, I’m going to start off with you. I initially called this Elder Abuse. That was the name of the podcast title. And you suggested something different. That we should be using Elder Mistreatment, Prevention, and Solution as our title. Why did you suggest that, Eric?

Carrie 03:13

Thanks for asking that question. Abuse is a scary word. I think words matter, and nobody wants to think about, engage, or even really talk about abuse. But in our field, mistreatment prevention solutions, this is a way to really focus on the opportunities, like Tony’s already said, that we can bring to the table, that we can intervene, that we can creatively care for the most vulnerable people.

Eric 03:48

Yeah.

Julia 03:49

And people give you a funny look. If you say you’re into elder mistreatment, you gotta couch it with some prevention and care. For sure.

Eric 03:56

Well, let me ask you that, Julie. Cause, like, when I think about.

Tony 03:59

I thought.

Eric 03:59

I thought it was Elder mistreatment was both elder abuse and neglect. I’m pretty sure I actually had that in our podcast with Laura Mosqueda. Is that not no longer the words that we should be using, or is it something different?

Julia 04:14

I think the words that are in vogue kind of come and go, and, you know, it depends on who you talk to. But I think what’s ultimately most important is how we’re reaching down from, you know, the proverbial ivory tower to the people we’re taking care of. What do our patients understand? What words are they using to describe their situation? And through that, we can come to this common understanding. But in my practice, I say elder mistreatment as an umbrella term.

Eric 04:41

Yeah. What do you do, Tony?

Tony 04:43

You know, from my perspective, I feel like mistreatment describes what we’re. The phenomenon that we’re trying to focus on and combat. But I also recognize that we want to. We want to talk to people about what they understand the phenomenon to be. And so mistreatment, I think, better encompasses what we think we’re trying to focus on preventing and finding solutions for.

But I know that elder abuse is still a term that a lot of folks use. And so we want to make sure that they know that that’s still what we’re talking about, is what has been called elder abuse and neglect. And.

Eric 05:29

And then what is the phenomenon? So what is. What’s encapsulated underneath that umbrella?

Julia 05:35

Well, certainly in that umbrella, you’ve got all the types of abuses. You’ve got physical abuse, Sexual abuse, emotional abuse. Some people call financial exploitation financial abuse or break it off into its own category with scams and fraud. And then you’ve got the neglect category, whether it’s by a caregiver or yourself in both domains of physical, medical and mental health. And then of course, exploitation and everything that goes with it is under that elder mistreatment heading.

Eric 06:02

Yeah.

Tony 06:03

And from our perspective, again, and I don’t want to give a definition, but I think it’s probably also useful for us to hear the definition and make sure that we’re talking about the same thing. I think the definition that most of us think of and use is that elder mistreatment is defined as an intentional act or a failure to act that causes or creates the risk of harm to an older adult by a caregiver or another person who is trusted. And so to pause for a second, those are all important ideas.

It’s not just action. It can also be inaction and it’s not just harm. It can also be risk of harm. And it’s not. And it’s not necessarily a 63 year old walking down the street who gets his or her purse snatched. This is someone who has in a trusting relationship with the older adult. And that’s the phenomenon that I think we’re talking about and that we want our colleagues to think about and we want patients to understand and think about as well.

Eric 07:18

So like Nigerian prince scams would not fit under that definition.

Carrie 07:24

They would fit under that definition if the person is vulnerable, is considered a vulnerable adult.

Eric 07:30

But it’s not a trusted relationship.

Alex 07:32

Right.

Tony 07:33

You know, it’s such a great, it’s such a great question, Eric. And it is often debated, but I think most of us would say that these are confidence scams and these are scams that are about developing a trusting relationship. In fact, the trust is at the core of the scam. And so while the Nigerian prince scam is not necessarily your son taking your money, it is unequivocally something where you are exposing an older adult who, who is at risk. And in fact, some folks will add that to the definition that an older adult is specifically at increased risk because of their age or disability.

Eric 08:16

Well, what, what are the risk factors that we should beside, Is there any other besides age that we should be thinking about when we think about who are the highest risks for elder mistreatment? I almost said abuse elder mistreatment.

Alex 08:30

I know it’s hard to not.

Julia 08:33

Cognitive impairments is, I think what shows up most in our line of work. I do work in capacity Assessments of those who’ve experienced elder mistreatment. And we’re always getting back to that. And that gets to some of the prevalence rates in cognitively healthy people living in the community. We Expect to see 1 in 10 give take experiencing elder mistreatment. But you had some cognitive impairment, especially rising to the level of decisional incapacity, not being able to care for yourself or make those decisions. And it goes up to. Up to one in two, potentially. So it’s a huge risk factor.

Eric 09:07

One in two.

Alex 09:08

One in two. Half of people who have cognitive impairment such that they’ve lost decisional capacity may be experiencing elder mistreatment at any given time.

Carrie 09:20

And there’s a lot of reasons for that. There’s a lot of reasons for that. Some of it has to do with the caregiver strains and expectations that we have in a community where. In a society where we don’t support. Some of it has to do with the older adult who was living with dementia and unable to report. And all of these things together really significantly increase the risk, as you’ve just heard.

Eric 09:49

Do we know at all about where it falls in as far as financial neglect, physical sexual abuse, verbal abuse, psychological abuse, Is there one that’s the most common?

Julia 10:02

I don’t know if there’s one that’s the most common, but certainly a codependent dyadic or caregiver patient relationship increases the risk. If there’s financial dependence of the caregiver on the person they’re caring for, that increases the risk of financial exploitation, for example, or a caregiver with multiple caregiving responsibilities, such as someone in a sandwich generation, They’ve got younger people and older people. That’s a risk factor for neglect, for example.

Tony 10:32

And I think. I would say that. I think what we’ve found is that financial exploitation, psychological exploitation, and neglect are more common, in fact, substantially more common than physical abuse and sexual abuse. I think that what’s also worth pointing out is that as an older adult becomes more dependent, what we’re starting to find is that neglect becomes more common as care needs increase and as dementia worsens. And so I think that’s another important thing for us to think about.

Eric 11:08

All right, I got a question. Go ahead, Alex.

Tony 11:10

Well, but.

Alex 11:11

And this may be jumping your outline, Eric, but before we talk about, you know, should we screen for this? Should, et cetera, could I just hear from you briefly, each of you, about why you are interested in this issue. Often we ask this question up near the front. Would that be all right? All right, Carrie, could we Start with you.

Carrie 11:35

Absolutely. You’re going to hear a theme here because we talked about this, me and my co guests, mentorship and influence. I think that for me. So Paige Ulre is innovative, leading expert in elder abuse prosecution in King County, Seattle. And she came and talked to my residents and fellows over 10 years ago now, and I invited her to do that. She had done that in the past.

And as she’s leaving, she said, hey, Carrie, we need a geriatrician to be part of our King county elder abuse multidisciplinary team. Would you like to join? And I said, I’m no expert in this. And she said, yes, you are. Come join us. And so her mentorship and then Laura Mosqueda has been a mentor of mine throughout my entire career. These people have helped me realize that planting that stake to be involved in this work helps me remember why I’m here to begin with.

Alex 12:41

And that is your focus on people who are extraordinarily vulnerable?

Carrie 12:46

Yes. To be able to create, you know, to work with teams to create and think about prevention, you know, in the clinical setting and solutions when, when we’re faced with these difficult situations is a privilege to be able to do that.

Alex 13:05

Julia, how about you?

Julia 13:07

So I think a lot of my career in geriatrics came back to serendipity of running into these amazing mentors at just the right time. And for me, I. I’ll be honest, I really didn’t have any interest in it throughout fellowship, but I walked into my role as brand new faculty and as the new kid on the block, I had space in my clinical schedule and they said, hey, we’re going to stick you with some elder mistreatment work and see, see how you like it.

And ended up being the best thing ever. And so I was honored to be mentored for a couple years by, you know, the late, great Carmel Dyer and now, you know, Laura Mosqueda, but also so many others in the field. I watch and listen to Yalls podcasts and I was like, man, that’s an important person. That’s an important person. But mentorship and sometimes just being where you need to be to get that experience amounts for so much.

Tony 14:00

Yeah.

Alex 14:00

And what is it about this specific issue, elder mistreatment, that draws you?

Julia 14:05

I really, you know, at risk of sounding like a medical student interview, I care a lot about helping people when they are at their most vulnerable and when they feel like there’s no way back up to the surface for air and being able to talk to people at that really vulnerable period and meaningfully do something right. Then, you know, over the next, you know, couple months, that changes their experience, gets them to be safer or to be, you know, start the process of making them whole again. I find that really fulfilling and I, I love the relational aspect of that as well.

Alex 14:42

Yeah, thank you. Julia and Tony, you’re an emergency medicine doc, slightly different perspective than the geriatricians. What drew you to this? Elder mistreatment?

Tony 14:50

Yeah, you know, I actually came to elder mistreatment at the very beginning of medical school. I arrived at medical school already interested. I’d come from public health and I was interested in older adults, and I was also interested in intentional violence as a public health problem. And I happened to land at Cornell where Mark Lacks, who’s been my mentor since the very beginning of medical school and is a friend of many of us on the podcast, he really introduced me to this community.

And so I think that one thing that’s probably worth reemphasizing is that as challenging of a topic as this is, the community that works on this and the community that’s devoted their lives to this vulnerable population is an extraordinarily supportive, generous group of folks, and frankly, hopefully growing group of folks. And it’s great. I mean, Laura Mosqueda has been a mentor to all of us and it’s really a special group to be a part of. And you feel like you’re really having an impact and you’re really working with folks that are, that are thinking about how to help people at a really challenging time. And I’m an ER doc.

And in emergency medicine, what we’re really trying to look for is people that might have a life threatening thing that you can’t see. It’s obvious if you come in with a blood pressure of 50. But from my perspective, what we’re supposed to be looking for is, hey, there’s something life threatening going on that might be subtle. See if you can identify it before they leave the emergency department. And I think that elder mistreatment is something that we can do a much better job of in all clinical settings. But of course, I’m particularly interested in the emergency department.

Eric 16:33

Well, let me ask you this. I love the line of things that you can’t see. One is that you, you can look for things. Another is just general screening. But I do believe USPSTF came out with their recommendations maybe less than a year ago that follow up previous recommendations that there just isn’t enough evidence to recommend routine.

Alex 16:56

It doesn’t say don’t screen.

Eric 16:58

It’s just there’s no Evidence, no evidence for the screening tests, no evidence that they, that there are like solution, like there’s just not enough evidence in this field. What’s your take on that?

Julia 17:09

I think there’s a bit of a disconnect from the clinical reality of what people and what, you know, physicians and other healthcare providers are seeing versus you know, maybe what the evidence, you know, hasn’t quite caught up to seeing. I think anyone who does this work, who takes care of older adults is certainly seeing that these are vulnerable people who benefit from the screenings and the observations and the interventions. But you know, it I will say seeing the, the U.S. preventative Services Task Force say that it was a great kick in the butt to start doing some research to change their minds. And I’ve seen that in my colleagues and myself that we all were kind of like, okay, you want evidence? We’re, we’re coming, we’re coming.

Eric 17:50

That’s great, I love it. Go ahead, Tony.

Tony 17:54

No, I was just going to say I, I agree many of us here, we’re all working on projects to try to help fill those gaps. So perhaps you’ll invite us or other colleagues back in a couple years and we’ll have more to say. But I think that’s really, really an important thing is to say we can do better, we can find better ways both to improve screening processes, but also, and I think another really important thing is as clinicians we’re much more enthusiastic about screening for things when we really feel like they’re excellent solutions.

And so from my perspective, I think we also want to work on solutions so our clinical colleagues can say of course I want to screen for this if I find it. I got this great opportunity to help this older adult in this family.

Eric 18:43

Do any of you currently would recommend screening for like, aside from USPSTFsAs for primary care providers to screen for elder abuse?

Julia 18:53

I certainly think it’s important and I think we’re starting to see a shifting trend. Centers for Medicare and Medicaid services came out with their new record recommendations for screening in vulnerable adults. And kind of one of the sub areas is looking in, in an age friendly systems starting to mandate it. So I, I think the tides are shifting but in primary care that’s where the longitudinal relationship is. They can see those subtle changes. They have that trusting relationship to open up and, and help their patients. They know the resources in their community.

Alex 19:25

And Tony, you had an article in JAGS about this recently finding I think just to summarize a long and complex study that people who had experienced elder mistreatment were no less likely to see their primary care physician than people who hadn’t. Do you want to expand on that?

Tony 19:42

Yeah. The first thing I’ll say is that one of the reasons we did that is we first. We had found that people are more likely to see the ER in the hospital. We thought, oh, that makes sense. They’re more likely to get shuffled into that part of the system. And so we maybe thought, well, maybe that means they’re less likely to see the primary care provider. And we were wrong. We were wrong. In fact, they are just as likely, in some cases immediately afterwards are particularly likely to see primary care. And so it really emphasizes the big opportunity that primary care providers have to identify this.

And again, just as Julia was saying, like, most of my patients I’ve never met before, whereas these are folks that you’ve seen longitudinally and you can identify, hey, this looks a little bit different things. Suddenly, they’re not filling their meds quite the same way. They’ve missed a couple appointments. They’re not quite looking the same way. The caregiver isn’t behaving in a way that I remember him behaving last time. Those are the kind of longitudinal things that primary care folks have access to. And so from our perspective, we. We thought it was in some ways, good, good that we were wrong, because it identifies this opportunity for primary care providers to identify this.

Eric 20:58

And as a.

Carrie 20:58

And this is. This is our specialty. We are pattern recognition specialists. We know normal aging, and we know abnormal aging. And when you see, for instance, bruising showing up in the inner thighs or somewhere where you would not expect it, we need to be thinking about this when. When people. And we. And we’re. We’re good at this. We can notice these changes, especially when we have the privilege of having these relationships over time.

Eric 21:30

But it. It’s harder, though, like, than in peds, because there’s some things like bruising, again, probably in particular areas, you’d be worried more. But bruising is actually fairly common in older adults, too. Missing medications like. And I think that is one of the issues with a lot of these screening tests is the specificity of it isn’t very good. Tony, you’re gonna disagree. I see you’re shaking.

Tony 21:55

No, no, actually, I couldn’t agree more, Ari. I was gonna say that we have a mentor who’s since retired who said elder abuse. It’s not rocket science. It’s way harder. And I think that’s true. Like, you know, we care for kids in emergency medicine, and identifying bruising patterns that are unusual in kids is much, much easier. And identifying things that are out of the ordinary in kids are much, much. Is much, much easier.

And by the way, there’s a much larger evidence base to support any conclusion that you have. And so what I think that means for us is that it isn’t necessarily only about screening for primary care providers. It’s about keeping this on the differential. It’s about thinking about this when you’re seeing patients and using that kind of spidey sense that we all develop. You know, things aren’t quite adding up here. Why aren’t they adding up? Is there something that I should be. That I. Something else that I should be thinking about?

Eric 23:03

Carrie, would you agree? Kind of. It’s more about kind of the spidey sense, keeping a differential or.

Carrie 23:08

Yes. And I think this comes back to really making sure that it’s a training piece we need. You know, again, people think about elder abuse as this severe, you know, out this severe, experience a severe outcome, and therefore they’re. They’re not keeping it high in the differential when things are more subtle. If we train people well to identify these subtle changes, to keep this on the differential, to consider this, and then to think about how do we use our teams early on when we start seeing some of these concerning potentially harmful things happening. That’s the opportunity.

Tony 23:51

I would add, though, that from my perspective, back to your question of screening, if you do. If folks, if your listeners do, go back to Listen to the June 12, 2020 episode from Laura Mosqueda, who’s amazing and it was a great episode, she talks about three questions and I think it might be worth re emphasizing that you have an opportunity in primary care to say, has anyone close to you harmed you? Has anyone close to you failed to give you the care that you need?

Has anyone tried to force you to sign papers or use money against your will? Thinking about those three questions and Laura, who’s, as I said, a leader and a mentor for all of us. She says those are questions that I ask my patients and that’s one way to think of primary care screening.

Julia 24:41

Better ears are burning with all of her name dropping.

Eric 24:44

Yeah, I love that. I love. Thanks for the callback to our prior episode too. Okay, then what? So I think you also mentioned, like, you know, in part, we worry about screening when we feel like there’s nothing we could do. Aside from calling aps, what are other solutions?

Julia 25:04

That is a tricky wicket. And one thing that I find in. When I’m. When I’m going around, you know, various Parts of even just the state of Texas, because we’re demographically incredibly diverse here. I’ll come in, you know, from my Houston perspective, coming from the world’s biggest medical center and say, oh, there’s this resource and that resource. And then I get these smaller town folks and going, that’s fantastic.

I don’t have any of those things, so that’s a really hard question. But I think there’s a lot of opportunities surrounding caregivers and support in caregivers and building that up. I don’t know if those resources are as strong as they need to be. In fact, I’m going to argue that they’re not. But how we support our caregivers is hugely impactful for the care that they can give. And colleagues of mine work on interventions to support caregivers to drive down elder mistreatment risk, but also actual elder mistreatment in practice.

Eric 26:01

So it’s going back to what you said earlier, that dyadic relationship, the caregiver, the older adult. And instead of like waiting for the elder abuse to happen, what supports do we have for that caregiver to try to prevent that at risk relationship turning into.

Carrie 26:18

That’s in the, in the, you know, office setting, but also in the policy setting. What are we doing for, you know, considering paid caregiving? Right. What are the opportunities to make sure that this is not only that, but training our caregivers, meaning the workforce, and valuing the workforce of paid caregivers so that there’s an opportunity to support family members when they’re going through something like this.

Tony 26:47

We like to say that interventions that support caregivers and support families are elder mistreatment prevention. You may not be calling them that, but they really are Elder mistreatment prevention.

Eric 26:58

Do we have any evidence for that? Is there any studies looking at something focused on caregivers that decreases elder abuse risk?

Tony 27:04

It’s a great question and the answer is hopefully coming, but nothing yet that that confirms that from an evidence perspective that I’m aware of at least.

Julia 27:13

You know, Zach Gasumas had been working on some interventions with caregivers. I believe it was called kinder. And I don’t remember all the details of it, but essentially the outcome was that they were able to bring down elder mistreatment. I believe in the caregiver support intervention group down to 0, 0. And it was probably a pretty small study. I don’t want to say anything out of term without having it in front of me, but I think, I think it’s coming. I think we’re Going to find more and more of this work and keep out an eye in the nursing literature too. I think there’s a lot of work coming from nursing too.

Tony 27:53

And then that’s a great point. I should probably cut my, cut myself out out. Because that’s absolutely right. And I don’t. It’s not, it’s not caring. I’ll come up with the study in a minute. But, but there is. That’s absolutely right.

Eric 28:03

Well, let me ask you this, Tony, because you have another thing that I’ve been reading about in jags called Vulnerable Elder Protection Team or vept. What’s that?

Tony 28:14

So for us, one of the. I’m an ER guy and we’re used to child protection teams and the reason a child protection team exists is that the ER doctor and the hospitalist are busy with the heart attacks and strokes. And when a patient comes in that might be a victim of child abuse, people are like, well, I don’t know that I know what five phone calls I need to make and what I need to do next. And in our experience there are about a thousand or more than a thousand child protection teams that are hospital based in the country.

And we knew of no elder protection teams. And so that’s what we thought. We’d create something that was ER and hospital based, a consulting, a consultation service. And what we were hoping was that if you create a consultation service, you’re going to cause two things. One is that your colleagues in the ER and hospital are going to be more likely to recognize this and two, that when they recognize it, it’s going to be less work for them. And that’s what we found. We weren’t sure. We sort of set it up saying, well worth seeing, maybe people will call us, maybe people won’t call us. But we get called a lot.

And it feels like we’re getting called more and more as more folks around our health system get to know what it is that we’re doing. And also that folks outside our health system get to know what we’re doing. But I want to add a couple of quick things about the program. The first is that we set it up as sort of a physician led program. We thought we were going to be physician consultants and then we added social workers and found that they’re way more important than us. They’re really the heart of our program. And I think that what we’re trying to think about is can we consult inside the hospital, can we support folks in a hospital setting? In other words, unfortunately, I’m a reactive doc. I’M the doc. When things go badly, you end up in the ER and then you end up in the hospital.

And so we’d love to talk more about prevention, but in our world, we also want to be able to support inside the hospital clinicians that might see stuff but might not know what to do next. And so we’ve really felt like it’s been an impactful program and it’s one that we’re excited about. And we’ve got colleagues in Colorado that have just developed sort of a program that’s similar to ours, probably even better than ours. And we’re thinking about ways to expand this model…

Eric 30:46

And who’s on the interprofessional team?

Tony 30:49

Right now we have, in our program we have er, ER clinicians who see the patient initially, we have social workers and then we have a geriatrician. But interestingly, we also have buy in from folks, everyone from security to legal to patient services. It turns out that there are a lot of issues around elder mistreatment issues as different as well. What if the healthcare proxy is the abuser? There are all kinds of things that are useful to build a team around and to think about, well, maybe ethics should be involved in this case. How can we support this family? And once we discharge this patient, is there a way for us to support them once they return to the community?

Alex 31:34

Carrie, what kind of team do you have up in Seattle at Swedish or if anyone.

Carrie 31:40

Yeah, so this, you know, there’s a lot of similarities. So I participate in this elder abuse multidisciplinary team that is out of King county, and it is a group of diverse and brilliant professionals. Geriatrics is the medical specialist involved, but we have aps and so APS brings its most difficult cases. We have Aging and Disability Services, which is sort of our AAA center. We have specialists, police representatives, law enforcement, attorneys. Paige Ulre is the co founder of our mdt. We have financial specialists that are specialists in looking at people’s bank accounts when they, when there are concerns for exploitation.

And you know, again, this is a opportunity that potentially, if enough people in the community know about it, it can increase their likelihood of, of reporting. Because this, what happens with this team is the cases get brought to these people as we come together. And my trainees, my geriatric medicine fellows are part of this team too, which is a fabulous experience, important experience, and we can come up with creative solutions that nobody would ever thought of alone and bring that back. We bring in to this core team. We bring in the pcp. Sometimes we bring in the case manager from their community.

We bring in sometimes a community service officer that noticed something in the neighborhood and brings it to us. So this is a tremendous opportunity to come up with creative solutions that could prevent things from getting worse.

Eric 33:39

And Julian, Houston, do you have anything similar to that?

Julia 33:43

Yeah, so I’m lucky to get to participate in more meetings that I want. But kind of three multidisciplinary teams, really composed of very similar people, as Carrie described sitting at her table. But I work. Probably the unique one that I’ll highlight is an elder abuse fatality review team which partners with our medical examiners in Houston. And we receive referrals on situations that might have result, elder mistreatment might have resulted in someone’s death.

And we are able to look at it from the ground level on up and look to see if there’s systemic changes that we can implement with, you know, getting personal care homes and boarding homes licensed and monitored with the same rigor that, you know, facilities are supposed to be. Were there opportunities for, you know, emergency medical services personnel who are boots on ground in these homes to make APS reports and just looking at all these opportunities and seeing what policy change can be enacted from that. But in addition to that, I do run of the mill, you know, elder justice, multidisciplinary teams, again, very similar to what Carrie is describing. It’s actually one of, one of the first things I think we bonded over.

Eric 35:01

And then I guess my question is how much is. Is it important to have these multidisciplinary teams versus that we have APS involved? Like, isn’t also this the. The point of aps, or is this in conjunction with aps? Like, how does that all fit in?

Carrie 35:17

I would love the opportunity to talk about aps, because I think this came up on your last podcast on this topic. I think a lot of clinicians feel like APS is a black box where you send your concerning situations in and you get nothing back. And I really want people to understand that APS is not an emergency response system. So if you’re in an emergency, don’t call aps. But aps, think of it as a safety net, right? And I’ve worked a lot with APS on these teams. I know Julia has as well. Tony, you’ve had a lot of communication, I’m sure, with aps. Guess what?

They want to hear from us, they want to talk to us, they want to collaborate on your concerns. But they just assume, and this is no joke, they assume you don’t have the time. And so for every situation where you make an APS report. And I encourage you to learn your state’s and your community’s ways to report. Consider tracking down the APS investigator and communicating with them. Because I think that is a way to allow APS to do what it does best, which is investigate and then bring resources that an individual might need. These teams, these, you know, multidisciplinary interprofessional teams that Julia and I are just talking about, they are for the toughest cases when it really hasn’t made progress through aps because you’re bringing in even more folks that are expert in this area to come up with solutions.

Eric 37:04

Well, how about for you, Tony, since how does APS fit into the VEPT team?

Tony 37:09

It’s a great question. For us, a close connection to APS is a really important part of our program. We connect with them. When we see a patient, we’re able to find out from them whether they have active information, whether they have concerns. And we work with them to make sure that once we’re ready to discharge a patient, that we’re handing off warmly to them in the community. And so I think that one of the things that’s really important is the closer a relationship and the stronger a relationship you have with aps, the more confident you can be that the services that they’re going to help provide and the work that they’re going to do is going to support your patient.

Julia 37:50

And I think the corollary to that is when APS gets to know, you know, the physicians in their community and knows, you know, who, who, who’s out there ready to talk to him, it makes APS more and more comfortable to reach out to us with these questions, with these opportunities to engage and help, you know, the, the patients, the clients that we’re all taking care of. So it’s a two way street.

Carrie 38:15

Limitations. There are limitations. I heard recently an APS investigator said they had 40 new cases. You know, this, the resources probably need, they need more resources with aps. And then, you know, APS can’t force folks to accept help.

Alex 38:35

And so does that change? Do you think that APS should be given the ability to force folks to change? Or is that too much of an infringement?

Eric 38:47

You mean to accept their help?

Alex 38:49

Yes. Right.

Julia 38:50

I’ll go ahead and say no. I, I think, I think the preservation of autonomy, even to make, you know what I think maybe people would collectively call a bad decision, is just kind of one of those fundamental rights of, you know, being an adult and, and growing up. Now does it mean you get individuals showing up with APS recidivistically. Absolutely. And that is, I think, a big discomfort for people, especially those who don’t work explicitly in the elder mistreatment care and prevention space. I think that’s a big area of discomfort. And, you know, every, every kind of niche, every field has a point that hurts. But I, I think we have to preserve autonomy. As long as they have the capacity to refuse and understand. I, I think we have to do it even at.

Alex 39:39

I want to push back a little bit about this and say that, you know, that, for example. So Brandon Saliner is a Greenwall scholar. He’s a PhD professor out east, and he’s really interested in what do we do with people who are recidivist, particularly around substance use. And that there is a role, at some point, he’s come to believe, for law enforcement stepping in and enforced treatment. And I wonder if we will, if that’s like a leading edge and that we may get to a similar place in elder mistreatment.

Tony 40:12

I was going to say it’s a really good question. I think to some degree, ultimately self neglect becomes a real ethical dilemma. We allow our patients, our citizens, ourselves, our fellow citizens, ourselves, to make really risky decisions. The dignity of risk is at the core of how we see the human condition. However, there becomes a time when folks can no longer make safe decisions. And also there is folks that live in apartments.

And if you live in an apartment and you’re leaving the stove on, you might not just be endangering yourself, you might be endangering folks that are above or below you. And so I think that, Alex, it’s a really provocative and thoughtful question. And I think that we are continuing to try to figure out how we can best serve these patients and families. And we’re continuing to try to figure out about how we can prepare for crises in older adults who may be not making great decisions.

Eric 41:16

I remember going around 20 years ago in my fellowship in geriatrics, I went around with aps and we would be visiting people in apartments. And the one thing that always stuck in my mind is I also learned that at least in San Francisco, sometimes people who call APS are the landlords, and not necessarily for good reasons. It’s that rent controlled apartment. Yeah. So it is this really big challenge. Speaking about fellowships, Julia, do you have a fellowship in this too?

Julia 41:47

Absolutely. No. I am so thrilled you asked about that. So as of January, we got approval from the Texas Medical Board to officially start and create our fellowship, which is Elder Capacity Assessment and Mistreatment or ECAMM as I like to call it. And that sprung from our fellow rotation, which I’ve been spearheading for, I guess the last eight years now. And yeah, no, it is a full year of training working with all these partners, all the people in our multidisciplinary teams, to learn their sides of the job and more on that.

Eric 42:23

Who’s it for? Physicians, mps, social workers.

Julia 42:27

It is for. For simplicity reasons, it’s currently limited to physicians with our preferences for people with backgrounds. Of course, in geriatric, that’s our top choice. But also internal medicine, family medicine, neurology, psychiatry, and of course, couldn’t forget you, Tony. Emergency medicine too.

Eric 42:44

Is there a website for it?

Julia 42:47

Yes, that is.

Eric 42:47

We will have a link to that on our show Notes. So I am going to just real quick, last minute, this is lightning round. If you had a magic wand, you can change one thing that practicing clinicians could do around elder abuse, what would you use that magic wand on, Tony?

Tony 43:05

I want clinicians to be thinking about this. I want clinicians to be, when they’re engaging with patients, thinking, is this something that could be contributing to why the patient is in front of me and what’s changed since I last saw them?

Eric 43:19

I love it. It’s like a shortness of breath. You always kind of think about pe like should be in the back of your head.

Julia 43:25

Julia I want mistreatment to be another m in the 4 or 5ms. Framework because I want it to roll off the tongue as easily as mo medication, mentation, what matters most. Because when we do that, it’s at the front of people’s minds and they’re thinking about it. It’s always on the differential. So I want that education to back it up.

Eric 43:47

Adding another M. Love it, Carrie.

Carrie 43:50

And leveraging the training. I want every medical student resident in the country to know that choosing geriatrics means understanding that elder mistreatment is a social justice issue. And this is where you can have an incredible impact.

Eric 44:05

I love that too. I’m going to add now, I think seventh M music. Alex, do you want to do a little seventh M?

Alex 44:15

(singing)

Eric 44:50

Julia, Carrie, Tony, thank you for joining us on this podcast.

Julia 44:54

Thank you.

Carrie 44:54

Thanks for having us.

Tony 44:55

Thank you so much.

Eric 44:56

And to all of our listeners, thank you for your continued support.

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