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Elder Mistreatment: Podcast with Laura Mosqueda



If you looked at the academic literature, you would think that elder abuse and neglect, collectively called elder mistreatment, did not exist before the 1990s.  Of course that's not true at all, it was hidden, covered, and not a major subject of research.  Several pioneers have placed elder mistreatment firmly on the map, including XinQi Dong, Mark Lachs, and today's GeriPal podcast guest, Dean Laura Mosqueda (@MosquedaMD) of the Keck School of Medicine at the University of Southern California and Director of the National Center of Elder AbuseArchstone Foundation, who funds our podcast, was a critical early investor in efforts to raise awareness, study, and intervene to prevent elder mistreatment.

Today we learn about what a long term care Ombudsman is, about the impact of Covid19 on elder mistreatment, and ethical issues at the core of elder mistreatment (autonomy vs. safety and public health).  

One major take home point that I'd like to emphasize here are three questions that Dean Mosqueda asks of all of her patients by way of screening:

1. Is anybody hurting you?
2. Are you afraid of anybody?
3. Is anybody using your money without your permission?

Finally, June 15th is Elder Abuse Awareness Day, and here's a link to find out more about how you can get involved.

And great song choice - Veronica by Elvis Costello - check out this YouTube video of Elvis talking about his grandmother who had Alzheimer's dementia and how talking with her he would "bounce around the years."

Enjoy!

-@AlexSithMD



  


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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have on the podcast today?

Alex: Today we are honored to be joined by Laura Mosqueda, who is Professor of Family Medicine and Geriatrics and Dean of the Keck School of Medicine at the University of Southern California and Director of the National Center of Elder Abuse. Welcome to the GeriPal Podcast.

Laura: Thank you. It's a pleasure to be here.

Eric: I don't think we've had a dean on before, Alex.

Alex: This is our first dean. We're moving up.

Laura: Be gentle. [laughter]

Eric: Well, we're going to be talking about elder abuse and neglect and mistreatment and figuring out what all those different words mean. But before we get into this topic, Laura, do you have a song request for Alex?

Laura: Yes. I'd like for you to play Veronica by Elvis Costello.

Alex: And can you tell us why?

Laura: Once people hear the lyrics they'll know.

Alex: I have to say, I love this album, the Spike album. I love this song, but I didn't actually know what the lyrics were until I looked them up because I have a hard time understanding Elvis Costello, particularly when he gets to the chorus of these songs.

Laura: When you see his video, you get it.

Alex: Yes. This is about his grandmother who had Alzheimer's and some of the lyrics are about abuse and I'll try to sing them more clearly than Elvis does.

Alex: (singing).

Eric: We'll get a little bit more of that too at the end of this podcast, because I kind of want to hear more of the lyrics. Before we get into the meat of discussion, just want to also acknowledge we are still in the middle of a pandemic. We are kind of waking up as a nation to some of the systemic injustices that we have as a nation and how it impacts minority populations, including blacks protests going on. Today is, we're recording this on June 5th. Laura, can you just give us kind of a brief, how are things going in LA right now?

Laura: Yeah, we've been pretty wild here in LA and one of the nice things about being the dean of a medical school is I'm able to say things like black lives matter and that racism is a public health crisis. I'm able to work with people so that we can do something about it. So that's what we're setting about doing. This morning at 10:00 AM I was outside with a large group of students and fellow clinicians and researchers and had our 8 minutes and 46 seconds of silence in honor of George Floyd's memory. So it's had a big impact on us here and it's really inspired and motivated us to do something, not just a bandaid but something at a really systemic level in addition to the little things that we can do starting tomorrow.

Alex: Do you have a sense what those changes might be?

Laura: Yeah, we're looking at a number of things right now, like some... so we're starting with educating ourselves. I'm starting by listening. I've got to listen to particularly some of my black colleagues, students, residents, practicing physicians, and hear more about their experiences. I spent about an hour and a half doing that last night on a large Zoom call. And it was extraordinary to understand what people have been through and have not been allowed to express or have been afraid to express or haven't been welcomed to express it. So I think listening and learning from people is really, really key right now. And then there's lots of things we can do. So we're talking about new courses. We've already, fortunately about 18 months ago, I started an office on social justice and appointed an associate dean for social justice at the school.

Laura: So we have the infrastructure in place to really run with this. I think one of the things is our tendency to do, particularly as physicians is we want to do something like something's wrong, let's do something about it. I think one of the important things to do right now for me, is to shut up and listen and understand what it is we can do together across the university, certainly across the school of medicine, but across the university and with our community that will a longstanding, substantial change in people's lives.

Eric: Can I also ask, right now in LA, how are things going with COVID?

Laura: Well, things are ramping back up with COVID. So we had what seemed like a bit of a surge. I know people keep talking about peaks and I keep talking about rolling hills. So we have these rolling hills, but we are pretty concerned now that COVID seems to... the numbers just in the past few days are coming back up, particularly over at our County hospital. So our faculty worked in our private hospital at Keck hospital and in Verdugo Hills and our North Cancer Hospital. But we also provide a lot of the staffing for our County General Hospital, the LAC+USC Hospital. And we're really seeing an uptick there that has us pretty concerned. And now with the protests, we're concerned about people's exposure and a lot of people they're pretty close together and they're not wearing masks and we're worried is going to go up. Then the other thing, if you want, we can talk about is the effective COVID on older adults, particularly those in nursing homes.

Eric: Yeah. I think that would be great. We've had about 18-20 podcasts on COVID. We've done several on its effect on older adults, and nursing homes. I wonder you are a national expert on older adults, elder abuse, mistreatment, is there an impact at all on COVID and what we're seeing in that regard?

Laura: I'm sure there is, because it only makes sense that we could talk about why it only makes sense, but the sad reality is we have no good centralized mechanism for getting a handle on how much elder abuse is out there, which means we don't have a really good way to measure what kind of increase there has been. I'll tell you one thing that really, really scares me because I'm also a volunteer Long-Term Care Ombudsman is, we have not been allowed to go into nursing homes. Ombudsman have not been allowed to go in the nursing home so we don't know what the heck's going on.

Eric: Really. You can't go in? I feel like healthcare providers can go in, but Ombudsman can't?

Laura: Yeah. The Ombudsman have not been allowed. So I've just been working with the head of our Long-Term Care Ombudsman here in Los Angeles County to talk about what kinds of like PPE, et cetera, can at least the paid Ombudsman utilize to go back into in the nursing homes.

Eric: It just reminds me too, maybe taking a big step back and talking about definitions because I don't think I learned what Ombudsman was like, well into geriatrics fellowship. Can you first describe what that is and then we can describe like what elder abuse and neglect and all these other terms are.

Alex: That would be great.

Laura: Yeah. So I'd be happy to do that. So the Long-Term Care Ombudsman is a very specific type of ombudsman who go into nursing homes and really serve as advocates for people who live in nursing homes. Because that's probably most everybody listening to this podcast is aware, a lot of people in nursing homes are pretty physically and or cognitively disabled. And it's often a combination of both. They may or may not have family members who can advocate for them or who know how to advocate for them. So the Ombudsman, the Long-Term Care Ombudsman is a person who goes in, we get training in rules and regulations. So we can go into a nursing home and we look at like, do they have the right signs posted? Is it clear where people can go for variety of activities. But then it's also a matter of saying, "Well, it's nice that it's posted, but isn't really happening."

Laura: And then we also just go bedside one-on-one with the residents, the people who live there and kind of check in and see how they're doing. So it's a combination it's woefully underfunded. I know that's probably a common theme as well for a variety of things. so the paid ombudsmen rely on volunteer Long-Term Care Ombudsman to help them go into nursing homes and kind of monitor how things are going.

Eric: And correct me, when there are issues around elder abuse or neglect and nursing facilities, the Long-Term Care Ombudsman is the person that goes to instead of adult protective services.

Laura: Right. So when there's a suspected case of abuse or neglect in a licensed facility, it goes through ombudsman process and if outside of a licensed facility, it goes through adult protective services.

Eric: When I talk about elder abuse, should I be saying mistreatment, like what's the current, like what's the right thing to be saying here? Why do people use all these different terms?

Laura: We do it to confuse you. Has it worked?

Alex: It's worked. [laughter]

Eric: Wonderfully. It doesn't take much to confuse me, so there's that. [laughter]

Laura: Well, yeah. So it has been kind of ridiculously confusing. So let me just talk to you a little bit about the pros and cons and I'll just put on research hat for a minute and say that what happened is there was a National Academies panel that met probably a bazillion years ago at this point that tried to narrow the term and talked about, it narrowed it down to elder mistreatment, which means that it's either abuse or neglect happening by a trusted other. The reason the trusted other piece was put in was because if you're an older, if you're a really healthy 65 year old walking down the street, and somebody comes and robs you at gunpoint, is that elder abuse, or is it like a kind of your run-of-the-mill crime type of deal? And the argument was, well, that's not a trusted other, so that's really not what we're trying to get at here.

Laura: What we're trying to get at is when there's a relationship or a reasonable expectation of a trusting relationship. That was really for research purposes because we were all over the map doing research. I mean, everybody had their own definition and you could never... and then people would try and do a meta-analysis and combine data. It was just crazy. It still is crazy, but it's just a little less crazy now. So when I'm wearing my research hat, I talk about elder mistreatment and there has to be a trusted other and I go back to that kind of core definition. When I'm being a clinician, I don't care. I mean, the point is this person being abused or neglected?

Laura: You can call the elder abuse, you can call it elder mistreatment but the reality is if I have a reasonable suspicion I'm required to make a report. And part of the reason people got away from the word abuse is because it's a scary term and there's a lot of emotion that goes along with it too. So sometimes even as clinicians, we're afraid to call it elder abuse.

Eric: Yeah. And I also get confused too. So when we think about neglect, I always... like when we talk about elder abuse, I hear how common neglect is as a cause for elder abuse, but then I also hear abuse and neglect. So is neglect part of abuse or is it abuse different than neglect?

Laura: For me, it's all part and parcel the same thing, but at some point, like I'll just go with the flow on that. And if people want to say abuse and neglect, that's Mazeltov, that's fine and that way, at least you're clear. Because sometimes people think of abuse as the act of, I mean, the difference is it sort of can be active and passive. So abuse is doing something to somebody, hitting somebody, yelling at somebody, drugging somebody and neglect is sort of that more passive of not doing something that gets somebody into trouble. So it's reasonable to talk about abuse and neglect from that aspect of actively doing something and then actively not doing something.

Eric: And how big of an issue is this?

Laura: It's pretty big. And it's estimated that one in 10 older adults are abused and that's a lot of people. One thing that can be difficult when you're using words like abuse or neglect is sometimes as a clinician, I'm like, "Well, he's getting abused, but don't mean it, they don't know. Like they're doing the best they can." And we're trying to get people past that idea because even if it is at caregiver or a loved one doing the best they can, but reality for that older adult is they're still getting abused or neglected and it really is a big issue. So one in 10 it's huge. And the other thing I would mention is it's even bigger for people with dementia. So it's estimated that about 50%. So one in two people with dementia will get abused or neglected at some point during their course. So it's gigantic.

Eric: Wow. Does it vary on the type of abuse? Is it mostly financial abuse and neglect or is there psychological and sexual abuse and all those other and does it depend on dementia versus not dementia?

Laura: Yeah. Let's dissect through that a little bit. So this is now just my personal anecdotal observation and I fully understand that the plural of anecdote is not data, so I'm not trying to go there. But I will say my observation is that if you look at the stages of dementia, there's a certain correlation with types of abuse. So early stages of dementia, a little more subtle, the person's kind of confused, people do a lot of financial abuse. Then middle stages where you have people who may be having behavioral disturbances. This is why we're tending to see people getting physical hitting and physical abuse. Then the late stages when you become very dependent for feeding and grooming and hygiene is when we tend to see neglect.

Laura: So that's been my observation of related the types of abuse and stages of dementia. But clearly financial abuse and emotional abuse are two huge types of abuse if you look at the general older adult population. Sexual abuse occurs as well. It's more hidden and we don't know how prevalent it is. In the nursing homes is probably small, but it's still pretty awful.

Eric: Go ahead, Alex.

Alex: Well, so when the 75 year old protestor was hit by police and then was sent to-

Laura: You mean tripped Alex?

Alex: Right, tripped according to police, when he was knocked to the ground and then ended up in a hospital in critical condition, are those police the trusted other?

Laura: I would argue that they are. The reason I threw in that tripped thing is because initially at least that's the report I heard as the police said, he tripped. Then you look at the video and you're like, "Well, if you consider getting shoved in the chest and pushing you backward, tripping, okay." This is really important because this happens all the time when we're trying to figure out. The other thing is hard to figure out abuse and neglect. Older adults have all sorts of physiologic changes that A, make you more susceptible to abuse and neglect and B, it can also mask and mimic signs of abuse and neglect. So look, the same shove to a healthy 35 year old may be annoying, but to a 75 year old with Parkinson's disease, that can become deadly. So it's the same act depending on who it's performed on can be abusive or non abusive.

Alex: And are the laws equally applied, whether this is battery from a stranger or abuse from a trusted other?

Laura: Well, I don't actually know, it depends on... So every state has different laws, different States have different... and when they talk about elder abuse laws, they define elder differently, 58, 60, 65, some just say, don't have an age-based criteria, but talk about kind of functional level. Then they also have different kinds of abuse that are reported and defined. Which is another thing that makes research really hard because you have this huge gemisch of different definitions and criteria as well so you can't even compare across States. Even when you're in a state with the same laws, you can't really compare across counties. There's so much variability in terms of how things were applied. That was a long way to not answer your question. [laughter]

Alex: Well, I wanted to ask you, if you look at... I Googled Scholared elder abuse and neglect before we talked. And if you look at Google Scholar, then it seems like this really wasn't an issue before the 1990s. But you've been one of the people who helped put this on the map and show that, no, this is a big issue. Why is it taking so long to come to light and have attention on it because of course it's been going on for so long?

Laura: Yeah. Until you call it out, you don't know about it. And I give Archstone Foundation a lot of credit for this. I mean, they were the foundation in the 90s who grabbed onto this and maybe even earlier and said, "This is a problem." And they were one of the few funding it and funding it in a really serious way. Once you put a name on it, it's like what we've seen in other areas related to social justice issues too. Once you name it, people can then identify with it and say, "Yeah, that's what that was. That wasn't just, oh, she was frustrated so she finally hit her mom and now we can ignore it." Now, we have a name for it and we have the ability to say, "That's not okay, can't do that." Then once you're able to do that, you start saying, "Okay, well, how do we understand this and study it?"

Alex: I wonder, speaking of studying it, we don't want to get too researchy here, but in broad brush strokes, what are the current hot research topics in terms of elder mistreatment?

Laura: I'd say they're in a few different areas. So some just has to do with basic mechanisms on what we call forensic markers. So older adults bruise easily. They do, we know that. Capillaries become more fragile. You might be on an Aspirin, or you might be on something more for if you have atrial fibrillation, whatever. You may have been on steroids, so you have a lot of thinning of the epidermis. So yeah, older adults bruise more easily. So how do you tell when it's due to abuse? So you got to study it and figure that out. So we've done some studies on bruising. There's great work being done by colleagues at Cornell looking at fractures and fracture patterns. Because again, if somebody falls and breaks a hip, by the time I look at... they're an old person with dementia and they've got a broken hip, I don't know if anybody's shoved them.

Laura: So is there any difference when we look at fracture patterns? So the jury is still out, but I think some of these forensic markers that will help us as clinicians, not overly accept every injury we see and recognize that some of them may be due to abuse or neglect. How do you know if a pressure sore was due to abuse and neglect? As an example, if you want, we can talk in more detail about that. So that's one area. I think another area that's fascinating has to do with understanding basic changes in an aging brain, even without dementia and why older adults are more susceptible to financial abuse to scams and frauds, even if they test out normal cognitively. So that's a really fascinating area that's getting pursued as well.

Laura: We're also beginning finally, I think to look at some intervention studies because we don't know what works. We've thrown all kinds of stuff and I think you look at other movements like related to battered women and you see that with the very best of intentions, interventions were applied, but once they were studied, found to be maybe not so helpful. So we really have to study our interventions like forensic centers.

Eric: So I was actually just reading. So Alex was doing PubMed searches. I was reading the Archstone Foundation elder abuse and neglect initiative legacy report. And I'm really encouraged. We'll have a link to it for our listeners on our website, but a fair amount of talking about forensic centers. And when I hear forensic centers, I think like CSI and they're like analyzing blood splat patterns on the walls, is that what you're doing in forensic centers? What is that?

Laura: That's exactly what we're doing. So what happen is and this is my fault. I came up with the name, Elder Abuse Forensic Center, like before any of those things...

Eric: Before CSI.

Laura: Believe it or not, you young people listening, there was a time before CSI and all this other stuff. So this was back in the day before any of those things existed. And really if you look up forensics that has to do with the intersection of law and medicine. What we were seeing and this was through some early Archstone funded grants is we started some multidisciplinary teams. What I was seeing is that we could get together with adult predictive services and provide some geriatric expertise. I might go on a house call with APS and see somebody who was all bruised up and I would go, "Wow, somebody beat this person." Then we found it incredibly difficult to get the attention of the other systems that needed to be involved like criminal justice system.

Laura: We realized we all needed to really come to the table and talk. So the idea behind the forensic center was kind of like a multidisciplinary team on steroids. And sometimes now they're called enhanced multidisciplinary teams. You get all the right people at the table at the same time to talk about those three super complicated cases. And we found, hey, more efficient, more effective, taking care of people more quickly. There were times when I would go on a house call with an APS social worker, a police officer and somebody depending on what state you're in, who could help with guardianship issues. So that we would go out there as a group, I would want the police officer there because it may have been unsafe or difficult to get in and then we were safe getting in.

Laura: We could see the situation. I can do a capacity assessment sometimes, especially when it was traumatic, which it often was in terms of lack of capacity. And we could get the person into a safer what we... I don't want to be careful about this, what we perceive to be a safer environment. These were things that would have taken like four months to try and get everybody together in the past. But once we started the forensic centers, get everybody at the table talking and trying to help people more quickly. The other thing that was really important is we really educated each other. So I talked about the early days where the tower of Babel a little bit because one person would call the older adult a patient, somebody would call them a victim, somebody would call them a client.

Laura: And we were all talking about the same person, but you had to learn each other's language. And we had to learn and mostly talking about myself here, not to be accusatory, like, "What do you mean you can't go in and help." So we had a lot of vigorous conversations, but we ended up teaching each other a lot too, that I think helps us serve the older adults in our community better too.

Eric: How do people get into like, who do these forensic centers see?

Laura: Well, so the client, the way we set these up in the early days, and again, this was entirely through the Archstone Foundation. And in fact, one thing that I think was really...it's just still a memory seared in my brain was this needed to be something that we were doing with the community. At that time, I was at University of California, Irvine. We were in orange County, California, and we wanted to get this going. And Archstone said we will help fund this. They had funded some of our early work when we implanted a geriatrician and a general psychologist to work with APS, and we knew we wanted to expand.

Laura: They actually, Mary Ellen Coleman from the Archstone Foundation came with me to a meeting with the community and said, "We are really interested in this. Tell us County official people, what's your contribution going to be to this?" And it was just magic. It was a great opportunity where everything was getting leveraged from the university, from the community, from the foundation to really get us up and running.

Alex: I've always been interested in the ethical issues that sort of are at the core of particularly self neglect. Thinking about, you mentioned the word safety in a more safe environment and wanting to be careful around the words there, because that is one of the central tensions, isn't it? In this country, we allow people to take enormous risks to their own life. We value, there's a norm around this. The major rock climbing magazine has an obituary section. So we allow people to take tremendous risks. How is that different when a person turns 65?

Laura: It's not. It isn't different when a person turns 65 and it shouldn't be. What begins to happen though and you're exactly right. In terms of the ethical boundaries here is at what point do we allow... Everybody's allowed to make a bad decision. We do it all the time but at what point do we say you're not allowed to make a bad decision. And that tends to be when somebody, for example has a dementing illness and is signing away things that just isn't in keeping with anything related to prior history and values. It's what we see when an 85 year old man is courted by a 23 year old woman. And I understand true love can happen under those circumstances. I just think it's more unusual when he has moderately advanced dementia, is very, very wealthy and his bank account starts getting drained. But that's the argument that gets made. You know what? He's happy. Like who are you to say that his children should get his fortune? Those are the difficult conversations we have to have.

Alex: The other thing that struck me about this issue is as dean of the medical school, I'm sure you see this. So much medical training these days occurs in hospitals. So people are used to seeing older adults in this very protected environment. And then when they go into patient's homes, they have a very low threshold to say, they cannot live here like this. There is no way absolutely, they need to be hospitalized. They need to be in a nursing home. And yet as you know, geriatrics, palliative care and people who work in outpatient medicine, we see people make it under very difficult circumstances with some support in the home. I wonder if you could comment on that issue.

Laura: Yeah. And just to get to the research piece for a minute, a guy named David Burns is doing really interesting work in this area with something called Goal Attainment Scaling, which is based on like, how do we know if it's a good outcome? I know if it's a good outcome, I got this older adult out of that nasty situation, and now he's safe in a nursing home. Well, hello. Like, this is the one thing this guy never wanted. He would rather be at home and get abused to the degree he was getting abused than be in a nursing home. That's not a good outcome from his perspective. So these are the things that we really grappling with, especially in the early days of our elder abuse forensic center, which is what is it that makes a good outcome and how do we measure that. And you're right, people, it has to be as patient-centered or person-centered as possible, so that they're defining what the good outcome is for themselves.

Laura: And really our job is to try and help get that. And I would argue that sometimes the best thing we can do is mitigate the abuse that's going on, just make it better. And we can't get away from it entirely, but we can make it a lot better. There's a whole variety of ways we've done that through our forensics enter teams, but the person stays where they want to be. And the one person they still recognize and love is the person who's abusing them. So what can we do in that situation that still respects the autonomy to the maximum that we can for the older adult.

Eric: Yeah. I feel like for, especially when we're also dealing with like in the hospital residents and attendings, like somebody can be very marginal at home and they're going to be marginal. They're going to sink or swim but in the hospital, like we will not discharge them, because we're worried so much about their safety and what's going to happen. We have many people in many hospitals who are there for an extended period of time. How should we also be thinking about that? Any words of wisdom?

Laura: No. Yeah. So I mean, hospitals just love this, because it's not reimbursed time and DRGs are getting blown up and all that. So I think this is where if there is a forensic center in your area, it's really helpful because you can look at a reasonably safe discharge and recognizing that none of us are really completely safe anyway, but you don't want to be sending somebody back to a really horrible situation. Although we do it all the time with nursing homes, I will say people come in with awful pressure sores and we send them back there. The other thing though and this, believe it or not relates back to COVID is we're doing so much tele-health now that we're actually able to see into people's homes.

Eric: Yeah. For the first time.

Alex: Yeah.

Laura: Wow. Who would have thunk it? Yeah. So I think we really should be utilizing the telehealth tools now to get a sense of what the home environment is like too.

Eric: So I'm also guessing that to get into like a forensic center, you actually have to have providers, banks, social workers identify that elder abuse is happening and potentially screening for it. Is there a tool that we should be using for screening? Is there any evidence for that and how should we be thinking about this when we're seeing older adults? Or should we just be waiting for them to tell us, "Hey, I'm being abused."

Laura: Yeah. That would be a long wait and you would miss it. But we don't have any good data to say, "This is what you need to use." So I'll tell you just as a clinician, I generally ask people three questions. Are you afraid of anybody? Is anybody hurting you? Is anybody taking your money without your permission? That's for me is standard practice, I don't have an evidence base for saying it, but I do have some common sense. There's that famous idea of, we didn't need a randomized controlled trial to tell us the parachutes are necessary. So it's not quite that far but to me I'm willing to go with that without data to say, "These are the questions I need to be asking." There are screening tools, Terry Fullmer, who's now CEO of the Johnny Hartford Foundation published one of the really important ones that are used, but they're still not being used clinically as much.

Laura: We're now adapting those, some of the tools that she developed for screening in emergency rooms, there's lots of good work being done in this area. The other thing is we publish a bottle called AIM, the abuse intervention prevention model, AIM and I just carry it around in my head. And it's the thing that I'm simple minded has been very helpful with all this because it's pretty simple. There are three kind of buckets that we think about our three domains that we think about related to elder abuse, the older adult, the trusted other and the context of their situation.

Laura: So there's reasonable data to show that older adults with dementia, particularly dementia with behavioral disturbance are more likely to get abused or neglected. There's pretty good evidence that if you're a trusted other with a mental health problem, you're more likely to be abusive. We have contextual, something about contacts where social isolation seems to increase risk financial dependency. So I just carry that model around in my head and I'll see somebody in my practice, if we have time for a quick anecdote.

Eric: Yeah, please.

Laura: Okay. So here's my quick anecdote, which is we were seeing somebody who came through our clinical program, who were diagnosed with Alzheimer's disease and had a family conference. It was all kind of geriatric kumbaya stuff, right? We'll pull people together. This is what we think. This is why we think it. It's really not, doesn't look safe for mom to stay at home on her own because she had a gas range and a newspaper caught on fire. So there were some real dangers there. Family was like, "We understand it and we were anticipating this. So we have X daughter who we think can move in with mom." So it's all sounding good. And then you ask the question, "Well, why is she available?" And you do ask a few more questions and dig under the layers and it turns out that this daughter has schizophrenia which is controlled right now but much of the time is not controlled.

Laura: So we would have a woman with dementia who is having behavioral disturbance, being cared for by somebody with schizophrenia who is not under good control most of the time in a very isolated situation. And you can see abuse coming. So that's an opportunity to, as a clinician and say, okay, you can apply the AIM model and say, "That's probably not a good situation. What should we do about it?"

Alex: Which brings us to, what should our listeners who are overwhelmingly clinicians? What should they be doing? What can we be doing as clinicians caring for older adults in a variety of settings?

Laura: So I would ask those three questions. Are you afraid of anybody? Is anybody hurting you? And is anybody eating your money without your permission? The other thing I would do is like what we're really good at doing, and when we're taking care of older adults, which is just asking a question and stepping back and listening. So I will say I used to, I loved my grandparents as many geriatricians had close relationships with grandparents. And so early in my career, whenever a patient would say, "My grandson's moving in with me," I would always go, "That is so sweet." And they would always go, "Yes, it's lovely." But now that I became a cynical elder abuse researcher, I just say, "Oh, your grandson's moving in with you. What do you think about that?" And now I hear things like, "Well, I'm kind of worried because he just got out of prison."

Laura: Never heard that when I was just telling people how sweet. So I think we need to ask about these things and we need to ask about prior relationships, so that what the living situation is like, and not just assume it's nice because you're with family. But clinicians asking about what it's like at home, what the relationships are like, I think it's very important. Looking at the body language, not only of the older adult, but the caregiver or family member who comes with them. Are they in the corner of the office with their arms crossed kind of glaring at the older adult? Are they constantly correcting them right in front of you? Being good observers and listeners I think can help us prevent and can help us pick it up at early stages because the sad reality is by the time it gets to APS it's usually been going on for months or even years.

Alex: And if you could wave a magic wand and change the system in some way how would you change it? Would you give APS workers more authority to go into patient's homes? Would you create a national registry around elder mistreatment? What would you do to move the system forward on a policy level?

Laura: I think the most important thing is that we need to have structures available to support aging well. So the more people who age in a healthy way, the less vulnerable or susceptible they are to abuse or neglect. The other thing is the more structures we have in place, social structures, adult daycare programs, social services, food programs, et cetera. That's what we really need to concentrate on. I love my colleagues in APS, but there's not one shred of evidence that APS helps. So I'm not sure that that's the right way to... it might be let's study it. But I think a lot of it has to do with social structure and support for older adults and for caregivers.

Eric: Yeah. One of the common frustrations physicians and nurse practitioners have around APS is, they give a lot of information to APS, but they don't get any information back. And we hear that's because they can't give information back, but it definitely doesn't seem like a team collaborative effort. Because it's important for us to know kind of what, wait, what are you doing? Because we need to know this information too.

Laura: Yeah. It feels like a black hole, light comes in, but doesn't come out. And that is a frustration, now see, you're making you feel guilty like I never worked on... It's something I completely agree with and it's something we should work on. That should be an easy policy. I don't even know for sure that it is a policy, but we've been told that so many times we all believe it.

Eric: Yeah, I believed it.

Laura: Because it would be a hassle, right? What information is private, like I'm going, "At least tell me that you went out there and saw them. Like, I don't need for you to tell me details." But I think a lot of us clinicians just want some feedback that you went there and you saw them, or you tried to go there and you didn't see them. And for the most part, we don't even get that. There are some exceptions, there are some APSs around the country that do that but I would say they're not common.

Eric: The last question for me is, so when you're talking about supports that we're providing older adults, I mean, we've had a lot of discussions in recent podcasts about disparities in care and in the supports that we actually offer, how does this impact minority populations? And is it any different than non-minority populations?

Laura: So I can't quote you articles on this, but I mean, it has to be right. So we know now about the stresses in living situations and how that impacts health and wellbeing. I can have an 85 year old patient and I can tell her to get out and exercise more, but if she lives in a dangerous neighborhood and she's afraid to go out. She's not going to be able to exercise. So she becomes more frail and becomes more vulnerable to abuse and neglect as well. I think the other thing is that family dynamics matter as well. So understanding cultural norms is really important too. In some families it's considered normal and good for everybody to keep living together and in some cultures it's not. So we have to understand the cultural issues that come up as well.

Alex: Okay. Last question from me, I wrote a paper about elder self-neglect with Bernie Lowe and Louise Aronson. And we talked about creative ways that people could care for older adults and provide support in the home. One of the issues that frequently comes up is they won't let me in. They won't let in the support that we're talking about here to help people live at home where they want to be. Any creative tips or tricks that you have to get that needed support in the home to support the caregivers, to support the patients who want to be at home.

Laura: Yeah. I mean, I think we just do our best. We take a person centered approach to understand, to the very best of our ability, what the issues are. If it's somebody who has an illness such as Alzheimer's and there's no way to be rational and have a rational conversation or nothing will stick. Because you have a conversation and they agree, but 10 minutes later that's gone. There's not a lot you can do. So I think we talk about watchful waiting and sometimes I'll work with my families and say, "There's just nothing more we can do right now because pulling your dad out of his home, even though we know it's not safe would be so traumatic for him. We all agree it's not worth it." And what I'll say is we just need to prepare for the crisis and I don't know what it's going to be, but it's going to be something. It could be a fall. It could be a fire. It could be something and so sometimes I just get super pragmatic and say, "Let's just have a game plan for when something bad happens, because we know there's a pretty high likelihood."

Alex: Some of this is about harm reduction, maybe taking the knobs off the stove.

Laura: Absolutely.

Alex: One of the reviewers on that piece said talking about like the chagrin factor, like you don't want to wait until you're sifting through the charred remains of the house and finding the bones of your patient. And it's not just the patient's home, they may live in an apartment with a family next door. You're putting others at risk.

Laura: Absolutely. Yeah. I think that's another important piece of it is, does it put other people at risk? And that also then becomes a line or not a bright line, a fuzzy line, but it does become a line that we have to talk to families about when other people are at risk.

Eric: Well, Laura, is there anything else that you'd like to say to our listeners in the last couple of minutes of this podcast?

Laura: It's been a pleasure to talk to both of you. I really enjoyed it. I would like for anybody out there who's involved with geriatric fellows to consider having, all fellows have the experience of becoming volunteer Long-Term Care Ombudsman for a year or two. Because it's a wonderful learning experience that I think we would all carry with us.

Eric: Yeah. Our fellows also go to the forensic center, encouraged everybody else to see that too. With that I really want to thank you.

Alex: Thank you so much.

Eric: Real quickly because I think it was really important. The three questions again.

Laura: Is anybody hurting you? Are you afraid of anybody? And is anybody using your money without your permission?

Eric: That's going to be my main learning point. I'm going to remember those three questions.

Alex: I think we almost got the Hanukkah questions there though.

Eric: Yeah. Alex, you want to end this with a little bit more of Veronica.

Alex: A little bit more of Veronica. Here we go.

Alex: (singing).

Laura: Thank you.

Eric: Thank you again for joining us on this podcast.

Alex: Thank you so much.

Eric: And to all our listeners, thank you for joining us as well and to Archstone Foundation, thank you for both supporting this podcast and all of the work that you've done around elder mistreatment, abuse and neglect. Now you know, so I'm just going to say all of those words together.

Alex: Just, put them all in! [laughter]

Eric: Just in case... [laughter]

Eric: To all of our listeners, I do not want to get an email saying I missed the word. [laughter]

Eric: All right. Goodnight, everybody.

Alex: Goodnight everybody.



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