supporting family doctors to address elder abuse & … · supporting family doctors to address...

Supporting Family Doctors to Address Elder Abuse & Neglect in the Community

Sajaratulnisah Othman1, Choo Wan Yuen2, Noran Naqiah Hairi2, Farizah Mohd Hairi2, Sharifah Norsuhaida Syed Karim2, Fadzilah Hanum Mohd Mydin1, Tan Maw Pin3,

Zainudin Mohd Ali4, Suriyati Abdul Aziz4, Rohaya Ramli4, Rosmala Mohamad4, Norlela Hassan4, Rokiah Mohd5, Lailatul Rizwanah Awaludin5, Zailan Adnan6

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Video

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Peace Final2.mp4

Ageing

Change in physical, physiology and psychology

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‘A single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’

(Dixon et al., 2010)

ELDER ABUSE AND NEGLECT

Elder abuse and neglect: Reasons for concern

More vulnerable

Minor injuries can cause serious harm and permanent damage

Survive on limited income

Maybe isolated & lonely

Formal intervention not yet developed

Health care providers may not be properly trained

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6

(20 years)

Brazil China India

Malaysia

10%

10% 20%

20%

France (150 years)

AGED NATION when 15% of the total population comprises of older adults Malaysia is projected to be an aged nation by 2030 (Samad & Mansor, 2013).

Impact of ‘ageing tsunami’ • Societal issue • Public health issue • Welfare issue

EAN – distribution

& determinants

EAN –

role of social relationships and caregiver

strain

EAN – Education,

Training and Awareness for SERVICE PROVIDERS

EAN – Formal and Informal CAREGIVERS’ educational and Support

Program

Protecting elderly

against EAN – LEGAL

STRATEGY

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REBUILDING A BROKEN TRUST: The PEACE Initiative OBJECTIVES

EAN: Elderly abuse and neglect

OUTPUT FROM PEACE

• Longitudinal Study (MAESTRO)

• Site : Kuala Pilah, Negeri Sembilan

• Elder abuse and neglect (EAN) was measured using a questionnaire derived from the modified Conflict Tactic Scales

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OUTPUT FROM PEACE

Sooryanarayana R, Choo WY, Noran N Hairi. A review on the Prevalence and Measurement Of Elder Abuse in the Community. Trauma, Violence and Abuse Journal; 2013 14 (4), 316 - 325

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OUTPUT FROM PEACE

• Two years mortality :

• EAN victims 15 (9.6%) vs 124 (7.0%) non abused – significantly higher among the abused victims

Figure 1: Mortality percentage, % (n) among EAN victims according to sub-type of abuse Raudah MY, Noran N Hairi, Choo WY. Consequences of Elder Abuse and Neglect – A Systematic Review of Observational Studies. Trauma, Violence & Abuse. 2017 ; 1 . 1-17

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OUTPUT FROM PEACE

There is inadequate evidence to assess the effects of elder abuse interventions on occurrence or recurrence of abuse. There is a need for high-quality trials, including from low- or middle-income countries, to determine whether specific intervention programmes are effective in preventing or reducing abuse episodes among the elderly.

Primary Care Doctors

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“There is no special team or whatever to care for this abused

elderly. Geriatrics team does not have any support such as SCAN

team to help you to support if you suspect elderly abuse.”

(Dr 9)

”

Mydin FH, Othman S 14

Education and training primary care doctors on EAN

Phase 1: Needs assessments

Phase 2: Development of the

educational intervention

Phase 3: Implementation of the educational intervention

IDI with primary care doctors Literature

reviews

Literature

reviews Expert input Stakeholders input

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Clinical Pathway

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Clinical Pathway of Elderly with Suspected and/or Confirmed Abuse and Neglect

a = For elderly with cognitive impairment (such as dementia), refer to specialist services (secondary/tertiary services) or memory clinics in accordance to the CPG Management of Dementia, November 2009 - page 26. b= Referral to hospital with agreement from patient once stable.

Elderly taken to examination room

In contact with an elderly (attend health facilities and/or home visit)

Suspicious of abuse and neglect

Elderly further interviewed and examined by Family Medical Specialist and/or Medical Officersa

Emergency treatment is required

Early emergency treatment given and refer directly

to hospital

Yes

No

Elderly identifies self as abused and neglected

(Affirmed Elderly Abuse and/or Neglect)

Patient denies abuse but identifying risk factors

exist

(Suspected Elderly Abuse and Neglect)

Patient denies abuse and no identifying factor exist (Negative Elder Abuse

and Neglect)

• Assess immediate safety

• Assess health impact of abuse

• Assess pattern of abuse

• Communicate effectively with elderly on action plan if emergency occur.

• Agreement for older patient is compulsory for any further management:

o Referral if elderly need further assessment, living alone or need assistance b

• Document case by completing Penderaan dan Pengabaian Warga Emas (PPWE) form.

• Continuous support (follow-up appointment and/or scheduled home visit).

Equip older person on resources for help. Health education to carers on steps to caring for elderly









to hospital

Yes

No




exist



and Neglect)


















to hospital

Yes

No




exist



and Neglect)










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Negeri Sembilan

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Penang

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SASO Model

Older people have RIGHTS

Special situations

Document the case!

Take home message

• Unstable patient • Cognitively impaired • Victims who denied

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•Options •Safety

•Ask & assess

•Suspicion

S A

O S

SASO Model

What does victim want? Existing resources? Referral for assistance? Ongoing support

Autonomy •Get the

PERMISSION

•from the

patient before

taking any

action.

• Older people have the right to make decision, just like any other patient unless in special situation where the person are unable to make his/her decision.

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Figure 1: Overview of ADMEAN study flow.

Eligibility screening

Intervention Intensive Training Programme

(ITP)

Baseline assessment

Control

Allocation

Analysis Analysis

12-month follow-up

6-month follow-up

12-month follow-up

6-month follow-up

Enr

olm

ent

Ana

lysi

s Fo

llow

-up

Allo

catio

n

Recruitment

TRAINING FOR DOCTORS

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Intervention

N=195

Comparison

N=163

N=194 N=158

Mean Age (SD) 31.67 (5.56) 33.80 (5.74)

Female 70.3% 74.8%

Years of clinical practice 5.78 (4.41) 7.96 (4.76)

Position

FMS/ Medical officer In-charge 16.4% 17.1%

Medical officer 83.6% 82.9%

Average patient daily 45.16 (15.49) 55.97 (26.39)

Average elderly patient daily 18.27 (11.40) 23.21 (14.31)

Socio Demographic

Intervention Comparison

N=195 N=163

Came across suspected EAN for the past 12 months 37 (19.0) 35 (21.5)

Types of EAN (more than 1 answer allowed) N=37 N=35

Physical 5 (13.5) 5 (14.2)

Emotional 21 (56.8) 22 (62.8)

Financial 12 (32.4) 16 (45.7)

Sexual 1 (2.7) 0 (0.0)

Neglect 26 (70.3) 35 (100)

EAN documented and referral done 2 (5.4) 8 (22.9)

Experience Handling EAN

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Knowledge score (Pre & Post)

N

Percentiles

25th 50th (Median) 75th

Knowledge Score at T0 117 4.0 5.0 6.0




A statistically significant improvement in knowledge of statistics following participation in the

training program across the four time points (pre-intervention, post-intervention, 6-mth, 12-mth

follow-up), x2(3, n=117)=51.9, p < .005). Inspection of the median values showed an increase of

knowledge score from pre-intervention (5.0) to post-intervention (7.0), a sustained knowledge at 6-

month (7.0) but a decrease at 12-month (6.0).

Intervention group

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Practice score (Pre & Post)

N

Percentiles

25th 50th (Median) 75th




A statistically significant improvement in knowledge of statistics following participation in the

training program across the four time points (pre-intervention, post-intervention, 6-mth, 12-mth

follow-up), x2(2, n=117)=31.94, p < .005). Inspection of the median values showed an increase

of practice score from pre-intervention (20.0) to post-intervention at 6-month ((21.0) and

sustained at 12-month (21.0).

Total practice score range: 7-35

Intervention group

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Attitudes related to EAN intervention (Intervention group)50th Percentiles (Median)

of different Attitude

A1 A2 A3 A4

T0 6.0 5.0 5.0 4.0

T1 5.0 5.0 5.0 4.0

T2 4.0 4.0 5.0 4.0

T3 6.0 6.0 7.0 2.0

A1 "Whether or not I report an abuse would depend on the abuse severity"

A2 “I would not wish to report on the abuser as, there are other ways to approach the situation"

A3 "I would report an abuse if my safety is ensured" *

A4 "Matters related to abuse are best dealt internally, within the family circle"

p<0.05 for all except A1

Attitude score: 1-7 (7 being the preferable attitude)

Intervention group

Comparison between Intervention and Comparison Group for Mean Knowledge Score at 6 month and 12 months

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Comparison between Intervention and Comparison Group for Mean Attitude Score at 6 month and 12 months

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Comparison between Intervention and Comparison Group for Mean Practice Score at 6 month and 12 months

Lesson learnt

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One-off educational intervention

is not adequate to change the knowledge, attitude and

practice of doctors

A need for sustainable, system-wide change

Future direction

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Enablers • Top management support • Reinforce the importance of EAN intervention • Improve practice environment

• Clinical decision support • Checklist, flow sheets

• Redesign the processes • Organized follow-up • Booster sessions (additional training)

Multifaceted, skill-building, practice-enabling strategies

Summary:

• Prevalence of EAN is 8.1%

• EAN is associated with a higher mortality rate

• Primary care doctors faced barriers to intervene EAN

• A system wide change is required to improve primary care doctors intervention of EAN

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