Rev. Med. Chir. Soc. Med. Nat., Iaşi – 2016 – vol. 120, no. 4

INTERNAL MEDICINE - PEDIATRICS

ORIGINAL PAPERS

COMPLEMENTARY MULTIDISCIPLINARY ELDER ABUSE SERVICE IN A GERIATRIC CLINIC O. Gavrilovici1, Ioana Dana Alexa 2*, Aliona Dronic3 , Ioana Alexandra Sandu2 Adriana Pancu2, Anca Iuliana Pîslaru2 “Alexandru Ioan Cuza” University Iasi 1. Department of Psychology “Grigore T. Popa” University of Medicine and Pharmacy Iasi Faculty of Medicine 2. Department of Medical Specialties (II) 3 Psiterra Association, Iasi. *Corresponding author. E-mail: [email protected] COMPLEMENTARY MULTIDISCIPLINARY ELDER ABUSE SERVICE IN a GERIATRIC CLINIC (Abstract) Aim: To describe a pilot, innovative intervention project combining the adoption and adaptation for hospital use of a screening instrument designed for use in primary health care settings in Canada (and translated into 6 other languages) and a dialogical narrative therapeutic approach. The development of a complementary multidisciplinary elder abuse service (CMEAS) in a private-public partnership. Material and methods: Between June 2015 – March 2016 elderly hospitalized in Iasi town, Geriatric Clinic and suspected of being abused had the benefit of a complementary multidisciplinary elder abuse service (CMEAS) after being screened for abuse, neglect or abandonment experiences. Results: A total of 450 patients admitted to the Geriatric Clinic were invited for the study and 152 raised suspicion of abuse experiences and were screened with EASI. Of these patients, 132 where found positive and were invited to participate in CMEAS. Conclusions: Such a multidisciplinary service requires the collaboration between the geriatric team (medical service), psychologist, social worker, legal a dvisor, and psychiatrist, referral of cases to relevant public and private community services and their monitoring after hospital discharge throughout project duration. Keywords: COMPLEMENTARY SERVICES, MULTIDISCIPLINARY APPROACH, ABUSE, ELDERLY.

„Elder abuse is a global public health and human rights problem that crosses sociodemographic and socioeconomic strata” (1). The presence of abuse in geriatric care complicates health care exponentially. Elder abuse is associated with a long series of health problems, a high level of emergency service utilization, including readmissions within less than one month, and financial burden for the family and community public services (1).

Healthcare practitioners play a key role in the identification of elder abuse, quite often medical checkups being the only regular interaction that older people have outside their home. Nowadays, elder abuse is encountered routinely in medical practice (2). In Romania, elder abuse has not been systematically identified in public hospital or primary medicine settings. Elder abuse very recently became a health policy topic as the Romanian government adopted in

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July 2015” The National Strategy for the Promotion of Active Aging and the Protection of Elderly 2015-2020”. The pilot experimentation of a CMEAS in an Iasi geriatric clinic was done in the context of the lack of psychological, social, legal and psychiatric services in the public hospital and the lack of referral of potentially identifiable cases to the relevant existing community services. In this descriptive study of the CMEAS a public-private partnership was created between a geriatric clinic, two universities, and four professional associations (psychologists, family practitioners, nurses, and social workers). The partnership was funded via NGO Fund in Romania, under the project „I Refuse Silent Abuse”, initiated by the Psiterra Association based in Iasi. MATERIAL AND METHODS The medico-psycho-social-legal model used for the identification of abuse in the hospitalized elderly relies on hospital-based medical geriatric care and MCEAS and referral and monitoring after discharge in the community. This model was developed in a 13-month project and was implemented during the last 10 months of the project at a geriatric clinic. It had the following stages: 1) geriatric assessment; 2) obtaining informed consent; 3) use of Elderly Abuse Suspicion Index (EASI) as a screening instrument; 4) initial psychological assessment; 5) social inquiry report; 6) CMEAS team meeting with the patient - using both dialogical and narrative principles; 7) implementation of the personalized intervention plan; 8) patient’s discharge from hospital, monitoring, and the case closure. A total of 450 patients admitted to the Geriatric Clinic were invited for the study and 152 raised suspicion of abuse experiences and were screened with EASI. Of

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these patients, 132 where found positive and were invited to participate in CMEAS. The assessment interview was in fact a narrative conversation (6) facilitated by a psychologist previously trained in narrative therapy by courses accredited by the Romanian College of Psychologists organized by Psiterra Association in Iași, Romania. If abuse was suspected but the patient was denying it or was reluctant to disclose information, the psychologist left his/her contact information, the description of the CMEAS and of the project, letting the patient know that he/she could contact the team any time he/she is ready or becomes preoccupied with the abuse and its effects. If the patient accepted the CMEAS, or CMEAS and referrals, the social worker initiated the social inquiry. At this first meeting the psychologist’s goal was to get patient’s agreement for an open dialogue meeting (with the doctor, psychologist and social worker, at least) (7). The information collected in this study was evaluated using clinical and epidemiological methods, statistical and mathematical techniques and procedures, descriptive statistics were performed using software SPSS 18.0. RESULTS During the 10 months of CMEAS implementation of the Psiterra narrative and dialogical model of care 152 elderly patients of the total of 450 eligible admitted elders were screened using EASI. They were all referred to CMEAS and following psychological assessment the presence of abuse was substantiated in 132 (29.3%) of the referred patients. Working narratively and offering the patient the opportunity to decide on any aspect of the intervention plan, a total of 61 patients (46.2%) accepted to receive com-

Complementary multidisciplinary elder abuse service in a geriatric clinic

plementary services during hospital stay and accepted to be referred to community public and private services, including the services offered by the religious organizations (parishes they belonged to). Other 41 patients (31.1%) accepted only CMEAS services during their hospital stay, but no

referrals. That is, a total of 102 elderly patients with confirmed suspicion of abuse received services during their hospitalization. Only 30 elderly (22.7%) identified with abuse refused to receive services either from CMEAS or to be referred to existing community services.

Fig. 1. MCS process diagram DISCUSSION The demonstration project for the implementation of CMEAS based on dialogical and narrative principles proved influential on three levels: 1) clinical (micro), improving the wellbeing of the elderly patient (both during hospital stay and after discharge, the patients being monitored until the end of the project); 2) organizational (mezzo), by providing

complementary services only to the geriatric ones, through training seminars on the screening methods for elder abuse using the EASI scale, training seminars accredited by CMR on recognizing elder abuse and hospital-based multidisciplinary intervention; 3) by integrating medical, psychological and social services and promoting the awareness of elder abuse; and sectorial (macro) by the promotion of public awareness about elder abuse and by launching a

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dissemination campaign in professional media and to major public stakeholders in healthcare and psycho-social care in Romania. As to professional training and development, as other reports suggest (3), the healthcare professionals are in an ideal position to identify, support and refer the persons who experience abuse while aging. The lack of specialized training to deal adequately with cases of suspected abuse can be a possible explanation for the fact that many cases of elder abuse go unreported. The innovative intervention piloted the development of multidisciplinary complementary services in a public hospital in line with the new strategic directions within “The National Health Strategy and for the Promotion of Active Aging” (2015-2020). In the complex situation of geriatric patients exposed to abuse, neglect or abandonment it is even more relevant to read Rita Charon (Columbia University, New York) saying that „We are all united in the efforts to treat patients, no matter of our specific skills and responsibilities. We together have the capacity to confer dignity on the lives of the sick, and, one may argue, we require that all of us join in the commitment to dignified care” (8). Making central the voice of the abused elderly and giving priority to his/her voice permits „the facilitation of the freedom to choose among alternative behaviors, all the areas of functionality of the assisted person, contributes to his or her development, to his or her plenary experience of freedom and of meaningfulness. This axiological

experience is inducing a modification of what we may describe as internal motivation and a reorientation in relation to change, initially having an ambivalent position towards change” (9). Identifying the traumatic experiences that affect compliance and patient adaptation is crucial in the case of elderly patients; the rapid identification of abuse has also an effect on changing the perception of health care personnel regarding the quality of health care provided to the patients (10). CONCLUSIONS In our study, of the 450 patients admitted to the geriatric clinic during the 10monthscreening, one third (33.3%) were identified as having been exposed to various types of abuse, neglect or abandonment and were referred to CMEAS by the medical staff. The 20 false positive responses (13% of the total 152 patients screened for abuse with EASI) underscore the importance of professional training in the use of screening instruments as well as the need for immediate referral to psychological and social services able to substantiate abuse experience and to support the access to existing resources in the family and community. Our study underscores the high sensitivity of the assisted elderly in the communication with the medical staff, increased trust in participating in medical care activities, improvement of symptoms, and a shorter hospital stay; on the medical staff side, there was a greater sensitization towards the elder patient’s needs and a more open personal expression in relation to the patient.

REFERENCES 1. Dong XQ. Elder Abuse: Systematic Review and Implications for Practice. J Am Geriatr Soc 2015; 63(6): 1214-1238.

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2. Lachs MS, Pillemer K. Elder abuse. Lancet 2004; 364: 1263-1272. 3. Glasgow K, Fanslow JL. Family Violence Intervention Guidelines: Elder abuse and neglect.Wellington: Ministry of Health, 2006. 4. Lachs MS, Williams CS, O'Brien S, Pillemer KA. Adult protective service use and nursing home placement. Gerontol 2002;42(6): 734-739. 5. Seikkula J, Arnkil TE. Dialogical meetings in social networks. London: Karnac, 2006. 6. White M. Maps of narrative practice. New York: Norton and Norton, 2007. 7. Yaffe MJ, Wolfson C, Weiss D, Lithwick M. Development and validation of a tool to assist physicians’ identification of elder abuse: The Elder Abuse Suspicion Index (EASI ©). J Elder Abuse Negl 2008; 20(3): 276-300. 8. Charon R. Narrative medicine. Honoring the stories of ilness. New York: Oxford University Press, 2006. 9. Gavrilovici O. Construction of medical career and the professional identity of diabetologists. Studia UBB Philosophia 2013; 58(1): 71-81. 10. Druguș D, Oprean C, Azoicăi D. Study on health professionals’ perception of quality of healthcare provided to patients. Med Surg J 2015; 119(2): 517-521.

NEWS NOUTĂȚI CARDIOVASCULAR SAFETY OF CELECOXIB, NAPROXEN, OR IBUPROFEN FOR ARTHRITIS In the PRECISION trial (Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen) the goal was to asses cardiovascular, gastrointestinal, renal, and other outcomes with celecoxib compared with two nonselective nonsteroi dal antiinflamatory drugs (naproxen or ibuprofen). Patients who required NSAIDs were randomly assigned to receive celecoxib (100 mg twice a day), ibuprofen (600 mg three times a day), or naproxen (375 mg twice a day). For patients with rheumatoid arthritis investigators could increase the dose of celecoxib (200 mg twice a day), the dose of ibuprofen (800 mg three times a day) or the dose of naproxen (500 mg twice a day). Also for patients with osteoarthritis, increases of the doses of naproxen or ibuprofen were permitted. A total of 24,081 patients were assigned to the celecoxib group, the naproxen group, or the ibuprofen group for a mean trea tment duration of 20.3±16.0 months and a mean follow-up period of 34±13.4 months. 68.8% of the patients stopped taking the study drug, and 27.4% discontinued follow-up. The results showed that the risk of gastrointestinal events was significantly lower with celecoxib than with naproxen or ibuprofen. Also the risk of renal events was significantly lower with celecoxib than with ibuprofen but was not significantly lower with celecoxib than with naproxen. The study concluded that at moderate doses, celecoxib was noninferior to ib uprofen or naproxen with regard to the primary composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke (Nissen S, Yeomans N, Soloman D et al. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. New England Journal of Medicine 2016, DOI:10.1056/NEJMoa1611593). F. Mitu

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