AMA guidelines for doctors on detecting elder abuse and neglect

Aging, Spring, 1996

Any doctor who treats adult patients seen "at least one victim of family violence in the past two weeks," according to Robert E. McAfee, immediate past president of the American Medical Association (AMA). But what McAfee and some of his colleagues active in mobilizing their profession against violence in the family fear is that doctors still aren't asking the right questions and referring patients for help. In an interview with The Washington Post last year, McAfee acknowledged that "thinking back on his own patients, he now realizes that some of them were begging me to ask the right question.'"

Some of the right questions to ask elderly patients are outlined in "Diagnostic and Treatment Guidelines on Elder Abuse and Neglect," issued by the AMA in 1993:

* Has anyone at home ever hurt you?

* Has anyone ever touched you without your consent?

* Has anyone ever made you do things you didn't want to do?

* Has any one taken anything that was yours without asking?

* Has anyone ever scolded or threatened you?

* Have you ever signed any document that you didn't understand?

* Are you afraid of anyone at home?

* Are you alone a lot?

* Has anyone ever failed to help you take care of yourself when you needed help?

"We've talked a lot about elder abuse [by caregivers, such as nursing home aides], but we have not been willing to admit the prevalence of elder abuse by family members," an AMA board member, Palmer E. Formica, commented when the guidelines were issued. The guidelines state that the interview and physical exam should be done apart from the patient's caregiver and that doctors who suspect abuse should report it to the authorities. If the patient appears in immediate danger, the doctor should consider putting the patient in the hospital or getting a court order for protection.

"A physician may be the only person outside the family who sees the patient regularly," Formica said.

Older patients may also exhibit signs of emotional abuse or physical neglect But one doctor, an assistant professor of geriatrics noted in a Congressional report on elder abuse and neglect, that "Physicians might attribute social withdrawal or depression or weight loss and dehydration to chronic diseases when, in fact, these symptoms point to abuse or neglect.

Separate but related guidelines on abuse between intimate partners were also issued by the AMA and guidelines on child physical and sexual abuse. They are being distributed by the Physicians Coalition Against Family Violence, formed in 1992, which now has more than 7,000 members. In his interview with the Post, McAfee commented that while this may sound like a lot of doctors, there are more than 650,000 doctors in the country and the AMA's membership is 300,000.

The Coalition publishes a newsletter twice a year for member physicians who also receive a poster on domestic violence to place in their offices and a listing of all the members of the Coalition to promote collaboration in fighting family violence. Members may also receive the 4 sets of guidelines free of charge by calling 1-800-AMA-3211. For the general public, for 1-24 copies, the cost per copy is $3.00, with checks made payable to the American Medical Association and sent to Jean Owens, Dept. of Mental Health, AMA, 515 N. State Street, Chicago, 60610 (312) 464-5066

Getting doctors to ask patients about family violence isn't easy. The Post noted that a survey of doctors in Seattle found that "many were reluctant to broach the subject of domestic violence, likening it to 'opening Pandora's box.' Among other reasons, they cited fear of offending the patient, powerlessness to do anything about the problem and lack of time."

"Some 71 percent of the doctors said time constraints were the major deterrent to asking patients about violence in the home. 'You don't open a Pandora's box for the same reason you don't generally ask people, Do you have sexual problems?' one doctor replied. Not because it is not important, but because you don't have time ... to deal with all this."

Emergency room doctors are also in a unique position especially to spot spouse abuse. The U.S. Dept. of Health and Human Services has vowed as one of its health goals for 2,000 to insure that at least 90% of the nation's hospital emergency rooms use written protocols for identifying, treating and referring victims of domestic abuse.