Violence against elderly people.

Every year, more than one million older Americans are injured physically, debilitated psychologically, or exploited financially by a family member. Elderly men and women, who are from all socioeconomic, ethnic, and religious backgrounds and who have varying functional abilities are vulnerable to abuse and neglect. Health care professionals need to develop the skills to detect both patients at risk and those actively being abused. Barriers to detection of abuse and neglect are complex and include victims' resistance to disclosure due to their own ageist attitudes or feelings of shame and guilt; isolation of victims by their abusers; and the health care professional's discomfort with the situation and hesitancy to intervene, often as a result of inadequate knowledge and training in this area. Researchers have identified specific risk factors for abuse and neglect by family members, including psychopathology among family members, a family history of transgenerational violence, the elder's dependency, the elders and the caregivers' isolation, the caregivers' stress, and living arrangements. Thorough assessment of patients at risk by a multidisciplinary team including a physician, a nurse, and a social worker and the team's subsequent development of individualized intervention strategies can have a positive impact on this devastating problem.

Enhancement of proxy appointment for older persons: physician counselling in the ambulatory setting.

OBJECTIVE: To determine the effectiveness of physician-initiated counselling on the rate of health care proxy appointment. DESIGN: Observational study of an intervention in a convenience sample. SETTING: A geriatric outpatient clinic in a tertiary care teaching hospital, New York, New York. PARTICIPANTS: A total of 687 patients enrolled in the geriatric clinic during the study period March 1991 through June 1993. INTERVENTION: Physician counselling about the New York State Health Care Proxy Law, distribution of educational materials and healthcare proxy forms, and reminders in 331 of 466 eligible patients. MEASUREMENTS: Rate of healthcare proxy appointment in eligible and counselled groups; predictors of appointment and non-appointment; time elapsed from counselling to appointment; reasons for non-appointment; characteristics of the proxy appointment process. RESULTS: A healthcare proxy was appointed for 31.5% of patients eligible for counselling and for 44% of patients who actually received the intervention, compared with a 2.3% proxy appointment rate at baseline. Eighty-one percent of the patients completing the proxy appointment process did so at or before their third clinic return visit after the counselling intervention. Of the counselled patients who did not appoint a proxy, 25% explicitly declined, and 75% had not come to a decision by the end of the study period. Proxy completion was associated with ethnicity, education, and more frequent clinic visits. Of those who appointed a proxy, 97% had good or fair comprehension of the procedure, 92% discussed the appointment with their designees, 63% appointed a daughter or son, and 80% discussed their wishes for care at the end of life with their proxy. CONCLUSIONS: Physician counselling of older outpatients is an effective means of increasing healthcare proxy appointments.