Elder Justice Roundtable: Transcript

Wednesday, October 18, 2000
9:00 a.m.

U.S. Department of Justice
Bureau of Justice Assistance
Main Conference Room 3102
810 - 7th Street, N.W.
Washington, D.C.

P A R T I C I P A N T S

Ann Burgess, R.N., D.N.Sc., C.S., F.A.A.N.
Kerry P. Burnight, Ph.D.
Marie-Therese Connolly, J.D.
Carmel Bitondo Dyer, M.D., A.G.S.F., F.A.C.P.
Carl Eisdorfer, Ph.D., M.D.,
Charles W. Gambrell, Jr., J.D.
William E. Hauda, II, M.D.
Catherine Hawes, Ph.D.
Candance J. Heisler, J.D.
David R. Hoffman, J.D.
Ian Hood, M.D., J.D.
Mark S. Lachs, M.D., M.P.H.
Erik Lindbloom, M.D., M.S.P.H.
Patricia J. McFeeley, M.D.
Laura Mosqueda, M.D.,
Lisa Nerenberg, M.S.W., M.P.H.
Joanne Marlatt Otto, M.S.W.
Gregory J. Paveza, M.S.W., Ph.D.
Thomas H. Peake, Ph.D., A.B.P.P.
Karl Pillemer, Ph.D.
Susan M. Renz, M.S.N., R.N. C.S.
Arthur Sanders, M.D.
Sidney M. Stahl, Ph.D.
Randolph W. Thomas, M.A.
D. Jean Veta, J.D.
Rosalie S. Wolf, Ph.D.
Wendy Wright, M.D.
P R O C E E D I N G S

MS. VETA: Good morning, everyone. I am Jean Veta from the Department of Justice, and I'm delighted to welcome you to our Elder Justice Roundtable Discussion on Medical Forensic Issues. This is a very important event for us and, in fact, it is the first of its kind here at the Department of Justice. We feel quite honored to have all of you here with us today.

It is my pleasure this morning to introduce Dan Marcus, the Associate Attorney General. I'm happy to say that Dan is the person whom I have the privilege of working with every day. Dan joined the department in April of 1999 as the Principal Deputy Associate Attorney General and then became the Acting Associate Attorney General in October of 1999. The President's nomination of Dan was confirmed by the United States Senate in 2000.

MS. VETA: Prior to joining the Department of Justice, Dan was Senior Counsel in the Office of the Counsel to the President at the White House, and before that, Dan was a longtime partner in one of the pre-eminent Washington, D.C. law firm of Wilmer, Cutler and Pickering. As Associate Attorney General, Dan has responsibility for overseeing all of the litigating civil components of the department, as well as the grant-making agencies of the department.

I can tell you that one of the primary reasons we are all here today at this first-of-its-kind medical forensic forum on elder justice issues is because of Dan Marcus. His support has been critical in getting the -- all of the department to move forward on this issue, and without his support, we wouldn't be here today. So, with that, I would like to invite you to join me in welcoming Dan Marcus.

MR. MARCUS: Thank you, Jean.

MR. MARCUS: On behalf of the Attorney General, let me welcome you here to the Department of Justice. We expect that the Attorney General will be with us this afternoon, which is wholly appropriate, because she is really, I think, the real reason why we are all here today. Under the leadership of folks like M.T. Connolly, people in the department have been working hard on these issues for a number of years, working closely with our friends at the Department of Health and Human Services and other parts of the government to deal with these cross-cutting issues. But it is the Attorney General who, I think, has really transformed the Department of Justice into a real Ministry of Justice. She has really led the way in expanding our horizons and recognizing that there are lots of areas like this, where the traditional activities at the Department of Justice need to be melded with social service programs and health programs and science and technology efforts to really provide a real comprehensive justice program.

I think in this last year of the Janet Reno regime, elder justice is really coming into its own in the Department of Justice as an area that will be important long beyond this administration. I want to welcome you this morning to this forum on medical forensic issues in elder abuse and neglect. We really appreciate your having made the effort, often on short notice, to give us the benefit of your expertise in addressing these challenging issues.

In selecting who should participate in this discussion, it was striking how many roads led again and again to the same names. You are a distinguished community of experts. That being said, not only are today's participants pre-eminent in their respective fields, but so too are the individuals who are here as observers, and we're delighted you all could come.

We only have a few hours today to discuss this complex topic, and so, in the interest of having a manageable, focused discussion, we have had to limit the number of participants, despite our desire to include many more folks. We hope, however, this discussion today will serve as a springboard to many more discussions with all of you and with a larger community of folks who are working in this field.

Let me tell you very briefly who is represented here today. You are geriatricians, medical examiners, psychiatrists, pediatricians, nurses, social scientists, sociologists and psychologists. You are experts in internal medicine, family medicine, emergency medicine, elder sexual abuse, developing forensic centers and in the forensic application of large amounts of clinical data.

You are the experts in elder abuse and neglect from the National Institute on Aging and Adult Protective Services, and you are prosecutors and law enforcement officials, representing federal, state and local agencies.

Many of you have done groundbreaking research in this area, developing creative multidisciplinary response teams and clinical practices and pursuing vital prosecutions and training efforts. People like Dr. Rosalie Wolf and Dr. Karl Pillemer have been pioneers for decades in the fight against elder abuse and neglect. We are very grateful to each of you, participants and observers alike, for joining us today in the exciting opportunity to lay the groundwork in addressing this difficult and important area.

The number of older Americans will more than double in the next 30 years. We have a long way to go in learning how to detect and diagnose elder abuse and neglect and obtaining consensus on what forensic markers demand additional inquiry and action. We have a long way to go in promoting multidisciplinary efforts at the national, state and local levels.

These efforts must include healthcare, social service, public safety and law enforcement professionals. We have a long way to go in educating those professionals about elder abuse and neglect, and we must urge them to conduct the research that will help us prevent, treat, intervene in and, where necessary, prosecute cases of elder abuse and neglect.

The goal of this roundtable discussion is to make progress in each of these areas and to promote the multidisciplinary efforts in which so many of you are engaged. We hope that today's discussion will give you useful ideas to take back to your respective institutions, to include in training curricula and clinical practices, to catalyze research proposals that will fill the gaps in our current knowledge and to promote funding of all of these efforts.

We also want to hear from you what you think we at the Department of Justice and in the government, generally, should be doing. There is so much to do that we must use our scarce resources that can be devoted to this area in a wise fashion. We have two moderators today: Dr. Laura Mosqueda, a clinician, researcher and educator, is the Director of Geriatrics at the University of California at Irvine, where she is also Associate Clinical Professor of Family Medicine. Dr. Mosqueda, who is board-certified in family medicine and geriatrics, is the principal investigator on a three-year project investigating the use of multidisciplinary teams for evaluation of elder abuse cases.

In another study, she recently completed the collection of pilot data on the national history of bruising in older people and what patterns of bruising should raise the suspicion of abuse. Dr. Mosqueda is also involved in education, having created a day-long course in elder abuse for geriatricians. In addition, she has testified in numerous cases relating to elder abuse.

As our second moderator, we have one of our own department lawyers, David Hoffman. David is an Assistant U.S. Attorney in Philadelphia. We call these folks AUSAs. He brought the first Civil False Claims Act case to address systemic abuse and neglect in a nursing home in 1996. Since then, he has settled five such cases. Perhaps the most significant remedies in David's cases are not the monetary damages, but the measures designed to protect residents; for example, the imposition of temporary monitors and other requirements to improve deficient areas in a single facility or chain of facilities.

Before becoming a federal prosecutor, David was Chief Counsel to the Pennsylvania Department of Aging. We are very grateful to Laura and David for their contributions to this effort. I would also like to thank M.T. Connolly, whom I mentioned earlier. She is coordinator of our department's nursing home initiative and has been a real leader in this field. I also want to thank the Office of Policy Development in the department, particularly Andrea Tisi, our Office of Justice Programs, which has not only lent us this wonderful room, but has really been helpful in organizing this event; Carol Cribbs of the Justice Management Division; and Pam Frank, our contractor.

I look forward to hearing about your discussion and to reading the resulting publication, which will include the papers and a summary of today's discussion. Now I would like to turn the floor over to Laura and David.

MR. HOFFMAN: I too want to welcome the forum members, everyone at the table and everyone in this room, because you are, in fact, invited guests. So, this is not an open party. You bring something to the table, while not sitting there, and we want to hear from you during our breaks, as well. If you have questions and comments, we would like to hear from the invited guests, as well.

A common them that brings us all together here is the belief that elder abuse and neglect has to be addressed. It has to be identified; it has to be diagnosed; and, where appropriate, it has to be prosecuted, and the prosecution may be a civil prosecution or a criminal prosecution. In order to facilitate this goal, we're going to focus on four discrete areas today. When you review the agenda, you'll see what I'm talking about.

The first is the detection and diagnosis of abuse and neglect. The second area is how health-care professionals and law enforcement can work together to solve the problem of elder abuse and neglect. The third area is educating law enforcement and health-care professionals on forensic issues relating to elder abuse and neglect. And finally, it is improving the forensic science through research.

So, I think all of us would agree that we have a lot of ground to cover between now and 2:30. So, I will be very brief. I just want to tell you what this is not about. This forum is not a training session. It is a full and frank discussion from experts. We brought everyone together, not to show how smart we all are, but rather to try to get to the best practices and get the ball rolling in terms of explaining abuse and neglect, what needs to be done and communicating that message throughout the country.

It is not a discussion on self-neglect. We all recognize that self-neglect is a big issue, but for purposes of our discussion today, we will not be focusing on self-neglect for remedy purposes. This is not a discussion about financial exploitation. We all recognize that elder abuse and neglect includes financial exploitation, but we will not be addressing that particular issue.

Hopefully, we will not be in a debate on definitions as to abuse and neglect, because we will be here forever, and we're not going to do that, either. So, we're going to go with the traditional model of physical abuse and neglect, as all of us have come to know it, whether through prosecution or through what you see in your practices.

This will not be a discussion about end-of-life decisions, okay. That is certainly out there, but we will not be discussing that today. Finally, this roundtable will not be about--it is easier for me to talk about what it is not about, in case you have not gather that--not whether law enforcement is an appropriate remedy to elder abuse. We will say, given our position here at the Department of Justice, that law enforcement is an appropriate remedy to elder abuse.

Also, as Dan mentioned, as we go through our discussion, think about how this will play out when you go back to your various communities, your professions, your institutions, and how this can become part of a national plan, because we want to hear that from you, as well. Our procedure will be as follows: We have four lead presenters and you know who you are, and if you don't, it is too late and you will be called on. Our procedure will be the presenters will do three-to-five minutes, and we have a timer here, and now I'm going to bring the medical community into the legal world.

These were borrowed from the Supreme Court, so when this says stop, we really mean stop here on these things. So, this is by order of the Supreme Court. Green means go, yellow means you're running out of time and red means stop. Okay. So--and we do that because we're under time constraints. After that, after the initial presentation on each discrete issue, we will have a first responder, and those people know who they are, as well, to do follow-up. And then we want a full and frank discussion. We want to open it up.

I believe we will be calling on people, to the extent that is possible, but we do not want to sort of stifle any kind of discussion, so we will do it as quickly as possible. I think in the beginning we would like to have everyone introduce themselves, but, you know, there are 27 of us. So, that has to be done within about 15 seconds or less. But I thought it would be useful if we would just go around the table, who you are, where you're from and that probably will do it.

But I think that is how we would like to begin.

MS. CONNOLLY: I am M.T. Connolly. I have been coordinating the nursing home initiative for the Department of Justice.

DR. DYER: I'm Carmel Bitondo Dyer and I'm a geriatrician from Baylor College of Medicine.

DR. HAWES: I'm Catherine Hawes from the Texas A&M University in College Station.

DR. SANDERS: I am Art Sanders, Professor of Emergency Medicine at the University of Arizona.

DR. PAVEZA: I am Greg Paveza. I'm an Associate Professor at the School of Social Work at the University of South Florida.

DR. GAMBRELL: I'm Doug(sic.) Gambrell. I'm the Director of the South Carolina Medicaid Fraud Control Unit and a state prosecutor from South Carolina.

DR. BURNIGHT: I'm Kerry Burnight, a gerontologist from the University of California at Irvine.

DR. PILLEMER: I'm Karl Pillemer. I'm from Cornell University.

DR. STAHL: I'm Sid Stahl, Chief of healthcare Organizations at NIA, National Institutes of Health.

DR. PEAKE: Thomas Peake. I'm Professor of Psychology, Florida Institute of Technology and I'm adjunct at Florida Mental Health Institute in Tampa.

MS. BURGESS: I am Ann Burgess from the University Pennsylvania School of Nursing.

DR. LACHS: I'm Mark Lachs. I'm a geriatrician from Cornell Medical College in New York City.

DR. HAUDA: I'm Bill Hauda, an emergency physician, Falls Church, Virginia.

MR. THOMAS: I'm Randy Thomas. I'm a police officer and an instructor at the South Carolina Police Academy.

MS. OTTO: Joanne Otto, Adult Protective Services, Colorado.

MS. NERENBERG: I'm Lisa Nerenberg. I'm a consultant in private practice with experience working with community coalitions and elder abuse.

DR. WOLF: I'm Rosalie Wolf from UMASS Memorial healthcare in Worcester, Massachusetts.

MS. RENZ: I'm Sue Renz, geriatric nurse practitioner. I'm working as a federal monitor.

DR. LINDBLOOM: I'm Erik Lindbloom. I'm a family doctor and geriatrician at the University of Missouri.

DR. McFEELEY: I'm Patti McFeeley. I'm a medical examiner for the State of New Mexico. I'm also in the Department of Pathology, University of New Mexico.

DR. HOOD: I'm Ian Hood. I'm a forensic pathologist from Philadelphia and a newly-minted lawyer and the Deputy Medical Examiner in Philadelphia.

DR. WRIGHT: I'm Wendy Wright, a pediatrician from Children's Hospital in San Diego, California.

DR. EISDORFER: I'm Carl Eisdorfer. I'm a psychologist, psychiatrist, gerontologist, University of Miami.

MS. HEISLER: I'm Candace Heisler. I'm a retired San Francisco prosecutor and I now train and teach in this area.

DR. MOSQUEDA: Just a few reminders. One, I think we all now realize that we really do have to speak into the microphones, so please do so, so that everybody in the audience can hear you. Also, just to remind you, this is being transcribed, so, A, be careful what you say and, B, it will help for all of the folks to be able to hear us clearly.

I also would like to remind people that this is going to be leading to a presentation to the Attorney General later today, and one thing that we would like to have happen is for people to make some decisions as we're going along about what you want to bring back to your home office, so to speak, in terms of action items of what you may do, either new or different based on today's discussion, because that will be helpful to present to her later and something that I think I understand will be of great interest.

And I think with those comments, we'll probably move right into our first session.

DR. PAVEZA: I have one request. Could we have one of the monitors swung this way so that those of us on this side of the table don't have to crane our necks and sit back this way to watch the monitor? Is it possible to switch that monitor around?

DR. MOSQUEDA: Well, the only problem is the people in this audience will--are probably using that monitor, particularly because they have their backs to folks. So, the answer, I think, is no.

DR. PAVEZA: Yes, if that monitor could be swung just a little bit, then we could see that monitor over there.

DR. MOSQUEDA: You can also look right across and see people. All right. We're going to move on. And we will, at least initially, be trying to call on you by name to make it easier for the transcriber. So, forgive us if it sounds repetitive, but I think it will probably be helpful for all of us anyway to get to know each other.

So, with that, I think we will get our lead off hitter going. Since we're in the World Series, we can use that analogy and invite Dr. Mark Lachs to begin the first presentation.

DR. LACHS: Thank you very much, Laura. In keeping with the medical model, I brought some slides with me, four of them, in fact, and I will move through them very quickly, as I have been urged to do. If I could have the first one, please. I would begin just very quickly talking about another form of family violence. If I could have the first slide, please.

Just very quickly, this struck distract me as I was preparing for this morning. This is an article that was published in the New York Times about six or seven years ago, about a man in his 30s who had the bodies of his siblings who died in the early 1960s under mysterious circumstances exhumed. They were young children. The findings of that exhumation were findings that any pediatrician, any medical examiner in the year 2000 would have recognized as child abuse.

Many of you may have participated in this case. When they went back and pulled the death certificates of these kids who died in the early 1960--for example, I think the three-year-old had a diagnosis of sudden infant death syndrome, which is just epidemiologically impossible. I show this slide first to say that I think the state of medical science and forensic science in elder abuse and neglect in the year 2000 is about where child abuse was, maybe not in 1960, but perhaps in 1970, when we began to sort of look at whether or not there were diagnostic injuries of child abuse and neglect.

Let me cut to the chase. The major issue, I think, in elder abuse and neglect in terms of the forensics of it is a higher burden of chronic disease, which is going to lead to, I think, a higher rate of false positives and false negatives. And I would just give a few examples. Osteoporosis, common syndrome in older adults, my emergency department will see five hip fractures, I suspect, today. What causes hip fractures? Osteoporosis. Could it be anything else? Sure, it could be, but I think there is a complacency that would preclude that.

Depression. Depression is a common syndrome in older adults and the tendency might be in this premedical environment to give medication for depression. Depression is a totally appropriate response to an abusive or neglectful environment. If you don't ask, you don't find out. Alzheimer's disease, about one-third of the patients with Alzheimer's disease, during the course of their illness, will have delusions. It's part of the illness. What are the delusions? People are breaking into my home. People are stealing my things. Well, maybe they are, and I think we really need to get on the stick in terms of trying to recognize that patients are telling us something, and I think we are ignoring those cries.

In addition to the medical issues, I think there are problems with ageism, both in society at large and in the medical encounter. I very quickly just wanted to show you some data from the new cohort, and I will very quickly walk you through it. This y-axis is survival. This x-axis is time. This solid line are individuals who had no contact with Protective Services over a 13-year period. They were on average age 75 when the study started.

After 13 years, the survival is about 40 percent. This middle line here, rather, are self-neglecting individuals. We are not supposed to talk about them, but they had survival of about 19 present. And the lower group here are individuals who were victims of elder abuse and neglect. They had survival of nine percent. Why do I show this slide to illustrate ageism in the medical encounter? When I present this sort of data to internists, they say things to me like, "Mark, didn't these individuals have metastatic cancer, horrible, chronic congestive heart failure, terrible emphysema?"

And, in fact, when you begin to adjust for those particular issues, this number down here, after adjusting for age and chronic disease, the risk of dying after a period of elder abuse and neglect is about threefold. That rivals the death conferred for many, many chronic diseases, many chronic diseases.

In my own clinical practice, I cannot get older women to take estrogen because it confers the risk of breast cancer on the order of about 1.1 or 1.2. Here's an odds ratio of three, which is a stunning risk for death. And then, when one goes to look at certificates in these individuals, and this was sort of stunning to me and appropriate for a forensic forum, these are the no-APS group. These are the self-neglecting group. These are the mistreated group.

Physicians, when filling out death certificates, in no case in the mistreated group ascribed death to injury or poisoning, but there was a slightly higher prevalence of symptoms of signs of ill-defined conditions, really sort of fascinating. I think there is an enormous opportunity, an opportunity to really look at index conditions that this group could talk about to identify elder abuse and neglect.

I see that my time is up and I will stop my comments there. I got through my first slides. Thank you.

MR. HOFFMAN: Thanks, Mark. Listen, in talking about the identification of specific medical conditions that warrant further review, in most, if not in all cases, we are sort of trying to figure out what would trigger a further review and then discuss what that further review would be about. And I would ask Dr. Hood to talk about, based on your experience, Dr. Hood, the kinds of things from what you have seen, conditions that would warrant further review in terms of the practice of medicine.

DR. HOOD: I have reviewed some of these in my paper presentation, but obviously there are things we're used to seeing that make us think about abuse and they unfortunately occur routinely in fragile, elderly people and are not necessarily indicators of poor care. There is, unfortunately, no absolute pathognomonic condition that says this person was abused, absent, that is, outright assault that any forensic pathologist or indeed any physician could see as such. But fractures of long bones, fractures of ribs, almost always or should be an indicator for further investigation. A fracture of a hip, a fracture or a collapse fracture of vertebrae may not.

Decubitus over areas it is almost impossible to get somebody off of, their sacrum, their hips, if they have been adequately documented and appropriate wound care taken but it has still progressed and may not be an indicator of improper care or neglect. Decubitus that have been allowed to progress without proper documentation or referral are an indicator of neglect. You have to go and evaluate them for that. Decubitus that occur in areas that you could easily protect, such as knees, ankles, heels, or against urinary catheters that could've been protected are an indicator of poor nursing care and may well be an indicator of neglect.

If you see those, that is enough to say they need further investigation. Any kind of bruising in an elderly, fragile individual does not necessarily mean neglect or abuse. One of the toughest calls to make, and that is why we have just had this national study done, is first off is it a bruise, and if it was a bruise, was it obtained innocently? Frequently, clinicians never even think to address that issue. Forensic pathologists only get involved in a point in time when it is too late.

Obviously, it is often said of us that we know everything and do everything, but one day too late, and it is unfortunately true. We do have a part to play, though, in terms of the presentation of evidence. Frequently, if you're a lawyer and you are faced with pursuing or prosecuting a case, you will find that the forensic pathologist is your most practiced presenter of evidence and a good person to go to as a reference person to be your witness, even if you may be dealing with a living patient.

And unfortunately, Dave has begun to learn that about the forensic pathologists in Philadelphia. We're also blessed there with having a very active forensic nursing unit, which Dr. Burgess is in charge of, and they are proving their worth in that regard, as well.

DR. MOSQUEDA: Now, we would like to really open it up to discussion. As David mentioned, we are interested to hear--one thing I'm interested that I think the legal profession keeps asking is are there any types of indicators or markers where you would just say no doubt, this is absolutely abuse? And, if not, what markers would make us go toward further investigation and what would that investigation be? So, we will throw it open for discussion.

Dr. Burgess?

MS. BURGESS: I would like to add to Dr. Hood's list. In the sexual abuse area, what we have found is certainly suspicion--I cannot say they are absolute--but sexually transmitted diseases found in a nursing home resident. Urinary tract infection is a soft marker, but for example, if all of the residents in one room who are all being cared for by one aide or something like that might certainly be plea raised.

Bleeding. I think that bleeding, I know, was mentioned in Dr. Hood's markers of certainly being suspicious. Vaginal bleeding. Bruising, the pattern of bruising to the abdomen and pelvis area has certainly been seen in the cases that I have analyzed. And it is a particular patterning. It is not like, you know--it's really to the abdomen, where a massive amount of force has been used to the abdomen, and you'll see the pattern.

DR. MOSQUEDA: This is in sexual abuse cases; correct?

MS. BURGESS: Yes, I'm talking only in sexual abuse cases. Those would be the more markers. The psychological markers that we have seen are the fear and--you'll see this in the nursing notes--fear of males especially, the sexualized behavior onset, new onset of these kinds of behaviors. You certainly see the other, the withdrawing, the hypersomnolence, the depression. But it is more of an almost traumatic shock has been the way I describe it. They just go into a very different mode after the abuse.

MR. HOFFMAN: An area that I have seen in my prosecutions involved malnutrition and dehydration. I was interested in hearing from the medical experts those particular areas of what does that trigger in terms of response to profound malnutrition or dehydration in older adults? Any thoughts? Dr. Dyer?

DR. DYER: Well, you know, those should trigger some action, but sometimes they are not due to mistreatment and are instead a result of cancer. Not every malnourished person - some people choose not to eat. However, I think we should have an increased index of suspicion in individuals who have dementia, who have depression, who have psychosis, who can't otherwise take care of themselves.

So, if we see those problems, we need to at least consider elder abuse. The other thing is that as every good gerontologist knows, is you need to get a collateral history and you have to look at the whole picture. So, we all must have an increased index of suspicion for elder mistreatment, but to really confirm abuse, we need to talk to other involved and we need to look at the elder's social situation, functional situation and home situation.

MR. HOFFMAN: Carl, go ahead.

DR. EISDORFER: I would underscore the last remark. I think a lot of this has to be done in context, short of doing a blood test and looking for an abnormal level of drug or poison, most of this stuff really is contextual. So, I think we're very appropriate in talking about the high relative prevalence of false positives, but I think there's also going to be very high false negative rate, particularly because you have this problem going in both directions, and let me make just one or two comments. Severe decubitus in a nursing home setting should raise everybody's index of suspicion, particularly since they can be lethal.

That is the kind of thing that any good nursing home should be very sensitive to, but other issues, depression being a good example, depression is a treatable condition of someone chooses to treat it. And depression, in turn, will lead to the possibility of malnutrition and so on. On the other hand, if somebody is not fed, they are going to get malnourished.

These are the specifics of the theme I would like to indicate. So, I think what it really seems to me we have is the need to establish, A, the preconditions for whatever it is we find, and I will give you another example. Clearly falls in older people would lead more likely to broken bones, but if you have a pattern of falls in a nursing home, then you know that there is some kind of neglect, because patients should not keep falling. So, again I would emphasize the collaboration between the forensic and the clinical scientist.

DR. MOSQUEDA: Greg Paveza?

DR. PAVEZA: I'm going to go out on a bit of a limb and go back to David's first question, which is I know of no incontrovertible piece of evidence that would suggest to me that this is abuse and only abuse. Nothing in the epidemiologic studies I have seen has such a huge odds ratio or risk ratio that you can say if this shows up, you absolutely know it is abuse.

I mean, we're talking about odds ratios of two and three, and while they are strong, it does not say there is a likely cause. Kind of one of my issues is, if you see depression, to use the classic DSM4 phrase, in the absence of any other reason for why a person would be depressed, one needs to consider the fact that the person may be being abused or neglected.

But they're just isn't anything that says that's it. If you see it, you got it. Do something about it.

MR. HOFFMAN: Dr. Lindbloom?

DR. LINDBLOOM: Getting to the dehydration and malnutrition question, my own research right now looks at death certificate data from 1997 in our own State of Missouri, including all the death certificates with dehydration and malnutrition either as a primary or secondary cause of death. I found no postmortem exams or other investigation after the fact. So, not to say all those cases should have been autopsied, but I think I would echo the sentiment that there needs to be some evaluation ahead of time or at least at the time of death to assess a level of suspicion.

MR. HOFFMAN: Well, let's follow up with that, because I think that dovetails into part of the discussion of what needs to be done to address that, because I think we have all seen that on death certificates with no follow-up. What should be the protocol in that regard? Dr. McFeeley?

DR. McFEELEY: Well, speaking from a medical examiner point of view, essentially if someone dies of anything that is not entirely natural, it really should be a medical examiner case. But you know from death certificate data they are not being picked up. Many of them are not even being seen or referred to a medical examiner. We get cases referred to us for a fractured hip because it may be an accident, and those cases are often reviewed by paper, often because they're not reported at the time of death and there's not even someone to examine, if there was.

But deaths in a nursing home, as the nursing home says, they are expected. They are not even evaluated unless there really is an issue. So, I think your death certificate data is very poor. I look through the literature and there's one of the articles in the forensic literature talking about homicides in the elderly, ages 65 and up. In this 15-year study, they evaluated two cases they documented as abuse--clearly more than that in a very large county with a high population of elderly people.

So, I think although death is not your only criteria, and that does not make it easy just because they died. One would think that is easier than some of the people who have lesser injuries, for instance, it is still a very difficult diagnosis to make. But until you start looking at those people, you're never going to get any kind of data as to what the percentage are that die, and that is only the tip of the iceberg.

It's like in child abuse, it's important to look at and to evaluate the deaths because you learn something about the less significant injuries, but until you do that, you're not going to really have a handle of what the incidence is.

MR. HOFFMAN: Dr. Nerenberg?

MS. NERENBERG: I'm not a doctor, but thank you.

MR. HOFFMAN: I will call everyone Doctor. How is that as a deal, just to be safe?

MS. NERENBERG: I just wanted to get back to the issue of context, and we're focusing here on medical indicators, but oftentimes we need to look at other nonmedical indicators, in particular capacity issues. For example, in assessing an alleged rape, often whether or not it was a rape or not gets down to whether or not the person had the capacity to consent to sexual relationships.

Capacity is a very complex issue and many medical professionals are starting to get a handle on decision-making capacity for certain things, including end-of-life decisions or capacity for medical care. In elder abuse cases, we're looking oftentimes at different kinds of capacity. There is a lot less work that has been done in capacity, for example, for sexual contact, what level of decision-making capacity you need.

It has been looked at with younger populations, but not so much with the elderly.

MR. HOFFMAN: I would like to follow up to what Dr. McFeeley has said, in terms of how do we sort of back up when we get to malnutrition and dehydration. And at least it has been my experience that whether residents of institutions or in the community, there are visits to the emergency room prior to the last visit, prior to somebody dying.

The question I would have for those of you in the emergency room crowd who are a part of the table are what are you seeing, what are the triggers and how is it we could maybe address or start responding earlier before it turns into profound malnutrition and dehydration?

Dr. Sanders?

DR. SANDERS: Well, the way I think we need to approach it is kind of in Mark's presentation and his abstract, false positives and false negatives. We do this in other areas of medicine, depending on resources, where you set the bar. And I don't think it is only in emergency departments. I think primary care practices, orthopedic practices, et cetera. One, we need to do better research to find out what are the indicators and how sensitive is long-bone fractures or bruises or dehydration or things like that or a combination of the factors.

That is one level of case finding that would lead to--it seems to me that in general where elder abuse is detected, it is from a multidisciplinary group that goes out and does home visits, follows a patient over time and then makes a decision. We do that in clinical medicine. Nobody comes in exactly with a textbook presentation. We put various factors together and we say, "Well, I think the odds of having this are better than the odds of having this," and therefore you give someone a label or a syndrome or something like that.

So, using that same context, I think there needs to be an initial level of screening. Emergency departments, primary care practices, other subspecialties, and then a more comprehensive level of screening which involves, as people have talked about, these multidisciplinary groups, geriatric assessment units which involves law enforcement, social services, medical direction, et cetera. And they will make that final decision about both treatment of various conditions, as well as whether the Justice Department needs to get involved in terms of prosecuting people.

DR. MOSQUEDA: Yes, Joanne Otto?

MS. OTTO: I'd like to follow up on something Lisa said in terms of context and to put in a plea for common sense. We recently had a situation where in one month's time two very demented, bed bound women in the same facility showed up with vaginal bleeding and tearing. And the decision of the charge nurse was that it was self-induced and one wonders how that can happen.

So, just think about is it possible.

DR. MOSQUEDA: Catherine Hawes?

DR. HAWES: I'd like to follow-up on that, because I see a lot of pictures of residents who were bruised, and it looks like defensive wounds to me, where they have held their hand up and their face is beaten and they have flung themselves against the bed rails repeatedly, according to the nursing home. There are things like that I think it is right to talk about the more things that are the index of suspicion, that are not obvious.

But when you see residents who have clearly been beaten up or scalded or who have severe malnutrition and they are from a nursing home and you see repeated cases, those are not getting picked up either, so it is not just the kinds of subtle things that people might miss and think are normal aging, it is also things that I think most of us believe are obvious.

The second thing is to follow up on the context. You know, if you look at the MDS data from nursing homes, you'll find that rates of malnourishment for people without an explicit terminal prognosis range from eight percent of the residents to 27 percent of the residents. And there are facilities where nearly one-third of the residents have severe undernutrition. So, the suspicion ought to be just not individual cases, but also patterns of care.

DR. MOSQUEDA: I think that is a great point. When we're talking about facilities, is there any method to know that if people go to multiple different emergency rooms, if there is a pattern in a facility. But I think we certainly all would agree that some of the markers--it doesn't matter if it's in a nursing home if there has been a scalding or if you live at home, that we need to be concerned about abuse really in all settings, and we do not want to turn this into a nursing home based conference.

So, I think one question is there anything different in terms of abuse at home versus nursing homes that would make you suspicion one place and not another, and the other, I think, important question is that this all sounds well and good. I mean, it is nice to sit here at this table and say, "Well, gee, if somebody comes in with this pattern of bruising, we need to look further."

But let's also talk about what we know is the reality in that office practice, in the busy emergency room, is that going to happen and what really ought to happen if somebody comes in and has maybe not these really obvious markers like a scald or a cigarette burn, but has something more subtle, bruising on the forearm in a maybe slightly unusual location where somebody has an explanation for it. What ought we to do?

Sue Ren?

MS. REN: Laura, you brought up a good point because as you were speaking, I was thinking about how far we have come, hopefully, within that last 10 years. When I think about 1990 in Philadelphia, and Dr. Hood can speak about this, too, the case of Elizabeth Ellis, who was a woman who had probably 17 or 18 ER admissions through at different hospitals throughout the Philadelphia area and eventually ended up dying of sepsis from decubitus ulcers, dehydration, malnutrition and severe contractures.

And it wasn't until a temporary nurse in one of the emergency rooms who was doing a tour in a new hospital recognized that there was something wrong with this person and said, "We need to call the police. We need to find out what is going on with this resident at this nursing home."

And I would hope that we could talk about today that--I know it is difficult in emergency rooms situations to really look at those indicators, but we need to move in that direction that we're going to look at those indicators that we have already talked about, the bruises, the fractures, the dehydration and malnutrition, if a person comes in and looks like they are malnourished or their labs indicate that they have protein calorie malnutrition or severe contractures and try to distinguish what is the difference between the normal aging process concurrent with disease and abuse or neglect.

And we have done education throughout the country to health-care providers about what those indicators are, but it has to continue and people have to stop, as Dr. McFeeley said, and take a look.

DR. MOSQUEDA: Do people here believe that it is the physician's responsibility, be it an emergency room physician or the primary care physician, to do that further investigation, and what resources do they have available?

Dr. Wolf?

DR. WOLF: I just want to mention that there is, I think, the practice of trying to do some universal screening of every older person who comes into the emergency room. There now are some studies which should be considered. Have tested a screening tool of five or six questions, that might help you. Now, it is true that the person may deny and the older person may not be able to respond, but a skillful practitioner should be able to work around it and to come up with some level of suspicion.

MR. HOFFMAN: Dr. Lachs?

DR. LACHS: Laura mentioned the role of the primary care physician. I just can't say enough about this. For older adults, often socially isolated--for child abuse, I assume there is some modern-day equivalent of a truant officer that, you know, you come to school with a bruise or you don't come to school, and you make it into some system that identifies a child. For an older person, that annual visit to a physician may be the only contact that individual has with someone outside of the abuse or victim dyad--I mean, that is so compelling--or with that emergency physician for one particular visit and yet physicians practice in an environment which is increasingly hurried, the role of not only professional education, but allowing time for these complex evaluations, which cannot be done in a six-minute managed care visit, I worry deeply about.

MR. HOFFMAN: Well, let's hear from Dr. Gambrell. Just kidding. Bill?

DR. GAMBRELL: I do want to address the issue of notice, and Randy Thomas I think has brought with him--we have done in South Carolina basically an adult abuse protocol where we attempt to educate the various health-care components by going on ETV programs and doing other sorts of things. And while I cannot claim the success ratio is particularly high with respect to that, I think that is a vital component that is necessary that can come from law-enforcement and a prosecution arm in providing some assistance in doing that, so that there is some awareness and some option where people know where to call or when they have a suspicion know whom to contact. I think that is extremely valuable.

MR. HOFFMAN: Randy, to follow up?

MR. THOMAS: It provides a structured way for physicians to screen for possible suspected cases of abuse or neglect. It also capitalize on a system that we have used for long time in South Carolina in child abuse. And so, our law-enforcement people are familiar with the forensic package that goes with this, and that is a real advantage. You get that mind set and, as talked about, it is in context.

They are familiar with the fact that this is an evidence collection issue and has to be handled properly. And I did something I am going to leave with you to take a look at.

MR. HOFFMAN: Dr. Wright?

DR. WRIGHT: I think I just wanted to say two quick things. One is my perspective is a little different. Being a pediatrician, I feel like I'm sort of on the outside, looking in. One of the things in my work involved with elder abuse, it has struck me, is the appreciation--not appreciation, but the acceptance of death in older people, I think. If a young person dies, everyone says a young person is not supposed to die. We better figure out what happened.

If an older person dies, someone says, "Older people die. They must've died from old age, from whatever it is." So, I think that at the beginning, the appreciation for the cause of death in older people really needs to be investigated. I am echoing, I think, what Dr. McFeeley said about the need for autopsies. I think that a lot of medical practitioners are unwilling to report potential cases of physical abuse or abuse, in general, in elders because they don't feel like they have the support of the medical literature behind them, that if it becomes involved with law, they don't know what medically is acceptable or not acceptable.

And that is because that body of evidence does not exist in elders in terms of hallmark--what we were talking about, actual forensic markers. I think that just like sudden infant death syndrome or shaken baby syndrome in children, until we started doing autopsies on children that died, we did not realize that there was a difference between the two, and there could be a constellation or a pattern of injuries that you see in elderly people that could be a forensic marker, but currently is not being recognized because of the lack of information after death.

The other is, just real quickly, is that I think it is very difficult when you're approaching a problem to want to do everything at once. For instance, in child abuse, we have shaken infant syndrome on one spectrum and, for instance, perhaps a failure to thrive on the other. One is them is a hallmark, slam dunk, pathomnemonic child abuse and the other is that constellation of psychosocial factors, medical disease in a child, which may or may not be abused.

And I think that, from my perspective in dealing with child abuse, sometimes you're better off going for the big bang for the buck in trying to come up with a pathomnemonic diagnosis or things that are much more likely to be physical abuse, people can start with that and hang their hat on it and then work their way into some of the more complex social situations, which are very difficult.

It seems like that is where everyone wants to go to start with. They want to start with the malnutrition and the nursing home, but that is the most complicated social-medical situation to start with, yet you have elder people dying with 49 broken bones, four Stage IV decubitus and subdurals, and those aren't getting prosecuted because there's not a physician who is willing to go to court and say that had to have been abuse.

So, I think that would be my slant, in terms of looking for forensic medical markers to try and get a better body of information and maybe that starts with autopsy findings and start with some of the easier cases, if there is such a thing.

MR. HOFFMAN: Dr. Pillemer?

DR. PILLEMER: I would just really like to second that. I think the problem is made incredibly more complicated by the undifferentiated treatment of different kinds of abuse and neglect, even as it is worded here. And it seems to me, what I understand as a nonmedical person from the conversation so far--it seems to me to be how do we establish abuse in a very specific kind of a situation, namely where the victim is incompetent and can't give an account and nobody has witnessed the actual abuse occurring, and in particular in cases of malnutrition or dehydration where in every case there is a potential perpetrator, whether in an institution or at home, the person will almost invariably have another explanation for why the event occurred.

I think that those cases provide, both from a research perspective, if you're looking for risk factors, and I'm sure from a forensic perspective an almost impossible challenge in the state-of-the-art that just is not there. I absolutely agree that if it is possible to focus on risk markers for essentially places where they are easier to establish, like in cases of physical abuse, in cases where the elder is competent or somewhat competent, I think that makes an awful lot of sense.

I think we complicate the problem for ourselves excessively by talking about elder abuse and neglect in a setting like this, even in meeting somebody who suffers from dehydration to somebody who has been raped and brutally beaten, I think it just makes the problem almost impossibly difficult.

MR. HOFFMAN: Dr. Lindbloom?

DR. LINDBLOOM: I would also like to emphasize from a primary care perspective, the importance not only of contact with the primary-care doctor, but the lack of contact. Frequent missed appointments, for example, or mildly demented elders coming to clinic alone, maybe put on public transportation to get to their clinic appointment with no one accompanying them - I found that, over the last few years, to be relatively sensitive for a neglectful or abusive situation at home.

DR. MOSQUEDA: Dr. Hood?

DR. HOOD: I would like to echo what obviously is a common theme, which is we have a pyramid of cases in terms of how sure you are that they are neglect or abuse. You have a tremendously-wide base of cases that present to all of us in all aspects of clinical practice where it is not enough to do much more than just say this could be something suspicious. And finally at the top, you have what the legal side wants. You have an identified victim. You have an identified and charged perpetrator. You have evidence and you have a witness who can present it. Now you're ready to go and get a successful prosecution.

For every one of those, there is a huge base of patients that are seen only briefly and who have raised a suspicion on somebody's part, whether it be a nurse in an emergency room, whether it be a social worker, a family physician who has just had his HMO-allowed six-minute interview with a patient. What you need to deal with that is correspondingly a hierarchical system of how you will refer and investigate those cases.

So, the large base--need to have something simple and easy that the person who is suspicious can do. There is no point calling in law-enforcement at that point. Certainly if you were to do that in Philadelphia, you would be referred to a detective who would simply say, "What breach of the law has occurred?" And if you can't tell him, well, that is fine, a 48 will be filed and it will be the end of that.

You do need to have a hierarchical system. It will vary, depending on your own individual state and county set-ups as to how it will start. It may be that you have a very good Adult Protective Services, with a large ombudsman base and you can just call a hotline, call the ombudsman and nothing more may happen. Or you may go further up to the point where the health department or whoever is in charge of licensing the nursing homes or personal care facilities will intervene and do some kind of inspection and monitoring.

It is at that point, I might add, that particularly forensic pathologists and coroners and medical examiners can get into the issue, you can use them because one of the things you can do is what we've done in Philadelphia, where you have had one incident in a particular nursing home or chain of nursing homes, as a form of monitoring you can now say you're not allowed to sign your own death certificates. Anyone who dies in that institution must now be referred to the medical examiner's office.

And that is basically all we do. Any case coming out of those nursing homes or institutions--and they are mostly, I might add, personal care facilities. There is a distinct difference. They simply get a relatively straightforward examination at the medical examiner's office. If we had autopsy all of them, we would not be able to do it, either. But it is relatively easy to start a case file, undress them, take all the dressings off whatever wounds they may have, clean them, straighten them out, something that could not be done in life, and photograph them.

The mere fact that was done on every case that died and came out of the nursing home and the fact that they know that it was being done is remarkably effective at maintaining awareness in that nursing home or personal care facility that they are being monitored and that alone is all you need.

DR. MOSQUEDA: Dr. Eisdorfer?

DR. EISDORFER: Just a couple points. Dr. Wright opened up a critical issue. Old people die. They are much more likely to die than are any other age group, and so we have a context effect, because not only are they dying, but they're seeing doctors, a lot of old people seeing, arguably, a lot of doctors. And so, the question then is what is the index of suspicion on the part of the physician, that this particular older person is more likely to be abused than the other 100 that they have seen in this now classic six-minute hour.

The belief, I think, on the part of physicians--and it was true of all of us, including pediatricians, 35 or 40 years ago--was that families do not abuse their own. Child abuse, for example, we keep trying to forget, is relatively recent as something that is under suspicion on the part of emergency room family practitioners. Let me give you a couple of context areas. We have believed that older people have suicide pacts. It is a widespread belief.

Well, Dr. Cohen and I have been looking this problem for about five or six years. We discovered there are very few suicide pacts, and, in fact, we have very good reason to believe that it is violence perpetrated against women, because a lot of the times it is almost invariably the husband who does the killing of the wife with a gun and the bullets are going through the wife's hand.

But there also some indications of the husband, his precondition. The point I'm trying to make here is for the forensic pathologist, it is a no-brainer at one level. They can see a bullet wound. They can see the second bullet wound. There may be a statistical problem because you have two deaths very often uncorrelated unless you go to the raw data and then you link them, and that makes a statistical problem, but the more important thing is that only by a psychological autopsy can you recognize that, okay, now you have got a coupled problem and very often there are predictive factors.

So, I think one of the things we really ought to do is to broaden the context of the autopsy from a purely physical pathologic to more a psychosocial thing, because I think what we're talking about now again--I hate to reverse it--is the context, and there are indications one might say could be looked at in looking at a death or a battering of an older person.

DR. MOSQUEDA: I think that what is happening here, what we're seeing is research, education and practice all coming together, because we have to--again, if we want to get practical and have something like Dr. Hood's idea, that sort of model, set up for the practitioner in the office, if somebody comes in with a bruise that might be just suspicious and is not an obvious sort of abuse, I think we've answered what do we do, which is typically not much.

But now the question is what ought we do, again, keeping the real world in mind, which is we do tend to have very short office visits. Is it reasonable to expect or even ask a clinician to do a more thorough evaluation, and the answer to that might be yes, it is. And then, if it is not, what resources need to be created so that more of an evaluation can be done?

Dr. Peake?

DR. PEAKE: I'm struggling some with the medical and the psychological kinds of issues. In the State of Florida, we have, I believe, 13 what are called memory disorder clinics. And it is an interesting concept. It is a wonderful training setting for our doctoral students. What we found in the community is that people will come to this clinic where we end up doing a short cognitive evaluation, a thorough medical history. We look at the family. We look at their history. And so, in about an hour-and-45 minutes, we've got a pretty good screening of a lot of areas.

We do a triage every week, probably we screen 25 or 30 folks a week. The doctoral students and the medical students are involved with this, but what we find is even though that is not the medical kind of abuse that we're talking about, but we may overlap with that, people will come here who will not go to other places. If they say, "You know, Grandma, we're going to take you to see the doctor, your memory is not so good," they won't go.

But they will come here, and we end up picking up all kinds of things, and then we begin to develop to get referrals from the psychiatric hospitals, from nursing homes and so forth. People come every year for this re-screening. The snowbirds who come down every year, come and make it an outing for these kinds of screenings.

So, this does not solve all of it, but we have found it to be a way to get people to come into who like the young people who are screening. We go through this. We have this information and it may be a model that could be a useful one in terms of can you set a place where people can go--the old notion of primary or secondary or tertiary kind of prevention.

DR. MOSQUEDA: Right. So, one opportunity might be where we can do screening and then we're still going to get to the, "Then what?" question in terms of evaluation, but that might be a very good model for picking up.

DR. PEAKE: Well, the other thing we talked about is that primary physicians do not have the time to do it, and then that becomes a referral of the agency to ones that can follow up because you have got the information to justify more of a thorough investigation.

DR. MOSQUEDA: Joanne Otto?

MS. OTTO: Well, there are 44 states that have mandatory reporting of elder abuse, and in every state that I know of, physicians and other health-care professionals are mandated reporters in those states. And yet what we see, Mark talked about the fact that almost every elderly person goes to the physician more often than he goes probably even to his preacher, less than 10 percent of the referrals are coming from the health-care professionals.

So, I'm just kind of wondering is there a problem for APS and the health-care folks that we're not communicating?

MR. HOFFMAN: Well, I think we want to still be moving towards what needs to be done, so we have gotten some markers. What is incumbent in the responsibility? We have a mandatory reporting environment, so there is where the legal requirements are, and yet the reporting on the data that I have seen, the reports from the health-care professionals, especially physicians, is extremely low.

Those cases are not being reported and I think there is a process going on, and I cannot speak for physicians, "Well, I'm not really sure. I don't know what's going on here. I suspect these are indicators, but I'm not going to make the report, because then I got brought into the system and I may have to testify. There may be other things that go on, when I'm really not sure." So, it gets processed out and there is no further investigation.

So, again, we're back to we have indicators; we have some markers that everyone has talked about. What occurs next?

Dr. Sanders?

DR. SANDERS: I think for exactly those reasons and for the reasons that the other system has failed, we cannot expect the front-line physicians to do it, whether it is primary care or emergency physicians, to do a complete work-up. What we can ask is they detect--I like the analogy of the pyramid--they detect the bottom part of the pyramid, and it is easier in child abuse, because there are pathomnemonic signs.

But the discussion was great in terms of saying it is just not clear and it is not an easy thing to do, plus I don't think most primary care physicians or emergency physicians have the expertise to sort it out. So, it is a very complex issue, that--if we needed to find what they need to do, and it is probably something like I said before. It is basically take high-risk criteria that is well-defined and then the educational thing will flow from that--it is a simple thing--and make a call.

Now, it has to be part of a system. You know, if you do CPR in a small town in Honduras, the patient is going to die because it is not connected to a system that will go out and investigate, do the home visits, do a multidisciplinary geriatric assessment, et cetera. So, the whole system has to be in place.

DR. MOSQUEDA: I'm just going to go to another medical person quickly, and then we'll go to Lisa and to Greg.

DR. WRIGHT: Just real quickly to speak to that, I think that is an excellent point, is that in my community, at least, and in a lot of child abuse communities, the people who do forensic child abuse work like myself feel like we have actually spoiled our medical community, in that my regular pediatricians in the community won't even report a belt-bruise that they see on a little kid because they feel like it is out of their area of expertise.

What they can do is call me in a heartbeat. I will see the child, do the whole forensic evaluation and then do the reporting, do the documentation, go to court. So, it eliminates the responsibility of them to follow up on some things. It increases the reporting because they feel like they have some backup in terms of medical expertise to go to.

The biggest question that comes of that, though, is the remuneration for the services, how do you find someone or pay for the services of the forensic expert, if you will, and that is a question that child abuse is struggling with across all sorts of--everywhere throughout the nation. And it is done very differently, and I think one of the things we have to think about is if we're going to legislate reporting of elder abuse and we're going to legislate investigations and prosecution or, at least, talk about legislations of exams and things like that, we have to also include in it funding and some streams of resources to the people who are going to have to do that work.

DR. MOSQUEDA: Lisa?

MS. NERENBERG: I wanted to make the point that you really can't look at the medical indicators totally in isolation. You know, we're starting to see now sophisticated fraud investigators who are seeing situations where--you know, sweetheart scams or somebody they believe is being ripped off financially, where they are starting to investigate whether or not the person is being physically neglected as a way of hastening their death or that they are being even poisoned. We're starting to hear reports of that.

And so, when a medical examiner sees a neglect situation or a situation where medications are being mismanaged, they need to know what is going on in the home. They need to know who the care giver is. Is it a care giver who is well-intended and simply not trained or over stressed to the point where they cannot provide good care, or is this the wife of two months or is this a child that stands to inherit?

So, I really want to reemphasize what Joanne is saying, that physicians, medical professionals, need to make reports to the folks that can go out and do these broader kinds of examinations.

DR. MOSQUEDA: Greg Paveza?

DR. PAVEZA: There are a couple of things which I think all fit into this concept of what ought we to do. First of all, one of the issues that I see as being critical is we need to expand beyond physicians, per se. One of the issues that we have not talked about, for instance, is the large number of professionals, social workers and nurses who engage principally in home healthcare, who are a prime set of people to identify abuse and neglect.

A lot of the discussion right now has really gotten to the point of so they show up dead, what do we do? Well, you know, my background is in public health and I would like to think about the fact that there are a lot more alive people who are being neglected and abused, then show up in our offices or in our medical examiner's offices, and we need to be aware of those folks.

Law enforcement needs to be included in this process. While in Philadelphia, it may go to a detective, I can tell you I have ridden with beat officers who get calls on a regular basis to got out to homes because some neighbor dials 911 and says, "Do something." And that beat officer spends four hours at a home waiting for a APS to show up, because it takes that long for an APS worker to get notified that they need to do an emergency investigation.

We need to be prepared to use the system, and I realize that the system is not perfect, but it is one of the excuses that most of us in the health professions use for not reporting to APS, which is APS is not going to do anything. To some degree, APS cannot respond to that , and that is a critical issue.

MR. HOFFMAN: Okay. I think we are at a point in the break. Just to follow up, Greg, on your point, I do not think we're going to be able to solve sort of the whole system today. The key components to this group and what our goals are, I think, is just to identify indicators to get the ball rolling, because APS is not getting the call or nursing home neglect and abuse is continuing and there has been no report and no response.

So, if we can get to the point of reporting, then we'll get to the system, also. I think it is imperative that when you make the call, that there is a response and we will talk about multidisciplinary teams and the appropriateness of that. But I think it is critical, at least from the law-enforcement side, that we at least hear about these cases, that we get a chance to take a look and try to find a remedy, whether it be a civil or a criminal remedy, to some very difficult problems.

So, with that, we will take a 15 minute break. We will reconvene at 10:30, 10-minute break.

[Recess at 10:19 a.m.]

DR. MOSQUEDA: We would like to go ahead and get started with the second session so that we try and give these discussions their full time available. One housekeeping issue in case you have not yet discovered it, because some of you do look a little bit stressed, is the restrooms are upstairs. I know where the women's room is, but I do not know where the men's room is. Not the same place, but close to each other.

MS. HEISLER: Same neighborhood.

DR. MOSQUEDA: Close to each other.

MR. HOFFMAN: We want to pick up with the second session talking about the application of forensic science and working with law-enforcement. And I think we will probably be revisiting some issues from the first session while go through this discussion. But we wanted to start with Candy Heisler, who has trained law-enforcement officials, has worked with medical personnel, has just been out there and we want to put her on the clock for the five minutes.

She will be familiar with the box, just to get us started.

Candy?

MS. HEISLER: I'm going to talk really fast, because if you have been around lawyers and some of you are us, you know that five minutes is not very much time. I've got a huge topic to talk about, but let me just start by saying we cannot do criminal prosecution or investigation of elder abuse and neglect without cooperation and collaboration with the medical side. It simply cannot be done.

So, what do I mean by that? I think there are two distinct areas where we rely on medical expertise. The first has to do with cognitive functioning, and by that I'm talking about how is this person, whether it is our victim or our suspect, able to communicate and what is their level of functioning and legal competency, both today, when they may be going to court and in the past, when an event which may be an issue occurred.

The first issue within that discussion is first, is this person, victim or witness legally competent to testify? By that, I mean do they understand their duty to tell the truth, to understand the oath, do they have the ability to distinguish truth from fantasy and are they able to communicate information?

The second is the victim able to give consent, and this, of course, becomes particularly important when we're looking at sexual assault and the issue of consent. It becomes a little more complicated because typically, by the time a matter arrives in a courtroom, a number of months have occurred. And while a victim may appear hugely demented today or in some degree of confusion, the question is often when the incident occurred, six months ago, five months ago, a year ago, what was their level of functioning in the past?

There is a sub-issue of that, and that is how did this person present to the suspect at the time that the alleged consent occurred? Could the suspect reasonably believe this person understood and was able to give legal consent? And then, an issue that bears on credibility today in the courtroom, is this victim or witness legally going to be reliable, someone that is going to be a credible witness in front of a jury?

We also need to consider the suspect, because one of the evolving areas that we have to deal with is what do we do with the elderly suspect or defendant who is charged with a crime such as a homicide and now contends they have a disease, such as Alzheimer's, which prevents them and in the past prevented them from forming specific intent. We need the help of the mental health professional, the medical profession, to help us determine if this person, in fact, could form criminal intent. If they cannot, we may be looking at a different sort of response from the criminal justice system.

We are also dealing with present competency in the courtroom proceeding with our suspect. Does this person currently have the ability to understand the charges against them and to cooperate with counsel? So, that is a run through sort of the cognitive area. Let me turn now to the other area, which is diagnosis and identification of injuries and our reliance on you for really three functions.

They are: First, the recognition of elder abuse, and much of what we were talking about in the first hour are some of the issues that we have to deal with you; the documentation of what you see and learn; and then finally, reporting as provided for by your particular state law.

Among the areas that are clustered under this broad category are the following: What are we looking at; what is this; is it an injury or is this some sort of result of either aging or a disease process that has nothing to do with an injury inflicted by someone else? The second part of that is this an intentional injury or is it the result of an accident, and by that I mean is there something about the location, appearance or type of injury that you have identified that tells us that this, in fact, is medical injury resulting from infliction of an assault by someone else, or is this something that is an accidental injury that someone fell or bruised?

How long, to the extent possible--how long did it take this particular decubitus ulcer to get to the Stage IV it is today and what sorts of information would the care provider have had in the way of appearance, smell, or medical need that would tell us this person should have realized we had a person who required medical attention and that they were suffering from neglect?

With that injury, with the decubitus ulcer, do we have any indications that this person received care for their injury and was it adequate care and is the injury the results, the proximate cause of death or did this person not die from the severe beating that they received, but rather died from the cancer that was growing in their bodies?

Finally, to what degree of medical certainty do you have this opinion and will you state it in a courtroom? And then finally, help us anticipate what the other side will do. What attacks would you anticipate would be made to the opinion you're going to render in a courtroom and are those attacks that we can defend against and overcome?

MR. HOFFMAN: Okay. Thanks, Candy. I want to open it with Bill Gambrell, and based on your experiences, Bill, in prosecuting some of these difficult cases, what your experience has been and your expectation from the medical community?

DR. GAMBRELL: Well, my experience has been that I have never had presented to me any of these obvious cases that we seem to be talking about here today. I told someone if anybody has any slam dunks, please send them my way. I would appreciate it. I think there are a myriad of issues that are involved in these things. My interaction with the medical community has been most of the time excellent, sometimes not so good.

Randy Thomas and I were talking ahead of time, too. There are two things that prosecutors and law enforcement people look for. They are sort of investigative opinions, you know, the early on, should we be looking at this? Are we heading in the right direction? Is this something we should be devoting time and energy to? And then the more important testimonial opinion, in other words, can I go to court with respect to this case?

I can tell you I have never been to a case where I have not had a doctor on the other side basically say, "No, that did not happen that way and no, there are 10,000 other logical explanations for the bruises that start from the forehead and go down to the shins." That is the nature of the beast in these matters, as we know, but that is just a reality, which is why it is so crucial early on to have competent medical advice in these matters.

South Carolina, luckily, is a small enough state geographically that we can get to the medical university in Charleston and get to the medical school in Columbia, and so we can usually find individuals to speak to. But I have had, I think, the typical problems, that there is a general reluctance on the part of doctors to get involved in these matters.

There is typically, in most of my cases, it is not a whodunit as much as it is a who didn't do it, frankly, in other words, instances of neglect in matters such as that where there are oftentimes doctors in the chain of authority, candidly, about it and everybody is pointing the finger at everyone else. "Well, the nurse should've caught that and when the nurse didn't catch it, it wasn't the doctor's fault because he didn't catch it."

And so, my experience has just generally been frustrating in that end. My last quick observation about that is, however, I think prosecutors too often cherry-pick these cases, I guess is my phrase. I've been doing this five years. We have had a Medicaid Fraud Control Unit for five years. We have got a 100-percent conviction rate on all of our abuse cases, and there have been 60 or 70 of them in that period of time.

That tells me obviously we're not pushing the envelope as we should do in the sense that we are catching people who are the obvious people who are doing these things, and the obvious people oftentimes are not the people who are doing the most harm in the long run. I think the people further up the system in facilities, directors of nursing, administrators, the doctors who are responsible for overseeing the care of the individuals in the facilities, have a significant liability in these matters, but too often it is easy to focus on the lower-level individuals, which we, as prosecutors, I think do.

But I do think that sort of having an expert step up to the plate, so to speak, to help you is probably our biggest problem, and in that collaborative protection that everyone feels when a community of professionals is in the target zone, so to speak, is a significant factor.

MR. HOFFMAN: Okay, Bill. Randy Thomas?

MR. THOMAS: I want to just capitalize on what Bill said. I tend to look at this as a law enforcement investigator. First, in the first session, we talked about triggers and that brings up an interesting point. Until law enforcement becomes involved, somebody has to tell us. It is a reporting kind of thing. We rely on the fact that if you called us, you think something suspicious is involved, otherwise there would be no reason for us to be there.

That creates two problems for us. First is access to the medical community. It is all well and good to talk about large areas with a great deal of sophistication where you can find it, but a large part of the United States and a large number of law enforcement agencies serve very small, very rural populations where just finding an emergency room physician that understands trauma is a rare exception, let alone something as sophisticated as this.

The second thing, and I've had this happen to me as a child abuse investigator, as well as elder abuse, finding a medical person that will render a non-attributable opinion. Give me something to go by. I learned over time doing child abuse kind of how to do that myself in many cases. This is a far more complicated area, I think, medically.

I'm not going to put you up on the stand, but give me sense of direction. I always say in training the quickest way to clear out a hospital emergency room is wave a subpoena for a physician and they will all disappear. It is part joking and part very true. It is very hard to pin somebody down. Even finding that, I need to be able to come back to that system as I develop my case.

Understand that detectives very often do not work this area exclusively, and so therefore they may be homicide today. They may have done robbery yesterday. So, they are not going to have that base of expertise. I think over the years we have developed that for child abuse where we do have trained child abuse investigators, but as the departments get smaller, the less likely that is going to occur. And these cases don't just happen in big cities.

As a matter of fact, right now in South Carolina, a large portion of our caseload is in our small counties where we actually, as Bill says, we can get anywhere in two-and-a-half hours, so we can send the expertise to them, but that they may not hold true. My concerns are primarily looking at the challenges. Once it does get reported to us, we make the assumptions somebody found a trigger, but it has to be clearly articulated to us as to what you think happened here.

DR. MOSQUEDA: I have a question for the physicians in the audience, and that is, pardon me, not for the people who see living patients--have you ever had a police officer call and ask you to review something and give an opinion as to whether or not you think there may have been abuse? And, if so, is that common or rare for you to get that kind of a call?

Carmel Dyer?

DR. DYER: Yes, our team has received several calls. We work together with the APS in Harris County and we're known for doing elder work there. The key thing was that there was good documentation, our records and from the reports we gave--we didn't really get called in. If the physician can document things well, the police have the evidence.

The biggest problem, though, with working with the police is that they do not often take the case any further because the patient themselves lacks the capacity to participate in the proceedings and, in fact, the lack of capacity really turns into a lack of advocacy for them, and so the cases are often dropped.

MR. HOFFMAN: Candy Heisler?

MS. HEISLER: If we look at the lessons learned in domestic violence, if we look at the lessons learned from child abuse, we've become quite proficient in learning how to build cases that don't rest on the shoulders of the victim, and we know that there are some cases, if the evidence is collected from the ground up, if there's a good preliminary and follow-up investigation and all of the pieces are put together from the beginning with the goal of going forward without a prosecution by the victim, then we can, in many cases, go forward.

The problem is we have not really, across the country, applied that approach to elder abuse. And it is going to take a certain amount of retooling our thinking and a little bit of experience and a whole lot of training, both for law enforcement and prosecutors. We will get there, but it is going to take us some time to do the foundational work.

MR. HOFFMAN: Dr. Hauda?

DR. HAUDA: Just echoing some of those comments, one of the biggest issues, I think, at least being a physician who is commonly asked by law enforcement, because I work with law enforcement on a regular basis as a medical examiner, is getting that call early, too. Obviously, we have talked already about an hour how do you identify the cases; the second issue often is we're better at this in child abuse than we are in elder abuse, is getting the cases really early, so that not only do you have the family practitioner who is seeing the person, the emergency room physician who is seeing the person, both of which do not want to go to court, you have someone who does want to go to court or is willing to go to court and testify to what they see, and if we can see that early, it makes a big difference, because then it's my eyes and ears that have talked with the person or seen it, not just I reviewed some medical records and this is what I found.

The second piece of that is we can often help the investigators plan their approach, as we have sort of already mentioned. We do that with child abuse. If the emergency department said this is a suspicious factor, we document this, that and the other thing, if you get a forensic physician involved, they can get the bone series done; they can get the pediatrician's records; they can start building some that information so when the case goes forward, you have got as much information as you could possibly have.

Obviously, that takes law enforcement or Adult Protective Services sort of taking the initiative to identify physicians that are willing to review these cases, willing to look at the patient, and can get paid for it, which is obviously something we have not talked about yet, but it is obviously one of the big issues. Most emergency physicians don't want to go to court.

Most family practitioner don't want to go to court, because they earn more money working than they are going to earn going to court. So, it is not in their interest really to testify for that patient, even though it's obviously in the patient's interest. But providing mechanisms, and there are lots of different mechanisms across the country, for paying physicians to be that expert, I think, is important.

In Virginia, my main role here is as one of those physicians who is working towards that end. There is actually legislation enacted two years ago for the physical abuse of kids, paralleled the same programs that were started a number of years ago, that now has this past year gone into any victim of any crime, you can have the commonwealth attorney pay a physician to evaluate that person.

So, Virginia has sort of taken this step forward. All of us are a little concerned--how do we apply that as physicians? Who is the physician that evaluates the person, what facility do you need? Obviously, as we have already mentioned in elder abuse what do you look at? What's the information that a forensic physician should garner and put together for the case, because obviously these are sometimes very difficult cases to put together.

And I think for a lot of people in the country, that is going to be the main focus, is trying to identify those physicians who are your experts and getting them paid for their services so that can continue to provide that service in lieu of whatever their other occupation is.

DR. MOSQUEDA: Are there enough experts?

MR. THOMAS: No.

MR. HOFFMAN: Law enforcement is saying no. What does the medical community believe? Any thoughts? Any clue? Well, we will take no, then, as the answer.

MR. THOMAS: Well, let me maybe qualify that, just two points. For one thing, our state does not have medical examiners. We have, I think, what, three forensic pathologists in the entire state? That is a problem. We are not alone or unique in that. The second thing is when you talk about identifying experts, there may be a lot of experts out there.

The truth is, law enforcement does not know who they are. We do in child abuse. We have learned that over time, but right now, we do not, and they may be there. I'm not saying they are not, but there is no handy-dandy list that you can reach for at 11 o'clock at night in somebody's home when you need to talk to somebody, nor do we have that many level-one trauma centers that you can even talk about trauma centers.

MR. HOFFMAN: I thought I saw another hand.

DR. LINDBLOOM: Talking to my own pathologist at the University of Missouri, I asked him about who we have in our own state who are interested and experts in forensic pathology and elder abuse and neglect, and he paused and said, "Well, I guess that would be me."

He sounded reluctant to take responsibility for that. He said that his own interest stemmed from the fact that he found that, in the rest of the state, there was not that level of interest there and took it upon himself to teach himself about some warning signs and other factors.

So I would definitely echo everyone else's opinion that there are not enough experts out there.

MR. HOFFMAN: Bill Gambrell?

DR. GAMBRELL: A point I wanted to make too related to it is incumbent upon law enforcement and prosecutors really to develop multidisciplinary teams, and I think that is the key, because one of the things we can do--because the medical expertise, the time is so valuable--is one of the things we have tried to do is to find doctors who would participate in educating part of the team so that it isn't as necessary as often to go badger a physician if there is a nurse assigned to the team, if there is a social worker assigned to the team, an APS worker who has been educated who can oftentimes help the street cop and actually have that case turned over from the street cop to the team is the idea, but to have them provide guidance so that it doesn't always have to rise to the level of a physician.

But that is an absolute necessity when it comes time to go to the courtroom. I say that, I actually have prosecuted cases without doctors as experts just because I couldn't get a doctor as an expert in that particular case and have had to rely on another level of medical expertise.

MR. HOFFMAN: Okay.

Dr. Wolf?

DR. WOLF: I think the situation is really indicative of the fact that we really don't have enough geriatric physicians to begin with. So, what you're asking for is even a more-specialized kind of practitioner. We may have to look elsewhere; that is, do more training of other primary care physicians in this field.

MR. HOFFMAN: I think that's a great point.

Sue Ren?

MS. REN: I just wanted to comment that in Pennsylvania, approximately two years ago, the attorney general's office appointed a board that is comprised of prosecutors, detectives, people from Protective Services, nurse practitioners and geriatricians from all over the state.

The purpose of the board is to review cases that come into the attorney general's office, and where there is a discussion much like what we're were talking about right now, about what evidence do we have, how do we proceed, what kind of experts do we need, and also let me say there is also representation from the Department of Health there. We can talk about what are the expectations of care and institutionalized elderly, personal care homes and nursing homes.

And how that board has been productive has been to tease out some of these cases to really determine do we have anything here, first of all. And there has often been disagreement about that among the professionals there, but secondly then, if we're going to proceed, what else do we need to look for? What records do we need to get from the facilities? Who do we need to interview? Who do we charge and what do we charge them with, and who do we need as experts?

Do we need a physician? How about a nurse practitioner, someone from the Department of Health, et cetera? And that board is voluntary, our involvement in that is voluntary. However, if experts are needed, we're paid for our services, nurse practitioners and physicians are paid a fee for the time spent in record review and if they have to go to court.

MR. HOFFMAN: Before we get into a discussion of sort of multidisciplinary teams, I just want to sum up. At least it has been my experience, and I think what we have heard from other law enforcement officials, are basically we need causation, we need medical expertise to say what caused this harm, whether it be a death, whether it be malnutrition, dehydration, development of pressure ulcers, the treatment that was associated with that, whether they were preventable.

We will always hear from defendants or potential defendants that this was unavoidable and that is really the hurdle that we have to overcome, that these things were avoidable, that these medical conditions were not inevitable. That is what we will hear in virtually all cases. But we will also hear the defense that if things were so bad, at least for people who have been hospitalized on multiple locations--if things were so bad, why would the hospital send somebody back, and if it really was poor care, why weren't the medical professionals who we are treating and seeing, why would they endanger somebody and put someone back into that environments?

And that is again raising the issue, going back again--I hate to go back--but from our first panel in talking about what do we do next after you have these suspicions to move this thing along so that there is involvement by professionals to take a look at whether there is abuse and neglect.

And that plays out in the legal world, as well, because it becomes a defense: If it was really that bad, these medical professionals would not have sent them back. I mean, they would not do that deliberately.

And that is why I just want to raise that with you in terms of getting to what you do next when you have these suspicions.

Dr. Peake?

DR. PEAKE: Well, healthcare only pays for acute treatment and this is a long-term issue. I mean, you come in, the acute condition is there. If that can be addressed--but then the follow-up, what kind of follow-up will there be in terms of the systems or the places where people are going to go back to?

DR. MOSQUEDA: Dr. Eisdorfer?

DR. EISDORFER: In direct answer to your question, it is reminiscent of that joke, and I don't mean to make light of this situation, about why the chronic gambler went to the gambling casino believing that the wheel was rigged. His comment was it was the only wheel in town.

We have a resource problem of really considerable substance. I would like Theresa to comment on this. Where do you send people? If you have abuse in the home, which is rare--and to answer another question, I have gotten several cases, both from the state and federal justice system. In every instance of a referral, it has been a nursing home.

The one case of abuse we have picked up in the home, we picked up as part of a project that I was doing. So, that is one issue. But where are the resources to be able to send people, and let me take another second. In the case of, for example, family abuse or abuse against women, one of the things we have learned is that if the abuse is taking place in the home, then you need to find secret safe-houses for women, because to accuse the abuser very often means the abuse will escalate from physical violence to murder.

What do we do with an older, frail, dependent, often demented person who is abused in either a nursing home, which by the way doesn't really like these kinds of patients because they don't make a lot of money on this group, or in the home itself? So, one of the issues, by answering the question, is we need a safety net for these people, and that will explain why we send them back. I wouldn't know where else to send them than back where they came from.

DR. MOSQUEDA: Lisa Nerenberg?

MS. NERENBERG: Well, actually, I wanted to comment on something, to just go back a couple of people. In the area of finding forensic specialists who can testify in elder abuse cases, I recently go an e-mail from a police officer who was a specialist in forensics entomology, who had been called into a case to analyze maggots in a neglect situation involving an older person. And he went into great detail about what they do, which I will not go into.

But it got me curious about what forensic folks do, what different areas of expertise there are. So, I got online and was looking through one of the forensic association membership categories, and there were just thousands and thousands of people around the country, specialists in dentistry and orthopedics. It just occurred to me that Rosalie talked about trying to train geriatricians in doing forensics work.

I think the flip side of that is finding all these people that are already skilled in testifying in forensics issues and teaching them about elder abuse. I think a lot of that expertise is already there, if they understood our issue.

DR. MOSQUEDA: And, I think that works after somebody is dead. But, I mean, in terms of training the forensic experts in geriatrics, at least my understanding is that mostly you get involved later on. But, you're right. I think in an ongoing case, maybe we need to involve more forensic experts.

I just want to get us back to the issue that David brought up, and I think one reason we're not getting a good answer is because it is an answer we do not like. And the question is what do we do when we suspect abuse and what should we do when we suspect abuse in the office setting, but maybe before it gets to the forensic expert? The other thing to keep in mind, at least, I think, from a clinician's perspective, is we do not want to go after all these people and put them in jail.

There are different types of perpetrators, and I do not know if we will get into that much today, but the answer for everybody, as was mentioned in the opening remarks, is not always prosecution and putting them in jail. Although we're focusing on the forensic aspects today, I think we need to keep in mind that there are going to be different avenues to go through when we're looking at the perpetrators of abuse, also.

So, what should we be doing when we suspect abuse and what do we need in order to do it?

MR. HOFFMAN: Dr. Burgess?

MS. BURGESS: I would like to speak to that, plus one other thing that you just brought up. But on what to do, we can use the models that already exist for child protection and domestic violence. There has to be a safe place, if it is determined that there is abuse, that the go to.

One of the things we have heard even in nursing homes, and I can't believe this also doesn't happen in private homes, is that the elder will not want anything said because they are going to--they will get more abuse, if you will, from whoever, from the attendant or whoever is perpetrating the abuse. So, it has to be very carefully orchestrated.

So, that speaks to what I've heard, the theme that there needs to be a model a system or a system in place that people have to be able to follow to keep the elder safe. So, I like your idea perhaps there needs to be a shelter perhaps specifically for elders, that might be something that is taken up by the women's groups or something.

The second point I wanted to make that I hope at some point today we will talk about the perpetrator, because I think that does help in making the case, in putting it together; that we need to see what are the various motivations for who is perpetrating the abuse and to be able to counter that from however the defense is going to be able to portray it.

I would absolutely agree. Every single abuse or even sexual assault situation I have seen, there always has been an explanation, even if the person has been observed--there is an eyewitness to it.

MR. HOFFMAN: Okay.

Rosalie Wolf and then JoAnn?

DR. WOLF: There is the beginning of a network of shelters for elders across the country, just a beginning. However, they have great difficulties in terms of funding. Secondly, some elders do not want to be separated from the perpetrator. This represents their only companion, maybe someone they've been married to 50 years or more, and they would rather be there than in a nursing home or separated.

So, these are much more challenging, I think, cases than of the younger woman.

MR. HOFFMAN: And we want to move on to sort of the approach of multidisciplinary teams, because there is some concern that a case is reported and how it is pursued, there is a critical role for working together to really get at the issue. That includes a big medical component, and I think that is an area that some people are involved in, and we would like to hear, in terms of a potential model for going forward.

So, JoAnn?

MS. OTTO: Well, I would like to second what Rosalie said, in terms of there are some shelters available. Many victims do not want to leave home. Sixty percent or more of the abusers are family members. One of the things we have encountered with local multidisciplinary teams, which kind of follows on what other people have said, is that physicians and health-care professionals often cannot attend those teams because it is money out of their pocket to even go to a local team and do a review at the local level.

DR. MOSQUEDA: Wendy Wright?

DR. WRIGHT: Just real quickly, it speaks, I think, to both multidisciplinary teams in collaborating together and also remembering your role. Most states have mandated reporting laws, and if you recognize a case of abuse and you are a physician, you are a mandated reporter. So, it is not my job as a physician to decide the outcome of my report. That is why there is an investigatory process and why there are multidisciplinary teams.

It gets back to speaking about what David said about when you have a dead person that was in the hospital seven or eight times, why wasn't that reported? If everyone, especially from a medical perspective, says, "But I don't want them to leave their home. I don't want the perpetrator to go to jail. I'm not going to report," first of all, you're breaking the law. Second of all, you have perhaps not availed services that are open to that person by not making the report.

So, I want everyone, I think, in the health-care field to remember that as a mandated reporter, it is the law. You have to do it and you shouldn't decide by yourself the outcome of that case. That is the purpose of multidisciplinary teams, and if you have a multidisciplinary team, you can make the report and maybe nothing will come of the report. That's great.

Then the second time you make it, the third time you make it, the fourth time you make it, pretty soon you're building a case that then something is needs to be done and perhaps there are more services that can be offered, but if we in the health-care field say, "Well, I like the perpetrator.

It's just a case that they are overwhelmed, so I am not going to report," well, first, you know, you broke the law, and second of all, perhaps there were services, not necessarily homes for the person to go to, but in homes services, intensive preservation services that were available that they did not get to avail themselves of.

MR. HOFFMAN: To follow up, criminal and civil prosecution is not the end result and I guess we should disabuse people of the notion that somebody is going to jail in every case. That is just not happening or us we would not have this discussion, because I think there would be a huge deterrent effect, but we're not putting people in jail for this.

So, I would just keep that open, and when we're talking about law enforcement, I want to again mention there are civil remedies, as well as criminal remedies. There is consumer production. There is injunctive relief. There are ways to force people to not act in a fashion that jeopardizes people, especially in an institutional setting.

So, I don't want us to just be focused on jail time, because that has a certain problem associated with it.

Jean?

MS. CONNOLLY: David, I wanted to follow up on your point and the point that Dr. Wright made, and that is I understand the concern that people don't want to report because they don't want something bad to happen to their care giver or they don't want to get themselves in even worse trouble. As you point out, despite those concerns; it is the legal responsibility of someone who is required under law to report.

But, that said, I think it is also important, as you indicated, that we think about how do we deal with the older victim and, in some cases, the care giver/perpetrator, where the hard-line prosecution is not the answer. As David indicated obviously we have a few more keys on the piano to play, but it seems that the multidisciplinary approach is the preferred approach.

So, my question to the group is what does the multidisciplinary team do? For example, you still need to do the reporting, but tell us more about what the multidisciplinary team does, both with respect to the older victim and the care giver.

MR. HOFFMAN: Carmel?

DR. DYER: Yes. The geriatric assessment team, although expensive, is really the ideal way to approach it, because they address everything that Candy talked about and what everyone else is talking about. They assess cognition routinely. These teams make these diagnoses in elderly people. They recognize and they learn how to document it.

This is under the purview of geriatricians, just like child abuse is in the purview of pediatricians. Now, the other thing is geriatric teams are used to assessing what elderly people die of. What is natural, what is not? We take care of these people all the time and we follow them in long-term care. Now, in Houston, with no additional dollars, we formed a team by linking the existing geriatric assessment team at the public hospital with the already-existing APS and it didn't take a time.

Now we are a resource for the law enforcement in that region and we are starting to spread out throughout the State of Texas. The one other thing we do, is try to prevent guardianships. Out of 100 cases last year, only five went to guardianship and only two were initiated by our team. The other three were brought to us from the guardianship program at APS.

We try to treat the underlying medical diagnoses and we monitor those patients through house calls. So, we go and we see what happens. And so, even if we do not take action right there, we can see if there are ongoing problems and hopefully prevent them.

MR. HOFFMAN: Okay.

Dr. Lachs?

DR. LACHS: Just a clinical observation is the incredible heterogeneity of this entity. I mean, elder abuse is a patient with Alzheimer's disease who becomes assaultive as part of his syndrome. It is a care giver who becomes briefly assaultive as part of care giving. This is a schizophrenic child beating up on an aging parent. It is spousal assault that is simply age.

So, what does a geriatric assessment or a multidisciplinary team do? They tailor interventions. I mean, the alcoholic kid needs something different than the care giver who is stressed out. These community partnerships that Carmel is describing where geriatrician's, APS, community service organizations that are well-acquainted with the kinds of resources in each community that need to be implemented, I think really is the key to sort of addressing this.

This is not a single diagnostic entity. This is an incredibly heterogeneous entity ranging from egregious assault and violence that we all would agree upon to stressed care givers, and to criminalize it is quite worrisome to me in every case, and it echoes the comments you made earlier, David.

MR. HOFFMAN: Catherine Hawes?

DR. HAWES: I want to say something about what I think you should add to multidisciplinary teams if the person is in a residential long-term care setting, a nursing home or a personal care home, and it was because I was struck by what Bill said about you can prosecute the certified nursing assistant and you can win, but you don't get the medical director or the director of nursing, and you didn't even mention the owner of the nursing home or the personal care home who may have created an environment in which the abuse and the neglect was inevitable, either by the way they structure resources or the way they structure incentives.

And I think it is important to have on the team someone who knows how to read cost reports, who understands financial accounting, who can look for the structures that make it occur in an institutional setting, not just the individual perpetrator.

MR. HOFFMAN: Okay.

Carrie Burnight?

DR. BURNIGHT: I think there is a variation in how familiar people are with multidisciplinary teams, and I think sometimes it is an easy term to throw around. What we need is a multidisciplinary team, and I thought it might be useful to take a second to really think through who are the members of the interdisciplinary team, because there may not be agreement in that of who needs to be on there, also some discussion of what the team does.

Dr. Lachs mentioned one thing we do is we tailor intervention to the very heterogeneous cases that we see. I am from California, and we have implemented a multidisciplinary elder abuse response team, and our funding came from the Archstone Foundation, a foundation in California, that enabled us to get going for three-year projects. We were lucky to have that foundation's support and not everybody does.

We're hoping that we can use this as one model, and Dr. Dyer, certainly we've built upon the model she has. Some of the players that we think are key, of course, a medical doctor, a psychologist--and a psychologist has been important in addressing capacity and undue influence and some of the financial issues that was just alluded to.

A social worker is very important in their interaction with Adult Protective Services, who are primarily social workers. Adult Protective Services has been extremely key to be on the team, because the reports are going through Adult Protective Services and come to us that way--a gerontologist, a little self-plug, and that is important in my opinion because, to keep track of the data so we can evaluate the effectiveness of what we're doing. So, not only are we doing, but we're really taking a step back and saying what works, what doesn't work in something that's new.

It's important to partner closely with the law enforcement, the police and the sheriff, with the district attorney and also the private legal community. In terms of what we do, it's getting the cases in, deciding what is and is not appropriate, and that is a big step, because there are many calls that are not necessarily--they can be handled in just an e-mail or just a telephone conversation.

So, to keep track of that--but they're not necessarily going through the whole team--then having a forum to sit down together with a group of players on a regular basis. We started more generally and had get more specific, that we meet every single week and go over every case, because sometimes just by being in the same room with all the players, you know, "Did that get there? Did that get connected?" The names of people and really knowing the players involved and sitting down with them and then proper documentation and then making sure that we're doing a follow up, because a lot of times we do our medical piece, it moves on and we didn't know what happened subsequently--so, instituting follow-up calls to say what happened in that case?

Many of the things are not as--I don't have a light, but if had one, it would be coming on--cases are not necessarily always so sinister that it is not sending somebody to jail, but it is getting some social services to help the care giver understand that it is not appropriate to be medicating somebody in that way just because they need to go to work or whatever it is.

So, there are the sinister cases, but there are also some where the perpetrator just needs some help.

MR. HOFFMAN: Dr. Pillemer?

DR. PILLEMER: I think this is a really important issue, and I think one way maybe I can speak to it is with Rosalie and Lisa, maybe having down one of the only at least quasi-scientifically conducted evaluations of several model projects, one of which was a multidisciplinary team project.

To me, I mean, it is just a no-brainer. At least, from a research perspective, the problem is what the sociologist would call simply an overdetermined problem. I mean, any case has so many causes and, an Mark has pointed out, the cases are so typically heterogeneous and so hard to pin down that I'm not even sure if assessment and intervention can even take place, if it is not in a multidisciplinary context.

Let me just say one or two quick reasons for that. The one thing which is important to remember and we have not really touched on it is that the incidence of serious elder abuse and especially of physical elder abuse is relatively low compared to other family violence problems. So, it is not a high base rate phenomenon, and the signs and symptoms often can be caused by benign factors.

So really, even more than we said, the chances of false positives are really enormous, and I think a multidisciplinary team is critical in order to avoid those, because the consequences are so devastating. Second of all is I think we have effectively established clear forensic signs of elder abuse or physical signs that would lead you invariably to a conclusion that elder abuse has occurred are so rare, are extremely rare occurrences, and that's what the team does, too.

But I think the third thing is an issue which has already been touched on. I just want to touch on it again, is that the importance of context is so critical that it can only be accurately assessed by a multidisciplinary team. I mean, I have seen in expert testimony work signs and symptoms which could clearly be attributed to something else, but that are leapt on by surveyors as signs of abuse even when the context of the nursing home would argue against it.

The final thing I would say is that these teams--I mean, but we do have different categories of certainty. So, we have a case of a clear pattern of injuries that couldn't be explained any other way and maybe it doesn't need a team or maybe it's a fairly straightforward event. However, it goes all the way down to a dysphagic, combative nursing resident who suffers from mild malnutrition. I just don't think it's possible for a single individual professional to accurately assess it.

So, if you couple that with the evaluation data that exist, it is just--I mean, that this particular entity really seems to work.

MR. HOFFMAN: Randy Thomas?

MR. THOMAS: I would just very quickly like to give what I think is a law enforcement perspective on, as Carl says, a no-brainer issue, whether or not we should have an MDT, and this comes from my experience both in participating in child and elder MDTs, first is access to expertise. As a police officer, as a detective, I need to talk to people who have expertise I do not have.

Second and corollary to that is the more I do that, the better educated I become and the better educated they become on how I work. The third thing is that personal contacts and relationships can never be underestimated. It is that ability to call somebody you know, that you deal with, and talk realistically about what you are. That brings up this barrier issue. There are legal barriers, issues with confidentiality.

A lot of times, the MOAs for MDT's get past all that. It becomes now a protecting-your-turf kind of issue. It more becomes a question of how big do you want the MDT? How sophisticated is it going to be? We tend-ours tend to work in a small state better with intake issues than they do long-term stuff. But I've seen variations on a theme.

MR. HOFFMAN: Okay, Patti McFeeley?

DR. McFEELEY: Well, I think speaking also to the multidisciplinary team approach, and I tend to jump right in and say, well, but unless they die, the forensic pathologist is not involved. I think forensics can be very much involved, and using the model of child abuse, I mean, most forensic pathologists examine live children. Many of them go to the hospital and participate. There are many that actually specialize in examining children, for instance, for the kind of pattern injuries and the kind of things that Dr. Hood described in his brief paper, that sometimes a forensic pathologist can identify better, as far as patterns or obvious ideas of abuse that may not be as clear to someone who does general medicine, for instance.

But, in addition, the other aspects of forensic can be very much utilized. She was talking about the entomologist being involved. That is not really that far out. The odontologist--we had an odontologist coming in and deciding whether that really is a bite mark and does that bite mark actually match with someone else. The DNA people, if you're talking about multiple rapes or sexual assaults in an institution, it may be not only identifying a perpetrator, but it may be identifying that strain of STD is the same and that so that is, in fact, by the same person or passed around the same area.

Those forensic experts should be part of that team or at least have entree to that team that you can utilize, because I think they can really add a lot to the investigation or to deciding whether you really have an abuse instance.

MR. HOFFMAN: Just a follow-up with that, because I think it is a critical point and I think it would provide great evidence, but are forensic pathologists getting involved and is there a willingness, because I can't even get them in actual death cases, and I live in a big city where it is being done, but the surrounding counties where counting coroners are unwilling to autopsy older people, especially out of the facility. There is an unwillingness to move forward and sort of be cooperative in that fashion.

You don't have attendings ordering autopsies because they also are the medical director, and it sort of becomes a self-reporting problem potentially as to their position. I mean, how do we sort of move that forward as part of the multidisciplinary response? Do you think including pathologists on this kind of team would get them on board with that or what is the approach?

Dr. Hood?

DR. HOOD: Well, Patricia and I, Patti McFeeley and I, have both been involved in that kind of thing. We have both sat on multidisciplinary teams and you're getting the same message. We do have our part to play. Frequently, your forensic pathologists are your best witnesses because they do it all the time. And they have also seen the very worst end of the spectrum, so they are in much better position to say that this was a non-self-inflicted and deliberately inflicted by another pattern of wounding.

It is a lot easier for people like us to get up and swear on a stack of Bibles and say that very confidently within a reasonable medical certainty than a family practitioner or a gerontologist may be able to do, because most of the time they're not looking at those kinds of injuries. Even though they may see a case, be appalled by it, dutifully report it, when it comes down to talking to the law-enforcement people, you discover they don't handle themselves well under cross-examination because you were taught, as a scientist going through medical school, to accept that there are many possible ways by which a thing could happen.

Frequently, if they're asked on the stand by the defense, "Well, couldn't it be or is it possible that," the answer is yes, and it frustrates the hell out of the prosecutor who has just prepped the individual, not realizing they were going to answer that way, because they don't understand the implications of that; whereas I might be inclined to answer and say, "Well, anything is possible," and then wait and let the prosecutor intervene, object appropriately, just simply because they don't understand what's going on in the court and how evidence is presented, and because they have an academic training.

It took most of us as forensic pathologists five years of training to get out of that mode of thinking. So, it does help to have people like your forensic pathologists on the team, but they are by no means the be-all and end-all of getting a good case put together or not even getting a good case together, but just getting a good result.

As I have already said, a good result doesn't necessarily mean that somebody gets prosecuted. In fact, that may not help at all. It may just simply remove one abusive nursing aide and have them replaced with another low-cost version of the same thing in the same nursing home. I have certainly seen that. I would reiterate what you have heard already, that you want a team that is not too big and unwieldy, and particularly of people who can themselves fan out and bring in, if need be, a whole bunch of experts that you might otherwise have regarded as rather abstruse, like the forensic entomologist, the maggot person and that kind of thing.

There's no point having them sit on the multidisciplinary team up front, but you need somebody on the team that knows about them and can bring them in, and you should have a core team of about half-a-dozen people.

DR. MOSQUEDA: Right. So, let's just address that issue a minute with this group of experts. If there is general agreement, which it seems there is, that a multidisciplinary team would be useful--well, let me ask. Is there general agreement on that? Is there anybody who disagrees with that? Who dare say so?

Then who should be the members of the core team who always need to be at the table, and if we can do this sort of quickly without big explanations as to why, but just to throw it out.

Carl Eisdorfer?

DR. EISDORFER: That is clear, it depends. For example, in the memory disorder clinics that exist in the State of Florida and going back, actually the project we created in Seattle 20 years ago or more, we always included a neurologist and a psychiatrist. And, in Seattle, we actually included an architect around the issue of falls and problems in the home that might have to be changed.

In the VA project that we are running now, it is a combined geriatric medicine/geriatric psychiatry project, and I want to add something about that. The latest data we have coming out of that combination of a multidisciplinary team, maybe ultimately it saves money, because the early detection of depression and cognitive disability changes the nature of the medical and often surgical care.

So, it may not be more expensive. Indeed, it may be less expensive.

DR. MOSQUEDA: But let's get to the issues. I'm sorry to interrupt. For a multidisciplinary team, for elder abuse.

DR. EISDORFER: My problem is you want one, two, three, four, five, and people don't come packaged like that, at least I haven't seen any. So, the issue is what is it you are trying to establish? If you're trying to establish the cause of a suicide, you need one group of people. If you're trying to look at the cause of a depression, you need another group of people. If you want a general medical approach, then you need a geriatrician, for sure, plus other screening people, plus a second tier of people who can become the experts.

MR. HOFFMAN: I think there should be a core component, at least in working with law-enforcement, a core component, then you can sort of expand