By David R. Snyder, MA, NREMT-P
and Colleen Christmas, M.D.
Jones and Bartlett Publishers
2003

Reviewed by Loree Cook-Daniels

YES!

If you have ever dreamed of integrating elder abuse awareness, prevention, and treatment options throughout a whole course of medical study, I warn your heart: this document is your dream come true, at least for emergency medical services or technicians (also known as EMSs, EMTs, paramedics, first responders, and pre-hospital personnel).

Originally David Snyder, the initiator of this project, approached the National Center on Elder Abuse (NCEA) with his vision. As an EMT himself and someone with personal experience with elder abuse, he was keen to make sure his colleagues could recognize and deal with the elder abuse they come across. However, he argued, they didn't know basic geriatric information, and they needed that foundation before they could be effective in elder abuse situations. So, he said, he wanted a comprehensive geriatrics course with a strong elder abuse component.

NCEA was not willing to sponsor his full vision, and Mr. Snyder ended up recruiting the American Geriatrics Society to help him. (NCEA did send a letter to the 2001 National Policy Summit on Elder Abuse dated February 21, 2003, saying it still intended to develop "a [training] module for emergency service personnel." The National Association of State Units on Aging, NCEA's lead partner, also provided a representative for the Steering Committee that oversaw Snyder's project.) The result is this truly impressive document and supporting infrastructure.

Tone, Design, and Content

The oversized, full-color, 381-page paperback text is sold for $38.95. Its fifteen chapters, mostly written by different authors, are linked together by strong design elements and consistent training methods. For instance, each chapter opens with a list of learning objectives and a case study. Each includes at least two more case studies related to the topic and closes with "Case Study Summaries" that explain in detail how an EMT should respond, and why. The text is studded with green "communication tips," gold "attitude tips," blue "controversy" boxes, and lavender "medication tips." There are pictures of actual old people on nearly every page, and -- I was so impressed to see this, given its rarity -- explanatory drawings actually depict old (albeit usually pretty thin) bodies! Care was obviously taken to ensure those portrayed -- both first responders and "patients" -- represent the full range of races/ethnicities, physical abilities, and genders. The text also sets off some text in red, marked with a red "ALS" diamond in the margin, that gives additional advice to those first responders who have been trained in advanced life support techniques. For those who are looking for pictures of decubitus ulcers and evidence of physical elder abuse, they're here (pages 241 and 295, to be precise). Other key themes pulling the chapters together include the key role medication plays in many older people's lives, including the great potential for such medications (or their non-use) to cause illness or injury, and the importance of knowing the normal effects of aging so that accurate medical assessments can be made.

The content, at least as it appears to this non-medically trained reviewer, seems comprehensive and accurate. Each chapter was reviewed pre-publication by at least one expert; this reviewer commented on both the elder abuse and quality of life chapters. For better or worse, some of the language is definitely medical, and the glossary only very rarely listed the terms for which I was constantly consulting it. Not knowing exactly what's contained in the training first responders have (the text says EMT-Basic training consists of at least 110 hours training -- one of which is devoted to the older patient), it's difficult to judge whether all first responders will be able to grasp all of what's presented. But the "tips" are written in an easy style, and these "take-home messages" alone should improve the care given by those who absorb them. Some of these include:

• With an attitude of compassion and caring, you can have a profound positive impact on the lives of older patients.

• Referring to an older person as "honey" or "dear" or calling the older person by his or her first name are subtle forms of ageism.

• Allow an older patient the time to discuss complicated issues in their native language with family if he or she desires to do so.

• Remember that "DNR" does not mean "do not treat!"

• Proper padding during immobilization is much more than a comfort issue to older patients. Lack of padding under "empty" spaces can lead to unnecessary spinal injuries, and inadequate skin protection at bony contact points can produce pressure sores that occasionally lead to life-threatening infections.

• Always let the patient and family know how much you care, not how much you know.

• Most EMS systems have "frequent fliers" -- people who continually call upon EMS with seemingly non-urgent needs. It is natural to become frustrated when responding to these calls, but for the older adult, frequent contact with caring, competent professionals may be an important part of their social support network. If an older adult begins to call frequently for EMS response, especially for non-urgent complaints, the health care team must assess for the presence of significant depression. Do not become complacent in treating any patient.

• As an advocate for your older patients, in addition to providing care for any immediate problem or need, remember that providing resource referral for the patient or their family is a valuable support service with which you can assist.

A strong and progressive strand throughout the book is the idea that EMS can and should play a significant role in community-based prevention and public education efforts. One "attitude tip," for instance, says:

In addition to participating in injury prevention, home safety evaluation, and medical information access programs in your community, you should support programs that promote EMS drop-in visits (between calls) to older patients living alone, at risk for health declines, or who are frequent consumers of EMS in your area. (p. 309)

A chart on page 310 summarizes three such programs that represent "innovative integration between fire/EMS and social service agencies."

Another strong, positive message is that EMS workers are part of a collaborative team, but with a unique role: they may be the only ones who see the patient in his or her environment, and thus the only ones who may have access to important information that would aid in understanding what has happened and how the patient's life can be improved.

Elder Abuse Content

Elder abuse awareness explicitly shows up in nearly every chapter. In the chapter on communicating with older people and their caregivers, for instance, trainees are urged to "Be sensitive to the caregiver's emotions. Listen carefully and document what they tell you. Be respectful and nonjudgmental, but don't forget to be alert for signs of abuse or neglect." The chapter on trauma reminds readers, under the subheading "elder abuse," that, "Assaults account for 4% to 14% of all trauma admissions in the United States for older patients and most commonly are committed with blunt objects." The chapter on improving quality of life has a diagram outlining what to do if problems are noted with the patient's living environment. First, the provider is to engage the elder in dialogue "if doubt exists as to patient choices/values." Then, dependent on the answers, the trainee is directed to look at three possibilities:

• Abuse/neglect
  o Mandatory reporting to proper authority
  o If transported, report to ED staff
  o If not transported, involve police

• Possible self-neglect
  o Possible mandatory report and/or referral to social service agency
  o Complete report to ED staff if transported

• Unsafe conditions
  o Provide injury prevention information
  o Educate on community resources
  o Possible at-risk referral to social service. (p. 309)

Most importantly, elder abuse is explicitly included in the GEMS Diamond, a symbol and schema that sums up what this textbook hopes to convey (see accompanying illustration). As the fourth item under Social Assessment, EMS providers are asked to assess for any signs of elder abuse or neglect.

The integration of elder abuse awareness into the very fabric of the GEMS concept is probably far more important in changing trainees' awareness and behavior than the elder abuse chapter itself. However, that chapter has much to recommend it (and some to disagree with).

The chapter starts with background, definitions, theories of abuse and neglect, incidence, and profiles of abuse victims and abusers. This section notes that elder abuse can happen both in the home and in care institutions. A full two pages is devoted to a summary of rights of nursing home patients.

Under "Assessment for Signs of Elder Abuse and Neglect," first responders are told to look for factors that increase the risk of elder abuse and neglect:

• Those with chronic, progressive, disabling illnesses that impair function and create care needs that exceed or will exceed their caregivers' ability to meet them, such as: dementia; Parkinson's disease; severe arthritis; severe cardiac disease; severe chronic obstructive pulmonary disease (COPD); severe non-insulin-dependent diabetes; recurrent strokes

• Those with progressive impairments who are without support from family or neighbors, or whose caregivers show signs of burnout.

• Those with a personal history of substance abuse or violent behavior or a family member with a similar history.

• Those who live with a family in which there is a history of child or spousal abuse.

• Those with family members who are financially dependent on them.

• Those residing in institutions that have a history of providing substandard care.

• Those whose caregivers are under sudden increased stress due, for example, to loss of job, health, or spouse.

First responders are urged to do an environmental assessment focusing on such things as whether there are hazards in the home, whether the elder is confined to one part of the home, and whether assistive devices, if needed, are available. About interviewing the patient EMS providers are cautioned, "Although patient condition and priority will determine the time that can be spent on the interview, try not to rush it. Increased age equals more history. Additionally, some aging patients tend to integrate past events with the present. That is, they may talk about previous life experiences along with events of the present." Interviewers are told to watch for such signs as the patient appearing fearful of a family member or caregiver; whether the caregiver is "hovering" around the patient and refusing to give the EMS provider and patient privacy; and whether the patient sounds like he or she is reciting a "script" explaining the injuries. Some of the questions the text suggest first responders ask (away from the potential abuser) if abuse is suspected are:

• Are you afraid of anyone at home?

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

• Have you ever signed any documents you didn't understand?

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

Although trainees are not advised to interview suspected abusers, the text does suggest questions and procedures if it is "necessary" to interview the caregivers who are suspected of abuse. For instance, EMS providers are advised to focus initially on the history of the present illness, and then move to more broad questions regarding the patient's general condition. For example:

• hat happened to the patient today?

• What is the patient's medical history?

• What kind of care does the patient require?

• Who provides this care?

• Is there anything else I should know about the patient?

The clinical assessment section provides specific direction on assessing the patient's overall hygiene, head and neck, skin, thorax and abdomen, musculoskeletal system, neurological system, and genitourinary system. Some of this advice is fairly basic -- look for facial bruises -- and some is far more sophisticated. For instance, there is a section on Grey Turner's sign and Cullen's sign, bruising around the abdominal flanks and around the umbilicus, respectively, which may be the result of injuries incurred when the person experienced abdominal trauma. Providers are also asked to consider the possibility that ill-fitting dentures are the result of weight loss from malnutrition.

A "controversy" box in the section on "Intervention Decisions" discusses self-determination and how an EMS provider should view his or her role:

Some patients choose to remain in an abusive or neglectful situation, despite an offer of assistance. If the patient is competent, often little can be done, since their rights must be honored. Document the refusal of care. If a pattern emerges of a history of refusing care, your document could help give social services evidence to open an investigation. You may not be able to help today, but documenting the patient's refusal could lead to help later. (p. 298)

This section also notes that "the burden of proof [that abuse has taken place] does not reside with the EMS provider," but "[d]ocumentation and reporting your objective findings can have significant impact on elder abuse cases."

What, precisely, the first responder is told to document is:

• Why EMS was called to the scene

• Chief complaint, if different from how the call was received

• Complete past medical history

• Social history/assessment findings

• Environmental assessment

• Patient's current prescribed medications, and whether these medications are being taken by the patient. This will be important later in determining whether therapeutic levels are present.

• Allergies

• Physical assessment

• Any statements made by the patient or caregiver. These statements must be written in quotes. If you ask specific questions about elder abuse, document the question that was asked as well as the response.

• Assessment of the interaction between the patient and the caregiver

• Interventions provided

• If the police were called to the location, document the responding officer's name and agency

• Name of the physician or health care provider assuming care of the patient

"Because most APS workers are not health care professionals, a well-documented assessment by the EMS provider will prepare the APS worker and aid in the diagnosis." (p. 299)

The chapter ends with recommendations. This section deserves quoting in its entirety:

EMS systems should have written protocols in place that address assessment, treatment, and referral of elder abuse and neglect. The development of such protocols should be a collaborative effort involving EMS, law enforcement, APS, local/state departments of aging, the state attorney general's office, and members of the physician community. Protocols must reflect local, regional, and state laws and policies regarding reporting of elder abuse cases. Elder abuse awareness programs should be incorporated into initial EMS certification and continuing education programs. These training efforts should involve APS and social service workers to help open lines of communication and help make the identification and referral process more effective. Feedback should be given to EMS providers on cases that are reported. Good communication needs to take place among EMS, law enforcement, social service agencies, and APS workers regarding elder abuse cases.

Training Methods and Possibilities

• A very exciting part of the GEMS manual is its associated structure. The American Geriatrics Society, National Council of State EMS Training Coordinators, and Jones and Bartlett Publishers have established a website -- www.GEMSsite.com -- specifically to promote and support the program. This website includes, to name but a few:

• Information on upcoming GEMS courses scheduled throughout the country, including Train-the-Trainer programs;

• Advice and tips on conducting a GEMS course;

• Sample GEMS course schedules;

• Promotional materials trainers can use;

• Advice on obtaining continuing education credit certification;

• A bulletin board for posting questions and comments that can be read by other users; and

• A section for course coordinators only, to provide "an easy alternative to paperwork."

In addition to the Textbook reviewed here, the GEMS program offers many more resources designed to make training easier:

Toolkit CD-ROM ($ 194.95)
This CD contains a wealth of time-saving tools and classroom enhancements including:

• PowerPoint presentations that correspond to the lecture outlines

• Lecture Outlines that outline the topics covered in the text

• Image bank providing the most important images and tables found in the text

• Administrative forms for the Course Coordinator's convenience

Resource Manual ($36.95)
Contains:

• Helpful teaching tips and guidelines for teaching a GEMS course

• Lecture outlines that correspond to the PowerPoint presentations

• Skill station strategies and activities

• Scenarios that will keep providers engaged in group discussions

• Administrative forms for the Course Coordinator's convenience.

Slide Set ($194.95)
The dynamic and engaging 35mm slides are keyed to the PowerPoint presentations and lecture outlines for the Course Coordinator's convenience. Both ALS [advanced life support] and BLS [basic life support] slides are included.

Video ($194.95)
Containing real life footage of the field, this video will captivate providers and show them how to perform important BLS and ALS skills and procedures.

GEMS Skill Station ($9.95)
These notecards are a necessity for any GEMS Course. The notecards are printed on cardboard perforated pages and printed with role play information for the GEMS skill stations. There are five sheets of notecards.

There are also packages available that combine various sets of the materials.

Usefulness to Non-EMS Professionals

As mentioned earlier, much of the textbook contains medical language that is never explicitly defined, making those parts a difficult read for those who do not have extensive medical training. However, even these (in particular, the chapter on normal changes with age) will impart valuable information on aging to those willing to wade through. For instance, did you know that, "Pain from an injured area may not be felt in the affected tissue, but rather in the surrounding areas"?

Some chapters and sections, however, deserve far greater dissemination. The first chapter on aging is one of these "gems." It addresses ageism, demographics, primary health conditions affecting older people, types of care facilities, sociological concepts, psychology, and providing care to other ethnic groups. It's a good introduction for almost anyone working with elders.

Similarly, the chapter on communicating with older adults could be used with most anyone with adequate literacy skills (although parts do contain rather sophisticated medical language). An especially intriguing part of this chapter deals extensively with hearing aids, including a long list of how problems with such aids can be troubleshot (p. 43). There are separate advice lists for communicating with those with aphasia and those with dementia (p. 45).

The textbook also contains examples of living will and Do Not Resuscitate forms (pp. 59-60), warning signs for burnout (p. 64), a sample fall prevention resource card (p. 107), a geriatric depression scale short form (p. 205), charts of possible drug interactions (pp. 262-263) and medications that may cause adverse effects in older patients (p. 272), a drug and supplement diary form (p. 348), and an exhaustive home safety checklist (pp. 349-357).

In short, this is a program not only to recommend to your community's first responders, but one that is worth your active support in getting implemented. It may also be a reference piece you should keep on your own desk -- for inspiration about how elder abuse awareness can be taught, if nothing else!