Elder Abuse

Emergency Medical Services Perspectives on Identifying and Reporting Victims of Elder Abuse, Neglect, and Self-Neglect

BACKGROUND

Emergency Medical Services (EMS) providers, who perform initial assessments of ill and injured patients, often in a patient's home, are uniquely positioned to identify potential victims of elder abuse, neglect, or self-neglect. Despite this, few organized programs exist to ensure that EMS concerns are communicated to or further investigated by other health care providers, social workers, or the authorities.

OBJECTIVE

To explore attitudes and self-reported practices of EMS providers surrounding identification and reporting of elder mistreatment.

METHODS

Five semi-structured focus groups with 27 EMS providers.

RESULTS

Participants reported believing they frequently encountered and were able to identify potential elder mistreatment victims. Many reported infrequently discussing their concerns with other health care providers or social workers and not reporting them to the authorities due to barriers: 1) lack of EMS protocols or training specific to vulnerable elders; 2) challenges in communication with emergency department providers, including social workers, who are often unavailable or not receptive; 3) time limitations; and 4) lack of follow-up when EMS providers do report concerns. Many participants reported interest in adopting protocols to assist in elder protection. Additional strategies included photographically documenting the home environment, additional training, improved direct communication with social workers, a dedicated location on existing forms or new form to document concerns, a reporting hotline, a system to provide feedback to EMS, and community paramedicine.

CONCLUSIONS

EMS providers frequently identify potential victims of elder abuse, neglect, and self-neglect, but significant barriers to reporting exist. Strategies to empower EMS providers and improve reporting were identified.

[Three years experience in the detection and follow-up of violence against the elderly in a tertiary hospital]

OBJECTIVES

The Hospital Clínico San Carlos Committee against violence established a protocol in 2012 in order to detect and follow-up violence against elderly persons. This article presents the experience after 3years of its introduction, as well as an analysis comparing the differences between those younger and older than 65years of age.

MATERIAL AND METHODS

All cases were collected during years 2013, 2014, and 2015, and were divided into two groups, A and B, according to age, younger or older than 65years. Parameters studied were: gender, place of detection (emergency department, during hospital admission, or outpatient clinics), type of professional worker who detected each case (social workers, nurses, or physicians), previous history of violence, type of aggression (physical, psychological, financial), institutional procedures once aggression was confirmed, and deaths after one year of follow-up. The SPPS v.18.0 package was used for the statistical analysis.

RESULTS

A total of 172 cases were detected, of which 140 of them were included in groupA (<65years), and 32 in groupB (>65 years, 22.8%). Gender: GroupA: women: 93.5%. GroupB: women: 78.1% (P=.014). Registration site: GroupA: emergency department: 90.7%, hospital wards: 6.4%, outpatient wards: 3.0. GroupB: emergency department: 65.6%, hospital wards: 31.6%, outpatient wards: 2.8% (P=.001). Notification: GroupA: social worker: 25%, physician: 67.8%, nurse: 6.4%. GroupB: social worker: 65.2%, physician: 28.1%, nurse: 6.2% (P<.001). Previous violence history: GroupA: 62.1%. GroupB: 68.7%. Type of abuse: GroupA: physical: 56.4%, psychological: 2.8%, physical +psychological: 30.4%, physical +psychological +economic: 10.1%. GroupB: physical: 31.1%, psychological: 5.1%, neglect: 18.7%, physical +psychological: 10.1, physical +psychological +economic: 9.8, economic: 25.1 (P<.0001). Resources employed and follow-up: Injuries: Group A: 63.5%. Group B: 31.2% (P=.001). Judicial protection measures: GroupA: 12.8. GroupB: 15.6 (P=.773). Removal order: GroupA: 2.1. GroupB: 6.25 (P=.235). More than one-third of patients in groupB, and none of the patients in groupA, died in the year of follow-up.

CONCLUSIONS

There are more problems detected in the Emergency Department. There is a history of previous violence in more than half of the cases in both age groups. The profile of the victim is an elderly woman with significant physical and cognitive impairment. Economic abuse and neglect are more frequent in the elderly population. In our series, more than one-third of elderly patients who are victims of ill-treatment die each year. The hospital registry is fundamental for the detection and follow-up of abuse in the elderly.

Financial capacity in dementia: a systematic review

OBJECTIVES

Financial capacity (FC) refers to a set of cognitively mediated abilities related to one's competency to manage propriety and income. Identifying intact from impaired FC in older persons with dementia is a growing concern in geriatric practice, but the best methods to assess this function still need to be determined. This study aims to review data on FC in dementia and on instruments used to assess this domain of capacity.

METHODS

Database search was performed in Medline, ISI Web of Knowledge, LILACS and PsycINFO. Studies that objectively assessed FC in dementia of any etiology were included.

RESULTS

Of a total of 125 articles, 10 were included. Mild Alzheimer's Disease (AD) was associated with impaired complex FC abilities, namely checkbook management, bank statement management and financial judgment, but simple FC skills were preserved. Moderate AD was associated with impairment in all domains of FC. The Financial Capacity Instrument (FCI) was applied in most of the selected studies and correlated with neuropsychological and neuroimaging variables.

CONCLUSIONS

Early dementia is associated with partially preserved FC. More validation studies using objective and evidence-based FC assessment tools, such as the FCI, are still needed.

Interventions for preventing elder abuse: applying findings of a new Cochrane review

There is evidence that elder abuse is a significant public health problem that is destined to grow as population age. Countries are considering how best to act and this requires an understanding of the complex causal mechanisms contributing to its occurrence and the identification of effective interventions which can potentially make a difference. Previously, a high quality synthesis of evidence for policy and practice has been missing. In this paper, we describe a new Cochrane review of interventions to prevent the occurrence or reoccurrence of elder abuse. Overall, the quality of the evidence available for decision making is very low and there is little to guide practice. Amongst the interventions, there is some evidence that teaching coping skills to family carers of persons with dementia might make the situation better. We argue that poor quality and wasteful research needs to be avoided, and front-line agencies be supported in undertaking comparative evaluation of their services.

Multiple approaches to understanding and preventing elder abuse: Introduction to the cross-disciplinary National Institutes of Health workshop

On October 30, 2015, the National Institutes of Health (NIH) convened a workshop, "Multiple Approaches to Understanding and Preventing Elder Abuse," in Bethesda, Maryland. The workshop brought together experts from across disciplines to discuss research challenges, opportunities, and lessons learned from other fields. Participants included experts in elder abuse, child abuse, intimate partner violence (IPV), emergency medicine, and neuroscience. In this special issue of the Journal of Elder Abuse and Neglect, participants address topics explored before, during, and after the day-long workshop.

Difficulty Managing Medications and Finances in Older Adults: A 10-year Cohort Study

BACKGROUND

Difficulty managing medicines and finances becomes increasingly common with advanced age, and compromises the ability to live safely and independently. Remarkably little is known how often this occurs.

OBJECTIVES

To provide population-based estimates of the risk of developing incident difficulty managing medications and finances in older adults.

DESIGN

A prospective cohort study.

SETTING

The Health and Retirement Study (HRS), a nationally representative study of older adults.

PARTICIPANTS

9,434 participants aged 65 and older who did not need help in managing medications or managing finances in 2002. Follow-up assessments occurred every 2 years until 2012.

MEASUREMENTS

The primary outcomes were time to difficulty managing medications and time to difficulty managing finances. Risk factors such as demographics, comorbidities, functional status, and cognitive status were assessed at baseline. Hazard models that considered the competing risk of death were used to estimate both the cumulative incidence of developing difficulty managing medications and finances and to identify potential risk factors. Analyses were adjusted for age, gender, race, marital status, wealth and education.

RESULTS

The 10 years incidence of difficulty increased markedly with age, ranging from 10.3% (95% CI 9.3-11.6) for managing medications and 23.1% (95% CI 21.6-24.7) for managing finances in those aged 65-69, to 38.2% (95% CI 33.4-43.5) for medicines and 69% (95% CI 63.7-74.3) for finances in those over age 85. Women had a higher probability of developing difficulty managing medications and managing finances than men.

CONCLUSION

This study highlights the importance of preparing older adults for the likelihood they will need assistance with managing their medicines and finances as the risk for having difficulty with these activities over time is substantial.

Complicated Dementia: Teaching Caregivers to Recognize Signs and Take the Next Steps

Older adults who exhibit extreme behaviors present a complex diagnostic and management picture for home healthcare clinicians and family caregivers. This case study describes the situation of Mrs. M, whose aggressive, combative behavior was so difficult for her children to comprehend and manage, she was secluded in a locked basement of her home. This article details assessment techniques, symptom presentation and possible diagnostic implications, as well as resources for caregivers.

Validation of the Italian Version of the Caregiver Abuse Screen among Family Caregivers of Older People with Alzheimer's Disease

Introduction. Elder abuse is often a hidden phenomenon and, in many cases, screening practices are difficult to implement among older people with dementia. The Caregiver Abuse Screen (CASE) is a useful tool which is administered to family caregivers for detecting their potential abusive behavior. Objectives. To validate the Italian version of the CASE tool in the context of family caregiving of older people with Alzheimer's disease (AD) and to identify risk factors for elder abuse in Italy. Methods. The CASE test was administered to 438 caregivers, recruited in the Up-Tech study. Validity and reliability were evaluated using Spearman's correlation coefficients, principal-component analysis, and Cronbach's alphas. The association between the CASE and other variables potentially associated with elder abuse was also analyzed. Results. The factor analysis suggested the presence of a single factor, with a strong internal consistency (Cronbach's alpha = 0.86). CASE score was strongly correlated with well-known risk factors of abuse. At multivariate level, main factors associated with CASE total score were caregiver burden and AD-related behavioral disturbances. Conclusions. The Italian version of the CASE is a reliable and consistent screening tool for tackling the risk of being or becoming perpetrators of abuse by family caregivers of people with AD.

Integration or specialization? Similarities and differences between Sweden and the United States in gerontology education and training

This article examines the similarities and differences in the education and training of gerontologists and others who work with older people in Sweden and the United States. It outlines the aging trends in both countries and assesses the level of training for those who provide care in a variety of fields. Both countries are aging, but the programs for gerontological training are quite different in the two countries, reflecting underlying cultural values. Sweden's education is generally more oriented toward the integration of some aging education in more disciplinary fields, such as nursing and social work and thus could benefit from more specialized, aging-specific courses. The United States is highly specialized, with multiple programs in various subfields of aging (e.g., geropsychology; aging services administration) and could benefit from integrating more aging knowledge into courses in other disciplines. The authors challenge professionals to consider if there is a basic but global curriculum and/or set of competencies in gerontology that could be agreed upon. As an increasingly global village, the ability to share and learn is more easily achievable. Sweden and the United States have much to learn from each other in terms of appropriately educating and training those who support our older people.

Describing visible acute injuries: development of a comprehensive taxonomy for research and practice

BACKGROUND

Little literature exists classifying and comprehensively describing intentional and unintentional acute injuries, which would be valuable for research and practice. In preparation for a study of injury patterns in elder abuse, our goal was to develop a comprehensive taxonomy of relevant types and characteristics of visible acute injuries and evaluate it in geriatric patients.

METHODS

We conducted an exhaustive review of the medical and forensic literature focusing on injury types, descriptions, patterns and analyses. We then prepared iteratively, through consensus with a multidisciplinary, national panel of elder abuse experts, a comprehensive classification system to describe these injuries.

RESULTS

We designed a three-step process to fully describe and classify visible acute injuries: (1) determining the type of injury, (2) assigning values to each of the characteristics common to all geriatric injuries and (3) assigning values to additional characteristics relevant for specific injuries. We identified nine unique types of visible injury and seven characteristics critical to describe all these injuries, including body region(s) and precise anatomic location(s). For each injury type, we identified two to seven additional critical characteristics, such as size, shape and cleanliness. We pilot tested it on 323 injuries on 83 physical elder abuse victims and 45 unintentional fall victims from our ongoing research to ensure that it would allow for the complete and accurate description of the full spectrum of visible injuries encountered and made modifications and refinements based on this experience. We then used the classification system to evaluate 947 injuries on 80 physical elder abuse victims and 195 unintentional fall victims to assess its practical utility.

CONCLUSIONS

Our comprehensive injury taxonomy systematically integrates and expands on existing forensic and clinical research. This new classification system may help standardise description of acute injuries and patterns among clinicians and researchers.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank

INTRODUCTION

While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims.

PATIENTS AND METHODS

We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury."

RESULTS

3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults.

CONCLUSIONS

Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.

Identification and management of elder physical abuse in the routine of dentistry - a systematic review

OBJECTIVE

To perform a systematic search in the literature in order to verify whether the dentists are able to identify and manage cases elder physical abuse.

BACKGROUND

Dentists may play an important legal role contributing to the management of abused patients through the identification of injuries in their face, head and neck.

MATERIALS AND METHODS

The present systematic review was performed following the PRISMA Statement and was registered in the PROSPERO database. A search was conducted in the following electronic databases: PubMed, LILACS, SciELO, Embase, Web of Science, OpenGrey, Google Scholar. Specifically, the last two databases were used to search the 'grey literature'. The research question was based on the PVO strategy for systematic exploratory review. Two examiners determined the eligibility criteria for selecting the studies and performed all the research steps.

RESULTS

The initial search resulted in 842 studies, from which eight were considered eligible. Six studies used questionnaires to assess the perception, knowledge and attitudes of dentists towards the identification and management of cases of elder abuse, while two studies assessed this information through personal interviews. Two studies were rated as high quality, while six studies reached moderate quality. Male and female dentists were assessed separately in six studies. Only three studies specified the aggressor.

CONCLUSION

The dentists revealed insufficient knowledge on elder abuse. Most of the dentists are not able to identify and manage these cases in the clinical routine.

Diagnosis of Elder Abuse in U.S. Emergency Departments

OBJECTIVES

To estimate the proportion of visits to U.S. emergency departments (EDs) in which a diagnosis of elder abuse is reached using two nationally representative datasets.

DESIGN

Retrospective cross-sectional analysis.

SETTING

U.S. ED visits recorded in the 2012 Nationwide Emergency Department Sample (NEDS) or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS).

PARTICIPANTS

All ED visits of individuals aged 60 and older.

MEASUREMENTS

The primary outcome was elder abuse defined according to International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (ORs) were calculated to identify demographic characteristics and common ED diagnoses associated with elder abuse.

RESULTS

In 2012, NEDS contained information on 6,723,667 ED visits of older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% confidence interval (CI) = 0.012-0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed greater weighted odds of elder abuse diagnosis in women (odds ratio (OR) = 1.95, 95% CI = 1.68-2.26) and individuals with contusions (OR = 2.91, 95% CI = 2.36-3.57), urinary tract infection (OR = 2.21, 95% CI = 1.84-2.65), and septicemia (OR = 1.92, 95% CI = 1.44-2.55). In the 2011 NHAMCS dataset, no cases of elder abuse were recorded for the 5,965 older adult ED visits.

CONCLUSION

The proportion of U.S. ED visits by older adults receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted.

State of the science on prevention of elder abuse and lessons learned from child abuse and domestic violence prevention: Toward a conceptual framework for research

The goal of this review is to discuss the state of the science in elder abuse prevention. Findings from evidence-based programs to reduce elder abuse are discussed, drawing from findings and insights from evidence-based programs for child maltreatment and domestic/intimate partner violence. A conceptual measurement model for the study of elder abuse is presented and linked to possible measures of risk factors and outcomes. Advances in neuroscience in child maltreatment and novel measurement strategies for outcome assessment are presented.

The Forensic Lens: Bringing Elder Neglect Into Focus in the Emergency Department

We present 2 case studies of older patients who were brought to the emergency department (ED) in severely debilitated states. Both presented with severe malnutrition, contractures, and decubitus ulcers, and were nonverbal, with histories of dementia and end-stage disease. Their primary caregivers, adult children, were uncooperative with Adult Protective Services and disregarded treatment recommendations. Although both elders had signs suspicious for neglect, a comprehensive review revealed many layers of complexity. We use these cases to illustrate an approach to the assessment of possible elder neglect in ED settings and how to intervene to ensure patient safety. We begin with a discussion of the differences between willful, unintentional, and unsubstantiated neglect by a caregiver and then describe when to suspect neglect by evaluating the elder, interviewing the caregiver and first responders, assessing the caregiver's ability to meet the elder's needs, and, if possible, obtaining medical history and information about the home care environment. These cases illustrate the importance of careful documentation in cases of suspected neglect to assist investigative agencies, reduce the risk of further harm, and improve patient outcomes.

The Abuse Intervention Model: A Pragmatic Approach to Intervention for Elder Mistreatment

Ten percent of older adults experience elder mistreatment, and it is much more common in older adults with dementia. It is associated with higher rates of psychological distress, hospitalization, and death and, in the United States, costs billions of dollars each year. Although elder mistreatment is relatively common and costly, it is estimated that fewer than 10% of instances of elder mistreatment are reported. Given these data, there is a great need for research on interventions to mitigate elder mistreatment and for a practical model or framework to use in approaching such interventions. Although many theories have been proposed, adapted, and applied to understand elder mistreatment, there has not been a simple, coherent framework of known risk factors of the victim, perpetrator, and environment that applies to all types of abuse. This article presents a new model to examine the multidimensional and complex relationships between risk factors. Theories of elder mistreatment, research on risk factors for elder mistreatment, and 10 years of experience of faculty and staff at an Elder Abuse Forensics Center who have investigated more than 1,000 cases of elder mistreatment inform this model. It is hoped that this model, the Abuse Intervention Model, will be used to study and intervene in elder mistreatment.

Resident Aggression and Abuse in Assisted Living

This article estimates the prevalence and identifies risk factors of resident aggression and abuse in assisted living facilities. We conducted multivariate analyses of resident-level data from an analytic sample of 6,848 older Americans in the 2010 National Survey of Residential Care Facilities. Nationwide, 7.6% of assisted living residents engaged in physical aggression or abuse toward other residents or staff in the past month, 9.5% of residents had exhibited verbal aggression or abuse, and 2.0% of resident engaged in sexual aggression or abuse toward other residents or staff. Dementia and severe mental illness were significant risk factors for all three types of resident aggression and abuse. Resident aggression and abuse in assisted living facilities is prevalent and warrants greater attention from policy makers, researchers, and long-term care providers. Future research is needed to support training and prevention efforts to mitigate this risk.

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.