Developing the Geriatric Injury Documentation Tool (Geri-IDT) to Improve Documentation of Physical Findings in Injured Older Adults

Elder abuse geriatrics: describing an important new medical specialist

Elder mistreatment, including elder abuse and neglect, is a difficult diagnosis to make and manage for most providers. To address this, two elder abuse consultation teams were developed for patients in the hospital and emergency department settings. As these teams have developed, the providers involved have obtained specialized training and experience that we believe contributes to a new field of elder abuse geriatrics, a corollary to the well-established field of child abuse pediatrics. Providers working in this field require specialized training and have a specialized scope of practice that includes forensic evaluation, evaluation of cognition and capacity, care coordination and advocacy for victims of abuse, and collaboration with protective services and law enforcement. Here we describe the training, scope of practice, ethical role, and best practices for elder mistreatment medical consultation. We hope this will serve as a starting point for this new and important medical specialty.

Elder Mistreatment: Emergency Department Recognition and Management

Elder mistreatment is experienced by 5% to 15% of community-dwelling older adults each year. An emergency department (ED) encounter offers an important opportunity to identify elder mistreatment and initiate intervention. Strategies to improve detection of elder mistreatment include identifying high-risk patients; recognizing suggestive findings from the history, physical examination, imaging, and laboratory tests; and/or using screening tools. ED management of elder mistreatment includes addressing acute issues, maximizing the patient's safety, and reporting to the authorities when appropriate.

Screening for Brain Injury Sustained in the Context of Intimate Partner Violence (IPV): Measure Development and Preliminary Utility of the Brain Injury Screening Questionnaire IPV Module

Abstract Intimate partner violence (IPV) is associated with risk for multi-etiology brain injury (BI), including repetitive head impacts, isolated traumatic brain injuries (TBI), and anoxic/hypoxic injury secondary to nonfatal strangulation (NFS). IPV-related injuries are often unreported, but evidence suggests that survivors are more likely to report when asked directly. There are currently no validated tools for screening of brain injury related to IPV that meet World Health Organization guidelines for this population. Here, we describe measure development methods and preliminary utility of the Brain Injury Screening Questionnaire IPV (BISQ-IPV) module. We culled items from existing IPV and TBI screening tools and sought two rounds of stakeholder feedback regarding content coverage, terminology, and safety of administration. The resulting stakeholder-informed BISQ-IPV module is a seven-item self-report measure that uses contextual cues (e.g., being shoved, shaken, strangled) to query lifetime history of IPV-related head/neck injury. We introduced the BISQ-IPV module into the Late Effects of TBI (LETBI) study to investigate rates of violent and IPV-specific head/neck injury reporting in a TBI sample. Among those who completed the BISQ-IPV module (n = 142), 8% of the sample (and 20% of women) reported IPV-related TBI, and 15% of the sample (34% of women) reported IPV-related head or neck injury events that did not result in loss or alteration of consciousness. No men reported NFS; one woman reported inferred BI secondary to NFS, and 6% of women reported NFS events. Those who endorsed IPV-BI were all women, many were highly educated, and many reported low incomes. We then compared reporting of violent TBIs and head/neck injury events among individuals who completed the core BISQ wherein IPV is not specifically queried (administered from 2015-2018; n = 156) to that of individuals who completed the core BISQ preceded by the BISQ-IPV module (BISQ+IPV, administered from 2019-2021; n = 142). We found that 9% of those who completed the core BISQ reported violent TBI (e.g., abuse, assault), whereas 19% of those who completed the BISQ+IPV immediately preceding the core BISQ reported non-IPV-related violent TBI on the core BISQ. These findings suggest that standard TBI screening tools are inadequate for identifying IPV-BI and structured cueing of IPV-related contexts yields greater reporting of both IPV- and non-IPV-related violent BI. When not queried directly, IPV-BI remains a hidden variable in TBI research studies.

Forensic Characteristics of Physical Elder Abuse and Current Status and Issues of Collaboration between Forensic Medicine Departments and Related Institutions in Japan

This study sought to clarify the characteristics and trends of physical elder abuse and the status of collaboration between forensic medicine departments and related institutions in Japan. Questionnaires were sent to 82 forensic medicine departments and 2857 institutions randomly selected from hospitals, municipalities and public community general support centers. The survey period was February to June 2021, including an extension period for collection. Responses from 675 facilities were analyzed. The most common finding in cases of physical elder abuse at forensic medicine departments was subcutaneous hemorrhage on the head (85.7%), with mixed old and new injuries most commonly observed in the lower limbs (70%). There were few cases in which there was collaboration between forensic medicine departments and other institutions. Among the issues identified, there is a need to provide related institutions with information obtained in forensic medicine departments. A new collaboration system is needed to achieve this.

Trauma Forensics in Blunt and Sharp Force Injuries

Trauma forensics is the concept of examining trauma from a medicolegal standpoint in a given jurisdiction. Blunt and sharp force traumas are classified based on the different mechanisms of causation, which have a medicolegal significance. Adopting a standard approach to the medical evaluation of such injuries in patients would serve both the purposes of rendering appropriate treatment and the documentation and preservation of medical evidence. However, most trauma cases are seen by medical practitioners with very limited forensic knowledge and skills, and they are still expected to meet the needs of the court or the judicial mechanism in subsequent legal proceedings. Therefore, some measures, including 10 practical considerations, which are applicable in attending to blunt and sharp force traumas, would limit the risk a clinician faces in the crossfire of medicine and law.

Family Violence Associated with Self-Rated Health, Satisfaction With Life, and Health Service Use in Primary Care Older Adults

We aimed to document in primary care older adults the relationship between family violence (FV) and mental and physical health, satisfaction with life, and health service use, by gender. The study sample included data from 1,658 older adults recruited in primary care practices, in one of the largest health regions in the province of Quebec. The presence of FV (partner/spouse, adult child) was assessed with the 21-item Family Violence Scale (FVS) adapted from the conflicts Tactics Scale 2. Self-rated mental health (SRMH) and self-rated physical health (SRPH) were assessed with single-item measures. Satisfaction with life (SWL) was measured using a validated French version of the SWL scale. Health service use over a 2-year period included outpatient consultations (number), emergency department (ED) visits (yes/no), and hospitalizations (yes/no). Multi-level logistic and Poisson's regression models were conducted to assess study outcomes as a function of FV. Analyses were stratified by perpetrator and gender. There was an association between FV and SRMH in women (OR = 0.41, 95% CI = [0.27, 0.62]), and SWL in both men and women (B = -5.74, 95% CI = [-6.71, -4.76]; B = -10.07, 95% CI = [-14.16, -5.98], respectively). Significant associations were found in women between FV and ED visits (OR = 1.45, 95% CI = [1.12, 1.18]), hospitalizations (OR = 1.36, 95% CI = [1.32, 1.43]), and outpatient consultations (RR = 1.25, 95% CI = [1.19, 1.30]). SWL moderated the association between FV and likelihood of hospitalization. Gender differences were observed between FV and SRMH and SWL. FV was associated with increased health service use in women but not men. These gender differences may suggest stigma-related barriers to health service use. Victims of violence with higher SWL had a lower likelihood of being hospitalized. Public health programs aimed at increasing awareness of the different types of FV and interventions aiming to improve resilience in victims are needed.

Identifying gaps and improving investigation of fatal elder abuse and/or neglect

Death investigator and autopsy reports for decedents 65 years and older within a major metropolitan area over a five-year period were assessed for the possibility of elder abuse and/or neglect. The study consisted of two stages. A simple two-question screening criteria was used to determine whether the decedent was (1) dependent on another for at least one activity of daily living and (2) had a presence of at least one indicator of abuse and/or neglect. Second, only cases with affirmative criteria responses were reviewed to identify inconsistent or deficient variables that precluded (or if present, allowed) determination of abuse and/or neglect. A multidisciplinary panel of local and national experts, including forensic pathologists, law enforcement, and geriatricians assessed these indicators as indicative of presence of abuse/neglect, and these indicators were subsequently developed as a supplemental data collection tool. Of a possible 2798 cases, 2324 (83%) were excluded using the screening criteria. This reduced the number of cases that warranted further investigation to 474 (17% of elderly deaths in this timeframe). All 474 decedents were dependent on another for at least one ADL and 322 (68%) had unexplained injuries. In 180 (38%) cases had recorded notation of a suspicion of abuse and/or neglect at the time of death. The results support the premise that a simple, two-criterion screening can effectively identify cases of potential abuse and/or neglect and, when followed by a supplemental data collection tool, cases can be efficiently evaluated.

Can diagnostic imaging help improve elder abuse detection?

Elder abuse is an underdetected, under-reported issue with severe consequences. Its detection presents unique challenges based on characteristics of this vulnerable population, including cognitive impairment, age-related deconditioning, and an increased number of co-morbidities, all of which predispose to increase vulnerability to injury. While radiologists play a critical role in detection of child abuse, this role is currently not paralleled in detection of elder abuse. We conducted a thorough review of the literature using MEDLINE to describe the current knowledge on injury patterns and injury findings seen in elder abuse, as well as barriers to and recommendations for an increased role of diagnostic imaging in elder abuse detection. Barriers limiting the role of radiologists include lack of training and paucity of rigorous systematic research delineating distinctive imaging findings for physical elder abuse. We outline the current ways in which imaging can help raise clinical suspicion for elder abuse, including inconsistencies between purported mechanism of injury and imaging findings, injury location, multiple injuries at differing stages of healing, and particular patterns of injury likely to be intentionally inflicted. We additionally outline the mechanism by which medical education and clinical workflow may be modified to increase the role for imaging and radiologist participation in detecting abuse in older adult patients, and identify potential future directions for further systematic research.

Elder Abuse in the Out-of-Hospital and Emergency Department Settings: A Scoping Review

This scoping review aimed to synthesize the available evidence on the epidemiology, patient- and caregiver-associated factors, clinical characteristics, screening tools, prevention, interventions, and perspectives of health care professionals in regard to elder abuse in the out-of-hospital or emergency department (ED) setting. Literature search was performed with MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, PsycINFO, and the Cochrane Library. Studies were eligible if they were observational or experimental and reported on elder abuse in the out-of-hospital or ED setting. A qualitative approach, performed independently by 2 reviewers, was used to synthesize and report the findings. A total of 413 citations were retrieved, from which 55 studies published between 1988 and 2019 were included. The prevalence of elder abuse reported during the ED visit was lower than reported in the community. The most commonly detected type of elder abuse was neglect, and then physical abuse. The following factors were more common in identified cases of elder abuse: female sex, cognitive impairment, functional disability, frailty, social isolation, and lower socioeconomic status. Psychiatric and substance use disorders were more common among victims and their caregivers. Screening tools have been proposed, but multicenter validation and influence of screening on patient-important outcomes were lacking. Health care professionals reported being poorly trained and acknowledged numerous barriers when caring for potential victims. There is insufficient knowledge, limited training, and a poorly organized system in place for elder abuse in the out-of-hospital and ED settings. Studies on the processes and effects of screening and interventions are required to improve care of this vulnerable population.