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

Nonmedical problems among older adults visiting the emergency department for low acuity conditions: A prospective multicentre cohort study

Background

Data on the predictors of nonmedical problems (NMP) in older adults attending the emergency department (ED) for low acuity conditions is lacking and could help rapid identification of patients with NMP and integration of these needs into care planning.

Objectives

To determine the prevalence and predictors of NMP among older adults attending EDs for low acuity conditions.

Methods

Prospective cohort study in eight EDs (May-August 2021). We included cognitively intact ≥65 years old adults assigned a low triage acuity (3-5) using the CTAS. A questionnaire focusing on 11 NMP was administered. We used multiple logistic regression to identify predictors of NMP.

Results

Among the 1,061 participants included, the mean age was 77.1 ± 7.6, majority were female, and 41.6 % lived alone. At least one NMP was reported by 704 persons. Prevalence of each NMP: outdoor (41.1 %) and indoor (30.2 %) mobility issues, difficult access to dental care (35.1 %), transportation (4.1 %) and medication (5.4 %), loneliness (29.5 %), food insecurity (10.3 %), financial difficulties (9.5 %), unsafe living situation (4.1 %), physical/psychological violence (3.4 %), and abuse/neglect (3.3 %). Predictors of NMP were: age (OR 1.04 for each additional year), living alone (OR 2.20), pre-existing mental health conditions (OR 3.12), heart failure (OR 1.42), recent surgery/admission (OR 1.75), memory decline (OR 2.76), no family physician (OR 1.74) and consulting for a fall/functional decline (OR 2.48).

Conclusions

Nonmedical problems are frequent among older adults. We need to implement holistic ED processes that integrate these problems into care planning.

Screening for elder mistreatment in a Swiss emergency department: a prospective cohort study

AIM OF THE STUDY

The mistreatment of older adults is a global and complex problem with varying prevalence. As there are no data on the prevalence of elder mistreatment in European emergency department populations, we aimed to translate and culturally adapt the Emergency Department Senior Abuse Identification (ED Senior AID) tool for German use, assess the positive screen rate for elder mistreatment with the German version, and compare characteristics of patients who screened positive and negative.

METHODS

To assess the prevalence of elder mistreatment, we created a German version of the ED Senior AID tool. This tool identifies intentional or negligent actions by a caregiver or trusted person that cause harm or risk to an older adult. Then, the German ED Senior AID tool was applied to all consecutively presenting patients aged ≥65 years at our academic emergency department in the Northwest of Switzerland from 25 April to 30 May 2022. Usability was defined as the percentage of patients with completed assessments using the German ED Senior AID tool.

RESULTS

We included 1010 patients aged ≥65 years, of whom 29 (2.9%) screened positive with the ED Senior AID tool. The patients who screened positive were older, more severely cognitively impaired, hospitalised more frequently, and presented with higher frailty scores than those who screened negative. Mortality up to 100 days after presentation was comparable in all patients (p = 0.861), regardless of their screening result. The tool showed good usability, with 73% of assessments completed.

CONCLUSION

This is the first prospective investigation on the prevalence of elder mistreatment in a European emergency department setting. Overall, 2.9% of patients screened positive using a validated screening tool translated into German.

TRIAL REGISTRATION

This study was registered with the National Institute of Health on ClinicalTrials.gov with the registration number NCT05400707.

On tackling abuse of older people: The forensic challenges in fatal cases investigation

The World Health Organization recently presented the priorities for tackling abuse of older people in a coordinated and strategic way. However, data on the forensic scenario is still lacking. In this context, the aim of the present work was to provide a comprehensive literature review of this inherently complex phenomenon in the post-mortem setting, in order to better characterize it from a forensic point of view. A comprehensive literature search was performed in three electronic databases following the PRISMA guidelines. Sociodemographic and medical data of victims and perpetrators, post-mortem data, types of abuse and risk factors were extracted from non-aggregated data. Forty-eight papers dealing with abuse in the post-mortem setting were included, with a predominance of case reports and case series. The review showed that neglect was the most common type of abuse and victims are predominantly older women who are abused in a domestic setting by trusted family member. To generate more and better data, expanded research in the forensic field requires standardized methods and the raise of professional awareness about abuse of older people.

Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study

INTRODUCTION

Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs.

METHODS

This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65 years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse.

RESULTS

A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]).

CONCLUSION

When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.

The Prevalence of Elder Abuse and its Association with Frailty in Elderly Patients at the Outpatient Department of a Super-Tertiary Care Hospital in Northern Thailand

Background and Objectives: The global population is undergoing rapid aging, resulting in an increase in geriatric syndromes and hidden health issues such as elder abuse. However, the prevalence of elder abuse varies across different settings. The objective of this study is to determine the prevalence and factors associated with elder abuse at the outpatient department of a super-tertiary care hospital in northern Thailand. Materials and Methods: This cross-sectional study involved 210 elderly patients who visited Maharaj Nakorn Chiang Mai Hospital between May and August 2022. The participants completed several assessments, including the Mini-Cog, Thai Geriatric Depression Scale-6, Core Symptom Index-15, FRAIL scale, Barthel Activities of Daily Living, Interview Guideline for Screening for Elder Abuse, and Diagnostic Criteria for Elder Abuse. Fisher's exact test was used to examine the association between the factors and elder abuse. Results: The Screening for Elder Abuse yielded noteworthy results, with 15.7% of the elderly patients having experienced psychological abuse. However, only a smaller subset of study participants, comprising five individuals or 2.38%, met the diagnostic criteria for elder abuse. Furthermore, statistical analysis revealed no significant correlation between elder abuse and the other factors examined in the study. Conclusions: As a result, it is crucial for hospitals to consider preventive measures and implement routine screening protocols.

Cinematic Virtual Reality for Educating Health Care Providers About Type 2 Diabetes, Disability, and Elder Abuse and Neglect: A Pilot Study

BACKGROUND

Diabetes care for older adults is complex and must consider geriatric syndromes, disability, and elder abuse and neglect. Health care providers would benefit from professional training programs that emphasize these risks. One new educational approach is cinematic virtual reality (cine-VR). We conducted a pilot study to evaluate a cine-VR training program based on an older patient with type 2 diabetes and multiple geriatric syndromes who is at risk for elder abuse and neglect.

METHODS

We employed a single-arm, pre-post-test study to assess changes in attitudes to disability and self-efficacy in identifying and managing elder abuse and neglect.

RESULTS

Thirty health care providers completed the pilot study (83.3% women, 86.7% white, 56.7% physicians, 43.4% practiced in outpatient clinics). We observed change in attitudes toward discrimination (Z = -2.628, P = .009, Cohen's d = .62). In addition, we observed changes in six of the eight self-efficacy items, including how participants would ask questions about abuse (Z = -3.221, P = .001, Cohen's d = .59) and helping an older patient make a report to the police or social services (Z = -2.087, P = .037, Cohen's d = .52). In addition, we observed positive changes in understanding the documentation needed to complete whether a patient reports abuse (Z = -3.598, P < .001) as well as the legal knowledge for how to report elder abuse and neglect (Z = -2.556, P = .011).

CONCLUSION

Findings from this pilot study suggest that cine-VR training may increase health care providers' awareness of discrimination and improve self-efficacy toward identifying and managing elder abuse and neglect. Research with a proper control condition is needed to confirm its effectiveness.

Dealing with the elder abuse epidemic: Disparities in interventions against elder abuse in trauma centers

BACKGROUND

Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults.

METHODS

Analysis of the 2017-2018 ACS TQIP. All trauma patients ≥60 years with an abuse report for suspected physical abuse were included. Patients with missing information on abuse interventions were excluded. Outcomes were rates of abuse investigation initiation following an abuse report and change of caregiver at discharge among survivors with an abuse investigation initiated. Multivariable regression analyses were performed.

RESULTS

Of 727,975 patients, 1405 (0.2%) had an abuse report. Patients with an abuse report were younger (mean, 72 vs 75, p < 0.001), and more likely to be females (57% vs 53%, p = 0.007), Hispanic (11% vs 6%, p < 0.001), Black (15% vs 7%, p < 0.001), suffer from dementia (18% vs 11%, p < 0.001), functional disability (19% vs 15%, p < 0.001), have a positive admission drug screen (9% vs 5%, p < 0.001) and had a higher ISS (median [IQR], 9 [4-16] vs 6 [3-10], p < 0.001). Perpetrators were members of the immediate/step/extended family in 91% of cases. Among patients with an abuse report, 1060 (75%) had abuse investigations initiated. Of these, 227 (23%) resulted in a change of caregiver at discharge. On multivariate analysis for abuse investigation initiation, male gender, private insurance, and management at non-level I trauma centers were associated with lower adjusted odds (p < 0.05), while Hispanic ethnicity, positive admission drug screen, and penetrating injury were associated with higher adjusted odds (p < 0.05). On multivariate analysis for change of caregiver, male gender, and private insurance were associated with lower adjusted odds (p < 0.05), while functional disability and dementia were associated with higher adjusted odds (p < 0.05).

CONCLUSIONS

Significant gender, ethnic, and socioeconomic disparities exist in the management of physical abuse of older adults. Further studies are warranted to expand on and address the contributing factors underlying these disparities.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Therapeutic/Care Management.

Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care

Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.

2021 SAEM Consensus Conference Proceedings: Research Priorities for Developing Emergency Department Screening Tools for Social Risks and Needs

Introduction: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting. Methods: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health. Results: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting? Conclusion: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.

Nonaccidental Injury in the Elderly: What Radiologists Need to Know

Elder abuse may result in serious physical injuries and long-term psychological consequences and can be life threatening. Over the past decade, attention to elder abuse has increased owing to its high prevalence, with one in six people aged 60 years and older experiencing some form of abuse worldwide. Despite this, the detection and reporting rates remain relatively low. While diagnostic imaging is considered critical in detection of child abuse, it is relatively underused in elder abuse. The authors discuss barriers to use of imaging for investigation and diagnosis of elder abuse, including lack of training, comorbidities present in this vulnerable population, and lack of communication among the intra- and interdisciplinary care providers. Moreover, imaging features that should raise clinical concern for elder abuse are reviewed, including certain types of fractures (eg, posterior rib), characteristic soft-tissue and organ injuries (eg, shoulder dislocation), and cases in which the reported mechanism of injury is inconsistent with the imaging findings. As most findings suggesting elder abuse are initially discovered at radiography and CT, the authors focus mainly on use of those modalities. This review also compares and contrasts elder abuse with child abuse. Empowered with knowledge of elderly victims' risk factors, classic perpetrator characteristics, and correlative imaging findings, radiologists should be able to identify potential abuse in elderly patients presenting for medical attention. Future recommendations for research studies and clinical workflow to increase radiologists' awareness of and participation in elder abuse detection are also presented. An invited commentary by Jubanyik and Gettel is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Predictors of Physical Abuse in Elder Patients With Fracture

INTRODUCTION

Elder abuse is a public health issue requiring attention. Unlike abuse in the pediatric population, predictors of elder abuse in patients with fracture have not been well defined.

METHODS

Elderly patients with physical abuse and fracture were abstracted using the 2007 to 2017 National Emergency Department Sample database. Univariate comparisons, multivariate regression, and adjusted odds ratios were used to determine independent predictors of elder abuse compared with nonabuse fracture controls.

RESULTS

Thirteen percent of elder physical abuse patients presenting to the emergency department had fracture. Of all patients with fracture, elder abuse patients tended to be younger; be female; belong to lower income quartiles; and have codiagnoses of volume depletion, mental disorders, dementia, and intellectual disability. Presentation with other forms of elder abuse, such as psychological abuse, neglect, and sexual abuse, and multiple fractures were also associated with elder physical abuse. Multivariate regression found elder abuse to be more likely in the setting of skull and rib fractures and less likely in the setting of femur and foot and ankle fractures.

DISCUSSION

This study identified predictors of elder physical abuse in fracture patients older than 60 years. As with pediatric abuse, heightened awareness of potential physical abuse should be considered, especially in higher risk patients.

'I care a lot' a commentary on the depiction of elder abuse in the film

In I Care a Lot, we follow Marla Grayson, a self-proclaimed "Professional Carer" who makes a living by financially abusing older adults. Elder abuse, financial or otherwise, is seldom explored in cinema and must be handled with care. Cinema can help raise awareness on this social problem and play an important role in the de-stigmatization of older adults. Unfortunately, in our opinion, I Care a Lot fails to do so.

Research priorities for elder abuse screening and intervention: A Geriatric Emergency Care Applied Research (GEAR) network scoping review and consensus statement

The Geriatric Emergency Care Applied Research (GEAR) Network (1) conducted a scoping review of the current literature on the identification of and interventions to address elder abuse among patients receiving care in emergency departments and (2) used this review to prioritize research questions for knowledge development. Two questions guided the scoping review: What is the effect of universal emergency department screening compared to targeted screening or usual practice on cases of elder abuse identified, safety outcomes, and health care utilization?; and What is the safety, health, legal, and psychosocial impact of emergency department-based interventions vs. usual care for patients experiencing elder abuse? We searched five article databases. Additional material was located through reference lists of identified publications, PsychInfo, and Google Scholar. The results were discussed in a consensus conference; and stakeholders voted to prioritize research questions. No studies were identified that directly addressed the first question regarding assessment strategies, but four instruments used for elder abuse screening in the emergency department were identified. For the second question, we located six articles on interventions for elder abuse in the emergency department; however, none directly addressed the question of comparative effectiveness. Based on these findings, GEAR participants identified five questions as priorities for future research - two related to screening, two related to intervention, and one encompassed both. In sum, research to identify best practices for elder abuse assessment and intervention in emergency departments is still needed. Although there are practical and ethical challenges, rigorous experimental studies are needed.

The burden of proximal femur fractures and other skeletal injuries during the Covid-19 pandemic lockdown: a retrospective comparative study

Limiting people's movement is one of the main preventive measures deployed for the control of coronavirus 2019‑nCoV pandemic. This study aims to assess the impact of COVID-19 lockdown on the incidence of the most common skeletal injuries and to provide a management algorithm specific for hospitalized fractured patients.We comparatively analysed the Emergency Department (ED) admissions between March 9th and May 4th 2020 with the same period in 2019. The frequency of the most common skeletal injuries has been derived. Data from the pre-hospitalization phase to discharge of all patients were considered. The impact on clinical orthopaedic consulting has been evaluated. All patients requiring orthopaedic care followed different pathways of hospitalization based on COVID positivity. Data of surgical activity has been analysed.During the 9 weeks of lockdown the access of patients to ED drastically decreased: 11726 accesses compared to 21501 in the same period of 2019. This trend was followed by the most common skeletal injuries but not by proximal femur fracture (PFF) that showed the same absolute numbers compare to the previous years (64 vs 63). If analysed in relation to the total ED access, PFF showed a relatively increase in their frequency.The data from this experience suggest that healthcare providers should strategically allocate resources for management and treatment of PFF during the COVID-19 pandemic. With the begin of the reopening phase, a "rebound effect" for orthopaedic care was observed leading to delayed treatments with a potential overall increased morbidity.

Contribution of Substance Use in Acute Injuries With Regards to the Intent, Nature and Context of Injury: A CHIRPP Database Study

Introduction

Using the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) sentinel surveillance system, the objective of this study was to compare intent, circumstances, injury type and patient demographics in patients who used a substance prior to the injury versus those who did not use any substances.

Methods

Data were retrospectively collected from November 1^st 2016 to October 31^st 2017. All patients presenting to the Hôpital de l’Enfant-Jésus ED following trauma were included, aside from those who left without seeing a physician or had no physical injury (e.g., overdose without any trauma was excluded). Patients voluntarily completed a standardised form or agreed to be contacted later. Medical charts of all attendances were reviewed by the CHIRPP’s program coordinator. Substance use included illicit drugs, medications for recreational purposes, alcohol or other used either by the patient or another person involved.

Results

A total of 12,857 patients were included. Substance use was involved in 701 (5.5%) cases and was associated with injuries sustained by males (p < .001). The mean age of patients injured while using substances was 42.8 years, compared to 45.5 years in those who did not use substances (p < .001). Substance use was involved in 3.6% of unintentional injuries, compared to 26.2% of injuries intentionally inflicted by other and 38.9% for self-inflicted injuries (p < 0.0001). When substances were used, the odds of intentional injuries were 7.5 times greater compared to non-intentional injuries (95% CI 6.7, 8.5). Burns, head injuries and polytraumas were more prevalent when drugs or alcohol were involved.

Conclusion

This study outlines the significant contribution of substance use in intentional injuries, suggesting that it could potentially be beneficial to specifically target patients who present with deliberate physical injuries in preventive and therapeutic interventions offered in the ED.