Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department

Examining ethical issues that arise in providing ED/hospital care for patients experiencing elder mistreatment and approaches to address them

Clinicians in the emergency department and hospital who treat patients experiencing elder mistreatment (EM) can expect to encounter challenging ethical dilemmas. Collaboration with ethics and EM consultation services offers teams an important opportunity to improve patient-centered outcomes and address value-based concerns when treating these patients. This article describes the role of a hospital clinical ethics consultation service and best practices for collaboration between ethics and EM consultation services. Illuminated via four case studies, the article presents several core ethical frameworks, including allowing patients the dignity of risk, considerations around a harm reduced discharge, involving abusers in surrogate decision making, and providers' experience of moral distress when dealing with patients experiencing EM. Increasing collaboration with ethics and elder mistreatment services can help teams more effectively respond to EM.

Injury patterns and demographics in older adult abuse and falls: A comparative study in emergency department settings

BACKGROUND

Falls and interpersonal violence pose significant threats to older adults, leading to injuries, hospitalizations, and emergency department (ED) visits. This study investigates the demographics and injury patterns in older adults (aged 60 and above) who sought ED care due to assaults, comparing them with those who experienced falls to gain a deeper understanding of older adult abuse patterns.

METHOD

This study utilizes data from the National Electronic Injury Surveillance System (NEISS) All Injury Program (2005-2019) to examine injuries among older adults aged 60 years and above. Participants were categorized into two groups: older adult abuse and injuries due to falls. The differences between the groups by demographics, injury locations, patterns, and temporal trends were analyzed using statistical methods accounting for the weighted stratified nature of the data. Cosinor analysis and Joinpoint regression were used for temporal analysis.

RESULTS

Over 15 years, there were an estimated 307,237 ED visits for older adult abuse and 39,477,217 for falls. Older adults experiencing abuse were younger and had lower hospital admission rates compared to fall patients. Injuries associated with abuse included contusions/abrasions, penetrating injuries, and fractures to the head/neck, fingers, toes, ribs, and lower extremities. In contrast, fall patients had higher admission rates, with more fractures, including cervical spine and hip fractures. Temporal patterns showed a higher rate of assaults during the summer, whereas abuse demonstrated bimodal peaks in the summer and fall.

CONCLUSIONS

Injuries associated with abuse such as facial, upper trunk, and upper extremity fractures should raise suspicion even in the absence of severe symptoms. These findings emphasize the importance of early identification to connect older adults with support resources, as patients experiencing abuse often get discharged from the ED.

Perspectives on elder mistreatment screening and responding in emergency departments: A qualitative study with survivors

OBJECTIVE

Elder Mistreatment (EM) occurs in approximately 10% of older adults and is associated with trauma-related outcomes including depression, anxiety, post-traumatic stress disorder, and early mortality. Low screening and older adult self-reporting rates, especially within Emergency Departments represent missed opportunities for identify and mitigate future EM occurrences and consequences. To date, no studies have obtained EM survivors perspectives of EM screening and response practices in emergency departments.

METHODS

Semi-structured interviews with 19 EM survivors with Adult Protective Services validated EM were completed in the older adult's home. The Elder Mistreatment Emergency Department Screening and Response Tool (EM-SART) was used to guide the interview questions. All interviews were recorded, transcribed, and analyzed using qualitative thematic analyses.

RESULTS

The participants were mostly female (63%) and white (58%) with an average age of 74 years. Physical abuse accounted for 67% of the EM incidents. Three themes emerged indicating the survivor preference for (1) building rapport and approaching the older adult with compassion and care, (2) setting the context before asking the EM questions, and (3) allowing mutuality, collaborative work, and shared decision-making during the response.

CONCLUSIONS

Older adults are agreeable and willing to self-report and actively engage in the EM screening and response practices in the emergency department if trauma-informed care principles are utilized.

Nonspecific Complaints in Older Emergency Department Patients

Nonspecific complaints such as generalized weakness and fatigue are common in older adults presenting to an emergency department. These complaints may be caused by acute or chronic medical problems, or they may be exacerbated or caused by socioeconomic risks factors. Acute causes may be related to serious medical conditions requiring prompt treatment. A thorough history and physical examination in conjunction with an interdisciplinary approach allows emergency departments to identify acute conditions as well as geriatric syndromes and unmet home needs, such as food insecurity and caregiver burden. A whole-health system approach should be used for safe transitions of care.

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.

Development and validation of the short form domestic elder abuse assessment questionnaire (SF-DEAQ)

BACKGROUND

The present study aimed to design and determine the psychometric properties of a short-form questionnaire to investigate the domestic elder abuse.

METHODS

This study consisted of two phases: in phase 1 we employed a modified Delphi approach with 18 participants. Consequently, content and face validity, and item analysis were applied. In Phase 2 we evaluated structural validity and convergent validity. Reliability was assessed by looking at internal consistency, stability, and absolute reliability.

RESULTS

The findings led to the development of a 27-items short form of domestic elder abuse in four domains that jointly accounted for 74.14% of the variance observed. The short form showed high internal consistency (Cronbach's alpha = 0.93) and significantly correlated (r = 0.91; p < 0.001 for both scales) with the comprehensive (49-item) domestic elder abuse.

CONCLUSION

The short form of domestic elder abuse was found to be reliable and valid as the longer version. The short form of domestic elder abuse could lessen the burden on respondents.

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.

Experiences of patient advocacy among nurses working in a resource constrained emergency department in Ghana

BACKGROUND

Patient advocacy at the emergency department is stressful and cumbersome as a result of the increasing patient-to-nurse ratio and high patient turnovers. It is also unclear what patient advocacy entails and the experiences of patient advocacy in a resource-constrained emergency department. This is significant because advocacy underpins the care provided in the emergency department.

AIM

The primary aim of this study is to explore the experiences and underpinning factors that influence patient advocacy among nurses working in a resource constrained emergency department.

METHODS

A descriptive qualitative study was conducted among 15 purposively sampled ED nurses working at a resource-constrained secondary-level hospital facility. Study participants were individually interviewed via a recorded telephone conversation, after which the interviews were transcribed verbatim and inductively analyzed using the content analysis approach. The study participants described patient advocacy, situations in which they advocated for patients, the factors that motivated them and the challenges they encountered practicing patient advocacy.

RESULTS

Three major themes generated from the study included: "stories of advocacy", "motivating" factors and "challenging" factors. ED nurses understood patient advocacy and also advocated for patients in various instances. There were factors such as personal upbringing, professional training and religious training that motivated them and they were challenged by negative inter-professional experiences, patient and relatives' attitudes and healthcare system factors.

CONCLUSION

Participants understood patient advocacy and incorporated it into daily nursing care. Unsuccessful advocacy causes disappointment and frustrations. There were no documented guidelines on patient advocacy.

Emergency Department and Hospital Utilization Among Older Adults Before and After Identification of Elder Mistreatment

Importance

Elder mistreatment is common and has serious health consequences. Little is known, however, about patterns of health care utilization among older adults experiencing elder mistreatment.

Objective

To examine emergency department (ED) and hospital utilization of older adults experiencing elder mistreatment in the period surrounding initial mistreatment identification compared with other older adults.

Design, Setting, and Participants

This retrospective case-control study used Medicare insurance claims to examine older adults experiencing elder mistreatment initially identified between January 1, 2003, and December 31, 2012, and control participants matched on age, sex, race and ethnicity, and zip code. Statistical analysis was performed in April 2022.

Main Outcomes and Measures

We used multiple measures of ED and hospital utilization patterns (eg, new and return visits, frequency, urgency, and hospitalizations) in the 12 months before and after mistreatment identification. Data were adjusted using US Centers for Medicare and Medicaid Services Hierarchical Condition Categories risk scores. Chi-squared tests and conditional logistic regression models were used for data analyses.

Results

This study included 114 case patients and 410 control participants. Their median age was 72 years (IQR, 68-78 years), and 340 (64.9%) were women. Race and ethnicity were reported as racial or ethnic minority (114 [21.8%]), White (408 [77.9%]), or unknown (2 [0.4%]). During the 24 months surrounding identification of elder mistreatment, older adults experiencing mistreatment were more likely to have had an ED visit (77 [67.5%] vs 179 [43.7%]; adjusted odds ratio [AOR], 2.95 [95% CI, 1.78-4.91]; P < .001) and a hospitalization (44 [38.6%] vs 108 [26.3%]; AOR, 1.90 [95% CI, 1.13-3.21]; P = .02) compared with other older adults. In addition, multiple ED visits, at least 1 ED visit for injury, visits to multiple EDs, high-frequency ED use, return ED visits within 7 days, ED visits for low-urgency issues, multiple hospitalizations, at least 1 hospitalization for injury, hospitalization at multiple hospitals, and hospitalization for ambulatory care sensitive conditions were substantially more likely for individuals experiencing elder mistreatment. The rate of ED and hospital utilization for older adults experiencing elder mistreatment was much higher in the 12 months after identification than before, leading to more pronounced differences between case patients and control participants in postidentification utilization. During the 12 months after identification of elder mistreatment, older adults experiencing mistreatment were particularly more likely to have had high-frequency ED use (12 [10.5%] vs 8 [2.0%]; AOR, 8.23 [95% CI, 2.56-26.49]; P < .001) and to have visited the ED for low-urgency issues (12 [10.5%] vs 8 [2.0%]; AOR, 7.33 [95% CI, 2.54-21.18]; P < .001).

Conclusions and Relevance

In this case-control study of health care utilization, older adults experiencing mistreatment used EDs and hospitals more frequently and with different patterns during the period surrounding mistreatment identification than other older adults. Additional research is needed to better characterize these patterns, which may be helpful in informing early identification, intervention, and prevention of elder mistreatment.

Depression as a Consequence of Elder Mistreatment: A Case Report

A 61-year-old elderly woman came to the emergency room in tertiary hospital in Jakarta, Indonesia due to epigastric pain for the past 7 months which was worsened in the past 4 days. Due to her illness, her daughters prevent her to do daily chores and her hobbies, such as singing and gardening. On admission, she had hypertension with moderate dependency, frail, cognitive impairment, malnutrition, risk of sarcopenia, and risk of depression. She was later diagnosed with poorly differentiated colon adenocarcinoma and adjustment disorders with anxiety and depressive reaction due to emotional elder mistreatment. There are a variety of forms of elder abuse, not only physical, but also emotional, sexual, financial, and neglect. The prevalence of elder mistreatment is projected between 5% and 10% all over the world and it is thought to be underdiagnosed. Among the consequences of mistreatment or abuse include social alongside, economic, physical, and mental (e.g., isolation, constrained relationships, and broken social networks). This is a case report of depression because of elder mistreatment.

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.

Expanding the role of interdisciplinary teams in the emergency department: Using a consultative model to serve older adults who are abused

This Editorial comments on the article by Rosen et al. in this issue.

Vulnerable Elder Protection Team: Initial experience of an emergency department-based interdisciplinary elder abuse program

BACKGROUND

An emergency department (ED) visit provides a unique opportunity to identify elder abuse and initiate intervention, but emergency providers rarely do. To address this, we developed the Vulnerable Elder Protection Team (VEPT), an ED-based interdisciplinary consultation service. We describe our initial experience in the first two years after the program launch.

METHODS

We launched VEPT in a large, urban, academic ED/hospital. From 4/3/17 to 4/2/19, we tracked VEPT activations, including patient characteristics, assessment, and interventions. We compared VEPT activations to frequency of elder abuse identification in the ED before VEPT launch. We examined outcomes for patients evaluated by VEPT, including change in living situation at discharge. We assessed ED providers' experiences with VEPT via written surveys and focus groups.

RESULTS

During the program's initial two years, VEPT was activated and provided consultation/care to 200 ED patients. Cases included physical abuse (59%), neglect (56%), financial exploitation (32%), verbal/emotional/psychological abuse (25%), and sexual abuse (2%). Sixty-two percent of patients assessed were determined by VEPT to have high or moderate suspicion for elder abuse. Seventy-five percent of these patients had a change in living/housing situation or were discharged with new or additional home services, with 14% discharged to an elder abuse shelter, 39% to a different living/housing situation, and 22% with new or additional home services. ED providers reported that VEPT made them more likely to consider/assess for elder abuse and recognized the value of the expertise and guidance VEPT provided. Ninety-four percent reported believing that there is merit in establishing a VEPT Program in other EDs.

CONCLUSION

VEPT was frequently activated and many patients were discharged with changes in living situation and/or additional home services, which may improve safety. Future research is needed to examine longer-term outcomes.

A Guide to the Postmortem Investigation of Starvation in Adults

ABSTRACT

Starvation is a rare cause of death in developed countries and is a complex multifaceted pathological process. To complicate the forensic investigation of starvation further, many medical conditions independent of starvation may cause wasting. This article provides one of the first comprehensive guides to the postmortem investigation of starvation in adults, with reference tables on organ-specific macroscopic and microscopic features, as well as features for excluding alternative causes of wasting. The eclectic literature on this complex topic is summarized in an accessible and easily referenced format, including mechanisms of death and ancillary postmortem investigations.

Elder abuse and hospitalization in rural Malaysia

Our study aims to describe and determine factors associated with hospitalization among victims of elder abuse and neglect (EAN) in rural Malaysia. A cross sectional study based on the baseline data of the Malaysian Elder Mistreatment Project (MAESTRO) collected from November 2013 until July 2014 involving 1927 older adults in Kuala Pilah, Negeri Sembilan was conducted. EAN was determined using the modified Conflict Tactics Scale (CTS) and hospitalization rates were determined based on self-report. The prevalence of overall EAN was 8.1% (95%CI 6.9–9.3). Among male respondents, 9.5% revealed history of abuse and among female respondents, 7.2% reported experiencing EAN. The annual hospitalization rates per 100 persons within the past one year among EAN victims and non-victims were 18 per 100 persons (SD = 46.1) and 15 per 100 persons (SD = 64.1) respectively. Among respondents with history of EAN, 16.0% (n = 21) had been hospitalized in the past 12 months while among respondents with no EAN experience, 10.2% (n = 153) were hospitalized. Multivariable analyses using Poisson regression did not show any significant association between EAN and hospitalization. This could be due to the complex interactions between medical and social circumstances that play a role in hospital admissions, factors affecting the health care system, and access to health care among EAN victims.

Understanding older adults' functioning and health-seeking behaviour during the COVID-19 pandemic in Ghana: A descriptive qualitative study

Little research has been conducted to explore the functional status of community-dwelling older adults in sub-Saharan Africa, including Ghana, especially during the COVID-19 pandemic. This study investigated the functional status and the health-seeking behaviour of older adults during the COVID-19 pandemic in Ghana. Utilising a descriptive qualitative approach, semi-structured interviews were used to collect data from 12 eligible older adults from southern Ghana. With the use of NVivo (v12), descriptive and focused coding techniques were employed to analyse the data. The following five themes were identified after the data analysis: (a) older adults' health status during COVID-19 pandemic, (b) feeling limited, (c) feeling of unhappiness for being inactive, (d) striving to be active and (e) seeking healthcare during COVID-19 pandemic. This study revealed the unique health and social-related needs of Ghanaian older adults during the COVID-19 pandemic. This study's findings draw attention to the urgent need for the state to devise practical health and social-related initiatives to support older adults during and after the COVID-19 pandemic.

Nurses' Role in Identifying Elder Financial Abuse

One of the current worldwide public health problems is elderly financial abuse (EFA). Although EFA remains a hidden social phenomenon, it has been recognized as a serious concern in the United States, and currently, one in 18 cognitively intact older adults is affected by EFA. Detecting EFA is difficult because the perpetrators are often family members, trusted friends, or guardians. Thus, EFA is frequently unrecognized and grossly under-reported. In the coming decades, EFA will increase as the elderly population continues to grow rapidly worldwide. This article highlights the magnitude of the problem and the role of nurses and other health care providers in identifying, intervening in, and reporting EFA. [J Contin Educ Nurs. 2022;53(1):30-34.].

Developing a tool to assess and monitor institutional readiness to address elder mistreatment in hospital emergency departments

Hospital emergency departments (EDs) lack the tools and processes required to facilitate consistent screening and intervention in cases of elder abuse and neglect. To address this need, the National Collaboratory to Address Elder Mistreatment has developed a clinical care model that ED's can implement to improve screening, referral, and linkage to coordinated care and support services for older adults who are at risk of mistreatment. To gauge ED readiness to change and facilitate adoption of the care model, we developed an organizational assessment tool, the Elder Mistreatment Emergency Department Assessment Profile (EM-EDAP). Development included a phased approach in which we reviewed evidence on best practice; consulted with multidisciplinary experts; and sought input from ED staff. Based on this formative research, we developed a tool that can be used to guide EDs in focusing on practice improvements for addressing elder mistreatment that are most responsive to local needs and opportunities.

Diagnostic Coding of Elder Mistreatment: Results From a National Database of Medicare Advantage and Private Insurance Patients, 2011-2017

Health care providers may play an important role in detection of elder mistreatment, which is common but underrecognized. We used the Health Care Cost Institute insurance claims database to describe elder mistreatment diagnosis among Medicare Advantage (MA) and private insurance patients in the United States from 2011 to 2017. We used International Classification of Diseases (ICD) coding to identify cases, examining the impact of transition from ICD-9 (Ninth Revision) to ICD-10 (Tenth Revision), which occurred in October 2015 and added 14 new codes for "suspected" mistreatment. 8,127 patients (0.051% of all aged ≥ 65), including 6,304 with MA (0.058%) and 1,823 with private insurance (0.026%) received elder mistreatment diagnosis. Transition from ICD-9 to ICD-10 was associated with a small increase in diagnosis rate, with "suspected" codes used in 45.3% of ICD-10 versus 9.7% of ICD-9 cases. Overall rates remained low. Rates, settings, and types of diagnosis differed between MA and private insurance patients.

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.

Elder Abuse-A Guide to Diagnosis and Management in the Emergency Department

Elder abuse affects many older adults and can be life threatening. Older adults both in the community and long-term care facilities are at risk. An emergency department visit is an opportunity for an abuse victim to seek help. Emergency clinicians should be able to recognize the signs of abuse, including patterns of injury consistent with mistreatment. Screening tools can assist clinicians in the diagnosis of abuse. Physicians can help victims of mistreatment by reporting the abuse to the appropriate investigative agency and by developing a treatment plan with a multidisciplinary team to include a safe discharge plan and close follow-up.

Development and usability evaluation of VOICES: A digital health tool to identify elder mistreatment

BACKGROUND/OBJECTIVES

A major barrier for society in overcoming elder mistreatment is an inability to accurately identify victims. There are several barriers to self-reporting elder mistreatment, including fear of nursing home placement or losing autonomy or a caregiver. Existing strategies to identify elder mistreatment neglect to empower those who experience it with tools for self-reporting. In this project, we developed and evaluated the usability of VOICES, a self-administrated digital health tool that screens, educates, and motivates older adults to self-report elder mistreatment.

DESIGN

Cross-sectional study with User-Centered Design (UCD) approach.

SETTING

Yale School of Medicine and the Agency on Aging of South-Central Connecticut.

PARTICIPANTS

Thirty eight community-dwelling and cognitively intact older adults aged 60 years and older, caregivers, clinicians, and social workers.

INTERVENTION

A tablet-based self-administrated digital health tool that screens, educates, and motivates older adults to self-report elder mistreatment.

MEASUREMENTS

Qualitative and quantitative data were obtained from: (1) focus groups participants including: feedback from open-ended discussion, demographics, and a post-session survey; (2) usability evaluation including: demographics, usability measures, comfortability with technology, emotional state, and open-ended feedback.

RESULTS

Focus group participants (n = 24) generally favored using a tablet-based tool to screen for elder mistreatment and expressed comfort answering questions on elder mistreatment using tablets. Usability evaluation participants (n = 14) overall scored VOICES a mean System Usability Scale (SUS) score of 86.6 (median = 88.8), higher than the benchmark SUS score of 68, indicating excellent ease of use. In addition, 93% stated that they would recommend the VOICES tool to others and 100% indicated understanding of VOICES' information and content.

CONCLUSION

Our findings show that older adults are capable, willing, and comfortable with using the innovative and self-administrated digital tool for elder mistreatment screening. Our future plan is to conduct a feasibility study to evaluate the use of VOICES in identifying suspicion of mistreatment.

Identifying patterns of health care utilisation among physical elder abuse victims using Medicare data and legally adjudicated cases: protocol for case-control study using data linkage and machine learning

INTRODUCTION

Physical elder abuse is common and has serious health consequences but is under-recognised and under-reported. As assessment by healthcare providers may represent the only contact outside family for many older adults, clinicians have a unique opportunity to identify suspected abuse and initiate intervention. Preliminary research suggests elder abuse victims may have different patterns of healthcare utilisation than other older adults, with increased rates of emergency department use, hospitalisation and nursing home placement. Little is known, however, about the patterns of this increased utilisation and associated costs. To help fill this gap, we describe here the protocol for a study exploring patterns of healthcare utilisation and associated costs for known physical elder abuse victims compared with non-victims.

METHODS AND ANALYSIS

We hypothesise that various aspects of healthcare utilisation are differentially affected by physical elder abuse victimisation, increasing ED/hospital utilisation and reducing outpatient/primary care utilisation. We will obtain Medicare claims data for a series of well-characterised, legally adjudicated cases of physical elder abuse to examine victims' healthcare utilisation before and after the date of abuse detection. We will also compare these physical elder abuse victims to a matched comparison group of non-victimised older adults using Medicare claims. We will use machine learning approaches to extend our ability to identify patterns suggestive of potential physical elder abuse exposure. Describing unique patterns and associated costs of healthcare utilisation among elder abuse victims may improve the ability of healthcare providers to identify and, ultimately, intervene and prevent victimisation.

ETHICS AND DISSEMINATION

This project has been reviewed and approved by the Weill Cornell Medicine Institutional Review Board, protocol #1807019417, with initial approval on 1 August 2018. We aim to disseminate our results in peer-reviewed journals at national and international conferences and among interested patient groups and the public.

Screening for elder mistreatment in emergency departments: current progress and recommendations for next steps

Emergency Department (ED) visits provide an important but seldom realized opportunity to identify elder mistreatment. Many screening tools exist, including several that are brief and may be effective, but few have been specifically designed for or tested in EDs. In addition to the absence of validated tools, other challenges with implementing ED elder mistreatment screening include difficulty integrating anything longer than a few questions into a busy clinical encounter and resources required to respond to positive screens. The Electronic Health Record (EHR) offers a critical tool to facilitate elder mistreatment screening through required data entry and real-time monitoring of compliance and results. We describe current work in the field and recommend next steps including design and testing of a two-step screening process, implementation research to accelerate adoption, development of ED-based interventions and referral protocols for positive cases, and consideration of the important role of pre-hospital providers in case identification.

Competências dos médicos no atendimento a idosos em situação de violência: revisão de escopo

Resumo Objetivo descrever, por meio das evidências da literatura, as competências dos médicos de serviços hospitalares diante de situações de violência contra a pessoa idosa (VCPI). Método revisão de escopo com busca em bases de dados/plataformas/buscadores e literatura cinzenta abrangendo Medline; BVS; Embase; CINAHL; Web of Science; BDTD, OpenGrey, OpenThesis, RCAAP, Portal de Teses e Dissertações da CAPES, DART-Europe E-theses Portal e Theses Canada Portal (catálogos Aurora e Voilà). Os descritores e palavras-chave utilizados, combinados com os operadores booleanos OR, AND e NOT, foram: “Physicians”, “Médicos”, “Atitude”, “Attitude”, “Conhecimento”, “Knowledge”, “Behavior”, “Atendimento Médico”, “Cuidados Médicos”, “Medical Care”, “Serviços Hospitalares”, “Hospital Services”, “Hospital”, “Hospitalists”, “Médicos Hospitalares”, “Maus-Tratos ao Idoso”, “Elder Abuse”, “Physical Abuse”, “Elder Neglect”, “Aged Abuse”, “Elder Mistreatment”. Resultados seis trabalhos foram selecionados. Evidenciou-se falta de conhecimento sobre o tema e a abordagem, e de treinamento específico. Quanto às habilidades, os achados que mais levaram os médicos a suspeitarem de abuso foram achados físicos ligados à aparência, higiene e lesões - problemas de comunicação e relacionamento foram pouco apontados. Na atitude houve pesquisa de abusos em apenas 44% das suspeitas e percentuais baixos ou nulos de denúncia de casos. Apenas um estudo explorou a atitude frente às negligências, onde 24,8% relataram aos serviços sociais e 21,3% informaram à polícia. Conclusão a maioria dos casos de VCPI continua não percebida e, consequentemente, não reportada ou manejada. Há múltiplos problemas quanto às competências dos médicos hospitalares ao abordarem tais situações, cenário que expõe a demanda por medidas de sensibilização, capacitação e incentivo ao adequado enfrentamento da VCPI.

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.

Developing the Emergency Department Elder Mistreatment Assessment Tool for Social Workers Using a Modified Delphi Technique

Elder mistreatment is common and has serious consequences. The emergency department (ED) may provide a unique opportunity to detect this mistreatment, with social workers often asked to take the lead in assessment and intervention. Despite this, social workers may feel ill-equipped to conduct assessments for potential mistreatment, due in part to a lack of education and training. As a result, the authors created the Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS) using a multiphase, modified Delphi technique with a national group of experts. This tool consists of both an initial and comprehensive component, with 11 and 17 items, respectively. To our knowledge, this represents the first elder abuse assessment tool for social workers designed specifically for use in the ED. The hope is that the ED-EMATS will increase the confidence of ED social workers in assessing for elder mistreatment and help ensure standardization between professionals.

Developing a rigorous, systematic methodology to identify and categorize elder mistreatment in criminal justice data

Elder mistreatment is complex, with cases typically requiring integrated responses from social services, medicine, civil law, and criminal justice. Only limited research exists describing elder mistreatment prosecution and its impact. Researchers have not yet examined administrative prosecutorial data to explore mistreatment response, and no standardized analytic approach exists. We developed a rigorous, systematic methodologic approach to identify elder mistreatment cases in prosecutorial data from cases of crimes against victims aged ≥60. To do so, we operationalized elements of the accepted definition of elder mistreatment, including expectation of trust and vulnerability. We also designed an approach to categorize elder mistreatment cases, using the types of charges filed, into: financial exploitation, physical abuse, sexual abuse, verbal/emotional/psychological abuse, and neglect. This standardized methodological approach to identify and categorize elder mistreatment cases in prosecution data is an important preliminary step in analyzing this potentially untapped source of useful information about mistreatment response.

Can artificial intelligence help identify elder abuse and neglect?

A health care encounter is a potentially critical opportunity to detect elder abuse and initiate intervention. Unfortunately, health care providers currently very seldom identify elder abuse. Through development of advanced data analytics techniques such as machine learning, artificial intelligence has the potential to dramatically improve elder abuse identification in health care settings.

Maltrato a las personas mayores: una revisión narrativa

El maltrato a las personas mayores es un tema de interés creciente, tanto así que se considera un problema de salud pública. Hay particularidades que hacen del entorno colombiano un ambiente propicio para generar situaciones de maltrato: la exposición a la “violencia a gran escala”, la diferencia de género y el cambio de la pirámide poblacional. Según el estudio SABE Colombia, el 12,9 % de las personas mayores informó haber sufrido maltrato, del cual el más común es el psicológico, seguido por el físico, el financiero y el sexual. A pesar de que el Estado reconoce al adulto mayor como “sujeto de especial protección”, aún hay desconocimiento por parte de los profesionales de la salud a la hora de enfrentar estos casos. Este debería ser un tema de obligatoriedad moral, por lo que se debe abordar a profundidad para así identificarlo oportunamente y proponer estrategias de prevención de una manera contextualizada. Esta revisión de la literatura tiene por objetivos sintetizar la información epidemiológica disponible, los factores de riesgo y las estrategias de evaluación y plantear las rutas de atención idóneas asentadas en los aspectos legales alrededor del maltrato hacia los ancianos en Colombia.