Improving Quality of Care in Hospitals for Victims of Elder Mistreatment: Development of the Vulnerable Elder Protection Team

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.

Emergency department and hospital-based programs responding to elder mistreatment: developing consensus about an idea whose time has come

Elder mistreatment is common, serious, and under-recognized, with Emergency Department and hospital clinical encounters offering a potential but currently unrealized opportunity to identify and help older adults experiencing mistreatment. Interdisciplinary emergency department and hospital-based response teams represent a promising care model to address this. This manuscript describes two such teams and introduces a special issue dedicated to this work.

Strategies for dissemination of ED/hospital elder mistreatment response team model

Interdisciplinary Emergency Department/hospital-based teams represent a promising care model to improve identification of and intervention for elder mistreatment. Two institutions, Weill Cornell Medicine/NewYork-Presbyterian Hospital and the University of Colorado Anschutz Medical Campus have launched such programs and are exploring multiple strategies for effective dissemination. These strategies include: (1) program evaluation research, (2) framing as a new model of geriatric care, (3) understanding the existing incentives of health systems, EDs, and hospitals to align with them, (4) connecting to ongoing ED/hospital initiatives, (5) identifying and collaborating with communities with strong elder mistreatment response that want to integrate the ED/hospital, (6) developing and making easily accessible high-quality, comprehensive protocols and training materials, (7) offering technical assistance and support, (8) communications outreach to raise awareness, and (9) using an existing framework to inform implementation in new hospitals and health systems.

Enhancing healthcare access for an older population: The age-friendly emergency department

Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.

Factors associated with elder abuse and neglect in rural Uganda: A cross-sectional study of community older adults attending an outpatient clinic

BACKGROUND

Elderlies are vulnerable to abuse, and evidence suggests that one in three elderlies experience abuse. Abuse can impact the well-being of older persons, decreasing their quality of life, leading to mental health challenges, and increasing morbidity and mortality rates. Evidence on older person/elder abuse and neglect is vital to facilitate initiatives, but there are fewer studies on elder abuse and neglect in Africa, particularly in Uganda. Thus, this study aimed to determine the prevalence of different types of abuse and neglect, and their associated factors among older persons (aged 60 years and above) attending an outpatient clinic.

METHODS

In this cross-sectional study, information on sociodemographic characteristics, functional impairment using the Barthel Index, and elder abuse severity using the Hwalek-Sengstock Elder Abuse Screening Test were collected. In addition, types of abuse were assessed using questions adapted from the US National Research Council on elder mistreatment monograph. Linear and logistic regression analyses were used to determine the factors associated with elder abuse severity and the different types of abuse, respectively.

RESULTS

Overall, the prevalence of elder abuse was 89.0%. Neglect was the most common type of elder abuse (86%), followed by emotional abuse (49%), financial abuse (46.8%), physical mistreatment (25%), and sexual abuse (6.8%). About 30.4% of the abused elders experienced at least two forms of abuse. Factors associated with elder abuse severity were having a secondary level of education and physical impairment. Moderate to severe functional dependence was associated with almost all forms of abuse. Individuals who reported the presence of a perpetrator were likely to experience neglect, emotional, and physical mistreatment. However, those who reported their perpetrators to the police had a higher likelihood of experiencing emotional abuse but were less likely to experience financial abuse. Emotional abuse was also associated with age above 80 years and attaining education (primary and secondary). Physical impairment and chronic medical conditions reduced the likelihood of experiencing neglect and financial abuse, and physical abuse, respectively.

CONCLUSIONS

Uganda has a high prevalence of elder abuse and neglect. There is a need to design interventions for older adults at risk to prevent elder abuse from escalating further, where the present findings can be worthy of help.

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.

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.

Reliability of the longitudinal experts all data (LEAD) methodology for determining the presence of elder mistreatment

Developing reliable screening tools to identify elder mistreatment requires an accurate and reproducible reference standard. This study sought to investigate the reliability of the Longitudinal, Experts, All Data (LEAD) methodology as a reference standard in confirming presence of elder mistreatment. We analyzed data from a large, emergency department-based study that used a LEAD panel to determine the reference standard. For this study, a second, blinded LEAD panel reviewed clinical material for 40 patients. For each panel, five content experts voted on whether elder mistreatment was present. We found moderate agreement between the two LEAD panels in determining presence of elder mistreatment: 85% agreement; k = 0.58; 95% Confidence Interval 0.28-0.87. Individual raters for both LEAD panels reported being mostly certain or certain >90% of votes. Efforts to further characterize and improve the reliability of the LEAD methodology in this context are warranted.

Factors influencing intention to intervene in elder abuse among nursing students

Purpose

This study aimed to identify the factors influencing the intention to intervene in elder abuse among nursing students.

Methods

A descriptive survey design was used, and questionnaires were completed by 182 nursing students. Statistical analysis was performed on the data collected, using SPSS 25.0, χ²-test, t-test, correlation, and regression analysis to confirm predictors of intention to intervene in elder abuse.

Results

Awareness of abuse, legal and institutional knowledge, and attitude were positively correlated with the intention to intervene in elder abuse. Factors influencing the intention to intervene by nursing students were education courses about elder abuse, awareness of elder abuse, legal and institutional knowledge, and attitude.

Conclusion

The findings suggest that it is necessary to provide educational protocols for nursing students to improve their awareness and knowledge of elder abuse. Based on the findings of this study, there is a need for specific education programs and guidelines to increase the assessment of, and intervention in, elder abuse.

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.

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.

Bringing Advances in Elder Abuse Research Methodology and Theory to Evaluation of Interventions

The elder abuse field needs high-quality intervention research to assess the best strategies to combat the problem, but few such studies exist. Significant advances have been made in elder abuse research methodology, measurement, justice theory, and other relevant areas, which may remedy this gap. Particular advances include the use of elder abuse severity measures and goal attainment scaling, and the application of restorative justice theory to intervention. Elder abuse research also may benefit from advances in biomedical clinical trial methodology, including characterizing and following up with subjects excluded from trials or those who drop out, estimating numbers needed to treat to assess cost-effectiveness, and a priori stopping rules for when an intervention proves quickly beneficial or harmful. In this article, we argue these advances can and should inform elder abuse intervention research, propose a theoretical framework to guide such efforts, and demonstrate how this framework can inform practice, using elder abuse multidisciplinary teams and nursing home shelters as examples.

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.

Effects of the COVID-19 Outbreak on Elder Mistreatment and Response in New York City: Initial Lessons

New York City is currently experiencing an outbreak of COVID-19, a highly contagious and potentially deadly virus, which is particularly dangerous for older adults. This pandemic has led to public health policies including social distancing and stay-at-home orders. We explore here the impact of this unique crisis on victims of elder mistreatment and people at risk of victimization. The COVID-19 outbreak has also had a profound impact on the organizations from many sectors that typically respond to protect and serve victims of elder mistreatment. We examine this impact and describe creative solutions developed by these organizations and initial lessons learned in New York City to help inform other communities facing this pandemic and provide guidance for future crises.

Violence In Older Adults: Scope, Impact, Challenges, And Strategies For Prevention

Although often perceived to be a problem of the young, violence commonly affects older adults, a rapidly growing segment of the population. Violence can be directed toward older adults (elder abuse and intimate partner violence), self-directed (suicide), or perpetrated by older adults against others (intimate partner violence and violence in dementia). Across forms of violence, firearm access increases lethality, and veterans may be a particularly high-risk population. The forms of violence in older adults have some common risk factors (such as medical or psychiatric illness) and common challenges for prevention (such as balancing autonomy and well-being in vulnerable adults). The integration of prevention strategies across the life span, disciplines, and forms of violence offers promise for promoting older adult health and well-being. Looking forward, key areas for attention will include raising awareness about these topics and prioritizing funding for the implementation and evaluation of violence prevention interventions in health care settings and the community.

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

Elder abuse and neglect are common and may have serious medical and social consequences but are infrequently identified. An emergency department (ED) visit represents a unique but usually missed opportunity to identify potential abuse and initiate intervention. ED assessment should include observation of patient-caregiver interaction, comprehensive medical history, and head-to-toe physical examination. Formal screening protocols may also be useful. ED providers concerned about elder abuse or neglect should document their findings in detail. ED interventions for suspected or confirmed elder abuse or neglect include treatment of acute medical, traumatic, and psychological issues; ensuring patient safety; and reporting to the authorities.