Towards the development of a screening tool to enhance the detection of elder abuse and neglect by emergency medical technicians (EMTs): a qualitative study

Developing a model for providing feedback to reporters of elder abuse

Lack of feedback about reports made to Adult Protective Services (APS) is an important barrier to elder mistreatment reporting. To better understand barriers and facilitators to APS-reporter communication, we conducted an environmental scan of state policies and practices. We gathered publicly available information from 52 states and territories on APS administrative structure, reporting, intake, investigation, and feedback processes; performed a secondary analysis of focus groups with Emergency Medical Services providers and APS staff; and interviewed 44 APS leaders in 24 states/territories. Results revealed variation in information-sharing with reporters. Qualitative analyses revealed three overarching themes related to whether, when, and how information is shared. Results were used to develop a model illustrating factors influencing APS decisions on sharing information. This model incorporates the type of reporter (professional or nonprofessional), their relationship with the APS client (brief or ongoing), and the potential risks and benefits of sharing information with the reporter.

"Older people are weak": perceptions and meanings of ageing and abuse against older people

Introduction

This paper addresses the broader issue of elder abuse and seeks to analyse how victims and non-victims of abuse connect and explain the perception of ageing and the phenomenon of violence against older people.

Methods

A qualitative study was conducted based on evidence gathered through 45 semi-structured interviews with people aged 60 or above who are part of the Portuguese EPIPorto population cohort. The interviews were analysed using grounded theory.

Results/discussion

The results show that respondents link the ageist narratives that exist in our societies to the prevalence and naturalisation of violence against older people, that the risk of abuse increases with the weakening of family support networks, and that abuse is both a manifestation of asymmetrical power relations between victims and perpetrators and a severe violation of human rights. The findings also highlight the need to broaden the concept of violence against older people to include offences in the public sphere and not just in the context of the family and institutions.

Global Approaches to Primary, Secondary, and Tertiary Elder Abuse Prevention: A Scoping Review

Public health professionals use a three-pronged approach to address broad-reaching issues of societal concern: primary prevention, secondary prevention, and tertiary prevention. Applying this framework to the study of elder abuse, the purpose of this review is to describe the status of elder abuse prevention research on a global scale. Elder abuse prevention articles published between 2015 and 2021 were identified through electronic bibliographic searches (PubMed, Medline, CINAHL, APA PsycINFO, and AgeLine). After removing articles based on inclusion and exclusion criteria, articles were sorted into the three main prevention types and further divided into subcategories for a more in-depth review. Most of the studies identified were conducted in North America (n = 42). Of the 72 articles identified, 13 articles focused on primary prevention (agism, education, and intervention), 35 articles focused on secondary prevention (developing and evaluating screening tools, identifying and reporting abuse, and barriers to detecting and reporting abuse), and 21 focused on tertiary prevention (professional response to cases of abuse, intervention methods, and impact of policy). Collectively, findings bring greater understanding of elder abuse as a public health problem and identify ways of addressing the complexities of elder abuse. Several gaps were identified in the elder abuse prevention literature including the need for global research that includes older adults as stakeholders, evidence-based education and intervention programs, and cultural sensitive and valid tools to identify elder abuse.

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.

The Chronic Health Effects of Work-Related Stressors Experienced by Police Communications Workers

Background

Law enforcement communications (i.e., 911 dispatch and call takers) is a challenging and stressful occupation. The purpose of this study is to identify the main stressors associated with employment in law enforcement communications, and to identify and provide context to how these stressors affect workers' health and wellbeing.

Methods

This research study included focus groups with 23 call takers and 911 dispatchers employed by a large, urban law enforcement agency in 2018. Thematic analyses were conducted to identify trends.

Results

Four themes of stressors emerged (i.e., the high stakes nature of some 911 calls for service, understaffing, supervisor-related stress, and recruiting practice). Two health-related themes emerged as being occupation-related: weight gain and poor sleep patterns/insufficient sleep). Specifically, participants reported negative eating habits resulting in weight gain and obesity, lack of sleep and irregular sleep schedules, and development of hypertension and/or diabetes since beginning their jobs.

Conclusion

Law enforcement communications professionals experience a number of the same stressors facing law enforcement officers in patrol. These stressors, combined with the sedentary nature of the job, could result in long-term, chronic health problems.

Identification of Elder Abuse through Out-of-Hospital Emergency Care Providers

BACKGROUND AND PURPOSE

Elder abuse, neglect, and exploitation are under-detected and under-reported. The purpose of this qualitative study was to describe out-ofhospital emergency care providers' experiences of identifying elder abuse.

METHODS

Individual theme interviews were conducted with nine prehospital emergency care providers and three community paramedics in spring 2019. The transcribed data were analyzed using inductive content analysis.

RESULTS

Although the short duration of care contacts made the identification of elder abuse challenging, the emergency care providers detected indicators of physical, psychological and social abuse, unethical action, material exploitation, and self-neglect/self-abuse. The professionals based their observations on patient and family interviews, on clues in the home environment, on caregiving quality combined with the patient's medical history, and on physical signs, which were the easiest to identify.

IMPLICATIONS FOR PRACTICE

The identification of elder abuse may be improved by multiprofessional collaboration, by increased attention given to risk groups and common indicators of abuse, and by adoption or creation of screening tools to assist detection and reporting. Training on the detection of elder abuse should be included in nursing and social work curricula and in the continuing professional development of emergency care providers.

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.

Validation of the detection of elder abuse through emergency care technicians (DETECT) screening tool: a study protocol

INTRODUCTION

Elder mistreatment (EM) is a high prevalence threat to the health and well-being of older adults in the USA. Medics are well-positioned to help with identification of older adults at risk for EM, however, field robust screening tools appropriate for efficient, observation-based screening are lacking. Prior work by this team focused on the development and initial pilot testing of an observation-based EM screening tool named detection of elder abuse through emergency care technicians (DETECT), designed to be implemented by medics during the course of an emergency response (911) call. The objective of the present work is to validate and further refine this tool in preparation for clinical dissemination.

METHODS AND ANALYSIS

Approximately 59 400 community-dwelling older adults who place 911 calls during the 36-month study observation period will be screened by medics responding to the call using the DETECT tool. Next, a random subsample of 2520 of the 59 400 older adults screened will be selected to participate in a follow-up interview approximately 2 weeks following the completion of the screening. Follow-up interviews will consist of a medic-led semistructured interview designed to assess the older adult's likelihood of abuse exposure, physical/mental health status, cognitive functioning, and to systematically evaluate the quality and condition of their physical and social living environment. The data from 25% (n=648) of these follow-up interviews will be presented to a longitudinal, experts and all data panel for a final determination of EM exposure status, representing the closest proxy to a 'gold standard' measure available.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Committee for the Protection of Human Subjects at the University of Texas School of Public Health. The results will be disseminated through formal presentations at local, national and international conferences and through publication in peer-reviewed scientific journals.

The geriatric emergency literature 2019

Geriatric Emergency Medicine is an important frontier for study and innovation by emergency practitioners. The rapid growth of this patient population combined with complex medical and social needs has prompted research ranging from which tests and screening tools are most effective for geriatric evaluation to how we can safely manage pain in the elderly or address goals of care in the Emergency Department. This review summarizes emergency medicine articles focused on the older patient population published in 2019, which the authors consider critical to the practice of geriatric emergency medicine.

Evaluation of the Detection of Elder Mistreatment Through Emergency Care Technicians Project Screening Tool

IMPORTANCE

Elder mistreatment is underdetected and underreported. The more than 800 000 medics providing services in every county in the United States represent an important and underused surveillance system.

OBJECTIVE

To investigate the association between the Detection of Elder Mistreatment Through Emergency Care Technician (DETECT) screening tool use and the number of medic reports made to Adult Protective Services (APS) over a period of approximately 3 years.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a difference in difference in differences design and included adults aged 65 years and older who were reported to Texas APS in the study region (246 cities in Denton, Johnson, and Tarrant Counties) between December 31, 2014, and February 28, 2018.

EXPOSURES

The DETECT screening tool.

MAIN OUTCOMES AND MEASURES

Reports to APS.

RESULTS

The mean (SD) age of the 11 178 older adults included in this study was 76 (8) years (range, 65-105 years); there was no reported data on patient sex. A total of 18 080 reports of elder mistreatment were recorded. Medics within the study region reported more cases of elder mistreatment during the implementation of the screening tool (relative risk [RR], 4.14; 95% CI, 3.25-5.27). After adjusting for changes in the number of elder mistreatment reports in the comparison groups (ie, underlying changes in reporting trends), the number of reports to APS increased (RR, 3.03; 95% CI, 2.06-4.46). The occurrence of elder mistreatment was validated in 83% (95% CI, 75%-91%) of the reports investigated by APS during the periods when medics did not have access to the screening tool compared with 82% (95% CI, 77%-87%) during the periods when medics had access to the screening tool, indicating that there were no differences in the proportion of reports that resulted in a validated APS investigation.

CONCLUSIONS AND RELEVANCE

The findings suggest that incorporating the DETECT screening tool into the routine practices of medics is associated with substantial increases in the frequency with which clinicians report potential cases of elder mistreatment to APS.

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.

Pilot testing the detection of elder abuse through emergency care technicians (DETECT) screening tool: results from the DETECT pilot project

OBJECTIVE

To pilot test the feasibility of implementing an elder abuse (EA) screening tool (DETECT) designed for medics.

METHODS

Testing occurred between September 17th, 2015 and October 26th, 2015. MedStar Mobile Healthcare medics completed the DETECT tool when responding to calls for community-dwelling patients 65 years of age or older.

RESULTS

The DETECT tool was used 1,248 times by 97% of medics responding to an eligible 911 call. Medics responded affirmatively to at least one screening item on 209 of the completed screenings (16.8%). Immediately following the introduction of the DETECT tool, there was an increase of 5.4 (226% above baseline) reports per month (p = 0.0056).

CONCLUSIONS

The DETECT tool was easily incorporated into medic's field-based practice and resulted in an increase in medic generated reports of EA to APS. Future research designed to evaluate the tool's validity and reliability are warranted.

Elder neglect-Oral diseases and injuries

Elder neglect (EN) is the failure of a designated caregiver to meet the needs of a dependent older person. World EN prevalence, meta-analyzed in this study, is 1.0% or 1.8% according to different statistical methods. Referring alleged EN cases to Adult Protective Services (APSs) by healthcare workers (HCWs) is mandatory in many countries. However, only few claims are substantiated, as EN could be confused with Self-Neglect, and neglect could be unintentional or due to caregiver unawareness. Screening tools are inaccurate, and their use is discouraged by public health organizations, because they lead to too many false positives, which engulf the already overwhelmed APSs. HCWs need effective tools with objective judgments, which do not hamper the HCW-caregiver-patient rapport and prevent lawsuits when allegations are unfounded. Orofacial EN manifestations (poor oral/denture hygiene, lack of needed/improper dentures, dry mouth, skin/mucosal rashes) are essential Forensic Markers of EN. I classified EN-associated oral diseases according to the unmet needs into four groups: (1) traumatic injuries due to lack of caregiver vigilance (e.g., maxillofacial fractures); (2) diseases due to oral hygiene deficiency (e.g., root caries); (3) diseases typical of the elderly with late/no diagnosis (e.g., oral cancer); and (4) diseases typical of the elderly exacerbated by psychological distress (e.g., oral lichen planus).