It is estimated that 5% to 10% of older adults in the United States suffer from abuse, neglect, or exploitation and this mistreatment cost patients, their families, and the healthcare system billions of dollars annually. “Unfortunately, failure to identify elder abuse is common,” says Tony Rosen, MD, MPH. “Some research suggests that just one in 24 cases are ever reported to the proper authorities.” Delays in detection and intervention can contribute to abuse-related morbidity and mortality.
According to Dr. Rosen, ED visits provide a unique opportunity to identify elder abuse. Medical assessment for injury or illness may be the only time a victimized older adult leaves their home. “The potential to spot elder abuse in the ED may be higher than that of other healthcare settings because these visits are typically unplanned,” he says. This can leave perpetrators and victims little or no time to align histories or suppress evidence of abuse. Also, the typical ED visit is prolonged with many providers able to observe, examine, and interact with a patient.
Over the last several decades, EDs have become critical sites for detecting child abuse. ED physicians and emergency personnel now receive comprehensive training in identifying child abuse, but the same has not happened yet for elder abuse. “Despite its prevalence and the potential value of identifying elder abuse in the ED, emergency providers often miss it for many reasons,” says Dr. Rosen (Table).
In Annals of Emergency Medicine, Dr. Rosen and colleagues described strategies to improve the identification of elder abuse by ED personnel. “We should leverage the unique potential of EMS providers, triage providers, nurses, radiologists, radiology technicians, social workers, and case managers to contribute,” says Dr. Rosen. “EMS personnel can be especially helpful because they often examine the home and collect important information about the overall safety of the environment and any evidence of abuse.”
In the ED, victims may have difficulty reporting that they are being abused or asking for help, particularly if the abuser is also present. “To better identify elder abuse, communication about any suspicions should be encouraged from nurses and any other employees who interact with patients,” says Dr. Rosen. Training ED personnel on signs of elder abuse has the potential to facilitate early detection. It may also be beneficial to assess patients’ social support systems.
Unfortunately, there are currently no tools designed to screen specifically for elder abuse in the ED setting. “A brief, accurate screening protocol to assess all older adults for abuse would be valuable, but currently there is no such tool for ED personnel,” Dr. Rosen says. “Researchers are actively working to develop screening tools and determine the best place to conduct these screens.”
A Team-Based Approach to Intervention
According to Dr. Rosen, a multidisciplinary team-based approach in the ED may also potentially improve interventions once elder abuse is identified. In most states, healthcare teams are mandated to report elder abuse if they know or reasonably suspect that it has occurred. Adult Protective Services receive and investigate elder abuse reports, but they typically cannot become involved while patients are hospitalized. In many parts of the U.S., funding is insufficient to enable them to provide comprehensive services. Furthermore, response times from Adult Protective Services are often slow.
“There is an important opportunity for ED-based teams to help these vulnerable patients,” says Dr. Rosen. ED-initiated interventions may be particularly valuable for dependent older adults whose care is suboptimal but does not meet criteria for Adult Protective Services to intervene. “Developing a multidisciplinary approach—similar to what is used for victims of child abuse—and measuring its efficacy and impact is an important future step in improving care for these victims,” adds Dr. Rosen.
Currently, published studies on elder abuse identification and intervention in the ED are lacking. “Efforts are needed to develop evidence-based approaches that aim to optimize screening and interventions for elder abuse,” Dr. Rosen says. There have been recent signs that this issue is becoming a greater priority for policymakers, with groups such as NIH, the White House, and others highlighting elder justice and increasing funding.
For any program to be sustainable, payment mechanisms are needed to support the considerable amount of additional work that is involved in evaluating and treating patients vulnerable to elder abuse. Dr. Rosen and colleagues note in their article that there is hope that funding will come from partnerships with insurance companies, accountable care organizations, and other groups so that EDs can be more proactive about reducing the burden of elder abuse.
Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying elder abuse in the emergency department: toward a multidisciplinary team-based approach. Ann Emerg Med. 2016 Mar 18 [Epub ahead of print]. Available at: http://www.annemergmed.com/article/S0196-0644(16)00088-3/fulltext.
Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373:1947-1956.
National Institute on Aging. NIH workshop: multiple approaches to understanding and preventing elder abuse 2015. Available at: https://www.nia.nih.gov/about/events/2015/nih-workshop-multipleapproaches-understanding-and-preventing-elder-abuse.