Take a Multidisciplinary, Team-based Approach on Elder Abuse
Experts say elder abuse is not only common, it is also linked with adverse outcomes among victims, costing the country billions of dollars every year. Despite the scope of the problem, signs of elder abuse often go unreported and unrecognized. That’s understandable, given that it can be difficult to discern between abuse and various disease processes that occur in older adults.
Nonetheless, new research suggests there is ample room for improvement in the way elder abuse is identified and managed, and as with so many other issues, the emergency setting offers perhaps the best opportunity to identify elder abuse and begin to remedy a situation in which an elder person is unsafe at home.
Why do staff often miss signs of elder abuse in the emergency setting? There are multiple contributing factors, according to Anthony Rosen, MD, MPH, an emergency physician at New York-Presbyterian Weill Cornell Medical Center.
“There are disincentives to evaluate this. [Emergency providers] are busy, and we realize that if we do identify this, then suddenly we’ve got a whole set of things that we have to deal with,” he explains. “In addition, physicians [often] aren’t educated on this, aren’t comfortable assessing for it, or aren’t comfortable with what they would do if they found something to be positive.”
Rosen, who specializes in geriatric emergency medicine, adds that while physicians may feel ethically and morally obligated to report signs of potential elder abuse, they are much less confident in assessing for this issue.
“If you are assessing a patient in a hallway, assessing a patient very briefly, or assessing a patient with the perpetrator standing right next to the patient, you are not likely to find it,” he says.
Further complicating the assessment process is the fact that it is often difficult for the at-risk patient to be interviewed alone without the presence of a caregiver, and it can be inconvenient to conduct an exam without a caregiver present, Rosen says.
“In addition, patients themselves may have significant incentives not to tell us the truth,” he says. “Particularly for older patients, the caregiver is providing them care; even if [he or she] is also abusing them or neglecting them, this person is also providing them care, and there is a significant concern among many patients ... that this caregiver will abandon them and they might go to a nursing home or there will be another very concerning outcome for them.”
Add to these challenges the reality that some of these older patients have dementing illnesses that may make it difficult for them to report neglectful or abusive behavior.
“Even if they do report it, the provider may not be sure that the report is accurate because of the dementing illness, and so the provider will doubt the story,” Rosen notes. “The fact the caregiver is more easily able to offer information may incline the physician to trust the perpetrator.”
In other instances, the older adult may not suffer from cognitive impairment, but he or she may speak a different language, complicating the reporting process.
“The translator may be the caregiver at the bedside who may also be the perpetrator, and so we may not take the time to use a translator to speak to the patient alone,” Rosen explains.
Providing great care to a victim of elder abuse requires time and setting up a circumstance whereby one can actually communicate with the patient reliably and alone, Rosen says.
“In addition, it takes time to then do follow-up, whether that means connecting with a social worker, connecting with adult protective services [APS], or connecting with the police,” he explains. “If you find something, you are likely to have created additional work for yourself.”
While most states require providers to report suspected cases of elder abuse to APS, there is little evidence that this requirement has incentivized more reports in the same way a similar requirement has prompted providers to report cases of suspected child abuse.
Rosen acknowledges providers may well be concerned about negative consequences if a suspected case turns out not to be elder abuse at all. But he also observes that providers apparently feel very differently about child abuse.
“With suspected child abuse, providers would much rather identify a case and have someone else tell them later that it was not child abuse than let a questionable case go home,” Rosen notes. “We have decided as a society that we would rather be sensitive than specific with child abuse.”
However, providers have not made the same calculation with respect to elder abuse, Rosen says.
“Because we are only finding one in every 24 cases, the pendulum needs to swing more toward overdetection,” he says. “Right now, we are dramatically underdetecting.”
Rosen acknowledges that it is often much more difficult to detect signs of elder abuse than child abuse, for which there is a large base of literature documenting that certain injury patterns are almost unequivocal red flags. He notes older adults are more likely to bruise because of blood thinning medications, and they are more likely to present with fractures due to diseases such as osteoporosis or medications that can cause bone thinning.
To get around some of these issues, Rosen and colleagues are working to identify injury patterns that are consistent with elder abuse so that providers have more tools to work with in identifying a problem that can be very difficult to confirm.
Rosen also advocates for a multidisciplinary, team-based approach to identify elder abuse in the ED, and he is working with colleagues to establish such a team in his own setting.1
“Every person can have a role, and every set of eyes is worth training to have focused on this issue because [elder abuse] is worth finding, and it is really hard to find,” he explains. “Training every member of the team and empowering every member of the team is important.”
For example, Rosen notes that in many EDs the radiology suite is the only area in which a patient is free to discuss sensitive issues without input or influence from others. Consequently, an observant radiology tech could prompt a discussion with the patient about the source of an injury or the patient’s safety at home.
“People don’t go into the radiology suite with their spouse or their daughter or their mother, so the radiology suite is truly a zone of privacy,” Rosen says. “In an emergency practice, it is the only place where you are guaranteed to have the patient alone.”
Further, Rosen suggests that EMS providers offer a key perspective, given they have actually seen the patient in his or her home setting, but the other members of the team have to be open to receiving and acting on the information.
“In my own clinical experience, one of the real challenges is making sure that the information that EMS learns — a lot of which is gold, some of which relates to elder abuse, and some of which relates to all kinds of different things that are important to knowing how to care for the patient — does not get lost in the EMS/ED interface,” he explains. “That is a ripe area for improvement.”
In fact, Rosen notes that he and colleagues working on this issue find EMS workers are often frustrated that their reports about situations in a patient’s home are ignored or discounted, he explains. For instance, when EMS providers bring to the ED an elderly patient who has suffered a fracture from a fall, they may inform a social worker and the emergency medical team that there is a fall risk in the home.
“A week later they are called back to the same place for the same patient for the same problem,” Rosen explains. “They get a lot of feedback that their information is not getting passed on.”
To encourage such reporting, emergency providers need to recognize the critical information that EMS provides, Rosen stresses.
“Make sure to seek it and act on it,” he says. “EMS has a critical role here. They can open up the refrigerator, look at the pill bottles ... and notice an unusual interaction in the home.”
Marguerite DeLiema, PhD, a postdoctoral researcher at the Stanford University Center on Longevity, agrees that prehospital providers can play a critical role in giving emergency providers a clearer picture of what is actually happening with an older patient. She has reported on how physical signs or symptoms can easily be misinterpreted.2
“The real story is in the home and in the interactions between the caregiver and the patient,” she explains. “That will give you so much more information on whether a patient is a victim of criminal negligence or whether [the caregivers] are just struggling and can’t meet the needs of an older person even though they are doing the best they can.”
Paramedics are in a prime position to know where the older person is living in comparison to other family members and whether the environment is clean and safe. Unlike with social workers’ planned visits, for example, there is little chance for the environment to be staged by a caregiver or perpetrator of elder abuse, Rosen notes.
Another benefit of the multidisciplinary team approach is that it provides opportunities for clinicians to expand on their command of the issue.
“Physicians can learn a lot by working with a geriatrician who identifies the signs [of elder abuse] or working with a social worker who understands more of the nuanced social side of caregiving and why some people might show up in the ED looking the way they do,” DeLiema says. “It brings the issue [of elder abuse] more on their radar screen ... and informs the physician’s decision about what is a safe place for the patient moving on.”
DeLiema would like to find a way for emergency providers to interact more with APS, but she observes that resources are strained.
“Funding [to APS] has not kept pace with the growth of the older adult population, and there is a lot of turnover in those agencies and a lack of follow-up,” she explains.
Another concern is that in cases of suspected elder abuse or neglect in which older adults have maintained their cognitive capacity, they have the right to refuse APS services.
“A lot of times we see these older adults being brought in by a caregiver, and the older adults will defend their caregiver no matter what,” DeLiema says. “They would rather live in an acknowledged abusive situation than face the risk of maybe being moved into a nursing home or assisted living facility, or having anything bad like an arrest happen to their caregiver ... so APS has its hands tied in a lot of situations, and providers know that.”
Even in cases in which an older adult refuses services, however, it is important for emergency providers to note their concerns.
“Keep really accurate documentation so that if law enforcement or APS needs these records they can subpoena them ... if the case goes to court,” DeLiema explains. “It really is the emergency providers who might be the first providers that these patients see. They are on the front lines.”
While it’s clear that elder abuse is significantly underreported, Rosen believes this is an area that emergency providers can improve. In fact, he likens the state of affairs on this issue to the way things used to be with respect to intimate partner violence (IPV).
“One of my mentors told me that 20 or 30 years ago, emergency providers didn’t even ask about intimate partner violence or spousal abuse. They had nothing to offer the victims, so it [apparently] wasn’t even worth knowing about,” he explains.
While emergency providers generally don’t feel this way about IPV anymore, Rosen suspects providers now may be reluctant to identify elder abuse, feeling they don’t have the resources, time, or expertise to address it.
Rosen has received feedback on his elder abuse research from emergency providers, telling him that without money or resources, emergency providers should not be expected to address yet another social problem.
“That is a reasonable perspective,” Rosen offers. However, he and his research colleagues offer a different perspective. “We make the argument that [elder abuse] is medical, and that the ED is the ideal place to evaluate for it.”
There is no question that large, academic medical centers such as New York-Presbyterian Weill Cornell Medical Center often are better equipped to take on the issue than small community hospitals.
“We have a social worker available 24/7 in our ED, but many of my colleagues and former residents don’t have that luxury and it changes the dynamics of what you are able to do,” Rosen explains.
To get around such barriers, Rosen and colleagues are making a business case for developing incentives that would encourage providers to take on elder abuse.
“You could certainly imagine settings in which payers would be interested in reducing all the associated medical costs, which are thought to be in the billions of dollars,” Rosen says. “This is worth finding.”
DeLiema agrees, but observes there is too little evidence that medical providers are stepping up to the plate.
“This is a big concern, but only lip service is being paid to detecting elder abuse, and not just in the ED, but for many different providers,” she says.
What can providers do to improve their recognition and management of elder abuse? Rosen notes that resources are available nationally and locally. In particular, he suggests emergency providers reach out to the National Center on Elder Abuse (http://www.ncea.aoa.gov/). Further, he encourages EDs to find and connect with groups targeting this issue in their local communities.
“Most of these local task forces or teams are desperate for physician input and physician communication,” he says. Another source is Geri-EM, a website (http://geri-em.com/) that offers training and a range of information on caring for the older adult.
Additionally, Rosen and colleagues are preparing some training resources on elder abuse designed specifically for emergency providers. Rosen notes that providers should feel free to reach out to him if they are interested in obtaining these materials or if they have any questions about how to move forward on this issue in their own settings.
- Rosen T, Hargarten S, Flomenbaum N, et al. Identifying elder abuse in the emergency department: Toward a multidisciplinary team-based approach. Ann Emerg Med 2016 Mar [Epub ahead of print].
- DeLiema M, Homeier D, Anglin D, et al. The forensic lens: Bringing elder neglect into focus in the emergency department. Ann Emerg Med 2016 Mar [Epub ahead of print].
New research suggests there is ample room for improvement in the way elder abuse is identified and managed, particularly in the emergency setting.
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