Elizabeth M. Bloemen

Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse

BACKGROUND Elder abuse is under-recognized by emergency department (ED) providers, largely due to challenges distinguishing between abuse and accidental trauma. OBJECTIVE To describe patterns and circumstances surrounding elder abuse-related and potentially abuse-related injuries in ED patients independently known to be physical elder abuse victims. METHODS ED utilization of community-dwelling victims of physical elder abuse in New Haven, CT from 1981-1994 was analyzed previously. Cases were identified using Elderly Protective Services data matched to ED records. Sixty-six ED visits were judged to have high probability of being related to elder abuse and 244 were of indeterminate probability. We re-examined these visits to assess whether they occurred due to injury. We identified and analyzed in detail 31 injury-associated ED visits from 26 patients with high probability of being related to elder abuse and 108 visits from 57 patients with intermediate probability and accidental injury. RESULTS Abuse-related injuries were most common on upper extremities (45% of visits) and lower extremities (32%), with injuries on head or neck noted in 13 visits (42%). Bruising was observed in 39% of visits, most commonly on upper extremities. Forty-two percent of purportedly accidental injuries had suspicious characteristics, with the most common suspicious circumstance being injury occurring more than 1 day prior to presentation, and the most common suspicious injury pattern being maxillofacial injuries. CONCLUSION Victims of physical elder abuse commonly have injuries on the upper extremities, head, and neck. Suspicious circumstances and injury patterns may be identified and are commonly present when victims of physical elder abuse present with purportedly accidental injuries.

Narratives of Self‐Neglect: Patterns of Traumatic Personal Experiences and Maladaptive Behaviors in Cognitively Intact Older Adults

To identify patterns of personal experience or behavior in self‐neglect by exploring narratives of cognitively intact older adults.

Emergency Medical Services Perspectives on Identifying and Reporting Victims of Elder Abuse, Neglect, and Self-Neglect

BACKGROUND Emergency Medical Services (EMS) providers, who perform initial assessments of ill and injured patients, often in a patients home, are uniquely positioned to identify potential victims of elder abuse, neglect, or self-neglect. Despite this, few organized programs exist to ensure that EMS concerns are communicated to or further investigated by other health care providers, social workers, or the authorities. OBJECTIVE To explore attitudes and self-reported practices of EMS providers surrounding identification and reporting of elder mistreatment. METHODS Five semi-structured focus groups with 27 EMS providers. RESULTS Participants reported believing they frequently encountered and were able to identify potential elder mistreatment victims. Many reported infrequently discussing their concerns with other health care providers or social workers and not reporting them to the authorities due to barriers: 1) lack of EMS protocols or training specific to vulnerable elders; 2) challenges in communication with emergency department providers, including social workers, who are often unavailable or not receptive; 3) time limitations; and 4) lack of follow-up when EMS providers do report concerns. Many participants reported interest in adopting protocols to assist in elder protection. Additional strategies included photographically documenting the home environment, additional training, improved direct communication with social workers, a dedicated location on existing forms or new form to document concerns, a reporting hotline, a system to provide feedback to EMS, and community paramedicine. CONCLUSIONS EMS providers frequently identify potential victims of elder abuse, neglect, and self-neglect, but significant barriers to reporting exist. Strategies to empower EMS providers and improve reporting were identified.

Imaging findings in elder abuse: a role for radiologists in detection

Purpose Emergency department assessment represents a critical but often missed opportunity to identify elder abuse, which is common and has serious consequences. Among emergency care providers, diagnostic radiologists are optimally positioned to raise suspicion for mistreatment when reviewing imaging of geriatric injury victims. However, little literature exists describing relevant injury patterns, and most radiologists currently receive neither formal nor informal training in elder abuse identification. Methods We present 2 cases to begin characterisation of the radiographic findings in elder abuse. Results Findings from these cases demonstrate similarities to suspicious findings in child abuse including high-energy fractures that are inconsistent with reported mechanisms and the coexistence of acute and chronic injuries. Specific injuries uncommon to accidental injury are also noted, including a distal ulnar diaphyseal fracture. Conclusions We hope to raise awareness of elder abuse among diagnostic radiologists to encourage future large-scale research, increased focus on chronic osseous findings, and the addition of elder abuse to differential diagnoses.

Trends in Reporting of Abuse and Neglect to Long Term Care Ombudsmen: Data from the National Ombudsman Reporting System from 2006 to 2013

We utilized the National Ombudsman Reporting System (NORS) to describe national trends in reporting of abuse and neglect in nursing facilities to long term care ombudsmen (LTCO) from 2006 to 2013. We investigated complaints made against facility staff or residents with the following codes: physical abuse, verbal/mental abuse, sexual abuse, financial exploitation, gross neglect, and resident to resident physical or sexual abuse. Nationally, LTCO received an annual average of 11,749 abuse and neglect-related complaints in nursing homes from 2006 to 2013. These complaints trended down significantly, from 7.5 to 5.6 reports per 1000 beds (P < 0.0001). Physical abuse by a non-resident was the most frequently reported, representing an average of 28% of total abuse/neglect complaints. Improved understanding of the reasons for declines in reporting, increased training on other types of abuse and neglect, and expansion of the NORS database to allow for more comprehensive analysis are needed.

Acute Precipitants of Physical Elder Abuse: Qualitative Analysis of Legal Records From Highly Adjudicated Cases.

Elder abuse is a common phenomenon with potentially devastating consequences for older adults. Although researchers have begun to identify predisposing risk factors for elder abuse victims and abusers, little is known about the acute precipitants that lead to escalation to physical violence. We analyzed legal records from highly adjudicated cases to describe these acute precipitants for physical elder abuse. In collaboration with a large, urban district attorney’s office, we qualitatively evaluated legal records from 87 successfully prosecuted physical elder abuse cases from 2003 to 2015. We transcribed and analyzed narratives of the events surrounding physical abuse within victim statements, police reports, and prosecutor records. We identified major themes using content analysis. We identified 10 categories of acute precipitants that commonly triggered physical elder abuse, including victim attempting to prevent the abuser from entering or demanding that he or she leave, victim threatening or attempting to leave/escape, threat or perception that the victim would involve the authorities, conflict about a romantic relationship, presence during/intervention in ongoing family violence, issues in multi-generational child rearing, conflict about the abuser’s substance abuse, confrontation about financial exploitation, dispute over theft/destruction of property, and disputes over minor household issues. Common acute precipitants of physical elder abuse may be identified. Improved understanding of these acute precipitants for escalation to physical violence and their contribution to elder abuse may assist in the development of prevention and management strategies.

Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team

Background An ED visit provides a unique opportunity to identify elder abuse, which is common and has serious medical consequences. Despite this, emergency providers rarely recognise or report it. We have begun the design of an ED-based multidisciplinary consultation service to improve identification and provide comprehensive medical and forensic assessment and treatment for potential victims. Methods We qualitatively explored provider perspectives to inform intervention development. We conducted 15 semistructured focus groups with 101 providers, including emergency physicians, social workers, nurses, technologists, security, radiologists and psychiatrists at a large, urban academic medical centre. Focus groups were transcribed, and data were analysed to identify themes. Results Providers reported not routinely assessing for elder mistreatment and believed that they commonly missed it. They reported 10 reasons for this, including lack of knowledge or training, no time to conduct an evaluation, concern that identifying elder abuse would lead to additional work, and absence of a standardised response. Providers believed an ED-based consultation service would be frequently used and would increase identification, improve care and help ensure safety. They made 21 recommendations for a multidisciplinary team, including the importance of 24/7 availability, the value of a positive attitude in a consulting service and the importance of feedback to referring ED providers. Participants also highlighted that geriatric nurse practitioners may have ideal clinical and personal care training to contribute to the team. Conclusions An ED-based multidisciplinary consultation service has potential to impact care for elder abuse victims. Insights from providers will inform intervention development.

Describing visible acute injuries: development of a comprehensive taxonomy for research and practice

Background Little literature exists classifying and comprehensively describing intentional and unintentional acute injuries, which would be valuable for research and practice. In preparation for a study of injury patterns in elder abuse, our goal was to develop a comprehensive taxonomy of relevant types and characteristics of visible acute injuries and evaluate it in geriatric patients. Methods We conducted an exhaustive review of the medical and forensic literature focusing on injury types, descriptions, patterns and analyses. We then prepared iteratively, through consensus with a multidisciplinary, national panel of elder abuse experts, a comprehensive classification system to describe these injuries. Results We designed a three-step process to fully describe and classify visible acute injuries: (1) determining the type of injury, (2) assigning values to each of the characteristics common to all geriatric injuries and (3) assigning values to additional characteristics relevant for specific injuries. We identified nine unique types of visible injury and seven characteristics critical to describe all these injuries, including body region(s) and precise anatomic location(s). For each injury type, we identified two to seven additional critical characteristics, such as size, shape and cleanliness. We pilot tested it on 323 injuries on 83 physical elder abuse victims and 45 unintentional fall victims from our ongoing research to ensure that it would allow for the complete and accurate description of the full spectrum of visible injuries encountered and made modifications and refinements based on this experience. We then used the classification system to evaluate 947 injuries on 80 physical elder abuse victims and 195 unintentional fall victims to assess its practical utility. Conclusions Our comprehensive injury taxonomy systematically integrates and expands on existing forensic and clinical research. This new classification system may help standardise description of acute injuries and patterns among clinicians and researchers.