Prescriptions for Potentially Inappropriate Medications from the Beers Criteria Among Older Adults Hospitalized for Heart Failure.

BACKGROUND: We sought to better understand patterns of potentially inappropriate medications (PIMs) from the Beers criteria among older adults hospitalized with heart failure (HF). This observational study of hospitalizations was derived from the geographically diverse REasons for Geographic and Racial Differences in Stroke cohort. METHODS AND RESULTS: We examined participants aged 65 years and older with an expert-adjudicated hospitalization for HF. The Beers criteria medications were abstracted from medical records. The prevalence of PIMs was 61.1% at admission and 64.0% at discharge. Participants were taking a median of 1 PIM (interquartile range [IQR] 0-1 PIM) at hospital admission and a median of 1 PIM (IQR 0-2 PIM) at hospital discharge. Between admission and discharge, 19.1% of patients experienced an increase in the number of PIMs, 15.1% experienced a decrease, and 37% remained on the same number between hospital admission and discharge. The medications with the greatest increase from admission to discharge were proton pump inhibitors (32.6% to 38.6%) and amiodarone (6.2% to 12.2%). The strongest determinant of potentially harmful prescribing patterns was polypharmacy (relative risk 1.34, 95% confidence interval 1.16-1.55, P < .001). CONCLUSIONS: PIMs are common among older adults hospitalized for HF and may be an important target to improve outcomes in this vulnerable population.

N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study.

Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.

Development of the Verbal Autopsy Instrument for COVID-19 (VAIC).

BACKGROUND: Improving accuracy of identification of COVID-19-related deaths is essential to public health surveillance and research. The verbal autopsy, an established strategy involving an interview with a decedent's caregiver or witness using a semi-structured questionnaire, may improve accurate counting of COVID-19-related deaths. OBJECTIVE: To develop and pilot-test the Verbal Autopsy Instrument for COVID-19 (VAIC) and a death adjudication protocol using it. METHODS/KEY RESULTS: We used a multi-step process to design the VAIC and a protocol for its use. We developed a preliminary version of a verbal autopsy instrument specifically for COVID. We then pilot-tested this instrument by interviewing respondents about the deaths of 15 adults aged ≥65 during the initial COVID-19 surge in New York City. We modified it after the first 5 interviews. We then reviewed the VAIC and clinical information for the 15 deaths and developed a death adjudication process/algorithm to determine whether the underlying cause of death was definitely (40% of these pilot cases), probably (33%), possibly (13%), or unlikely/definitely not (13%) COVID-19-related. We noted differences between the adjudicated cause of death and a death certificate. CONCLUSIONS: The VAIC and a death adjudication protocol using it may improve accuracy in identifying COVID-19-related deaths.

Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases.

STUDY OBJECTIVE: Elder abuse is common and has serious health consequences but is underrecognized by health care providers. An important reason for this is difficulty in distinguishing between elder abuse and unintentional trauma. Our goal was to identify injury patterns associated with physical elder abuse in comparison with those of patients presenting to the emergency department (ED) with unintentional falls. METHODS: We partnered with a large, urban district attorney's office and examined medical, police, and legal records from successfully prosecuted cases of physical abuse of victims aged 60 years or older from 2001 to 2014. RESULTS: We prospectively enrolled patients who presented to a large, urban, academic ED after an unintentional fall. We matched 78 cases of elder abuse with visible injuries to 78 unintentional falls. Physical abuse victims were significantly more likely than unintentional fallers to have bruising (78% versus 54%) and injuries on the maxillofacial, dental, and neck area (67% versus 28%). Abuse victims were less likely to have fractures (8% versus 22%) or lower extremity injuries (9% versus 41%). Abuse victims were more likely to have maxillofacial, dental, or neck injuries combined with no upper and lower extremity injuries (50% versus 8%). Examining precise injury locations yielded additional differences, with physical elder abuse victims more likely to have injuries to the left cheek or zygoma (22% versus 3%) or on the neck (15% versus 0%) or ear (6% versus 0%). CONCLUSION: Specific, clinically identifiable differences may exist between unintentional injuries and those from physical elder abuse. This includes specific injury patterns that infrequently occur unintentionally.

Developing standard data for elder abuse multidisciplinary teams: A critical objective.

Multidisciplinary teams (MDTs) represent a prominent and growing form of elder abuse intervention in communities across the U.S. and around the world. Despite the proliferation and promise of MDTs as a model of elder abuse intervention, the field lacks infrastructure, including a standardized data collection strategy, to facilitate a coordinated and informed MDT effort. This commentary presents an exploratory study, which sought to examine existing strategies of case-level electronic data collection implemented by MDTs across the U.S. Using a snowball sampling strategy, we identified 11 MDTs using an electronic data collection strategy. Our analysis found a tremendous range in both the extent and nature of data collection across MDTs, yet it identified common domains of data. A standardized MDT data collection strategy would benefit several MDT stakeholders, including coordinators tracking everyday operations, funders requiring reporting, and researchers conducting large-scale comparative research to identify best MDT practices.

Can artificial intelligence help identify elder abuse and neglect?

A health care encounter is a potentially critical opportunity to detect elder abuse and initiate intervention. Unfortunately, health care providers currently very seldom identify elder abuse. Through development of advanced data analytics techniques such as machine learning, artificial intelligence has the potential to dramatically improve elder abuse identification in health care settings.

Developing a rigorous, systematic methodology to identify and categorize elder mistreatment in criminal justice data.

Elder mistreatment is complex, with cases typically requiring integrated responses from social services, medicine, civil law, and criminal justice. Only limited research exists describing elder mistreatment prosecution and its impact. Researchers have not yet examined administrative prosecutorial data to explore mistreatment response, and no standardized analytic approach exists. We developed a rigorous, systematic methodologic approach to identify elder mistreatment cases in prosecutorial data from cases of crimes against victims aged ≥60. To do so, we operationalized elements of the accepted definition of elder mistreatment, including expectation of trust and vulnerability. We also designed an approach to categorize elder mistreatment cases, using the types of charges filed, into: financial exploitation, physical abuse, sexual abuse, verbal/emotional/psychological abuse, and neglect. This standardized methodological approach to identify and categorize elder mistreatment cases in prosecution data is an important preliminary step in analyzing this potentially untapped source of useful information about mistreatment response.

Prevalence and determinants of Hyperpolypharmacy in adults with heart failure: an observational study from the National Health and Nutrition Examination Survey (NHANES).

BACKGROUND: While an expanding armamentarium of pharmacologic therapies has contributed to improved outcomes among adults with heart failure (HF) over the past two decades, this has also been accompanied by an increase in the number of medications taken by adults with HF. The use of at least 10 medications, defined as hyperpolypharmacy, is particularly notable given its association with adverse outcomes. We aimed to assess the prevalence and identify determinants of hyperpolypharmacy among adults with HF. METHODS: We studied adults aged ≥50 years with self-reported HF from the National Health And Nutrition Examination Survey (NHANES) in 2003-2014. We calculated weighted means and percentages to describe patient characteristics. We conducted a multivariable Poisson regression analysis to identify factors independently associated with hyperpolypharmacy; we adjusted for survey sampling, socio-demographics, comorbidity, geriatric conditions, and health care utilization. We examined 947 participants, representing 4.6 million adults with HF. RESULTS: The prevalence of hyperpolypharmacy was 26%. In a multivariable regression analysis, comorbidity count, ≥10 ambulatory contacts, and ≥ 3 hospitalizations were independently associated with hyperpolypharmacy. Interestingly, functional impairment and cognitive impairment were not independently associated with hyperpolypharmacy; while low annual household income and low educational status were each associated with an almost 2-fold increase in hyperpolypharmacy. CONCLUSION: Hyperpolypharmacy is a common condition among adults with HF. We additionally found that low household income and low educational status are independently associated with hyperpolypharmacy, suggesting that non-medical factors may be contributing to this potentially harmful condition.

Elder Abuse.

Because older victims of abuse tend to be isolated, their interactions with physicians are important opportunities to recognize abuse and intervene. This review explores the manifestations of elder abuse and the role of multidisciplinary teams in its assessment and management.

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.

Resident-to-Resident Mistreatment: Evaluation of a Staff Training Program in the Reduction of Falls and Injuries.

Resident-to-resident elder mistreatment (R-REM) occurs frequently in long-term services and support settings. The purpose of the current study was to evaluate the effect of a R-REM training program for nursing and other frontline staff on resident falls and injuries in a cluster randomized trial of units within four nursing homes. Interview and observational data from a sample of 1,201 residents (n = 600 and n = 601 in the usual care and intervention groups, respectively) and staff were collected at baseline and 6 and 12 months. A generalized linear model was used to model the falls/injuries outcome. The net reduction in falls and injuries was 5%, translating to 10 saved events per year in an averagesized facility. Although the result did not reach statistical significance due to low power, the findings of fall prevention associated with implementing the intervention in long-term care facilities is clinically important. [Journal of Gerontological Nursing, 44(6), 15-23.].

Addressing the measurement challenge in elder abuse interventions: need for a severity framework.

The field of elder abuse is evolving toward an emphasis on intervention research. However, researchers currently rely on binary approaches to measure elder abuse phenomena, which fail to capture changes in problem status over the course of intervention. This commentary develops a case for severity as a framework to operationalize and measure elder abuse in intervention research and practice. A severity framework provides enhanced elder abuse measurement responsiveness and aligns with the dominant client-centered, harm-reduction clinical approach to intervening with elder abuse cases.

The feasibility of goal attainment scaling to measure case resolution in elder abuse and neglect adult protective services intervention.

OBJECTIVES: This pilot study describes implementation procedures of goal attainment scaling (GAS) and examines the feasibility of using GAS to measure the multifarious intervention outcome of case resolution in elder mistreatment (EM) adult protective services (APS). METHODS: Substantiated EM victims (n = 27) were recruited prospectively from the State of Maine APS. An adapted GAS approach was implemented involving development of a pre-populated goal scale menu and web-based GAS application. RESULTS: The GAS menu comprised 18 goals and corresponding scales spanning several domains of case resolution: social support, service access, health/functioning, enhancing independence, and protective measures. The overall GAS process had mean length 33.8 min per case. The mean GAS summary t-score (54.3) aligned with theoretical expectations. DISCUSSION: Without a measure of case resolution, research cannot compare the effectiveness of different EM intervention models. Findings suggest that GAS is a feasible, client-centered strategy to measure the multifarious EM intervention case resolution outcome.

Prevalence of Financial Fraud and Scams Among Older Adults in the United States: A Systematic Review and Meta-Analysis.

BACKGROUND: The financial exploitation of older adults was recently recognized by the Centers for Disease Control and Prevention as a serious public health problem. Knowledge of the prevalence of elder financial exploitation is mostly limited to the category of financial abuse, which occurs in relationships involving an expectation of trust. Little is known about the other major category of elder financial exploitation-elder financial fraud and scams, which is perpetrated by strangers. A valid estimate of elder financial fraud-scam prevalence is necessary as a foundation for research and prevention efforts. OBJECTIVES: To estimate the prevalence of elder financial fraud-scam victimization in the United States based on a systematic review and meta-analysis. SEARCH METHODS: Multiple investigators independently screened titles and abstracts and reviewed relevant full-text records from PubMed, Medline, PsycINFO, Criminal Justice Abstracts, Social Work Abstracts, and AgeLine databases. SELECTION CRITERIA: To maximize the validity and generalizability of prevalence estimation, we restricted eligibility to general population-based studies (English speaking, 1990 onward) using state- or national-level probability sampling and collecting data directly from older adults. DATA COLLECTION AND ANALYSIS: Information on elder financial fraud-scam prevalence and study-level characteristics was extracted independently by 2 investigators. Meta-analysis of elder financial fraud-scam prevalence used generalized mixed models with individual studies as levels of a random classification factor. MAIN RESULTS: We included 12 studies involving a total of 41 711 individuals in the meta-analysis. Overall pooled elder financial fraud-scam prevalence (up to 5-year period) across studies was 5.6% (95% confidence interval [CI] = 4.0%, 7.8%), with a 1-year period prevalence of 5.4% (95% CI = 3.2%, 7.6%). Studies using a series of questions describing specific fraud-scam events to measure victimization found a significantly higher prevalence (7.1%; 95% CI = 4.8%, 9.4%) than studies using a single, general-question self-report assessment approach (3.6%; 95% CI = 1.8%, 5.4%). AUTHOR'S CONCLUSIONS: Elder financial fraud and scams is a common problem, affecting approximately 1 of every 18 cognitively intact, community-dwelling older adults each year; it requires further attention from researchers, clinicians, and policymakers. Elder financial fraud-scam prevalence findings in this study likely underestimate the true population prevalence. We provide methodological recommendations to limit older adult participation and reporting bias in future population-based research. Public Health Implications. Elder financial exploitation victimization is associated with mortality, hospitalization, and poor physical and mental health. Health care professionals working with older adults likely routinely encounter patients who are fraud-scam victims. Validation of instruments to screen for elder financial fraud and scams in clinical settings is an important area of future research. Without effective primary prevention strategies, the absolute scope of this problem will escalate with the growing population of older adults.

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.

The Prevalence of Resident-to-Resident Elder Mistreatment in Nursing Homes.

BACKGROUND: Resident-to-resident elder mistreatment (R-REM) in nursing homes can cause physical and psychological injury and death, yet its prevalence remains unknown. OBJECTIVE: To estimate the prevalence of physical, verbal, and sexual R-REM in nursing home residents and subgroups. DESIGN: 1-month observational prevalence study. SETTING: 5 urban and 5 suburban New York state nursing homes. PARTICIPANTS: 2011 residents in 10 facilities randomly selected on the basis of size and location; 83% of facilities and 84% of eligible residents participated. MEASUREMENTS: R-REM was identified through resident interviews, staff interviews, shift coupons, observation, chart review, and accident or incident reports. RESULTS: 407 of 2011 residents experienced at least 1 R-REM event; the total 1-month prevalence was 20.2% (95% CI, 18.1% to 22.5%). The most common forms were verbal (9.1% [CI, 7.7% to 10.8%]), other (such as invasion of privacy or menacing gestures) (5.3% [CI, 4.4% to 6.4%]), physical (5.2% [CI, 4.1% to 6.5%]), and sexual (0.6% [CI, 0.3% to 1.1%]). Several clinical and contextual factors (for example, lower vs. severe levels of cognitive impairment, residing on a dementia unit, and higher nurse aide caseload) were associated with higher estimated rates of R-REM. LIMITATIONS: Most facilities were relatively large. All R-REM cases may not have been detected; resident and staff reporting may be subject to recall bias. CONCLUSION: R-REM in nursing homes is highly prevalent. Verbal R-REM is most common, but physical mistreatment also occurs frequently. Because R-REM can cause injury or death, strategies are urgently needed to better understand its causes so that prevention strategies can be developed. PRIMARY FUNDING SOURCE: National Institute on Aging.

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 patient's 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.

Radiologists' Training, Experience, and Attitudes About Elder Abuse Detection.

OBJECTIVE: Elder abuse is underrecognized, and identification of subtle cases requires a high index of suspicion among all health care providers. Because many geriatric injury victims undergo radiographic imaging, diagnostic radiologists may be well positioned to identify injury patterns suggestive of abuse. Little is known about radiologists' experience with elder abuse. Our goal was to describe knowledge, attitudes, training, and practice experience in elder abuse detection among diagnostic radiologists. SUBJECTS AND METHODS: We conducted 19 interviews with diagnostic radiologists at a large urban academic medical center using a semistructured format. Data from these sessions were coded and analyzed to identify themes. RESULTS: Only two radiologists reported any formal or informal training in elder abuse detection. All subjects believed they had missed cases of elder abuse. Even experienced radiologists reported never having received a request from a referring physician to assess images for evidence suggestive of elder abuse. All subjects reported a desire for additional elder abuse training. Also, subjects identified radiographic findings or patterns potentially suggestive of elder abuse, including high-energy injuries such as upper rib fractures, injuries in multiple stages of healing, and injuries inconsistent with reported mechanism. CONCLUSION: Radiologists are uniquely positioned to identify elder abuse. Though training in detection is currently lacking, providers expressed a desire for increased knowledge. In addition, radiologists were able to identify radiographic findings suggestive of elder abuse. On the basis of these findings, we plan to conduct additional studies to define pathognomonic injury patterns and to explore how to empower radiologists to incorporate detection into their practice.