Elder Mistreatment Documentation by Prehospital Clinicians: An Analysis of the National Emergency Medical Services Information System Database.

OBJECTIVES: Elder mistreatment (EM), encompassing abuse and neglect, is a significant public health issue, affecting up to 10% of community-dwelling older adults annually. Elder mistreatment is a growing concern with a higher prevalence in institutional settings and substantial associated healthcare costs. Prehospital clinicians (PHCs) such as emergency medical technicians and paramedics are uniquely positioned to detect and report EM during their interactions with older adults in their homes. The objective of the study is to describe the rate and characteristics of EM documented by PHCs using the National Emergency Medical Services Information System (NEMSIS) database. METHODS: This study analyzed data from NEMSIS, which includes standardized information about PHC emergency response encounters across the United States. In 2018, 22,532,890 activations were included from 9,599 agencies in 43 states and US territories. Elder mistreatment was identified using specific International Classification of Diseases (ICD) codes related to EM. Demographic data, injury location, and associated physical findings were also examined. RESULTS: Out of 9,605,522 EMS encounters for patients aged ≥60, EM was coded in 1,765 encounters (0.02%). Most EM cases were listed as the cause of injury (64%), followed by the clinician's first impression (25.4%). Physical abuse was the most common type of mistreatment reported (20.8%), followed by sexual abuse (18.2%), neglect (9.7%), and psychological/emotional abuse (0.34%). The median age of patients with documented EM was 72, and 62.3% were female. The most common anatomic locations of injuries were the lower extremities, head, and upper extremities. CONCLUSIONS: Despite the high prevalence of EM, PHCs infrequently document EM in their encounters with older adults. Additional training and comprehensive protocols are needed to improve the identification and reporting of EM, mainly elder neglect. Empowering PHCs through education and protocol development can significantly impact the detection and intervention of EM.

Building resilience: A specialty clinic tailored to older adults at risk of violence and abuse.

OBJECTIVE: Both structural (e.g., ageism) and personal (e.g., stigma) barriers hinder older adult's access to and engagement with mental health care). These barriers are particularly problematic for those vulnerable to interpersonal violence and abuse (e.g., due to social isolation). This study presents a quality improvement program aimed at older adults who have experienced significant stress events, particularly elder mistreatment, within a larger trauma specialty clinic. Leveraging home-based telemedicine, the clinic provides evidence-based psychotherapy tailored to older adults' needs. METHODS: From 2021 through 2023, the authors retrospectively examined treatment initiation, engagement, completion, and clinical outcomes among 231 older adults age 60+ who reported trauma that met DSM-5 criterion A criteria for Post-traumatic Stress Disorder (PTSD), depression and other mental health comorbid conditions related to their traumatic event. The clinic uses an automated measurement-based care approach that facilitates Quality Improvement projects, allowing us to track treatment initiation, engagement, completion, and clinical outcomes for all patients. RESULTS: The results indicated high treatment completion, high engagement with telemedicine-delivered interventions, and, most importantly, significant changes in clinical outcomes. CONCLUSION: These findings highlight the importance of expanding telemedicine-based mental health services for older adults, challenging ageist norms, and prioritizing older adults' mental health needs by providing tailored services to this patient population.

Perspectives on elder mistreatment screening and responding in emergency departments: A qualitative study with survivors.

OBJECTIVE: Elder Mistreatment (EM) occurs in approximately 10% of older adults and is associated with trauma-related outcomes including depression, anxiety, post-traumatic stress disorder, and early mortality. Low screening and older adult self-reporting rates, especially within Emergency Departments represent missed opportunities for identify and mitigate future EM occurrences and consequences. To date, no studies have obtained EM survivors perspectives of EM screening and response practices in emergency departments. METHODS: Semi-structured interviews with 19 EM survivors with Adult Protective Services validated EM were completed in the older adult's home. The Elder Mistreatment Emergency Department Screening and Response Tool (EM-SART) was used to guide the interview questions. All interviews were recorded, transcribed, and analyzed using qualitative thematic analyses. RESULTS: The participants were mostly female (63%) and white (58%) with an average age of 74 years. Physical abuse accounted for 67% of the EM incidents. Three themes emerged indicating the survivor preference for (1) building rapport and approaching the older adult with compassion and care, (2) setting the context before asking the EM questions, and (3) allowing mutuality, collaborative work, and shared decision-making during the response. CONCLUSIONS: Older adults are agreeable and willing to self-report and actively engage in the EM screening and response practices in the emergency department if trauma-informed care principles are utilized.

Risk Factors for Elder Mistreatment Among Older Korean Americans.

Using data from a sample of older Korean Americans (n = 2,150), we examined the prevalence and associated factors of physical, emotional, and financial mistreatment. Given the importance of contextual factors, we examined the effect of immigration-related (years in the U.S. and acculturation) and interpersonal/community-related (family solidarity, social network, and ethnic community social cohesion) factors in addition to sociodemographic and health-related characteristics. The rate of experiencing physical, emotional, and financial mistreatment during the past year was 3%, 37.9%, and 16.1%, respectively. Younger age and lower family solidarity were common risk factors for emotional and financial mistreatment. The experience of emotional mistreatment was also more likely among females and those with higher level of acculturation, smaller social networks, and lower ethnic community social cohesion. Chronic disease was an additional risk factor for financial mistreatment. The findings suggest targeted prevention and intervention strategies for elder mistreatment.

Emergency department and hospital-based programs responding to elder mistreatment: developing consensus about an idea whose time has come.

Elder mistreatment is common, serious, and under-recognized, with Emergency Department and hospital clinical encounters offering a potential but currently unrealized opportunity to identify and help older adults experiencing mistreatment. Interdisciplinary emergency department and hospital-based response teams represent a promising care model to address this. This manuscript describes two such teams and introduces a special issue dedicated to this work.

Social support and elder mistreatment in Brazil: exploring relationships and moderating effects.

Prior literature has demonstrated a negative association between social support and elder mistreatment. Furthermore, social support may moderate the negative relationship between health-related indicators and elder mistreatment. This study is the first to investigate these assertions in Brazil using nationally representative data. We employ the 2019 National Health Survey and a series of binary logistic regressions. Overall, increased social support from stronger ties, like family and close friends, reduces the likelihood of elder mistreatment. However, increased participation in broader and more distant social networks and circles of sociability may increase the risk of mistreatment. Moreover, the negative relationship between health-related indicators and elder mistreatment is partially moderated by increased social support. While findings on other support dimensions vary, family support appears crucial in mitigating elder mistreatment. This study contributes by underscoring the intricate interplay of social support, health, and mistreatment, advocating for family-centered interventions to improve elder well-being in Brazil.

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.

Elder abuse geriatrics: describing an important new medical specialist.

Elder mistreatment, including elder abuse and neglect, is a difficult diagnosis to make and manage for most providers. To address this, two elder abuse consultation teams were developed for patients in the hospital and emergency department settings. As these teams have developed, the providers involved have obtained specialized training and experience that we believe contributes to a new field of elder abuse geriatrics, a corollary to the well-established field of child abuse pediatrics. Providers working in this field require specialized training and have a specialized scope of practice that includes forensic evaluation, evaluation of cognition and capacity, care coordination and advocacy for victims of abuse, and collaboration with protective services and law enforcement. Here we describe the training, scope of practice, ethical role, and best practices for elder mistreatment medical consultation. We hope this will serve as a starting point for this new and important medical specialty.

ED/hospital program contributions to community multi-disciplinary team meetings: Different models.

Elder mistreatment (EM) is a complex problem, with response and prevention requiring contributions from professionals from many disciplines. Community-based multi-disciplinary teams (MDTs) that conduct meetings to discuss challenging cases and coordinate services are a common strategy to ensure effective collaboration. Though they play an important role in EM identification, intervention, and prevention, hospitals and hospital-based healthcare professionals have been particularly difficult to engage in MDTs. Two hospitals in different communities recently launched Emergency Department (ED)/hospital-based response teams to consult in cases of potential EM, and both participate in MDTs. We explored similarities and differences between the MDTs in these communities including in the role of the ED/hospital-based response team. The comparison demonstrates both core common features as well as large variations. These differences reflect different circumstances in the models on which they were based, on MDT development in these communities, available resources and infrastructure, and the ED/hospital program's role.

Examining ethical issues that arise in providing ED/hospital care for patients experiencing elder mistreatment and approaches to address them.

Clinicians in the emergency department and hospital who treat patients experiencing elder mistreatment (EM) can expect to encounter challenging ethical dilemmas. Collaboration with ethics and EM consultation services offers teams an important opportunity to improve patient-centered outcomes and address value-based concerns when treating these patients. This article describes the role of a hospital clinical ethics consultation service and best practices for collaboration between ethics and EM consultation services. Illuminated via four case studies, the article presents several core ethical frameworks, including allowing patients the dignity of risk, considerations around a harm reduced discharge, involving abusers in surrogate decision making, and providers' experience of moral distress when dealing with patients experiencing EM. Increasing collaboration with ethics and elder mistreatment services can help teams more effectively respond to EM.

A collaboration between adult protective services and forensic accounting examiners to investigate complex financial exploitation: formative evaluation findings.

Financial exploitation (FE) is one of the most common reports to Adult Protective Services (APS) and the cases are often complex. Consequently, APS caseworkers report FE investigations to be among the most difficult while simultaneously reporting low confidence in productive outcomes for these investigations. This necessitates finding ways to support APS FE investigations. This paper describes the structure, process, and formative findings of a collaboration between forensic accounting examiners and APS workers to investigate complex cases of FE. Among the 77 FE cases completed, forensic examiners reviewed multiple years of financial records which included over 101,000 transactions, totaling over $213,000,000.00 in finances, and identified over $8,000,000 in questionable activity. Scores on the 8-item Client Satisfaction Questionnaire were high indicating high program satisfaction by APS workers, subject matter experts, and forensic examiners. These findings support the feasibility and acceptability of forensic accounting and APS collaborations to investigate complex cases of FE.

Strategies for dissemination of ED/hospital elder mistreatment response team model.

Interdisciplinary Emergency Department/hospital-based teams represent a promising care model to improve identification of and intervention for elder mistreatment. Two institutions, Weill Cornell Medicine/NewYork-Presbyterian Hospital and the University of Colorado Anschutz Medical Campus have launched such programs and are exploring multiple strategies for effective dissemination. These strategies include: (1) program evaluation research, (2) framing as a new model of geriatric care, (3) understanding the existing incentives of health systems, EDs, and hospitals to align with them, (4) connecting to ongoing ED/hospital initiatives, (5) identifying and collaborating with communities with strong elder mistreatment response that want to integrate the ED/hospital, (6) developing and making easily accessible high-quality, comprehensive protocols and training materials, (7) offering technical assistance and support, (8) communications outreach to raise awareness, and (9) using an existing framework to inform implementation in new hospitals and health systems.

Elder mistreatment experiences, perceptions, and help-seeking behaviors of Asian American older adults.

This study examined the experiences and the perceptions of elder mistreatment (EM), as well as help-seeking knowledge and behaviors, particularly about Adult Protective Services (APS), among community samples of Asian American older adults, including Koreans, Chinese, and others (N = 288). Approximately 27% of the study participants experienced at least one EM incident in the past year. Between 27% and 38% of the participants reported that they were likely to seek help from APS for different types of EM. Significant differences were found across the three Asian groups in their perceptions toward EM and intention to seek help from APS in the event of EM. However, many Asian American older adults in the study did not know about APS prior to participating in the study (75.5%) and other formal sources of help (66.3%). Implications for helping professionals, particularly APS and community-based organizations serving Asian Americans, are discussed.

Elder Mistreatment Experienced by Older Caregiving Adults: Results from a National Community-Based Sample.

BACKGROUND: With an aging population, older adults are increasingly serving as caregivers to others, which may increase their risk of adverse interpersonal experiences. OBJECTIVE: To investigate the prevalence and types of elder mistreatment experienced by older caregiving adults. DESIGN: Cross-sectional analysis PARTICIPANTS: National sample of community-dwelling US adults over age 60 in 2015-2016. MAIN MEASURES: Caregiving (assisting another adult with day-to-day activities) was assessed by interviewer-administered questionnaires. Experience of elder mistreatment was assessed by participant-reported questionnaire in three domains: emotional, physical, and financial. Multivariable logistic regression models examined associations between caregiving status and each domain of elder mistreatment, adjusting for age, race, ethnicity, gender, education, marital status, concomitant care-receiving status, overall physical and mental health, and cognitive function. Additional logistic regression models examined associations between being the primary caregiver (rather than a secondary caregiver) and each domain of mistreatment among older caregivers. KEY RESULTS: Of the 1898 participants over age 60 (including 1062 women and 836 men, 83% non-Hispanic white, and 64% married or partnered), 14% reported serving as caregivers for other adults, including 8% who considered themselves to be the primary caregiver. Among these older caregivers, 38% reported experiencing emotional, 32% financial, and 6% physical mistreatment after age 60. In multivariable models, caregiving was associated with experiencing both emotional mistreatment (AOR 1.61, 95% CI 1.15-2.25) and financial mistreatment (AOR 1.72, 95% CI 1.18-2.50). In analyses confined to caregiving older adults, those who served as primary rather than secondary caregivers for other adults had an over two-fold increased odds of emotional mistreatment (AOR 2.17, 95% CI 1.07, 4.41). CONCLUSION: In this national cohort of older community-dwelling adults, caregiving was independently associated with experiencing emotional and financial mistreatment after age 60. Findings suggest that efforts to prevent or mitigate elder mistreatment should put more emphasis on vulnerable older caregivers.

Detecting elder abuse in dermatology: A clinical and practical review.

The pace of aging in our population is dramatically increasing, raising concern for rising prevalence of elder abuse. Given the visual nature of the occupation, dermatologists can play a crucial role in identifying certain types of elder mistreatment, especially physical abuse, sexual abuse, and neglect. Nonetheless, many dermatologists report insufficient training in the diagnosis of elder abuse as well as appropriate interventions. This review article aims to synthesize and assess recent clinical, screening, and practical developments surrounding elder abuse. Implementation of some of these screening methods and recommendations in clinical practice and in dermatology residency curriculums could lead to increased awareness among physicians and improved patient outcomes. Like all other clinicians, dermatologists have a legal, moral, and ethical obligation to report suspicion of mistreatment and help suffering patients. Elder abuse is and will continue to be, an important issue that will require efforts from physicians across all fields to ensure the health and safety of patients.

The critical role of the specialized social worker as part of ED/hospital-based elder mistreatment response teams.

The emergency department and hospital provide a unique and important opportunity to identify elder mistreatment and offer intervention. To help manage these complex cases, multi-disciplinary response teams have been launched. In developing these teams, it quickly became clear that social workers play a critical role in responding to elder mistreatment. Their unique skillset allows them to establish close connections with community resources, collaborate with various hospital stakeholders, support patients/families/caregivers through challenging situations, navigate the legal and protective systems, and balance patient safety and quality of life in disposition decision-making. The role of the social worker on these multi-faceted teams includes conducting a comprehensive biopsychosocial assessment, helping to develop a safe discharge plan, and making appropriate referrals, among other responsibilities. Any institution considering developing a multi-disciplinary program should recognize the critical importance of social work.

Novel methods for assessment of vulnerability to financial exploitation (FE).

Financial exploitation (FE) is a complex problem influenced by many factors. This article introduces two novel methods for assessment of FE vulnerability: (1) performance-based measures of financial skills using web-based simulations of common financial tasks; (2) scam vulnerability measures based on credibility ratings of common scam scenarios. Older adults who were male, younger, Hispanic, more educated, with higher incomes performed better on the simulated financial tasks. Better performance was also related to higher cognitive function and numeracy, and more experience with technology. On the scenario-based measures, older adults who were male, younger, African American, less educated, and lower income showed higher FE vulnerability. Higher scam vulnerability was also related to poorer performance on the simulated financial tasks, lower cognitive function, less experience with technology, more financial conflict/anxiety, more impulsivity, and more stranger-initiated FE. Findings indicate that these novel measures show promise as valid indicators of vulnerability to FE.

Typology of family caregivers of older persons: A latent profile analysis using elder mistreatment risk and protective factors.

This study sought to identify subpopulations of caregivers of older persons based on their profiles of individual characteristics and caregiving contexts and aimed at examining the associations between caregiver profiles and elder mistreatment. A convenient sample of 600 adult caregivers of community-dwelling older people in Hong Kong participated. Results of latent profile analysis support a typology of 3 distinctive caregiver profiles: (a) non-vulnerable caregivers; (b) isolated, vulnerable caregivers; and (c) traumatized, vulnerable caregivers. Isolated and traumatized caregivers reported greater risk factors related to elder mistreatment: They had higher levels of caregiver stress and burden, lower levels of social support and resilience, greater neurotic personality orientation and problematic gambling behavior, and more severe childhood traumatic experiences. The two groups also display significantly higher level of abusive behaviors than non-vulnerable caregivers.

Racial/Ethnic Group Differences in Older Adults' Involvement with Adult Protective Services.

This paper represents the first study to focus on quantifying racial/ethnic group differences in older adults' involvement with adult protective services (APS).  Across 3 independent county programs, the rate of APS reports was about twice as high for Black older adults compared to White older adults.  These differences were greater for clients who were older and male but remained similar across allegation type.  The percent of reports validated was slightly but consistently lower for Black clients than for White clients, and a lower percentage of Black clients' cases were closed due to investigation or service refusal. Findings for Hispanic clients differed by county, so it was impossible to generalize about their APS experience.  Researchers should distinguish racial/ethnic group differences that persist across multiple programs from those that are program-specific.  Further studies with larger data sets are needed to guide APS practice and ensure equity for all clients served. .

Chronic disease and elder mistreatment: A meta-analysis.

OBJECTIVE: This meta-analysis investigated the relationships between chronic diseases and different forms of elder mistreatment (physical, emotional, sexual, financial, neglect, or overall abuse). METHOD: Twelve different chronic disease risk markers linked to elder mistreatment were gathered from 48 studies (yielding 178 effect sizes (ESs) and a combined sample size of n = 390,785), then organized in to four broad chronic disease categories: endocrine disease, heart disease, neurological disease, and other chronic diseases. Data were analyzed with Comprehensive Meta-Analysis Software using a random effects approach. RESULTS: Neurological disease (odds ratio [OR] = 1.51), endocrine disease (OR = 1.38), heart disease (OR = 1.17), and other chronic diseases (OR = 1.26) were all significantly associated with elder mistreatments. Neurological disease (OR = 1.51) was found to have a significantly stronger association with elder mistreatment when compared to the heart disease category (OR = 1.17) and the other chronic disease category (OR = 1.26). When specifically investigating emotional abuse, there was a significantly stronger link with neurological disease (OR = 1.48) compared to other chronic diseases (OR = 1.21). CONCLUSIONS: This study provides the first meta-analytic benchmarks for understanding the links between chronic disease risk markers and different forms of elder mistreatment.