Recognizing and Managing Elder Abuse in the Emergency Department
Elder Abuse Suspicion Index
The Elder Abuse Suspicion Index (EASI) is a short screening tool that has been validated for cognitively intact patients being treated in family practice and ambulatory care settings, and may be used in EDs.44 The tool comprises six questions: five for patient response, and a sixth question for clinician response. This tool is available at https://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index.46
Interventional Measures
When elder mistreatment is suspected or confirmed, health care providers must first address any acute medical, traumatic, or psychological issues. Bleeding, orthopedic injuries, metabolic abnormalities, infections, and agitation must be treated and/or stabilized, while neglected or inappropriately managed chronic medical conditions may require treatment.
Hospitalization should be considered for an older adult who needs extended treatment or observation and, in cases of immediate or continued danger of abuse, separation from contact with the suspected abuser. These measures present several challenges, particularly if the suspected abuser is the patient’s health care proxy, in which case early involvement of the hospital’s legal department, social services, and administration may be necessary—especially in navigating the guardianship process.
Engaging security also may be necessary if the patient requires one-to-one patient watch or when the perpetrator must be removed from the ED. Social workers, patient services representatives, and law enforcement officials should be informed when such intervention is necessary.
In instances when a patient is not at risk of immediate harm, interventions can be more individualized. Coordination with primary care physicians (PCPs) must also be facilitated prior to discharge, to ensure consistent longitudinal follow-up care, and social workers should provide any needed out-of-hospital resources to the patient—and caregiver—such as Meals-on-Wheels, medical transportation services, adult day care/senior center participation, and substance abuse treatment.
Patient Decision-Making Capacity
When a patient experiencing abuse declines interventions or services, the EP must evaluate the patient’s decision-making capacity. In unclear cases, a psychiatric evaluation can help to assess decision-making capacity. If the victim is deemed to have capacity with regard to care and/or discharge, the patient’s choice of returning to an unsafe environment must be respected, as is true in instances of intimate partner violence among younger adults—but not in child abuse cases. In such situations, the EP should nevertheless discuss safety planning, offer psychoeducation about violence and abuse, suggest appropriate community referrals, and encourage abused patients to return or call a contact person whenever they desire or feel the need to talk further. For a victim who is deemed not to possess capacity, providers should proceed with treatment considered to be in the best interest of the patient.
Reporting Abuse
Emergency department providers should notify the appropriate authorities when elder abuse is suspected or identified. A report may be made to the local Adult Protective Services (APS), but this agency operates much differently than Child Protective Services. Case workers with APS will not open a case while a patient is in the ED or hospital, as it is deemed a safe environment and any investigation they undertake will only commence upon discharge. Because of this, contacting the local police department prior to discharge should be considered.
Mandatory elder abuse-reporting laws vary from state to state. Health care providers should therefore contact their respective state or city department of health to obtain local legislation.
Multidisciplinary Approach
Ideally, a multidisciplinary, ED-based intervention team modeled on child abuse teams18,19 would help to optimize treatment and ensure the safety and treatment of vulnerable older adults. These teams could conduct thorough medical, forensic, and social work assessments, allowing ED providers to attend to other patients. The team could also assist in arranging for appropriate and safe dispositions. An innovative Vulnerable Elder Protection Team was recently launched at New York-Presbyterian Weill Cornell Medical Center to provide these services, and its impact is currently being evaluated.
Case Conclusion
The EP who treated the patient realized that blows from a blunt object held by a right-handed person would tend to land on the left side of the victim’s face and upper torso, and that a right-handed victim who successfully blocked the blows intended for her face would instead sustain an isolated right ulna or radius midshaft fracture. These findings, together with the concomitant presence of both old and new fractures, led the EP to question the patient alone and, after obtaining a different history of the events that led to the injuries, admit her for further evaluation, treatment, and interventions to prevent continuing abuse.
Summary
Elder abuse has the potential to affect an increasing number of older adults in this growing population, and an ED visit may offer the only opportunity to identify victims and provide intervention, in turn reducing morbidity and mortality. The results of ongoing research will improve the ability of EPs and ED staff to accurately assess the presence or risk of elder abuse and respond more effectively. It is essential that EPs always consider elder abuse and neglect as a possible etiology when evaluating injuries in this population. Moreover, when identified, addressing elder mistreatment may dramatically improve quality of life or save the lives of these vulnerable patients.
