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1. ADDRESSING ELDER ABUSE Hiding in Plain Sight The Solution

2. ADDRESSING ELDER ABUSE Every day, during every shift, the victims of elder abuse present to emergency departments across the country, but we, as clinicians, almost never recognize it. We treat our patient’s symptom, but fail to identify the underlying cause. Ten percent of older Americans experience abuse or neglect each year. Victimization of elder adults increases the risk of mortality, nursing-home placement, dementia, and depression. The ED is often the only place where victims of elder abuse are seen in public, the only time that multiple trained professionals have the opportunity to piece together an otherwise obscure picture of abuse. And its resources are available 24/7.

3. TAKING ACTION Health care professionals can recognize an abusive situation and take the effective steps to secure the health and ultimate safety of the patient. The Approach • Screening • Assessment • Intervention • Reporting • Documentation • ED as a multidisciplinary response team

4. SCREENING

5. EASI While universal screening of older adults in the ED for abuse or neglect improves identification of the problem, many EDs currently ask only a single question about a patient’s safety. This is inadequate. The National Institute of Justice is currently sponsoring the development and testing of an ED-specific screening tool. The Elder Abuse Suspicion Index (EASI)is a short instrument that has been validated for cognitively intact patients in ambulatory-care settings and may be appropriate for the ED.

6. RISK FACTORS FOR BECOMING A VICTIM In addition to screening with confidential questions, observe if the patient has any of the risk factors commonly identified with people suffering elder abuse: • Functional dependence or disability • Poor physical health • Cognitive impairment/dementia • Poor mental health • Low income/socio-economic status • Social isolation/low social support • Previous history of family violence • Previous traumatic-event exposure • Substance abuse

7. PERPETRATOR DEMOGRAPHICS Patients suffering abuse often present at the ED under the watchful eye of their abuser. If possible, during the ED visit, you might be able to get an understanding of the guardian’s background, elements of which may indicate the potential of being an abuser: • History of mental illness • History of substance abuse • Undergoing caregiver stress • Previous history of family violence • Financial dependence on the older adult

8. INTERACTIONS Signs of a strained relationship between the patient and caregiver: • Caregiver not able to give details of the patient’s medical history or routine medications • Inconsistent history of the reason for injury between the patient and caregiver • Patient or caregiver reluctant to answer questions • Caregiver answers the questions addressed to the patient • Abandonment of the patient in the emergency department by the caregiver

9. ASSESSMENT

10. THE ASSESSMENT In developing an assessment, providers have an array of tools to investigate a suspected abuse situation. Just a simple observation of interactions by EMS, a social worker, or nurse can indicate a potential situation. There can be telltale indications in the patient’s current physical exam or medical history that can suggest the presence of abuse. And, of course, imaging and lab testing can further build an understanding of what is going on underneath the surface appearance.

11. PHYSICAL EXAM The physical exam is targeted to determine if the trauma is inconsistent with the purported mechanism. A head-to-toe exam is performed, looking for any evidence of physical abuse, sexual abuse, or neglect – including atypical bruising, patterned injuries, genital/rectal trauma, cachexia, pressure sores, and poor hygiene. When appropriate, a SAFE exam is performed.

12. ABUSE SIGNS IN AN EXAMINATION Physical Abuse • Bruising in atypical locations not over bony prominences on lateral arms, back, face, ears, or neck • Patterned injuries bite marks, injury consistent with the shape of a belt buckle, fingertip, or other object • Wrist or ankle lesions or scars suggesting inappropriate restraint • Burns particularly stocking/glove patterns suggesting forced immersion or cigarette pattern • Multiple fractures or bruises of different ages • Traumatic alopecia or scalp hematomas • Subconjunctival, vitreous, or retinal ophthalmic hemorrhages Intraoral soft tissue injuries

13. ABUSE SIGNS IN AN EXAMINATION Sexual Abuse • Genital, rectal, or oral trauma, including erythema, bruising, lacerations • Evidence of sexually transmitted disease Neglect • Cachexia/malnutrition, muscle wasting, temporal wasting, sunken eyes • Dehydration, dry mucous membranes, sunken eyes, skin tenting, severe constipation/fecal impaction • Pressure sores/decubitus ulcers • Poor body hygiene, unchanged diaper • Dirty, severely worn clothing • Elongated toenails • Poor oral hygiene

14. ABUSE SIGNS IN THE MEDICAL HISTORY If abuse is suspected, a medical history can reveal a pattern of abuse or neglect. Any interview of the patient must be conducted in private. A guardian’s refusal to allow such an interview can be taken as a sign of an abusive situation.

15. ABUSE SIGNS IN THE MEDICAL HISTORY Patient Indicators • Poor living conditions according to paramedics or others • Unexplained injuries • Past history of frequent injuries • Elderly patient referred to as “accident prone” • Delay between onset of medical illness or injury and seeking of medical attention • Recurrent visits to the ED for similar injuries • Using multiple physicians and emergency departments for care rather than one primary-care physician (doctor hopping/shopping) • Noncompliance with medications, appointments, or physician directions

16. ABUSE SIGNS IN IMAGING Although the literature on radiology descriptions of potential imaging correlating to elder abuse is limited, radiologists trained to look for co-occurring old and new fractures, high-energy fractures despite a low-energy mechanism, distal ulnar diaphyseal fractures, and small bowel hematomas can provide valuable evidence for potential abuse. Alert the radiologists to focus on whether or not the imaging findings are consistent with the purported mechanism, as well as to be alert for other signs of abuse. Consider additional screening imaging tests—including maxillofacial CT scan and chest X-ray—to evaluate for acute and chronic fractures, analogous to the skeletal survey routinely performed in potential victims of child abuse.

17. ABUSE SIGNS IN MEDICAL AND LAB MARKERS No lab tests can definitively identify abuse, but the presence of certain signs revealed in a test should elevate suspicions of potential abuse. • Dehydration • Electrolyte abnormalities • Anemia • Malnutrition • Rhabdomyolysis • Potential malnutrition • Dehydration • Anemia • Hypothermia/Hyperthermia

18. ABUSE SIGNS IN MEDICAL AND LAB MARKERS Blood and urine tests for medication levels, drugs, or toxins can reveal: • A low or undetectable medication level, which may suggest intentional or neglectful withholding or diversion • An elevated medication level, which may suggest intentional or unintentional overdose • The presence of a toxin or medication that has not been prescribed, which may indicate poisoning

19. INTERVENTION

20. CAPACITY EVALUATION Interventions of suspected elder abuse cases differ from cases of child abuse; the situation is more similar to the ED management of intimate partner violence among younger adults. When a victim has capacity to refuse care or to request discharge, the choice to return to what we might consider as an unsafe environment must be respected. If a patient experiencing abuse or neglect declines intervention or services, an assessment of his or her capacity to refuse is needed. If the ED provider is unsure about a patient’s decision-making capacity, an evaluation by a psychiatrist may be helpful.

21. CAPACITY EVALUATION Even in those situations, providers should offer psychoeducation about violence and abuse, discuss safety planning, suggest appropriate community services, and encourage the older adult to return to the ED whenever they desire. For patients who are unable to make independent decisions, providers should proceed with treatments that are in the patient's best interest, including hospitalization, as appropriate.

22. DETERMINATION OF ACUTE SECURITY NEEDS Any patient in immediate danger should be separated from the suspected abuser. Interventional approaches may be more individualized for those not at risk for imminent harm. Social work can often provide counseling, safety planning, and appropriate resources to the patient and caregiver.

23. REPORTING

24. ELDER ABUSE IS A CRIME Emergency providers should report potential cases of elder abuse or neglect to the appropriate authorities. A reasonable cause to suspect abuse is all that is necessary to make a report: providers should report cases even when they are not certain that abuse or neglect has occurred.

25. LEGAL OBLIGATIONS Health care providers are mandatory reporters for elder abuse in most, but not all, US states. In many states, elder abuse must be reported even if the victim does not want a report made. Laws vary so ED providers should be aware of the particular requirements in one’s own state. More information is available from a state’s Department of Health website, and a summary is available at:  • http://www.napsa-now.org/wp-content/uploads/2014/11/Mandatory-Reporting-Chart-Updated-FINAL.pdf

26. AVAILABLE PROGRAMS For community-dwelling older adults, Adult Protective Services (APS) is the agency that leads the investigation of these complex cases. Information on how to contact state or local APS in different areas is available at:  • http://www.napsa-now.org/get-help/help-in-your-area/ For suspected or confirmed elder abuse in nursing homes, board and care homes, or assisted-living facilities, ED providers should report to Long-Term Care Ombudsman in their state. Information on Long-Term Care Ombudsman programs may be found at:  • https://theconsumervoice.org/get_help

27. THE ROLE OF APS When preparing to make a report, providers must be aware of the scope of APS’s role in investigations. In most states, the older adult must meet three criteria in order for the case to be opened. The older adult: • Must have a physical or mental impairment • Must be in need of protection from actual or threatened harm • Must not have anyone who is willing or able to assist Despite these guidelines, providers are encouraged to make referrals to APS if concern persists. Providers must also understand that APS operates differently than Child Protective Services. APS does not respond to referrals in real time, as the hospital is considered a safe environment. Their investigation commences only after discharge. As a result, ED providers should not hesitate to report to local law enforcement when concerned about a patient’s safety or that crime has been committed.

28. DOCUMENTING

29. DOCUMENTATION METHODS The patient’s responses to questions should be comprehensively documented, using the patient’s own words whenever possible. Social information, including functional status, the caregiver’s relationship to the patient, and the living situation should also be documented. Providers should describe the physical exam in detail. Include the general appearance of the patient upon arrival to the ED. Potential signs of neglect – including dirty clothing, poor dental hygiene, and untrimmed nails – should be described, if present. For each injury, the ED provider should describe its size, location, stage of healing, and whether it is consistent with the reported mechanism. Using a body diagram/traumagram – which is available as part of many electronic medical records – may increase accuracy when describing findings. Geriatric-Injury Documentation Tool Link

30. PHOTO EVIDENCE ED providers should photograph physical findings and add these photographs to the medical chart when possible and approved by hospital administration. These images may be helpful forensically in the future. To assist in ED providers, a protocol for photographing injuries in the acute-care setting was recently published. General Principles • Include identifiable information • Use a ruler and color guide • 90° angle to the injury • Hold the ruler 1-2” off the skin

31. ED AS A MULTIDISCIPLINARY RESPONSE TEAM

32. THE EMERGENCY DEPARTMENT AS A MULTIDISCIPLINARY RESPONSE TEAM The ED itself is an ideal team to pull together an understanding that a patient may be suffering abuse or neglect. The amount of time spent in the ED, the number of people seeing the patient, and the opportunity to isolate the patient, allows clinicians to piece together a strong narrative of the patient’s underlying situation.

33. MULTIDISCIPLINARY TEAM A multidisciplinary team can help lift the burden of that response by having a core team of trained experts. This team can be called in on suspicion to do in-depth interviewing, gather evidence, contact proper authorities and follow up with social services. Everyone needs to be empowered to contribute: • EMS • Triage • Nursing • Tech/radiology tech/escort • Radiologists • Social workers • Care Coordinators/Patient Navigators Setting up a response team can help the ED meet its health care obligations to address this pressing problem.

34. TEAM CONFIGURATION A team configuration could look like this: • Core Members (involved in all consultations) • Emergency department social worker • Geriatric emergency physician Additional Members (involved as appropriate) • Geriatric inpatient/consultation team • Emergency psychiatric team • Emergency radiology team • Hospital security • Patient Services • Hospital administration/legal Even in an ED that lacks the depth of resources for a large-scale team, providing a dedicated expert with an understanding of how to deal with the issues can make a significant impact.

35. RESOURCES The task may appear daunting, but there are significant resources to assist you. You can find additional details on this approach at: • http://elderabuseemergency.org Email questions and comments to Dr. Tony Rosen, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Program Director, Vulnerable Elder Protection Team (VEPT): • aer2006@med.cornell.edu

36. Content Developed By Dr. Tony Rosen, MD, MPH NewYork-Presbyterian Hospital Content Crafted By Learning Solutions / Talent Development NewYork-Presbyterian Hospital This Program Has Been Supported By The Fan Fox and Leslie R. Samuels Foundation

37. ADDRESSING ELDER ABUSE The Solution