Elder Abuse in the Out-of-Hospital and Emergency Department Settings: A Scoping Review

GERIATRICS/REVIEW ARTICLE

Elder Abuse in the Out-of-Hospital and Emergency Department Settings: A Scoping Review Éric Mercier, MD, MSc*; Alexandra Nadeau, PhD; Audrey-Anne Brousseau, MD, MSc; Marcel Émond, MD, MSc; Judy Lowthian, PhD, MPH; Simon Berthelot, MD, MSc; Andrew P. Costa, PhD; Fabrice Mowbray, RN; Don Melady, MD, MSc; Krishan Yadav, MD, MSc; Christian Nickel, MD; Peter A. Cameron, MD, MBBS *Corresponding Author. E-mail: [email protected], Twitter: @EM_ULaval.

This scoping review aimed to synthesize the available evidence on the epidemiology, patient- and caregiver-associated factors, clinical characteristics, screening tools, prevention, interventions, and perspectives of health care professionals in regard to elder abuse in the out-of-hospital or emergency department (ED) setting. Literature search was performed with MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, PsycINFO, and the Cochrane Library. Studies were eligible if they were observational or experimental and reported on elder abuse in the out-of-hospital or ED setting. A qualitative approach, performed independently by 2 reviewers, was used to synthesize and report the findings. A total of 413 citations were retrieved, from which 55 studies published between 1988 and 2019 were included. The prevalence of elder abuse reported during the ED visit was lower than reported in the community. The most commonly detected type of elder abuse was neglect, and then physical abuse. The following factors were more common in identified cases of elder abuse: female sex, cognitive impairment, functional disability, frailty, social isolation, and lower socioeconomic status. Psychiatric and substance use disorders were more common among victims and their caregivers. Screening tools have been proposed, but multicenter validation and influence of screening on patient-important outcomes were lacking. Health care professionals reported being poorly trained and acknowledged numerous barriers when caring for potential victims. There is insufficient knowledge, limited training, and a poorly organized system in place for elder abuse in the out-of-hospital and ED settings. Studies on the processes and effects of screening and interventions are required to improve care of this vulnerable population. [Ann Emerg Med. 2020;75:181-191.] 0196-0644/$-see front matter Copyright © 2019 by the American College of Emergency Physicians. https://doi.org/10.1016/j.annemergmed.2019.12.011

INTRODUCTION Elder abuse is a global health problem. Epidemiologic surveys in community-dwelling older adults living in highincome countries have shown prevalence rates ranging from 7.6% to 10%.1-5 People living with dementia are victims of domestic physical (11%) and psychological abuse (19%).6 Furthermore, across low- and middle-income countries, it is estimated that 15.7% of people aged 60 years and older are subjected to some form of abuse.7 Because older adults are proportionately the highest consumers of emergency department (ED) care and because the population is ageing, ED care professionals need to be able to identify and intervene when elder abuse is suspected.8 However, there is a consensus among clinicians and researchers focusing on geriatric care that elder abuse is likely one of the most underrecognized and underreported conditions in the out-of-hospital and ED settings.9-11 Elder abuse is complex and clinicians are confronted with multiple barriers affecting the care they provide to potential victims of elder abuse.9,10 For instance, the initial presentation involves a large range of behaviors and varies widely from seemingly trivial physical injury to psychological distress or malnourishment; and the ED screening and reporting Volume 75, no. 2 : February 2020

processes can be further complicated with ethical, legal, and logistic challenges.12,13 Nevertheless, the out-of-hospital and ED environments are unique in that they provide an important opportunity to care for vulnerable populations.9 The ED is often the only interface with formal health care services for older adults who are victims of abuse because they are less likely to have regular medical follow-up.9,14 Furthermore, the consequences of abuse extend well beyond the immediate event and carry significant morbidity. Abuse has been linked to long-term debilitating psychological effects, including anxiety, depression, and suicidal ideation,15,16 as well as increased risk of hospitalization,17 long-term facility placement,18 and death.19-21 Delay in recognizing elder abuse has a detrimental effect on the patient’s quality of life and outcome. Accordingly, elder abuse has been identified as one of the most important geriatric research priorities.22,23 This scoping review was conducted to develop a knowledge base for acute care and research related to elder abuse. The aims were to synthesize current knowledge in regard to elder abuse in out-of-hospital and ED settings. Specific objectives were to describe the epidemiology, Annals of Emergency Medicine 181

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patient and caregiver factors associated with abuse, clinical presentation, screening tools, prevention strategies, interventions, and ED care professionals’ knowledge and perspectives about elder abuse.

narrative, or systematic), editorials, and letters to the editor were scrutinized and citation tracking was conducted to retrieve potentially relevant studies. Unpublished data were sought through the examination of relevant conference or congress abstracts.

MATERIALS AND METHODS We followed published guidance for conducting a scoping review.24 The study protocol was initially developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols (PRISMA-P) statement25 (Appendix E1, available online at http://www.annemergmed.com). The reporting was based on the PRISMA Extension for Scoping Reviews Checklist26 (Appendix E2, available online at http://www. annemergmed.com). This study was approved by the Université Laval ethics review committee. Studies were considered eligible for inclusion if they were original studies reporting on elder abuse in the out-ofhospital setting, ED, or trauma reception units. Case series (2 patients), retrospective or prospective observational studies, and trials were considered, whereas individual case reports were excluded. Studies performed in the community, in long-term care facilities, or during hospitalization were not included unless data from the ED were independently presented. In accordance with the United Nations’ working definition, patients aged 60 years or older were considered older adults.27 Therefore, studies reporting on patients younger than 60 years were excluded unless data for older adults could be extracted. Elder abuse and neglect were defined as action or negligence against a vulnerable older adult that causes harm or risk of harm, either committed by a person in a relationship with an expectation of trust or when an older person is targeted according to age or disability.28 Specific definitions of abuse and neglect in each study were considered if they were in accordance with described concepts of abuse and neglect. The following forms of elder abuse were considered: physical, sexual, financial, emotional/psychological, and neglect. Self-harm was excluded. An electronic search review of the peer-reviewed literature was conducted with 5 databases: MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health, PsycINFO, and the Cochrane Library (from inception to May 8, 2019) (see Appendix E3 [available online at http://www.annemergmed.com] for the MEDLINE search strategy). A dedicated search strategy was created for each database with the help of a medical librarian. There were no language, publication status, or date restrictions applied. Previous reviews (invited,

Data Collection and Processing EndNote X9 (Clarivate Analytics, Philadelphia, PA) was used to combine citations and remove any duplicates. All citations were independently reviewed by 2 authors (E.M. and A.N.) using the title, the abstract, and the complete article when needed. A full-text review was conducted for all included abstracts. Disagreements were resolved by consensus. Two reviewers, one emergency physician with epidemiology training and one PhD in psychology (E.M. and A.N., respectively), independently extracted the relevant data from the included studies, using a standardized Excel form (Appendix E4, available online at http://www.annemergmed.com). Data extracted and findings from each study were compared and consensus between the 2 reviewers was used to resolve disagreements. Authors of included or potentially included studies were contacted if relevant data were not available. Given the nature of a scoping review, risk of bias and quality appraisals were not performed.24

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Data Presentation Seven domains (epidemiology, factors associated with elder abuse, screening tools, clinical characteristics and presentation, prevention, interventions, and knowledge or perspectives of ED care providers in regard to elder abuse) were predetermined by expert consensus to guide the reporting of the results. Studies were classified in the domains they were relevant to. Subsequently, data were combined by domains in the Excel form. Data were further synthesized across all domains. No coding was used. When 2 studies reported a similar finding, they were presented in parallel, whereas studies with different results were compared. Where appropriate, study results were contextualized. When a domain was completed, the synthesis was sent to an external group of coauthor experts (2 or 3) along with the included articles. No statistical analysis or pooling was conducted because of heterogeneity of the data. RESULTS The search strategy yielded 413 citations, from which 92 full articles were reviewed (Figure 1). A total of 55 studies met the inclusion criteria and were included. All included Volume 75, no. 2 : February 2020

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Iden fica on

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Records iden fied through database searching (n = 735)

Addi onal records iden fied through other sources (n = 7)

Screening

Records a er duplicates removed (n = 413)

Records screened (n = 413)

Eligibility

Records excluded (n = 321) Full-text ar cles assessed for eligibility (n = 92)

Included

Records excluded (n = 37)

Studies included in qualita ve synthesis (n = 55)

No original content (n=22) No out-of-hospital or ED (n=5) No elder abuse (n=10)

Figure 1. Flow diagram of included studies.

studies were in English and published between 1988 and 2019. The majority (50 studies) came from North America and 5 from elsewhere. The characteristics and the main findings of the included studies are presented in Table E1 (available online at http://www.annemergmed.com). Epidemiology Elder abuse was infrequently identified in the ED.29-33 The prevalence was assessed in 2 prospective studies. In a cohort study of 138 older adults on the prevalence of nonmedical problems in the ED, 9 patients (6.5%) reported psychological or physical abuse to a research assistant, whereas none were identified in the medical record.34 During the development of the Emergency Department Senior Abuse Identification tool, 7% of patient screened positive for suspected elder abuse.35 Among professionals surveyed, 90% recalled having encountered at least 1 case of suspected elder abuse during their career,36 whereas approximately 50% remembered identifying at least 1 case within the last 6 to 12 months.37-40 Reporting of suspected cases to law enforcement authorities Volume 75, no. 2 : February 2020

by emergency physicians and other acute care professionals varied widely.36,37,41 Paramedics had the highest reporting rate.38,41,42 The average annual rate of ED visits was 2.11 for older adults who were known victims of elder abuse in the community compared with 0.74 visit per patient per year for older adults with no previously reported abuse.43 Patients with verified cases of physical abuse presented to the ED more frequently before the identification of abuse than nonabused older adults, and 66% had at least 1 recent ED visit related to a physical injury.44 Also, victims of elder abuse previously identified during home care assessments tended to present more frequently to the ED after the home care assessments, mostly for low-acuity conditions.45 The most common type of elder abuse identified in the ED was neglect,29,36,37,46 followed by physical abuse.29,36,46 Some authors reported distinctions between willful neglect and unintentional neglect.47 Psychological abuse was less frequently identified in the ED.36,43,46,48 Finally, financial abuse36,46 and sexual abuse36 were rarely identified in the ED. When neglect was detected, there was Annals of Emergency Medicine 183

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a high probability that the person also screened positive for physical abuse, psychological abuse, or both.49 Abuse was associated with longer inhospital length of stay29,32,50 and a higher likelihood of being discharged to a long-term care facility.32 Approximately 25% of patients died in the 6 months after identification of neglect in the ED.48 Factors Associated with Elder Abuse Female sex was more common in identified cases of neglect and physical abuse in the ED literature.29,31,43,44,48,51-53 No association between age and abuse was reported in most studies, with the exception of a retrospective cohort including 1,467 cases of elder abuse from the US Nationwide Emergency Department Sample 2012 database, in which most identified victims were aged 60 to 69 years.50 Among other factors, a higher frailty score,45,54 a lower level of education,43 and psychiatric55 and drug or alcohol abuse disorders52,55 were more prevalent in abused older adults. Another frequently reported factor common to identified cases of abuse was the presence of cognitive impairment and dementia.45,46,48,52,55 Problematic behaviors such as being physically or verbally aggressive, as well as an inability to sleep at night, were triggers to physical abuse leading to ED visits.46 Patients with dementia who received a diagnosis of a fracture in the ED exhibited more forensic markers of abuse, such as poor hygiene and bruises, than those who consulted in an outpatient setting.56 Overall, the level of dependence on the caregiver seemed to have an influence on the risk of being physically abused or neglected. This dependence can take several forms. Dependence in daily life activities because of physical limitations was more common with physical abuse in a trauma registry study.52 From a medical perspective, patients with complex chronic diseases such as chronic obstructive pulmonary disease were more likely to be victims of neglect.44,52 Also, neglected older adults were more frequently dependent on their caregivers for help with ambulation, feeding, and personal hygiene compared with nonneglected older adults.49 Urinary and fecal incontinence, unmet need for assistance with activities of daily living, lack of support, and social isolation were more common in patients identified as victims of physical abuse and neglect.46,49,51,55 Finally, the type of abuse seemed to vary according to mobility status. Bed-bound patients seemed to be more often victims of neglect than physical abuse, whereas ambulatory community-dwelling patients were more frequently victims of physical abuse, with 82% of physically abused older adults being independently mobile in a single cohort.31 However, most included 184 Annals of Emergency Medicine

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studies did not differentiate the subgroups of elder abuse, although they might have different risk factors and patient characteristics. In a study of 36 cases of elder abuse in the ED, the perpetrators had provided home care for an average of 10.5 years.46 They were more frequently a relative of the abused older adult,46 with the son being the most frequently involved perpetrator, although spouses, daughters, grandchildren, and other relatives have been involved.48 In an ED study comparing neglected with nonneglected older adults, paid caregivers were significantly more likely to be neglectful than those who provided care without pay.54 Previous childhood trauma, lower socioeconomic status, and poorer health status were factors associated with neglectful caregivers.54,55 Psychiatric and substance abuse disorders were frequent among perpetrators,46,55 as was being the sole caregiver of a patient.54,55 Patients unaccompanied by the caregiver during the ED visit were more likely to screen positive for neglect.49 Financial dependence on the caregiver was also associated with abuse but commonly overlooked in the ED.46,48,49 Screening for Elder Abuse The utility of screening tools was often limited by the available time and the interview process required. Although it was suggested that the ideal screening tool for elder abuse should be brief, with dichotomous questions, and should not require questioning the older adult or the caregiver,42,47 most developed tools did not fulfill those criteria.59 In regard to the role of each health care professional when confronted with a situation in which abuse was suspected, a Delphi study identified 192 specific roles integrated in a model of elder abuse intervention.60 Paramedics, nurses (at triage and during care), emergency physicians, radiologists, radiology technicians, and social workers were presented with specific roles.28,61 Furthermore, the rate of detection varied according to the screener’s experience, with an expert clinical team demonstrating higher neglect detection rate than ED clinicians.54 Improved communication between clinicians and radiologists was also proposed to enhance the role of radiologists in recognizing potentially suspicious injuries.62 Three screening tools are presented in the Table. One of these tools, the Detection of Elder Abuse Through Emergency Care Technicians, was developed for the outof-hospital setting, whereas 2 tools, the Elder Assessment Instrument and the Emergency Department Senior Abuse Identification, were studied within an ED.35,59,63 Characteristics of these tools are presented in the Table. In the out-of-hospital setting, after the implementation of the Detection of Elder Abuse Through Emergency Care Volume 75, no. 2 : February 2020

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Table. Elder abuse screening tools studied in the out-of-hospital or ED setting. Screening Tool

Components

Reported Characteristics and Applicability in the ED

Detection of Elder Abuse Through Emergency Care Technicians

Total: 26 items; 8 domains of elder abuse encountered by paramedics

Relies entirely on the paramedic observations of the older adults’ physical and social environment64 Intended to determine the need for making referral64

Elder Assessment Instrument

Total: 41 items General assessment (5 items) Possible abuse indicators (7 items) Possible neglect indicators (14 items) Possible exploitation indicators (6 items) Possible abandonment indicators (4 items) Summary (5 items)

Easy to use in the ED63 High sensitivity (71%) and specificity (93%) to detect abuse63 Subjective scale more likely to result in inconsistent and biased ratings59

Emergency Department Senior Abuse Identification

Cognition: Ottawa 3DY Elder abuse questions (5 items) Physical examination (findings potentially suggestive of abuse and special circumstances; 12 items)

Good interrater reliability, sensitivity (94%), and specificity (90%)35

Technicians tool, the number of monthly reports of suspected elder abuse to the proper authorities increased by 5.4 (226%).64 This 26-item tool was used as a screening tool aiming to identify patients who might benefit from a referral for elder abuse assessment. The Elder Assessment Instrument and the Emergency Department Senior Abuse Identification were studied in the ED. The Elder Assessment Instrument is a 41-item elder abuse assessment tool that incorporates potential indicators of neglect, abuse, and exploitation.35,59,63 The Emergency Department Senior Abuse Identification is shorter and includes a cognitive assessment; in a single study, assessment with the tool was performed by research assistants who thereafter mentioned the results of a potential case of abuse to the emergency physician. This increased the number of detected elder abuse cases. One ED study suggested that the Identification of Seniors at Risk tool, usually used to predict functional decline, could determine who should be screened for abuse because functional decline is a potential risk factor for abuse. The tool has no specific elder abuse content and this was not replicated elsewhere.65 No screening processes and tools have been validated in a multicenter study, but research supported by the National Institute of Justice to develop and validate an ED screening tool for elder abuse is ongoing. Finally, the effects of screening patients for elder abuse on patient-oriented outcomes were not assessed by the included studies. Two studies showed that only 16.0% to 43.0% of ED health care professionals would be comfortable asking a direct question about elder abuse when confronted with potential mistreatment.36,37 In a survey of multidisciplinary ED health care professionals, a majority of the respondents believed that it is the older person’s responsibility to report Volume 75, no. 2 : February 2020

the abuse.57 Approximately one third of identified abused older adults directly reported an abusive relationship during their ED visit.46,48 The patient interview was frequently cited by the ED professional as the key factor leading to heightened suspicion of elder abuse.36 The potential influence of the interview’s location and timing on the identification rates were not addressed by the included studies. Fear of increased risk of further harm can contribute to the reluctance to report a situation.46 Patients with mild to moderate cognitive impairment had the ability to report the abuse.58 Presentation and Clinical Characteristics Most identified victims of physical abuse or neglect presented to the ED by ambulance, with 80% of presentations being for an injury sustained the same day.31,49 The main complaints leading to ED visits by older adults who were known victims of elder abuse were often vague and involved a trauma or a psychiatric disorder rather than a sole medical complaint.46 In the Nationwide Emergency Department Sample database, contusion, urinary tract infection, and septicemia were common ED diagnoses in verified victims of abuse at home.29 Injuries were also common both as the presenting complaint and the discharge diagnosis during ED visits before the identification of abuse.44 In a large Canadian cohort study, ED diagnoses were similar between patients who previously screened positive for elder abuse during home care assessments and those who did not.45 Acute intoxication was the only diagnosis found to be associated with elder abuse, with those receiving such a diagnosis representing a higher proportion of older adults reporting abuse.45 In the 5 years before the identification of abuse, 65.8% of patients had at least 1 visit with an International Annals of Emergency Medicine 185

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older adult victims of neglect tended to consult tardily compared with physically abused older adults.48 Elder neglect can be difficult to recognize and diagnose because it is often confounded with end-of-life physiologic states.47 Finally, cluster presentations from intentional administration of substances such as opioids were described and successfully identified by ED care professionals, highlighting the need for real-time injury sentinel surveillance programs.71 Initial appearance, complete head-to-toe evaluation, and documentation of all physical findings were highlighted as important by expert consensus.72 A standardized tool to document clinical findings was proposed, but challenges including additional clinician burden, parallel documentation, and difficulty with integration into existing electronic medical records were identified.72 If needed, injuries could be photographed by nonprofessionals when a protocol was used.73 Physicians were later reliably able to characterize the size and location of the injury and the type of bruising by using this photography.73 Prevention of Elder Abuse No out-of-hospital or ED studies dedicated to primary prevention of elder abuse were identified.

Figure 2. Common findings in cases of identified elder abuse.

Classification of Diseases, Ninth Revision injury code and 37.8% had at least 1 visit deemed to be of a high probability of being related to abuse.44 In a prospective study specifically examining nonmedical complaints with ED bedside interviews in cognitively intact older adults, otherwise undetected psychological and physical abuse was frequent.34 Figure 2 summarizes the history, trauma mechanism, clinical, radiologic, and laboratory findings most common in identified victims of elder abuse. In regard to physical findings associated with physical abuse, two thirds of the injuries were located on the upper extremities and the maxillofacial region.66,67 Unfortunately, although specific injury patterns may be associated with nonaccidental trauma, current out-of-hospital and ED research was mostly inconclusive.44,68,69 Fractures of the distal ulnar diaphyseal were rarely sustained during accidental injuries and could be associated with self-defense against an assault.70 Overall, there was no recognized pathognomonic pattern of injury linked to physical abuse and there was no convincing evidence that some physical injuries distinguish accidental from nonaccidental trauma. In regard to neglect, 186 Annals of Emergency Medicine

Interventions Literature pertaining to out-of-hospital or ED-initiated interventions was scarce. A multidisciplinary approach was suggested to leverage the perspectives and competencies of every health care professional involved. For instance, paramedics often enter a patient’s residence, giving them unique insight into living arrangements and concerns that may arise from informal observation.42 This information can be used to guide clinical practice and plan for a safe transfer of care into the community. Social workers should be key members of any multidisciplinary team caring for an older adult because they have a distinct skill set to identify and address social concerns that commonly accompany ill older adults. In a small series of identified cases, 58% of older adults were referred to social services,31 whereas the police were involved in 82% of cases.1 The admission rate for older adults with suspected abuse was between 12.0% and 88.1%.44,48,50 A study published in 1994 and conducted in the United States showed that standard operating procedures for reporting suspicious cases to state agencies and referrals for additional services were most likely to exist where reporting was regulated by state laws.30 In this study, trauma centers were also more likely to have an established referral procedure in place compared with general hospitals.30 Volume 75, no. 2 : February 2020

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No intervention specific to out-of-hospital care was studied. In April 2017, a new multidisciplinary ED-based intervention for potential victims of elder abuse, the Vulnerable Elder Protection Team program, was launched in New York City.74 The team is a multidisciplinary 24hour consultation service that may be activated by any ED care professional. The goal of this service is to screen for potential mistreatment, and to connect with the appropriate resources to ensure safe discharge and adequate follow-up. The initial assessment is performed by a social worker, who then contacts the Vulnerable Elder Protection Team medical provider. Before the implementation of this program, all ED providers were trained on potential signs associated with elder abuse. Health Care Professionals’ Knowledge and Perspectives The rate of elder abuse identification in the ED is low; the proportion of older adults with a formal diagnosis of elder abuse is estimated to be 0.01% to 0.03%.34,36,41,57 According to health care professionals, the lack of training for diagnosis, intervention, documentation, and reporting is likely to contribute to current low rates of recognition.32,34,61,75,76 The lack of a screening tool adapted for the fast-paced and crowded ED has also been identified as an important barrier to identifying potential cases.76,77 Health care professionals reported having poor knowledge on elder abuse.33,78 Between 24% and 75% of emergency physicians and nurses did not recall receiving any formal training on this topic.36,59,79 Among individuals who could state that they received training, 83% considered that it was insufficient37 or, despite the training, considered they were unprepared to assess for elder abuse.80 One study showed that a short didactic lecture followed by simulated patient scenarios was potentially useful to improve clinician confidence in diagnosing elder abuse.81 However, in another similar study, only 23% of individuals demonstrated knowledge retention and were confident in recognizing more subtle elder abuse presentations after a didactic session.76 Figure 3 presents the identified barriers relative to the reporting of elder abuse when it is suspected or confirmed. The barriers most frequently reported were the associated emotional burden and moral anxiety42,47,75,77,80,82 and the insufficient community resources availability to respond.32,36,37,76 Lack of reporting procedures was also an important concern. For instance, only 14 of 35 statewide paramedic protocols (eg, systems protocols, procedures, guidelines) had content concerning elder abuse.83 To help improve health care professionals’ awareness and comfort with elder mistreatment, it was suggested that Volume 75, no. 2 : February 2020

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all ED professionals receive training, and all EDs should have a standardized well-established reporting procedure.75 Availability of social workers and case managers in the ED was also considered an important facilitator to assist screening and reporting of suspected cases.36 LIMITATIONS Our findings should be considered in light of some limitations. Most studies were undertaken in North America, potentially limiting worldwide generalizability because cultural variations may influence the care of older adults and because of the social acceptability of different attitudes and behaviors. Furthermore, included studies were limited in terms of sample size, methodological quality, and long-term follow-up, with no randomized controlled trials and few studies identified as using a prospective design or a comparison group. Given the purpose of a scoping review, risk-of-bias and quality appraisals were not performed.24 Also, data from 5 included studies were available only as an abstract. The effect of elder abuse detection and interventions on patientimportant outcomes in the ED is unknown. The definition of elder abuse was also of concern because different studies used various definitions without standardization, but the underlying concepts were similar. Finally, available data are limited to cases of abuse that were identified by health care professionals. The generalizability of those findings to the whole population of elder abuse victims is unknown. DISCUSSION This scoping review highlights a lack of evidence relative to identification and notification of elder abuse among outof-hospital and ED health care professionals. To our knowledge, this is the first such review to be undertaken. Although challenging, global out-of-hospital and ED care for older adults who are potential or known victims of elder abuse can be improved. Results from preliminary studies have shown that a screening process is feasible, and training can be provided to health care professionals, leading to increased awareness and reporting rates. However, to improve care of this vulnerable population, important knowledge gaps and barriers need to be promptly addressed. First, physical abuse and neglect were consistently underrecognized in the ED in comparison to the reported prevalence in the community.29-32 It is, however, not surprising that a single ED visit could be insufficient to arouse suspicion of elder abuse because a study of nursing in-home care visits concluded that an average of 10.5 visits is needed to detect cases of abuse.84 Nevertheless, out-of-hospital and ED screening lacks widely validated Annals of Emergency Medicine 187

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Figure 3. Perceived barriers relative to elder abuse reporting by health care professionals.

processes and easy-to-use tools. For instance, the Detection of Elder Abuse Through Emergency Care Technicians tool is the only one developed for the out-ofhospital setting.64 It was shown to improve reporting rates in a pilot study, but its generalizability, acceptance, and effect on patient-important outcomes are unknown.64 The Emergency Department Senior Abuse Identification, the only screening tool developed specifically for the ED setting, is also promising, with good interrater reliability, but multisite validation is lacking.35 Furthermore, the individual role and value of potential abuse indicators, such as higher functional disability, mood disorders, or atypical injuries, as triggers to initiate screening are unclear.45,85,86 The optimal interview process is also uncertain. To maximize the potential for disclosure, interviews in a secure and private environment may encourage patients to speak more freely. Using moments such as the out-of-hospital transport or medical imaging could be helpful.29 Caregivers should also be involved in the screening because they are sometimes willing to report abusive behavior, often verbal but rarely physical.87 Elder abuse is a hidden phenomenon and innovations are required to enhance detection.11 Future studies should address the optimal interview and screening processes to enhance detection but also consider how this screening may affect patient-important outcomes. Second, increasing awareness of clinicians is a key step toward improving the care of this population. Multiple studies have demonstrated the inadequate training and insufficient knowledge relative to elder abuse that contribute to poor detection rates.33,78 In addition to didactic sessions, case-based learning and multidisciplinary 188 Annals of Emergency Medicine

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simulations have been proposed as potential pedagogies.88 Web sites dedicated to geriatric out-of-hospital and ED care and education, including basic knowledge and clinical pearls, can also be used to improve knowledge and deliver continuous medical education. Third, even when abuse is suspected, multiple barriers prevent reporting such as fear of further harm and potential legal implications for the health care professional involved.47 Standardized protocols addressing the procedures that should be followed to report a case of suspected elder abuse are critical. They need to be developed and promoted at local, regional, and provincial levels. Those protocols could also alleviate the anxiety faced when a case of elder abuse is reported. Furthermore, although some institutional programs relative to elder abuse have been described and implemented, most have focused solely on education and only half have evaluated their influence.89 Unfortunately, integration of the ED in those programs was often overlooked.89 Furthermore, inadequate community resources to respond to suspicious cases of elder abuse were often identified as a barrier by health care professionals.32,36,38,76 Data linkage between ED health care professionals, general practitioners, and community-based professionals could facilitate follow-up on provider suspicion. Finally, few studies have evaluated the effect of interventions that target older adults who experienced abuse or that target perpetrators on short- and long-term outcomes in the community.90 Data on prevention are even more limited.90 Out-of-hospital or ED-initiated interventions that could be linked to the community should be developed and studied. Fourth, acute care systems are also often poorly organized to support and facilitate screening and to help initiate management in the ED. Older adults have specific needs, including necessary social supports, that are often inadequately met by current models of care.91 Furthermore, the traditional ED model of care is challenged with time pressures, resulting in inadequate assessments, diagnoses, and treatments for this complex patient cohort.91 Victims of elder abuse are prone to utilize the ED rather than other care settings and are less likely to have regular medical follow-up,10,14,34 emphasizing the key role of frontline professionals. Creating geriatric-friendly physical environments and processes might facilitate and improve the global care of older adults, including those who are victims of elder abuse.92 For instance, multidisciplinary training, established protocols, and data linkage with community services are all integrated in geriatric-friendly EDs and would facilitate the care of potential victims of elder abuse. Prevalence of elder abuse in the ED was lower than that reported in community and outpatient settings; however, it Volume 75, no. 2 : February 2020

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is likely to be underrecognized and underreported because of current ED processes. The most commonly detected type of elder abuse in the ED was neglect, followed by physical abuse. Female sex, cognitive impairment, lower level of education, higher level of functional disability, higher frailty, social isolation, psychiatric comorbidities, and substance use disorders were more common in victims of elder abuse. There is an urgent need to improve care of this vulnerable population by developing and validating screening tools and interventions for out-of-hospital and ED clinicians, as well as training them to recognize and act on suspected elder abuse. Supervising editor: Timothy F. Platts-Mills, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/ editors. Author affiliations: From Centre de recherche sur les soins et les services de première ligne de l’Université Laval, Quebec, Canada (Mercier, Nadeau, Émond); Centre de recherche du CHU de Québec, Quebec, Canada (Mercier, Nadeau, Émond, Berthelot); Département de médecine d’urgence, l’Université de Sherbrooke, Sherbrooke, Quebec, Canada (Brousseau); Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia (Lowthian, Cameron); Bolton Clarke Research Institute, Melbourne, Victoria, Australia (Lowthian); Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Costa, Mowbray); the Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada (Melady); the Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada (Yadav); and the University Hospital of Basel, Basel, Switzerland (Nickel). Author contributions: EM led study conceptualization and wrote the first draft of the protocol with input from all the authors. Database search strategies were elaborated by AN. EM and AN screened all citations, selected studies, and extracted data from included studies. EM and AN performed the first data synthesis and wrote the first draft of the manuscript. Based on each authors’ expertises, specific domains were reviewed by a group of coauthors (ME, JL and AC: epidemiology and factors associated with elder abuse; AAB, DM, PAC and KY: screening and clinical characteristics; SB, FM and CN: prevention, interventions, and health care professional’s knowledge and perspectives). EM and AN then combined the comments obtained. All authors then critically revised the manuscript as a whole and suggested changes. All authors approved the final revised manuscript. EM takes responsibility for the paper as a whole. All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Volume 75, no. 2 : February 2020

Elder Abuse Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This work was supported by a research grant from the Département de médecine familiale et de médecine d’urgence de la Faculté de Médecine de l’Université Laval. Publication dates: Received for publication August 15, 2019. Revisions received November 14, 2019 and December 5, 2019. Accepted for publication December 6, 2019. REFERENCES 1. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63:S248-S254. 2. Brozowski K, Hall DR. Aging and risk: physical and sexual abuse of elders in Canada. J Interpers Violence. 2010;25:1183-1199. 3. Burnes D, Pillemer K, Caccamise PL, et al. Prevalence of and risk factors for elder abuse and neglect in the community: a populationbased study. J Am Geriatr Soc. 2015;63:1906-1912. 4. Peterson JC, Burnes DP, Caccamise PL, et al. Financial exploitation of older adults: a population-based prevalence study. J Gen Intern Med. 2014;29:1615-1623. 5. Amstadter AB, Begle AM, Cisler JM, et al. Prevalence and correlates of poor self-rated health in the United States: the National Elder Mistreatment Study. Am J Geriatr Psychiatry. 2010;18:615-623. 6. McCausland B, Knight L, Page L, et al. A systematic review of the prevalence and odds of domestic abuse victimization among people with dementia. Int Rev Psychiatry. 2016;28:475-484. 7. Yon Y, Mikton CR, Gassoumis ZD, et al. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Global Health. 2017;5:e147-e156. 8. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011;68:131-155. 9. Phelan A. Elder abuse in the emergency department. Int Emerg Nurs. 2012;20:214-220. 10. Bond MC, Butler KH. Elder abuse and neglect. Definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29:257-273. 11. Beach SR, Carpenter CR, Rosen T, et al. Screening and detection of elder abuse: research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse. J Elder Abuse Negl. 2016;28:185-216. 12. Lachs M, Pillemer K. Elder abuse. N Engl J Med. 2015;373:1947-1956. 13. Allison EJ, Ellis PC, Wilson SE. Elder abuse and neglect: the emergency medicine perspective. Eur J Emerg Med. 1998;5:355-363. 14. Bridges J, Meyer J, McMahon K, et al. A health visitor for older people in an accident and emergency department. Br J Community Nurs. 2000;5:75-80. 15. Wu L, Shen M, Chen H, et al. The relationship between elder mistreatment and suicidal ideation in rural older adults in China. Am J Geriatr Psychiatry. 2013;21:1020-1028. 16. Hybels CF, Blazer DG. Epidemiology of late-life mental disorders. Clin Geriatr Med. 2003;19:663-696, v. 17. Dong X, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013;173:911-917. 18. Lachs MS, Williams CS, O’Brien S, et al. Adult protective service use and nursing home placement. Gerontologist. 2002;42:734-739. 19. Schofield MJ, Powers JR, Loxton D. Mortality and disability outcomes of self-reported elder abuse: a 12-year prospective investigation. J Am Geriatr Soc. 2013;61:679-685.

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