Elder Abuse:  Identification and Reporting by Physicians

            One of the fastest-growing demographic in America are older Americans. America is aging, rapidly. Since 1900, the percentage of Americans aged 65 and older, nearly quadrupled (from 4.1% in 1900 to 16.5% in 2019), and the number increased more than 17 times (from 3.1 million to 54.1 million). In 1950, 8% of the US population was aged 65 and over. Of total US population of 328.3 million in 2019 (World Bank, 2019), 54.1 million were aged 65 and older. The percentage of Americans aged 65 and older is projected to increase to 21.6% or 80.8 million in 2040. America’s 65-and-over population is nominally projected to nearly double over the next three decades, to 88 million by 2050, (Statista Research Department, Oct 28, 2021). In the next nine years (by 2030) elderly Americans will account for 73,100,000 or one in five citizens. By 2034, for the first time in U.S. history, elderly Americans will outnumber America’s children. 

The National Council on Aging (NCOA) in its January 2021 article, “Get the Facts on  Healthy Aging” estimates that not only will the elderly 65 and older population increase to 98 million in 2060, but that as of current period, the age expectancy of an average 65-year-old American is 84 years. Good health and healthy living are critical to elderly Americans maintaining their independence and remaining productive and engaged during their golden years. Undeniably, chronic diseases (including heart problems, cancer, stroke, Alzheimer’s and  

respiratory diseases, and diabetes), behavioral and mental health illness, inactivity, poor dental health and falls, negatively impact the quality of life of elderly Americans (NCOA, 2021).      

            Not only is America progressively aging, but chronic diseases affect the elderly population more than any other population segment. According to NCOA, 2021, more than 4 in 5 elderly Americans suffer from at least one chronic disease. For those elderly Americans receiving Medicare, almost 70% of this group suffers from two or more chronic conditions and account for 93% of all Medicare dollars spent. Continues NCOA 2021, aged Americans with two or more chronic diseases are responsible for two-thirds of all health care costs. These chronic diseases have a detrimental impact on the health of elderly Americans and contribute to them losing their independence, becoming homebound, and requiring long term care or increasingly, institutional care. 

In this paper, we will be looking at how physicians may have the opportunity to identify abuse in elderly patients with whom they come into contact with, and whether the physicians are equipped with the knowledge and the support of their institution’s procedures to evaluate, identify  and support elderly patients who may be subjected to elder abuse. Although elderly Americans die primarily from falls and the non-fatal injuries of falls, the exposure of physicians to injured elderly Americans is significant. According to Pereira, 2021, a public health problem is created just from violence against and falls by elderly people which results in injury, sedentary behavior and sometimes death, social and emotional isolation, fear and dependence on the perpetrators. In looking only at how falls affect America’s elderly population, NCOA, 2021 reports that every year, 25% of the elderly sustain a fall. This translates to an elderly person receiving emergency room treatment each 11 seconds. Elders who are abused are 3 times more likely to die than elders who are not abused, yet these abused individuals are less likely to report sexual, physical, emotional or neglect abuse than are elderly who report financial abuse (which amounts to as much as $36.5 billion each year) NCOA, February 2021. 

According to NCOA, February 2021, as many as 5 million elderly Americans are abused each  year, which translates to one in every 10 elderly American. Of those abused elderly Americans, only 4% of those abused Americans are identified as abused and are reported to authorities. The National Center on Elder Abuse in its article “Get the Facts on Elder Abuse”, February 2021, distinguishes between seven different types of elder abuse. These include physical abuse, sexual abuse, emotional abuse, financial/material exploitation, neglect, abandonment, and self-neglect. While emotional abuse often coexists with other forms of abuse, and it is the most difficult to identify, it is the extremely pertinent statistic that, every year, 25% of the elderly sustain a fall; which translates to an elderly person receiving emergency room treatment each 11 seconds.

According to Weill Cornell Medicine, Emergency Medicine, abuse of the elderly more likely occurs in the home rather than outside the home. Although this abuse may occur because of the elderly person’s age, disability or vulnerability when associating with trusted person with ill-intentions, when an elderly person suffers sever life threatening abuse, they are more likely to present themselves to the Emergency Department for treatment of their acute physical injuries as compared to them visiting their primary-care physician for the treatment of less severe injuries. When abused elderly Americans sustain injuries that warrant medical attention, they are more apt to visit an Emergency Department than they are to visit their primary care physician. Continues the Weill Cornell Medicine, Emergency Medicine article, because a patient is likely to be in the Emergency Department for several hours, there are ample opportunities for medical personnel to identify elder abuse because the elder is likely to be attended to by medical staff across multiple disciplines. Health Care workers should feel honored since they are positioned to be the professional who may best be able to identify and report suspected elder abuse cases (Ferreira et al, 2015). However, the question  under review is “how prepared and trained are physicians and members of the Emergency Department to report elder abuse/mistreatment once it has been recognized?” 

Though elderly abuse occurs in approximately 5% to 10% of the elder population, less than 5% of abuse cases are identified and reported (Rosen, T et al, 2016). Continues the authors, abuse related illness (including depression and dementia) and sometimes even death occur because of the abuse towards the elderly. Abuse of the elderly is not just limited to the home, but the elderly are abused in elderly communities and also skilled nursing facilities, where abuse may be committed by both residents and members on staff. According to Rosen, T et al, 2016, although it is difficult to identify abuse of the elderly, this abuse of the elderly costs society many billions of dollars annually. So again, the question is, what is responsible for this failure to identify and intervene in cases of suspected elder abuse? Why is it that only 5% of elder abuse cases are identified and reported, in spite of the older persons increased rate of mortality and abuse related morbidity (Rosen, T et al, 2016)?   

Rosen, T et al, 2016) believes that not only do abused elders report their abuse when visiting the Emergency Department, but medical personnel working in the Emergency 

Department should be more likely to discern elder abuse in their patients due to the spontaneous nature of emergency visits. Even if the elder is accompanied to the emergency room by the perpetrator, because of the rushed nature of the visit, the perpetrator may not be able to either hide the evidence of abuse (e.g. bruise marks) or to get the abused elder to learn and regurgitate a confabulated story to fool the hospital staff of the abuse. Rosen, T et al, 2016) refers to a study which found that of cognitively intact older patients visiting the Emergency Room, a stunning 7% reported being abused either psychologically or physically within the past 12 months. The study predicted that the abuse among elders with cognitive impairment would be even higher, and if neglect and financial abuse were also considered, the finding of elder abuse would be significantly higher than 7%.

            Why, when abused elders present to the Emergency Room, do medical personnel fail to recognize and report the abuse? According to Patel, K et al, 2021, most or 74% of Emergency Department physicians, did not believe that elder abuse was clearly defined while 58% did not believe that they could identify abuse in the elderly. Physicians do not want to risk being sued should they incorrectly identify an elder as being abused and being proved otherwise later. Continues Patel, K et al, 2021, most physicians report that they have received 10 hours or less of training in recognizing abuse signs in the elderly. Emergency personnel are adept at recognizing child abuse because they have received extensive training and there is usually an interdisciplinary approach among hospital personnel to identify the child abuse. Continues Rosen, T et al, 2016, Emergency Room personnel do not identify elder abuse with similar success because they have not received comprehensive training, because hospitals do not take an interdisciplinary approach to identifying elder abuse, because they do not believe that intervention will lead to improved quality of life of the patient, and because the medical personnel are not sure of the process which must be followed once the suspected abuse has been identified. Additionally, Rosen, Tet al, 2016 states that abuse signs are subtle and may have “non-specific” signs. Continues the authors, in the elderly, it can be tricky to distinguish between deliberate and accidental injuries, and those which might be in spite of appropriate care received. When elder abuse might be present, emergency physicians may be required to spend a significant amount of time gathering multi-sourced information. This challenge can be confounded when an unaccompanied, cognitively impaired elder presents at the emergency room (Rosen, T et al, 2016).

            Southerland, Lauren (2020) states that there are numerous reasons why Emergency Room doctors do not identify and report elder abuse and neglect, including a lack of education, there not being an easy validated screening assessments in the hospital, poor documentation, the patients being unlikely to voluntarily report, cultural barriers and medical personnel believing that they must rely on a preponderance of injuries.  

            An over-riding view of medical personnel is that there must be an interdisciplinary approach and more training by Emergency Department physicians to identify and report elder abuse. Identifying elder abuse is challenging, and all stations or specialty services that interact with the elderly person while in the emergency department, including the EMS and triage personnel, social workers, case managers, radiologists, nurses. Everyone, from the EMS personnel who may have entered the home to transport the elder to the hospital, can provide information on the condition of the home, the elder and any caregiver, to the nurse and radiologist who may be able to speak to the elder in separate from any caregiver who might accompany the elder to the hospital. Continues (Rosen, T et al, 2016), the first impressions of the hospital staff (including the triage nurse and the EMS personnel), the nurses providing bedside care, the radiologists/specialists who can identify possible injury patterns, and case managers or social workers who can evaluate and counsel the elder. Emergency Department physicians have to be willing to take on the lengthy evaluation process and the legal system in their pursuit of safeguarding our vulnerable and elderly population. 

As Patel, K et al, 2021 have determined, we need to increase the 10 hours or less training in elder abuse that most physicians self-report. Medical schools have to make training in elder care and abuse a part of residency training, as only half of residency programs currently have elder abuse training. Our population is aging and being the percentage of the elder population that is being subjected to elder abuse is on the rise. We have to develop comprehensive multi-disciplined programs within hospitals in order to identify and report elder abuse. Concurrently, physicians have to receive the necessary training to have the skills and confidence to identify elder care. Our older generations are depending on our generation of physicians to protect them from being victims of elder abuse.    

Bibliography

National Council on Aging, January 01, 2021. https://www.ncoa.org/article/get-the-facts-on-healthy-aging

National Council on Aging, February 23, 2021. https://www.ncoa.org/article/get-the-facts-on-elder-abuse

Pereira C, Bravo J, Reis G, Mendes F. Aging safely in Alentejo – understanding for action – preventing falls and violence against older people: study rationale, aims, design, and preliminary results. BMC Public Health. 2021 Nov 10;21(Suppl 2):861. doi: 10.1186/s12889-021-10807-8. PMID: 34758786; PMCID: PMC8582092.

Rosen, T., Hargarten, S., Flomenbaum, N. E., & Platts-Mills, T. F. (2016). Identifying Elder Abuse in the Emergency Department: Toward a Multidisciplinary Team-Based Approach. Annals of emergency medicine, 68(3), 378–382. https://doi.org/10.1016/j.annemergmed.2016.01.037

Weill Cornell Medicine, Emergency Medicine. Elder Abuse: The Problem, Hiding in Plain Sight, Elder Abuse. https://emed.weill.cornell.edu/divisions-programs/vulnerable-elder-protection-team-vept/elder-abuse-problem

Ferreira M, dos Santos CL, Vieira DN. Detection and Intervention Strategies by Primary Health Care Professionals in Suspected Elder Abuse. Acta Med Port. 2015 Nov-Dec;28(6):687-94. doi: 10.20344/amp.6706. Epub 2015 Dec 31. PMID: 26849751

Patel, K., Bunachita, S., Chiu, H., Suresh, P., & Patel, U. K. (2021). Elder Abuse: A Comprehensive Overview and Physician-Associated Challenges. Cureus, 13(4), e14375. https://doi.org/10.7759/cureus.14375

Rosen, T., Hargarten, S., Flomenbaum, N. E., & Platts-Mills, T. F. (2016). Identifying Elder Abuse in the Emergency Department: Toward a Multidisciplinary Team-Based Approach. Annals of emergency medicine, 68(3), 378–382.https://doi.org/10.1016/j.annemergmed.2016.01.037

Southerland, Lauren M.D. (2020). Elder Mistreatment. Microsoft PowerPoint-Elder Abuse and Neglect Final. https://ccme.osu.edu/WebCastsFiles/963Elder%20Abuse%20and%20Neglect%20-%204.pdf

U.S. – seniors as a percentage of the population 1950-2050

Published by Statista Research Department, Oct 28, 2021

https://www.statista.com/statistics/457822/share-of-old-age-population-in-the-total-us-population/

2019 https://datatopics.worldbank.org/world-development-indicators/