Eric Mercier: Elder Abuse in the Emergency Department

INTRODUCTION

Elders are proportionately the highest consumers of emergency department (ED) care.(1) With the population ageing in an unprecedented way, ED physicians need to recognize and adequately intervene on geriatric specific conditions. For instance, elder abuse is a geriatric condition that is insufficiently and inadequately addressed by current ED clinical care. ED physicians are frequently confronted to confirmed or suspected cases of elder abuse and, as of now, it remains one of the most under-recognized and under-reported condition.(2-4)

Elder abuse is defined as an 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 based on age or disability.(5). Elder abuse is surprisingly frequent although good prevalence data are scant.(6) Epidemiologic surveys from Canada and USA in community-dwelling elders have shown abuse rate ranging from 7.6 to 10%.(7-11) These numbers likely represent under-estimation, as patients needed to self-report their situation making demented patients unable to answer while dementia is a known strong risk factor to be a victim of abuse.(12) Numbers as high as 33% have been reported in the medical literature.(13, 14) A recent systematic review highlighted that 11% and 19% of demented patients are victim of domestic physical and psychological abuse, respectively.(15)

RATIONALE

ED is a unique environment that provides unequal opportunity to identify and intervene on many vulnerable populations such as elders at risk or victims of abuse.(2) Geriatric patients who are victims of abuse are more prone to use ED and are less likely to have regular medical follow-up. ED is often their only interfacing with formal health-care services(2) and their needs exceed their primary presenting problem.(16) In the context of time pressure to assess, diagnose and treat, increased awareness and development of easy, applicable and rapid screening tools are cornerstone of success. ED healthcare providers often feel poorly equipped to intervene and the training seems insufficient.(5) Therefore, the importance of appropriate training(17, 18) and the use of a multidisciplinary approach involving emergency medicine services (EMS), ED physicians, research assistants and nurses are increasingly recognised.(5, 19)

Accurate ED epidemiologic data are difficult to obtain. Although not easily quantified, it is estimated that only 5 % of elder abuse cases are recognized and less than 2% are reported by ED physicians.(20) Therefore, only a few ED cases are reported to the proper law authorities.(21)

Research on elder abuse is charged with methodological challenges including strong legal and ethical aspects. Cases of elder abuse are often complex and can be highly confronting to clinicians.(22) Initial presentation involves a large range of behaviours and varies widely from trivial physical injury to psychological distress, malnourishment and life-threatening conditions. Moreover, the consequences of abuse extend well beyond the immediate traumatic injury and carry significant morbidity. For instance, abuse has been linked to long-term debilitating psychological effects that include, but are not limited to, anxiety, depression and suicidal ideation.(23, 24) Elders victim of abuse are also at increased risk of hospitalisation(25) and long-term facility placement.(26) Furthermore, they are at increased risk of death compared with other individual presenting similar demographic characteristics and chronic physical health disorders.(27-29) Unfortunately, delay in recognising this condition has detrimental effect on the patient’s quality of life. Frequently, recognition is difficult as comorbid conditions such as dementia and dependency to the abuse perpetrator contribute to this hidden phenomenon with poor prognosis.

A precise characterisation and specific Canadian ED point-of-view of elder abuse is essential to guide and optimise patient’s care. The emergency physician caring for geriatric patients will encounter an elder victim of abuse on a regular basis.. Fortunately, elder abuse has recently been identified as one of the geriatric research priority(30, 31) and it is becoming an increasingly prominent concern for the whole society.(32)

RESEARCH AGENDA

  1. Scoping review of elder abuse in the ED
  • Objective: To describe the epidemiology, risk factors, clinical presentation, screening tools, prevention and interventions regarding elder abuse in the emergency department.
  • Methods: Systematic scoping review of the literature
  • Timeline: Expected to be completed by March 2018
  1. Epidemiology and ED attendances
  • Objectives: i) To describe the characteristics of geriatric patients who are victims of abuse at home as self-reported during a home care assessment; ii) To describe the frequency of ED attendances and the ED discharge diagnosis of geriatric patients who are victims of abuse at home as self-reported during a home care assessment; iii) To describe the current and the trends on elder abuse reporting in the SCHIRPT database
  • Methods: Databases survey (CIHI, InterRAI, CHIRPP), cohort and case-control studies
  • Timeline: Expected to be finished by December 2018
  1. What is next? How?

REFERENCES

 

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