Elder Mistreatment Prevention and Solutions: Experts Discuss Challenges and Interventions

The complexities surrounding elder mistreatment, from its nuanced definition to effective prevention strategies and the critical role of interdisciplinary collaboration, were thoroughly examined in a recent episode of the GeriPal Podcast. Hosted by Eric Widera and Alex Smith, the discussion featured a panel of distinguished experts: Dr. Julia Hiner, a geriatrician and fellowship director at the University of Texas Health Science Center in Houston; Dr. Carrie Rubenstein, a geriatrician and fellowship director at Swedish in Seattle; and Dr. Tony Rosen, an emergency medicine doctor and researcher at Weill Cornell and New York Presbyterian Hospital. The conversation, which served as an update to a previous podcast on the topic from six years prior, delved into the evolving terminology, risk factors, screening challenges, and innovative solutions being implemented across the country.

Evolving Terminology and Scope of Elder Mistreatment

The discussion began with a critical examination of the terminology used to describe the abuse and neglect of older adults. Dr. Carrie Rubenstein advocated for the term "elder mistreatment" over "elder abuse," explaining, "Abuse is a scary word. I think words matter, and nobody wants to think about, engage, or even really talk about abuse. But in our field, mistreatment prevention solutions, this is a way to really focus on the opportunities… that we can intervene, that we can creatively care for the most vulnerable people." Dr. Julia Hiner concurred, noting that "mistreatment" serves as an effective umbrella term.

Dr. Tony Rosen further clarified the definition, stating, "Elder mistreatment is defined as an intentional act or a failure to act that causes or creates the risk of harm to an older adult by a caregiver or another person who is trusted." He emphasized that this definition encompasses not only actions but also omissions, and importantly, that the perpetrator is someone in a position of trust, distinguishing it from random acts of violence. This definition includes various forms of abuse such as physical, sexual, and emotional abuse, as well as financial exploitation and neglect, encompassing both self-neglect and neglect by caregivers in physical, medical, and mental health domains.

Identifying Vulnerable Populations and Risk Factors

A significant portion of the discussion focused on identifying individuals at higher risk for elder mistreatment. While age itself is a primary risk factor, the experts highlighted cognitive impairment as a particularly potent vulnerability. Dr. Hiner noted that among cognitively healthy older adults living in the community, an estimated 1 in 10 may experience elder mistreatment. However, this figure dramatically increases to potentially one in two for individuals with cognitive impairment, especially those who have reached a state of decisional incapacity. This heightened vulnerability is often exacerbated by the increased strain on caregivers and the inability of the affected individual to report the mistreatment.

The dynamic between caregiver and care recipient was also identified as a crucial factor. Dr. Hiner pointed out that codependent relationships, financial dependence of the caregiver on the elder, and caregiver burnout, particularly in "sandwich generation" individuals juggling multiple caregiving responsibilities, significantly increase the risk of neglect and financial exploitation. Dr. Rosen added that financial exploitation, psychological exploitation, and neglect are substantially more common than physical or sexual abuse. He also underscored that as an older adult’s dependency increases, often due to worsening dementia, the risk of neglect escalates.

The Challenge of Screening and the Importance of Clinical Suspicion

Despite the clear risks, the implementation of routine screening for elder mistreatment in clinical settings faces significant hurdles. The U.S. Preventive Services Task Force (USPSTF) has previously stated that there is insufficient evidence to recommend for or against routine screening for elder abuse. However, Dr. Hiner expressed a perceived disconnect between this stance and the clinical reality observed by healthcare providers who regularly encounter such situations. "I think anyone who does this work, who takes care of older adults is certainly seeing that these are vulnerable people who benefit from the screenings and the observations and the interventions," she stated.

The experts agreed that while formal screening tools may lack robust evidence for effectiveness, the principle of keeping elder mistreatment on the differential diagnosis is paramount. Dr. Tony Rosen drew a parallel to emergency medicine’s approach to identifying subtle, life-threatening conditions that may not be immediately apparent. He emphasized the need for clinicians to develop a "spidey sense" – an intuitive feeling that something is amiss – and to investigate further. Dr. Carrie Rubenstein highlighted the unique advantage of geriatricians and primary care providers who, through longitudinal relationships, can recognize subtle changes in a patient’s condition, behavior, or the demeanor of their caregiver. These changes, such as missed appointments, altered medication adherence, or unusual bruising patterns, can be indicators of underlying mistreatment.

Dr. Rosen also referenced previous work by Dr. Laura Mosqueda, a respected leader in the field, who proposed three key screening questions for primary care providers: "Has anyone close to you harmed you? Has anyone close to you failed to give you the care that you need? Has anyone tried to force you to sign papers or use money against your will?" These questions offer a practical starting point for initiating conversations about potential mistreatment.

The Rise of Multidisciplinary Teams and Interprofessional Collaboration

A significant theme emerging from the discussion was the critical role of multidisciplinary teams in addressing elder mistreatment. These teams bring together professionals from various disciplines to provide comprehensive support and develop creative solutions for complex cases.

In Seattle, Dr. Rubenstein participates in an elder abuse multidisciplinary team (MDT) in King County, which includes representatives from Adult Protective Services (APS), Aging and Disability Services, law enforcement, attorneys, financial specialists, and geriatricians. This collaborative approach allows for the pooling of expertise to tackle challenging situations, such as financial exploitation and cases where the healthcare proxy might be the abuser.

Similarly, in Houston, Dr. Hiner is involved in several MDTs, including a unique Elder Abuse Fatality Review Team that collaborates with medical examiners. This team examines cases where elder mistreatment may have led to death, aiming to identify systemic issues and advocate for policy changes, such as improved licensing and monitoring of personal care homes and boarding homes.

Dr. Rosen described the development of Vulnerable Elder Protection Teams (VEPTs) in emergency departments and hospitals. Inspired by the established Child Protection Teams, VEPTs serve as consultation services to assist ED and hospital clinicians in recognizing and managing potential elder mistreatment cases. These teams typically include ER clinicians, social workers, and geriatricians, with essential buy-in from security, legal, and patient services. The emphasis is on providing support to clinicians who may not have specialized expertise in elder mistreatment and ensuring a smoother transition of care for patients upon discharge. The success of these teams is evident in the increasing number of consultations they receive, indicating a growing recognition of their value.

The Role of Adult Protective Services (APS) and Systemic Challenges

The relationship between multidisciplinary teams and Adult Protective Services (APS) was also a key point of discussion. Dr. Carrie Rubenstein emphasized that APS is not an emergency response system but rather a crucial safety net. She encouraged clinicians to actively communicate with APS investigators, recognizing that APS often assumes healthcare providers lack the time for such follow-up. Building a strong connection with APS is vital for ensuring effective investigation and the provision of necessary resources to vulnerable elders.

However, limitations within APS were also acknowledged, including resource constraints and the inability to force individuals to accept help. This raises complex ethical dilemmas regarding patient autonomy versus the need for intervention, particularly in cases of self-neglect or recidivism. Dr. Julia Hiner articulated a strong stance on preserving autonomy, stating, "I think the preservation of autonomy, even to make, you know what I think maybe people would collectively call a bad decision, is just kind of one of those fundamental rights of, you know, being an adult." This perspective underscores the delicate balance between respecting an individual’s right to make their own choices and intervening when those choices pose a significant risk to themselves or others.

The Future of Elder Mistreatment Prevention and Training

The conversation concluded with a forward-looking perspective on prevention and education. Dr. Tony Rosen expressed a desire for clinicians to consistently consider elder mistreatment as a contributing factor to a patient’s condition, much like pulmonary embolism is considered for shortness of breath. Dr. Hiner advocated for integrating "mistreatment" as a standard mnemonic, similar to the "5 Ms" framework (Mobility, Multiple comorbidities, Medication, Mind, and what Matters Most) used in geriatrics, to ensure it remains at the forefront of clinical thinking. Dr. Rubenstein stressed the importance of training future healthcare professionals, particularly in geriatrics, to recognize elder mistreatment as a social justice issue and to understand the profound impact they can have in this field.

The establishment of specialized training programs, such as the Elder Capacity Assessment and Mistreatment (ECAMM) fellowship at the University of Texas Health Science Center, signifies a growing commitment to equipping healthcare professionals with the necessary skills and knowledge to combat elder mistreatment. This one-year interprofessional training program aims to immerse physicians from various backgrounds, including geriatrics, internal medicine, emergency medicine, and psychiatry, in the complexities of elder capacity assessment and mistreatment intervention.

The discussion underscored that addressing elder mistreatment requires a multi-pronged approach involving heightened clinical awareness, robust interprofessional collaboration, a commitment to supporting caregivers, and ongoing advocacy for systemic improvements and resources. As the population of older adults continues to grow, the importance of these efforts in safeguarding their well-being and dignity becomes increasingly critical.