Journal of Elder Abuse & Neglect

ISSN: 0894-6566 (Print) 1540-4129 (Online) Journal homepage: http://www.tandfonline.com/loi/wean20

Screening Elders in the Emergency Department at Risk for Mistreatment: A Pilot Study Patrick J. Eulitt, Ryan J. Tomberg, Tina D. Cunningham, Francis L. Counselman & Robert M. Palmer To cite this article: Patrick J. Eulitt, Ryan J. Tomberg, Tina D. Cunningham, Francis L. Counselman & Robert M. Palmer (2014) Screening Elders in the Emergency Department at Risk for Mistreatment: A Pilot Study, Journal of Elder Abuse & Neglect, 26:4, 424-435, DOI: 10.1080/08946566.2014.903549 To link to this article: http://dx.doi.org/10.1080/08946566.2014.903549

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Date: 09 October 2017, At: 09:45

Journal of Elder Abuse & Neglect, 26:424–435, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0894-6566 print/1540-4129 online DOI: 10.1080/08946566.2014.903549

Screening Elders in the Emergency Department at Risk for Mistreatment: A Pilot Study PATRICK J. EULITT, MD and RYAN J. TOMBERG, BA Eastern Virginia Medical School, Norfolk, Virginia, USA

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TINA D. CUNNINGHAM, PhD Graduate Program of Public Health, Eastern Virginia Medical School, Norfolk, Virginia, USA

FRANCIS L. COUNSELMAN, MD Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA

ROBERT M. PALMER, MD Glennan Center for Geriatrics, Eastern Virginia Medical School, Norfolk, Virginia, USA

Impaired functional status is associated with risk of elder mistreatment. Screening for functional impairment in elderly patients admitted to emergency departments could be performed to identify patients at risk for elder mistreatment who might benefit from further evaluation. This study utilized a modified Identification of Seniors at Risk (ISAR) screening tool to identify the proportion of elderly at risk for mistreatment due to functional difficulties presenting to two emergency departments in southeastern Virginia, one urban, the other rural. Of a 180-patient cohort (90 per site), 82 screened positive (46%), ISAR > 2 (range 0–6), indicating nearly half of all patients enrolled are at risk for mistreatment. Patients presenting to the urban emergency departments were potentially more at risk than their rural counterparts (p < 0.01). Health care professionals, particularly in urban settings, should consider screening seniors with a simple tool to identify patients at risk of elder mistreatment. KEYWORDS health outcomes, screening, population density

Address correspondence to Patrick J. Eulitt, Eastern Virginia Medical School, 825 Fairfax Avenue, 2nd Floor, Norfolk, VA 23507, USA. E-mail: [email protected] 424

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INTRODUCTION Elderly patients represent a growing proportion of the American population. In 2011, there were an estimated 39,179,000 Americans ≥ 65 years old, accounting for about 12.8% of the total U.S. population (U.S. Census Bureau, 2011). The problem of elder mistreatment, encompassing self-neglect of functionally impaired patients as well as abuse, has been growing with the aging of the population. The 2010 National Elder Mistreatment Study found that 1 in 10 respondents reported emotional, physical, or sexual mistreatment or potential neglect within the past year (Acierno et al., 2010). A smaller study performed in South Carolina found that 10% of participants reported either emotional, physical, sexual, or neglectful mistreatment within the past year, and 20% reported mistreatment since age 60 (Amstadter et al., 2011). Perhaps more disturbing is the amount of cases that go unreported; estimates of unreported cases are as high as 84% in national surveys (Tatara, 1998). Various models have been constructed in order to better understand elder mistreatment and neglect, as these conditions often coexist with chronic diseases, cognitive impairment, and complex interactions between caregivers and patients. One example of these models is the risk-andvulnerability model, which attempts to explain how external forces and intrinsic forces contribute to elder neglect (Fulmer et al., 2005). In this model, risk encompasses external environmental stressors or hazards, including caregiver depression, caregiver burden, and poor social support, whereas vulnerability encompasses the intrinsic characteristics of the elderly, including poor elderly cognition, elder depression, and poor functional status. Any characteristics that make the elderly more vulnerable will also place them at risk for mistreatment, and a certain percentage of vulnerable elders will eventually end up being mistreated. Elderly patients who become unable to independently perform activities of daily living (ADL) are at greater risk (vulnerable) for elder mistreatment, justifying screening in the emergency department (ED) to exclude patients at risk and to further evaluate those who might be (Fulmer et al., 2005; Lachs & Pillemer, 1995; Lachs, Williams, O’Brien, Hurst, & Horwitz, 1997). There are many elder mistreatment screening assessments available in different settings (Fulmer, Guadagno, Bitondo Dyer, & Connolly, 2004). Methods for determining the prevalence of elder mistreatment also vary widely, from convenience studies in outpatient clinics (Fulmer et al., 2012), to random digit dialing with phone interviews (Amstadter et al., 2011), to ED screenings (Fulmer & Cahill, 1984; Geroff & Olshaker, 2006). Screening and implementation in an ED setting has proven to be difficult due to time constraints and the transient nature of patient flow. Two of the primary published screening tools, the elder assessment instrument and the brief abuse screen for the elderly, have significant practical drawbacks. The elder assessment instrument encompasses 42 questions, which may be impractical for use in

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the typical hurried environment of the ED, and the brief abuse screen for the elderly requires training of administrators that is not easily implemented in the ED (Fulmer, Paveza, Abraham, & Fairchild, 2000; Reis & Nahmiash, 1995). To our knowledge, no recent study has attempted to determine risk of elder mistreatment using a tool that screens for physical difficulty as a vulnerability. To do so, we screened for functional decline, defined as requiring more help with ADLs than required 6 months prior to the ED visit, with the use of a screening tool. The primary objective of this pilot study was to determine the proportion of elderly at risk for mistreatment as determined by a positive ISAR screen. The secondary objective was to determine the difference in proportion of at-risk elderly patients presenting to an urban ED and a rural ED in southeastern Virginia. Additional objectives included comparing demographic information between the two cohorts and determining the association between demographic variables and the ISAR screen that place seniors at risk for mistreatment. This study was approved by the Institutional Review Board of Eastern Virginia Medical School.

DESIGN AND METHODS Participants and Setting The study design is a cross-sectional survey of elderly patients admitted to two hospital-based EDs, one rural, the other urban, in southeastern Virginia. Hospital 1 is a community hospital located in Suffolk, Virginia, while hospital 2 is a teaching hospital located in downtown Norfolk, Virginia. Although these two hospitals are only 22 miles apart, the 2010 U.S. Census classifies hospital 1 as “rural,” as it is located outside of an urbanized area, and hospital 2 is classified as “urban,” as it is located in an urbanized area (U.S. Census Bureau, 2010). The rural hospital has 168 hospital beds, 23 ED beds, and 44,071 total visits in 2012, with 19.7% of the patients aged 65 or older. The urban hospital has 525 hospital beds, 41 ED beds, and 69,674 total visits in 2012, with 13.9% of the patients aged 65 or older. A convenience sample of each ED was taken between March 17, 2012, and August 17, 2012, during the hours of 9am and 9pm. Care was taken to ensure that each site was visited equally at the same time and day of the week to minimize sampling bias. Patients were approached sequentially after stabilization and evaluation by an emergency medicine physician and prior to disposition. Inclusion criteria required participants to be aged 65 years or older, English speaking, conscious, and able to give informed consent. Patients were excluded if they screened positive on the Mini-Cog or failed the “teach back” test (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000; Weiss, 2007).

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Measures MINI-COG The Mini-Cog screened for dementia. A patient who was screened positive on the Mini-Cog was likely significantly demented and not capable of providing informed consent to enroll in this study. The Mini-Cog includes a three-item recall and clock drawing test, which quickly and accurately discriminates demented from nondemented patients and is clinically validated (Borson et al., 2000; Borson, Scanlan, Chen, & Ganguli, 2003).

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TEACH BACK TEST Patients who screened negative for dementia on the Mini-Cog were asked to pass the teach back test before enrollment into the study as an additional measure to ensure patient understanding and cognitive capabilities. Teach back is commonly used in clinical practice to ascertain patient understanding (Weiss, 2007). Patients were asked to repeat the research associate’s description of the study and estimated time commitment. Patients correctly describing the study and the estimated time commitment in two attempts or less were considered eligible for enrollment. IDENTIFICATION

OF

SENIORS

AT

RISK TOOL

The Identification of Seniors at Risk (ISAR) tool was used to screen patients for functional decline (McCusker et al., 1999). The ISAR has excellent construct and predictive validity (Dendukuri, McCusker, & Belzile, 2004; McCusker, Bellavance, Cardin, Belzile, & Verdon, 2000). The clinically validated, six-item, self-report ISAR has been identified as the best predictor of functional decline and the easiest to use in clinical practice when compared to similar instruments: the ISAR was found to have the best negative predictive value (93.6%) and sensitivity (92.9%) at a cutoff of two positive responses qualifying patients as at risk, but had relatively poor specificity (39.3%) and positive predictive value (36.4%) (Hoogerduijn, Schuurmans, Korevaar, Buurman, & de Rooij, 2010). The ISAR contains six items focusing on the following: presence of daily home help, increased dependency, hospitalizations over the previous 6 months, vision impairment, serious memory problems, and number of daily medications. A score of two or more out of six qualified a patient as potentially at risk. ED physicians were informed if their patients were determined to be potentially at risk for elder mistreatment. One item of the original tool was modified: instead of the item: taking “more than three different medications every day,” for this study we changed the item response to “more than eight different medications every day” in recognition of the growing number of necessary medications taken by older Americans (Kaufman, Kelly,

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Rosenberg, Anderson, & Mitchell, 2002). Throughout 2007–2010 over 65% of Americans over 65 years old took three or more medications (National Center for Health Statistics, 2013). Patients were also asked a series of demographic questions to analyze as covariates. Variables included: race, income, education, marital status, living situation, gender, and reason for presentation to the ED. These variables have been analyzed in other studies but have not been compared across a rural and urban population. Two research associates, authors Patrick J. Eulitt and Ryan J. Tomberg, enrolled all patients into the study at the two sites. Interobserver reliability testing was performed on 10 patients, not included in the study, to confirm agreement between the two associates administering the same survey. The research associates were in agreement with the qualification status of all 10 patients, 59 of the 60 survey responses recorded, and classification of at-risk status as determined by the ISAR in all 10 patients.

Statistical Analyses The prevalence of elderly patients at risk for elder mistreatment presenting to two EDs in southeastern Virginia was measured by calculating the proportion of ISAR positive patients who were enrolled in the study. Second, we determined the prevalence of patients at risk for elder mistreatment seen in a rural and an urban ED setting using a two-sided test of proportions at an alpha level of 0.05. Standard descriptive statistics of the rural and urban cohorts were also calculated. Chi-squared tests or Fisher’s exact tests were used to compare proportions of participants with or without each characteristic who were ISAR positive or negative. For interval data, t-tests were employed to test for differences between cohorts. In addition, logistic regression analysis was used to compare the odds ratios of being at risk between the rural hospital and urban hospitals. The mean age and standard deviation were similar between the two cohorts; thus, no stratification of age groups was necessary. All statistical analysis was done by Statistical Analysis System (SAS: Cary, NC).

RESULTS 180 patients were enrolled in this study, 90 at the rural hospital and 90 at the urban hospital. The various characteristics of the enrolled patients are summarized in Table 1. The mean age of patients at the rural hospital was 74.0 years and at the urban hospital was 75.4 years; 55.5% of study participants at the rural hospital were female and 60% at the urban hospital were female. At the rural hospital, 51.1% of the patients enrolled were classified

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Elders at Risk for Mistreatment TABLE 1 Characteristics of Enrolled Patients

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Characteristics Age, mean Gender Male Female At-risk (ISAR screening) Negative Positive Race African American & other White Annual income (dollars) ≤ 15,000 15,001–30,000 30,001–50,000 ≥ 50,000 Prefer not to answer Education level High school or below College or above Marital status Currently not married Currently married Living situation Alone With spouse With nonspouse family Supervised setting

Rural Hospital, n = 90 (%)

Urban Hospital, n = 90 (%)

74.0

75.4

40 (44.4) 50 (55.6)

36 (40.0) 54 (60.0)

58 (64.4) 32 (35.6)

40 (44.4) 50 (55.6)

44 (48.9) 46 (51.1)

52 (57.8) 38 (42.2)

47 13 10 10 10

37 9 10 18 16

(52.2) (14.4) (11.1) (11.1) (11.1)

(41.1) (10.0) (11.1) (20.0) (17.8)

59 (65.6) 31 (34.4)

49 (54.4) 41 (45.6)

46 (51.1) 44 (48.9)

55 (61.1) 35 (38.9)

23 42 19 6

30 35 21 4

(25.6) (46.7) (21.1) (6.7)

(33.3) (38.9) (23.3) (4.4)

Note. ISAR = Identification of Seniors at Risk Tool.

as white, while 42.2% were white at the urban hospital. Of the 180 patients enrolled, 82 were ISAR + (46%), and 98 were ISAR – (54%). Of the clinical variables assessed in this study, only the at-risk variable was found to be significantly different between the rural hospital and the urban hospital. (See Table 2.) Results demonstrate that the odds of a patient being at risk (ISAR +) was 2.93 times greater (95% Confidence Interval [CI] = 1.43 to 5.98) at the urban hospital compared to the rural hospital. Odds ratio was 2.98 times greater (95% CI = 1.34 to 6.66) for at-risk patients whose education level was high school or less compared to attending college or higher. Finally, the odds ratio was 14.24 greater (95% CI = 2.30 to 88.22) for poor health outcomes if patients lived in a supervised setting such as a nursing home as opposed to living alone. Other variables were not statistically significant. (See Table 3.)

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P. J. Eulitt et al. TABLE 2 Differences in Proportion of Clinical Variables by Hospital Emergency Department Sitea Variable Gender At-risk (ISAR screening) Race Annual income Education level Marital status Living situation

Valuea

p value

0.36 7.26 1.43 5.59 2.32 1.83 2.06

0.55 0.007∗ 0.23 0.23 0.13 0.18 0.56

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Note. ISAR = Identification of Seniors at Risk Tool. a Analyzed by Chi-square test or Fisher’s exact test. ∗ p < .05.

TABLE 3 Logistic Regression Analysis Comparing the Odds Ratio of Being at Risk Between Sites (Significant Variables) Variable Site Urban hospital vs. rural hospital Education level High school or less vs. college or more Living situation Supervised setting vs. alone ∗

Odds Ratio

95% Confidence Interval

2.93∗

1.43−5.98

2.98∗

1.34−6.66

14.24∗

2.30−88.22

p < 0.05.

DISCUSSION Our study screened elderly patients and determined the proportion at risk for functional decline using the ISAR tool. Overall, 46% of elderly patients screened positive. Because this screening tool is a validated predictor for functional decline, and functional decline is a significant risk factor for elder mistreatment, as many as 46% of the elderly patients presenting to the two EDs are at potential risk for elder mistreatment (Fulmer et al., 2005; Hoogerduijn et al., 2010; Lachs & Pillemer, 1995; Lachs et al., 1997). The proportion of elderly patients with a positive ISAR screen in our study (46%) was similar to the proportion observed in the original ISAR study performed in Canadian EDs (51%), despite a 13-year gap between studies and different patterns of health care and ED use between the two countries (McCusker et al., 1999). Although there have been recent studies estimating the prevalence of elder mistreatment, there has been a lack of recent literature attempting to quantify patients at risk for mistreatment in the United States. The only two recent studies were performed in outpatient medical and dental clinics. A pilot study performed in a dental clinic found that 48.4% of elderly screened positive for risk of abuse (Russell et al., 2012). A separate study performed in both a medical and dental clinic found that 3% and 35%

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screened positive for risk of elder abuse, respectively (Fulmer et al., 2012). However, to our knowledge, there have been no recent studies attempting to determine the prevalence of elderly at risk in an emergent setting, where we found that 46% were at potential risk for elder abuse due to functional impairment based on the ISAR. The secondary goal of this study was to determine if patients presenting to a rural ED were more at risk for functional decline and elder mistreatment than patients presenting to an urban ED. We hypothesized that elderly patients from a rural environment would be more at risk than their urban counterparts due to resource limitations, travel and geographic complications, and educational/training limitations. However, we found that elderly patients in urban EDs appear to be more likely to be at risk for functional decline and, hence, elder mistreatment than those in rural EDs. There is no obvious reason for this, as the two cohorts were not statistically different in any demographic variable recorded (other than zip code). One possible explanation was provided by a study performed in Canada suggesting that increased continuity of care seen in rural environments may be protective against ED utilization (Ionescu-Ittu et al., 2007). Another explanation could be that patients presenting to urban EDs are more acutely ill than those presenting to rural EDs. Variables such as gender, race, income, and marital status were not found to have a significant association with at-risk status or study site. Further studies are needed to confirm our findings. Finally, we collected demographic information about the enrolled subjects to determine which characteristics are shared by elderly at risk for mistreatment. We found that risk was greater for seniors whose highest education level was high school compared to those who had some postsecondary education. A possible explanation for this observation is that seniors with higher education levels are perhaps more likely to remain healthier through more effective self-care and improved socioeconomic status. Our study also suggests that risk was greater for seniors residing in supervised settings compared to their counterparts living alone. This finding could be explained by the greater degree of physical and cognitive impairments encountered in institutionalized patients. These impairments may hinder reporting and recognition of elder mistreatment and are one of many reasons that elder mistreatment in supervised settings has been historically difficult to assess (Hawes, 2002). Other factors complicating recognition and reporting include inspector biases, lack of alternative facilities, and differing reporting protocols across states (Phillips, Guo, & Kim, 2013). Centralization or standardization of Adult Protective Services’ guidelines would be an ideal start to understanding the true prevalence and incidence of elder mistreatment in assisted living facilities. Medical personnel working at these facilities should maintain a high level of vigilance for elder mistreatment and may be aided by the administration of a short screening questionnaire such as the ISAR.

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Further research and policy development will guide interventions to better protect this vulnerable population. The strengths of the study include bias minimization, through the use of interobserver reliability testing and equal site visits at the same time of day and week, and the novelty of comparing risk of elder mistreatment in a rural and an urban cohort. Limitations of the study include its small sample size, convenience sampling, and the lack of a gold standard diagnosis of elder mistreatment. The ISAR has high negative predictive value for functional decline but lower positive predictive value. Hence, the ISAR might be better at identifying patients who are at low risk for elder mistreatment. The ISAR was not developed to directly detect patients at risk for elder mistreatment; rather, it has been validated to detect seniors at risk for functional decline and is not an ideal screening tool (Carpenter et al., 2011). However, compared to other screening tools the ISAR is a superior predictor of functional decline, and a significant risk factor for elder mistreatment (Hoogerduijn et al., 2010; McCusker et al., 1999). Altering the ISAR study by changing the number of medications taken to be classified as at risk likely decreased the sensitivity of the tool for identifying at-risk seniors and likely improved the specificity. The percent of at-risk patients might be even higher than we found, as demented patients were excluded from enrollment, and dementia is a risk factor for elder mistreatment (Coyne, Reichman, & Berbig, 1993; Pillemer & Finkelhor, 1989; Rose & Killien, 1983). Finally, although the rural hospital in Suffolk, Virginia, was classified as rural by the 2010 U.S. Census, Suffolk is a community in transition, with both rural and suburban features. Results of screening with ISAR may be different in a more isolated rural community. This pilot study suggests that a difference exists between rural and urban seniors who are admitted to ED. Further studies are needed to clarify the differences between these cohorts and to better understand interventions that might be effective in reducing the risk of mistreatment. Some potential interventions that have been previously studied include staff educational programs, telephone follow-up, and comprehensive geriatric assessments (Hastings & Heflin, 2005). One study utilized referral to primary and home care services following ISAR administration and found that this intervention significantly reduced the rate of subsequent functional decline (McCusker et al., 2001).

CONCLUSIONS Administering a brief screening test, such as the modified ISAR that identifies vulnerable patients, could increase recognition of patients at greater risk of elder mistreatment. If results are confirmed in other areas of the United States, then physicians, nurses, and other staff should be trained to screen for and assure further evaluation of at-risk elderly patients.

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ACKNOWLEDGEMENTS The authors would like to thank Dr. Catherine Ferguson for her vision and guidance during the conceptualization and initiation of this project.

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Screening elders in the emergency department at risk for mistreatment: a pilot study.

Impaired functional status is associated with risk of elder mistreatment. Screening for functional impairment in elderly patients admitted to emergenc...
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