Introduction
Objectives
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Improve knowledge on the subject
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Define standard medico-legal assessment procedures
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Agree upon a common terminology
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Identify qualitative indices, and
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Suggest areas requiring further investigation
Methodology
Consensus conference organization
Conference questions and literature review
Assessment of the quality of evidence
Authors, year (reference number) | Document type | Quality ratinga |
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Abete et al. 2017 [32] | Primary study | **** |
Britt et al. 2005 [33] | Primary study | *** |
Brown et al. 2017 [22] | Systematic review | *** |
Callahan et al. 2000 [34] | Primary study | *** |
Callahan et al. 2004 [35] | Primary study | **** |
Chipi et al. 2018 [36] | Primary study | **** |
Clayman et al. 2005 [37] | Primary study | **** |
Corbi et al. 2018 [38] | Primary study | **** |
Deveugele et al. 2002 [39] | Primary study | **** |
Ferrari et al. 2017 [40] | Primary study | **** |
Gardner et al. 2018 [29] | Narrative review | * |
Girtler et al. 2012 [41] | Primary study | *** |
Hashmi et al. 2014 [23] | Systematic review | * |
Hildebrand et al. 2016 [30] | Review | * |
Hogan et al. 2011 [31] | Review | * |
Ishikawa et al. 2005 [42] | Primary study | *** |
Laidsaar-Powell et al. 2013 [24] | Systematic review | ** |
McIntyre et al. 2013 [25] | Systematic review | * |
New Zealand Guidelines Group 2003 [12] | Guideline | **** |
Petek Ster et al. 2008 [43] | Primary study | **** |
Regione Toscana 2017 [13] | Guideline | *** |
Reuben et al. 2004 [44] | Primary study | **** |
Sammy et al. 2016 [26] | Systematic review | ** |
Sawa et al. 2018 [27] | Systematic review | *** |
Schmidt et al. 2009 [45] | Primary study | *** |
Storti 2009 [46] | Primary study | *** |
Tähepold et al. 2003 [47] | Primary study | *** |
Wolff et al. 2008 [48] | Primary study | **** |
Wolff et al. 2011 [28] | Systematic review | ** |
Wolff et al. 2012 [49] | Primary study | **** |
Wolff et al. 2017 [50] | Primary study | ** |
Wooldridge et al. 2010 [51] | Primary study | **** |
Consensus conference day and following steps
Summary of evidence
Evidence that traumatic injury outcomes are different between older and younger people and its relevance for the assessment of personal damage
Level of evidence | Questions and Jury Panel statements/recommendations |
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Systematic reviews (2 of average quality, 1 of low quality, 2 of very low quality), 2 non-systematic reviews of very low quality, and the experts’ opinions | 1.1 Is there evidence that traumatic injury outcomes are different between older and younger people? There is evidence that the most unfavourable outcomes of a traumatic injury are usually associated with ageing. However, different old age-related factors may contribute to the risk of worse outcomes. 1.2 Which medico-legal relevance does this evidence have for personal damage assessment? A comprehensive and personalized assessment of age-related critical factors is essential for the evaluation of personal damage in the medico-legal context. |
Reconstruction and evaluation of the pre-injury health status
Reconstruction of the pre-injury status
Medico-legal evaluation of pre-existing status modification
Level of evidence | Questions and Jury Panel statements/recommendations |
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Theoretical/doctrinal contributions, and the experts’ opinions | 2.1 Under which circumstances should a medico-legal expert, besides assessing the pre-injury status of the affected area, also examine the general pre-injury status of an older person? The reconstruction of the pre-existing status represents a fundamental step in any medico-legal assessment process. |
2.2 What information about the pre-existing status should always be collected? Data concerning the pre-existing status should include information on pre-existing diseases, pharmacological therapies, ageing process, physical and cognitive performance, and social relationships. The evaluation of the pre-existing status should be aimed at defining what the person was able to do beforehand, i.e., sedentary lifestyle, and autonomy in feeding, ambulating, dressing, personal hygiene and in body functions; social skills and relationship level. | |
2.3 Which methodology should be followed to achieve a reliable reconstruction of the pre-existing status? The optimal procedure to obtain a valid reconstruction of pre-injury conditions relies mainly on: a) Anamnesis (clinical history) obtained from the patient, family and/or caregivers, and clinical documents provided; b) Legally obtainable medical data and information, including access to formal and informal care resources (day care centres, supplementary home care, formal caregivers). Information collection must comply with privacy and personal data protection laws and should not be cause of action estoppel/trial issue preclusion/collateral estoppel. 2.4 How should the modification of the pre-existing status in older people be evaluated from a medico-legal standpoint? An evaluation that considers the physical and cognitive performance of the aged person before the injury is highly recommended. The evaluation criteria should consider the actual reduction of the patient’s pre-existing psychophysical status and should not be necessarily limited to the barème indications that are developed with reference to the impairment due to single injuries affecting a theoretical integrity. |
Examination procedures for the medico-legal ascertainment of personal damage in older people
Criteria to establish the minimum time interval before the injured person undergoes medico-legal examination
Duration of the medico-legal examination in an older person
Participation of a family member and/or caregiver in the medical-legal visit
Appropriateness of home visit
Level of evidence | Questions and Jury Panel statements/recommendations |
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Experts’ opinions | 3.1 Which criteria should be used to establish the minimum time interval before the injured person undergoes medico-legal examination? Based on the currently available evidence, it is not possible to define a minimum time interval that should be respected before the injured party undergoes medico-legal examination. |
Observational studies (4 of high quality, 3 of average quality), and the experts’ opinions | 3.2 Should the time required to examine an older person differ from that required for other age ranges? The examination time required for an elderly patient is different from that required for patients of other age ranges. 3.3 Which is the appropriate minimal duration of a medico-legal examination of an older person? Based on the currently available evidence, it is not possible to define a minimal duration for the medico-legal examination of an older person. However, due to the overall social, clinical, and managemental complexity, a longer duration of the examination compared to a younger patient should be considered. The high heterogeneity of the elderly population and injury types does not allow for a minimal standard duration for the medico-legal examination to be established. |
Two systematic reviews of low quality, observational studies (3 of high quality, 2 of average quality, 1 of low quality), and the experts’ opinions | 3.4 Under which circumstances should a family member or caregiver attend the medico-legal visit? The presence of a family member and/or a caregiver during a medico-legal visit can be useful in the case of elderly patients with psychophysical disabilities. The presence of an accompanying person must comply with the legislation regarding informed consent. 3.5 How should a family member or caregiver take part in the medico-legal visit? The presence of a family member or a caregiver can be useful when the accompanying person adopts an encouraging behaviour towards the patient during a medico-legal visit; in point of fact, the accompanying person can improve patient-doctor communication and provide logistic support to patients with physical disabilities.a |
A narrative review of very low quality, and the experts’ opinions | 3.6 Under which circumstances should the medico-legal visit be made at the injured person’s home? It is appropriate to consider holding the medico-legal visit at the injured patient’s home for patients suffering from serious mobility or psychic disability, or for those at high risk of falls (also for an environmental assessment), or suffering from terminal illnesses, or with no access to transportation.b |
Multidimensional assessment and scales
When an MDA is necessary
Assessment domains and tools
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Clinical status (comorbidity): Cumulative Illness Rating Scale; Charlson Index
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Functional status: Basic Activities of Daily Living-BADL (Katz Index, Barthel Index) and Instrumental Activities of Daily Living-IADL (Lawton-Brody scale)
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Cognitive status: Short Portable Mental Status Questionnaire, Mini Mental Status Examination, Clock Drawing test
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Affective status: Geriatric Depression Scale (15- or 5-item version)
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Social interactions: Oslo-3 Social Support Scale
Level of evidence | Questions and Jury Panel statements/recommendations |
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One observational study of high quality, theoretical/doctrinal documents, synthesis of evidence documents, and the experts’ opinions | 4.1. When should a medico-legal expert obtain or perform a multidimensional assessment (MDA) of the older person in order to assess personal damage? It is recommended to perform an MDA depending on the complexity of the case, namely when high comorbidity or significant alterations of the motor or cognitive functional status are present, especially in people aged over 75. |
Two observational studies of high quality, guidelines (1 of high quality, 1 of average quality), synthesis of evidence documents, and the experts’ opinions | 4.2 Which domains should always be assessed? In the medico-legal practice, the MDA of an older patient with a significant reduction or a loss of autonomy, and in relation to the complexity of the case, should include the evaluation of the following domains: clinical status (presence of comorbidity); functional status (BADL, IADL); cognitive status; psycho-affective status; social interactions, and environmental context. 4.3 Which are the recommended assessment tools? Several tools that can be used to perform MDAs of older patients have been available for a long time in clinical practice. Nevertheless, no formally validated multidimensional tools are available in the personal damage assessment context. To properly perform a medico-legal assessment of personal damage, MDA tools should be the ones used for the pre-injury status assessment. 4.4 Which assessment tools of older people’s functions validated in Italian are most useful for medico-legal purposes? The tools generally used in clinical practice for first-level screening can also be used for medico-legal purposes. In selected cases, II level assessment screening might be required. This is normally performed by a specialist in the field (geriatrician, psychiatrist, etc.) and the most appropriate tools are chosen according to the evaluation purposess |