Towards the development of a screening tool to enhance the detection of elder abuse and neglect by emergency medical technicians (EMTs): a qualitative study

Older adults who experience abuse or neglect have 300 % greater risk of mortality and more chronic health problems, including depression or anxiety, chronic pain, high blood pressure and heart problems, than adults over 65 who are not abused or neglected [1‐4]. These health conditions attributable to elder abuse and neglect increase healthcare expenditures by an estimated $5.3 billion annually [5].

The etiology of elder abuse and neglect is complex and appears to vary by abuse type [6‐9]. For example, cohabitation and an established relationship with the perpetrator are risk factors for physical and emotional abuse [10, 11], but not financial exploitation [11]. In fact, victims of financial abuse tend to have known the perpetrator for only a short period of time and tend to live alone [6]. In many cases, the perpetrators of financial abuse tend to be the victim’s adult children [12]. Similarly, older adult victims of neglect tend to have cognitive impairments but not mental health conditions [6]. They also tend to have a greater burden of chronic disease and report greater levels of functional dependence upon others than those who do not experience neglect [6]. Victims of all forms of abuse (including physical, emotional, sexual abuse and neglect) have low social support with the exception of financial abuse [9]. Notably, physical and emotional abuse are most commonly reported to the police [9, 13]. Although a subset of older adults do experience multiple forms of victimization [7], these distinct etiologies make detection and intervention in cases of elder abuse, neglect and maltreatment difficult.

One of the primary challenges to fully understanding, and appropriately addressing elder abuse, neglect, and exploitation (EA) is under-detection and underreporting of its occurrence [9, 13‐15]. For example, Acierno and colleagues found that roughly 11 % of older adults experience EA each year, but only 1 in 14 cases are reported to the authorities [9, 16, 17]. Similarly, results from one of the most comprehensive epidemiological studies on EA to date suggest that for every documented case of EA, 24 cases go unreported [13].

Because older adults are four-times more likely to use in-home emergency medical services than younger adults [18], EMTs are uniquely positioned to identify potential abusive or neglectful situations. EMTs can identify indicators of abuse or neglect (such as family interactions, home upkeep, medication availability, safety concerns and sanitation) not available to other emergency personnel, social workers or health care providers. In fact, during an investigation of the regional effects of EA underreporting, a representative from the region’s largest mobile healthcare (ambulance) service provider raised concerns over potential underreporting among area emergency medical technicians (EMTs). In 2013, this mobile healthcare provider responded to roughly 30,000 calls for older adults (aged 65+), but only reported 23 cases of EA to Adult Protective Services (APS) despite state-mandated reporting of suspected EA in Texas [19, 20]. Under-reporting is of particular concern because social isolation, dementia, and health and functional status are risk factors for elder abuse [21], and may hinder older adults’ ability to self-identify and self-report abuse or neglectful situations [22]. Alternatively, older adults with cognitive or functional limitations may fear retaliation by a family member or caregiver, and as a result, continue to live in abusive or neglectful situations. Concerns over this apparent under-reporting prompted the authors, who work closely with this mobile healthcare provider on a number of initiatives, to better understand the reasons for underreporting and opportunities to improve reporting rates by EMTs.

In a previous study authored by our research team, five general themes related to barriers to reporting EA among EMTs were identified. These themes included: (1) EMT apprehension towards violating older adults’ personal freedom to determine the conditions of their living environment; (2) EMT moral anxiety about the perceived negative consequences of an APS investigation on the older adult and/or their caregiver(s); (3) the time burden associated with reporting elder abuse or neglect to APS; (4) a perceived lack of case recall ability by EMTs, and, (5) low EMT confidence regarding ability to correctly identify potential elder abuse or neglect [23]. EMTs strongly believed that an appropriate EA screening tool would mitigate these barriers, and, as a result, increase the probability that they would report cases to APS [23]. In this study, we build on our previous investigation by identifying the most salient indicators of EA that such a screening tool should capture. Additionally, we will discuss the practical elements of the tool, such as format, length, and types of response options available, that could impact EMT uptake and use of the screening tool. In summary, our goal is to create a user-friendly screening tool with a small number of items that strongly predict confirmed cases of EA after investigation by APS.

This study identified eight domains of indicators that may be observed by EMTs during calls for service to begin to address the problem of EA under-reporting. The domains that should be considered for inclusion on such a tool include: (1) the condition of the outside areas around the home; (2) conditions inside the home; (3) the presence/adequacy of social support; (4) medical history and medication use/misuse; (5) caregiving indicators; (6) the physical condition of the older adult; (7) the older adult’s behavior; and, (8) EMTs’ instincts.

These domains are generally consistent with the literature on risk factors for EA [11, 16, 34, 35], with the exception of EMT instincts. A study of elder maltreatment in New York identified poverty and caregiver disengagement as the only two indicators of abuse or neglect that could be identified by third parties, such as EMTs [13]. Lachs et al. identified other domains of abuse noted in this study, including functional and cognitive impairment, low overall social support and fewer social ties [16]. Lachs also found that older adults who live alone are less likely to be abused or neglected than those who live with family or a caregiver [16]. There is disagreement in the literature on this topic, as data from the National Crime Victimization Survey suggest that those who live in a single person household were up to five times more likely to be victimized than those who live with a spouse or a spouse and children [36].

Our second aim was to identify the characteristics of an EA screening tool that were likely to affect its utility in the field. Our results suggest that the screening tool should: (1) be easily integrated into their current workflow—including their electronic charting systems; (2) be very brief (5–10 items); (3) be based on observable cues in the physical / social environment; (4) not necessitate directly questioning the older adult or caregiver; and, (5) provide a risk score or reporting guidance to alleviate moral anxiety associated with making decisions to report a suspected case to APS [23].

Several screening tools for EA currently exist, but none to our knowledge are appropriate for use by EMTs in their current form [27‐29, 37‐40]. For example, some existing tools require that questions be asked of the caregiver and/or the older adult [31]. If a caregiver is not present when EMTs enter a residence, these tools that require a caregiver response could not be completed. Other tools were designed for physicians and are simply not practical for prehospital care, field-based settings [27, 29]. In the field, EMT’s goal is to provide medical care; detection of elder abuse is ancillary. However, it is important to note that existing screening tools, such as the Elder Abuse Suspicion Index (EASI) [29], incorporate clinical judgement into the final assessment (equivalent to our ‘gut instinct’ item). Finally, other tools are very lengthy and cannot reasonably be completed in a field setting [41]. The limitations of previous developed screening tools highlight the need for a validated tool that relies upon EMT’s contextual observation rather than questionnaires.

Importantly, Lachs and Pillemer suggest that screening tools designed to detect elder abuse are limited in that older adults and their caregivers may actively attempt to hide symptoms of elder abuse from the person administering the screening tool [35]. In their review, Lachs and Pillemer suggest that older adults may wish to hide symptoms of victimization from a physician when visiting a doctor’s office [35]. This highlights the utility of in-home observation by EMTs, as medical emergency calls for service provide little time for caregivers or older adults seeking to hide visible symptoms of elder abuse in their home.

Despite these limitations, this is the first study to provide formative data about the need for, and design of, a screening tool specifically for EMTs. The successful development and deployment of an EA screening tool has the potential for broad public health impact. Because the practice of under-reporting is likely not limited to one city in Texas, there may be millions of similarly missed opportunities to detect EA nation-wide each year. Additionally, the support and access we received from leadership at the mobile healthcare provider and APS allowed for an uncensored discussion of a sensitive subject. The results of the current study provide evidence that EMTs do, in fact, regularly interact with older adults who are living with risk factors for abuse, and that they desire a screening tool to help them overcome current barriers to reporting. This information enabled us to conduct a unique study that moves the field towards one potential solution that could help address the underreporting of EA. Future research should seek to develop and validate a tool to enhance detection and reduce the underreporting of EA. This will not only benefit EMT and APS investigations, but ultimately improve the lives of older adults.

APS, Adult Protective Services; EA, elder abuse, neglect, and exploitation, EMTs, emergency medical technicians