Elder Maltreatment Screen and Follow-Up Plan

Measure Specification

Mistreatment of older adults represents a widespread problem and elder maltreatment is being increasingly recognized as a global health issue. Screening for potential elder maltreatment provides a method of identifying those who may be at risk and provides an opportunity for interventions to be instituted to decrease further incidence, decrease or prevent harm, and improve the overall quality of life for the elderly victim and their family and/or caregiver(s).

Identification and proper interventions would assist in providing support to the elderly patient and their family or caregiver(s) [1]. Providing support and early institution of interventions could potentially prevent actual abuse. The American College of Obstetricians and Gynecologists (ACOG) published a Committee Opinion in 2021 stating that ACOG “supports screening of patients older than 60 years to help identify victims of abuse and provide them with appropriate medical and psychosocial care and referrals” [2].

Elder maltreatment has been largely overlooked and has been a contributing factor to the health and well-being of the elderly population. Healthcare providers should screen patients routinely for abuse and neglect. The process of standardized screening using one or a combination of validated assessment(s) and/or instrument(s) should be done to ensure that signs of abuse or neglect are not overlooked.

Tools that aim to detect elder mistreatment in areas such as safety access, cognitive and emotional status, health and functional status, social and financial resources, and frequency, severity, and intent are recommended to be utilized. Assessment tools contribute to the identification of the factors linked in the development of elder abuse and, therefore, facilitate early interventions to prevent patient mortality or negative patient outcomes.

Screening tools for elder abuse have the ability to provide a multidisciplinary objective assessment to detect potential elder abuse [3]. Rosay and Mulford reviewed self-report data from the 2010 National Intimate Partner and Sexual Violence Survey (NISVS) to produce weighted estimates for past-year occurrences of abuse. Results from regression analysis showed “more than 1 in 10 adults who are 70 years of age or older (14.

0%) have experienced some form of abuse in the past year, with 12.1% experiencing psychological abuse and 1.7% experiencing physical abuse. One in five victims (20.8%) were abused by both intimate and nonintimate partners” [4]. Williams, Davis, and Acierno discussed “the number of people age 65 and older will triple to well over one billion or 16% of the world’s population by 2050” [5].

Several studies noted that elder abuse is under-reported [6,7,8]. Health care providers represent one of the lowest proportions of those reporting elder maltreatment and a failure to report elder abuse is a missed opportunity. Dong states, “almost all U.S. states have mandatory reporting legislation requiring healthcare professionals to report reasonable suspicions of elder abuse to APS.

Despite these laws, many healthcare professionals are reluctant to report elder abuse because of concerns about lack of time, limited knowledge, fear of offending the individual and family, and sense of inability to make a difference” [6]. Hirst et al. also included other factors related to under-reporting of abuse such as lack of protocols to identify elder abuse, liability concerns, and limited availability of resources [9].

Prevalence rates of elder abuse can vary across populations. With respect to race, Dong reported that Black older adults experienced higher rates of financial exploitation and psychological abuse (three times and four times respectively) as compared with other populations [6]. Similarly, Beach et al. found that African American older adults have a “significantly higher” risk of financial exploitation and “more than two times” the risk of psychological mistreatment as compared with non-African American counterparts [10].

Latino and Native American populations also experience higher rates of elder abuse as compared with the general population. A study found 40.4% of elder Latinos experienced some form of abuse and/or neglect within the previous year [11]. For Native Americans, Crowder, et al.’s meta-analysis found that rates of elder abuse range from 4.3% to 45.9% depending on study, location and tribal affiliation, though “large studies with comparison populations found higher rates” [12].

Diminished cognitive or physical functioning can impact both prevalence rates of elder abuse. Dong’s review found prevalence rates ranging from 10% in populations without cognitive impairment to 47.3% in populations with dementia [6]. Burnes, et al. found that both physical and emotional abuse were “significantly less likely to occur in older adults with greater functional capacity” [13].

Additionally, at least one study suggests that cognitive impairment among older adults is a barrier to reporting elder abuse [14]. Elder abuse and neglect victims experience increased rates of hospitalization and use of behavioral health services. Abuse can contribute to the individuals decline, both mentally and physically, and ultimately lead to premature mortality [15].

Bond and Butler reported the cost of elder abuse annually is estimated in the tens of billions of dollars and can affect approximately 700,000 to 1.2 million elderly people [16]. A greater use of health resources is associated with elder abuse. Dong cites emergency room use, hospitalizations, and 30-day readmissions as areas where health care use has been impacted.

Costs such as physical and psychological injury, exacerbation of health problems, increased mortality risk, and untimely or early nursing home placement contribute to the overall cost of elder abuse [6].

Common types of elder mistreatment are physical abuse, psychological or emotional abuse, financial abuse, sexual abuse, and neglect. Prevention, detection, and intervention strategies are essential to guard older adults from abuse and neglect in these areas. The use of standardized tools is supported and provides a common approach to assess older adults for abuse and neglect.

Adult Protective Serves (APS) is a supported intervention that investigates alleged cases of abuse for older adults [17]. Risk assessment and mitigation tools should be utilized in the health care setting to examine patients for elder abuse and neglect (EAN). Once EAN is identified, notification of Adult Protective services (APS) is recommended as a best practice.

Screening assists the health care professional in better identifying an individual’s areas of needs, categorizing the individual’s risk, and developing a multidisciplinary plan to provide appropriate interventions and support [18]. Care of the elder abuse and neglect victims should be a multidisciplinary approach and include the facilitation of access to supportive services.

According to evidence, all healthcare providers should screen patients older than 60 routinely to help identify victims of abuse and provide them with appropriate medical and psychosocial care and referrals (e.g., ACOG 2021) [2]. The process of standardized screening using any assessment or instrument should be done to ensure that signs of abuse or neglect are not overlooked [3].

However, current evidence is insufficient to assess the balance of benefits and harms of screening for abuse and neglect where there are no recognized signs and symptoms of abuse [19]. Strategies for detecting elder mistreatment include using a combination of physical assessment, subjective information, and data gathered from screening instruments.

Providers should provide older adults with emergency contact numbers and community resources. When appropriate, referrals to regulatory agencies should be made. From implementing these recommendations, potential benefits include a reduction in harm of elderly patients through appropriate referrals as well as increased use of interventions to promote patient safety.

For health care providers, potential benefits of screening through use of instruments or screening tools such as the Modified Caregiver Strain Index and Geriatric Depression Scale could improve evaluations and patient management that may also develop positive relationships between caregiver and older adult patients [20]. Whenever possible, clinicians should use judgement regarding the need to seek corroborating information from family members, caregivers, and/or care facility staff for patient reports during elder abuse screening for individuals with cognitive impairment.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient for the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.

The documented follow-up plan must be related to positive elder maltreatment screening, example: “Patient referred for protective services due to positive elder maltreatment screening.” Cognitively impaired patients are included in the denominator of this measure and need to be screened using an elder maltreatment screening tool.