Tara McMullen, M.P.H., Ph.D.(c), and Kimberly Schwartz
Centers for Medicare & Medicaid Services
Mark Yaffe, M.D., C.M., MClSc, CCFP, FCFP
Department of Family Medicine, The McGill University
Scott Beach, Ph.D.
University Center for Social and Urban Research,
University of Pittsburgh
This article reviews information and data presented at the IOM Forum on Global Violence Prevention Workshop on Elder Abuse and Its Prevention. This paper details the screening and detection of elder maltreatment with a focus on the Elder Abuse Suspicion Index (EASI ©). The paper also discusses the measurement of maltreatment within the Physician Quality Reporting System (PQRS) by the Centers for Medicare & Medicaid Services (CMS), and concludes with a more general discussion of issues and challenges in elder abuse screening and detection.
The association of elder maltreatment with hospitalizations, hospital admissions, and mortality emphasizes the need to explore and expand appropriate measurement and assessment of maltreatment—across multiple settings and provider types (Mosqueda and Dong, 2011; Dong et al., 2011d, 2012d; Dong, 2012). CMS, among various agencies and stakeholder groups, intends to increase detailed reporting of measures that address a population which warrants representation related to actions of abuse, whether it is neglect, financial, physical, psychological, and/or emotional abuse. Current CMS reporting of maltreatment includes reporting of the Elder Maltreatment Screen and Follow-up Plan measure, created for the PQRS, a physician reporting program within CMS. This measure specifically assesses the percentage of patients ages 65 and older with a documented elder maltreatment screen and follow-up plan on the date of positive screen (CMS, 2013). This measure has been reported since 2009 in each reporting period for patients seen by the provider.
Following the inception of the Elder Maltreatment Screen and Follow-up Plan measure into the PQRS program, CMS has intended to expand the measurement of elder maltreatment to address a larger venue of providers
and settings. This is based on the understanding that opportunities to screen for elder abuse are not just confined to the physician’s office or emergency department (McMullen and Schwartz, 2012). Moreover, CMS would like to encourage greater participation in the reporting of elder maltreatment (McMullen and Schwartz, 2012). As noted from preliminary statistics of the Elder Maltreatment Screen and Follow-up Plan (2012) measure, the incidence of applicable denominator cases reported in the first 6 months of 2012 were 53,915,669. That is, nearly 54 million individuals were eligible to receive a maltreatment screen when visiting their physician. Of these 54 million reported cases, only 1,438 individuals were actually screened for maltreatment. Cases were reported by psychologists, geriatricians, and occupational therapists, among others. This number reflects the very low participation in reporting of this measure by eligible providers, addressing the need to encourage reporting of elder abuse from a patient safety perspective and patient engagement, and, quite possibly, the expansion of this measure (Quality Insights Pennsylvania, 2013).
The CMS Elder Maltreatment and Care Symposium
With a defined focus on expanded reporting and assessment of elder maltreatment, CMS hosted the Elder Maltreatment and Care Symposium to explore the current state of elder maltreatment screening and elder care practices across Medicare and Medicaid beneficiary populations and care settings. Moreover, this symposium attempted to develop a framework to build a more comprehensive measure specification for the PQRS. Preliminary analyses from this symposium suggest:
1. There is a consensus that there should be consistency in how to define elder maltreatment across HHS agencies;
2. Crosscutting screening tools are available and could be used in various care settings, by multiple providers, and may evaluate elder abuse and burden on the provider. Three screening tools were identified for increased use in practice for the screening of elder maltreatment (EASI, HS-EAST, and the Vulnerability to Abuse Screening Scale, or VASS). These tools were identified for their ability to assess multiple types of abuse, for the specifications of the measure, and for the focus of each tool when combined;
3. The impact of screening on the provider–patient relationship should be taken into account;
4. Cultural diversity should always be considered in any elder maltreatment measurement; and
5. Awareness of the feasibility and burden on the provider should be kept in mind.
Many questions continue to exist within the domain of elder maltreatment measurement and assessment. Detection, assessment, and reporting of abuse from multiple providers in different settings are imperative. With a focus on assessments, there are uncertainties about what factors are most important to screen for, and what the most valid, reliable assessment tools are. In collaboration with the IOM and CMS, Dr. Mark Yaffe and Dr. Scott Beach discussed factors for screening maltreatment, detailing specifications of a reliable and valid tool for assessment of maltreatment: EASI.
The Elder Abuse Suspicion Index
EASI was conceptualized and validated to respond to the following realities: (1) family physicians are well positioned to try to identify elder abuse, and therefore a tool was necessary for use in the ambulatory office setting; (2) to promote compliance by family physicians with tool usage, the time to administer it needed to be very short, while using language content that was acceptable to them; (3) research ethics requirements would limit validation to those aged 65 or older with Folstein MMSE (Mini-Mental State Examination) scores of 24 or greater; and (4) a tool meeting these requirements would be useful for screening or case finding, but given the complexity of elder abuse, the minimum expectation of the tool would be to generate suspicion about the presence of mistreatment or neglect sufficient to justify further discussion of the issue between doctor and patient, or patient referral to a community expert in elder abuse for in-depth evaluation (Yaffe et al., 2008).
The validated EASI consists of six questions, five asked by the doctor to older adults, and one answered by the doctor based on observation of the patients. Of the doctors in the validation study, in responding to a post-tool usage survey, 96 percent indicated the tool was somewhat to very easy to use, two-thirds doing so in 2 minutes or less. In collaboration with the World Health Organization (WHO), EASI has been shown to have content validity in seven diverse countries (WHO, 2013). There are eight known linguistic versions of the EASI—English, French, German, Hebrew, Italian, Japanese, Portuguese, and Spanish (Yaffe et al., 2012).
Self-administration of the EASI in a slightly modified form (EASI-sa) has been shown to be feasible, acceptable, and comprehensible. This approach also appears to improve seniors’ awareness of elder abuse and its manifestations (Yaffe et al., 2012).
In Canada, through a collaboration of the EASI team and the National Initiative for the Care of the Elderly, the EASI has been distributed as a pocket card to 24,000 primary care doctors; there is also a digital version of the tool available online. To date, however, there are no data on the actual uptake of the tool.
Because professionals from various disciplines may approach elder abuse differently, it is productive to explore use of the EASI by different groups (Yaffe et al., 2009). For example, the validation of the EASI in Spain was accomplished using social workers (Perez-Rojo et al., 2010). Meanwhile, in Canada there are preliminary attempts by others in Canada to study nurses’ use of EASI in emergency rooms and nursing home settings. No data have been published yet on these two experiences.
Elder Abuse Screening and Detection
Both the CMS work and that of Dr. Yaffe and his colleagues on the EASI focus primarily on screening for elder abuse in health care settings. This last section provides a broad, though necessarily brief, summary and overview of elder abuse screening and detection. The section is summarized in Table II-1. Note that references cited in the text below are examples and not meant to be comprehensive.
Screening and Detection in Community-Dwelling Older Adults
As shown in the table, a variety of approaches have been used to attempt to screen for and detect elder abuse in community-dwelling older adults. One of the key challenges facing the elder abuse field is developing methods for detection in cognitively impaired older adults. As shown, direct victim surveys of both general and disease-specific populations are possible for cognitively intact persons (Laumann et al., 2008; Acierno et al., 2010), but not for those who are cognitively impaired. For impaired populations, researchers must use more indirect methods such as caregiver or potential perpetrator surveys (Wiglesworth et al., 2010), health care provider screening, reports from social service providers or others who come into frequent contact with older adults (“sentinels”) (National Center on Elder Abuse, 1998), and forensic analysis of bruising patterns (Wiglesworth et al., 2009). Note that all of these techniques are also appropriate for cognitively intact older adults. Of course, official APS reports can also be used, but there is general agreement that elder abuse is greatly underreported and that these official reports represent merely the “tip of the iceberg” (NRC, 2003).
Screening and Detection in Institutionalized Older Adults
Paralleling community-dwelling methods, long-term care resident surveys are also possible for those who are cognitively intact, although these direct surveys are somewhat rare. More common methods applicable to both cognitively intact and cognitively impaired residents—who make up
TABLE II-1 Overview Summary of Elder Abuse Screening and Detection Methods and General Issues/Challenges
Methods for Community-Dwelling Older Adults
Methods for Institutionalized Older Adults
• Direct victim surveys (random sample)*
• Direct victim surveys (targeted disease)*
• Direct caregiver surveys (targeted disease)
• Direct perpetrator surveys
• Health care screening (physicians, emergency department, hospital, dental clinics)
• Community "sentinels"
• Social service providers (adult day care)
• Forensic analysis (bruising)
• APS/official reports
• Resident surveys*
• Staff surveys
• Family surveys
• Resident informant/proxy surveys
• Forensic analysis (bruising)
• Video monitoring of public areas
• Long-term care (LTC) ombudsman/official reports
(Both staff–resident and resident–resident abuse)
|General Issues and Challenges
• Elder abuse from whose perspective? Older adult victims? Clinicians? Proxy informants?
• If cognitively intact, should we always get the victim’s perspective? (maintain autonomy versus "objectivity" of clinicians?)
• General self-report issues (accuracy, disclosure, motivation, etc.)
• Health care provider compliance with screening
• Access to and cooperation from long-term care facilities
• Which screening/measurement tool to use? (many options may need more psychometric testing, development)
• Interviews vs. self-administered? Technology for data collection? (impact on perceived privacy, comfort reporting)
• Setting, context important—own home, primary care physician’s office, waiting room, emergency department (impact on perceived privacy, comfort reporting)
• Neglect particularly challenging—omission (not helping) or commission (actively preventing access to food, water, medicine)? Co-occurrence with self-neglect?
• Financial exploitation also especially challenging—stranger fraud/scams versus family/trusted others (different dynamics)
• Sensitivity to the wider cultural context
* Cognitively intact only.
a large portion of the institutionalized population—include staff surveys (Castle and Beach, 2013) and family member surveys (Zhang et al., 2012). These methods have been used to detect both staff-to-resident and resident-to-resident abuse, which Lachs and colleagues (2007) have argued are the most prevalent forms of abuse occurring in long-term care settings.
Resident informant/proxy surveys are also a possibility, as is forensic bruising analyses (Wiglesworth et al., 2009). An intriguing though unexplored possibility is the use of video monitoring and direct observation of staff–resident and resident–resident interaction in public areas such as hallways and dining areas. Finally, official ombudsman reports are also available, but likely represent only a small portion of the cases actually occurring.
General Issues and Challenges in Elder Abuse Screening and Detection
The methods briefly reviewed above each have both strengths and weaknesses. Elder abuse is a largely hidden phenomenon that people are reluctant to acknowledge, much less discuss openly with strangers. Table II-1 summarizes a few of the key issues and challenges that confront researchers and health care providers as they attempt to screen for and detect elder abuse. They include issues around autonomy versus clinician “objectivity,” potential self-report issues, health care provider compliance, access to and cooperation from long-term care facilities, selection of appropriate tools and measures, mode of data collection and use of technology, and how the setting or context in which the abuse screening or questioning occurs may affect responses. As one example, Dr. Scott Beach’s work has shown that removing the interviewer from the situation in direct victim surveys through use of survey technologies like audio computer-assisted self-interviewing (A-CASI) can result in prevalence rates for financial and psychological abuse that are two to three times higher than when an interviewer asks the questions (Beach et al., 2010). In contrast, older adults may be more willing to tell their physician directly about abuse given increased trust and rapport. As screening for elder abuse in health care settings becomes more common through the previously described work of CMS, issues around health care provider compliance and the best tools and methods for different care settings (physician offices, emergency department, dental clinics, etc.) will need to be addressed. Table II-1 also notes that neglect and financial exploitation pose unique challenges for screening and detection. Finally, any effort to screen for and detect elder abuse must be sensitive to the wider cultural context, and interesting work is occurring both among diverse groups in the United States (Dong and Simon, 2010; DeLiema, 2012) and in the international context (WHO, 2008).