6
Screening and Case Identification in Clinical Settings

Elder mistreatment research must be conducted in a variety of settings in order to maximize understanding and make it possible to take proper measures for prevention and management. These settings include geographically defined communities and households, social service agencies, the law enforcement and judicial systems, and the health care system. Pertinent health service settings include all levels of primary, secondary, and tertiary care, including long-term care institutions. While it is important to understand the determinants and occurrence rates of elder mistreatment through population-based studies, it is also critical to identify victims in diverse settings where they frequently appear and where many of the consequences of mistreatment are likely to be manifest.

This chapter focuses on case ascertainment of elder mistreatment in the clinical setting. The American Medical Association’s (AMA) Diagnostic and Treatment Guidelines on Elder Abuse and Neglect (1992) urge “every clinical setting” to utilize a protocol for the detection and assessment of elder mistreatment, following a “routine pattern” in each case (see Figure 6-1). Implementation of such a structured protocol, however well intentioned, could be costly and counterproductive in the absence of careful planning. Since most older patients are not mistreated, and mistreatment is probably uncommon in most general health service settings, any case ascertainment method or program must be accurate and efficient, because it will consume resources and have important consequences, especially if cases are misclassified. Also, many health care delivery settings are so complex that careful case ascertainment is difficult to achieve in practice.



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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America 6 Screening and Case Identification in Clinical Settings Elder mistreatment research must be conducted in a variety of settings in order to maximize understanding and make it possible to take proper measures for prevention and management. These settings include geographically defined communities and households, social service agencies, the law enforcement and judicial systems, and the health care system. Pertinent health service settings include all levels of primary, secondary, and tertiary care, including long-term care institutions. While it is important to understand the determinants and occurrence rates of elder mistreatment through population-based studies, it is also critical to identify victims in diverse settings where they frequently appear and where many of the consequences of mistreatment are likely to be manifest. This chapter focuses on case ascertainment of elder mistreatment in the clinical setting. The American Medical Association’s (AMA) Diagnostic and Treatment Guidelines on Elder Abuse and Neglect (1992) urge “every clinical setting” to utilize a protocol for the detection and assessment of elder mistreatment, following a “routine pattern” in each case (see Figure 6-1). Implementation of such a structured protocol, however well intentioned, could be costly and counterproductive in the absence of careful planning. Since most older patients are not mistreated, and mistreatment is probably uncommon in most general health service settings, any case ascertainment method or program must be accurate and efficient, because it will consume resources and have important consequences, especially if cases are misclassified. Also, many health care delivery settings are so complex that careful case ascertainment is difficult to achieve in practice.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America FIGURE 6-1 Diagnostic and treatment guidelines on elder abuse and neglect, Part I. SOURCE: American Medical Association (1992:13). Thus, research is needed to improve detection methods for elder mistreatment, particularly those that could lead to improved case management. The benefits of careful case finding go beyond protecting the victim. Accurate case identification can lead to rational resource allocation, creation and funding of specialized services, and improved professional and public education. Improving accuracy in case designation also has important

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America implications for the social service and criminal justice systems, particularly in the areas of prevention and perpetrator prosecution. As noted in Chapter 1 and in the paper by Wolfe (this volume), however, a preoccupation with case identification can also have high costs; recent experience in child abuse indicates that a single-minded emphasis on case investigation (when accompanied by the threat of prosecution or other disruptive interventions) can undermine the goal of protection. A FRAMEWORK FOR ELDER MISTREATMENT SCREENING AND CASE IDENTIFICATION Several approaches are used to identify persons with important conditions or situations in the clinical setting, and general principles have been well developed (Rich and Sox, 2000; Neilsen and Lang, 1999). Figure 6-2 represents a framework for screening approaches, emphasizing that case screening and investigation are parts of a multistage process, although the nature and timing of each stage is varied. Validation of each step is an important aim of research. A LEAD standard would be the appropriate means of validating any proposed screening method prior to its widespread application. Typically, the process of clinical screening and case identification starts with designating appropriate settings and situations for carrying FIGURE 6-2 A framework for clinical screening and case identification.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America out this important function. These may include emergency rooms, primary care settings, social service agencies, and public health clinics; research on the feasibility of other potential settings is indicated. A Sequential Process As shown in Figure 6-2, prescreening may occur, formally or informally, through use of warning signs thought to signal an elevated risk, such as being from a high-risk geographic area or having a certain cluster of clinical symptoms or conditions or repeated admissions. To the extent that clinicians rely on such a prescreening process, epidemiological research could improve the accuracy and efficiency of the process by helping to identify the warning signs. Another possible approach is the development and use of case registries. Appearance in a data repository of persons who have been suspected, evaluated, assessed and/or treated for elder mistreatment through the health, social, or justice systems could be used as a basis for initiating a more focused screening process. The next level is the screening process itself (Figure 6-2). This may take many forms but most often has been based on short screening questionnaires (see detailed discussion below). Various approaches may be of value, however, and the potential utility of different approaches to screening aside from interviewing is an area in need of additional investigation. A critical feature of the screening process is the cutoff point for deciding whether the case is screened in or out; this task often involves considerable discretion, highlighting the continuing tension between statistical and clinical methods of screening. When the screening activity indicates a positive result, a case identification investigation is initiated in order to definitively confirm or refute the positive suspicion. While investigation of cases screened as positives is a general characteristic of screening programs, it is worth reiterating that this can be a time-consuming and difficult process; screening programs should be initiated cautiously (with a higher threshold of concern, for example) if resources for case investigation are scarce. For those cases that are identified after investigation, management programs and teams need to be available to address the demands of the particular situation. Statistical Approaches to Evaluation Standard statistical methods can be used to determine the accuracy of screening tests, including any that could be explored for elder mistreatment. Techniques include the use of such measures as sensitivity, specificity, predictive values of positive and negative tests, and receiver operator curves, all available in standard references. For example, the proportion of patients with proven mistreatment who are designated as positive on the

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America screening test represents the sensitivity of that test. For that same test, the predictive value of a positive test is the proportion of persons who screen positive and have the condition being screened. This is not the same as sensitivity, and both are important properties to understand. The proportion of patients screened negative for mistreatment who have not been mistreated represents the specificity of the method; highly specific tests correctly identify those people who do not have the condition. While a detailed discussion of these measures is beyond the scope of this chapter, it should be noted that variation in screening test application, target conditions, and condition occurrence may alter the measurement properties of a given screening test. These methods are more readily applied to conditions that can definitely be designated as being present or absent. For example, a clinical outcome such as a cancer, high blood pressure, or high blood cholesterol can be reliably determined in most circumstances, and the properties of screening tests are well understood. As long as researchers utilize the same cutoff points, outcomes can be compared across studies and conclusions based on data drawn from many studies may be reached in a reliable manner. However, the manifestations of elder mistreatment may be varied, depending on the type of victim and perpetrator and the social context. This variation in disease outcome across study settings may decrease the generalizability of screening test findings. Even with attempts at uniform case definitions, such as that used by Dolan and Blakely (1989:33) to describe elder neglect (“a pattern of conduct which deprives another person of the minimum amount of care which is necessary to maintain physical and mental health”), the definition may be interpreted in myriad ways. Each researcher’s interpretation of phrases such as “pattern of conduct” and “minimum amount of care” will be different and hard to operationalize. It is thus extremely important that researchers explicitly and carefully state their operational definition of elder mistreatment when developing screening tools and assessing their accuracy. SCREENING Approaches to Screening As noted above, although little research has been done in most of these areas, several approaches to screening and prescreening are possible: short questionnaires, geographic characteristics, the presence of certain types or patterns of injuries, clinical or research biomarkers, lack of adherence to or success with various medical regimens, unusual behavioral manifestations, or a history of prior victimization, either recent or remote (Bowen, 2000). Automated medical record systems may be developed that could flag cer-

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America tain patients who are at increased risk of mistreatment based on validated indicators and formulas. These are all in need of further exploration. Research is also needed on the best ways to verify and manage situations in which patients spontaneously report possible episodes of mistreatment. Many health centers have domestic abuse detection and management systems in place, providing an important opportunity for clinical research on elder mistreatment. As noted, most efforts to screen elder mistreatment in the clinical setting have involved short, directly administered questionnaires. For example, the AMA guidelines (American Medical Association, 1992) encourage physicians to “incorporate routine questions related to elder abuse and neglect into daily practice.” Table 6-1 contains a listing of published screening methods for elder mistreatment, along with information on their measurement properties. While several screening tools are now available to identify possible cases of elder mistreatment, it is not known if these tools are widely utilized; anecdotal evidence indicates they are not. Most emergency rooms, one logical place to institute screening procedures, do not routinely screen for elder mistreatment (Jones et al., 1997). The existing tools have rarely been validated in diverse clinical settings, and they have not been adequately validated overall. Some have been evaluated in the emergency room setting, others in the home setting, but none in the office, nursing home, or community settings (such as senior centers or adult day care programs). Several of the current tools depend on accurate responses from the possible victim, who may be unable to give reliable answers due to dementia, fear, or other cognitive or emotional factors. Others depend on responses from the caregiver or trusted other, who may not be willing to provide accurate, truthful responses or may be incapable of doing so. The caregivers of many frail and dependent elders may themselves be equally frail and impaired (Schultz and Beach, 1999). Even among published screening tools, improvements in design and measurement properties may be indicated. There is also need for extending screening instruments into a wider range of settings, such as the physician’s office, adult day care programs, and, despite the challenges, long-term care facilities. These instruments must be practical for those settings. While some of the existing instruments have been available for many years, few have received confirmatory validation by other investigators. Because some cases of mistreatment are obvious and overt, testing the current screening tools to see if they correctly identify these cases may be a reasonable starting point. Once we know that the clear-cut cases are identifiable, it should be easier to proceed to the gray areas where many cases of possible mistreatment lie. In order for a screening tool to be practical in a clinical setting, it should not only be accurate, but also easy to use and efficient. Some of

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America TABLE 6-1 Maltreatment Screening Instruments Instrument and Citation Purpose Type of Elder Maltreatment BASE The Brief Abuse Screen for the Elderly Reis et al. (1993) 5 items Trained practitioner evaluation of caregiver and elder. To help the practitioner assess the likelihood of abuse. Physical, psychological, neglect, financial IOA Indicators of Abuse Screen Reis and Nahmiash (1998) 29 items Trained practitioner assessment of caregiver and elder. To enable practitioners to identify abuse cases among health and social services agency clients. Physical, psychological, neglect H-S/EAST Hwalek-Sengstock Elder Abuse Screening Test-Revised Hwalek and Sengstock (1986) 15 items Elder as respondent. To help agencies identify situations likely to be or become abusive or neglectful. Physical, psychological, financial

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Evaluation Validation Method Validation Setting Reliability Estimates Reis et al. (1993) Paper presented at the Canadian Association on Gerontology Face Validity 86-90% agreement by 3 different trained practitioners. Home assessment of health and social services agency cases. Not analyzed Reis and Nahmiash (1998) Construct Validity The performance of the IOA was evaluated against the BASE measure. Scores of 16 and above have a sensitivity of 85% and a specificity of 99%. Home assessment of 341 health and social services agency cases (55 and older). Chronbach’s alpha = 0.91 Hwalek and Sengstock (1986) Predictive Validity services cases. Using known abuse cases and control cases, 9 items were 94 % accurate in classifying cases into abuse and nonabuse cases. 97 social-health 100 elders living in public housing Not analyzed Moody et al. (2000) Predictive Validity Using known abuse/ nonabuse cases, discriminate function analysis showed that 6 items were as effective as the 9-item model in classifying cases (71.4%) as abused.  

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Instrument and Citation Purpose Type of Elder Maltreatment EAI Elder Assessment Instrument (revised) Fulmer et al. (2000) 35 items Caregiver as respondent. To identify individuals at high risk of mistreatment who should be referred for further assessment. Abuse, neglect, exploitation, abandonment CASE Caregiver Abuse Screen Reis and Namiash (1995) 8 items specifically worded to be nonblaming. Filled out by caregiver. To identify caregivers who are more likely to be abusers. Physical, psychological, neglect those published, such as the Hwalek-Sengstock Elder Abuse Screening Test and the Elder Assessment Instrument, require referral to a more specialized assessment process. Often, no well-established or specialized assessment process is available in many clinical settings; putative cases are reported to the community adult protective systems, which may vary in assessment rigor and standardization, adding to the challenge of screening instrument evaluation. This referral and evaluation process could be another direction for research on the screening process for elder mistreatment. Another important challenge is the design and validation of new instruments and approaches to detect the various types of elder mistreatment in addition to overt physical abuse in the home, particularly abuse in the institutional setting, intentional neglect, and financial abuse. While these types of mistreatment may overlap, it is likely that different markers will be

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Evaluation Validation Method Validation Setting Reliability Estimates Fulmer and O’Malley (1987) Content validity: 0.83 Acute care. Chronbach’s alpha = 0.84 Reis and Namiash (1995) Predictive Validity Using known abusers and a control groups, overall scores of abusers were significantly higher on the CASE (mean 3.2) than nonabusers (mean 1.9). Construct Validity CASE scores were positively correlated (0.41) with IOA scores. 44 known abusive caregivers and 45 nonabusive caregivers receiving care from a social services center. Chronbach’s alpha = 0.71 present in the domains of subject, trusted other, and social embeddedness (see Chapter 3). Challenges in Screening A variety of factors make screening challenging and difficult. Mistreatment may occur as a single act or as a chronic, subtle series of events. In fact it is often difficult to know when an event or series of events have crossed the line from inappropriate conduct to actual mistreatment. At what point does inadequate care become intentional neglect? Expectations across different settings may also influence the identification and definition of cases. For example, different standards of care may be applied to the professional staff of a nursing home in contrast to a family caregiver or

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America volunteer in-home helpers. In addition, common physiological changes in the elderly complicate the assessment of elder mistreatment. Bruises and fractures and even death may be indicators of abusive assaults, but they are also common occurrences in frail and dependent elders due to spontaneous falls and tissue fragility. How do we know when a bruise is an indicator of abuse rather than an expected result of a person’s medical condition and functional status? As is evident throughout this report, the context in which an injury occurs is often as important as the injury itself in screening for elder mistreatment. Instruments for screening and case identification would be likely to benefit from considering contextual risk factors as well as characteristics of the elder subject and characteristics of the trusted other. As an example, the places where elders reside and spend time may affect the risk for mistreatment. For those living in a skilled nursing facility or who are housebound, residential or institutional risk factors take on greater importance. Others may spend time in a variety of settings, such as senior centers or adult day care centers. The varied distribution of social environments may alter risk profiles and the performance of screening instruments. The sociocultural milieu in which elder mistreatment occurs is another potentially important contextual issue that has received little research attention. Understanding how variations in race, ethnicity, religious beliefs, and socioeconomic status affect the risk and occurrence of elder mistreatment is critical to improving screening and case identification methods. Further complicating screening and case identification of elder mistreatment is the problem of cognitive impairment. Depending on the degree of impairment, different methods may be employed to elicit needed information. Some with mild impairment may be able to give a reasonably accurate history of neglect or abuse, but those with moderate or severe dementia may not be able to do so (see further discussion of this issue below). There is good evidence that mistreatment is a substantial problem among Alzheimer’s disease patients (Paveza et al., 1992). Screening and diagnosis must then be done via interviews of caregivers or others who are knowledgeable about the elder’s situation and via clinical evaluation of the patient. Screening the trusted other in these circumstances is an important research direction as environmental and social factors in elder mistreatment are ascertained. CASE IDENTIFICATION As emphasized throughout in this volume, the range of behaviors subsumed under elder mistreatment is large, diverse, and multidimensional. While some cases are obvious and easy to designate, many are not, and the definitions of elder mistreatment should be the subject of research, as noted

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America in Chapter 2. That chapter also discusses use of the LEAD standard methodology to validate case identification methods. In addition, the clinical process of case investigation in the community practice setting has substantial implications for the social service (adult protective services) and justice systems. The Adult Protective Services experience is of particular interest. In a survey (National Association of Adult Protective Services Administrators) for 1999–2000 in which all 50 states responded, of the complaints received by adult protective services, only two-thirds were investigated. Of those investigated, half were substantiated for abuse or neglect. While the complaints and investigative processes are tracked by every state, the methods of case validation preceding the finding varies widely from state to state. The starting point for adult protective services response to a complaint of alleged elder mistreatment is the state statute and administrative rules. A total of 26 states respond to complaints for people age 60 years and older, and 18 states respond to complaints for people age 65 and older. Two states include any adult who is vulnerable or has disabilities. As discussed earlier, state statutes also differ significantly in their definitions. For example, some statutes do not cover neglect. If the complaint received by adult protective services meets the local statutory definitions, a caseworker is assigned to assess or investigate the situation, determine if the abuse is substantiated, and develop a plan to protect the person from further harm. The assessment-investigation process is often identified by adult protective services workers as one of the most difficult aspects of their work. There is a paucity of training for them prior to receiving a caseload, with only a handful of states requiring significant training. In addition, states differ in their emphasis on case identification versus provision of social services. Some states are more weighted toward investigation, that is, the process of making a finding about the allegation and abuse registries, while others spend more time on the provision of services and less on investigating. Once a case of elder mistreatment has been assigned for investigation, most state statutes require a face-to-face visit with the alleged victim within a prescribed time period, more quickly depending on the seriousness of the report, but typically within 48 hours. Once at the home or residence, in the majority of instances, the adult protective services worker must first receive consent of the client for the assessment-investigation. If the client refuses, the worker cannot proceed. When conducting an assessment-investigation, the worker’s task is not only to find out what happened and determine if it was abuse or neglect, but it may also include an evaluation of the person’s functional capacity, and his/her ability to live independently (physical tasks) and to make judgments (mental tasks). This knowledge helps to determine what support should be offered so that the person can live as independently as possible, and it is also useful in determining their ability to protect

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America themselves from further harm. The assessment should also include evaluation of the risk of future abuse. While adult protective services units have developed several instruments and guidelines to carry out their state mandate—for example, screening, investigation and evaluation of mental competence—and have shared best practices among the states, they are well aware of the need for validation and research and of the subjective nature of the decision making often required in conducting assessments-investigations. The processes of case identification and case management are in need of research for all of its components. Some of the major challenges for both the clinical and community settings are discussed below. Standardized Criteria for Case Identification A major barrier to the identification of cases of elder mistreatment is that the researcher or clinician is rarely in a position to directly observe the relevant event(s). Most of the time, the identification of a case is made indirectly, relying on the report of the victim—or the perpetrator—or on the presence or absence of observable signs and symptoms believed to be indicative of mistreatment, such as emotional distress or bruises. However, indirect approaches may be uncertain. The accuracy of self-report by victims or perpetrators is not quantitatively established in most clinical settings. The value of self-report may be further undermined when the victim is ill or cognitively impaired. The capacity of older persons to provide accurate accounts of their observations or experiences is an important area for research. In many situations, case identification is predicated largely on the injured person’s account of the circumstances. Whether adult protective services or a prosecutor acts on the possible mistreatment is dependent in such an instance on the credibility of the victim. If an allegation is brought, whether a court even hears the injured person’s account may be dependent on a finding of his or her competence to testify. If the older person has cognitive impairments, then the admissibility of his or her testimony may be contingent on judicial findings that the witness had the ability to form a “just impression of the facts” (i.e., to perceive the situation) at the time that the injury occurred, that the witness has the ability to recall the situation and communicate that memory, that the witness understands the difference between truth and falsity, and that the witness knows the nature of an oath and understands the obligation to tell the truth in court (see Myers, 1993). Ultimately, the application of these standards arguably depends on an assessment of the jury’s ability to make sense of the witness’s testimony. Given that time will be consumed in any event by a determination of a witness’s competence, the victim’s testimony should be heard if it is not

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America likely to mislead or confuse the jury. In such a case, however, the jury still has to consider the witness’s credibility, and expert opinions may be introduced about the possible effects of the witness’s cognitive impairments (Melton et al., 1997, § 7.07). There is now a large body of research on children’s credibility and competence as witnesses. Many studies have addressed child witnesses’ suggestibility and accuracy of recall (see Saywitz et al., 2002). Extension of this research to elders with dementia poses significant challenges, because the impact of the impairments to statements about victimization will be affected by medications, comorbidities, the experience of trauma, and the severity of the dementia itself. However, some of the methods used in research on child witnesses could be applied in studies of testimony by mildly or moderately confused elders. Research assessing the capacity of older persons with cognitive impairments to provide accurate testimony is needed for improving the accuracy of case identification, not only in clinical settings, but also in legal settings, including prosecutorial decision making and formal adjudication. Another impediment to accurate case identification is that many elders have conditions that are associated with physical frailty and other medical problems as well as psychological or emotional problems. For example, as many as 18 percent of seniors report depressive symptoms (although many of these are mild symptoms)—much higher than can be accounted for by mistreatment alone. Also, normal age-related changes make an elder more susceptible to serious consequences of seemingly minor illnesses. An older person with atrial fibrillation taking an anticoagulant may have easy skin bruising, and thus the presence of bruising will be less helpful than otherwise as a sign of possible mistreatment. This “fact” is clinically accepted and makes intuitive sense, yet no studies quantify bruising rates under normal circumstances, compared with cases of mistreatment. Fragile capillaries and thinner skin, both age-related changes, also make elderly individuals more susceptible to bruising. Quantification and standardization of mistreatment-related clinical observations are necessary to explore their utility in designating cases of mistreatment. Because so little is known about the signs and symptoms of mistreatment, it is easy to assume that an injury is due to a certain constellation of natural changes and illnesses rather than to mistreatment. There are no studies that help illuminate when to consider an injury as a marker of mistreatment. Retrospective studies may be a valuable tool in understanding markers, particularly in cases of ongoing abuse. If elders with severe injuries secondary to mistreatment are identified, one may be able to look at their histories and see if there were markers that would have made it possible to identify mistreatment at an earlier stage. A critical step to advance the field is the development of a consensus around the determination of whether or not a case of mistreatment has

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America occurred. Since elder mistreatment is almost always assessed by indirect means, a gold standard of case identification may not yet be possible. Investigators will need to create new approaches to case standardization and develop alternative benchmarks for case identification. One useful approach discussed in Chapter 2, applies the LEAD (longitudinal, expert, all data) standard. This method must be well described, widely accepted, and replicable in a variety of settings in which mistreatment might be encountered. Applying Causal Logic to Case Finding In addition to the determination of relevant conduct and harm, the occurrence of mistreatment requires a determination of cause, especially in studies aiming to improve clinical methods of case identification and screening. In some cases the co-occurrence of harm and relevant conduct is such that an unequivocal determination that the perpetrator’s conduct caused the harm can be made. For example, a caregiver might be observed striking an elder. In many situations, however, the critical issue is whether the observed harm suffered by the victim was attributable to the trusted other’s conduct. (As noted in Chapter 2, in some circumstances there is conduct of interest but no evidence of harm. The issue of causality is not relevant in such cases, unless there is concern that harm has not been detected, in which case the problem involves the detection of consequences.) Determination of cause is most relevant in two types of situations. In one type, consequence and conduct could both be detected but neither alone would constitute mistreatment, unless the conduct was shown to have caused the consequence. This scenario is most relevant to neglect. For example, an older person might have fallen and fractured her hip at the same time that the caregiver was known to leave her alone at home for several hours during the day. If the elder had a problem walking and always needed help to get around, it might be concluded that the lack of supervision was critical to the older person’s fall and thus constituted mistreatment. In contrast, if the elder had no problems walking and fell because she rushed to go downstairs to answer the phone, the caregiver’s conduct would not constitute mistreatment. Applying causal reasoning that meets research standards to this sort of circumstance is clearly complex. While logical inference is critical to determine whether certain prerequisites are met (e.g., “Did the conduct occur before the consequence?” or “Was the conduct such that the specific consequence would be expected to have resulted from it?”), ultimately, the determination of causality may often be judgmental, requiring a process by which the determination can be made. This decision process itself may be the object of important research and at a minimum should have high face

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America validity and reliability and be sufficiently delineated so that it can be replicated. The other situation in which causal reasoning could be called on is one in which a harm has been detected without a clear conduct that could have caused it. While this too could be considered a failure in the measurement of conduct, some research indicates that there are certain harms that older persons may suffer that can only have been by mistreatment (or have a such high probability of having been caused by mistreatment that they are presumed to be due to mistreatment until proven otherwise). An example of such a presumed case would be the presence of a clinical phenomenon that could only have occurred by the conduct of another person. Identifying Physical Markers of Elder Mistreatment Some physical findings in children, such as shaken baby syndrome, are considered to be hallmarks of abuse. Characteristic injuries in this syndrome include retinal hemorrhages, subdural hematomas, and rib or long bone fractures. Are there similar hallmarks that may comprise a syndrome of physical abuse or neglect in the elderly? Possible examples discussed by Dyer et al. (this volume) include lacerations of specific body parts, certain types of burns, dehydration in certain contexts, and possibly specific types of bone fractures. Further clinical, behavioral, and forensic research in this area is needed to determine what harms under what circumstances would constitute almost unequivocal evidence of having been caused by the conduct (acts or omissions) of another person. There are to our knowledge no published studies of physical markers of elder mistreatment that help distinguish preventable, unavoidable signs from those that are intentional, inflicted, or avoidable. One study of skin tears in nursing home residents described the characteristics of the tears, but almost half (48 percent) of the tears had an unknown cause, and the possibility of mistreatment was not addressed (Malone et al., 1991). The only study on bruising that included elderly subjects did not address the influence of medications, functional status, illnesses, or living situation, nor did it address etiology (Langlois and Gresham, 1991). Possible markers of neglect and abuse include bruises, pressure sores, fractures, burns, and abrasions. A key to interpretation of these markers is not merely their presence but their characteristics—such as anatomic location, extent, morphology, severity, and multiplicity—which may help differentiate between an intentional injury and an avoidable one. For example, a single bruise on the back of the forearm is probably common in cases of accidental bruising, but multiple bruises in various stages of healing on the neck, anterior upper arm, and abdomen raise a suspicion of physical abuse. Also, it is not known if hip fractures due to spontaneous falls have

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America a different radiographic appearance than those due to an inflicted injury. Research is needed to help illuminate the characteristics of common injuries, such as their etiology, natural course, distribution, and severity so that the process of identifying cases of elder mistreatment can become more accurate and reliable. While certain physical signs (such as burns and ligature marks) are likely to be more reliable indicators of elder mistreatment than others (such as fractures and pressure sores), neither the challenge nor the importance of advancing knowledge in this area should be underestimated. Mistakenly characterizing a spontaneous bruise or other injury as intentionally inflicted may lead to substantial clinical, social, and legal jeopardy for all concerned. CONCLUSIONS The need for accurate and efficient screening and case identification methods for elder mistreatment is immense. We must minimize false negatives to protect the elder subject and minimize the false positives to avoid false accusations of the trusted other. Just as mistreatment can have devastating consequences for an elder, a false accusation can have devastating consequences for the trusted other. It is likely that screening and case identification will hinge on understanding the constellation and interaction of signs, symptoms, findings, and the context in which they occur. Substantial research is needed to improve and develop new methods of screening for possible elder mistreatment in a range of clinical settings. These methods should be able to detect a broad range of categories of mistreatment and be highly accurate and efficiently deployed. Candidate techniques include improved questionnaire designs; record linkage to other clinical, public health, social and legal databases; automated alerts based on concurrent clinical records; and previously defined risk status based on prescreening methods. Special attention should be placed on the predictive value of various clinical injuries and other relevant clinical findings as indicators of mistreatment for therapeutic, social, and forensic reasons. Also, the panel sees value in economic analyses of cost-effectiveness for elder mistreatment screening in various clinical settings. Research is needed on the process of designating cases as incidents of mistreatment in order to improve criteria, investigative methods, decision-making processes, and decision outcomes. The absence of a gold standard for case identification, and the momentous consequences of inaccurate decisions, highlight the need for studying and improving the process of case investigation and designation. The impact of resource constraints on the designation process and its consequences for affected persons should also be studied.