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A Comparative Study of Elder Abuse Reporting at Two Large Veterans Affairs Medical Centers
ISSN: 2167-7182

Journal of Gerontology & Geriatric Research
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A Comparative Study of Elder Abuse Reporting at Two Large Veteran?s Affairs Medical Centers

Vognar L1,2*, Sarfraz S1,2, Adhikari R2, Rackson K4 and Dosa D1,2,3
1Center of Innovation, Providence VA Medical Center, USA
2Department of Medicine, Brown University, Providence RI, USA
3Department of Health Services, Policy & Practice, Brown University, Providence RI, USA
4Virginia Commonwealth University, Richmond, VA, USA
*Corresponding Author: Vognar L, Division of Geriatrics and Palliative Care, Brown University, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI, USA, Tel: 310-619-0127, Email: [email protected]

Received Date: Oct 30, 2018 / Accepted Date: Nov 16, 2018 / Published Date: Nov 21, 2018

Abstract

Purpose of the study: One to two million elderly Americans are injured, exploited, or otherwise mistreated by someone on whom they depend on for care or protection. Elder abuse (EA) is detrimental to the individual and has significant societal and health cost implications. Despite these profound consequences, research suggests that elder abuse is often underreported. We conducted a retrospective review of reported EA cases over a 7 year period at 2 large VA Medical Centers (VAMC) to assess the types of EA cases reported, the characteristics of those patients who were reported and the 1 year outcome.

Design and methods: A retrospective review of all cases of elder abuse reported to Adult Protective Services at two large VA Medical Centers between 2006 and 2012 was conducted as part of an educational initiative to improve health care provider identification and triage of elder abuse.

Results: Thirty cases of EA were reported at the Providence VAMC and 25 were reported at the Durham VAMC during the study period. A dementia diagnosis was common among EA cases, present in 50% of cases in Providence and 72% in Durham. The majority (41/55) of referrals were made by the medical team but cases were also reported by caregivers and patients themselves. In over half of the cases, the Veteran was able to remain in the home environment with support from additional community based services, such as home health aides, physical and occupational therapy.

Implications: Based on the published prevalence of elder abuse in elderly populations, EA was likely underreported in the two large VAMCs. More research is necessary to help determine the prevalence of elder abuse among Veterans, to identify risk factors that might aid diagnosis, and to develop interventions that target this important problem.

Keywords: Elder abuse; VA Medical Centers (VAMC); Veteran’s Affairs (VA); Reporting

Introduction

Elder abuse represents a growing problem in the United States. According to the National Research Council panel, an estimated one to two million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depend on for care or protection [1] Recent data show that elder abuse is not only detrimental to the individual but also has societal and healthcare consequences. Victims of elder abuse have fewer support systems and fewer physical, psychological, and economic reserves [2]. As a result, the impact of one single incidence of elder abuse is magnified: victims have a higher 10-year mortality and morbidity than older adults who have not been abused [2]; they have significantly higher emergency room utilization and higher hospitalization rates [3]. Victims also have an increased risk for institutionalization [2]. Economic estimates suggest that cases of elder abuse contribute more than 5.3 billion dollars to the annual healthcare expenditure in the United States [4]. Despite these profound consequences, studies have estimated that elder abuse is often underreported. For every 1 case of elder abuse, 5 more cases go unreported [5]. It is likely that a busy clinician who sees between 20 to 40 patients daily could encounter at least one victim of elder abuse per day [6].

The Veterans Health Administration is the largest integrated, federally funded health care system [7]. The Department of Veterans Affairs census estimates that there are approximately 13 million Veterans and their single surviving spouses who are age 65 and older, representing about a third of the total senior population and 45.3% of the total veteran population [8]. A 2000 comparative analysis of health status and medical resource use showed that the VA patient population had poorer health status, more medical conditions, and higher medical resource utilization including more physician visits per year, more hospital admissions per year, and more days spent in the hospital per year, when compared with the general patient population [9]. Elderly veterans are also eligible for a wide variety of VA benefits, such as disability and pension compensation that might place them at a higher risk for exploitation [10] (2010 GAO report). A 2010 GAO Report revealed that guardians stole or otherwise improperly obtained $5.4 million in assets from 158 incapacitated Veterans, many of whom were older adults [10].

The prevalence of elder abuse among Veterans is not known given that many cases are never diagnosed or reported. Veterans also offer a particular challenge to healthcare providers. There are likely inherent biases against reporting suspected cases of abuse due to the predominance of male patients and a perception that Veterans are not easily abused.

Nevertheless, as a matter of policy, all VA medical centers, VA OPCs, Vet Centers, VA CLCs, Home Based Primary Care, Home and Community based programs, State Veterans Homes and CBOCs are required to comply with their own state laws for reporting abuse and neglect [7]. Each VA Medical Center Director is required to ensure that policies and procedures addressing the identification, evaluation, treatment, referral and mandatory reporting of abuse and/or neglect are in compliance with the applicable state laws [7]. In order to learn more about the types of Veterans reported to experience elder abuse, we undertook a review of all cases of elder abuse reported to Adult Protective Services at two large VA Medical Centers between 2006 and 2012 to examine the characteristics of reported elder abuse patients, and the type of abuse that warranted reporting. We also sought to understand the one year outcomes of Veterans with suspected elder abuse reported.

Methods

Prior to beginning research, an Institutional Review Board at both the Providence and Durham VAs reviewed the protocol and deemed it non-research quality improvement. A retrospective chart review of all cases of EA reported by the Providence and Durham VAMCs to their state‘s respective Department of Elderly Affairs (DEA) and/or Adult Protective Services was conducted by three authors at each center.

Sample

Each Department of Social Work is required to record reported cases of elder abuse within the Veteran’s electronic medical record. The Department of Social Work at both facilities provided the authors with a list of Veterans reported to experience elder abuse between 2006 and 2012. Relevant charts were reviewed for distinguishing characteristics that might predispose the Veterans to a high risk of abuse and the type of abuse was also evaluated. Exclusion criteria included referrals to APS for guardianship as a result of psychiatric illness.

Review criteria

Applicable cases were evaluated for the Veteran’s demographic profile including the age, race, and gender. Charts were also reviewed for the Veteran’s number of medications at the time of the reported abuse, the number of comorbid illnesses based on the problem list at the time of reporting, the number of Emergency room visits in the preceding year and the presence of a dementia diagnosis in the problem list or in relevant notes from the preceding year. Each chart was also reviewed for the relevant type of elder abuse reported. EA cases were classified as Physical, Neglect, Self-Neglect, Financial, or Mixed. Cases of elder abuse were also screened for relevant outcomes within one year of reporting and if an elder abuse diagnosis was listed in the medical record. Relevant outcomes that were explored included death, greater than 5 emergency room visits, and discharge to home with increased social support services.

Analysis

Demographic characteristics were tabulated for each report by three different reviewers and then compared for accuracy. Discrepancies were re-reviewed for clarification. Descriptive statistics were calculated using Microsoft Excel.

Results

Between 2006 and 2012, a total of 30 cases of elder abuse were reported at the Providence VAMC and 25 were reported at the Durham VAMC. Of the 55 cases, only one chart in Providence had elder abuse listed within the problem list or as a diagnosis related group in the encounter summary.

Types of elder abuse

Figure 1 describes the types of elder abuse identified in the chart review. In Providence, the most common form of abuse reported was Self Neglect (11, 37%) followed by cases defined as Mixed Abuse (9, 30%). Over a 7 year period, there was only 1 case (3%) of reported physical abuse. In Durham, Mixed Abuse was most common (11, 44%) followed by Self Neglect (9, 36%). There were no cases of physical abuse reported in Durham.

gerontology-geriatric-research-abuse

Figure 1: Category of reported elder abuse types (2006-2012).

Characteristics of veterans who had elder abuse reporting

Table 1 lists the demographic profile of reported cases of elder abuse for each medical center. In general, reported cases of elder abuse tended to be male, >85 years old and unmarried. A dementia diagnosis was common among EA cases, present in 50% of cases in Providence and 72% in Durham. They were also likely to utilize more than 10 medications and suffer from multiple comorbidities.

Variables Durham, NC (N=25)
(#, %)
Providence, RI (N=30)
(#, %)
Both
(%)
Veteran Demographics
65-75 years 8.32% 6.20% 26%
76- 85 years 13.52% 16.53% 52.5%
Male 25.100% 28.93% 96.5%
Married 11.44% 6.20% 32%
Have children 19.76% 24.80% 78%
Encounter Demographics
Dementia Diagnosis 18.72% 15.50% 61%
Medications> 10 15.60% 14.46% 53%
Medical Diagnosis>10 19.76% 20.66% 71%

Table 1: Demographics.

One-year outcome

Elder abuse reporting: Using the date of reporting as a baseline, those with EA reports were screened for health outcomes over the following year. Table 2 presents outcome data for both sites. A total of 20 of the 55 cases (36%) were deceased within a year. Fourteen of the cases recorded greater than 5 ER visits in the following year. Nevertheless, nearly half (26/55; 47%) of suspected EA cases were able to remain in their home environment with additional services.

One-year Outcomes Durham, NC (N=25) (#, %) Providence, RI (N=30) (#, %) Both (%)
>5 Emergency Room visits 10.40% 4.14% 25%
Remained at home with services 13.56% 13.43% 47%
Death 12.48% 8.26% 36%

Table 2: One-year patient outcomes.

Prevalence of elder abuse

Using utilization data for both facilities, the Providence VAMC served 59,193 Veterans and the Durham VA served 112,622 Veterans during the 7-year time period. As such, we determined the rate of reporting as 0.02% in the Durham VAMC and 0.05% at the Providence VAMC.

Discussion

We undertook a retrospective review of cases of elder abuse reported to Adult Protective Services at two large VA Medical Centers over a 7-year period. During this time period, we identified only 55 cases of suspected elder abuse were reported to area Adult Protective Services at two large medical centers representing a 0.02% and 0.05% reporting rate at Durham and Providence respectively. Though it is impossible to determine the actual rate of elder abuse, our findings when viewed in the context of other published studies, suggests that elder abuse was significantly underreported. A 2006 study that reviewed the medical records of 575 veterans who received services within a Geriatrics Outpatient Clinic identified a prevalence rate of 5.4% [11]. Though considerably higher, it is noteworthy that our study considered the institution as a whole as opposed to the high-risk age group described in the Los Angeles study.

Our findings suggest that the majority of cases of reported elder abuse involved either self-neglect or mixed cases of abuse. The majority of cases at both facilities had documented dementia. They were also likely to utilize more than 10 medications and suffer from multiple comorbidities. These findings might be useful to clinicians when defining at risk individuals for abuse. Their presence might also trigger mandated social work consultation that may expose previously unrecognized signs or symptoms of abuse.

Finally, the lack of reporting in no way presumes that Veterans were not appropriately cared for at these institutions or followed in the absence of state reporting. In addition, our findings do not presume that state reporting is adequate in dissuading or extinguishing abuse even when it does occur. Indeed, our findings seem to suggest that most elder abuse cases can be resolved by swift recognition and timely addition of in-home community-based support services in lieu of institutionalization.

Conclusion

Our research suggests that elder abuse is likely underreported at two VA medical centers. More research is needed to help determine the prevalence of elder abuse among Veterans, to identify risk factors that might aid practioner’s in diagnosing cases, and the development of interventions that target this important problem.

Funding Agencies

Center of Innovation, Providence and VAMC.

References

Citation: Vognar L, Sarfraz S, Adhikari R, Rackson K, Dosa D (2018) A Comparative Study of Elder Abuse Reporting at Two Large Veteran’s Affairs Medical Centers. J Gerontol Geriatr Res 7:493. DOI: 10.4172/2167-7182.1000493

Copyright: © 2018 Vognar L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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