Elder Justice Roundtable: Executive Summary

On October 18, 2000, Attorney General Janet Reno convened a group of preeminent experts for a groundbreaking roundtable discussion of medical forensic aspects of elder abuse and neglect. The roundtable discussion—entitled Elder Justice: Medical Forensic Issues Relating to Elder Abuse and Neglect—was, according to the Attorney General, a "profound step toward successfully addressing elder abuse."

The panel of 27 experts represented a variety of professions and areas of expertise, including geriatrics, forensic pathology, family medicine, psychiatry, pediatrics, gerontology, nursing, social work, psychology, emergency medicine, adult protective services (APS), and Federal, State, and local law enforcement. Prior to the discussion, participants submitted brief papers. The papers are included in this report as appendix E; a transcript of the discussion is included as appendix F.

The discussion focused on four distinct but overlapping subjects relating to elder abuse and neglect: (1) detection and diagnosis, (2) application of forensic science, (3) education and training, and (4) research. At the conclusion of the discussion, participants briefed the Attorney General on the status of each area, described what they would "take home" from the discussion, and offered recommendations for the future. Participants agreed that it was imperative for detection and diagnosis to identify indicators of abuse and neglect and to develop an instrument to screen for elder abuse and neglect.

A general consensus emerged among the participants: Elder abuse and neglect is a national issue that has been overlooked, underreported, and understudied. As a result, we miss too many cases of elder abuse and neglect, victims too often do not receive adequate treatment and remain at risk, and even when indicated, referrals to forensic experts and reports to APS or law enforcement are rare.

Indeed, the experts were of the view that the state of medical and forensic science relating to elder abuse and neglect in the year 2000 is about the equivalent of where child abuse was 30 years ago. Given the lack of the most basic scientific research on all aspects of elder abuse and neglect, the experts pleaded for a national multidisciplinary research agenda to ascertain the real scope of the problem and whether interventions and treatments are working. The experts also described the frequent inability of frontline responders and others to detect or diagnose elder abuse and neglect; the paucity of adequate education and training on these issues; inadequate efforts among the healthcare, social service, and law enforcement professionals to collaborate in responding to elder abuse and neglect; and no comprehensive effort to address the issue nationwide. These factors have made it extremely difficult for professionals to effectively prevent, detect, diagnose, treat, intervene in, or, where necessary, prosecute elder abuse and neglect.

Detection and Diagnosis

The expert panel concluded that elder abuse and neglect is an underdiagnosed and underreported phenomenon based on several factors, including the following:

1. No established signs of elder abuse and neglect. There is a paucity of research identifying what types of bruising, fractures, pressure sores, malnutrition, and dehydration are evidence of potential abuse or neglect. This impedes detection and complicates training. Some forensic indicators, however, are known. For example, certain types of fractures or pressure sores almost always require further investigation, whereas others may not require investigation if adequate care was provided and documented.
2. No validated screening tool. There is no standardized validated screening or diagnostic tool for elder abuse and neglect. Such a tool could greatly assist in the detection and diagnosis of elder abuse and neglect and would serve to educate, and, where appropriate, to trigger suspicion, additional inquiry, and/or reporting to APS or law enforcement. Research is needed to create and validate such a tool.
3. Difficulty in distinguishing between abuse and neglect versus other conditions. Older people often suffer from multiple chronic illnesses. Distinguishing conditions caused by abuse or neglect from conditions caused by other factors can be complex. Often the signs of abuse and neglect resemble—OR ARE MASKED BY—those of chronic illness. Elder abuse and neglect is very heterogeneous; medical indicators should be viewed in the context of home, family, care providers, decisionmaking capacity, and institutional environments.
4. Ageism and reluctance to report. Ageism results in the devaluation of the worth and capacity of older people. This insidious factor may result in a less vigorous inquiry into the death or suspicious illness of an older person as compared with someone younger. Such ageism may impede and result in inadequate detection and diagnosis, particularly where combined with physicians' disinclination to report or become involved in the legal process,
5. Few experts in forensic geriatrics. In the case of child abuse, doctors who suspect abuse or neglect have the alternative of calling a pediatric forensic expert who will see the child, do the forensic evaluation, do the documentation, and, if necessary, do the reporting and go to court. This eliminates the responsibility of primary care physicians to follow up and relieves them of the burden of becoming involved in the legal process. It increases reporting because the frontline providers feel like they have medical expertise backing them up. Training geriatric forensic specialists to serve an analogous role should similarly promote detection, diagnosis, and reporting, and increase the expertise in the field.
6. Patterns of problems. In the institutional setting, data indicating a pattern of problems also may facilitate detection. For example, the minimum data set (MDS) information for a single facility or for a nursing home chain may indicate an unacceptably high rate of malnourishment, that-absent an explicit terminal prognosis—should trigger additional inquiry. Similarly, a survey may cite a facility for putting its residents in "immediate jeopardy" as a result of providing poor care. Or emergency room staff may identify a pattern of problems from a particular facility. In these examples, the data itself may be a useful tool in facilitating detection of abuse and neglect. This type of information is accessible not only to healthcare providers but also to others.

Application of Forensic Science

This topic was discussed in two parts: Participants first discussed "what lawyers need to prove a case of elder abuse or neglect," and then they discussed multidisciplinary teams (MDTs).

Elder abuse and neglect has been prosecuted civilly and criminally. Medical testimony is critical to ensuring the successful outcome of these cases. For example, physician testimony is critical to determine whether a particular condition is evidence of abuse or neglect, or the result of some other condition. Unfortunately, the paucity of geriatric forensic experts and rigorous research data on elder abuse and neglect makes prosecutions more difficult than they otherwise would be. The forensic pathologists pointed out that their involvement could be useful in cases involving living as well as deceased victims. A wide variety of actions can take on legal relevance in an elder abuse or neglect prosecution. For example, if a hospital emergency room consistently returns residents to a nursing home known to have problems, that fact subsequently might be used defensively by the nursing home to argue "if the facility was so bad, why were the residents returned there?"

There was general consensus that the use of MDTs can be extremely effective in investigating and addressing elder abuse and neglect. Despite diverse views about who should be included on any particular team, the panelists agreed that a team should include at least medical practitioners, social workers, and law enforcement personnel. Other potential team members include forensic pathologists, financial analysts, and members of the clergy. Different types of MDTs have been formed in communities across the country with varying functions. In a few locations, MDTs not only respond to individual cases of suspected elder abuse and neglect but also attempt to determine and address systemic problems giving rise to those individual cases.

There was general consensus that MDTs with any sort of investigative focus also should include forensic specialists and pathologists who have extensive experience in investigating suspected wrongdoing and determining whether a particular condition was caused by abuse or neglect versus other causes.

Participants also discussed another type of multidisciplinary endeavor—medical forensic centers (similar to those for child and sexual abuse). Such centers could analyze whether elder abuse or neglect had occurred and provide supporting documentation, expert opinions, and testimony, if necessary. Three different models for forensic centers were discussed: national, regional, and local/mobile. A national forensic center potentially could be broadly accessible to medical professionals via telemedicine consultations and e-mail record review. This would provide centralized national accessibility to much-needed expertise without duplicating the local infrastructure costs of creating a separate facility in various locales. Participants also discussed creating regional forensic centers, similar to forensic centers for child abuse and neglect, serving a more localized region. Finally, there was a recommendation for mobile medical forensic units that could visit homebound and isolated older people whose plight otherwise might go unnoticed.

The group also discussed the benefits of creating a national database or network of medical forensic experts (from various disciplines) and resources, and of building relationships with university medical centers and similar institutions to promote attention to elder abuse and neglect.

Education and Training

Participants decried the lack of training in elder abuse and neglect, even for those who encounter victims most frequently, such as geriatricians, police officers, social workers, and even APS workers. Some believed that there was a low level of interest in training except to learn about State mandatory reporting laws. The scarcity of research was cited as an impediment to the design of training programs. It was generally acknowledged that determining whether abuse or neglect has occurred can be a complex inquiry given the highly heterogeneous nature of elder mistreatment. Thus, experts agreed that it was important to provide interdisciplinary training to those who come in contact with older people on the systemic and contextual factors that contribute to abuse and neglect.

The types of training recommended by participants fall into two broad categories: discipline specific and multidisciplinary. Training also should be appropriate for the level of expertise of those being trained, and training/education programs should be evaluated as to their effectiveness.

Law enforcement has moved more quickly than other professions in developing training efforts, ranging from basic training in police academies to legal training for attorneys. Although training for prosecutors is not mandated yet in any State, prosecutors in some States are voluntarily learning how to investigate and prosecute elder abuse and neglect.

Research

The participants cited a desperate need for research and for the development of a national research agenda in the area of elder abuse and neglect. Even the most basic question—"How frequently does elder abuse occur?"—cannot be answered. The experts agreed that incidence and prevalence studies relating to elder abuse and neglect are imperative. They also agreed that because of the scarcity of data on this topic, it would be helpful to pursue a few specific contained, less complex research projects (for example, to establish what types of long bone fractures are evidence of possible abuse, or what types of pressure sores are evidence of possible neglect). Broad-based research also needs to be done on what types of bruising, malnutrition, dehydration, falls, fractures, and pressure sores are indicators of potential abuse and neglect.

Research is needed in assessing all types of remedial efforts as well. And although those on the frontlines strive to protect older people, there is little or no rigorous research to verify which efforts to prevent, intervene, treat, or prosecute are effective, and to what degree.

Therefore, participants strongly recommended including a validated evaluation component in all ongoing and future programs to increase scientific rigor, legitimize outcomes, and stimulate further research spending. These efforts will enhance the body of knowledge in this area.

Participants generally were of the view that with increased grant dollars, research on elder abuse and neglect would become more "prestigious" and, in turn, attract more researchers and practitioners to the field. The experts opined that the current demographic trend toward an older population could result in heightened awareness of the issue by medical and legal professionals. In addition, the current National Academy of Sciences study, sponsored by the National Institute on Aging, should expand the knowledge base and stimulate development of additional research proposals and funding in this area.

In sum, the experts called for increased training, coordination, funding, and rigorous research on all aspects of elder abuse and neglect. They also urged identification of a list of indicators to help all practitioners determine when fractures, bruising, pressure sores, malnutrition, or dehydration are evidence of abuse or neglect in elders. Moreover, several participants encouraged exciting and productive "next steps" and spoke of implementing what they learned during the roundtable in their respective institutions or practices.