Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole, and we have a panel for you today to talk about elder abuse. Joining me is Alyssa Elman. She's a licensed clinical social worker and the supervising social worker for the Vulnerable Elder Protection Team at New York-Presbyterian Hospital Weill Cornell Medical Center; and Dr. Michael Ethan Stern, he's an Associate Professor of Clinical emergency medicine at Weill Cornell Medical College Cornell University, and the Chief of Geriatrics Division in the New York-Presbyterian Hospital Weill Cornell Medical Center. Thank you both for being with us today.

And Dr. Stern, I'd like to start with you. How common is elder abuse? What's the scope of what we're talking about here today and what kinds of abuse are we really talking about? What's the most prevalent?

Dr. Michael Stern: Okay. Well, thank you for having us. Elder mistreatment, which is a term that encompasses many different types of abuse, and we can discuss that in a minute, is significantly underreported, although very common. It's estimated to impact between 5 and 15% of community-dwelling older adults each year with nursing home residents at even higher risk. However, only 1 in 24 cases of abuse is identified and reported to the authorities. And as the older adult population grows, elder mistreatment will become an even greater public health concern. So in the hospital environment, we see physical abuse and neglect most frequently, which makes sense as those happen to have medical ramifications. But mistreatment of elders also includes emotional and verbal abuse, unfortunately sexual abuse, and financial exploitation. Given the fact that this is such a prevalent problem, it is slowly gaining traction in society and even among lawmakers who are now having a better understanding of the scope and severity of the problem.

One of the pivot points that brought it to light was actually the testimony of Mickey Rooney in 2011 at a Senate Special Committee on Aging. So, this is widespread problem that is underreported, and that's one of the reasons why the Vulnerable Elder Protection Team Consult Service is so important.

Melanie Cole, MS: Thank you so much, Dr. Stern. This is such an important topic we're discussing. And Alyssa, I'd like you to tell us about Weill Cornell New York Presbyterian Vulnerable Elder Protection Team. Now, do we call it VEPT or is it V-E-P-T?

Alyssa Elman: We call it VEPT for short. And basically, what we realized was that an ED or an emergency department encounter is a really important opportunity to identify elder mistreatment and initiate intervention. However, oftentimes this opportunity is missed. And we also realize that older adults often are not connected to primary care providers, so it may be one of the only times they're leaving their home for medical care. Also if somebody came in for physical abuse and maybe broke their arm, a primary care provider, even if they had one, is going to send them to the emergency department. Despite all of this, ED providers almost never diagnose elder mistreatment or report their concerns to the authorities. And this can be due to a whole host of reasons, including lack of time to do a proper assessment, difficulty distinguishing intentional from unintentional injuries, lack of training, hesitation about involving the authorities.

And so as a result of all of this, we developed the VEPT Program to help empower providers to think about elder mistreatment when they're caring for older adults. And with this type of established program to sort of outsource the bulk of the work, we hoped that identification would increase while decreasing the burden on really busy ED providers. And what we really hope to do is assess, treat, and ensure the safety of elder mistreatment victims while also collecting evidence when appropriate and working closely with the authorities. And hopefully, our colleagues in the ED and the hospital feel that we help them do just that.

Dr. Michael Stern: I wanted to add to what Alyssa just said, which is quite comprehensive, that in a sense, because the ED is such a chaotic environment, it really is not an ideal place for any older person, certainly those that are most vulnerable, such as elder mistreatment victims. And we wanted to introduce a "push the button" philosophy, sort of a focus on offloading what ultimately is a very comprehensive, thorough, and time-consuming evaluation and assessment, and then management decisions from the primary care provider in the emergency department, enabling the multidisciplinary team approach to undertake this thorough and comprehensive evaluation.

And so, that's what this concept of VEPT is. It's a push-the-button consult service that offloads what is needed in order to properly care for these patients.

Melanie Cole, MS: Dr. Stern, I'd like you to expand for just a minute. If we think about child protection teams, which do exist in many hospitals, we've heard more about that than elder mistreatment. Expand a little on the goal to increase that identification while also not putting that burden on the emergency department team, which, as you've said, is chaotic and probably overworked, but how that appropriate intervention and reporting works. Explain a little bit about how this all works together and what that entails.

Dr. Michael Stern: Sure. Well, one of the key features of the Vulnerable Elder Protection Team Consult Service was taken directly from the longstanding programs that were established in pediatric emergency departments. To ensure optimal care for potential child abuse victims, ED-based child protection teams were developed and established more than 50 years ago. And there wasn't any such thing for elder abuse, elder mistreatment victims. And so, we incorporated the concept of an on-call multidisciplinary team with expertise in order to improve our ability to detect elder abuse patients and, as well, begin the process, sometimes lengthy, in establishing improved care and safety for them.

And so, by doing so, we established a service that brings together many different areas within the domain of healthcare. And those expertises are played out. Social workers, nurses, medical providers, radiologists, techs, security, pre-hospital care with emergency medicine technicians, everybody's a stakeholder and we all work together to provide this comprehensive care.

Melanie Cole, MS: Alyssa, now Dr. Stern just really gave us a good answer about the multidisciplinary team and how many people are truly involved in this and we applaud you because what a great program. Tell us a little bit about some of the services to protect those adults once they're identified.

Alyssa Elman: Well, what we may not have mentioned is that our program is available 24/7. So, anytime a patient comes to the hospital and there's any concern for elder mistreatment, we're immediately a resource that can be considered. And we offer a lot of services to these patients. Our medical provider, like Dr. Stern, might be on call and recommend additional imaging or lab work that can reveal certain injuries that might be indicative of abuse or dehydration or malnutrition. We also might run drug panels, STD testing, or check for levels of prescribed medications, if applicable. There's also a comprehensive head-to-toe exam, which is done for all of our patients.

And you might be surprised to know that, unfortunately, that's not always the norm in a busy ED, because it takes quite a bit of time. And then, our social workers, myself included, conduct a thorough biopsychosocial assessment, which might include speaking with patients, family, friends, community agencies who might be involved, outpatient providers, and any other involved parties.

And as Dr. Stern had mentioned earlier, we also will arrange for involvement of security, ethics, patient services, geriatrics, any other hospital teams that might need to be aware of what's going on and contribute to ensuring the safety of this older adult while they're in the hospital. The VEPT social worker then also is very connected to community resources and will make appropriate referrals to agencies like Adult Protective Service or APS, NYPD, or whatever the local police precincts might be. There's an organization called CEASe, which is part of the Cornell Network that has a lot of elder mistreatment programs for both older adults and professionals and concerned others, as well as several other community-based agencies that might facilitate community followup and ensure that the individual is safe at home.

Dr. Michael Stern: I wanted to add to what Alyssa said, which is that in contradistinction to child abuse, elder abuse sometimes is a little bit more difficult to pick up. And what I mean by that is that, in child abuse victims, unfortunately, there are certain pathognomonic injury patterns that the providers are trained to pick up, which are highly suspicious for child abuse. These are injury patterns or radiologic patterns on x-rays that are characteristic of abuse, very specifically. The situation is much less clear and is more ambiguous in elder mistreatment victims. There has been some research by our own Tony Rosen, who is the Director of our VEPT program. And some other colleagues at NYP Cornell, as well as some other colleagues in this area that have begun to catalog injury patterns that are indicative of abuse in older patients.

And so, it's a burgeoning field, but it requires a nuanced understanding of how older mistreatment victims present themselves. And that's one of the expertise that the VEPT program provides.

Melanie Cole, MS: I also would imagine different than when we're talking about child abuse and you have to then deal with the abusers directly because they are in charge and they are the guardians. And so, I imagine the layers of red tape are so incredible for you all when you're dealing with this sort of thing and certainly with elder mistreatment. So, I just really think what a great program. I'd like you to speak, Dr. Stern, about your outcomes. Tell us how it's working. How is it going?

Dr. Michael Stern: Well, I certainly am happy to report some of our outcome figures, which are in our minds quite astounding and reveal an efficacy that heretofore was not seen at all. But before I do that, I just wanted to add to what it is that you had said about some of the complex issues with regard to the potential perpetrators being in positions of caregiving. And that makes it very complex. And at times, we need to take those situations into consideration and often involve both ethics, as well as legal, those departments within our hospital and institution for their expertise in helping to determine what is in the patient's best interest in a complex situation.

To answer your question about outcomes, the most important outcome is obviously to improve the safety of the elder mistreatment victim. And what we found is that once VEPT has been consulted and we've become involved, that upwards of 50-60% of patients have a change in their living situation, whether that means a new environment, i.e., different apartment, a different community dwelling that they can move to, or a specific elder mistreatment, elder abuse program within a long-term care facility, or a change in the locks, or simply added help for the caregiver who can be overburdened, and this help at home sometimes is enough to change the safety and the living situation. And so, given those numbers, we're very proud of what it is that VEPT has been able to accomplish and more data is being collected with regard to other outcomes, secondary outcomes, as well.

Alyssa Elman: Yeah, just to build upon what Dr. Stern just said, we're in the process now of conducting follow up calls with our patients and their safe family members to see if the resources and referrals that we made have been impactful and to determine if their safety has been sustained. And we're hoping to really learn obviously a lot from their feedback. And we're conducting these calls periodically over the course of a year to determine how we can better improve our program and ensure that our impact is long lasting. So, that'll be really interesting to see and to also learn about what the goals of our patients are for those who are able to engage in that type of conversation. We want to, of course, meet them where they're at and do interventions that feel aligned with their goals.

Melanie Cole, MS: I'd love to give you each a final thought here. So Alyssa, why don't you tell us about the Elder Abuse Helpline that's run by Weill Cornell through the Office of Victim services and is the only one of its kind in the state.

Alyssa Elman: So, colleagues of ours at CEASe, which is the Center for Elder Abuse Solutions here at Cornell, is a helpline that is available during business hours, Monday through Friday, and offers services in Spanish and English. And it's a really great program. This helpline is able to provide supportive counseling, guidance around next steps, answer questions about elder mistreatment, and make appropriate referrals for anyone who might be concerned that a friend, family member, whoever, neighbor, might be enduring elder mistreatment. So, they can call. The concerned person can live anywhere in the United States, but the older adult has to reside in New York State. And they can call 9 to 5, and if they miss them, they can leave a message and they'll call back pretty quickly to provide any kind of support they may need. Their number is 844-746-6905.

Dr. Michael Stern: And I would like to add that the Office of Victim Services, which funds the Center for Elder Abuse Solutions, is also a funder for our program, VEPT, and has provided us with a generous grant. And we're on a second cycle of this funding from the New York State Office of Victim Services. We initially were funded by a smaller amount of money from a private foundation as a pilot to get the program off the ground. But now, our funding is through the New York State Office of Victim Services.

Melanie Cole, MS: Dr. Stern, last word to you. I'd like you to offer your best advice for prevention and/or red flags, because as Alyssa mentioned, if you know someone who you suspect is being mistreated and they reside within New York. Give us some of the red flags. What are people looking for? And what are some tips for loved ones to hopefully prevent this from happening in the first place?

Dr. Michael Stern: Well, one of the key concepts for potential prevention is addressing ageism in this country, and individuals should be aware that ageism is still quite prevalent in terms of a way in which one thinks of our older adults in society. And so, one of the ways in which one can do that is is by recognizing that there are physiologic changes of aging that are considered normal, that are different and distinct from actual disease states, that are different and distinct from depression, from confusion, from malnutrition, from injuries like excessive bruising. And so, being aware that some of these things that some people may consider to be just parts of normal aging are actually not and could represent manifestations of elder mistreatment. So, ascribing serious medical problems to the vicissitudes of normal aging may divert true attention from the circumstances surrounding a health problem. So, we're talking about decubitus ulcers, which may be linked to elder abuse, but could also be as a result of end-stage disease processes; mobility issues, malnutrition. They may indicate caregiver neglect. Depression, for instance, is very, very common among older abused patients.

And one thing to add is that the caregivers that may end up being the perpetrators of elder abuse are also often overburdened themselves and have risk factors for perpetrating elder mistreatment such as chronic illness of their own, mental health issues, cognitive impairment, psychiatric disease. And so, part of the conglomerate of treatment is recognizing what are the risk factors and how we can actually help the caregivers themselves so that the cycle of being burdened by a particularly vulnerable elder patient is broken by a caregiver that has some issues of their own.

Melanie Cole, MS: Well, I think we're going to do another podcast on this topic. And we can discuss all of those things, the risk factors, the prevention, what to look for when you are hiring caregivers or putting your loved one into some place to live if you cannot be a caregiver. Because as someone who has done that, I know what, It's like, and it is not easy. So, I'd love to invite you both back on to do a separate one on just those kinds of issues. Thank you both for joining us.

And you can reach the Elder Abuse Helpline run by Weill Cornell through the Office of Victim Services at 844-746-6905. And Weill Cornell Medicine continues to see our patients in person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, and Pandora. For more health tips, please visit weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast.. We have so many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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