Objective: To understand how an expert neglect assessment team comprised of a geriatric nurse practitioner, a social worker, and geriatrician process and diagnose complex geriatric cases referred for suspected elder neglect. What are the key themes that must be understood in order to determine if neglect should be suspected and confirmed?
Design: Qualitative descriptive
Sample and Setting: The 19 cases analyzed in this study were collected from a large urban medical center emergency department, which sees over 90,000 patient annually with 11% of those visits comprised of adults over age 65. In order to be eligible for inclusion, the older adult had to be over age 70, English or Spanish speaking, have a telephone in the home, a Mini-mental status examination score of 18 or better, and a caregiver for 20 hours per week or more.
Concept under study: What are key themes that emerge from analysis of audio taped transcripts of an expert neglect assessment team, as team members process cases for suspected elder neglect? Using the Elder Assessment Instrument Screen (Fulmer, et.al, 1984,2000) to guide the team discussion, the diagnosis of suspected elder neglect was made first by nurses in the emergency department. This clinical instrument has eight subsections: demographic data, general assessment , physical assessment, usual lifestyle, social assessment, medical assessment, summary assessment and disposition. It is the patient data from these screens that were discussed by the neglect assessment team and taped for analysis.
Methods: Transcripts from 4 consecutive neglect assessment team meetings were analyzed, using the method of concept analysis described by Strauss and Corbin, (1990). A purposive sample of 19 cases was analyzed. All of the cases were audio taped during the weekly neglect assessment team meetings over a 3-week period. This neglect assessment team has been responsible for confirming suspected elder abuse and neglect referrals for over 10 years, and are widely recognized as experts on this topic. The person taping the sessions (TF) was present as the reviews were in session. The neglect assessment meetings served to produce pilot data for a larger quantitative study, which examines elder-caregiver dyads and vulnerability to neglect.
Findings: Four major themes emerged as key concepts required to diagnose cases of elder neglect. . These themes were: “Understanding the underlying health status of the elder and caregiver” “Understanding the socioeconomic and life circumstances of the dyad” “The dependability and meaning of the assessment data” “The consequences of the assessment outcome”
Conclusions: Elder neglect is a complex phenomenon that requires more than a checklist approach for determining positive cases. While data from screens are extremely important for determining if a patient is high risk, an expert team is the preferable diagnostic process, given the themes that emerged from analysis of case discussions of emergency department screens. In busy emergency departments, it is not often possible for clinicians to conduct a comprehensive geriatric health assessment, nor is it necessarily appropriate. The circumstances of the older person’s life and caregiving arrangements are essential to the confirmation of neglect. Further, this expert neglect team continuously discussed not only the dependability of the assessment data, but also the meaning of the assessment data. Context is essential in the understanding of these cases. Finally, consequences of a neglect diagnosis are foremost in the minds of experts as they process cases.
Implications: These findings offer insight into the development of future clinical screening and assessment procedures used to make diagnosis of about elder neglect, as well as the guidelines that govern neglect assessment. Understanding not only the high risk signs and symptoms, but the context and consequences of neglect and the diagnosis of neglect is critical. Future screening and assessment instruments should be developed with these data in mind. It may be equally important to train expert teams to review suspect cases in the acute care setting.
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