Abstract
OBJECTIVES
To characterize assessments of a patient’s ability to report elder abuse within the context of an emergency department (ED)–based screen for elder abuse.
DESIGN
Cross-sectional study in which participants were screened for elder abuse and neglect.
SETTING
Academic ED in the United States.
PARTICIPANTS
Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses.
MEASUREMENTS
All patients completed the four-item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient’s ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients.
RESULTS
Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient’s ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient’s ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5).
CONCLUSIONS
In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment.
Keywords: cognitive dysfunction, dementia, emergency medicine, geriatrics, mental status, elder abuse
An estimated 3 million individuals in the United States are affected by elder abuse annually.1,2 The emergency department (ED) visit provides a valuable opportunity to screen for elder abuse, as people who experience elder abuse are twice as likely to visit the ED compared to nonabused older adults.3,4 Unfortunately, elder abuse is rarely identified in the ED.5,6 Further, despite the magnitude of this problem, no screening protocols designed for the ED have been described. Although many EDs screen for domestic violence, most do so using only a single question about safety at home, which has been found inadequate for elder abuse.5,7 Although the geriatric ED guidelines provide elder abuse screening recommendations,8 the percentage of US EDs that are consistently screening for elder abuse using a tool designed for elder abuse screening is likely close to 0%.6
One important component of an ED-based elder abuse screening tool is an efficient method of determining whether the patient can accurately report abuse. This challenge is particularly salient in the ED, where an estimated 31% of older adult patients have some degree of cognitive impairment.9–11 A recent study found that many adults with dementia, in addition to being aware of their own cognitive impairment, can accurately recall and describe emotional experiences even after a time delay and without cues,12 suggesting that many cognitively impaired older adults have the ability to accurately report abuse. Nonetheless, a better understanding of which patients can and cannot report abuse is needed to ensure effective and efficient comprehensive screening.
The objective of this work was to describe the relationship between formal assessments of patients’ cognition and the ability to report abuse among older adults receiving care in the ED.
METHODS
Study Design and Setting
The Emergency Department Senior Abuse Identification study is a federally funded study to develop and validate an elder abuse screening tool for use in the ED. The screening tool is written in English and has a Flesch-Kincaid reading level of 2.6 (ie, third grade). Additional details of the tool’s development and properties are described elsewhere.13 We conducted a cross-sectional study of the screening tool at an academic ED between January 2017 and November 2017. Patient interviews were conducted by trained assessors. Assessors included research assistants with prior experience interviewing older ED patients and nurses with clinical experience working in the ED. Training involved conducting two mock interviews with standardized patients and then direct observation of real patient evaluations by the trainee under the supervision of the study principal investigator (an experienced emergency physician). Instructions regarding the completion of specific question responses were provided to research assistants/registered nurses during training and were available within the questionnaires and in the standard operating procedure for the study. Assessors were not informed of the goal of this study, to examine the relationship between patient cognitive test results and the assessor’s judgment of the patient’s ability to report abuse. To assess percentage agreement between assessors, two assessors were in the patient’s room during the interview for a subset of patients. For these paired assessments, one assessor conducted the interview and both assessors independently recorded patient responses. Written consent was obtained from each patient or a legally authorized representative. The study was approved by the local institutional review board, and we adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines (Supplementary Table S1).14
Participants
ED patients, aged 65 years or older, were eligible, except for the following exclusion criteria: on a psychiatric hold, non-English speaking, enrolled in another research study, critically ill (defined as patients with an emergency severity index score of 1),15 receiving face-mask oxygen or positive pressure ventilation, already admitted or discharged, or not in their room during at least two attempts. Capacity to consent was established based on correct answers to three questions about the study: (1) What is required of patients to participate in the study? (2) What is a risk of the study? (3) Can the patient stop participating in the study if he/she chooses?16 For patients lacking capacity to consent, consent was sought from a legally authorized representative. This approach adheres to current recommendations for obtaining consent from patients with cognitive impairment.17 After obtaining consent from either the patient or legally authorized representative, all individuals accompanying the patient were asked to leave the room to limit their influence on patient responses.
Measures
The ED interview assessed patient demographics, cognitive ability, and patient safety. Cognitive ability was first assessed with the Abbreviated Mental Test 4 (AMT4). An AMT4 score of 3 or less has a sensitivity of 74% and a specificity of 88% for detecting cognitive impairment among ED patients aged 65 years or older.9 Patients with AMT4 scores of 3 or less completed the Mini-Mental State Examination (MMSE), which was purchased from Psychologic Assessment Resources.18
All patients responded to an elder abuse screen consisting of 15 questions designed to detect physical abuse, psychological abuse, financial abuse, and neglect. Assessors completed a physical examination to detect bruising, patterned injuries, abrasions, evidence of dehydration, poorly controlled medical problems, malnutrition, or neglect. Assessors then made a holistic judgment on whether they suspected abuse, using results from the elder abuse questions and any physical examination findings. Assessors communicated concerns of elder abuse to the attending emergency physician and to adult protective services.
The primary outcome was assessor confidence in the patient’s ability to report elder abuse based on assessor response to the question, “How confident are you that the patient has the ability to report abuse?” To answer this question, assessors were encouraged to use all information available to them, including appearance, behaviors, facial expressions, speech patterns, attentiveness, responses to questions, and any physical examination findings. Assessors recorded their confidence as absolutely confident, confident, somewhat confident, or not confident, after each cognitive measure (AMT4 and MMSE) and after the elder abuse questions were completed. Assessors also recorded the types of information used to determine the patient’s ability to report abuse.
Statistical Analysis
We determined the proportion of patients with suspected abuse, including what types of abuse were suspected. We also examined the proportion of patients for whom assessors were absolutely confident, confident, somewhat confident, and not confident in the patient’s ability to report abuse. Changes in assessor confidence after administering each of the three instruments (AMT4, MMSE, and safety interview) are visually represented using a Sankey diagram, a flow diagram in which the widths are proportional to the number of patients, allowing a visual representation of the magnitude of changes in assessor confidence between the three instruments. Percentage agreement between paired assessors and Cohen κ was calculated for assessor confidence in the patient’s ability to report abuse following the safety interview. Statistical analyses were conducted using STATA 14.1 and Tableau. The Sankey diagram was created using an online generator (http://sankeymatic.com/build/).
RESULTS
Of 1038 patients screened, 576 were eligible, 280 consented, and 276 completed the evaluation (Supplementary Figure S1). Assessors included six research assistants and three nurses. Of the 276 included in our study, most patients were white (75.0%), female (59.8%), lived independently (90.0%), and lacked a college degree (60.1%) (Supplementary Figure S2). Most (90%) scored a 4 on the AMT4. Among the 27 patients with AMT4 scores of 3 or less, 4 had an MMSE score of 24 or greater (no impairment), 12 had MMSE scores of 18 to 23 (mild impairment), and 11 had an MMSE score of 17 or less (severe impairment).19 Eighteen patients (6.5%) were identified with suspicion of elder abuse: 15 suspected of experiencing psychological abuse, 8 suspected of experiencing neglect, 6 suspected of experiencing financial abuse, and 4 suspected of experiencing physical abuse (Table 1, categories not mutually exclusive). Only one person suspected of experiencing abuse had a provider note of abuse or neglect in his/her ED medical record that did not result from our screening.
Table 1.
Characteristics of individuals identified with suspicion of abuse (n = 18)
| Type of abusec |
||||||||
|---|---|---|---|---|---|---|---|---|
| Age | Sex | Race | AMT4, MMSEa | Confidence in patient ability to report abuseb | Psychological | Financial | Physical | Neglect |
| 65 | F | White | 4 | Absolutely | ||||
| 65 | F | White | 4 | Absolutely | ||||
| 66 | F | White | 4 | Absolutely | ||||
| 67 | M | Black | 2, 21 | Absolutely | ||||
| 68 | F | Black | 4 | Absolutely | ||||
| 68 | M | Asian | 4 | Absolutely | ||||
| 69 | F | Black | 4 | Absolutely | ||||
| 71 | F | White | 4 | Absolutely | ||||
| 71 | F | Black | 2, 18 | Somewhat | ||||
| 73 | F | Black | 4 | Absolutely | ||||
| 73 | F | Black | 3, 17 | Absolutely | ||||
| 75 | M | White | 4 | Absolutely | ||||
| 76 | M | White | 4 | Absolutely | ||||
| 76 | M | White | 4 | Absolutely | ||||
| 77 | F | White | 4 | Absolutely | ||||
| 79 | F | White | 2, 16 | Confident | ||||
| 84 ≥90 |
F F |
White White |
4 4 |
Absolutely Absolutely |
||||
Abbreviations: AMT4, Abbreviated Mental Test 4; F, female; M, male; MMSE, Mini-Mental State Examination.
MMSE scores of 18 to 23 indicate mild impairment, and scores of 17 or less indicate severe impairment.
Assessor confidence in patient ability to report abuse following completion of the evaluation: absolutely confident, confident, somewhat confident, not confident.
Not mutually exclusive.
Following the AMT4, assessors were confident or absolutely confident in the patient’s ability to report abuse for 95.7% of all patients. This increased to 98.2% after the completion of the safety questions (Table 2 and Supplementary Figure S3). Among patients with AMT4 scores of 4 (n = 249), the assessors were confident or absolutely confident in patient ability to report abuse for 100% at the completion of the safety interview. For patients with AMT4 scores of 3 or less (n = 27), assessors were confident or absolutely confident in the patient’s ability to report abuse for 59% of patients following the AMT4. This increased to 63% following the MMSE and to 81% following the safety interview. Among patients completing the MMSE, assessors were confident or absolutely confident in patient ability to report abuse for 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with moderate to severe cognitive impairment (Figure 1). Paired evaluations of patients were completed for 131 patients. When patients for whom assessors were absolutely confident or confident in ability to report abuse were compared with patients for whom assessors were only somewhat confident or not confident, percentage agreement was 97.0% and κ was 0.5.
Table 2.
Assessor confidence in patient ability to report abuse following administration of AMT4 (n = 276), MMSE (n = 27), and safety questions (n = 276)
| Time point | Value, no. (%) | |
|---|---|---|
| After AMT4a | ||
| confident | 248 | (89.9) |
| Confident | 16 | (5.8) |
| Somewhat confident | 10 | (3.6) |
| Not confident | 2 | (0.7) |
| After MMSEb | ||
| Absolutely confident | 13 | (48.2) |
| Confident | 4 | (14.8) |
| Somewhat confident | 8 | (29.6) |
| Not confident | 2 | (7.4) |
| After safety interview | ||
| Absolutely confident | 264 | (95.7) |
| Confident | 7 | (2.5) |
| Somewhat confident | 4 | (1.5) |
| Not confident | 1 | (0.3) |
Abbreviations: AMT4, Abbreviated Mental Test 4; MMSE, Mini-Mental State Examination.
Scores of 3 or less indicate impaired cognition.
Administered to patients with AMT4 scores of 3 or less (n = 27).
Figure 1.
Assessor confidence in patient ability to report abuse at the completion of the screening and patient Mini-Mental State Examination (MMSE) among patients with Abbreviated Mental Test 4 scores of less than 4 (n = 27).
Assessors reported using the following information to determine the patient’s ability to report abuse: general appearance on physical examination; alertness; ability to attend to conversation; perceived accuracy of responses to questions based on level of detail provided, consistency of responses, and plausibility; and concordance between information provided, tone of voice, and facial expressions to suggest understanding of questions.
DISCUSSION
This cross-sectional study provides three important findings relevant to screening for elder abuse in the ED. First, among patients with AMT4 scores of 4, assessors were confident or absolutely confident in the patient’s ability to report elder abuse for 100% of 249 patients. This finding suggests that it is reasonable to consider patients with an AMT4 score of 4 as having the ability to report abuse.20 Second, most patients with cognitive impairment based on an AMT4 score of 3 or less were judged by assessors to have the ability to report abuse, which included a patient with an AMT4 score of 0 and an MMSE score of 9. These results suggest that in most cases there is utility to asking safety questions to cognitively impaired patients. This finding is important because cognitive impairment is a major risk factor for elder abuse, and these patients are an important subgroup for screening efforts.21–23 Third, the AMT4 may be a useful tool for sorting older ED patients into two groups: (1) patients with AMT4 scores of 4, who likely have the ability to report abuse; and (2) patients with AMT4 scores of 3 or less, for whom physical examination and consideration of other context clues are more frequently needed to determine the presence of abuse. Of note, the prevalence of elder abuse in our study was 6.5%, which is similar to the 7% prevalence found by Stevens et al.5
There was only one patient for whom confidence in ability to report abuse decreased from the AMT4 to subsequent assessments; for the remaining 275 patients, assessor confidence either increased or remained the same. This likely occurred because assessors were conservative in assessing ability to report abuse following the first measure of cognitive ability. Assuming assessors in our study are representative of nurses or other ED staff conducting screening, it is probably rare for patient ability to report abuse to be overestimated following a brief cognitive assessment.
Although no prior work has characterized the relationship between cognitive status and ability to report elder abuse, several areas of research have some relationship to the inquiry presented here. Outside the field of elder abuse, researchers have examined the ability of older adults with cognitive impairment to provide information about self-reported health and quality-of-life outcomes. Findings from that work suggest that cognitively impaired patients can provide meaningful responses to questions about quality of life, although individuals with severe impairment may need to be asked questions with binary rather than multilevel responses.24 Similarly, the primary validation study for the Dementia Quality of Life Instrument found that “persons with mild to moderate dementia can be considered good informants of their own subjective states.”25 These findings are consistent with those from the work presented here, that more than half of patients with severe cognitive impairment have the ability to report elder abuse.
Decision-making capacity is a critical determination for people who experience elder abuse: individuals who have capacity may decline interventions, but individuals who lack capacity require legal intervention, such as appointment of a guardian.26,27 Within this context, determination of capacity is usually performed by a geriatrician or psychiatrist. There is not a standardized measure of cognition that defines capacity, in part because capacity is a holistic and often complex determination about an individual’s ability to make a specific decision. The relationship between ability to report abuse and capacity to make decisions about the need for interventions for elder abuse has not been studied.
There are several limitations to our study. Our sample includes a relatively small proportion of patients with severe cognitive impairment, in part because these individuals did not have capacity to consent to participate in a research study and so were excluded if a legally authorized representative was not present to consent on their behalf. Despite this, the numbers are sufficient to support some inferences and valuable because no prior studies have assessed the ability of patients with cognitive impairment to report abuse. Another limitation is that some patients were not included in the study because accompanying individuals refused to leave the room. It is possible that, in some circumstances, this occurred because of an abusive relationship, which we were not able to further assess. The AMT4 is not a perfectly accurate screening tool for cognitive impairment, and it is possible that some patients with mild cognitive impairment were able to answer all AMT4 questions correctly. Health literacy may confound cognitive screening tools,28 but the health literacy of the patients in our study was not assessed. Other variables may have influenced assessor judgment as well, including patient sex, age, and race. Additionally, assessors were not blinded to the primary outcome of the study, and so may have been more likely to believe patients were able to report abuse. Our rate of percentage agreement between assessors may be slightly elevated because both recorded patient responses to a single assessment rather than administering the same assessment separately. This approach allows us to focus on disagreement resulting from variation in the assessors’ interpretation of responses, but does not include disagreement that might occur due to variation in the administration of the screening tool. Finally, this study was conducted at a single site with assessors trained in administering the safety interview. Assessments of the ability of older ED patients to report abuse may differ in other settings.
Among a sample of older adults presenting to the ED, a normal score on a brief cognitive assessment identified a large subgroup of individuals for whom assessors were confident or absolutely confident in ability to report abuse. Even among patients with moderate or severe cognitive impairment, many individuals were also judged by assessors to be able to report abuse. A brief cognitive screen may serve to efficiently differentiate between patients for whom questions are sufficient to screen for abuse and those individuals for whom further assessment is appropriate.
Supplementary Material
Supplementary Table S1: STROBE statement—checklist for cross-sectional studies
Supplementary Figure S1: Patient eligibility and participation.
Supplementary Figure S2: Characteristics of study participants (n = 276).
Supplementary Figure S3: Changes in assessor confidence in patient ability to report abuse after the AMT4 (initial assessment) and after the safety interview (final assessment), displayed using a Sankey diagram (n = 276).
ACKNOWLEDGMENTS
Financial Disclosure: This project was supported by Award No. 2015-IJ-CX-0022, awarded by the National Institute of Justice, Office of Justice Programs, US Department of Justice.
Sponsor’s Role: The opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect those of the Department of Justice.
Footnotes
Conflict of Interest: There are no conflicts of interests, other than those reported in funding, by any of the authors of the article.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article.
REFERENCES
- 1.Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health 2010;100:292–297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: a systematic review. Age Ageing 2008;37:151–160. [DOI] [PubMed] [Google Scholar]
- 3.Dong X, Simon MA. Association between elder abuse and use of ED: findings from the Chicago Health and Aging Project. Am J Emerg Med 2013;31: 693–698. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Dong X, Simon MA, Evans D. Prospective study of the elder self-neglect and ED use in a community population. Am J Emerg Med 2012;30: 553–561. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of nonmedical problems among older adults presenting to the emergency department. Acad Emerg Med 2014;21:651–658. [DOI] [PubMed] [Google Scholar]
- 6.Evans CS, Hunold KM, Rosen T, Platts-Mills TF. Diagnosis of elder abuse in U. S. emergency departments J Am Geriatr Soc 2017;65:91–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Gallione C, Dal Molin A, Cristina FVB, Ferns H, Mattioli M, Suardi B. Screening tools for identification of elder abuse: a systematic review. J Clin Nurs 2017;26:2154–2176. [DOI] [PubMed] [Google Scholar]
- 8.Carpenter C, Bromley M, Caterino JM, et al. Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Acad Emerg Med. 2014;21(7):806–9. [DOI] [PubMed] [Google Scholar]
- 9.Carpenter CR, Banerjee J, Keyes D, et al. Accuracy of dementia screening instruments in emergency medicine: a diagnostic meta-analysis. Acad Emerg Med 2019;26:226–245. [DOI] [PubMed] [Google Scholar]
- 10.Wilding L, Eagles D, Molnar F, et al. Prospective validation of the Ottawa 3DY scale by geriatric emergency management nurses to identify impaired cognition in older emergency department patients. Ann Emerg Med 2016;67:157–163. [DOI] [PubMed] [Google Scholar]
- 11.Barbic D, Kim B, Salehmohamed Q, Kemplin K, Carpenter CR, Barbic SP. Diagnostic accuracy of the Ottawa 3DY and Short Blessed Test to detect cognitive dysfunction in geriatric patients presenting to the emergency department. BMJ Open. 2018;8:e019652. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Wiglesworth A, Mosqueda L. People With Dementia as Witnesses to Emotional Events. Washington, DC: National Institute of Justice; 2011. [Google Scholar]
- 13.Platts-Mills TF, Dayaa JA, Reeve BB, et al. Development of the Emergency Department Senior Abuse Identification (ED Senior AID) tool. J Elder Abuse Negl. 2018;30(4):242–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008;61:344–349. [DOI] [PubMed] [Google Scholar]
- 15.Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams JG. Reliability and validity of scores on the Emergency Severity Index version 3. Acad Emerg Med. 2004;11:59–65. [DOI] [PubMed] [Google Scholar]
- 16.Resnick B, Gruber-Baldini AL, Pretzer-Aboff I, et al. Reliability and validity of the evaluation to sign consent measure. Gerontologist. 2007;47:69–77. [DOI] [PubMed] [Google Scholar]
- 17.Prusaczyk B, Cherney SM, Carpenter CR, DuBois JM. Informed consent to research with cognitively impaired adults: transdisciplinary challenges and opportunities. Clin Gerontol. 2017;40:63–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198. [DOI] [PubMed] [Google Scholar]
- 19.Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40:922–935. [DOI] [PubMed] [Google Scholar]
- 20.Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying elder abuse in the emergency department: toward a multidisciplinary team-based approach. Ann Emerg Med 2016;68:378–382. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Dong X, Simon M, Rajan K, Evans DA. Association of cognitive function and risk for elder abuse in a community-dwelling population. Dement Geriatr Cogn Disord 2011;32:209–215. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Pillemer K, Burnes D, Riffin C, Elder abuse LMS. global situation, risk factors, and prevention strategies. Gerontologist. 2016;56:S194–S205. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Beach SR, Carpenter CR, Rosen T, Sharps P, Gelles R. Screening and detection of elder abuse: research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse. J Elder Abuse Negl. 2016;28:185–216. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kane RA, Kling KC, Bershadsky B, et al. Quality of life measures for nursing home residents. J Gerontol. 2003;58:M240–M248. [DOI] [PubMed] [Google Scholar]
- 25.Brod M, Stewart AL, Sands L, P W. Conceptualization and measurement of quality of life in dementia: the dementia quality of life instrument (DQoL). Gerontologist. 1999;39:25–36. [DOI] [PubMed] [Google Scholar]
- 26.O’Connor D, Hall MI, Donnelly M, Assessing capacity within a context of abuse or neglect. J Elder Abuse Negl 2009;21:156–169. [DOI] [PubMed] [Google Scholar]
- 27.Lachs MS, Pillemer KA. Elder abuse. N Engl J Med 2015;373:1947–1956. [DOI] [PubMed] [Google Scholar]
- 28.Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:2386–2391. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Table S1: STROBE statement—checklist for cross-sectional studies
Supplementary Figure S1: Patient eligibility and participation.
Supplementary Figure S2: Characteristics of study participants (n = 276).
Supplementary Figure S3: Changes in assessor confidence in patient ability to report abuse after the AMT4 (initial assessment) and after the safety interview (final assessment), displayed using a Sankey diagram (n = 276).