Invited Commentary: Elder Abuse and Neglect—Radiologists Ready to Join the Identification and Referral Team

See also the article by Badawy et al in this issue.

Elder abuse is a life-threatening public health issue that can result in serious physical and psychologic harm, affecting as many as one in six elderly Americans. Emergency departments and other ambulatory health care settings represent a unique window of opportunity for elder abuse identification. However, the quality of screening assessments varies significantly, as many patients are queried “rapid-fire” with the perpetrator potentially present. In this issue of RadioGraphics, Badawy and colleagues make a compelling case for the increasing role that radiologists can play in the detection and reporting of elder abuse, just as they have led in the identification of child abuse (1).

Badawy et al (1) describe current barriers to using imaging to identify elder abuse, including lack of training, patient comorbidities, and lack of communication among medical providers. The authors do a commendable job highlighting the vast array of imaging findings that may raise particular concern for elder abuse, including specific fracture types, soft-tissue and organ injuries, and imaging findings that are inconsistent with the reported injury mechanism. Following an overview of the domains in which child and elder abuse overlap, the authors also describe how child and elder abuse detection diverge. Whereas a neurotypical child follows a predictable developmental progression, older adults of the same age vary significantly in their physical and cognitive functional status. The likelihood that a fracture was caused by abuse as opposed to being caused during normal activities is therefore quite difficult to predict within the older adult population.

The authors conclude by recommending more training regarding elder abuse in radiology training programs, greater communication between radiologists and frontline providers, and a multispecialty approach. The recommendation that radiologists engage with other specialists to help identify elder abuse victims is essential and should not be understated. Instead of simply writing “trauma” as the imaging indication, clinicians from other specialties could increase the specificity of the imaging examination by providing radiologists with any knowledge regarding the reported mechanism of an injury or the older adult’s functional status. In emergency medicine, innovative accreditation processes have been developed to identify Geriatric Emergency Departments (GEDs) (2). GEDs provide specialized expertise, equipment, and personnel to screen, diagnose, and treat elderly patients, with potential particular attention directed to elder abuse. These efforts may help diagnostic team members appreciate the full scope of elder abuse that may not be amenable to radiologic diagnosis, including sexual abuse, emotional abuse, confinement, passive neglect, willful deprivation, and financial exploitation. As GEDs become the norm, radiologists and other specialists can be part of a team-based approach to harness existing resources and develop new initiatives in identifying, treating, and supporting elderly patients at risk for elder abuse.

One interesting point noted by the authors is that clinicians might be reluctant to document potential elder abuse for radiologists in the setting of uncertainty. Temporally salient, all clinicians need to be aware that the 21st Century Cures Act allows patients (and perpetrators who may have proxy) access to electronic medical record (EMR) notes, data, and imaging reports (3). Particularly relevant to radiologists, the information-blocking provision of the Cures Act is designed to promote interoperability and essentially requires no delay in access to radiology reports once they are entered into the EMR. Before the Cures Act, many EMR systems and institutions employed time-delayed releases (embargos) of radiology reports to allow care coordination and closing of the referral loop before a potentially concerning finding was made visible to the patient or proxy. Currently, many institutions and radiologists are eliminating radiology report embargo policies to increase compliance and avoid potential financial penalties. In the case of elder abuse, the Cures Act has the potential to increase the risk for violence escalation if perpetrators are able to view immediately available chart entries or radiology reports that mention potential abuse or neglect.

We also recognize that practice settings and clinicians must have adequate resources available for referral and support for those who are identified as experiencing elder abuse. Mandatory reporting processes are the norm but vary by jurisdiction, and, given that radiologists may be reading imaging studies in various settings, it may be challenging and time-consuming to follow all reporting regulations. Moreover, because patients may disclose abuse to other staff in the radiology suite, including transport staff, clerks, and technicians, all personnel may benefit from training about mandatory reporting policies and procedures. Finally, we agree with the authors’ recommendation that there should be more education about elder abuse in residency training programs, but we note that it will first be critical to provide supportive evidence to the American Board of Radiology to consider incorporating the topic of elder abuse imaging in board examinations. Qualitative interviews of radiologists have shown almost uniform agreement in identifying the stark contrast between the minimal to absent instruction that radiologists had received on elder abuse findings compared with the rigorous training they had received in child abuse (1). With residency program directors having many competing demands for didactic programming, topics that are emphasized on board examinations are typically prioritized.

Overall, this review advocating for the increased role of radiologists in identifying elder abuse is welcome and timely, especially given data showing the increased incidence and severity of family violence during the COVID-19 pandemic, likely due to quarantines, socioeconomic instability, increases in substance use, and decreased access to social and community supports (4). It is hoped that the authors’ work will stimulate the future creation of large databases to harness artificial intelligence and digital health tools to identify patterns of injury consistent with elder abuse and to mitigate potentially preventable repeat physical abuse and long-term psychologic effects.