Intimate Partner Violence and Abuse of Elderly and Vulnerable Seniors-Senior

Summary of Recommendations and Evidence

Population	Recommendation	Grade (What's This?)
Women of Childbearing Age	The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services. Go to Clinical Considerations or more information on effective interventions.	B
Elderly or Vulnerable Adults	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect. Go to Clinical Considerations for suggestions for practice regarding the I statement.	I

Population

Recommendation

Women of Childbearing Age

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services.

Go to Clinical Considerations or more information on effective interventions.

B

Elderly or Vulnerable Adults

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect.

Go to Clinical Considerations for suggestions for practice regarding the I statement.

I

Importance

Intimate partner violence and abuse of elderly and vulnerable adults is common in the United States but often remains undetected. Nearly 31% of women and 26% of men report experiencing some form of IPV in their lifetime. Approximately 25% of women and 14% of men have experienced the most severe types of IPV in their lifetime.^1-3 These estimates likely underrepresent actual rates because of underreporting. In addition to the immediate effects of IPV, such as injury and death⁴^,⁵, there are other health consequences, many with long-term effects, including sexually transmitted diseases,⁶ pelvic inflammatory disease,⁷ and unintended pregnancy.⁸ Rates of chronic pain, neurological disorders, gastrointestinal disorders, migraine headaches, and other disabilities^9-11 are also increased. Intimate partner violence is also associated with preterm birth, low birth weight, and decreased gestational age.^12-14 Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior.^15-19 For adolescent and young adults, the effects of physical and sexual assault are associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions.²⁰^,²¹

Little information is available on the prevalence of abuse among noninstitutionalized elderly or vulnerable adults, although reported rates range from 2% to 25%.²²^,²³

Detection

For IPV, there is adequate evidence that available screening instruments can identify current and past abuse or increased risk for abuse. Several instruments used in more than 1 study were highly sensitive and specific.

The USPSTF found inadequate evidence on the accuracy of screening instruments for elderly or vulnerable adults.

Benefits of Detection and Early Intervention

The USPSTF found adequate evidence that effective interventions can reduce violence, abuse, and physical or mental harms for women of reproductive age.

The USPSTF found inadequate evidence that screening or early detection reduces exposure to abuse or reduces physical or mental harms or mortality for elderly and vulnerable adults.

Harms of Detection and Early Intervention

For IPV, the USPSTF found adequate evidence that the risk for harm to the individual from screening or interventions is no greater than small.

For elderly and vulnerable adults, the USPSTF found inadequate evidence on the harms of screening or interventions.

USPSTF Assessment

The USPSTF concludes with moderate certainty that screening women of childbearing age for IPV has a moderate net benefit.

The USPSTF concludes that the benefits and harms of screening elderly or vulnerable adults for abuse are uncertain, and that the balance of benefits and harms cannot be determined.

Patient Population Under Consideration

These recommendations apply to asymptomatic women of reproductive age and elderly and vulnerable adults. Reproductive age is defined across studies as ranging from 14 to 46 years, with most research focusing on women age 18 years or older. The term “intimate partner violence” describes physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy²⁴. A vulnerable adult is a person age 18 years or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired because of a mental, emotional, long-term physical, or developmental disability or dysfunction or brain damage. Definitions vary by state, and sometimes include the receipt of personal care services from others. Types of abuse that apply to elderly and vulnerable adults include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect.

Child abuse and neglect is addressed in a separate recommendation.

Assessment of Risk

Although all women are at potential risk for abuse, factors that elevate risk include young age, substance abuse, marital difficulties, and economic hardships.

Screening Tests

Several screening instruments can be used to screen women for IPV. Those with the highest levels of sensitivity and specificity for identifying IPV are Hurt, Insult, Threaten, Scream (HITS) (English and Spanish versions); Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/OVAT); Slapped, Threatened, and Throw (STaT); Humiliation, Afraid, Rape, Kick (HARK); Modified Childhood Trauma Questionnaire–Short Form (CTQ-SF); and Woman Abuse Screen Tool (WAST).

The HITS instrument includes 4 questions, can be used in a primary care setting, and is available in both English and Spanish. It can be self- or clinician-administered. HARK is a self-administered 4-item instrument. STaT is a 3-item self-report instrument that was tested in an emergency department setting.

The USPSTF found no valid, reliable screening tools to identify abuse of elderly or vulnerable adults in the primary care setting.

Screening Interval

The USPSTF found no evidence on appropriate intervals for screening.

Interventions

Evidence from randomized trials support a variety of interventions for women of childbearing age, including counseling, home visits, information cards, referrals to community services, and mentoring support. Depending on the type of intervention, these services may be provided by clinicians, nurses, social workers, nonclinician mentors, or community workers. Counseling generally includes information on safety behaviors and community resources. In addition to counseling, home visits may include emotional support, education on problem-solving strategies, and parenting support. One study used a 20-minute nurse case management protocol focusing on a safety plan, supportive care, and guided referrals. No intervention studies were identified for elderly or vulnerable adults. See the following discussion for suggestions for practice in this population.

Suggestions for Practice Regarding the I Statement for Elderly or Vulnerable Adults

Potential benefits. The estimated prevalence of elder abuse ranges from 2% to 10% based on a variety of different definitions, methods, and sampling strategies²². One study indicated that 1 in 10 elderly adults may experience abuse, but only 1 in 5 or fewer cases are actually reported²³.

Potential harms. Although there is no direct evidence, the existing evidence about the lack of harms resulting from IPV screening suggests that the harms of screening elderly and vulnerable adults might also be small. Some potential harms of screening include shame, guilt, self-blame, fear of retaliation or abandonment by perpetrators, and the repercussions of false-positive results.

Costs. There is no evidence about the costs of screening for or interventions to reduce elder abuse.

Current practice. Screening practices for elder abuse are limited for many reasons. Currently, there are no standards about how clinicians should ask elderly patients about possible abuse. In addition, there are varying definitions of abuse, a wide variety of mechanisms of elder abuse, no universal screening tools, wide-ranging risk factors, unclear guidance about whom to screen and what to do if abuse is identified, physician discomfort with screening, and time constraints. Screening is not done routinely and varies by locality. However, all providers should be aware of the laws in their states for reporting suspected abuse. Not all states mandate reporting, and some provide clear guidance about what type of injuries should arouse suspicion.

Useful Resources

The USPSTF has several recommendations that may be relevant, including screening for depression²⁵ and alcohol misuse (update in progress)²⁶.

Other useful resources include Web sites that contain materials useful to primary care providers. Providers often need guidance on how to address concerns about IPV with sensitivity and clarity and how to screen for IPV and provide follow-up care. Intimate partner violence introduces significant safety issues that compel a provider to be fully informed on such aspects as sensitivity. Providers also need easy access to available tools, specific guidelines, and other related materials to help them develop a clinical environment dedicated to the safety of their patients. Guidance is also available on how providers can work with local community-based domestic violence programs to receive training, information, and other resources to ensure effective management of patients who are victims of IPV.

Providers should also be aware of their state and local reporting requirements. The laws vary from one jurisdiction to another, with differences in definitions, whom and what should be reported, who should report, and to whom. Although reporting suspected elder and child abuse is mandated in all 50 states and the District of Columbia, this is not the case with IPV. In addition, providers also need to be familiar with requirements in the privacy regulations of the federal Health Insurance Portability and Accountability Act, which require that patients be advised on health information use and disclosure practices. Again, state laws around privacy issues or concerns vary.

The Centers for Disease Control and Prevention (CDC) has resources available for those needing additional information at http://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/resources.html This link goes offsite. Click to read the external link disclaimer.