Geriatric Abuse

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

OBJECTIVES

  • Define levels of abuse
  • Discuss patient assessment
  • Review prehospital treatment of the abused geriatric patient

 

   We were called for an 88-year-old female who had fallen, and her husband and daughter were unable to lift her. Expecting a routine lift assist, we were surprised to find Collette prone and covered in several blankets on the floor of an unheated porch. Even with a steady draft of cold fresh air, the stench of stale urine, feces and infected flesh was overwhelming.

   "When did Collette fall?" I asked.

   "Dad's not sure," the daughter, a geriatric patient herself, answered. "It has been a week since I was last here."

   Collette responded to verbal stimuli, had rapid, shallow breathing and was shockingly emaciated. In addition to severe dehydration, there were numerous pressure sores on her chest, chin, wrists, elbows and several other bone prominences that had been in contact with the cold floor for days.

   A bowl of water and a plate with a stale-looking sandwich were near her head. Her husband tried to explain that he thought she was OK and didn't want to bother anyone. He was clearly over-burdened caring for his aging wife, who had a history of dementia and frequent falls. Was his lack of action abuse? Did other caregivers have responsibilities for Collette they were neglecting? Was this current episode part of a larger pattern of abuse and neglect?

   With a growing elderly population in the United States, EMS professionals are more frequently assessing, treating and transporting geriatric patients. They are also more likely to encounter elder abuse, neglect and financial exploitation than ever before. Knowing signs and symptoms of abuse and neglect, as well as the risk factors and traits of abusers, is important for every EMS professional.

Definitions and Scope

   Elder abuse is specifically defined in state statute. The Texas Family Code, for example, defines an elderly person as someone over 65 years of age, and specifically defines abuse as "the negligent or willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical or emotional harm or pain to an elderly or disabled person by the person's caretaker, family member or other individual who has an ongoing relationship with the person."1 The Texas code also includes specific definitions for sexual abuse, neglect and exploitation.

   In general, abuse of elders, like abuse of children or intimate partners, is a recurring "pattern of coercive tactics that abusers use to gain and maintain power and control over the elderly." The National Clearinghouse on Abuse in Later Life (NCALL) states that elder abuse is "various types of abuse against someone age 60 or 65 and older." The abuse may have begun well before the patient became elderly. Intimate partner violence can persist for decades. Relationships also change or worsen over time with life and health changes. Types of abuse can include physical, sexual and emotional.2

   Physical abuse is to cause injury, pain or impairment through blunt and/or penetrating trauma. Slapping, punching, choking, hair-pulling, pushing, restraining, tripping and burning are forces that can cause injury.3,4

   Sexual abuse is non-consensual sexual contact of any kind. Examples of sexual abuse include unwanted touching, sexual contact with a person incapable of consenting, sexual assault or battery, and sexually explicit photography.1,3,5

   Emotional abuse, also known as psychological abuse, is a pattern of behaviors including withholding of affection, humiliation, condescension, yelling, name-calling and blaming to gain and maintain control over the victim.6

   An elder abuse victim is usually subjected to a combination of forms of abuse. If physical abuse is known or suspected, the patient is likely also experiencing sexual and/or emotional abuse.7

   Other types of elder harm include financial exploitation, neglect and abandonment.

   According to the National Committee for the Prevention of Elder Abuse, financial exploitation is the "illegal or improper use of an older person's funds, property or resources."8 The state of Illinois defines financial exploitation as "the misuse or withholding of an older person's resources to the disadvantage of the elderly person and/or the profit or advantage of another person."9 Theft of cash and other property, check-writing and forging, coercing signature of documents and other scams are examples of financial exploitation.8,10 It is estimated that there are up to five million financial exploitation victims each year.11 In Illinois, more than half of reported abuse allegations are for financial exploitation, compared with just 22% of cases that include physical abuse.9

   Neglect is failure to provide needed care. There are three types of neglect: active, passive and self. Active neglect is to willfully not provide care.12 Passive neglect is the inability to provide care due to "illness, disability, stress, ignorance, immaturity or lack of resources."12

   Examples of active neglect include withholding food, intentionally administering low or no doses of medication, denying access to heat or air conditioning, and not reporting new or worsening medical problems. Active neglect is not absent-mindedness or forgetfulness. It is understanding, but failing to adhere to medical, therapy or safety recommendations.3

   Many of us have observed passive neglect. For example, you arrive at a scene for an ill person and can't easily determine if the patient is the husband or the wife. Rita could not walk on her own and mostly used a scooter around her small apartment. Her husband, Bill, had worsening dementia and COPD. Rita's care responsibilities were growing faster than she could manage due to her disability, stress and lack of friends or family to assist. When we arrived, Bill had gone days without his medications, had a worsening respiratory infection that was exacerbating his COPD, and was dragging around 30 feet of oxygen tubing for a nasal cannula that wasn't actually connected to an oxygen tank.

   Neglect can also be physical or emotional damage from the failure of a caretaker to provide the food, shelter and medical needs of an elderly person. Failing to turn and monitor a bed-confined patient for skin damage is a form of neglect. Pressure sores can form quickly and lead to significant medical problems.

   Failure to provide for one's own health, hygiene, food, medical care and shelter is self-neglect.1,12 Self-neglect is often associated with mental illness, substance abuse and/or dementia. Rosa lived alone in a small home that we were barely able to enter because of the stacks of boxes, clothing and furniture that filled every room. Rosa had not bathed for weeks. Her hair was matted and her skin filthy. Before leaving the house, she insisted on using the toilet. Despite having 10 rolls of toilet paper, she used a single square and was frantic that additional squares would clog the toilet. Rosa's mental illness was causing her self-neglect. She did not have the capacity to understand her unsafe living conditions.

   June depended on her adult son to bring her meals and medication. He also maintained her finances and paid her bills. Unfortunately, he was a drug addict and began using her funds and trading her medications for the pills he desired. After he did not visit her for more than a week, June notified a neighbor that she had run out of medications days ago and her blood pressure was worsening. This is considered abandonment, which is desertion of an elder by anyone having care or custody for that person when a reasonable person would continue to provide care.13

   Geriatric abuse victims can be men or women, and abuse rate differences are not clear in available research.14 Abusers can be anyone who has a relationship with the victim, but are almost always a family member.7 Abusers can be a spouse, partner, adult child or grandchild, another relative or a caregiver. Abusers are typically male, and sexual abusers are almost exclusively men.15 In one study of sexual abuse, more than 90% of the victims were women and more than 90% of the abusers were men.16 Abusers typically have a dependency relationship with the victim, which may include dependence for money, food, housing and/or transportation.15 Abusers typically have problems of their own, including substance abuse, mental illness like depression, and cognitive impairment.15

   The incidence of elder abuse has increased with the rapid aging of the American population. One author noted that although elder abuse is under-reported, the incidence had increased 150% from 1986 to 1996.7 A 1998 study found that more than a half-million Americans older than age 60 were victims of domestic abuse. As many as two million adults older than 65 are estimated to have been "injured, exploited, or otherwise mistreated" by their caregivers.11,17 More than 80% of incidents of elder abuse go unreported.17

Why Abuse Happens

   Researcher Bonnie Brandl reviewed 13 published articles that attempted to answer why abuse happens to elders.18 The review of research challenged some commonly held assumptions about abuse and some potential situations that can increase the chance of abuse.

   Elder cognitive impairment, chronic disease and depression along with caregiver stress were not found to increase the likelihood of abuse,18 while financial and housing dependence of an adult child on his or her mother is associated with abuse and neglect. As previously noted, abusers are also likely to have a history as an abuse victim, substance abuse and/ or addiction problem, mental illness or cognitive impairment.18

Location

   Abuse can happen anywhere. In the home, the abuser may be a spouse, partner, adult child or caregiver who visits the patient at home. Since the great majority of elders live in their own home or the home of a family member, most abuse happens inside the home and is perpetrated by a family member.19

   In a residential setting, like an assisted living center or skilled nursing facility, abuse can be perpetrated by staff, vendors and even other residents. Although it does happen, abuse inside a nursing home or other type of residential facility is relatively rare. Only 4% of older adults live in nursing homes.19

Assessment

   Our assessment of an elderly male "fall victim" began in the doorway. The apartment was clean. The patient's spouse carefully explained her husband's middle-of-the-night fall, her inability to lift him, and her hesitancy to call for an ambulance until morning. My partner and I carefully listened for clues about the consistency of the mechanism with our exam findings, the patient's own report of the incident and previous medical problems.

   EMS professionals use the patient assessment to determine the nature and extent of injuries, but can also use it as a means to look for clues of elder abuse. In this case, all signs pointed toward a fall, need for immediate lift assistance, and conversation with the wife about the need for in-home care assistance as her husband's dementia and chronic illnesses worsened. Can you think of some ways this scenario could be only subtly different and show signs of abuse?

   Use the scene size-up to look for clues about the mechanism of injury, as well as the need for additional resources like law enforcement or adult protective services. During the initial assessment, assess for and treat immediate life threats with the tools and training you have.

   EMS professionals are most likely to find clues of elder abuse while conducting the secondary assessment. Note any injuries that seem incongruous with the complaint and/or mechanism of injury found with the focused or detailed head-to-toe physical examination. Like patients of other ages, some potential signs of physical abuse include:

  • Musculoskeletal injuries like sprains, strains, fractures and dislocations
  • Bruises in unusual areas like the inner arm or inner thigh
  • Burns from hot water or cigarettes
  • Wounds (bruises, burns, abrasions) in various stages of healing
  • Abrasions and/or bruises from being firmly held, pulled or restrained
  • Recurring injuries to the same area of the face, neck or upper extremities
  • Unusual markings from hand grips, bites, ropes or other restraints.4,19,20

       PreventElderAbuse.org explains that the following injuries are "rarely accidental":

  • Bilateral arm bruising from being grabbed, pulled, shaken or restrained
  • Circumferential arm and/or leg bruising from being restrained
  • Traumatic hair and tooth loss.4

   Some physical signs that can potentially indicate active, passive or self-neglect abuse include:

  • Skin turgor from dehydration
  • Soiled clothing, undergarments and bed linens
  • Clothing not appropriate for season and/or current weather
  • Thirst and hunger
  • Emaciation
  • Sunken eyes
  • Intoxication
  • Withdrawal
  • Malnutrition
  • Skin sores from prolonged stillness in a bed, wheelchair or ground
  • Poor personal hygiene and grooming: extreme body odor, long finger and toe nails, and unwashed hair.20

   Signs of sexual abuse might be noted as you conduct a physical examination or disrobe a patient for a procedure like 12-lead ECG tracing. Some physical signs of sexual abuse include:

  • Bruising to the genital areas or inner thighs
  • Anal or vaginal bleeding, pain and irritation
  • Torn, stained or bloodied underwear
  • Sexually transmitted diseases.5,19

   Many physical signs and injuries can be explained by other causes and are not the result of abuse. Thus it becomes important to gather clues throughout the patient assessment process to find patterns that raise suspicion about abuse. Then, objectively reporting and documenting the patient assessment findings allows the investigative process to continue by receiving facility staff, law enforcement and adult protective services.

   It should also raise your index of suspicion if the patient and/or caregiver are unwilling or unable to explain injuries, are dismissive about the cause or severity of injuries, and refuse to allow additional assessment or transport to the emergency department for the injury.19 If the patient and/or caregiver refuses transport and you suspect elder abuse, follow local procedures to report your suspicions to law enforcement or adult protective services.

   Emotional abuse lacks the overt outward signs associated with physical abuse and is therefore more difficult to assess. Some potential signs of emotional abuse include:19

  • Is suspicious toward caregivers
  • Not willing to answer questions
  • Evasiveness when asked about care

   If you are suspicious that abuse is happening, ask the patient questions like:

  • Do you feel safe in your home?
  • Are you well cared for by (name of caregiver)?
  • Do you have enough to eat?
  • Do you take your medications as prescribed?
  • Are you assisted as needed with bathing and personal care?
  • Are you able to ask for help when you need it?

   Don't ask these questions in the presence of the caregiver, family members or suspected abusers, as it could cause an immediate and potentially dangerous conflict. It could also lead the patient to refuse treatment/transport or the caregiver who has power of attorney for healthcare decisions to decline treatment/transport.

   The patient history, the subjective portion of the assessment, can also yield clues about elder abuse. Be observant for some of these indicators of potential abuse:

  • Delay between injury and seeking or receiving care
  • Repeat or similar injuries
  • Receiving treatment at multiple hospitals
  • Not having a regular doctor
  • Unlikely mechanisms of injuries
  • No witnesses to unexplained injuries
  • Conflicting or implausible explanations of how the injuries occurred
  • Fear of care provider.4,20

   EMS professionals may also observe suspected abusers. Remember, abusers are often dependent on victims for housing and/or financial support. Drug and alcohol abuse, mental illness and behavioral problems in the abuser are potential risk factors for elderly relatives.21

   Although you may not specifically reveal abuse, you may help start a conversation between the patient and other healthcare workers that can ensure the patient returns to a safer living situation. Adult protective service professionals, social workers, domestic violence advocates, nurses and physicians will likely ask more specific screening questions to determine the presence of abuse. Simple gestures like, "What can I do to help you be more comfortable?" or "We can administer medication to minimize your pain from that injury. Would you like us to administer pain medication?" give patients some control over their treatment.

Complicating Factors

   Geriatric assessment is complicated by several factors, regardless of whether abuse is suspected or known to exist. Dementia or impairment of cognitive function may make it impossible for the patient to recall and/or communicate about recent and past events. The patient may conflate multiple past experiences into a single event, and his inaccurate recall of medical history, medications and history of present illness may cast suspicion on any other reporting by him.

   Worsening dementia ("I am not as sharp as I used to be") puts geriatric patients at greater risk of financial exploitation. Complex insurance, housing assistance and financial issues force many geriatric patients to trust others to look out for their best interests. You have probably heard, "I don't know those details. My son/daughter handles those things for me."

   Geriatric patients are more likely to have impaired senses of sight, taste, hearing and vision, and may not be able to recognize a dangerous situation, like spoiled food, or be aware of an attacker.

   Multiple medications and other medical problems provide ready excuses. Falls are a risk for all geriatric patients. Blaming physical wounds, even facial trauma, on a simple fall is possible for an older patient. In younger patients, we expect them to brace a fall with their hands and have upper extremity injuries. When the elderly fall, they may not have the reaction time to raise their hands, resulting in facial wounds much like those received from a slap to the head or face.

Treatment

   When responding to any geriatric medical or trauma emergency, follow the patient assessment process to identify and treat life threats. If the patient is in immediate physical danger from an abuser, request law enforcement assistance, and, if you can, evacuate the patient to an area of relative safety.

   Use the secondary assessment to identify and prioritize problems for treatment. A systematic approach to patient assessment will help you identify things that are abnormal. If you suspect that there is more to a problem than a simple fall, instead of doing a detailed focused exam, do a full head-to-toe exam.

   Follow your agency's treatment protocols. Treat what you find with the tools and training you have. If abuse is known or suspected, the most important treatment you may be able to administer is providing the patient a safe and respectful environment.

   During the assessment and treatment process, don't confront the abuser with allegations. Focus on data collection and treating current problems efficiently and safely. If time and patient condition allow, do a visual scan of the patient's living conditions and make objective observations to include in the patient care report.

   Transport the patient to the most appropriate facility based on his request and/or receiving facility capabilities. Even if the patient does not have acute injuries, transport to a receiving facility will allow assessment of suspected or known abuse to continue in a neutral location with trained adult protective services professionals. Do not leave a suspected abuse victim at home alone with their suspected abuser or where they may be exposed to their suspected abuser without involving law enforcement or adult protective services.

Documentation

   Your patient care report will be a valuable component in the investigation of elder abuse. An objective and comprehensive report that factually reports the assessment findings and treatments provided is critical. When documenting known or suspected elder abuse, follow these general principles:

  • Report your factual observations of things like physical exam findings, patient living conditions and patient hygiene.
  • Withhold opinions about what you think or believe may have happened or who may be at fault.
  • Attribute the patient's own words with quotation marks.
  • Keep the patient's words in the context in which they were said.
  • Include statements made by the caregiver or family members in quotation marks.
  • Document family members, caregivers and other emergency responders present during the assessment.
  • Don't speculate on the cause or age of injuries in the healing process.
  • Include the names of any agencies, like law enforcement or adult protective services, that were contacted and when they were contacted.
  • Include the names of receiving facility staff who received report of known or suspected elder abuse.
  • Avoid the words abuse, abuser and victim, as these words suggest blame or fault.20

Reporting Requirements

   As EMS professionals, we are the rare healthcare providers who have access to patients' homes and can observe living conditions, interaction with caregivers and other clues to different types of abuse. In addition to providing immediate lifesaving interventions and stabilization, our other top responsibility is to document and report known or suspected elder abuse.

   A 2004 paper on assessing for abuse late in life stated that healthcare providers were mandatory reporters of known or suspected abuse in 44 states, and voluntary reporting systems were in place in the other six.7 If you are unsure about your requirements to report elder abuse, ask your supervisor and/or medical director for clarification. Seniorhomes.com has a listing of U.S. helplines & hotlines for suspected elder abuse.

   Specific reporting circumstances vary from place to place as well. In Illinois, EMTs and paramedics are required reporters, but are only mandated to report when an elderly person is unable to self-report.22 Nonetheless, they can still voluntarily report suspected abuse to the Illinois Department of Aging.

   In Pennsylvania, EMS professionals must report suspected child abuse and may report suspected elder abuse. Suspected elder abuse reports can be submitted to a statewide elder abuse hotline or to a local provider of adult protective services.20

   EMS professionals may make abuse reports independent of or in collaboration with hospital personnel, depending on local policies and procedures. In some cases, the hospital may file an abuse report using the EMS patient care report and verbal report along with the hospital's assessment findings. In other cases, EMS professionals may file a report, following applicable state procedures, on their own. Make sure you understand the specific reporting requirements of your state. In California, when two or more required reporters have knowledge of suspected elder abuse, only one person needs to make the verbal report to adult protective services and a single written report can be filed by the selected reporter. This allows paramedics to make a reporting agreement with a receiving facility nurse or physician about who will report suspected elder abuse.23

   Mandatory reporting may not include elderly persons who self-neglect without involvement of a third party.22 Many homeless persons are elderly with significant self-neglect issues, but, because they are not being mistreated by another, third party reporting is not required. In self-neglect situations, make sure you understand applicable local and state statutes. Cooperation with law enforcement and hospital personnel to determine the best services available to the patient may be necessary.

   Mandated reporting may also be required for other adults over age 18 who are not mentally competent and capable of reporting. In California, for example, a dependent adult means any person "18–64 who has physical or mental limitations which restrict his or her ability to carry out normal activities or to protect his or her rights. This includes persons who have physical or developmental disabilities or whose physical or mental capacities have diminished with age."23

   Penalties for failure to report abuse, when mandated, vary from state to state. In Illinois, a mandated reporter who suspects "abuse, neglect, or financial exploitation and who willfully fails to report the same, is guilty of a Class A misdemeanor."22 Conviction of a Class A misdemeanor could certainly impact your ability to keep and renew a state EMT or paramedic license. Do you know the consequence of failing to report known or suspected abuse in your state?

   Work with your supervisor and/or receiving facility staff to determine the reporting requirements in your state, including direct contact with law enforcement and/or adult protective services. According to PreventElderAbuse.org a report initiates an investigation by adult protective service programs to answer these questions:

  • Is the subject of the report in imminent danger?
  • Is the person in need of emergency services to prevent injury or loss?
  • What is the nature and extent of the abuse?
  • Is the abuse likely to occur again?
  • What is the level of risk?
  • Is the person able to make decisions about his or her care?
  • What measures are needed to prevent future abuse and ensure well being?24

Prevention

   There is a role for EMS professionals in preventing elder abuse. Cooperatively participate in prevention programs with other community agencies like adult protective services. Simply handing a brochure about elder abuse to all patients over 65 could be a simple way to raise awareness. Social contact, management of chronic health problems and assistance to caregivers could help lessen some of the stress of caring for an aging and ill spouse, parent or grandparent.

Behaviors of Potential Victims
The following list is from the National Clearinghouse on Abuse in Later Life paper “Recognizing Signs of Abuse.” Abuse victims may exhibit some or all of these behaviors. Abuse can exist without any of these behaviors being present:

  • Repeated “accidental injuries”
  • Appears isolated
  • Says or hints at being afraid
  • Considers or attempts suicide
  • Has history of alcohol or drug abuse
  • Presents as a “difficult” patient
  • Vague, chronic or non-specific complaints
  • Delays seeking medical help
  • Signs of depression.23

Conclusion

   Geriatric patients constitute a large percentage of the patients assessed and treated by EMS, and the number is likely to grow in the years to come. Most elder abuse goes unreported. Since you, as an EMS professional, observe elders' in-home living conditions and interactions with caregivers, you have an important role in recognizing and reporting suspected abuse. Most abuse is perpetrated by an adult relative who is dependent on the victim for things like food, shelter and money. Most of those abusers have underlying problems with things like addiction or mental illness. Use the patient assessment to identify clues about the presence of physical, emotional and sexual abuse, as well as passive or active neglect. Prioritize and treat problems as they are identified. Factually document your assessment findings in the patient care report. Share abuse suspicions with law enforcement, adult protective services, and/or the receiving facility based on your state's regulations for abuse reporting. Learn more and participate in elder abuse prevention efforts.

Behaviors of Potential Abusers

The following list is from the National Clearinghouse on Abuse in Later Life paper “Recognizing Signs of Abuse.” Abusers of adults later in life may exhibit some or all of these behaviors:

  • Is either verbally abusive or charming and friendly to workers
  • Says things like “he’s difficult,” “she’s stubborn,” “he’s so stupid,” or “she’s clumsy”
  • Attempts to convince others that the person is incompetent or crazy
  • Is overly attentive
  • Controls the older person’s activities and outside contacts
  • Refuses to let an interview take place without being present
  • Talks about the family member as if he/she is not there or not a person
  • Physically assaults or threatens violence against victim or worker
  • Threats of suicide or homicide or both
  • Threats of harassment
  • Stalking
  • Cancels elder’s appointments
  • Sabotages older person’s efforts to attend appointments by refusing to provide transportation or some other excuse
  • Takes elder to different doctors, hospitals and pharmacies to cover up abuse
  • Uses the legal system to harass the older person.23

References

   1. Texas Human Resources Code. http://www.statutes.legis.state.tx.us/Docs/HR/htm/HR.48.htm#48.002.

   2. National Clearinghouse on Abuse in Later Life. www.ncall.us/index.php.

   3. National Clearinghouse on Abuse in Later Life. Abuse in Later Life Wheel. http://ncall.us/docs/Later_Life_PCWheel.pdf.

   4. National Committee for the Prevention of Elder Abuse. Physical Abuse. www.preventelderabuse.org/elderabuse/physical.html.

   5. National Committee for the Prevention of Elder Abuse. Sexual Abuse. www.preventelderabuse.org/elderabuse/s_abuse.html.

   6. National Committee for the Prevention of Elder Abuse. Psychological Abuse. www.preventelderabuse.org/elderabuse/psychological.html.

   7. Bonnie Brandl. 2004. Assessing for Abuse in Later Life. www.ncall.us/docs/Assessing_and_Responding.pdf.

   8. National Committee for the Prevention of Elder Abuse. Financial Abuse. www.preventelderabuse.org/elderabuse/fin_abuse.html.

   9. Illinois Department on Aging. What is Elder Abuse? www.state.il.us/aging/1abuselegal/abuse_what-is.htm.

   10. National Committee for the Prevention of Elder Abuse. Financial Abuse. www.preventelderabuse.org/elderabuse/fin_abuse.html.

   11. National Center on Elder Abuse. Elder Abuse Prevalence and Incidence. www.ncea.aoa.gov/NCEAroot/Main_Site/pdf/publication/FinalStatistics050331.pdf.

   12. National Committee for the Prevention of Elder Abuse. Neglect and Self-Abuse. www.preventelderabuse.org/elderabuse/neglect.html.

   13. California State Definitions. www.centeronelderabuse.org/files/CaliforniaStateDefinitions.pdf.

   14. eMedicine. Elder Abuse. http://emedicine.medscape.com/article/805727-overview.

   15. Bonnie Brandl and Loree Cook-Daniels. Domestic Abuse in Later Life: Abusers. www.ncall.us/docs/DALL_abusers.pdf.

   16. Research on Abuse Later in Life http://www.ncall.us/docs/Research_AILL_2007.pdf.

   17. National Committee for the Prevention of Elder Abuse. http://www.preventelderabuse.org/.

   18. Bonnie Brandl and Loree Cook-Daniels. Domestic Abuse in Later Life: Causation Theories. www.ncall.us/docs/DALL_causation_theories.pdf.

   19. American Psychological Association. Elder Abuse and Neglect: In Search of Solutions. www.apa.org/pi/aging/resources/guides/elder-abuse.aspx.

   20. Pennyslvania Statewide Advanced Life Support Protocols. www.pitt.edu/~roth1/Protocols/alsprotocols717.pdf.

   21. National Center on Elder Abuse. Risk Factors for Elder Abuse. www.ncea.aoa.gov/NCEAroot/Main_Site/FAQ/Basics/Risk_Factors.aspx.

   22. Illinois Department on Aging. Reporting Elder Abuse: What Professionals Need to Know. www.state.il.us/aging/1news_pubs/publications/ea-prof_book.pdf.

   23. County of Santa Cruz. Suspected Elder and Dependent Adult Abuse Reporting. www.santacruzhealth.org/phealth/ems/PP/I%20ALS%20POLICIES/1340.pdf.

   24. National Committee for the Prevention of Elder Abuse. What Should I Do If Someone I Know Is Being Abused? www.preventelderabuse.org/elderabuse/help/help1.html.

   25. National Clearinghouse on Abuse in Later Life. Behavioral Indicators of Potential Abuse. www.ncall.us/docs/English_Recognizing_signs_of_abuse.pdf.

   Greg Friese, MS, NREMT-P, is director of education for CentreLearn Solutions, LLC. He is an educator, instructional designer, author, presenter and podcaster. Connect with Greg on Facebook, Twitter, or e-mail him at gfriese@centrelearn.com.

   Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a flight paramedic for Spirit Ministry Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.

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