Elder mistreatment is a common health problem affecting an estimated one in ten community-dwelling older adults 1-3. In addition to the immediate physical harm, elder mistreatment can lead to premature mortality, poor psychological health, and higher emergency department visits and hospitalizations 4. However, elder mistreatment remains severely underdetected. Primary care settings may offer one way to improve detection and prevention efforts; however, little is known about how older adults experiencing mistreatment engage with primary care services. In this issue of the Journal of the American Geriatrics Society, Yu and colleagues address this gap by leveraging a unique cohort of 114 legally adjudicated cases of elder mistreatment to explore primary care use in the 360 days prior to and after initial mistreatment identification. They include cases of mistreatment from Brooklyn, New York and Seattle, Washington, and, of these, 47% experienced physical abuse, 45% financial exploitation, 33% emotional abuse, and 1.8% neglect. The control group included 410 Medicare Fee-For-Service beneficiaries matched on age, sex, race, and residential zip code. Yu et al. hypothesized that older adults experiencing mistreatment would frequent primary care and ambulatory services less than matched controls due to unmet social needs, intentional isolation by abusers, or caregiver neglect. Contrary to their hypothesis, the authors found that those with elder mistreatment were more likely to have at least one primary care visit and visits to multiple primary care providers in the 720 days surrounding elder mistreatment identification, while no difference was seen in other primary care utilization measures. Although initially unexpected, these findings may be less surprising after close consideration. First, prior literature on this topic is focused on emergency department and inpatient hospital use, leaving little empirical evidence to base hypotheses regarding elder mistreatment and outpatient primary care. Second, primary care use likely differs by type of mistreatment. Older adults experiencing neglect may be the least likely to engage consistently with primary care; however, those with neglect only accounted for 1.8% of the cases in this study. In contrast, financial mistreatment was seen in nearly half of the sample and may not impact primary care engagement, particularly when visits are covered by insurance and are not a cost barrier. The sample of legally adjudicated cases also skewed heavily toward physical abuse, which made up nearly half of the sample. While many types of elder mistreatment, such as financial exploitation, may be identified in non-healthcare settings, physical abuse, particularly that serious enough to lead to criminal prosecution, more likely necessitates healthcare encounters. This biasing of the sample, particularly with the overall low sample size, may be an important driver of the findings. Future studies leveraging data sources that can disaggregate elder mistreatment types could improve understanding of the unique relationship of each type with primary care engagement. The results of this study may also be explained by understanding other unique features of this cohort. Literature suggests that only 1 in 24 cases of suspected elder abuse are reported to authorities, of which even fewer are legally adjudicated 5. Because the cases in this study are known and prosecuted, they may represent more severe elder mistreatment cases or ones that were already connected to services to have allowed for the initial reporting. Further, Yu and colleagues show a spike in primary care utilization immediately following mistreatment identification. It is possible that connecting with primary care was part of the intervention plan from Adult Protective Services after the mistreatment was first detected. Finally, there may have been misclassification within the control group. The authors leveraged Medicare claims data to identify matched older adults; however, Medicare claims underidentify elder mistreatment, with documentation of mistreatment at ~0.06% in Medicare claims data compared to the true estimate of at least 10% in the general older adult population 6. Ultimately, this study highlights the critical need for improved, high-quality, nationally representative data sources for elder mistreatment to better assess these questions. Though impacted by other forms of bias, such as participation bias, the National Social Life, Health, and Aging Project (NSHAP), a nationally representative survey of community-dwelling older adults, may offer a potential data source by using self-reported, rather than externally identified, cases of elder mistreatment to increase sensitivity 7. Despite these caveats, this study makes a valuable contribution as the first to specifically examine primary care use in the period surrounding elder mistreatment identification. Perhaps the most important takeaway is the negative finding—the absence of data to support that older adults experiencing elder mistreatment are less likely to engage in primary care. This challenges certain assumptions within the field of elder mistreatment research that have not been based on firm evidence. Findings in this study reinforce that primary care represents an important setting to detect elder mistreatment. Additionally, study findings that primary care visits among cases were highest in the immediate 120 days after identification underscore the opportunity to implement early elder mistreatment interventions in primary care settings. Longitudinal care and established relationships position primary care as a unique setting for detecting and responding to elder mistreatment. Longitudinal care may allow for subtle identification of early elder mistreatment cases triggered by noticing a change in patient appearance, abnormal caregiver dynamics, a shift in frequency of visits, or newly unfilled medications. Additionally, the trust of the patient-physician relationship may foster more open dialogue about potential mistreatment at home. Further, the multidisciplinary team of primary care, including social workers and care managers, can assess for unmet social needs and provide referrals to appropriate community resources. In some cases, elder mistreatment, specifically caregiver neglect, may be unintentional and avoidable with the appropriate education and wraparound support 8. While healthcare policy is starting to recognize the importance of identifying and responding to elder mistreatment in healthcare settings, the emphasis remains on acute care and the emergency department. For example, the Geriatric Emergency Department (GED) Accreditation Program, established in 2018 by the American College of Emergency Physicians, recognizes hospitals providing high standards of geriatric care 9, and for accreditation, encourages hospitals to adopt a protocol for identifying and intervening on elder abuse 10. For the inpatient setting, the 2025 Centers for Medicare & Medicaid Services (CMS) Age Friendly Hospital Measure mandates elder abuse screening and intervention as part of social vulnerability evaluation 11. Even though a recognized need, there remains a paucity of evidence on how to best screen for and address elder abuse. The 2025 U.S. Preventative Services Task Force (USPSTF) noted insufficient evidence to support mistreatment screening 12, and there is no standard screening protocol for elder mistreatment among outpatient primary care settings. Further, screening and management efforts are limited by several structural and clinician-level constraints. Multiple qualitative studies of outpatient clinicians suggest a struggle with time-limited encounters, competing clinical demands, difficulty identifying the caregiver(s), cultural and linguistic barriers, fear of damaging the patient-physician relationship, unfamiliarity in working with Adult Protective Services, and uncertainty around next best steps following identification 13, 14. Given this complexity, additional research is needed to determine the best approaches for primary care detection and management efforts, whether it be screening or alternative approaches, such as a universal education and service provision approach like that used in many clinical settings addressing intimate partner violence 15. One example of such ongoing work is the DETECT-RPC clinical trial that aims to assess a standardized screening tool for elder mistreatment among home-based primary care providers 16. Additionally, Rosen et al. are developing a primary care screening tool to detect abuse among older adults with a diagnosis of dementia 17. Finally, the Veterans Health Administration has implemented a standardized note template for mistreatment identification 18. Despite data limitations, Yu and colleagues conducted an important study that has challenged the prevailing view of how older adults experiencing elder mistreatment interact with the healthcare system. This disruption of assumptions is an invitation to researchers to take the next steps and leverage larger, more diverse data sets to expand knowledge that can ultimately improve the impact of healthcare encounters on the health and well-being of vulnerable older adults. All authors participated in the preparation of this editorial and have approved the final manuscript. The authors have nothing to report. Dr. Mara W Rosenberg is supported by the National Institute on Aging (T32-AG000212) and Dr. Lena K. Makaroun is funded by the U.S. Department of Veterans Affairs (VA HSR CDA IK2HX003330). The contents of this editorial are the sole responsibility of the authors and do not represent the official views of the National Institute on Aging, the U.S. Department of Veterans Affairs, or the United States Government. The sponsor had no role in the design or preparation of this editorial. The content is solely the responsibility of the authors. The authors declare no conflicts of interest. This publication is linked to a related research article by Yu et al. To view this article, visit https://doi.org/10.1111/jgs.70396.
Rosenberg et al. (Wed,) studied this question.