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Nonfatal physical assault-related injuries among persons aged [greater than or equal to] 60 years treated in hospital emergency departments--United States, 2001.

As the U.S. population ages, public health efforts have expanded to ensure the independence, function, and safety of older adults. Such efforts focus on consequences associated with the normal aging process. The incidence and consequences of violent victimization are assumed to be a problem of young populations and not an area of concern among older populations (1), and little data are available to monitor the incidence or consequences of violence-related injuries among older adults. To characterize serious injuries from physical assaults among older adults, CDC analyzed data from the National Electronic Injury Surveillance System-All Injury" Program (NEISS-AIP). This report summarizes the results of that analysis, which indicate that approximately 33,000 persons aged [greater than or equal to] 60 years in the United States were treated in hospital emergency departments (EDs) for nonfatal assault--related injuries in 2001, with injuries occurring disproportionately among persons aged 60-69 years. NEISS-AIP data can increase the understanding of nonfatal physical assault--related injuries among older adults and guide the development and evaluation of prevention strategies.

NEISS-AIP provides data on approximately 500,000 injury-and consumer product--related ED cases each year (2,3). NEISS-AIP data are drawn from a nationally representative subsample of 66 out of 100 NEISS hospitals, which were selected as a stratified probability sample of hospitals with a minimum of six beds and a 24-hour ED in the United States and its territories. For this analysis, NEISS-AIP provided national annualized, weighted estimates of nonfatal, non-sexual, physical assault--related injuries among persons aged [greater than or equal to] 60 years who were treated in U.S. EDs during 2001. Data from these cases were weighted by the inverse of the probability of selection to provide annualized national estimates (3). A direct variance estimation procedure was used to calculate 95% confidence intervals and to account for the complex sample design (4).

All cases were classified into mutually exclusive categories according to intent (i.e., physical assault, sexual assault, self-inflicted injury, injury related to legal intervention, and unintentional injury) of the most severe injury received. Annualized estimates for this report were based on weighted data for 488 nonfatal physical assault-related injuries treated in EDs during 2001. Suspected and confirmed instances of interpersonal violence were coded as assaults. Data were collected about sex, age, race/ethnicity, diagnosis, cause of injury, body part primarily affected, location, and disposition. To evaluate the "struck by/against" category of injury cause further, CDC analyzed verbatim text comments recorded in the NEISS-AIP database from ED patient charts for each injury. Subcategories of "struck by/against" were defined as body (e.g., hand, fist, elbow, or foot), blunt object (e.g., cane, baseball bat, or butt of gun), and push (i.e., injury sustained by fall secondary to being pushed). The remaining injuries in the "struck by/ against" category were classified as unspecified.

During 2001, an estimated 33,026 persons aged [greater than or equal to] 60 years were treated in U.S. hospital EDs for nonfatal assault--related injuries (rate: 72 per 100,000 population), compared with an estimated 1,154,579 persons aged 20-59 years (rate: 754.6); 21,309 (65%) persons were aged 60-69 years, 7,064 (21%) were aged 70-79 years, and 4,653 (14%) were aged [greater than or equal to] 80 years (Table). Rates for persons aged 60-69 years (105) were more than two times greater than those for the two older age categories (44 and 49, respectively). The majority (55.4%) of adults aged [greater than or equal to] 60 years who were examined in EDs were men. Older adults were at similar risk for being assaulted at home (25.9%) compared with a public area (27.5%). The types of injuries sustained were primarily contusion/abrasion (31.9%), laceration (21.1 %), and fracture (12.7%). Of the classifiable cases, the majority of older adults (83.7%) were injured as a result of being struck by/against, most often by a body part (20.3%), followed by a blunt object (17.1%), push (14.4%), and an undetermined cause (31.8%); 91.3% of assaulted older adults were treated and released from EDs, and 8.3% required hospitalization. Compared with persons aged 20-59 years, a greater proportion of older assault victims were women (43.4% versus 39.1% p = 0.11), had fractures (12.7% versus 9.8% p = 0.61), and were hospitalized at the time of diagnosis (8.3% versus 6.4% p = 0.52); however, these differences were not statistically significant.

Editorial Note: The findings in this report underscore the magnitude of nonfatal physical assault-related injuries among persons aged [greater than or equal to] 60 years. Some of the reported injuries probably represent a form of elder maltreatment (EM). EM refers to acts of commission or omission that result in harm or threatened harm to the health or welfare of an older adult, occurring within any relationship in which there is an expectation of trust (5). The various forms of EM include physical, sexual, and psychological abuse; abandonment; exploitation; and neglect, either intentional or unintentional. Reported EM cases comprise only a fraction of cases. A national incidence study estimated that approximately half a million older persons were maltreated in 1996; however, for every reported incident of EM, an estimated five were unreported (6).

The findings in this report are consistent with previous studies that indicate that older adults are less likely to be victims of violent crime than younger persons (7), possibly because younger persons might be at greater risk for violent assault within the broader community. This hypothesis is supported by perpetrator data for fatal assaults among older persons (CDC, unpublished data, 2003). Among younger victims, perpetrators are more likely to be strangers. Among older victims, the perpetrators are more likely to be family members or acquaintances.

The findings in this report are subject to at least five limitations. First, NEISS-AIP data are based on information in ED records and are not linked to or supplemented by other data sources (e.g., Adult Protective Services [APS] records). Second, outcomes are specific to ED visits and do not include subsequent outcomes of the injuries. Third, NEISS-AIP data reflect only those injuries that were severe enough to require treatment in an ED. Fourth, NEISS-AIP data might provide a conservative estimate of the number of physical assault-related injuries among older adults treated in EDs because the violent intent of injury might not be reported. Finally, although limited data are presented for settings in which assaults occurred (i.e., home or public area), data for perpetrators of assault-related injuries were unavailable.

Injury is a physical sign for EM, and EDs are a key point of contact for its recognition (8). However, reporting rates of EM by hospitals are low, and the majority of ED physicians are uncertain about EM definitions or applicable state laws (6,9). Because the older adult population is expected to more than double by 2025 (5), the number of physical assault-related injuries among the elderly probably will increase, requiring more attention from clinicians and public health agencies. ED workers should be prepared to explore the cause of injuries suggestive of physical assault to ensure that proper referral is made when needed.
TABLE. Estimated number, percentage, and rate of nonfatal
assault-related injuries among persons aged [greater than or equal
to] 60 years and those 20-59 years treated in hospital emergency
departments, by selected characteristics--United States, 2001

                           [greater than or equal to] 60 years

                                              Rate        (95% CI
Characteristic           No.      (% *)    ([dagger])   ([section]))

Sex
  Male                  18,292    (55.4)       92.4     (61.0-123.9)
  Female                14,734    (44.6)       56.2      (43.0-69.4)
Race/Ethnicity
  White non-Hispanic    13,518    (40.9)      -- **         -- **
  Black ([paragraph])   10,084    (30.5)      -- **         -- **
  Hispanic               3,028     (9.2)      -- **         -- **
  Other, non-Hispanic      811     (2.5)      -- **         -- **
  Unknown                5,585    (16.9)      -- **         -- **
Diagnosis
  Contusion-Abrasion    10,551    (31.9)       22.9      (19.2-26.6)
  Fracture               4,191    (12.7)        9.1       (5.7-12.5)
  Laceration             6,962    (21.1)       15.1       (8.7-21.6)
  Internal injury/
    Concussion           2,939     (8.9)        6.4       (2.5-10.2)
  Strain/Sprain          1,864     (5.6)        4.1        (2.5-5.6)
  Other                  6,519    (19.7)      -- **         -- **
Cause
  Cut/Pierce             1,901     (5.8)        4.1        (2.1-6.2)
  Human Bite             1,050     (3.2)      -- **         -- **
  Firearm                  542     (1.6)      -- **         -- **
  Struck by/against     27,641    (83.7)       60.1     (449.0-75.2)
  Other                  1,771     (5.4)        3.8        (2.8-4.9)
  Unknown                  120     (0.4)      -- **         -- **
Body part primarily
    affected
  Head/Neck             17,486    (52.9)       38.0      (27.5-48.5)
  Upper extremity        5,905    (17.9)       12.8       (8.0-17.7)
  Lower extremity        2,192     (6.6)        4.8        (2.6-7.0)
  Upper trunk            4,727    (14.3)       10.3       (6.2-14.3)
  Lower trunk            1,537     (4.7)        3.3        (1.5-5.1)
  Other                  1,178     (3.5)      -- **         -- **
Location of assault
  Home                   8,567    (25.9)       18.6     (13.7--23.5)
  Public area            9,096    (27.5)       19.8      (13.1-26.4)
  Other                  6,059    (18.4)      -- **         -- **
  Unknown                9,304    (28.2)       20.2      (11.8-28.7)
Disposition
  Treated/Released      30,150    (91.3)       65.5      (47.6-83.5)
  Hospitalized/
    Transferred          2,757     (8.3)        6.0        (2.7-9.3)
  Other                    119     (0.4)      -- **         -- **
  Unknown                3,222     (0.3)      -- **         -- **
  Total                 33,026   (100.0)       71.8      (53.5-90.0)

                                        20-59 years

Characteristic             No.        (%)      Rate      (95% CI)

Sex
  Male                    702,521    (60.9)   928.5   (708.6-1,148.5)
  Female                  451,796    (39.1)   584.1     (431.7-736.6)
Race/Ethnicity
  White non-Hispanic      398,908    (34.6)   -- **         -- **
  Black ([paragraph])     362,739    (31.4)   -- **         -- **
  Hispanic                125,762    (10.9)   -- **         -- **
  Other, non-Hispanic      47,657     (4.1)   -- **         -- **
  Unknown                 219,512    (19.0)   -- **         -- **
Diagnosis
  Contusion-Abrasion      340,133    (29.5)   222.3     (192.8-251.9)
  Fracture                113,511     (9.8)    74.2       (66.2-82.2)
  Laceration              277,828    (24.1)   181.6     (134.9-228.3)
  Internal injury/
    Concussion            101,508     (8.8)    66.3       (34.2-98.5)
  Strain/Sprain            90,253     (7.8)    59.0       (49.1-68.9)
  Other                   231,347    (20.0)   -- **         -- **
Cause
  Cut/Pierce              103,806     (9.0)    67.8       (42.6-93.1)
  Human Bite               40,337     (3.5)    26.4       (17.9-34.8)
  Firearm                  31,007     (2.7)    20.3       (10.5-30.0)
  Struck by/against       911,498    (78.9)   595.7     (459.0-732.5)
  Other                    63,693     (5.5)    41.6       (33.5-49.8)
  Unknown                   4,238     (0.4)   -- **         -- **
Body part primarily
    affected
  Head/Neck               603,160    (52.3)   394.2     (315.5-473.0)
  Upper extremity         235,050    (20.4)   153.6     (106.6-200.6)
  Lower extremity          71,949     (6.2)    47.0       (35.4-58.6)
  Upper trunk             121,076    (10.5)    79.1       (61.0-97.3)
  Lower trunk              57,276     (5.0)    37.4       (25.7-49.1)
  Other                    66,069     (5.7)    43.2       (21.5-64.9)
Location of assault
  Home                    254,636    (22.1)   166.4     (126.5-206.4)
  Public area             214,922    (18.6)   140.5     (111.4-169.5)
  Other                   255,077    (22.1)   -- **         -- **
  Unknown                 429,944    (37.2)   281.0     (197.8-364.2)
Disposition
  Treated/Released      1,074,241    (93.1)   702.8     (530.1-874.1)
  Hospitalized/
    Transferred            73,330     (6.4)    47.9       (30.5-65.3)
  Other                     3,786     (0.3)   -- **         -- **
  Unknown
  Total                 1,154,579   (100.0)   754.6     (574.7-934.5)

* Percentages might not total 100% because of rounding.

([dagger]) Per 100,000 population.

([section]) Confidence interval.

([paragraph]) Black includes Hispanic and non-Hispanic; Hispanic
excludes black Hispanic. Rates should be interpreted with caution
because of high percentage of unknowns.

** National estimates might be unstable because they are based on <20
cases or coefficient of variation is >30%.


References

(1.) CDC. Overview: surveillance for selected public health indicators affecting older adults--United States. In: CDC Surveillance Summaries (December 17). MMWR 1999;48(No. SS-8).

(2.) CDC. National estimates of nonfatal injuries treated in hospital emergency departments, United States, 2000. MMWR 2001;50:340-6.

(3.) U.S. Consumer Product Safety Commission. NEISS Coding Manual 2000. Washington, DC: U.S. Consumer Product Safety Commission, 2000.

(4.) Kessler E, Schroeder T. The NEISS Sample: Design and Implementation. Washington, DC: U.S. Consumer Product Safety Commission, 2000.

(5.) Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2002.

(6.) U.S. Department of Health and Human Services. Administration for Children and Administration on Aging: The National Eider Maltreat ment Incidence Study--Final Report. Washington, DC: U.S. Department of Health and Human Services, 1998. Available at http:// www.aoa.dhhs.gov/abuse/report/cexecsum-03.htm.

(7.) Klaus PA. Crimes Against Persons Age 65 or Older, 1992-97. Washington, DC: U.S. Department of Justice, 2000 (NCJ-176352). Available at http://www.ojp.usdoj.gov/bjs/pub/pdf/cpa6597.pdf

(8.) Lachs MS, Williams CS, Hurst L, Kossack A, Siegal A, Tinetti ME. ED use by older victims of family violence. Ann Emerg Med 1997;30:448-54.

(9.) Jones JS, Veenstra TR, Seamon JP, Khromer J. Elder mistreatment: national survey of emergency physicians. Ann Emerg Med 1997;30:473-9.

Reported by: RA Mitchell, Jr, MD, New Jersey Medical School, Newark, New Jersey. L Hasbrouck, MD, E Ingram, PhD, Div of Violence Prevention; C Dunaway, MS, JL Annest, PhD, National Center for Injury Prevention and Control, CDC.
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Article Details
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Title Annotation:Public Health and Aging
Author:Mitchell, RA, Jr.; Hasbrouck, L; Ingram, E; Dunaway, C; Annest, JL
Publication:Morbidity and Mortality Weekly Report
Geographic Code:1USA
Date:Aug 29, 2003
Words:2201
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