The Epidemiological Study of Elder Abuse

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The Epidemiological Study of Elder Abuse

• Robert B. Wallace, MD, MSc
• University of Iowa College of Public Health

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Three Components of Elder Mistreatment

• Trust relationship
• Intent and motivation
• Harm in some form

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Important Definitions

• Physical abuse
• Physical force that may result in bodily injury,
  pain or impairment (includes hitting, slapping,
  grabbing)
• Sexual abuse
• Non-consensual contact of any kind with an older
  person
• Emotional and psychological abuse
• Infliction of anguish, pain or distress
• Financial exploitation
• Illegal/improper use of funds, property or assets
• Neglect
• Refusal or failure to fulfill obligations or
  duties to an elder

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Are The Following Examples of EMIn the
Institutional Setting?

• Forcing a resistant elder to wash her hair twice
  a week?
• Using chemical restraints to improve patient
  safety?
• Not honoring holidays of all faiths in a
  long-term care facility?
• A capable family member who ignores an elder in a
  long-term care facility?
• Not providing a chapel in a long-term care
  facility?

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Some Definitional Issues

• Include Self Neglect?
• Is self-destructive behavior in a competent
  person a subject for social intervention?
• Assessing intent/ motivation.
• The role of legal and administrative definitions.
  
• Is refusing provide for someone else a crime, a
  social issue?
• Iatrogenic events e.g., inadequate care
  restraint use

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An Example A Legal Issue Resulting from Elder
Abuse Law

• Undertreatment of pain in clinical setting
• Abuse or malpractice?
• Multiple settings (home care, hospice, nursing
  homes, hospitals)
• Circumventing usual litigation pathways
• Lack of training in pain medicine
• Reticence to use pain medicine to the fullest

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Overview of Epidemiology of Elder Abuse

• Not clearly defined 1-10 annual prevalence
  among elders, depending on definitions, data
  sources, survey completeness, etc.
• Relative occurrence of abuse/ neglect/
  exploitation unclear
• Mode of data collection social service/
  protective agency gt clinical gt population survey
• In nursing home staff surveys, 30-40 said they
  had seen an episode of abuse

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A Model for EM in the Institution
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Elder Mistreatment in Assisted Living Facilities
A Problem?

• At least one million persons living in A.L.
• Moderate/ severe cognitive impairment in some A.
  L. sectors
• High privacy-high services 24
• Low privacy-high services 36
• Pilot study of knowledge of A. L. resources
• 25 knew about elder protective services
• Only a minority were able to recognize EM
  scenarios such as physical, verbal fiduciary
  abuse
• The Gerontologist 43753

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Consequences of Elder Abuse

• Physical Health
• Morbidity (skin wounds fractures, etc.)
• Death
• Dysfunction and disability
• Psychological Health
• Depression fear guilt shame distrust learned
  helplessness withdrawal post-traumatic stress
  syndrome
• Economic Status
• Loss of resources, possessions

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Mortality Associated with APS-Identified EM in a
Defined Population Lachs, JAMA 280428
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Risk Factors for Elder Abuse - I

• Victim dependency/ vulnerability
• Poor health disability/functional impairment
  poor personal defenses poverty possibly
  dementing illnesses (resp. to behav.)
• Gender--women
• Abuser dependency/deviance
• Alcohol and drug abuse mental illness poor
  employment record
• Social isolation
• Abuse undetected lack of social support to
  buffer stress
• Living arrangements
• Shared living arrangements greater opportunity
  for tension and conflict long term care
  facilities

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Risk Factors for Elder Abuse IIThe Disturbing
Role of Childhood Experiences

• Childhood Sexual and Physical Abuse Risk for
  Victimization in Adulthood Lancet 358450
• -Unwanted sexual intercourse lt 16 years RR
  3.5
• -Rape lt 16 years RR 2.6
• -Severe beatings by parents or carers RR 3.6
• Childhood Abuse and Attempted Suicide JAMA
  2863089
• -Emotional abuse RR 5.0
• -Sexual abuse RR 2.8
• -Battered mother RR 2.6
• -Mentally ill household member RR 3.3
• -Parents separated/divorced RR 1.9

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A Gene Effect on Early Childhood Abuse and Adult
Behavior Science 297851
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Indicators of Elder AbuseThe Gerontologist
38471-480

• Abusive Caregiver Characteristics
• Alcohol and substance abuse
• Mental health problems depression/ personality
  disorder behavioral problems care-giving
  reluctance, inexperience
• Generally poor interpersonal relationships poor
  pre-morbid relations current marital, family
  conflict lack of empathy, understanding of care
  needs and issues financially dependent on
  care-givee
• Abusive Care Receiver Characteristics
• Was abused in the past lacks social support

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The Clinical Recognition of EMPossible Risk
Factors

• 1. Frequent primary care or ER visits
• 2. Frequent or unexplained falls
• 3. Injuries inconsistent with explanations given
• 4. Evidence of neglect malnutrition,
  dehydration, hypotherm.
• 5. Overmedication poisoning, stupor
• 6. Undue physical restraint
• 7. Inappropriate clothing
• 8. Inadequate aids and devices
• 9. Lack of money, possessions social isolation

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The Role of Forensic ScienceA Midwestern
Program Ten-Year Experience

• Cases over 60 including homicide and neglect
• Homicide (avg age 72.1) Neglect (avg age 79.7)
• Gunshot 42 Pneumonia 50
• Beating 37 Sepsis 23
• Stabbing 19 Dehydration 9
• Asphyxia 10 Heart disease 9
• Fall 4
• Undetermined 4
• J. Forensic Sci. 49122

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The Role of Forensic ScienceA Midwestern
Program Ten-Year Experience - II

• Homicide cases
• (N 52)
• Perpetrators
• Spouse 15
• Other family 10
• Acquaintance 10
• Undeterm. 73

• Neglect cases
• (N 22)
• Residence
• With family 32
• Non-fam. caretaker 14
• Alone non-fam.
• caretaker 9
• Nursing home 18
• Unknown 27

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Findings from Autopsies of Patients Over 65 Years
with Antemortem EM Legal Medicine 57

• 15 Causes of Death in a Japanese Prefecture
• -Subdural hemorrhage(4) -Starvation
• -Hypothermia -Suffication (4)
• -Drowning -Arson
• -Strangulation -Traumatic brain inj.
• -Traumatic pneumothorax
• Perpetrators
• -Sons (7) -Grandson
• -Son-in-law -Son and Daugh.-in-law
• -Grandson (2) -Neighbor
• -Unk. -Others

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Some Potential Biomarkers of Abuse/Neglect

• Blood biomarkers--examples for consideration
  myoglobin acute phase reactants
• Patterns of fractures morphology
• Morphology and distribution of bruising
• Quick tests of malnutrition and dehydration
• Forensic testingsimilar to assault and rape
  investigations

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Data Sources for the Epidemiological Study of
Elder Mistreatment

• Formal professional reports
• a. Justice system (abuse, rape, murder)
• b. Forensic reports
• c. Adult protective services
• d. Health professional screening and reporting
• Same as infectious disease reporting
• e. Institutional reports (nursing homes)

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Data Sources for the Epidemiological Study of
Elder Mistreatment

• 2. Screening in clinical, social settings
• 3. Surveys of professionals/ professional records
• 4. Household surveys (1 or multi-stage)
• Potential victims
• Potential perpetrators
• Biomarkers without questionnaires

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Items to Assess Elder Abuse in Epidemiological
Surveys J Appl Gerontol 5153 - I

• 1. Has anyone tried to hurt or harm you?
• 2. Have you been forced to do things you dont
  want to do? Please give an example.
• 3. Have you been threatened with being placed in
  a nursing home?
• 4. Has anyone stolen from you or taken your
  possessions without permission?
• 5. Has anyone sworn at you or threatened you?

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Items to Assess Elder Abuse in Epidemiological
Surveys J Appl Gerontol 5153 - II

• 6. Has anyone confined you at home against your
  will?
• 7. Has anyone refused to provide you with food or
  with your medications
• 8. Has anyone beaten or assaulted you?
• 9. Have you ever signed any documents that you
  didnt understand?
• 10. Are you afraid of anyone in your home?

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Some Potential Problems with EM Screening and
Diagnostic Instruments

• Doesnt consider prior clinical exposures
• Length and complexity
• Lack of critical outcomes eval.
• Inadequate sensitivity and/or specificity

• Only some dimensions of EM addressed
• Measurement properties uncertain
• Dont apply all clinical data available
• Quantitative outcome doesnt allow easy clinical
  decisions

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Some Potential Problems with EM Screening and
Diagnostic Instruments - II

• Items do not assess social/ family context of
  events
• Checklist response range excludes many real life
  situations
• Perpetrator information often incomplete
• Not responding to evidence-based practice
  guidelines

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More General Underlying Problems

• Potential victims will not report abuse
• Fear of reprisal fear of social interventions
• Abuser may witness the interview
• Socially appropriate responding
• Unable for reasons of physical or cognitive
  impairment
• Caregiver interviews may be helpful but also
  under-report
• Operational definitions dont work well enough
• Policies when abuse/ neglect identified
• Informed consent
• Ethical imperative of reporting observed abuse
• State laws mandating reporting

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One Study of EM in a Population of Home Care
Screenees The Problematic Role of Clinical
Judgment

• Criteria for potential elder abuse (dependent
  variables)
• -Older person fearful of family member
• -Unusually poor hygiene
• -Unexplained injuries, broken bones, burns
• -Older person appears neglected or mistreated
• -Signs of physical restraint (? Inappropriate)
• (Shugarman, et al. JAGS 5124)

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Legal/ Ethical Challenges in EM

• Divulging confidentialities (e.g., caregiver
  support session HIPAA)
• Different laws in various jurisdictions
• Inadequate responses/ resources by existing
  protective services
• Disagreement on the fundamental mistreatment
  nature in various situations
• Remedies may make victims situation worse

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An Approach to Management of Confirmed EM
Adapted from Lachs Pillemer Lancet 3641263
Confirmed Case
Patient Willing to Accept Services
Patient Unwilling or Unable to Accept Services
Context-specific Intervention -Educate -Implement
-Referral
Patient Lacks Capacity -Go to official
agency -Financial asst. -Conservatorship/
guardianship -Special committee -Courts
Patient has Capacity -Educate patient -Provide
emergency numbers -Develop safety
plan -Develop follow-up plan
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Examples of Approaches to Managing EM Adapted
from Lachs Pillemer Lancet 3641263

• Potentially related to caregiver stress
• -Respite care -Adult day care
• -Carer education -Family carers recruit.
• -Carer psychother. -Reduce carer soc. isol.
• Longitudinal spousal violence
• -Marital counseling -Support groups
• -Shelters -Protection orders
• -Victim advocacy

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Interface of Elder Abuse/Neglect with Social
Organizations Overlap and Confusion

• Adults in need of protection
• -Public welfare
• -Social welfare
• -Legal services
• Elder abuse, neglect or exploitation
• -Aging services
• -Social services
• -Nursing services
• Family violence
• -Public health
• -Criminal justice

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Policy Approaches to Elder Mistreatment

• Mandatory Reporting Laws
• Adult Protective Services
• Investigation, assessment, care planning, case
  monitoring
• Other Care Providers
• Social service agencies hospitals long-term
  care insts.
• Law Enforcement-Criminal Justice System
• Victim assistance perpetrator prosecution
• Comprehensive Community Services
• Multidisciplinary teams community coalitions

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End of Presentation
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Laying the Foundation for Elder Mistreatment
Research
Social Expectations And Legal Norms
Phenomenology Of Mistreatment Events
Social Contexts And Processes Over Time
Concepts, Definitions And Measurements
Etiological Theories And Theory-Based
Interventions
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Theoretical Perspectives Explaining Elder
Abuse(From Rosalie Wolf)

• 1. Psychopathology -Mentally-disturbed perp.
• 2. Situational model -Overburdened caregiver
• 3. Exchange theory -Dependent victim/perp.
• 4. Social learning theory -Childhood
  abuse/neglect
• 5. Feminist theory -Power imbalance in relations
• 6. Political economy theory -Marginalization of
  elders
• 7. Ecological model -Complex/multiple factors

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One Study of EM in a Population of Home Care
Screenees The Problematic Role of Clinical
Judgment

• Criteria for potential elder abuse (dependent
  variables)
• -Older person fearful of family member
• -Unusually poor hygiene
• -Unexplained injuries, broken bones, burns
• -Older person appears neglected or mistreated
• -Signs of physical restraint (? Inappropriate)
• (Shugarman, et al. JAGS 5124)

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Brief Self-Report Screening InstrumentAustrali
an Longitudinal Study on Womens Health, 2000

• 1. Are you afraid of anyone in your family?
• 2. Has anyone close to you tried to hurt you or
  harm you recently?
• 3. Has anyone close to you called you names or
  put you down or made you feel bad recently?
• 4. Does someone in your family make you stay in
  bed or tell you youre sick when you arent?
• 5. Has anyone forced you to do things you dont
  want to do?
• 6. Has anyone taken things that belong to you
  without your okay?

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