Findings From an Elder Abuse Forensic Center

Increasing disclosures of older adult maltreatment: a review of best practices for interviewing older adult eyewitnesses and victims

The current article provides a contemporary review of the best practices for interviewing older adults about crimes they witnessed or experienced. Specifically, we provide a detailed overview of how investigators can use a range of interviewing adaptations and procedures to acquire detailed and accurate maltreatment disclosures from older adults. In addition to discussing well-established investigative interviewing practices (e.g. rapport building, free-recall, cognitive instructions and prompts), this article also summarizes more recent literature on the benefits of multidisciplinary investigations, use of assistive technology and interview accommodations, along with effective practices for working with minority and marginalized older adults. Lastly, several research, professional and policy recommendations are provided for supporting older adults during investigative interviews.

Forensic Characteristics of Physical Elder Abuse and Current Status and Issues of Collaboration between Forensic Medicine Departments and Related Institutions in Japan

This study sought to clarify the characteristics and trends of physical elder abuse and the status of collaboration between forensic medicine departments and related institutions in Japan. Questionnaires were sent to 82 forensic medicine departments and 2857 institutions randomly selected from hospitals, municipalities and public community general support centers. The survey period was February to June 2021, including an extension period for collection. Responses from 675 facilities were analyzed. The most common finding in cases of physical elder abuse at forensic medicine departments was subcutaneous hemorrhage on the head (85.7%), with mixed old and new injuries most commonly observed in the lower limbs (70%). There were few cases in which there was collaboration between forensic medicine departments and other institutions. Among the issues identified, there is a need to provide related institutions with information obtained in forensic medicine departments. A new collaboration system is needed to achieve this.

An assessment of interventions that target risk factors for elder abuse

Although there is increasing concern about both the prevalence of, and harms associated with the abuse of older adults, progress in the development of interventions to prevent its occurrence has been slow. This paper reports the findings of a systematic review of the published literature that identified studies in which the outcomes of preventative interventions are described. A total of eight different intervention trials, published since 2004, are described across the primary, secondary and tertiary levels of prevention and in terms of the types of risk factor that they target. The current evidence to support the effectiveness of these interventions is not only limited by the small number of outcome studies but also the poor quality of evaluation designs and the focus of many interventions on single risk factors. It is concluded that work is needed to strengthen the evidence base that supports the delivery of interventions to prevent elder abuse.

Prosecutors' Perspectives on Elder Justice Using an Elder Abuse Forensic Center

Prosecution is a rare outcome in elder financial exploitation. Previous studies have shown that elder abuse forensic centers-multidisciplinary teams that help investigate and respond to elder mistreatment-increase prosecution rates by enhancing teamwork across agencies. Research is needed to identify what aspects of this intervention model lead to better elder justice outcomes. Six District Attorneys (DAs) were interviewed about their experiences working with other agencies at an elder abuse forensic center (the "Center") and how participating in case discussions influenced their professional perspectives on elder abuse. Transcripts were analyzed qualitatively revealing three themes: (1) "goal-driven" versus "mission-driven" professional orientations; (2) role blurring; and (3) value added from participating in the Center team. Important factors for increasing rates of prosecution were: (1) having key decision-makers present at the meeting; (2) the forensic expertise provided by the geriatrician and neuropsychologist; and (3) cross-discipline learning. Influenced by the other disciplines, DAs sought goals beyond prosecution as the default approach to resolving elder financial abuse and advocated for interventions that could best respond to the victim's needs, such as restitution or protection.

State of the science on prevention of elder abuse and lessons learned from child abuse and domestic violence prevention: Toward a conceptual framework for research

The goal of this review is to discuss the state of the science in elder abuse prevention. Findings from evidence-based programs to reduce elder abuse are discussed, drawing from findings and insights from evidence-based programs for child maltreatment and domestic/intimate partner violence. A conceptual measurement model for the study of elder abuse is presented and linked to possible measures of risk factors and outcomes. Advances in neuroscience in child maltreatment and novel measurement strategies for outcome assessment are presented.

Interventions for preventing abuse in the elderly

BACKGROUND

Maltreatment of older people (elder abuse) includes psychological, physical, sexual abuse, neglect and financial exploitation. Evidence suggests that 10% of older adults experience some form of abuse, and only a fraction of cases are actually reported or referred to social services agencies. Elder abuse is associated with significant morbidity and premature mortality. Numerous interventions have been implemented to address the issue of elder maltreatment. It is, however, unclear which interventions best serve to prevent or reduce elder abuse.

OBJECTIVES

The objective of this review was to assess the effectiveness of primary, secondary and tertiary intervention programmes used to reduce or prevent abuse of the elderly in their own home, in organisational or institutional and community settings. The secondary objective was to investigate whether intervention effects are modified by types of abuse, types of participants, setting of intervention, or the cognitive status of older people.

SEARCH METHODS

We searched 19 databases (AgeLine, CINAHL, Psycinfo, MEDLINE, Embase, Proquest Central, Social Services Abstracts‎, ASSIA, Sociological Abstracts, ProQuest Dissertations & Theses Global, Web of Science, LILACS, EPPI, InfoBase, CENTRAL, HMIC, Opengrey and Zetoc) on 12 platforms, including multidisciplinary disciplines covering medical, health, social sciences, social services, legal, finance and education. We also browsed related organisational websites, contacted authors of relevant articles and checked reference lists. Searches of databases were conducted between 30 August 2015 and 16 March 2016 and were not restricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised trials, and quasi-RCTs, before-and-after studies, and interrupted time series. Only studies with at least 12 weeks of follow-up investigating the effect of interventions in preventing or reducing abuse of elderly people and those who interact with the elderly were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the studies' risk of bias. Studies were categorised as: 1) education on elder abuse, 2) programmes to reduce factors influencing elder abuse, 3) specific policies for elder abuse, 4) legislation on elder abuse, 5) programmes to increase detection rate on elder abuse, 6) programmes targeted to victims of elder abuse, and 7) rehabilitation programmes for perpetrators of elder abuse. All studies were assessed for study methodology, intervention type, setting, targeted audience, intervention components and intervention intensity.

MAIN RESULTS

The search and selection process produced seven eligible studies which included a total of 1924 elderly participants and 740 other people. Four of the above seven categories of interventions were evaluated by included studies that varied in study design. Eligible studies of rehabilitation programmes, specific policies for elder abuse and legislation on elder abuse were not found. All included studies contained a control group, with five of the seven studies describing the method of allocation as randomised. We used the Cochrane 'Risk of bias' tool and EPOC assessment criteria to assess risk of bias. The results suggest that risk of bias across the included body of research was high, with at least 40% of the included studies judged as being at high risk of bias. Only one study was judged as having no domains at high risk of bias, with two studies having two of 11 domains at high risk. One study was judged as being at high risk of bias across eight of 11 domains.All included studies were set in high-income countries, as determined by the World Bank economic classification (USA four, Taiwan one, UK two). None of the studies provided specific information or analysis on equity considerations, including by socio-economic disadvantage, although one study was described as being set in a housing project. One study performed some form of cost-effectiveness analysis on the implementation of their intervention programmes, although there were few details on the components and analysis of the costing.We are uncertain whether these interventions reduce the occurrence or recurrence of elder abuse due to variation in settings, measures and effects reported in the included studies, some of which were very small and at a high risk of bias (low- and very low-quality evidence).Two studies measured the occurrence of elder abuse. A high risk of bias study found a difference in the post-test scores (P value 0.048 and 0.18). In a low risk of bias study there was no difference found (adjusted odds ratio (OR) =0.48, 95% 0.18 to 1.27) (n = 214). For interventions measuring abuse recurrence, one small study (n = 16) reported no difference in post-test means, whilst another found higher levels of abuse reported for the intervention arms (Cox regression, combined intervention hazard ratio (HR) = 1.78, alpha level = 0.01).It is uncertain whether targeted educational interventions improve the relevant knowledge of health professionals and caregivers (very low-quality evidence), although they may improve detection of resident-to-resident abuse. The concept of measuring improvement in detection or reporting as opposed to measuring the occurrence or recurrence of abuse is complicated. An intervention of public education and support services aimed at victims may also improve rates of reporting, however it is unclear whether this was due to an increase in abuse recurrence or better reporting of abuse.The effectiveness of service planning interventions at improving the assessment and documentation of related domains is uncertain. Unintended outcomes were not reported in the studies.

AUTHORS' CONCLUSIONS

There is inadequate trustworthy evidence to assess the effects of elder abuse interventions on occurrence or recurrence of abuse, although there is some evidence to suggest it may change the combined measure of anxiety and depression of caregivers. There is a need for high-quality trials, including from low- or middle-income countries, with adequate statistical power and appropriate study characteristics to determine whether specific intervention programmes, and which components of these programmes, are effective in preventing or reducing abuse episodes among the elderly. It is uncertain whether the use of educational interventions improves knowledge and attitude of caregivers, and whether such programmes also reduce occurrence of abuse, thus future research is warranted. In addition, all future research should include a component of cost-effectiveness analysis, implementation assessment and equity considerations of the specific interventions under review.

Best-Practice Guideline on the Prevention of Abuse and Neglect of Older Adults

A systematic review of the literature was conducted to identify effective approaches to preventing and addressing abuse and neglect of older adults within health care settings in Canada. The review was conducted using databases searched from January 2000-April-May 2013. Additionally, expert panel members submitted article citations from personal archives. Two research associates (NRA) screened each title and abstract for inclusion. After inter-rater reliability was determined between the NRAs (Kappa score of 0.76), the records were divided, appraised, and data extracted independently. The review resulted in 62 studies that focused on identifying, assessing, and responding to abuse and neglect of older adults; education, prevention, and health promotion strategies; and organizational and system-level supports to prevent and respond to abuse and neglect. Abuse and neglect of older adults remains under-explored in terms of evidence-based studies; consequently, further research in all of the areas described in the results is needed.

Protecting victims of elder financial exploitation: the role of an Elder Abuse Forensic Center in referring victims for conservatorship

OBJECTIVES

The aim of this study was to examine the extent to which an Elder Abuse Forensic Center protects financial exploitation (FE) victims through referral to the Office of the Public Guardian (PG) for investigation and possible conservatorship (called 'guardianship' in many states).

METHOD

Los Angeles County Elder Abuse Forensic Center cases involving adults aged 65 and older (April 2007-December 2009) were matched using one-to-one propensity-score matching to 33,650 usual care Adult Protective Services (APS) cases. The final analysis sample consisted of 472 FE cases.

RESULTS

Compared to usual care, Forensic Center cases were more likely to be referred to the PG for investigation (30.6%, n = 72 vs. 5.9%, n = 14, p < .001). The strongest predictors of PG referral were suspected cognitive impairment, as identified by APS (odds ratio [OR] = 11.69, confidence intervals [CI]: 3.50-39.03), and Forensic Center review (OR = 7.85, CI: 3.86-15.95). Among referred cases, the court approved conservatorship at higher rates - though not statistically significant - for Forensic Center cases than usual care (52.9%, n = 36/68 vs. 41.7%, n = 5/12).

CONCLUSION

Conservatorship may be a necessary last resort to improve safety for some FE victims, and the Forensic Center appears to provide a pathway to this service. These findings suggest modification to the Elder Abuse Forensic Center conceptual model and contribute to an emerging body of evidence on the role of the Forensic Center in addressing elder abuse.

How do abused elderly persons and their adult protective services caseworkers view law enforcement involvement and criminal prosecution, and what impact do these views have on case processing?

This study examined law enforcement and prosecution involvement in 71 cases of elder abuse where pure financial exploitation (PFE), physical abuse (PA), neglect (Neglect), or hybrid financial exploitation (HFE) (financial exploitation co-occurring with physical abuse and/or neglect) occurred in a domestic setting. Victims of elder abuse and assigned Adult Protective Services (APS) caseworkers were systematically interviewed. Law enforcement officials were involved in 54% of the cases, and 18% of the cases were prosecuted. PA was significantly more likely to trigger a law enforcement response and to be prosecuted than Neglect or PFE. HFE involved prosecution for assault rather than financial exploitation. Generally, the victims of elder abuse were not receptive to criminal justice involvement, which appears to have a significant impact upon the level of this involvement. The reasons for this reluctance are discussed, as well as the challenges and limitations of criminal justice system involvement and related implications for policy and practice.

Holding abusers accountable: an elder abuse forensic center increases criminal prosecution of financial exploitation

PURPOSE

Despite growing awareness of elder abuse, cases are rarely prosecuted. The aim of this study was to examine the effectiveness of an elder abuse forensic center compared with usual care to increase prosecution of elder financial abuse.

DESIGN AND METHODS

Using one-to-one propensity score matching, cases referred to the Los Angeles County Elder Abuse Forensic Center (the Forensic Center) between April 2007 and December 2009 for financial exploitation of adults aged 65 and older (n = 237) were matched to a population of 33,650 cases that received usual care from Adult Protective Services (APS).

RESULTS

1 Significantly, more Forensic Center cases were submitted to the District Attorney's office (DA) for review (22%, n = 51 vs. 3%, n = 7 usual care, p < .001). Among the cases submitted, charges were filed by the DA at similar rates, as was the proportion of resultant pleas and convictions. Using logistic regression, the strongest predictor of case review and ultimate filing and conviction was whether the case was presented at the Forensic Center, with 10 times greater odds of submission to the DA (Odds ratio = 11.00, confidence interval = 4.66-25.98).

IMPLICATIONS

Previous studies have not demonstrated that elder abuse interventions impact outcomes; this study breaks new ground by showing that an elder abuse multidisciplinary team increases rates of prosecution for financial exploitation. The elder abuse forensic center model facilitates cooperation and group problem solving among key professionals, including APS, law enforcement, and the DA and provides additional resources such as neuropsychological testing, medical record review, and direct access to the Office of the Public Guardian.

Assessment in Adult Protective Services: do multidisciplinary teams make a difference?

This study compared 2 approaches to the assessment of Adult Protective Services (APS) cases. Using administrative data from 869 cases in 2 counties in Maryland, the differences between a nurse/social worker team and a lone social worker in case disposition, risk reduction, recidivism, and cost effectiveness were examined. Lone social workers were significantly more likely to confirm financial exploitation, physical abuse, and neglect by others; while the team approach resulted in significantly greater risk reduction. No differences were observed in relation to recidivism, self-neglect and cost savings. Given limited resources, research that examines optimal staffing patterns in APS agencies is warranted.

Elder abuse and self-neglect: "I don't care anything about going to the doctor, to be honest..."

Elder mistreatment encompasses a range of behaviors including emotional, financial, physical, and sexual abuse, neglect by other individuals, and self-neglect. This article discusses the range of elder mistreatment in community-living older adults, associated factors, and consequences. Although self-neglect is not considered a type of abuse in many research definitions, it is the most commonly reported form of elder mistreatment and is associated with increased morbidity and mortality. The case on which this article is based describes a 70-year-old woman who neglects herself and dies despite multiple contacts with the medical community. Despite significant gaps in research, enough is known to guide clinical practice. This article presents the practical approaches a health care professional can take when a reasonable suspicion of elder mistreatment arises. Public health and interdisciplinary team approaches are needed to manage what is becoming an increasing problem as the number of older adults around the world increases.

Screening for abuse and neglect of people with dementia

OBJECTIVE

To investigate characteristics of people with dementia and their caregivers (CGs) that are associated with mistreatment in order to inform clinicians about screening for mistreatment.

DESIGN

A convenience sample of CG-care recipient (CR) dyads were assessed for literature-supported factors associated with mistreatment, and evidence of mistreatment for the prior year was collected. An expert panel considered the evidence and decided on occurrences of psychological abuse, physical abuse, and neglect based on criteria adopted before data collection.

SETTING

Participants' homes.

PARTICIPANTS

One hundred twenty-nine persons with dementia and their CGs.

MEASUREMENTS

CG and CR characteristics (demographic, health, and psychosocial variables), relationship characteristics, and three elder abuse and neglect detection instruments.

RESULTS

Mistreatment was detected in 47.3%. Variables associated with different kinds and combinations of mistreatment types included the CG's anxiety, depressive symptoms, social contacts, perceived burden, emotional status, and role limitations due to emotional problems and the CR's psychological aggression and physical assault behaviors. The combination of CR's physical assault and psychological aggression provided the best sensitivity (75.4%) and specificity (70.6%) for elder mistreatment as defined by the expert panel. This finding has potential to be useful as a clinical screen for detecting mistreatment.

CONCLUSIONS

The findings suggest important characteristics of older adults with dementia and their CGs that have potential for use in a clinical screening tool for elder mistreatment. Potential screening questions to be asked of CGs of people with dementia are suggested.

Mixed methods in gerontological research

This article distinguishes between parallel and integrated mixed methods research approaches. Barriers to integrated mixed methods approaches in gerontological research are discussed and critiqued. The author presents examples of mixed methods gerontological research to highlight approaches to data integration at the levels of data analysis, interpretation, and research reporting. As a summary of the methodological literature, four basic levels of mixed methods data combination are proposed. Opportunities for mixing qualitative and quantitative data are explored using contemporary examples from published studies. Data transformation and visual display, judiciously applied, are proposed as pathways to fuller mixed methods data integration and analysis. Finally, practical strategies for mixing qualitative and quantitative data types are explicated, as gerontological research moves beyond parallel mixed methods approaches to achieve data integration.

Elder abuse and neglect

In the past 10 years, reports of the abuse of older adults have risen by 30%. Supported by a growing body of work, research, practitioner and policy communities are poised to confront the problem. This article represents a review of the elder abuse and neglect literature published since 2001. Literature on elder abuse and neglect tends to be grouped in the following categories: definitional issues; screening and assessment instruments; the scope of elder abuse and neglect; sexual abuse; risk factors; outcomes; studies of Adult Protective Services; multidisciplinary teams; interventions by medical, criminal justice and policy communities; long-term care facilities; and theoretical perspectives. The authors suggest that studies of elder abuse and neglect move beyond descriptive studies and include more nuanced statistical methods and mixed methods approaches, further explore the promising research design of crosslinking a variety of databases, include a theoretical underpinning and work toward more theorizing, explore incidence and prevalence approaches to eventually capture elder abuse and neglect on a national level, and focus on outcomes of interventions (e.g., education, agency/entity).