A collaboration between adult protective services and forensic accounting examiners to investigate complex financial exploitation: formative evaluation findings

Financial exploitation (FE) is one of the most common reports to Adult Protective Services (APS) and the cases are often complex. Consequently, APS caseworkers report FE investigations to be among the most difficult while simultaneously reporting low confidence in productive outcomes for these investigations. This necessitates finding ways to support APS FE investigations. This paper describes the structure, process, and formative findings of a collaboration between forensic accounting examiners and APS workers to investigate complex cases of FE. Among the 77 FE cases completed, forensic examiners reviewed multiple years of financial records which included over 101,000 transactions, totaling over $213,000,000.00 in finances, and identified over $8,000,000 in questionable activity. Scores on the 8-item Client Satisfaction Questionnaire were high indicating high program satisfaction by APS workers, subject matter experts, and forensic examiners. These findings support the feasibility and acceptability of forensic accounting and APS collaborations to investigate complex cases of FE.

Perspectives on elder mistreatment screening and responding in emergency departments: A qualitative study with survivors

OBJECTIVE

Elder Mistreatment (EM) occurs in approximately 10% of older adults and is associated with trauma-related outcomes including depression, anxiety, post-traumatic stress disorder, and early mortality. Low screening and older adult self-reporting rates, especially within Emergency Departments represent missed opportunities for identify and mitigate future EM occurrences and consequences. To date, no studies have obtained EM survivors perspectives of EM screening and response practices in emergency departments.

METHODS

Semi-structured interviews with 19 EM survivors with Adult Protective Services validated EM were completed in the older adult's home. The Elder Mistreatment Emergency Department Screening and Response Tool (EM-SART) was used to guide the interview questions. All interviews were recorded, transcribed, and analyzed using qualitative thematic analyses.

RESULTS

The participants were mostly female (63%) and white (58%) with an average age of 74 years. Physical abuse accounted for 67% of the EM incidents. Three themes emerged indicating the survivor preference for (1) building rapport and approaching the older adult with compassion and care, (2) setting the context before asking the EM questions, and (3) allowing mutuality, collaborative work, and shared decision-making during the response.

CONCLUSIONS

Older adults are agreeable and willing to self-report and actively engage in the EM screening and response practices in the emergency department if trauma-informed care principles are utilized.

Victimization in Unethical Unlicensed Small Residential Care Homes in the United States: The Case for Whole System Disruption

In the United States, small residential care homes provide affordable community-based care for disabled older adults. Also called adult foster care homes, residential care facilities, group homes, or board and care homes, small residential care homes are typically private, small businesses operating in single-family dwellings that provide round-the-clock care in a home-like setting in residential neighborhoods. While most states license small residential care homes they also exist, legally and illegally, as unlicensed and unregulated operations. The quality of care in some unlicensed and unregulated small residential care homes can be questionable. Disabled older adults are targeted and victimized by unethical small residential care home operators for financial gain. This commentary highlights the need for whole system disruption to end victimization in unethical unlicensed and unregulated small residential care homes through case studies of the abuse and neglect of residents living in unethical unlicensed operations and recommends ambitious goals centered on reducing secondary financial gains and medically neglectful practices. These recommendations are at federal, state, and local levels, and include creating a federal definition of small residential care homes, increasing and coupling government incomes with state registration and employee misconduct registry checks, increasing oversight and assessment, improving temporary guardianship processes, providing avenues for reporting abuse, and developing older adult fatality review teams.

Racial/Ethnic Group Differences in Older Adults' Involvement with Adult Protective Services

This paper represents the first study to focus on quantifying racial/ethnic group differences in older adults' involvement with adult protective services (APS).  Across 3 independent county programs, the rate of APS reports was about twice as high for Black older adults compared to White older adults.  These differences were greater for clients who were older and male but remained similar across allegation type.  The percent of reports validated was slightly but consistently lower for Black clients than for White clients, and a lower percentage of Black clients' cases were closed due to investigation or service refusal. Findings for Hispanic clients differed by county, so it was impossible to generalize about their APS experience.  Researchers should distinguish racial/ethnic group differences that persist across multiple programs from those that are program-specific.  Further studies with larger data sets are needed to guide APS practice and ensure equity for all clients served.  .

Meeting the challenges in conducting research in vulnerable older adults with self-neglect-notes from a field team

Gaining a systematic understanding of possible ways to increase the quality and lifespan of older adults experiencing self-neglect has unique challenges. These challenges include identifying self-neglect in the community and navigating levels of cognitive, physical, and/or psychological difficulties in this population that impact recruitment, consent, and accurate data collection. Conducting quality research under some of the environmental self-neglect conditions such as squalor, animal and insect infestations and no utilities can also challenge planned study protocols and study validity. This manuscript presents details of these overarching challenges and some of the workable solutions noted and implemented by research field-team members who have enrolled over 300 adults experiencing self-neglect for various studies. Usual research methodology must overcome these barriers to work to create consciousness about the self-neglect population. The classic series of cases is still a good alternative when describing self-neglect. Considerations for conducting future self-neglect research are presented.

IMPLEMENTATION OF THE ELDER MISTREATMENT EMERGENCY DEPARTMENT TOOLKIT AT LYNDON B. JOHNSON HOSPITAL

Lyndon B. Johnson Hospital (LBJ) has the busiest Level III trauma and emergency department (ED) in Texas. Located in the busiest Houston zip code for Adult Protective Services reports, LBJ staff routinely assess older adults for mistreatment with no formal screening and response protocol. An ED-wide staff assessment revealed formal training needs for elder mistreatment (EM) detection, management, and reporting. Between October and December 2019, 55% of ED bedside nurses were trained along with 75% of charge nurses, and 12 clinical and nurse case managers, resulting in improved knowledge regarding EM screening and response best practices. In January 2021, LBJ staff implemented the Elder Mistreatment Screening and Response Tool (EM-SART). This resulted in 1,218 complete screens, 23 cases of suspected EM (2%), and 4 confirmed EM cases. Despite the pandemic and other challenges, LBJ staff demonstrated resilience and dedication, and reported EM training, screening, and response protocol efficacy.

PERSPECTIVES OF THE EM-SART: INTERVIEWS WITH ADULT PROTECTIVE SERVICES CLIENTS

Older adults who experience mistreatment are more likely to visit emergency departments (ED), yet screening and response protocols in these health care settings are sorely lacking. Protocols designed with the mistreated older adult’s perspective in mind are needed to maximize efficacy and effectiveness. In this study, 18 mistreated older adults completed semi-structured perspective interviews regarding the ED Elder Mistreatment Screening and Response Tool (EM-SART). The findings highlight the importance of training healthcare staff to ask elder mistreatment (EM) questions in a preset context and to ask EM questions with empathy, concern, privacy, and clarity. Participants also stressed the desire to be reported to Adult Protective Services, but to also be included in the safety planning. These findings have direct implications for training health care workers to screen and respond to EM in the ED.

A statewide elder mistreatment virtual assessment program: Legal, ethical, and practical issues

Telecommunication assisted forensic assessments of capacity and mistreatment by geriatricians with expertise in elder abuse and self-neglect are helping to meet the demand for such forensic services for Adult Protective Services (APS) clients in remote and underserved areas of Texas. The use of synchronous audiovisual assisted interviews instead of in-person interviews with clients to provide capacity assessments has become more important with the arrival of the COVID-19 pandemic. There is growing interest in establishing similar programs in other states using geriatrician faculty from medical schools to serve the clients of their state Adult Protective Services agencies. The arrangement between APS and the geriatricians at McGovern Medical School in Houston, Texas is novel. The structure of the arrangement is important for the success of the program. Legal, ethical, and practical considerations are discussed in this article, including approaches to the Health Insurance Portability and Accountability Act, physician liability, state law, and resource limitations. It is hoped that sharing how one such collaboration has addressed these important issues will suggest approaches for the structuring of similar programs.

Enhancing and evaluating the capacity of elder abuse fatality review teams to assist victim services

Fatality review teams (FRTs) have been historically helpful in identifying systemic issues that may lead to child and domestic violence deaths to improve responses, guide prevention efforts, and better serve victims. More recently, these teams have formed to address similar concerns in elder abuse matters. The American Bar Association Commission on Law and Aging received an early grant to study elder abuse fatality review teams (EAFRTs) and in 2005 created its first Replication Guide. The current study reports on a subsequent national survey of EAFRTs, conducted 14 years later to identify important similarities and differences in team operations, impact and sustainability. EAFRTs are growing nationally in numbers, have positive impacts on member elder abuse and victim services knowledge, skills and confidence, but experience challenges to impact evaluability and sustainability due to low funding and membership time, turnover and commitment. Recommendations for supporting newly developing and currently functioning EAFRTs are provided.

Racial/ethnic disparities in use of surveillance mammogram among breast cancer survivors: a systematic review

BACKGROUND

Increasing number of breast cancer survivors in the USA have led to greater focus on the long-term health outcomes and surveillance care among these women. However limited evidence exists of use of surveillance mammography among breast cancer survivors and how it varies across racial/ethnic groups.

METHODS

We conducted a systematic review of the literature to explore disparities in use of surveillance mammogram among women breast cancer survivors by searching for relevant studies published between 2000 and 2020 from Medline (Ovid), PubMed (National Library of Medicine), and PsycINFO (Ovid) bibliographic databases. Two authors independently screened titles, abstracts, and full texts of all articles that reported surveillance mammography use across racial/ethnic groups. Data on study design, screening eligibility, sample size, operational definition, and/or measure of the use of a surveillance mammogram among breast cancer survivors and the association between race/ethnicity and use of a surveillance mammogram were summarized in the evidence tables.

RESULTS

We identified 1544 records from the three databases, and 30 studies examined the use of surveillance mammograms among breast cancer survivors across race/ethnic groups. Of these, 21 provided adjusted estimates of racial/ethnic disparities in use of surveillance mammograms, and 15 of these reported statistically significant disparities. In summary, most studies reported that non-white women (mainly Blacks and Hispanics) were less likely to receive a timely surveillance mammogram compared to White.

CONCLUSION

This study extends the evidence of racial/ethnic disparities beyond completion of initial treatment by finding similar disparities in receipt of surveillance mammograms among breast cancer survivors.

IMPLICATION FOR CANCER SURVIVORS

Our findings identify a need to improve efforts to increase post-treatment use of surveillance mammography among racial/ethnic minority women to reduce these gaps and improve overall clinical and quality of life outcomes.

Self-Neglect: One Pathway to Surrogate Decision-Making

Self-neglect, the most frequently reported allegation to Adult Protective Services (APS), involves profoundly harmful behaviors often due to functional or cognitive limitations, health problems, and insufficient resources that result in older adults insufficiently meeting their basic needs. Outcomes include high risk of illness, hospitalization and readmission, hospice and nursing home use, early mortality, and placement under surrogate decision-making authority of either well-intended or opportunistic others. APS staff are charged with assessing self-neglect and intervening to reduce client danger. A nationwide APS survey revealed program policies, procedures, resources, and needs affecting the client welfare. For example, 92% of APS programs have provisions for seeking guardianship for self-neglecting individuals, in 25% of programs staff serve as court-appointed guardians, and a wide variety of tools are used within APS programs to assess clients’ mental capacity. Key study findings, implications, and recommendations will be presented.

A Direct Reporting Platform for Financial Exploitation: From Banks to APS

Despite encouraging changes in regulations and practices, opportunities remain to strengthen the collaboration between Financial Services Institutions (FSI) and Financial Exploitation (FE) investigative agencies such as Adult Protective Services (APS). A major barrier to these collaborations is timely and effective information exchange, between the agencies, for maximizing client protection. Often times, the need for more information from the agencies involved delays or mitigates the provision of financial protection to the client/victim. Through the U.S. Office for Victims of Crime, funding has been provided to develop a single reporting platform for enhancing communication and collaboration between FSI and APS. The helpful platform provides an innovative conduit for providing timely and effective information exchange between FSI and APS agencies to better serve and protect older adults against FE. This presentation will discuss the platform development, the lessons learned, preliminary data and future research. Part of a symposium sponsored by Abuse, Neglect and Exploitation of Elderly People Interest Group.

Validation of the detection of elder abuse through emergency care technicians (DETECT) screening tool: a study protocol

INTRODUCTION

Elder mistreatment (EM) is a high prevalence threat to the health and well-being of older adults in the USA. Medics are well-positioned to help with identification of older adults at risk for EM, however, field robust screening tools appropriate for efficient, observation-based screening are lacking. Prior work by this team focused on the development and initial pilot testing of an observation-based EM screening tool named detection of elder abuse through emergency care technicians (DETECT), designed to be implemented by medics during the course of an emergency response (911) call. The objective of the present work is to validate and further refine this tool in preparation for clinical dissemination.

METHODS AND ANALYSIS

Approximately 59 400 community-dwelling older adults who place 911 calls during the 36-month study observation period will be screened by medics responding to the call using the DETECT tool. Next, a random subsample of 2520 of the 59 400 older adults screened will be selected to participate in a follow-up interview approximately 2 weeks following the completion of the screening. Follow-up interviews will consist of a medic-led semistructured interview designed to assess the older adult's likelihood of abuse exposure, physical/mental health status, cognitive functioning, and to systematically evaluate the quality and condition of their physical and social living environment. The data from 25% (n=648) of these follow-up interviews will be presented to a longitudinal, experts and all data panel for a final determination of EM exposure status, representing the closest proxy to a 'gold standard' measure available.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Committee for the Protection of Human Subjects at the University of Texas School of Public Health. The results will be disseminated through formal presentations at local, national and international conferences and through publication in peer-reviewed scientific journals.

Evaluation of the Detection of Elder Mistreatment Through Emergency Care Technicians Project Screening Tool

IMPORTANCE

Elder mistreatment is underdetected and underreported. The more than 800 000 medics providing services in every county in the United States represent an important and underused surveillance system.

OBJECTIVE

To investigate the association between the Detection of Elder Mistreatment Through Emergency Care Technician (DETECT) screening tool use and the number of medic reports made to Adult Protective Services (APS) over a period of approximately 3 years.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a difference in difference in differences design and included adults aged 65 years and older who were reported to Texas APS in the study region (246 cities in Denton, Johnson, and Tarrant Counties) between December 31, 2014, and February 28, 2018.

EXPOSURES

The DETECT screening tool.

MAIN OUTCOMES AND MEASURES

Reports to APS.

RESULTS

The mean (SD) age of the 11 178 older adults included in this study was 76 (8) years (range, 65-105 years); there was no reported data on patient sex. A total of 18 080 reports of elder mistreatment were recorded. Medics within the study region reported more cases of elder mistreatment during the implementation of the screening tool (relative risk [RR], 4.14; 95% CI, 3.25-5.27). After adjusting for changes in the number of elder mistreatment reports in the comparison groups (ie, underlying changes in reporting trends), the number of reports to APS increased (RR, 3.03; 95% CI, 2.06-4.46). The occurrence of elder mistreatment was validated in 83% (95% CI, 75%-91%) of the reports investigated by APS during the periods when medics did not have access to the screening tool compared with 82% (95% CI, 77%-87%) during the periods when medics had access to the screening tool, indicating that there were no differences in the proportion of reports that resulted in a validated APS investigation.

CONCLUSIONS AND RELEVANCE

The findings suggest that incorporating the DETECT screening tool into the routine practices of medics is associated with substantial increases in the frequency with which clinicians report potential cases of elder mistreatment to APS.

Stemming the Tide of Elder Mistreatment: A Medical School-State Agency Collaborative

In 1995, the Texas Department of Family and Protective Services: Adult Protective Service Agency began a partnership with the Baylor College of Medicine geriatrics program to form the Texas Elder Abuse and Mistreatment (TEAM) Institute. The medical school-state agency partners overcame institutional and bureaucratic barriers to work collaboratively on mutually beneficial projects, including research and publications. Interprofessional students gained first-hand experience about abuse and neglect cases. As of 2019, there are 4 divisions: Clinical and Forensic Evaluation, Education and Outreach, Research and Program Evaluation, and Senior Justice. TEAM members have published numerous articles and chapters, educated members from multiple disciplines, and served thousands of mistreated older patients. In 2017, TEAM launched the first statewide telecommunication program for elder mistreatment to improve practice for the entire state. Perseverance, teamwork, and dedication to the mission of the intervention and prevention of elder mistreatment have sustained this program for over 30 years. This article describes the steps to forming TEAM, the institute's early struggles, and the subsequent community and academic contributions of this medical school-state agency collaboration.

Socioecological indicators of senior financial exploitation: an application of data science to 8,800 substantiated mistreatment cases

Senior financial exploitation (FE) is prevalent and harmful. Its often insidious nature and co-occurrence with other forms of mistreatment make detection and substantiation challenging. A secondary data analysis of N = 8,800 Adult Protective Services substantiated senior mistreatment cases, using machine learning algorithms, was conducted to determine when pure FE versus hybrid FE was occurring. FE represented N = 2514 (29%) of the cases with 78% being pure FE. Victim suicidal ideation and threatening behaviors, injuries, drug paraphernalia, contentious relationships, caregiver stress, and burnout and victims needing assistance were most important for differentiating FE vs non-FE-related mistreatment. The inability to afford housing, medications, food, and medical care as well as victims suffering from intellectual disability disorder(s) predicted hybrid FE. This study distinguishes socioecological factors strongly associated with the presence of FE during protective service investigations. These findings support existing and new indicators of FE and could inform protective service investigation practices.

ELDER MISTREATMENT FOLLOW-UP: CONNECTING EMERGENCY DEPARTMENTS AND COMMUNITIES

To effectively address elder mistreatment (EM) in the emergency department (ED) hospitals must have mechanisms that promote and, to the extent possible, ensure patient safety post-discharge. However, the realities of working within busy hospitals--limited staff time, financial resources, and EM-specific expertise--prevent many EDs from being able to dedicate staff for patient follow up or develop EM multi-disciplinary teams. The fourth core element of the NCAEM’s ED Care Model aims to address this need with a roadmap for leveraging existing community resources. The roadmap provides streamlined tools to help hospitals assess their needs, identify existing teams and resources in their community, and connect with Adult Protective Services and other organizations. In this presentation we will present these tools and share case examples from beginning stages of feasibility testing in hospitals across the US. We will discuss specific strategies for implementing the model in hospitals of differing types, sizes, and resource levels.

USING DATA SCIENCE TO GENERATE PSYCHOSOCIAL PROFILES OF FINANCIAL EXPLOITATION IN SENIORS

Financial exploitation (FE) in older adults is a significant public health problem linked to outcomes including depression, financial ruin and early mortality. This study applied exploratory data science techniques to a multi-year statewide protective services dataset of over 8,000 elder abuse cases. The goal was to derive data-driven psychosocial profiles of abuse with an emphasis on determining which factors, commonly shared across abuse cases, were most important for determining when elder FE was occurring and whether it was occurring alone or in conjunction with other types of abuse. We found that pronounced psychological distress (i.e. verbalizing suicide, homicide, self-harm) was most important for indicating when abuse had occurred and predicted non-FE related abuse. Drug paraphernalia in the home and perpetrator drug/alcohol use were important predictors of FE-related abuse. When differentiating pure FE from hybrid FE, factors indicative of long-term FE occurrence and substantial financial loss were most important (i.e. facing foreclosure, lack of food, medications, and utilities). The findings parallel some existing work characterizing pure and hybrid FE, but also highlight new profile factors that may help determine when FE is occurring and when it is less likely. Applying data science approaches to other large protective service datasets and national datasets such as the National Adult Maltreatment Registry could help improve characterization of abuse types such as pure and hybrid FE resulting in better detection, response and prevention.

Measures of Financial Capacity: A Review

PURPOSE OF THE STUDY

Capacity to manage finances and make financial decisions can affect risk for financial exploitation and is often the basis for legal determinations of conservatorship/guardianship. Several structured assessments of financial capacity have been developed, but have not been compared regarding their focus, validity, or reliability. Therefore, we conducted a review of financial capacity measures to examine these factors.

DESIGN AND METHODS

We searched electronic databases, reference lists in identified articles, conference proceedings and other grey literature for measures of financial capacity. We then extracted data on the length and domains of each measure, the population for which they were intended, and their validity and reliability.

RESULTS

We identified 10 structured measures of financial capacity. Most measures could be completed in 25-30 min, and were designed to be administered to older adults with some level of cognitive impairment. Reliability and validity were high for most.

IMPLICATIONS

Measurement of financial capacity is complex and multidimensional. When selecting a measure of financial capacity, consideration should be made of the population of focus and the domains of capacity to be assessed. More work is needed on the cultural sensitivity of financial capacity measures, their acceptability, and their use in clinical work. Better understanding of when, and to whom, to administer different financial capacity measures could enhance the ability to accurately detect those suffering from impaired financial capacity, and prevent related negative outcomes like financial exploitation.

Review of Programs to Combat Elder Mistreatment: Focus on Hospitals and Level of Resources Needed

BACKGROUND

Elder mistreatment is common and has serious social and medical consequences for victims. Though programs to combat this mistreatment have been developed and implemented for more than three decades, previous systematic literature reviews have found few successful ones.

OBJECTIVE

To conduct a more comprehensive examination of programs to improve elder mistreatment identification, intervention, or prevention, including those that had not undergone evaluation.

DESIGN

Systematic review.

SETTING

Ovid MEDLINE, Ovid EMBASE, Cochrane Library, PsycINFO Elton B. Stephens Co. (EBSCO), AgeLine, CINAHL.

MEASUREMENTS

We abstracted key information about each program and categorized programs into 14 types and 9 subtypes. For programs that reported an impact evaluation, we systematically assessed the study quality. We also systematically examined the potential for programs to be successfully implemented in environments with limited resources available.

RESULTS

We found 116 articles describing 115 elder mistreatment programs. Of these articles, 43% focused on improving prevention, 50% focused on identification, and 95% focused on intervention, with 66% having multiple foci. The most common types of program were: educational (53%), multidisciplinary team (MDT) (21%), psychoeducation/therapy/counseling (15%), and legal services/support (8%). Of the programs, 13% integrated an acute-care hospital, 43% had high potential to work in low-resource environments, and 57% reported an attempt to evaluate program impact, but only 2% used a high-quality study design.

CONCLUSION

Many programs to combat elder mistreatment have been developed and implemented, with the majority focusing on education and MDT development. Though more than half reported evaluation of program impact, few used high-quality study design. Many have the potential to work in low-resource environments. Acute-care hospitals were infrequently integrated into programs.

Pilot testing the detection of elder abuse through emergency care technicians (DETECT) screening tool: results from the DETECT pilot project

OBJECTIVE

To pilot test the feasibility of implementing an elder abuse (EA) screening tool (DETECT) designed for medics.

METHODS

Testing occurred between September 17th, 2015 and October 26th, 2015. MedStar Mobile Healthcare medics completed the DETECT tool when responding to calls for community-dwelling patients 65 years of age or older.

RESULTS

The DETECT tool was used 1,248 times by 97% of medics responding to an eligible 911 call. Medics responded affirmatively to at least one screening item on 209 of the completed screenings (16.8%). Immediately following the introduction of the DETECT tool, there was an increase of 5.4 (226% above baseline) reports per month (p = 0.0056).

CONCLUSIONS

The DETECT tool was easily incorporated into medic's field-based practice and resulted in an increase in medic generated reports of EA to APS. Future research designed to evaluate the tool's validity and reliability are warranted.

Impact of acculturation on breast cancer treatment and survivorship care among Mexican American patients in Texas

PURPOSE

Given the increasing number and diversity of cancer survivors in the USA and persistent racial/ethnic disparities in breast cancer care, we sought to examine the role of acculturation in adherence to recommended surgical treatment and survivorship care recommendations.

METHODS

Study participants included 343 Mexican American women with stage I to III breast cancer who participated in the Ella Binational Breast Cancer Study and were treated at The University of Texas MD Anderson Cancer Center in Houston, Texas, between March 2007 and June 2011. Participants completed a questionnaire measuring acculturation, and clinical and demographic variables were obtained from an institutional database. Multivariable logistic regression models were constructed to examine differences in surgical procedures received and adherence to long-term survivorship care by acculturation level.

RESULTS

Bilingual (odds ratio [OR] = 1.85; 95% confidence interval [CI] = 0.85-4.02, P = .11) and English-dominant women (OR = 2.39; 95% CI = 1.02-5.61, P = .04) were more likely to receive breast-conserving surgery (versus mastectomy) than were Spanish-dominant women. Among all patients, adherence to surveillance mammography and clinic visits decreased over time; the decline in clinic visit adherence was statistically significant (P = .005). Although no statistically significant association was found between acculturation and adherence to long-term survivorship care, receipt of breast-conserving surgery (versus mastectomy) was significantly associated with higher adherence to surveillance mammograms.

CONCLUSION

Acculturation may play a role in decision-making about surgical management of breast cancer, and further studies with larger samples are needed to explore its role in adherence to survivorship care recommendations. Findings from this study may help identify patients requiring additional support while making decisions pertaining to their cancer treatment and survivorship care.

A Statewide Elder Mistreatment Virtual Assessment Program: Preliminary Data

OBJECTIVES

To describe the Texas Elder Abuse and Mistreatment Institute Forensic Assessment Center Network (TEAM-FACN), a novel statewide elder mistreatment (EM) virtual assessment program using low-cost videophone technology and innovative web-based coordination to connect an Adult Protective Services (APS) agency and its clients, rural and urban, to a centralized geriatric and EM expert medical team for virtual in-home assessments.

DESIGN

Descriptive.

SETTING

Community.

PARTICIPANTS

APS clients aged 18 and older.

INTERVENTION

Virtual and in-home assessments.

MEASUREMENTS

Program use and type of services provided.

RESULTS

In the first 8 months, 300 APS clients from all regions of the state were referred for assessment. Outcomes realized include a quadrupling in number of client assessments. TEAM-FACN physicians provided an average of 2 services, which included 216 mental health assessments, with 123 conducted virtually; 42 medical assessments; 45 guardianship filings; 5 employee misconduct registry reviews; and more than 230 interdisciplinary team meetings to discuss case findings, safety plans, and medical and social interventions.

CONCLUSION

TEAM-FACN provides an innovative and viable way to increase access of urban and rural older and adults who are being mistreated to expert geriatric and EM protective service assessments. J Am Geriatr Soc 67:151-155, 2019.

Feasibility of intervention in elder self-neglecters: Setting the stage for future research

OBJECTIVES

Interventions are critical to improving clinical outcomes in elder self-neglecters. This study assessed feasibility of a randomized controlled trial of oral vitamin D in Adult Protective Services-substantiated self-neglect clients ≥65 years.

METHODS

Participants were directly observed to consume ergocalciferol 50,000 IU (treatment) or ergocalciferol 400 IU (control), once a month, for 10 months. For months 6-10, half the control group randomly crossed into the treatment group (crossover). Intervention feasibility was measured by number of potential participants who agreed to participate and by retention rates during the study.

RESULTS

Ninety-four referrals were received and 59 (63%) agreed to participate. Forty-nine participants were enrolled after prescreening and 35 completed the two-phase trial for a 72% retention rate. The participants' average age was 75.2 ± 6.8 years, mainly female (59%), African-American (47%), and living alone (41%).

DISCUSSION

Despite assumptions that self-neglecters are resistant to care, we have successfully conducted the first clinical intervention in this vulnerable population.

Medication Regimen Complexity and Low Adherence in Older Community-Dwelling Adults With Substantiated Self-Neglect

Objective: Determine whether medication regimen complexity predicts medication adherence levels in a sample of community-dwelling adults 65 years and older with Adult Protective Services–substantiated self-neglect. Methods: A cross-sectional analysis of baseline data ( N = 31 participants) from a pilot intervention to increase medication adherence among the target group was performed. The Medication Regimen Complexity Index (MRCI) and the 8-item Morisky Medication Adherence Scale (MMAS-8)™ were the primary independent and dependent measures, respectively. A multivariable linear regression analysis, adjusting for potential confounders, was conducted to estimate the association between complexity and adherence. Results: Regimen complexity was high (mean MRCI = 19.6) and adherence was low (mean MMAS = 5.1). Even after controlling for confounders, increased complexity was significantly associated with lower adherence. Discussion: Older community-dwelling adults who self-neglect have complex medication regimens that contribute to low medication adherence. Medication regimen complexity may be a modifiable contributor to low adherence that can be targeted by future interventions to reduce self-neglect and its consequences.

Associations of carboxypeptidase 4 with ALDH1A1 expression and their prognostic value in esophageal squamous cell carcinoma

Esophageal cancer is an aggressive disease with poor prognosis because of early metastasis when diagnosed and recurrence after surgery. This study is aimed at investigating the expression of carboxypeptidaseA4 (CPA4) and aldehyde dehydrogenase 1A1 (ALDH1A1) in esophageal squamous cell carcinoma (ESCC) tumor tissues and analyzed their association and clinical significance. The expression of CPA4 and ALDH1A1 was determined by immunohistochemistry using the corresponding primary antibodies on two commercial tissue arrays. High level of CPA4 was observed in 87/150 (58%) ESCC samples and was significantly associated with histologic grade, lymph node metastasis, and TNM Classification of Esophageal cancer stage. The expression level of ALDH1A1 was much higher in ESCC than their corresponding normal epithelial tissues, with 66% positive rate. And, high levels of ALDH1A1 were significantly associated with lymph nodes metastasis (P < 0.05) and TNM stage (P < 0.05). Correlation analysis showed the expression level of CPA4 positively correlated with that of ALDH1A1 (r = 0.416, P < 0.01). In Kaplan-Meier survival analysis, either CPA4 or ALDH1A1 was significantly correlated with poor overall survival of ESCC patients. Multivariate Cox regression model showed that high expression of CPA4 was an independent prognostic factor for ESCC patients. In conclusion, our present study demonstrated for the first time that CPA4 might be used as an independent poor prognostic factor in ESCC. This study demonstrated for the first time that CPA4 was aberrantly expressed in ESCC tissues. Overexpression of CPA4 was closely associated with the putative cancer stem cell marker ALDH1A1 and might be used as an independent prognostic factor in ESCC.

Assessment of older adults' satisfaction with adult protective services investigation and assistance

This study examined elder self-neglect client satisfaction with services provided by an Adult Protective Services (APS) program. A total of 77 community-dwelling older adults with APS-substantiated self-neglect responded to the standardized and widely used 8-item Client Satisfaction Questionnaire. Approximately 75% of the participants reported being satisfied with the overall services. They felt that the services provided were responsive to their need(s) and helped them deal with their problem(s). Greater than 80% responded that they would refer a friend, would utilize APS in the future if necessary, and were at least satisfied with the amount of help received. The extent to which their needs were met received the lowest satisfaction scores. Future studies are needed to examine elder self-neglect client satisfaction in relation to specific services.

Correlates of depression in self-neglecting older adults: A cross-sectional study examining the role of alcohol abuse and pain in increasing vulnerability

Self-neglect among older adults results in increased morbidity and mortality rates. Depression is strongly linked to self-neglect and when untreated, severely complicates management of health and functional outcomes. The study aims to identify factors correlated with depression to inform approaches to service recruitment and retention that improve long-term outcomes. The sample included urban community-dwelling older adults (n = 96) 65 years of age and older with Adult Protective Services-substantiated self-neglect. All participants completed a range of validated cognitive, functional, and self-report demographic and clinical measures around health and mental health functioning. A secondary data analysis using multivariable logistic regression revealed that a positive screen for alcohol abuse, low self-rated health, and higher self-reported pain were associated with significantly higher odds of self-reported depression. Further research is needed to understand the temporality between these correlates and depression and to inform prevention and intervention practices for self-neglecting older adults.

Frailty in self-neglecting older adults: A secondary analysis

Self-neglect (SN) and frailty in older adults is associated with increased disability and mortality. Despite these commonalities, there have been no studies objectively assessing frailty in older adults who SN. This secondary analysis classified frailty in N = 37 older adults with Adult Protective Services validated SN using the Fried Frailty Phenotype (FFP) of weight loss, weakness, exhaustion, activity level, and walking speed. Overall, 3% were classified as robust, 62% as prefrail, and 35% as frail. Most (72%) were overweight/obese, with clinically significant decreases in activity level (60%) and walking speed (97%). Compared to the original FFP population, older adults who SN exhibit important differences in frailty phenotypes, and finding that the largest percentage of older adults who SN were prefrail may indicate a critical opportunity for intervening in this population to reduce future functional decline and mortality.

Five-year all-cause mortality rates across five categories of substantiated elder abuse occurring in the community

Elder abuse increases the likelihood of early mortality, but little is known regarding which types of abuse may be resulting in the greatest mortality risk. This study included N = 1,670 cases of substantiated elder abuse and estimated the 5-year all-cause mortality for five types of elder abuse (caregiver neglect, physical abuse, emotional abuse, financial exploitation, and polyvictimization). Statistically significant differences in 5-year mortality risks were found between abuse types and across gender. Caregiver neglect and financial exploitation had the lowest survival rates, underscoring the value of considering the long-term consequences associated with different forms of abuse. Likewise, mortality differences between genders and abuse types indicate the need to consider this interaction in elder abuse case investigations and responses. Further mortality studies are needed in this population to better understand these patterns and implications for public health and clinical management of community-dwelling elder abuse victims.

Four subtypes of self-neglect in older adults: results of a latent class analysis

OBJECTIVES

To determine whether there are subtypes of elder self-neglect (SN) with different risk factors that can be targeted using medical and social interventions.

DESIGN

Cohort study using archived data of Adult Protective Services (APS) substantiated cases of elder SN between January 1, 2004, and December 31, 2008.

SETTING

Houston, Harris County, Texas.

PARTICIPANTS

Adults aged 65 and older with APS region VI substantiated SN between January 1, 2004, and December 31, 2008 (N = 5,686).

MEASUREMENTS

Adult Protective Services caseworkers used the Client Assessment and Risk Evaluation (CARE) tool during home investigations, assessing risk of harm in the domains of living conditions, financial status, physical and medical status, mental health, and social connectedness. Latent class analysis was used to identify unique subtypes of elder SN.

RESULTS

Four unique subtypes of elder SN were identified, with approximately 50% of individuals manifesting physical and medical neglect problems. Other subtypes included environmental neglect (22%), global neglect (21%), and financial neglect (9%). Older age, Caucasian descent, and mental status problems were more strongly associated with global neglect behaviors. African Americans were more likely to experience financial and environmental neglect than Caucasians and non-white Hispanics.

CONCLUSION

Elder SN consists of unique subtypes that may be amenable to customized multidisciplinary interventions. Future studies are needed to determine whether these subtypes impose differential mortality risks and whether multidisciplinary tailored interventions can reduce SN and prevent early mortality.

Forensic Markers Associated with a History of Elder Mistreatment and Self-Neglect: A Case-Control Study

Elder mistreatment (EM) and elder self-neglect (SN) are risk factors for mortality. Medical examiners (ME) seldom investigate EM and SN as potential influences of death in older adults. Recognizing forensic markers associated with EM and/or SN may lead to further investigation into EM and SN as potential contributors and thus, may impact the cause and manner of death.

Methods

One-hundred and ninety-two Adult Protective Services (APS)-substantiated EM and SN cases 65 years of age and older, residing in Houston, Texas in Harris County with ME records were matched on age, race, gender and socio-economic status to individuals with ME records and no APS history. A conditional logistic regression was conducted to identify variables that reliably predict ME cases with an APS history.

Results

APS cases had significantly higher odds of having a history of pressure sores (OR: 2.4; 95% CI = 1.2 – 4.9), but had significantly lower odds of presenting with abnormally high body mass indexes (OR: 0.5; 95% CI = 0.3 – 0.9).

Conclusion

These data suggest that forensic case information such as a decedent history of pressure sores may indicate a past history of elder mistreatment or self-neglect. In contrast, having an abnormally high body mass index may indicate a lack of APS history. More studies are needed to better define these predictors and to identify other predictors that may assist forensic pathologists in identifying deaths in older adults that may have been impacted by EM and/or SN.