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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America
tain patients who are at increased risk of mistreatment based on validated indicators and formulas. These are all in need of further exploration. Research is also needed on the best ways to verify and manage situations in which patients spontaneously report possible episodes of mistreatment. Many health centers have domestic abuse detection and management systems in place, providing an important opportunity for clinical research on elder mistreatment.
As noted, most efforts to screen elder mistreatment in the clinical setting have involved short, directly administered questionnaires. For example, the AMA guidelines (American Medical Association, 1992) encourage physicians to “incorporate routine questions related to elder abuse and neglect into daily practice.” Table 6-1 contains a listing of published screening methods for elder mistreatment, along with information on their measurement properties. While several screening tools are now available to identify possible cases of elder mistreatment, it is not known if these tools are widely utilized; anecdotal evidence indicates they are not. Most emergency rooms, one logical place to institute screening procedures, do not routinely screen for elder mistreatment (Jones et al., 1997). The existing tools have rarely been validated in diverse clinical settings, and they have not been adequately validated overall. Some have been evaluated in the emergency room setting, others in the home setting, but none in the office, nursing home, or community settings (such as senior centers or adult day care programs). Several of the current tools depend on accurate responses from the possible victim, who may be unable to give reliable answers due to dementia, fear, or other cognitive or emotional factors. Others depend on responses from the caregiver or trusted other, who may not be willing to provide accurate, truthful responses or may be incapable of doing so. The caregivers of many frail and dependent elders may themselves be equally frail and impaired (Schultz and Beach, 1999).
Even among published screening tools, improvements in design and measurement properties may be indicated. There is also need for extending screening instruments into a wider range of settings, such as the physician’s office, adult day care programs, and, despite the challenges, long-term care facilities. These instruments must be practical for those settings. While some of the existing instruments have been available for many years, few have received confirmatory validation by other investigators. Because some cases of mistreatment are obvious and overt, testing the current screening tools to see if they correctly identify these cases may be a reasonable starting point. Once we know that the clear-cut cases are identifiable, it should be easier to proceed to the gray areas where many cases of possible mistreatment lie.
In order for a screening tool to be practical in a clinical setting, it should not only be accurate, but also easy to use and efficient. Some of