While the previous chapters have underscored the magnitude and burden of elder abuse and unique challenges that they present, this chapter focuses on applying what is known toward detecting and preventing abuse. Existing tools and models for screening and intervention are presented, along with discussions on increasing the effectiveness of ongoing efforts and opportunities for new interventions.
SCREENING
Screening tools have been developed for the detection of multiple forms of violence, including intimate partner violence, child abuse, and elder abuse. The effectiveness of such tools has been debated. Although the U.S. Preventive Services Task Force recommends that clinicians screen women for intimate partner violence, it has concluded that the current evidence for elder abuse and neglect screening is insufficient to assess its potential benefits or harm.1 Although the existing evidence is limited, considering the association between elder abuse and adverse health outcomes and the association of elder abuse with increased health services use, efforts are being made to develop and assess screening tools in multiple settings and grow the evidence base on their effectiveness. Workshop panelists presented some of these current efforts as well as challenges and opportunities for moving elder abuse screening and detection forward. A detailed overview of both
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1 See http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm.
screening tools and issues presented at the workshop are included in Part II of this report (see McMullen et al.). Below is a brief summary.
Workshop planning committee member Tara McMullen and speaker Kimberly Schwartz from the Centers for Medicare & Medicaid Services (CMS) presented the agency’s work in the areas of measuring and assessing elder abuse. CMS began this work because of the recognized lack of universal agreement on how to measure all aspects of elder maltreatment. One of the challenges CMS has identified with its current measure, the Elder Maltreatment Screen and Follow-up Plan, is that it seldom is reported by eligible providers, and CMS wants to increase the feasibility and reporting of its measure.
Workshop speaker Mark Yaffe from McGill University presented the Elder Abuse Suspicion Index (EASI), which is administered by family physicians in primary care settings. The EASI tool is intended to generate suspicion about the presence of mistreatment or neglect sufficient to justify further discussion of the issue between doctor and patient, or patient referral to a community expert in elder abuse for in-depth evaluation. Yaffe commented that family physicians are well positioned to detect elder abuse for several reasons: They may be the only people outside of family who regularly see some older adults. Often there is an established trust in a doctor–patient relationship, and trust in theory helps to promote disclosure; most patients are accustomed to doctors asking direct questions about sensitive topics, and the physical exam is an opportunity to look for abnormal lab findings and unexplained deterioration. Yaffe discussed several barriers to elder abuse screening in primary care settings: lack of awareness of elder abuse and its association with higher mortality rates, lack of knowledge of how to identify it, previous absence of screening detection tools that were appropriate for use in a doctor’s office, considerations about ethical and confidentiality issues, disbelief that detection will lead to a solution, ageism, concerns about legal issues, and confusing guidelines.
Yaffe also suggested that the focus of a family doctor’s approach should be evidence informed and patient centered. Forum member Brigid McCaw from Kaiser Permanente agreed that screening tools need to focus on patient centeredness, as well as facilitating clinician behavior change. As the implementers, physicians need to see the value in screening so that the tools will be used more often. Schwartz noted that a focus of CMS’s work on elder abuse measurement is to make it more patient centered and driven more toward an outcome-based versus a process-based measure. Workshop speaker Susan Lynch from the Department of Justice noted that, to increase reporting, elder abuse has to be defined so that people know what it is. The provider needs to be aware of the definition, be aware of the laws regarding reporting, and have the knowledge and understanding of the next steps. Another workshop participant commented that the context in which
the screening takes place is critical because if it is not done in a way that ensures trust and confidentiality, outcomes can be unpredictable, regardless of how good the tool is.
Although the EASI tool and much of the CMS work focus on screening in the primary care setting, workshop speaker Scott Beach from the University of Pittsburgh discussed screening for elder abuse in community-dwelling and institutional populations, drawing from work he and his colleagues have done as well as others. Table 5-1 lists different screening methods for community-dwelling and institutional populations, with members who are either cognitively intact or cognitively impaired.
Speaker Daniel Reingold from The Hebrew Home in Riverdale, New York, noted that facility staff have found screening is a very effective tool for elder abuse detection at the facility. The Hebrew Home has implemented mandatory elder abuse screening because so many victims come out of the hospital into postacute care without yet being detected. Through screening, they have identified more than 15 victims of elder abuse.
TABLE 5-1 Elder Abuse Screening and Detection: Overview
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| Community Dwelling: Cognitively Intact | Community Dwelling: Cognitively Impaired |
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• Direct victim surveys (random sample) • Direct victim surveys (targeted disease) • Direct caregiver surveys (targeted disease) • Direct perpetrator surveys (?) • Community “sentinels” (NEAIS) • Health care screening (physicians, emergency department, hospital, dental clinics) • Social service providers (adult day care) • Forensic analysis (bruising) • APS/official reports |
• Direct caregiver surveys (targeted disease) • Direct perpetrator surveys (?) • Community “sentinels” (NEAIS) • Health care screening (physicians, ER, hospital, dental clinics) • Social service providers (adult day care) • Forensic analysis (bruising) • Adult Protective Services (APS)/official reports • Mild cognitive impairment—able to self-report? |
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| Institutionalized/Long-Term Care (LTC): Cognitively Intact | Institutionalized/LTC: Cognitively Impaired |
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• Resident surveys • Family surveys • Resident informant/proxy surveys • Staff surveys • Video monitoring of public areas (?) • Forensic analysis (bruising) • LTC ombudsman/official reports (both staff–resident and resident–resident abuse) |
• Family surveys • Resident informant/proxy surveys • Staff surveys • Video monitoring of public areas (?) • Forensic analysis (bruising) • LTC ombudsman/official reports |
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NOTE: ER = emergency room; NEAIS = National Elder Abuse Incidence Study.
SOURCE: Beach, 2013.
Beach raised several issues and challenges he identified in conducting elder abuse screening:
• Who is being asked? Potential victims, clinicians, caregivers, proxies?
• Should the victim’s perspective always be included when he or she is cognitively intact?
• What tool should be used?
• How should the data be collected: self-administered, through an interview, or through technology?
• Considering privacy and comfort, in what setting should it be administered?
• What method should be used to screen for neglect and self-neglect? Or financial exploitation?
• How should cultural context inform the screening?
Considering the breadth of existing tools, several workshop speakers stressed the use of learning and adapting from existing tools and their evidence rather than reinventing the wheel. Workshop speaker Ronald Acierno from the University of South Carolina noted, “We have basic building blocks. We have what has been demonstrated as a phenomenal way of detection. We have the setting where you have shown where you can do it, and people get together to combine those methods.”
PREVENTION
Despite the magnitude of elder abuse around the world, little is known about how to prevent it before it occurs or how to stop it once it starts. Elder abuse is witnessed in many settings, and multiple sectors recognize the need to intervene. Some have started to take action; however, their efforts could be strengthened through increased knowledge sharing among stakeholders. Others are unsure of how to respond and need the tools to be able to take action. To facilitate discussions about opportunities for prevention, workshop participants engaged in breakout sessions on potential strategies and considerations for prevention in different settings: health care, the community, the legal system, and the financial sector. Breakout group leaders facilitated the sessions and individual participants provided comments from their perspective. Specific interventions suggested from within these different sectors were discussed throughout the workshop (see Boxes 5-1, 5-2, 5-3, and 5-4).
BOX 5-1
Elder Investment Fraud and Financial Exploitation Prevention Program: Training Health Professionals on Financial Exploitation
Workshop participant Don Blandin from Investor Protection Trust (IPT) described an IPT program, the Elder Investment Fraud and Financial Exploitation Prevention Program (EIFFE Prevention Program). IPT’s mission is to educate investors by providing information needed to make informed investment decisions. The EIFFE Prevention Program works to educate health professionals on how to identify abuse or potential abuse against their elder patients, and how to refer at-risk patients to State Securities Regulators or the local Adult Protective Services. These health professionals are educated through continuing medical education events, and materials for both clinicians and patients are available on the EIFFE Prevention Program website. This program was raised as an example of a program that could potentially be adapted to the legal sector.
SOURCE: Investor Protection Trust, http://www.investorprotection.org/ipt-activities/?fa=eiffe-pp.
Health Care
Within the context of health care, workshop breakout group facilitator Elsie Yan from the University of Hong Kong suggested that special attention needs to be paid to case management and the transition of care, for example, from hospital to home. Within that context, the use of a team approach and integrated partnership among different disciplines might be reinforced. Furthermore, training in interventions should target staff at all levels, including clinical and nonclinical. It was suggested during the session that curricula for different health disciplines should incorporate gerontological approaches to case management and elder abuse training. It was also suggested that health providers should inform individuals of their choices, for example, of the use of and distinctions among advanced directives, guardianship, and their right of self-determination.
When considering opportunities for prevention in the community, health care providers such as dentists are well positioned to intervene. Recognizing that within institutional settings most violence occurs between residents, increasing staff–patient ratios and changing the environment were suggested as opportunities for prevention. Another recommendation from a breakout participant was to promote options for counseling to the caregivers and inform them of the continuum of care and quality of nursing home care to help them in decision making.
BOX 5-2
Legal System Interventions
Lori Stiegel from the American Bar Association Commission on Law and Aging provided an overview of opportunities for the legal system to intervene and prevent elder abuse. These interventions exist at criminal, civil, and judicial levels and include
• Criminal justice system at the local, state, and federal levels: Law enforcement, prosecutors, corrections, community corrections, victim services (both system and community based), and victim compensation;
• Civil justice system: Public services lawyers (e.g., legal aid, law school clinics, and pro bono law) and private lawyers (e.g., elder law, probate and trust, and family law); and
• Judicial system: State and federal courts.
Participants in each of these systems have opportunities to prevent, detect, and remedy elder abuse. For example, civil lawyers can screen for elder abuse and counsel clients about how to prevent elder abuse. They can also prepare or revoke documents, such as powers of attorney, and can bring litigation in order to protect or recover a victim’s assets. Civil lawyers need to become more educated about and involved in efforts to prevent and detect elder abuse. The criminal justice system can play a critical role in detecting and preventing elder abuse through policing, punishment, restitution to victims, and supervision of offenders.
Judicial guidelines and standards, training, and tools for handling elder abuse cases have been developed by some organizations, such as the American Bar Association, the Florida International University, and the National Center for State Courts.
Limited resources have been developed for and within each of these systems to help professionals learn how to recognize and handle elder abuse cases. There are sporadic trainings for participants in the three systems, but there is great need for more resources, particularly for civil lawyers.
Special services are another way that law can intervene in elder abuse. For example, one criminal intervention is special prosecution units focusing on elder
Legal System
Workshop breakout facilitator Charles Sabatino from the American Bar Association commented that the legal system traditionally becomes involved later in cases of elder abuse rather than in primary prevention. The focus in primary prevention has been heavily on education and training and the competencies needed to screen for and detect abuse and exploitation as well as addressing it early and in many cases divert it from the legal system. He suggested that the stakeholders who should be targeted for training in
abuse. Some areas of the country have well-known units, such as Brooklyn, Manhattan, San Diego, and Seattle; in most of the United States, however, it is rare to find someone in a prosecutor’s office who knows about and understands elder abuse, and even more rare to find a specialized unit. Within the judicial system, court-focused elder abuse initiatives are a recent development. Examples of such initiatives include elder protection courts (special dockets for elder abuse cases) and elder protection order projects that enable older homebound persons to petition for protection orders by telephone.
Elder abuse multidisciplinary teams, such as elder abuse forensic centers, provide another opportunity for criminal and civil lawyers to prevent elder abuse and to improve systems. A recent study demonstrates that cases reviewed by elder abuse forensic centers have a 10 times greater likelihood of being presented to the district attorney (Navarro et al., 2013). However, because the criminal justice system is not focused on the needs of victims, it is important to include civil lawyers on multidisciplinary teams to ensure consideration of civil legal tools that may benefit victims. There is great opportunity for future research on the intervention of multidisciplinary teams.
The corrections and community corrections systems provide additional opportunities for prevention and intervention. It can be expensive to care for elderly prisoners, and a recent trend is to release old and ill prisoners. The possibility of elder abuse and family violence should be considered in this policy issue. A similar issue arises in the community corrections system, where professionals have an opportunity to direct offenders coming out of prison away from working in nursing homes or assisted living facilities, and to assess whether additional supervision might be warranted if an offender is living with elderly parents or grandparents.
Finally, it is important for the public and the professionals who serve them to be aware that—contrary to what they see on television—in the criminal justice system a crime is actually committed against the state, and victims are considered to be witnesses to that crime; it is up to the state to determine whether an alleged perpetrator of elder abuse should be prosecuted.
For more information, see http://www.elderabuseforensiccenter.com.
SOURCE: Lori Stiegel, American Bar Association Commission on Law and Aging.
legal interventions and opportunities for prevention are police, prosecutors, judges, and other professionals that are connected to the legal system, such as those in protective services and at financial institutions. The legal system and the courts often are part of an insular culture and are not naturally inclined to go out of their comfort zone; however, elder abuse prevention involves many sectors and collaboration is suggested to increase the effectiveness of prevention efforts.
A second issue that Sabatino reported on was guardianship. Guardianship often is seen in legal theory as a remedy for abuse and neglect and for
BOX 5-3
The Hebrew Home at Riverdale:
A Community-Based Intervention
Workshop speaker Daniel Reingold from The Hebrew Home at Riverdale in New York presented the elder abuse shelter model that was developed at The Hebrew Home and has been replicated in other locations. He emphasized that the community is required to create an elder abuse shelter; it is a collaborative model that uses the existing resources of a community. In particular, using a nonprofit long-term care facility, a nursing home is one of the greatest models and one of the reasons that internally within a long-term care facility there is an existing community that can be used to shelter, protect, and empower victims of elder abuse. The model is nimble and flexible and can be adapted to the specific community. (See Reingold et al. in Part II of this report for an in-depth discussion of the elder abuse shelter model.)
SOURCE: Daniel Reingold, The Hebrew Home at Riverdale.
issues of inadequate capacity, but it is often a part of the problem rather than the solution. It is frequently overused and courts tend to see guardianship as a black-and-white choice. Sabatino suggested that other intervention resources within the legal system could be more important, but are generally underfunded. There is often a lack of structure for various legal tools that could prevent elder abuse in the first place, particularly around powers of attorney and legal tools. Frequently this is the result of weak state laws or a lack of lawyer training in elder abuse, for example, when counseling clients on estate planning. Expanded use of ombudsman planning is another adjunct resource that could be helpful. Along with these resources and the courts, the lack of knowing what happens in these cases is a chronic problem. There are poor data systems and they tend to focus on the front and on how many cases were filed; often it is unknown what happens to these cases after they enter the system. One suggestion that came from a breakout group participant was mandating minimum institutional staffing ratios.
Community-Based
Breakout session facilitator Joy Solomon from The Hebrew Home at Riverdale provided some reflections from the community-based breakout discussions. She suggested that the most important question that was raised during the discussion was “What is community?” How community is defined affects prevention efforts and where in the community they occur. She noted that several breakout session participants suggested there may be valuable lessons learned in the area of community-based prevention
BOX 5-4
OWN IT: Wells Fargo Advisors and
Financial Exploitation Prevention
Ronald Long from Wells Fargo Advisors (WFA) presented WFA’s efforts to prevent elder financial exploitation. Recognizing that elders are targets for financial exploitation, WFA has put significant resources toward building its capacity to prevent it. WFA’s efforts include training most of its employees, a centralized response unit, client-focused information, educational outreach, and partnerships. They have developed the OWN IT model to raise awareness among their employees and empower them to act when they detect exploitation:
• Observe: Are there physical changes? Are patterns and habits different? How is the elder around the third-party person present?
• Wonder Why: Why are withdrawal multiples larger than before? Why is money sent to a new country?
• Negotiate: Can the transaction go later? Can the check go in two names, elder and trusted third party? Can we only give a fraction of the money today and more later?
• Isolate: Get the elder alone: “Ms. Smith, please step with me to confirm some account information” or “Please come with me to discuss some confidential information.”
• Tattle: Bring concerns to manager immediately. Use firm’s Adult Protective Services reporting process.
(See Long in Part II of this report for an in depth discussion of WFA’s model.)
SOURCE: Ronald Long, Wells Fargo Advisors.
from the fields of domestic violence and child abuse. Solomon reflected that the value of coalitions and the role of multidisciplinary teams is an important theme that has come up throughout the workshop. She stressed that within the community context, where there are many actors, multidisciplinary work is extremely important across different agencies but even within one agency. Workshop planning committee member and breakout session co-facilitator Jeffrey Hall from the Centers for Disease Control and Prevention observed from the breakout discussion that people use different jargon. In the context of community-based interventions, particularly ones that involve multidisciplinary teams, understanding different definitions of “community” is important for developing partnerships. He added that a key factor for moving forward will be the use of non-traditional partnerships to bring groups and individuals to the table in ways they have not in the past. At the same time that different stakeholder groups are being embraced, older adults themselves should be taught about prevention.
Solomon noted that there can be tension in the area of community-based intervention implementation between the “just do it” model and waiting for the evidence model. Hall suggested that, while the movement to build the evidence base for elder abuse and its prevention is underway, action will be needed. A reasonable accommodation would be to have guided exploration of particular interventions to address elder abuse and allow the collection of information to compile the evidence base for which future interventions can be launched. Commenting on the idea of frameworks, Hall cautioned that it is important to not allow frameworks to become barriers. The conversations about elder abuse prevention need to include multiple perspectives and use inclusive concepts.
Financial Sector
Workshop participant Naomi Karp from the Consumer Financial Protection Bureau provided some comments based on her participation in the financial sector breakout session. She noted that several of the session participants discussed the challenges of information sharing in financial exploitation prevention efforts. For example, when the front-line financial sector professionals detect what they suspect may be elder financial exploitation, they often have concerns about what information they can share with government entities and others without violating privacy rules. She said a number of federal agencies are making an effort to provide some clarification and guidance on information sharing and privacy protection. Karp also noted that there was discussion about enhancing the use of suspicious activity reports (SARs) at financial institutions. Now that there is a category for elder financial exploitation, efforts should be made to better collection data and share information based on the SARs.
Karp mentioned the need for financial institutions to delay transactions or freeze accounts when there is suspected abuse, and said it would be helpful if there was a catalogue of state remedies already in place. Karp also noted that financial institutions often have concerns about reporting and being held liable; state laws on mandatory reporting and related immunity provisions need to be made known. She also noted the Financial Services Roundtable has a new training curriculum for financial institutions that can provide vital information.
REFERENCES
Beach, S. 2013. Screening and detection. Presented at Elder Abuse and Its Prevention: A Workshop. Institute of Medicine, Washington, DC, April 18.
Navarro, A. E., Z. D. Gassoumis, and K. H. Wilber. 2013. Holding abusers accountable: An elder abuse forensic center increases criminal prosecution of financial exploitation. Gerontologist 53(2):303-312.
