To move the field of elder abuse research and prevention forward, innovative ideas are needed that will contribute to the evidence base, raise awareness, change attitudes, and provide the necessary tools to take action. At the close of the workshop, several speakers provided comments on the progress of health policy and awareness building toward these ends. Additionally, several speakers provided their reflections based on the discussions over the course of the 2 days on priority areas for moving the field forward. This chapter includes summaries of the comments they provided.
HEALTH POLICY AND PROMOTING AWARENESS
Workshop planning committee member and moderator Edwin Walker from the Administration on Aging acknowledged that elder abuse is no longer an invisible problem. Solutions can be developed collectively that bring about the cultural change necessary to globally address the issue and build systems that are truly responsive. Workshop speakers discussed elder abuse prevention through international collaboration, policy-level efforts in the United States, and increased awareness.
The International Network for the Prevention of Elder Abuse
Susan Somers from the International Network for the Prevention of Elder Abuse (INPEA) presented on INPEA’s global efforts. INPEA, which includes representation from 60 countries, aims to increase the ability of
societies to recognize and respond to mistreatment of older persons across settings through international collaboration. Considering the diversity of the cultures represented within their membership, reflecting on cultural relevance is an important aspect of their work. INPEA’s objectives are to
• promote education and training of professionals and paraprofessionals in identification, treatment, and prevention;
• further advocacy on behalf of abused and neglected elders; and
• stimulate research into the causes, consequences, prevalence, treatment, and prevention of elder abuse and neglect.
Collaboration with the United Nations
INPEA has nongovernmental organization (NGO) special consultative status to the United Nations (UN) Economic and Social Council and is given 2 or 3 minutes at every other session to speak. In 2008, INPEA organized a program on social isolation, which was the first time this issue was discussed at the UN. INPEA also has participated in the 2002 UN Second World Assembly on Ageing in Madrid, the Intergovernmental Conferences on Ageing for the 5-year regional follow-ups to Madrid, and the International Plan of Action on Ageing. The organization’s key UN strategies and challenges include
• building knowledge and capacity of NGOs and Member States and Older Persons;
• maximizing awareness of consequences of ageism, inequality, and gender discrimination;
• seeking out and sharing effective, evidence-based sustainable solutions; and
• identifying key stakeholders for collaboration.
World Elder Abuse Awareness Day
The World Elder Abuse Awareness Day (WEAAD) was first instituted by INPEA on June 15, 2006. On December 19, 2011, the UN General Assembly officially recognized elder abuse as a global social issue that affects the health and human rights of millions of older persons around the world.
Somers noted several urgent concerns in the area of elder abuse globally that INPEA has identified as priorities moving forward:
• violence against older women/widows;
• harmful cultural and traditional practices;
• lack of social protection;
• extreme poverty;
• self-neglect; and
The Elder Justice Act and Policy-Level Efforts in the United States
Robert Blancato from the Elder Justice Coalition presented on progress toward elder justice through policy efforts in the United States. The Elder Justice Act (EJA) was introduced in 2002 and 2003 and had grown out of hearings and the related work of the Senate Special Committee on Aging. The bill was motivated by two factors: (1) less than 2 percent of federal funds for violence prevention were being spent on elder abuse; and (2) no single person in the entire federal government worked on elder abuse. The EJA was the subject of numerous hearings in the Senate and House and passed in the Senate Finance Committee on three different occasions. Finally, in 2010, it became law as an amendment to the Patient Protection and Affordable Care Act (see Box 6-1 for details on the law). Since its passage, work has begun to secure funding for the authorizations in the bill; implement the law, and work to pass parts of the original bill that were not included, such as the Elder Abuse Victims Act.
Blancato noted that 2012 was a year of progress. That year the White House held a high-level WEAAD event; new grants were awarded to test best practices going forward, including funding to tribal organizations; and
Features of the Elder Justice Act
• Authorization of $777 million over 4 years in the areas of Adult Protective Services (APS) funding, state demonstration grants, long-term care ombudsman program, long-term care staffing support, training programs, improved data collection and dissemination, and research related to APS;
• Establishment of the Elder Justice Coordinating Council, which makes recommendations to the Secretary of the Department of Health and Human Services on the coordination of activities of federal, state, local, and private agencies and entities relating to elder abuse, neglect, and exploitation; and
• Establishment of a 27-member Advisory Board on Elder Abuse, Neglect and Exploitation, which has yet to be named or convened.
the Elder Justice Coordinating Council was convened, providing an opportunity for governmental agencies to share with each other the work they are doing. In addition, in 2012, the President’s budget included EJA funding for the second year in a row and the Department of Justice continued to work on the roadmap project. Blancato suggested that the range of related bills introduced in 2012 shows interest on a bipartisan basis (see Box 6-2).
Blancato noted progress that has continued in 2013:
• Violence Against Women Reauthorization Act of 2013 passed with elder abuse funding.
• Elder Abuse Victims Act of 2013 was introduced.
• First elder abuse hearing of this Congress’s Senate Aging Committee was held on March 13; the second was held on April 10.
• Senate Budget Resolution passed with Amendment No. 594 supporting the Older Americans Act, including Title VII.
While progress is being made, Blancato also illuminated several areas where work still needs to be done: funding the EJA; implementing the rest of the EJA (including the Elder Justice Advisory Council, the designated home for Adult Protective Services in the Department of Health and Human Services, data collection, enforcement of Centers for Medicare & Medicaid Services guidelines on reporting crimes in nursing homes, and more state applications for grants for criminal background checks); reintroducing 2012 bills in the 113th Congress and getting new movement; and passing the Older Americans Act.
Elder Justice-Related Bills Introduced in the 112th Congress
• Elder Abuse Victims Act (S. 462) (Sen. Kohl)
• Senior Financial Empowerment Act (S. 465) (Sen. Gillibrand)
• National Silver Alert Act (H.R. 112, S. 1263) (Rep. Doggett, Sen. Kohl)
• Elder Protection and Abuse Prevention Act (S. 2077) (Sen. Blumenthal)
• Older Americans Act Reauthorization 2012 (S. 3562) (second attempt in 2012) (Sen. Sanders)
• LGBT Elder Americans Act of 2012 (S. 3575), amendment to Older Americans Act (Sen. Bennet)
• Robert Matava Exploitation Protection for Elder Adults Act of 2012 (S. 3598) (Sen. Blumenthal)
• Improving Dementia Care Treatment in Older Adults Act (S. 3604) (Sen. Kohl)
Blancato provided several comments about the effects of sequestration on elder abuse prevention efforts. Sequestration cuts are affecting elder abuse detection programs around the country, including the Social Services Block Grant, which supports APS. Additionally, cuts to Title VII programs are in the double digits in some states. Blancato noted that sequestration could end starting in fiscal year 2014; however, in the worst case scenario, it could continue for another 9 years.
Reflecting on progress made to date, Blancato suggested that it has been possible due to leadership in the President’s Administration and bipartisan leadership in Congress, as well as sustained national state and local advocacy. The Elder Justice Coalition was founded 10 years ago and served to coordinate advocacy at the national level. It had 5 founding organizations and has grown to 3,000 members. Furthermore, media coverage has aided in the effort, especially of celebrated cases such as Brooke Astor and Mickey Rooney.
Going forward, particularly in a time of sequestration and deficit reduction, advocacy must be more aggressive, stressing prevention, and state of the art. The Elder Justice Coalition is starting a collaboration with the Ageless Alliance to increase visibility of elder justice through social media.
To make progress toward prevention, investments should be made in programs that target prevention and also save funding in other federal programs such as Medicaid and Medicare. Furthermore, because what is not reported cannot be stopped, investments need to be made in better detection, more reporting, and more resources to the entities where elder abuse is reported.
Elder abuse also needs to be recognized as a growing women’s issue, as well as a baby boomers’ issue. The average victim is an older woman living alone; nearly half of all women over 75 live alone. Baby boomers control 70 percent of disposable income in the United States and first-wave boomers are now 67.
Blancato noted that the Elder Justice Act expires in 2014, so 2013 is a pivotal year to show its value. Despite the progress that has been made to date, there is still much progress to be done. Going forward, the work that has been started by Congress and the Obama Administration needs to continue to push the field of elder abuse prevention forward.
Enhancing the Public Health Response: Priority Policy Issues
Woodrow Wilson International Center for Scholars
Workshop speaker Marie-Therese Connolly reflected back to the 2007 Institute of Medicine (IOM) workshop on Preventing Violence in Low- and
Middle-Income Countries, which was the founding event in the IOM beginning work to address violence prevention through the Forum on Global Violence Prevention. She remarked that at that workshop, elder abuse was an afterthought. While the field still has a long way to go, the workshop on elder abuse and its prevention in 2013 shows that it is no longer an afterthought. To continue to move the field of elder abuse forward, Connelly suggested seven actions, which are listed below and described in detail in Connolly and Trilling in Part II of this report:
1. develop policy to recognize elder abuse as a public health issue;
2. address research priorities critical to inform policy and practice: intervention, defining success, prevention, data collection, and cost;
3. translate what we know into practice;
4. address the resources issue;
5. implement law and developing policy infrastructure;
6. develop a political constituency; and
7. promote innovation.
MOVING PREVENTION FORWARD
Based on the discussions they observed and participated in during the 2-day workshop, several speakers provided comments from their perspective on priority issues for moving the field of elder abuse prevention forward.
Reflections from a U.S. Government Perspective
U.S. Assistant Secretary of Aging Kathy Greenlee,
Administration on Aging
As a member of the Forum on Global Violence Prevention since its founding in 2010, Administration on Aging Assistant Secretary Kathy Greenlee expressed her appreciation to the IOM and her Forum colleagues for undertaking a workshop on elder abuse and its prevention. While elder abuse has been part of the Forum’s work through its activities, dedicating a full workshop to it has shed light on a type of violence that often takes a backseat to other more readily recognized forms of violence, such as child abuse and intimate partner violence. Greenlee also expressed her appreciation to her colleagues from other U.S. government agencies who attended and participated in the event, demonstrating the multisectoral dedication to elder abuse prevention.
Greenlee noted that Pamela Teaster’s presentation on conceptual frameworks was helpful and showed that there is no structure by which work in this field is being analyzed. As the development of a conceptual framework moves forward, Greenlee offered two thoughts to consider. She suggested that part of the success in the work of domestic violence has been the critical support and training it took to include law enforcement. Elder abuse is a crime and whatever theoretical framework is developed, it has to be something that can translate to law enforcement, prosecutors, and judges so that the framework supports the understanding of elder abuse as a criminal activity. The other thought she offered about the framework was on the public health model. Greenlee noted that as a lawyer by training and public servant, she has struggled with applying the public health structure and the categorization of primary, secondary, and tertiary prevention to elder abuse because of ageism. Articulating primary prevention for older people can be very hard to do; some people incorrectly assume by the time someone has reached old age, primary prevention is too late or not feasible. She posited putting the model on its head with tertiary first and then secondary and then primary because primary is such a struggle. Greenlee suggested that if a framework can be developed that achieves these objectives of being inclusive of law enforcement and creating a practical public health approach, she could work with any structure that is developed.
Inclusion of Individuals with Disabilities
Greenlee noted that in addition to serving as Assistant Secretary for Aging, she also serves as Administrator for the Administration on Community Living (ACL). ACL serves people with disabilities and older adults as well as their families through what she refers to as a multicultural approach to aging and disability. She suggested that as work in the area of elder abuse moves forward, it needs to be done in a way that addresses the needs of people with disabilities who are not older and actually includes people with disabilities themselves. Alzheimer’s disease affects people of all ages even though there is a higher prevalence of people who are older, as does Parkinson’s disease and multiple sclerosis. Greenlee asked: “How can we make sure that when we tackle the twin pillars of cognitive impairment and social isolation, it is inclusive of people with disabilities?”
Elder Justice Act and Adult Protective Services
The fact that the Elder Justice Act has not been funded is a tremendous problem on which Greenlee will continue to work. Blancato mentioned
the desire for a designated federal home for Adult Protective Services, and Greenlee suggested that it could be possible to fund it through the Older Americans Act because elder abuse has always been incorporated into the goals of the Older Americans Act. However, she noted the limitations of funding and the amount of resources she can put toward it without Elder Justice Act funding.
The Twin Pillars
Greenlee also noted that while much can be learned from other fields, such as mental health, domestic violence, and child abuse, two issues must be addressed specifically in the area of elder abuse—cognitive impairment and social isolation.
Based on the content of the presentations and discussions throughout the workshop, Greenlee suggested that, in fact, there are assets at hand to work on moving elder abuse prevention forward. Although the field has “more brains than money,” she is optimistic that it will move forward.
Reflections from a Research Perspective
Terry Fulmer, Northeastern University
Be Proactive in Building the Evidence
Speaker and planning committee member Dr. Terry Fulmer suggested that, despite the fact that researchers in the field are highly critical of the research progress to date, the evidence base is moving forward. To continue the progress, she suggested that researchers should define the key elder abuse constructs and variables that we need to examine instead of waiting for others, such as policy makers or legal systems to define them, and establish the metrics and data to move ahead. Investigators should share their data and allow others to critique those data in order to strengthen the national and international science of elder mistreatment. Variability in approaches to data collection and nomenclature need to be examined, but also appreciated as there are multiple “ways of knowing.” Fulmer further noted that there is a clear imperative to move the Elder Justice Act and its reauthorization forward. She further recognized that approaches to research on elder mistreatment are challenging and more national and international collaborations need to take place to move the science forward.
Fulmer suggested that where collective partnerships are missing, they should be created. Stronger research relationships with the adult protective service system are urgently needed and strategies must be created to protect the privacy of individuals while using the data available through APS and other data systems such as electronic health records to study the problem and make progress in interventions that can work. Research in the field of elder abuse and elder abuse prevention is all-consuming and researchers need to be able to reach out to their colleagues for support and encouragement. In terms of developing work groups and research teams in areas such as measurement, Fulmer commented that rather than solely waiting for conference grants or other sources of funding, investigators need to push forward and start sharing by connecting through conference calls, Web-based video calls, and other lower cost strategies.
Take Programs Where They Are
Fulmer commented that throughout the workshop, promising intervention programs were presented: some are just starting and others are accelerating. She suggested that these intervention programs, such as the work that is being done at the Harry and Jeanette Weinberg Center for Elder Abuse Prevention at The Hebrew Home at Riverdale, need to be replicated, further researched, and continuously improved.
Fulmer also noted that, in the field of elder abuse, we have a great deal of evidence that is known and it should be used. She asked the participants to take not only what they have learned collectively during the workshop, but what they know from their disciplines, practices, and programs of research and move the evidence forward. She finally underscored the global nature of the workshop discussions, the inclusion of new and multiple perspectives, and expressed enthusiasm and optimism for future global collaborations.
Reflections from a Global Perspective
Greg Shaw, International Federation of Ageing
Workshop speaker Greg Shaw noted that, although elder abuse research is happening all over the world, the challenge that he often grapples with is, “How do we capture it and make networks much more effective across the world? What new suspicion index is being developed? Where can we build from the best of the best? … Where do we get a repository or clearinghouse with some interaction around discussion forums where groups
can come together to start talking about what they are doing in the field?” He suggested that these are important challenges to address, because the more knowledge is shared, the more power there will be to effect change. Several other challenges in moving elder abuse prevention forward that Shaw mentioned were making it a public health priority, educating health professionals, focusing on community-level efforts, and involving youth.
Public Health Priority
Shaw suggested the need to make elder abuse a priority public health problem that is recognized along with noncommunicable diseases as an area where resources should be devoted in the future.
Education and Training for Health Professionals
Health professionals are confronted all the time by cases of elder abuse, yet often they fail to recognize them. When they do, they often do not know where to go or how to handle the problem. Shaw suggested more research on screening tools and training for health professionals.
Several innovative community-level efforts were discussed during the workshop, such as the virtual shelter model and a training program for door attendants in Brazil. Shaw asked: “How can we build on creative community-level models? How do we interact with the people who know what is happening in their own communities, whether it’s hairdressers, door [attendants], or other community members?”
Shaw suggested that if a movement among youth can be fostered around identifying and understanding what elder abuse is, perhaps in the future, elder abuse can be prevented before it starts.