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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Part II Background Papers
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America This page in the original is blank.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America 10 Elder Mistreatment: Epidemiological Assessment Methodology Ron Acierno, Ph.D.* Epidemiological data on elder mistreatment can be obtained through (1) agency record review, (2) sentinel reports (trained observers in agencies that serve older adults but do not document abuse in official adult protective service [APS] records), (3) translation of criminal justice statistics using age and perpetrator data fields, (4) caretaker/family member interviews (in person or via telephone), and (5) interviews of elderly respondents themselves (in person or via telephone). Each of these assessment formats has been used with older adults, either in isolation or in combination with other methods to generate population estimates of physical, sexual, or emotional abuse, neglect, and financial exploitation. These mistreatment categories are typically divided according to perpetrator identity as either familial/spousal abuse or caretaker abuse. A final category of stranger abuse (i.e., stranger assault: physical, sexual, or emotional) may arguably be included under the heading elder mistreatment (with the caveat that risk factors will probably be different) because (a) psychological and health effects are similar to those caused by abuse by family members; (b) a significant proportion of elder mistreatment, particularly in the area of financial exploitation, is perpetrated by strangers; and (c) failure to assess similarly assaultive behaviors by strangers ignores potential mediating factors that might interact with familial abuse to predict medical health and mental health outcome. * Ron Acierno, Ph.D., is an assistant professor of psychiatry at the National Crime Victims Research and Treatment Center of the Medical University of South Carolina.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Another assessment issue of considerable importance that has not received sufficient attention, at least insofar as elder abuse is concerned, is the categorization of elder mistreatment along lines of cognitive impairment. Although the same behavior of physical abuse might be manifest against two individuals, one demented and the other nondemented, by the same class of perpetrator, the optimal method of assessing these two events may vary widely. Research to date has not thoroughly considered cognitive status as the major parameter determining relevance of assessment methodology. Rather, as mentioned above, assessment of elder mistreatment has been divided into abuse versus assault studies according to perpetrator identity. This is problematic in that researchers attempting to document the extent and rate of elder abuse (irrespective of cognitive status) have adopted methodologies that are better suited for one class or the other of older adults. That is, methods 1, agency record review, and 2, sentinel reports, may be effective in assessing abuse against cognitively impaired elders, whereas they will not be very effective in assessing abuse against nonimpaired elders, who may actually avoid these individuals and agencies. Similarly, method 5, anonymous older adult assessment, is probably preferred when cognitive status is intact but is precluded in instances of dementia. Method 4, caretaker assessment, walks the line between these two, in that its effectiveness is not determined by an elder’s cognitive status and may therefore be an appropriate stopgap or supplemental technique (see Pillemer and Finkelhor, 1988). However, this method is less statistically sensitive than respondent interviews (i.e., when cognitive status is intact) and probably should not be relied on exclusively. A distinction based on the mistreated elder’s cognitive status is conceptually, as well as methodologically, important in that the social context of abuse or assault of nondemented older adults by family members appears to more closely resemble domestic violence, whereas the social context of abuse of cognitively impaired older adults appears to be more akin to child abuse. This is particularly the case when one considers the nature of the relationship between violence perpetrators and recipients (Finkelhor and Pillemer, 1988; Utech and Garrett, 1992;Whittaker, 1996). Thus, violence between two individuals of equal or near-equal societal status, and of equal or near-equal cognitive development, describes both domestic violence and abuse of noncognitively impaired elders (Finkelhor and Pillemer, 1988). By contrast, violence between individuals of varied social status and dependency resulting from differences in cognitive functioning or independence (due to either dementia or lack of development) describes both child abuse and abuse of cognitively impaired elders.1 1 Additional justification for this conceptual distinction is provided by empirical, sociopolitical, and legal sources. For example, epidemiological data demonstrate that most
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America This conceptual distinction becomes even more important when considering that risk factors for violence against older adults probably vary as a function of cognitive status. Hence primary prevention strategies for abuse of cognitively impaired elders will differ from those for abuse of unimpaired elders, just as strategies to prevent child abuse differ from those used to prevent domestic violence. Thus, cognitive status of the respondent is pragmatically important in that it will determine the risk factors and intervention strategies most useful and important for a particular class of individuals. Cognitive status of the respondent is methodologically and conceptually important in that it will largely determine which assessment strategies from the domestic violence field and from the child abuse field, both of which are more developed than those of the elder mistreatment field, may be applied to older adults. The appropriateness of this application will vary in terms of the cognitive status of the respondent in that an assessment strategy that does not rely on victim report (which will be significantly affected by cognitive status) is indicated in cases of abuse of young children and cognitively impaired older adults. The National Elder Abuse Incidence Study methodology, for example, is appropriate in these instances. By contrast, methods involving some degree of self-report will be indicated in instances where cognitive impairment is not severe. These methods are described at length below. elder abuse is in fact spouse abuse, leading Pillemer and Finkelhor (1988) to state: “In the past, elder abuse was described primarily in analogy with child abuse. The present study suggests that elder abuse has much more in common with spouse abuse than child abuse” (p. 55). Utech and Garrett (1992) go even further, writing, “ . . . such parallels with child abuse have had an unfortunate impact on the study of elder abuse, including a tunnel vision effect, which precludes a comprehensive analysis of the problem” (p. 419). Considering sociopolitical factors, investigators have warned against the dangers of infantilizing the older adult victim, as illustrated by Finkelhor and Pillemer (1988): “much elder abuse does not conform to the child abuse model, and elder abuse victims are not necessarily in a structural relationship to their abusers parallel to that of children. . . . We argue that it may be useful to start examining elder abuse for more parallels with the spouse abuse situation: legally independent adults, living together out of choice for a variety of emotional and material reasons” (see also Whittaker, 1996). Finally, legal support for the conceptualization of mistreatment of non-cognitively impaired elders as spouse abuse, rather than child abuse, is provided by the fact that a debate is currently underway regarding mandatory reporting of mistreatment of unim-paired elders (the same debate is underway across the nation with respect to domestic vio-lence), whereas no such debate exists with respect to mandatory reporting mistreatment of cognitively impaired elders (see Daniels, Baumhover, and Clark-Daniels, 1989; Gordon and Tomita, 1990; Macolini, 1995).
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America ISSUES RELEVANT TO ASSESSMENT OF VIOLENCE AGAINST OLDER ADULTS There are two major points to consider when interviewing older adults, relative to younger adults. First, older adults are frequently more reluctant to disclose psychological and interpersonal problems of the past or present. Second, their verbal reports are more affected by physical factors (e.g., fatigue, hearing difficulty) (Ouslander, 1984; Patterson and Dupree, 1994). With respect to the first point, older adults may actually be less likely to disclose abuse than are their abusers (see Homer and Gilleard, 1990, Pillemer and Finkelhor, 1988). Older adults who have been abused or assaulted by family members may be unlikely to report these events for a variety of reasons. Among hypothesized explanations that require further study is the supposition that older adults feel responsible, at least in part, for their children’s abusive behavior because they “taught them to be that way.” That is, they blame their own parenting style for their adult child’s behavior. Another hypothesized explanation is that older adults may also feel extremely embarrassed that their offspring or spouses are abusing them and that they are powerless to stop the abuse. They may be very motivated to hide this powerlessness, both out of pride, and in order to deny any physical or cognitive declines associated with aging. Older and younger adults also report that simply being stigmatized or labeled as a victim is aversive, particularly in instances of sexual assault (Kilpatrick et al., 1992). As with younger victims of domestic violence, abused older adults may fear retribution or more intense assaultiveness from the perpetrator or other abusive parties. Financially or physically dependent older adults also face the very real fear that if the perpetrator is arrested or removed from the household following disclosure, they may be institutionalized or lose other freedoms. Indeed, adults of all ages who have never made or experienced a report of abuse probably do not have information about resources or outcomes of reporting abuse and hence may deny any query, considering truthful responses as potentially damaging but not potentially helpful. Finally, older adult victims may care deeply for or love the perpetrator and may try to avoid hurting or embarrassing the perpetrator in any way through disclosure to epidemiological researchers or authorities. Physical health barriers to reporting victimization events include deficits in cognitive functioning, hearing loss, increased susceptibility to fatigue, inability to remain sitting for extended durations (e.g., due to arthritis), and effects of medication on concentration and memory. Other factors to consider when assessing older adults include ageism, interview stress, increased somatic presentations that may mirror psychopathological symptoms, increased time needed to build trust and rapport, and increased medication use. Ageism refers to “a personal revulsion to, and distaste for, growing old, and a fear of powerlessness, uselessness, and death” (Patterson
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America and Dupree, 1994:374). Not only must assessors be trained to avoid ageist thinking or actions, but the assessment instrument itself must not be ageist in tone or content. Focusing on specific behaviors and events during assessment (e.g., using very clear, specific descriptions of behavioral events, rather than culturally or generationally defined phrases) appears to be an objective means by which to limit ageism, and, as illustrated below, is an important methodological strategy to increase sensitivity and accuracy of victimization assessment (Patterson and Dupree, 1994). In addition, it is important to conduct some assessment of cognitive functioning in order to determine the best form of violence assessment, and whether or not assessment of the older adult is even appropriate. Greater susceptibility to fatigue and concentration problems related to disclosure of highly personal content make it advantageous to limit stress during interviews (Gurland et al., 1978). This is particularly the case when interview disclosures potentially affect the interviewee’s life, or at least such potential impact is perceived (e.g., disclosing abuse, which then might be reported, leading to social service intervention). ASSESSMENT OF ELDER MISTREATMENT: EXISTING METHODS AND MEASURES The following review summarizes specific measures of elder mistreatment and their advantages and disadvantages. Measures are categorized in terms of the five forms of elder mistreatment assessment methodology outlined above. In general, factors such as feasibility, sensitivity, reliability, validity, and cost guide overall conclusions and recommendations for each strategy and measure. Agency Record Review Agency records provide a readily available source of information regarding investigated and substantiated cases of elder abuse, neglect, and exploitation. These data are not collected for the purpose of epidemiological or preventive research, however, and the specific information is not always exactly what a particular researcher desires. Moreover, the criteria by which cases are designated substantiated or not and the definitions for particular forms of elder mistreatment vary widely across social service agency, county, and state. The National Center on Elder Abuse (Tatara, 1997) collects and compiles into reports nationwide data from those social service agencies charged with protecting the health and welfare of older adults. Thus, these reports describe actual investigated and indicated cases of abuse and neglect in which family members were interviewed, households were visited, and in-
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America spections were conducted. Although the rate of reported cases has been increasing each year, the sensitivity of this method is extremely low because most cases of elder mistreatment are not reported to any social service authorities (Pillemer and Finkelhor  found only 7 percent of cases reported to authorities), and those incidents that are reported must be judged as valid to be considered substantiated. Again, the criteria by which a report is considered founded vary widely by center, as do the definitions of abuse. Ultimately, it is the judgment of individual caseworkers that determines whether or not a mistreatment event has occurred. A notable strength of agency record review studies such as that conducted by the National Center on Elder Abuse is the highly detailed nature of the data regarding the abuse event. Specifically, the context of elder mistreatment, the perpetrator characteristics, demographic variables, and social structures are usually specified and documented somewhere in agency records. Moreover, there is a relatively strong level of confidence that indicated cases did, in fact, occur. Relative to epidemiological surveys that are conducted solely for data collection and analysis (as opposed to service delivery), information from agency records exists independent of research protocols and is therefore relatively inexpensive to transfer to the research realm. By contrast, several significant weaknesses characterize agency record-based investigations. This method requires collecting data from a wide variety of agencies that may use dissimilar definitions of mistreatment. Even more problematic is that individual agencies vary widely in the resources directed to investigation of cases, training of caseworkers, and follow-up and substantiation of cases. Thus, even when standard definitions and criteria are used, the means by which agencies determine whether an event meets these criteria will differ. As such, sensitivity and reliability of findings will suffer. The utility of this approach for epidemiological researchers is further affected by the quality of agency record maintenance, accessibility to records, accessibility of the agency personnel, and overall quality of record keeping by an agency. Overall, the agency record review methodology is indicated when the population of older adults suffers from cognitive impairment and cannot otherwise be interviewed. However, this method is less sensitive than in other methods applicable to cognitively impaired populations and should probably be used only to guide initial efforts insofar as gross approximations of elder mistreatment are needed. Sentinel Reports The National Elder Abuse Incidence Study (NEAIS) sponsored by the Administration for Children and Families and the Administration on Aging
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America expanded its data sources from APS reports to include trained sentinel reports of substantiated or presumed substantiated cases. The NEAIS-targeted people living in their own homes, age 60 and above. This was an incidence study (new cases during a set time frame), not a prevalence study. Importantly, this study did not interview older adults themselves. Sentinels were professionals who served older adults and were randomly selected from more than 200 agencies. Sentinels were trained to complete data entry forms identical to those used by APS workers for elder abuse. The logic of the sentinel approach is based on the supposition that sentinels enhance sensitivity by detecting those older adult victims of abuse who are nonreporters or are not involved with APS but who nonetheless interact in some way with community-based service agencies. NEAIS data were gathered on domestic (i.e., noninstitutionalized) elder abuse and neglect cases from a nationally representative sample of 20 counties in 15 states. Reports from APS agencies were considered only when substantiated and reports from sentinels were presumed to be substantiated. The methodology of combining agency record reviews with sentinel reports to detect mistreatment has previously demonstrated success in three studies of child abuse. Moreover, the method is cost-effective, and identified cases are very likely true positives. Multiple data sources are consulted, and these typically have a very thorough familiarity with cases. Finally, multiple forms of mistreatment are identifiable. Weaknesses of this method include the fact that no direct assessment is made of the population in question. Thus, it is very likely that mistreatment rates derived from this study greatly underestimate the true scope of the problem of elder victimization because a great majority of cases go both unreported and undetected by existing formal and informal monitoring agents. Although this approach has been used three times with child abuse, there are several problems with this method when applied to elder abuse. First, and perhaps most relevant, is the fact that child abuse reporting statutes and subsequent education of an extremely wide range of service providers (e.g., schoolteachers, doctors, nurses, counselors, day-care workers, etc.) regarding these statutes is formally established and mature. That is, awareness of the problem of child abuse is far greater among the general and professional public, and thus sentinels in the child arena will be more familiar with the problem and its symptoms. Moreover, child abuse mandatory reporting and provisions for anonymous voluntary reporting have been in place nationwide and have been accompanied by national education campaigns. As such, it is likely that child protective services receive a significantly larger proportion of existing cases than APS. Indeed, mandatory reporting of elder abuse is not consistent across the nation and is still actively debated. National education campaigns for the general public and for health and social service providers on child abuse also increase the
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America likelihood that noncompelled reporters will approach sentinels for child abuse, relative to elder abuse. Thus, sentinels for child abuse have access to greater conduits of information than their older adult counterparts. Overall, the unresolved issue of mandatory reporting of elder abuse, the relative infancy of elder abuse public education, and the limited conduits of information on elder abuse cases flowing to potential sentinels may severely limit the application of this form of child abuse assessment to elder mistreatment in that the method may lack sensitivity. This lack of sensitivity will be particularly problematic for the population of non-cognitively impaired, relatively independent mistreated older adults who wish to avoid formal service agency involvement in their abuse situations. Criminal Justice System Statistics Translation There are several sources of victim statistics describing rates of violent crime in this country (e.g., National Crime Victimization Survey [NCVS], Federal Bureau of Investigation [FBI] Uniform Crime Reports [UCR], FBI National Incident Based Reporting System [NIBRS]). Official police or government estimates of assaultive violence are typically lower than those obtained by social scientists conducting epidemiological research. These differences are largely attributable to methodological variance across surveys (e.g., use of gateway versus behaviorally specific preliminary screening questions, or aggregation of official police reports versus population surveys, see discussion of this below). This variance is informative: failure to use direct, behavioral questions leads to failed case identification. The FBI’s UCR is a frequently cited index of violent crime that has been reported to police. The UCR is a case-based report, in which the worst FBI index crime (murder, rape, robbery, aggravated assault, burglary, larceny, motor vehicle theft, arson) reported by an individual is the only one that is recorded for that individual. However, since many crimes are not reported to police, and because many individuals are multiply victimized, UCR results are somewhat misleading. The Bureau of Justice Statistics overcomes this weakness in its annual NCVS of approximately 80,000 to 100,000 adults aged 12 years and older from approximately 45,000 households. Randomly contacted U.S. citizens are asked about both reported and unreported victimization experiences. In 1992, older adults (age 65 years and older) comprised 14 percent of survey respondents (Bachman, 1992). According to the NCVS, adults over age 50 were the least likely to be physically or sexually assaulted, with an annual violent crime rate of 12.5 per 1,000. However, once assaulted, older adults were more than twice as likely to be seriously injured and require
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America hospitalization following crime. Fully half of older injured victims, compared to about 25 percent of younger injured victims, required hospitalization. Moreover, elderly victims were more likely than younger victims to be assaulted or robbed by a stranger and were more likely to be victimized in or around their home. Half of elderly victims, compared to 26 percent of those under 65, experienced violence in or around their homes and were more likely than younger adults to face offenders armed with a gun (Bachman, 1992). Elderly men were at greater risk of violent crime than elderly women. Low income, minority racial status, and geography also contributed to increased risk of assault (Bachman, 1992). For example, African American older adults were victimized at twice the rate of Caucasian elderly, and older adults living in urban settings were three times as likely to experience crime. McCabe and Gregory (1998) used the FBI’s NIBRS to assess crime against the elderly. This system differs from the UCR in that each incident, not only the worst incident, of crime is recorded. Moreover, like the NCVS, the NIBRS includes information on the perpetrator’s relationship to the victim, permitting assessment of abuse versus assault rates. The NIBRS also includes demographic and gender information, providing some ability to conduct risk-factor research. Finally, the NIBRS differs from the UCR in that additional, nonindex crimes are also covered. Unfortunately, only crime reported to police is included in these records. An advantage of using criminal justice system (CJS) statistics is its nationwide data collection frame. That is, many CJS studies are actual population derivations, not sample estimates. In addition, information on reported (to police) crime includes data regarding gender, race, and perpetrator status. Moreover, older adults are more likely to report some forms of crime to police than younger adults, increasing the relative validity of published rates of reported crime. However, crimes of abuse and neglect are less likely to be reported, mitigating this advantage somewhat. In contrast to these strengths, CJS data generally have very poor sensitivity (excepting the NCVS). Furthermore, CJS data collection requires criminal justice system interaction for case identification (excepting NCVS), an activity that may be specifically avoided by older adults. Another weakness is that UCR and NIBRS data are entirely record-based and are removed from direct reports of victims. As a result, they are affected by subjective interpretations by police officers of (1) whether an event actually occurred and (2) classification of the event by police departments across the country. Overall, these forms of assessment methodology represent preliminary, as opposed to comprehensive, epidemiological data regarding elder mistreatment.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Spring, F.E., and W.N. Friedrich 1992 Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clinic Procedures 67:527–532. Stokes, S.S., and S.E. Gordon 1988 Development of an instrument to measure stress in the older adult. Nursing Research 37:16–19. Straus, M.A. 1979 Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. Journal of Marriage and the Family 41:75–88. Straus, M.A., S.L. Hamby, S. Boney-McCoy, and D.B. Sugarman 1996 The revised conflict tactics scales (CTS2). Journal of Family Issues 17:283–316. Tatara, T. 1997 The National Elder Abuse Incidence Study: Executive Summary. New York: Human Services Press. Tomita, S.K. 1982 Detection and treatment of elderly abuse and neglect: A protocol for health care professionals. Physical and Occupational Therapy in Geriatrics 2:37–51. Tomita, S.K. 1990 The denial of elder mistreatment by victims and abusers: The application of neutralization theory. Violence & Victims 5:171–184. Utech, M., and R. Garrett 1992 Elder and child abuse: Conceptual and perceptual parallels. Journal of Interpersonal Violence 7:418–428. Vida, S. 1994 An update on elder abuse and neglect. Canadian Journal of Psychiatry 39:S34– S40. Weeks, M.F., R.A. Kulka, J.T. Lessler, and R.W. Whitmore 1983 Personal versus telephone surveys for collecting household health data at the local level. American Journal of Public Health 73:1389–1394. Weiner, A. 1991 A community-based education model for identification and prevention of elder abuse. Journal of Gerontological Social Work 16:107–119. Wetle, T. 1986 An elder abuse assessment team in an acute hospital setting. The Gerontologist 26:115–118. Whittaker, T. 1996 Violence, gender and elder abuse. In Violence and Gender Relations: Theories and Interventions, B. Fawcett and B. Featherston, eds. Thousand Oaks, CA: Sage Publications. Wolf, R.S. 1988 Elder abuse: Ten years later. Journal of American Geriatrics Society 36:758–762. 1992 Victimization of the elderly: Elder abuse and neglect. Reviews in Clinical Gerontology 2:269–276. 1997 Elder abuse and neglect: An update. Reviews in Clinical Gerontology 7:177–182. Wolf, R.S., and K. Pillemer 1994 What’s new in elder abuse programming? Four bright ideas. The Gerontologist 34:126–129. 2000 Elder abuse and case outcome. The Journal of Applied Gerontology 19:203–220.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America APPENDIX ASSESSMENT TOOLS From Hwalek and Sengstock (1986). Elder Abuse Screening Test ** Do you have anyone who spends time with you, taking you shopping or to the doctor?3 *** Are you helping to support someone? ** Are you sad or lonely? * Who makes decisions about your life—like how you should live or where you should live? *** Do you feel uncomfortable with anyone in your family? ** Can you take your own medication and get around by yourself? *** Do you feel that nobody wants you around? *** Does anyone in your family drink a lot? * Does someone in your family make you stay in bed or tell you you’re sick when you’re not? * Has anyone forced you to do things you didn’t want to do? * Has anyone taken things that belonged to you without your OK? *** Do you trust most of the people in your family? *** Does anyone tell you that you give them too much trouble? *** Do you have enough privacy at home? * Has anyone close to you tried to hurt you or harm you recently? 3 A response of “no” to items 1, 6, 12, and 14; a response of “someone else” to item 4; and a response of “yes” to all others was scored in the “abused” direction. Identified factors: *violation of personal rights or direct abuse, **characteristics of vulnerability, and ***potentially abusive situation
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America From Fulmer and Cahill (1984). Elder Assessment Tool Date________________ Person completing form____________________________ Patient age___________ Patient sex Male____ Female____ PAYMENT STATUS __Medicare __Private Pay __Other RESIDENCE __Home __Nursing Home __Other ACCOMPANIED BY __Family __Friend __Alone MENTAL STATUS __Alert __Confused __Unresponsive REASON FOR VISIT __Orthopedic __Changed Mental Status __Other GENERAL ASSESSMENT Hygiene ____yes ____no Nutrition ____good ____fair ____poor Clothing ____good ____fair ____poor USUAL LIFESTYLE Maintenance of hygiene ____self ____assist Continent of bowel/bladder ____self ____assist Feedings ____self ____assist Ambulatory ____self ____assist ____Housebound ____Outings ____Sedentary ____Active Personal contact with ____family ____friends ____nursing home personnel Happy with living situation ____yes ____no Who manages finances ____self ____family ____other? Does financial arrangement work well ____yes ____no? If care provider is present, is the observed relationship ____good ____poor ____indifferent ____doesn’t apply History of recent life crisis ____yes ____no ____unsure PHYSICAL ASSESSMENT (evidence of) ___bruising ___lacerations ___abrasions ___diarrhea ___urine burns ___decubiti ___dehydration ___malnutrition ___alcohol abuse
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America MEDICATIONS Any duplication of similar medications? (i.e., multiple laxatives, sedatives, etc.) ___yes ___no Any unusual doses of medications? ___yes ___no If yes to #26, please comment__________________________________ Who gives medications? ___self ___family ___nursing home If patient or family gives medications, do they have an adequate understanding of medications? ___yes ___no ASSESSMENT Physical Abuse ___present ___absent ___suspect/high risk Psychological Abuse ___present ___absent ___suspect/high risk Material Abuse ___present ___absent ___suspect/high risk Outcome ___Referral to Elder Abuse team ___Referral to Clinical Advisor Summary Statement ___Too busy to fill out ___No abuse/neglect suspected
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America From Reis and Nahmiash (1998). INDICATORS OF ABUSE Indicators of abuse are listed below, numbered in order of importance.4 After two- to three-hour home assessment (or other intensive assessment) please rate each of the following items on a scale of 0 to 4. Do not omit any items. Rate according to your current opinion. Scale: Estimated extent of problem: 0 = nonexistent 00 = not applicable 000 = don’t know 1 = slight 2 = moderate 3 = probably/moderately severe 4 = yes/severe Caregiver Age ____years Caregiver and Care Receiver Kinship ___spouse ___nonspouse Caregiver Care Receiver __ 1. Has behavior problems __ 2. Is financially dependent __ 3. Has mental/emotional difficulties __ 6. Has alcohol/substance problem __ 7. Has unrealistic expectations __ 9. Lacks understanding of medical condition __ 10. Caregiver reluctancy __ 12. Has marital/family conflict __ 13. Has poor current relationship __ 14. Caregiver inexperience __ 17. Is a blamer __ 24. Had poor past relationship __ 4. Has been abused in the past __ 5. Has marital/family conflict __ 8. Lacks understanding of medical condition __ 11. Is socially isolated __ 15. Lacks social support __ 16. Has behavior problems __ 18. Is financially dependent __19. Has unrealistic expectations __ 20. Has alcohol/medication problem __ 21. Has poor current relationship __ 22. Has suspicious falls/injuries __ 23. Has mental/emotional difficulties __ 25. Is a blamer __ 26. Is emotionally dependent __ 27. No regular doctor 4 The majority of the most important indicators are the caregiver ones.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America From Reis and Namiash (1995). Caregiver Abuse Screen Please answer the following as a helper or caregiver YES NO 1. Do you sometimes have trouble making (___) control his/her temper or aggression? ___ ___ 2. Do you often feel you are being forced to act out of character or do things you feel bad about? ___ ___ 3. Do you find it difficult to manage (___’s) behavior? ___ ___ 4. Do you sometimes feel that you are forced to be rough with (___)? ___ ___ 5. Do you sometimes feel you can’t do what is really necessary or what should be done for (___)? ___ ___ 6. Do you often feel you have to reject or ignore (___)? ___ ___ 7. Do you often feel so tired and exhausted that you cannot meet (___’s) needs? ___ ___ 8. Do you often feel you have to yell at (___)? ___ ___
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America From Ferguson and Beck (1983). HALF Assessment HEALTH Almost Always Some of the Time Never 1. Aged Adult Risk Dynamics 1.1 Poor health _______ ________ ______ 1.2 Overly dependent on adult child _______ ________ ______ 1.3 Was extremely dependent on spouse who is now deceased _______ ________ ______ 1.4 Persists in advising, admonishing and directing the adult child on whom he/she is dependent _______ ________ ______ 2. Aged Adult Abuse Dynamics 2.1 Has an unexplained or repeated injury _______ ________ ______ 2.2 Shows evidence of dehydration and/or malnutrition without obvious cause _______ ________ ______ 2.3 Has been given inappropriate food, drink, and/or drugs _______ ________ ______ 2.4 Shows evidence of overall poor care _______ ________ ______ 2.5 Is notably passive and withdrawn _______ ________ ______ 2.6 Has muscle contractures due to being restricted _______ ________ ______ 3. Adult Child/Caregiver Risk Dynamics 3.1 Was abused or battered as a child _______ ________ ______ 3.2 Poor self-image _______ ________ ______ 3.3 Limited capacity to express own needs _______ ________ ______
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America HEALTH Almost Always Some of the Time Never 3.4 Alcohol or drug abuser _______ ________ ______ 3.5 Psychologically unprepared to meet dependency needs of parent _______ ________ ______ 3.6 Denies parent’s illness _______ ________ ______ 4. Adult Child/Caregiver Abuse Dynamics 4.1 Shows evidence of loss of control, or fear of losing control _______ ________ ______ 4.2 Presents contradictory history _______ ________ ______ 4.3 Projects cause of injury onto third party _______ ________ ______ 4.4 Has delayed unduly in bringing the aged person in for care, shows detachment _______ ________ ______ 4.5 Overreacts or underreacts to the seriousness of the situation _______ ________ ______ 4.6 Complains continuously about irrelevant problems unrelated to injury _______ ________ ______ 4.7 Refuses consent for further diagnostic studies _______ ________ ______ 5. Attitudes Toward Aging 5.1 Aged adult views self negatively due to aging process _______ ________ ______ 5.2 Adult child views aged adult negatively due to aging process _______ ________ ______ 5.3 Negative attitude toward aging _______ ________ ______ 5.4 Adult child has unrealistic expectations of self or the aged adult _______ ________ ______ 6. Living Arrangements 6.1 Aged insists on maintaining old patterns of independent functioning that interfere with the child’s needs or endanger aged adult _______ ________ ______
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America HEALTH Almost Always Some of the Time Never 6.2 Intrusive, allows adult child no privacy _______ ________ ______ 6.3 Adult child is socially isolated _______ ________ ______ 6.4 Has no one to provide relief when uptight with the aged person _______ ________ ______ 6.5 Aged adult is socially isolated _______ ________ ______ 6.6 Has no one to provide relief when uptight with adult child _______ ________ ______ 7. Finances 7.1 Aged adult uses gift money to control others, particularly adult children _______ ________ ______ 7.2 Refuses to apply for financial aid _______ ________ ______ 7.3 Savings have been exhausted _______ ________ ______ 7.4 Adult child financially unprepared to meet dependency needs of aged adult _______ ________ ______ M.T.C.S. PLEASE COMPLETE IF YOU HAVE HAD A ROMANTIC PARTNER IN THE PAST YEAR. No matter how well a couple gets along, there are times when they disagree on major decisions, get annoyed about something the other person does, or just have spats or fights because they are in a bad mood or tired or for some other reason. They also use many different ways of trying to settle their differences. The following is a list of some things that you and your partner or spouse might have done when you had a dispute. For each item on the list, please check the box that indicates how often each has occurred in the past year.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Never Once Twice 3–5 Times 6–10 Times 11–20 Times More Than 20 Times 1. A. Have you discussed the issue calmly o o o o o o o B. Has your spouse discussed the issue calmly o o o o o o o 2. A. Have you gotten information to back up your side of things o o o o o o o B. Has your spouse/partner gotten information o o o o o o o 4. A. Have you tried to bring in someone to help settle things o o o o o o o B. Has your spouse/partner o o o o o o o 5. A. Have you insulted or sworn at your spouse/ partner o o o o o o o B. Has your spouse/partner o o o o o o o 6. A. Have you sulked and/or refused to talk about it o o o o o o o B. Has your spouse/partner o o o o o o o 7. A. Have you stomped out of the room, house, or yard o o o o o o o B. Has your spouse/partner o o o o o o o 8. A. Have you cried o o o o o o o B. Has your spouse/ partner cried o o o o o o o 9. A. Have you done or said something to spite your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 13. A. Have you threatened to hit or throw something at your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Never Once Twice 3–5 Times 6–10 Times 11–20 Times More Than 20 Times 14. A. Have you thrown, smashed, hit, kicked something o o o o o o o B. Has your spouse/partner o o o o o o o 15. A. Have you hit or tried to hit your spouse with something o o o o o o o B. Has your spouse/partner o o o o o o o 16. A. Have you thrown something at your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 17. A. Have you pushed, grabbed, or shoved your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 18. A. Have you slapped your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 19. A. Have you kicked, bit, or hit your spouse/ partner with a fist o o o o o o o B. Has your spouse/partner o o o o o o o 22. A. Have you beat up your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 23. A. Have you threatened spouse/partner with a knife or gun o o o o o o o B. Has your spouse/partner o o o o o o o 24. A. Have you used a knife or gun on your spouse/ partner o o o o o o o B. Has your spouse/partner o o o o o o o
Representative terms from entire chapter: