Elder Abuse: The Tools to Make a Difference

1. Elder Abuse:The Tools to Make a Difference Leslie Pisani, BSW, RSW Alberta Health Services Alberta Hospital Edmonton Geriatric Psychiatry

2. Definitions Elder Abuse: A single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person (WHO, 2008) Self neglect: When older adults by choice or ignorance, live in ways that disregard their safety needs and can in some cases pose a hazard to others (AEAAN, 2008)

3. How much of a problem is it? World wide: 3-5% (WHO, 2002) 10 % of seniors are victimized in general but 64 % of those are victimized by someone known to them and nearly 50% by a family member (Statistics Canada, 2007) 25% of dependent populations are abused (Cooper, 2008)

4. The baby boomers are coming! • World’s population of seniors will triple between 2008-2050 • Over 80: 1.5-4.9% (USCB, 2008) • Canada: Proportion of seniors 13- 25% by 2026 • Over 85: double by 2026 (Stats Can, 2007)

5. Types Physical Psychological/emotional Financial/material Sexual Neglect Human rights, spiritual, institutional, medication, research, societal

6. Why don’t we hear about it?-Alberta Elder Abuse Awareness Network Fear Love of abuser Shame/Guilt Unaware of resources Acceptance as normal Dementia

7. Why don’t we hear about it?-Alberta Elder Abuse Awareness Network Cultural considerations Language Isolation Financial dependence Emotional dependence Cultural taboos

8. Dementia • Nearly 50% of people over 85 (AAGP, 2004) • New cases up to one million yearly by 2050 (Alzheimer's Association, 2008) • Co morbid psychiatric disorders • More likely to be victims of elder abuse (Patterson & Ploeg, 2007) • Most dependent are hospitalized

9. Cognitive impairments = increased risk of abuse Symptoms of the disease i.e. poor memory, executive planning problems, paranoia, unable to process complex information, and erratic unpredictable behaviour including sleep disturbances (O’Donnell et al., 2001) Increased social isolation, stress and burden experienced by their caregiver (Buckwalter et al., 1996) Sexual offenders were more likely to seek those unable to resist, mock, report and sought opportunities where they were more likely to “get away with it” (Jeary, 2005) Dementia patients “invite, allow or even demand boundary crossings” (Williams et al., 2006, p.567)

10. Cognitive impairments = increased risk of abuse Abuse screens ask verbal questions (Muehlbauer & Crane, 2006) Families have an “obligation to care with no understanding of dementia or services” (Boldy et al., 2005, p.5) “Furthermore, maltreated elders, who tend to be older (80 years or older), frail, and suffering from mental/cognitive impairments, are, like children, among the most vulnerable groups in society who cannot protect themselves against the pernicious effect of neglect and violence” (Choi & Mayer, 2000, p. 6).

11. ELDER ABUSE DATA COLLECTION Upon admission were there reports that the patient was the recipient / perpetrator of:

12. How to detect abuse Awareness of risk factors of abused Decline in mental health Physically or verbally abusive to caregivers Isolation Cognitive impairment Depression Poor health Impairment in ADL’s (Ploeg, Mueller, Hutchinson, 2001)

13. How to detect abuse Risk factors for caregivers Alcohol/drug use Psychiatric illness Financial dependence on the abused

14. How to detect abuse Indicators of abuse (WHO, 2002)

15. How to detect abuse Screens Debate on the benefits vs. harm Population fit Alberta experience Three types

16. Mortality rates increased for abused (Lachs, 1998) Abuse can be deadly

17. To screen or not to screen.. Objections to screens-Task forces in Canada, United Kingdom and US Challenge for more research not rejection of screens Clinicians challenged to examine why they would not include questions on violence

18. Ethically unacceptable not to screen given the high association between abuse, health problems and mortality, low levels of suspicion and low levels of self-reporting together with the evidence of high acceptance of screening by patients. (Perel-Levin, 2008)

19. The …ities • Readability • Ensures accuracy • Grade level • Validity • Acceptability

20. Sensitivity and specificity • False negatives prevent identification of abuse and keep the senior at risk • False positives can distress family can lead to loss of support

21. Screen variables (Fulmer, 2004) • Long screens/APS • Short screens/medical offices • More context if senior and caregiver addressed in screen • Single vs multiple abuse addressed

22. Screen variables • Different forms • Assessment instruments-MDS • Guidelines-AMA • Qualitative tools-SOAP • Quantitative-Elder Abuse Instrument • Combined approach-Comprehensive Geriatric Assessment

23. Screens for professionals • Indicators of Abuse Screen (IOA) • 22-29 item list of problems/risk factors for caregiver and care receiver • Based on opinion of assessor after 2-3 hour home visit • Reliable and valid • Expanded-IOA validated in hospital but patients with cognitive confusion excluded

24. Screens for professionals • Elder Assessment Instrument (EAI) • 44 item list of various indicators of abuse • Valid-but not on anyone with MMSE<18 • Short-15 mins. to score • Used by Seniors Outreach in David Thompson Region

25. Screens for professionals • Brief Abuse Screen for the Elderly (BASE) • 5 brief questions about professionals’ suspicions of abuse • Valid

26. Screens for professionals • Minimum Data Set Abuse Screen (MDS-A) • Completed after 1 hour interview • Not as sensitive as Modified Conflict Tactics Scale at detection of abuse • No direct questions of caregiver or senior

27. Screens for seniors • Improved sensitivity • Seniors wonder why they are seldom asked about abuse • Unstructured screens • General to specific • Specific • Just ask!

28. Screens for seniors • American Medical Association • 9 questions for the physician to ask • Covers several areas • Grade 9 reading level • Not tested for sensitivity and specificity • Poor choice for dementia patients

29. Screens for seniors • Hwalek-Sengstock Elder Abuse Screening Test (HS-East) • Identifies the suffering from or at risk of abuse • 15 (6) questions • Reliable and valid, short • Grade 6 reading level • Vague questions make it best used with other assessments

30. Screens for seniors • Vulnerability to Abuse Screening Scale (VASS) • 12 questions mailed out to women as part of an Australian longitudinal study • Seen as less intimidating • Grade 8 reading level/Problems for dementia • Offender has access to questionnaire

31. Screens for seniors • Conflict Tactics Scale • 19 item self report used to assess physical and verbal assaults in adult relationships • Grade six • Not validated with seniors • Neglect not addressed

32. Screens for caregivers • Awareness of inconsistent values on caregiver standards

33. Screens for caregivers • Caregiver Abuse Screen (Case) • 8 yes or no non blaming questions • Assesses for potentially abusive caregivers • Valid and suitable for clinical settings • Each yes needs to be further addressed

34. Screens for caregivers • Modified Conflict Tactics Scale (M-CTS) • Asks caregivers how often in the last 3 months they have acted in 5 psychologically and physically abusive ways • Validated with caregivers of seniors with Alzheimer's • Acceptable by caregivers

35. Screens for caregivers • M-CTS • One study asked caregivers and care recipients including those with moderate to severe cognitive impairments about potentially harmful behaviour • Multidimensional Assessment of Quality of Care-MAQOC

36. Successful implementation • Universal screening 1) reduces presumptive profiling 2) adds to naming and accepting of the problem 3) assists in destigmatizing the issue 4) provides the confidence that when they are ready to report they will be asked

37. Proper administration of screens • Away from caregiver • Part of a complete medical assessment

38. Interventions • Multidisciplinary assessments of various areas of concern • Consistent decision making tree • Ohioan referral protocols • Lachs/Pillemar Management tool

39. Support for professionals • Staff self awareness-personal experiences with violence or fear of offenders • Autonomy vs safety and the right to choose • Frequent refreshers • Updated resources • Listen, validation

40. Why does it occur? Situational-stressed caregivers Exchange-reciprocity and dependence Psychopathology-mentally disturbed abuser Social learning-intergenerational Feminist-imbalance of power Political economic-structural forces and ageism lead to conflict and violence (Perel-Levin, 2005)

41. Why does it occur? Ecological model Complex interplay between the person’s individual characteristics, interpersonal relationships, community and societal factors ( Perel-Levin, 2005)

42. Interventions • 2002 WHO recommends health leadership with elder abuse interventions using a public health approach • CNPEA: 2007 Promising Approaches in the Prevention of Abuse and Neglect: health should be a partner in all interventions • Pivotal role of mental health professionals

43. Prevention • Primary • Reducing factors that lead to abuse • Secondary • Early detection and intervention • Tertiary • Treatment to lessen the effects and reduce recurrence

44. Approaches • Criminal approach • Advocacy approach • Protective approach

45. Multi-system interventions • Social • Health • Legal

46. Interventions-Communityefforts Elder Abuse Intervention Team Elder Abuse Consultation Team Safe House Alberta Health resources Day Programs/CHOICE/Home Care/Hospital Respite/Alternate placements Legal resources Trustee/Guardian/EPOA/Personal Directives Civil suits, criminal cases

47. Undue Influence:Red Flags and Risk Factors

48. 1.Special trust relationship exists with the person exerting the undue influence. Be suspicious if… someone other than the affected individual initiates a change in the legal directives. this person of influence may be financially disadvantaged or require resources to fund a gambling or substance abuse habit.

49. 2.Relative isolation of the affected individual. Investigate possible enforced isolation if you suspect the following… that an individual may be subtly distorting the truth and limiting access to all necessary information for the affected individual to make an informed decision. there is family conflict present.

50. a previously trusted family member is no longer favored. the relationship may be newly formed, and coincide with the affected persons disability or frailty.