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Elder Abuse and Neglect Articles and Publications
July 2003 - June 2004
Ho, B., Friedland, J. Rappolt, S. & Noh, S.
Caregiving for Relatives with Alzheimer's Disease: Feelings of Chinese-Canadian Women
Journal of Aging Studies; Vol. 17 (3), 301-321; 2003.
Noting that both the Chinese population and the elderly segment of society in North America are growing, this article explores the impact of culture, caregiver stress and social support upon Chinese-Canadian women caring for relatives with Alzheimer's disease. Twelve female, Chinese émigrés were interviewed regarding their experiences as caregivers, within the framework of the model of caregiver stress outlined by Pearlin et al. Secondary stressors, such as role strain and intra-psychic strain, were the main focus of five open ended questions. Inductive qualitative analysis revealed multiple common themes such as filial obligation, anticipation of the role, differences between Chinese and western attitudes towards caregiving, intergenerational and other family conflicts, work role conflicts, loss of self and "role captivity." One poignant sentiment held by many of these caregivers was that their own children would be unlikely to follow in their footsteps and likewise provide care for themselves. Mediating factors that emerged included positive attitudes as well as the presence of formal and informal supports that were culturally congruent with their values and circumstances. Despite the belief in filial obligation, most of these caregivers intended to institutionalize the care recipient when they could no longer provide adequately for their needs. The authors postulate that the acceptance of this outcome is likely due to the perception that institutionalization is an extension of already utilized formal supports.
Jogerst, G. et al.
Domestic Elder Abuse and the Law
American Journal of Public Health; Vol. 93 (12), 2131-2136; December 2003.
This study, conducted by researchers at the University of Iowa's Department of Family Medicine, was designed to explore the impact of specific characteristics of state adult protective services (APS) legislation upon rates of reporting and investigation of domestic elder abuse. With the exceptions of Georgia, North Dakota (no data to provide), Colorado (inaccurate data) and Ohio (only report data), data was collected from APS administrators regarding the number of abuse reports, investigations and substantiations within their states (for 1999 or fiscal year 1999-2000). Domestic abuse reports from 17 states, investigations from 47 states, and substantiations from 35 states were analyzed. (The data collected deals only with reports of mistreatment of individuals aged 60 and over.) State statutes were then analyzed and 83 codes were identified that covered all aspects of abuse, neglect and self-neglect addressed by the legislation. Each state statute was coded by researchers (a multidisciplinary team comprised of a physician, a nurse, a lawyer, a social worker, a social work graduate student and a law graduate student). Among the findings, 190,005 reports were made within 17 states in 1999 (a rate of 8.6 per thousand elders); a total of 242,430 investigations were carried out within 47 states (a rate of 5.5 per thousand elders); and a total of 102,879 substantiated cases were identified within 35 states (2.7 per thousand). Reporting rates ranged from 4.5 to 14.6, investigation rates ranged from .5 to 12.1, and substantiation rates ranged from .1 to 8.6 (mean substantiation ratio was 44.8 percent.) Higher investigation rates were found among those states with mandatory reporting legislation (with penalties outlined for failure to report), and substantiation ratios were higher among those states with more detailed abuse definitions. Substantiation ratios were also higher among states that hired separate case workers for child and elder abuse and among states that track reports of abuse. (FOR REPRINTS, contact Dr. Jogerst at [email protected].)
Jogerst, G. et al.
Required Elder Abuse Education for Iowa Mandatory Reporters
Journal of Elder Abuse & Neglect; Vol. 15 (1), 59-73; 2003.
Iowa is the only state to require education for mandatory reporters of elder abuse and neglect. This study examines the investigation and substantiation rates of Iowa before and after the statute was enacted in order to consider its effectiveness. Rates of investigation and substantiation were compared for time periods before and after the statute was enacted. Although investigation rates ranged from .89 to .49 per 1,000 individuals aged 65 and over from 1984 through 2000, and substantiation rates ranged from .13 to .29 per 1,000, there were no significant increases and no significant trends identified. During the same time period, substantiation and investigation rates increased steadily in Texas, and investigation rates increased steadily in Wisconsin. Researchers project the cost of training over 100,000 potential mandatory reporters to be a half million to nearly two million dollars every five years, and therefore suggest that the funds may be more effectively spent on initiatives such as public outreach campaigns.
Kim, J. & Sung, K.
Marital Violence Among Korean Elderly Couples: A Cultural Residue
Journal of Elder Abuse & Neglect; Vol. 13 (4), 73-89; 2001.*
This study draws upon data from the Korean National Family Violence Survey. Eighty-eight male and 56 female participants aged 60 and over were surveyed by telephone regarding their experiences of domestic violence occurring during the preceding 12 months. Researchers used the Conflict Tactic Scale (CTS) to assess violence. Data revealed an intimate partner violence rate of 21.5 percent. While most of the incidents reported were relatively minor, 5.6 percent of the occurrences were threats or assaults involving the use of weapons. Unlike previous studies, socioeconomic factors did not appear associated with rates of abuse.
Koch, S. & Nay, R.
Reducing Abuse of Older People with Dementia and Their Carers
Australasian Journal on Ageing; Vol. 22 (4), 191-195; December 2003.
Literature indicates that individuals with dementia are more susceptible to abuse, while caregivers of these individuals also report that care recipients are aggressive as well. This study explores the phenomenon of elder abuse among people with dementia and their caregivers, paid and unpaid. Forums and in depth interviews were conducted throughout rural Victorian and metropolitan Melbourne areas with experts representing government, health and social service agencies regarding the nature and experience of abuse within these relationships. In all, 171 individuals participated and included one patient with dementia, 52 caregivers, 46 nurses (including RNs, managers, administrators, etc.), and other health and social service professionals. Content analysis of audiotaped sessions revealed several themes, including the need for a protocol for prevention and intervention, sufficient staffing and more education regarding cognitive impairment and available resources. Participants perceived that defining abuse is probably unnecessary, that abusive/aggressive behaviors should be considered in the context in which they occur, and that mandatory reporting is not essential. (Australia)
Kottwitz, D. & Bowling, S.
A Pilot Study of the Elder Abuse Questionnaire
Kansas Nurse; Vol. 78 (7), 4-6, & 13; August 2003.
As quoted from the article, "The purpose of this study was to review the literature and develop a questionnaire with scales to determine how targeted participants perceived elder abuse." A 25-item instrument was developed that reflected Neuman's holistic system, addressing five domains of the elder's life (physical, psychological, developmental, socio-cultural and spiritual). The questionnaire was tested by 49 participants (attorneys-in-fact for 40 residents in a Kansas long-term care facility along with employees of that nursing home). The alpha coefficient, .06687, is considered acceptable for a new instrument, but further study with various populations is indicated.
Lachs, M. et al.
The Clinical Epidemiology of Crime Victimization in Older Adults: A Multidisciplinary Pilot Study
Journal of Elder Abuse & Neglect; Vol. 13 (3), 79-90; 2001.*
Researchers identified a gap in the literature regarding the impact of crime on the health and mortality of elderly victims. In this pilot observational cohort study, gerontology and criminology professionals collaborated to explore these trends using data from the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE). At its inception in 1982, the stratified sample consisted of 2,812 community dwelling individuals aged 65 and over. Two-hundred randomly selected sample participants were matched with police records to determine the rate of police involvement. Among the findings, 47 elders (23.5 percent) had 86 police department contacts. In these contacts, the elder was the victim 43 percent of the time, the complainant 30 percent of the time, the alleged offender 10.5 percent of the time, and the witness 9.3 percent. Most frequent complaints involved burglary, followed by contacts with cognitively impaired or mentally ill elders. As quoted from the abstract: "...This methodology can detect a relative risk of mortality after crime of 1.4 with 90 percent power at an alpha level of 0.05 when all cohort members are matched to police records..." From this data, it appears that elders have a higher prevalence rate of contact with police than with either APS professionals or professionals from other aging services fields. The findings suggest that a similar methodology can be applied to the study of other health outcomes of crime by drawing upon data from police records.
Langa, K. et al.
Extent and Cost of Informal Caregiving for Older Americans with Symptoms of Depression
American Journal of Psychiatry; Vol. 161 (50), 857-863; May 2004.
The purpose of this study was to develop a national estimate of the additional time and costs associated with informal caregiving for older, community-dwelling Americans demonstrating symptoms of depression. Based on data from the 1993 Asset and Health Dynamics Among the Oldest Old Study (AHEAD, n=6,649), 44 percent of the participants indicated that they experienced one to three depressive symptoms within the preceding week, and 18 percent indicated they had experienced four to eight symptoms. After adjusting for differences in health profile, sociodemographics and caregiver networks, it was estimated that respondents with no depressive symptoms received an additional 2.9 hours of assistance weekly, while those with moderate symptoms received 4.3 hours per week, and those with more frequent symptoms required 6 hours weekly. This results in an estimated additional $9.1 billion cost for informal caregiving in the U.S. annually. The study appears to support the assumptions that depressive symptoms are extremely common, associated with higher levels of disability and an increased need for informal caregiving. Women were more likely to report depressive symptoms, and appear at greater risk of having unmet care needs, in part due to financial conditions and to the increased likelihood of living alone.
Lima, C., Levav, I., Jacobsson, L. & Rutz, W.
Stigma and Discrimination Against Older People with Mental Disorders in Europe
International Journal of Geriatric Psychiatry; Vol. 18 (8), 679-682; 2003.
The "Task Force on Destigmatization," established by the Mental Health Program of the World Health Organization/European Regional Office (WHO/EURO) in 2000, was authorized to investigate and address the impact of stigma and discrimination on older mentally ill Europeans. WHO mental health representatives from 17 countries were surveyed regarding both health care professional activities (such as research and teaching) and the public's attitudes towards elders with mental disorders. Among the results, two-thirds of the 15 countries that had conducted psychiatric epidemiological studies included the elderly in the samples; the 16 countries that include an old age psychiatry residency modality allot 10 percent of total curriculum time for such; two-thirds of the surveyed countries had specialized services (as compared to 100 percent for children); and stigma is perceived as greater towards elders with psychosis and depression (and their families) than towards patients with Alzheimer's disease.
Matthias, R. & Benjamin, A.
Abuse and Neglect of Clients in Agency-Based and Consumer-Directed Home Care
Health & Social Work; Vol. 28 (3), 174-184; August 2003.
The increase in chronically impaired individuals living in the community has helped to generate the growth of an alternative to the traditional agency-based home care services: consumer-directed home care. The three goals of this research are to identify any association between the home care service model and worker abuse of clients; to consider the association of the relationship between caregiver and care receiver upon abuse and neglect; and to consider other characteristics of the care provision context that may impact mistreatment. In the consumer-directed model (CDM), the client is responsible for selecting, training and supervising the worker. A stratified sample of 1,095 In-Home Supportive Services (California) clients was interviewed by telephone between October 1996 and March 1997. Of the sample, 511 were in the CDM group (with 240 family and 271 non-family caregivers), and 584 in the professional agency model (PAM). Fifty-two percent were aged 65 and over, 73.5 percent were female, and approximately one-third were classified as having severe disabilities. In addition to providing demographic information, participants were also asked about their functional status and their experiences with abuse and neglect by home care providers. Of the findings, while significantly more recipients denied experiencing neglect, nearly twice as many PAM recipients experienced neglect than the CDM clients (17.8 % compared to 9.2 %); 6.1 % of the PAM clients experienced yelling compared to 7.8 % of the CDM clients; and 5.3 % of the PAM clients reported material abuse, compared to 4.2 % of the CDM clients. CDM clients reported a higher sense of security than the PAM clients. Results indicate that consumer-directed providers were not more abusive or neglectful than agency professionals. Care recipients of family caregivers appeared to experience less abuse and neglect than those of non-family caregivers. Of the other characteristics considered, those clients with less complex needs and paramedical dependence, coupled with more stable caregiver relationships, reported less abuse and neglect. A potential limitation of the study is that despite stratification, fewer severely disabled clients from the PAM sample participated. It can also be argued that those unable to participate are more likely to be isolated and therefore at greater risk of mistreatment.
Survival Is Not Enough
Violence Against Women; Vol. 9 (12), 1478-1489; December 2003.
After reviewing the scant literature addressing the needs of older battered women in Australia, the author presents the findings of a study conducted as part of the Older Women Speak Up Project. Approximately 250 older women participated in seminars and interviews revealing their experiences of domestic violence, and another 20 discussed personal experiences by telephone. Information was also gathered from 100 completed questionnaires. Batterers were primarily male partners, though some victims were abused by sons, daughters, daughters-in-law and caregivers. The impact of the abuse was profound and long-lasting, with emotional withdrawal being a common response. Women also discussed their survival strategies, which ranged from avoidance and denial, to medication, to constructive and creative outlets (paid work and academic studies). Only two participants had reported the abuse to the police. A recurrent theme was the lack of or inaccessibility of help. Lack of emotional support and financial support were major factors in why many women could not or would not leave the perpetrators. The importance of empowerment through speaking out and receiving validation emerged as a key intervention in addressing this largely silent phenomenon.
A Novel System of Electronic Tagging in Patients with Dementia and Wandering
Age and Ageing; Vol. 33 (3), 304-306; 2004.
This brief article reports upon the effectiveness of an electronic tagging system to address the potentially dangerous wandering of older individuals with dementia. After a successful pilot study, four residents of a residential care home in the U.K., five hospital patients, and three community based individuals participated by wearing the tagging bracelet. There were no technical difficulties with the equipment, and there were no undetected incidents of wandering. In the residential care home, up to 15 instances of internal wandering occurred daily. Two instances of outside wandering were detected and immediately addressed. Although professional organizations raised ethical questions regarding the use of electronic tagging, clients, relatives and staff were not resistant to participation.
Mitchell, S. et al.
Clinical and Organizational Factors Associated with Feeding Tube Use Among Nursing Home Residents with Advanced Cognitive Impairment
Journal of the American Medical Association (JAMA); Vol. 290 (1), 73-80; July 2 2003.
Although recent medical research suggests that feeding tubes are not beneficial to older patients with advanced dementia, and may be associated with increased risks and complications, this study indicates that more than one-third of severely cognitively impaired nursing home residents in the U.S. have feeding tubes. The study draws upon data from the 1999 National Repository Resident Assessment Instrument Minimum Data Set (MDS). Resident characteristics associated with tube feeding are younger age, nonwhite race, divorced marital status, and cognitive impairments not attributed to Alzheimer's disease. Facility characteristics associated with increased feeding tube usage include for profit status, urban location, lack of specific dementia units, and a lower resident population with advanced directives such as "do not resuscitate" (DNR) orders. One observation is that long-term care facilities may use tube feeding as a cost cutting measure.
Montoro-Rodriguez, J., Kosloski, K. & Montgomery, R.
Evaluating a Practice-Oriented Service Model to Increase the Use of Respite Services Among Minorities and Rural Caregivers
The Gerontologist; Vol. 43 (6), 916-924; 2003.
In this study, a practice-oriented model (which focuses on service characteristics) of respite service use was compared to the more commonly used behavioral model (which focuses on user characteristics). Under the practice-oriented model, the three primary aspects of respite services considered are the visibility of the service, the accessibility of the service, and the users' intent to utilize the service. Both models were applied to interview data gathered from 1,158 caregiver participants of the Alzheimer's Disease Demonstration Grant to States project. Ethnic/cultural considerations were also examined. The results indicate that the practice-oriented model more fully explains the use of respite services by Whites and Hispanics, although the behavioral model continues to be more helpful in analysis of African American usage. A significant implication is that the use of the practice-oriented model allows program developers to alter features of services (such as affordability and availability) to encourage greater usage, whereas most factors analyzed by the behavioral model (such as gender, relationships, etc.) cannot be changed.
Intimate Partner Violence and Health Status Among Older Women
Violence Against Women; Vol. 9 (12), 1465-1477; 2003.
Intimate partner violence (IPV) in older women has not been well researched to date. This study was designed: "...(a) to describe the baseline prevalence of abuse in a cohort of functionally independent older women; (b) examine the sociodemographic, health, and psychological factors associated with abuse; and c) examine the association of abuse with self-reported health status..." A sample of 1,245 community-dwelling, postmenopausal women aged 50-79, presenting for enrollment in a clinical trial of women's health (San Antonio, 1997-2001) were interviewed regarding exposure to domestic abuse, including firearms accessibility in their homes. The Domestic Violence Screening Questionnaire (DVSQ, developed and tested for this research) was administered and participants were also surveyed about socio-economic status, race/ethnicity, education and employment status. In addition, participants completed the Medical Outcomes Study Short Form which assesses physical and mental health. Of the findings, 58.5 percent reported exposure to some type of abuse during their adult lifetime, and 5.2 percent to 22.8 percent reported experiencing abuse within the past year. Although reported exposure did not appear associated with poorer physical health, it appeared to significantly impact mental health. The appendix includes 13 questions for screening older women for IPV.
Mouton, C. et al.
Prevalence and 3-Year Incidence of Abuse Among Postmenopausal Women
American Journal of Public Health; Vol. 94 (4), 605-612; 2004.
Noting that a great deal of research on abuse of older women has focused on the frail and dependent elderly, the authors of this article suggest that such studies were influenced by issues of caregiver abuse and neglect. The goal of this study was to examine the incidence and prevalence of physical abuse and verbal abuse among a cohort of functionally independent, older women. It was also designed to analyze associated sociodemographic factors and health behaviors. Questionnaire responses from 91,749 participants of the Women's Health Initiative (WHI), aged 50 to 79, were analyzed for reports of physical and verbal abuse occurring within the year prior to completing the baseline survey. At baseline, 11.1 percent of the participants reported experiencing abuse within the preceding year. Of those abused, 2.1 percent experienced physical abuse only, 89.1 percent experienced verbal abuse only, and 8.8 percent experienced both. Exposure to abuse was associated with being younger than 58, non-white, a non-high school graduate, having a family income of less than 20,000, being divorced or separated, being a past or current smoker, and drinking more than one drink per week. Nearly 49,000 participants were surveyed three years later regarding subsequent exposure to abuse. Follow-up data indicated a five percent increase in the rate of reported abuse. Rates of abuse among functionally independent women appear similar to those of younger women.
Powerlessness and Abuse and Neglect of Older Adults
Journal of Elder Abuse & Neglect; Vol. 14 (1), 21-47; 2002.*
In this qualitative study, fourteen in-depth interviews with abused and neglected dependent adults, and two with their abusers, are analyzed for causal themes related to powerlessness. The research is based upon the theory that older adults are rendered powerless when they have insufficient resources and are susceptible to systemic problems, such as ageism. It draws upon an ecological framework of interaction among individual, interpersonal and environmental risk factors. The interactions are considered through the macro (societal), exo and meso (systems within society) and micro systems (such as the parent-child relationship). Participants lived in the community, were selected through social service and health agencies in the Montreal area, and represented six different ethnic groups. Of the victims, two were male and twelve female; one male and eleven of the females described themselves as caregivers as well as care recipients. Both abusers were under 55 and were daughters to their victims. Specific case studies illustrate particular themes. The impact of history is demonstrated by the holocaust survivor as she describes the circumstances which affected her mothering of her now sexually abusive son, and which contributes to her unwillingness to abandon him. Case studies highlight issues related to gender, ethnicity, and a sense of powerlessness in dealing with the health care system. (Canada)
Nelson, H. et al.
Factors Important to Success in the Volunteer Long-Term Care Ombudsman Role
The Gerontologist; Vol. 44 (1), 116-120; 2004.
In this study, 106 of 135 active volunteers in Oregon's Long Term Care Ombudsman Program were surveyed to determine what factors appeared associated with successful program implementation. Volunteers' motives and their satisfaction were considered along with successful outcomes. The majority of the participants were retired, female, white, educated, and approximately 40 percent had either a prior personal or familial involvement with the long-term care system. Motivation (broadly categorized as self-development, affiliation, and altruism) and satisfaction were measured using the Self Expression Instrument, and organizational commitment was measured by the 15-item Organizational Commitment Questionnaire. The program's success was measured by the following outcomes: number of monthly complaint reports; facility visits per month; total time committed to the role; and complaints filed against the ombudsmen by providers. All motives were significantly related to satisfaction, with the affiliation motivation being most fulfilling. Ombudsmen with higher organizational commitment spent more time in the role, visiting facilities and filing reports. Although the altruistic motive was less correlated with satisfaction than the other two motives, it was the only predictor of a success outcome (time devoted to the role). One surprising finding was that advanced Certified Ombudsmen had more complaints filed against them. This may be, in part, because they are more assertive in their advocacy and are likely to have more complicated cases to address. This study bears out the significance of organizational commitment in volunteering as it was tied to satisfaction, to all three classes of motivation, and every success outcome measure, except complaints against ombudsmen.
Ockleford, E. et al.
Mistreatment of Older Women in Three European Countries - Estimated Prevalence and Service Responses
Violence Against Women; Vol. 9 (12), 1453-1464; December 2003.
The authors of this study sought to survey the experiences of mistreatment among older women from Ireland, Italy and the United Kingdom, in comparison with prevalence studies conducted in the U.S. In addition, they interviewed professionals who work with older women regarding their perceptions of elder abuse among their clientele, and the existence and accessibility of services for older battered women. The convenience sample of women aged 60 and over, included 50 Irish, 50 Italian and 49 British participants. They completed a 34-item questionnaire addressing threats and experiences of physical abuse, psychological abuse and financial exploitation occurring since age 59. Fourteen percent were identified as having dementia but only one of these women reported being abused (7 percent). An overall prevalence of 14 percent of the total sample experienced threats of mistreatment, and 18 percent demonstrated an overall prevalence of actual abuse, with financial abuse being the most common. Spouses and other family members were the most common perpetrators of physical abuse and others (outside the family and social network) were most commonly perpetrators of financial abuse (79 percent). While acknowledging serious limitations with regards to the type and size of the sample, the researchers indicate that this study identifies the need for further cross-cultural research and increased accessibility of services for older battered women.
Understanding Differences in Opinion and 'Facts' Between Ombudsmen, Police Chiefs, and Nursing Home Directors
Journal of Elder Abuse and Neglect; Vol. 13 (3), 61-77; 2001.*
Little research has been conducted regarding the readiness of various disciplines to work together in addressing elder abuse. This study focuses on the philosophical differences and perceptions/misperceptions of three occupational groups that address elder abuse in nursing home settings: ombudsmen, police chiefs and nursing home directors. The research considers whether the three groups differ in their opinions on issues regarding elder abuse, and whether they vary in the knowledge of elder mistreatment. Seventy-three nursing home professionals, 119 police chiefs and 203 ombudsmen from four states completed the mailed survey, 20-item instrument which included the following scales: crime facts, nursing home facts, victim attribution opinions, media prevention opinions, and crime and punishment opinions and a general fact and general opinion scale. Among the results, the groups varied in their perception of the extent of both elderly victimization and the extent of victimization within nursing homes, as well as in their beliefs regarding the "appropriate" response of the criminal justice system. The research also assessed gender differences; male ombudsmen appeared more likely to blame the victim and underestimated the scope of institutional abuse than did female ombudsmen. The study also revealed that a number of the differences were related to misinformation versus opposing attitudes.
Payne, B. & Berg, B.
Perceptions About the Criminalization of Elder Abuse Among Police Chiefs and Ombudsmen
Crime & Delinquency; Vol. 49 (3), 439-459; July 2003.
Employing general systems theory, researchers analyzed the differences in sanctions favored by police chiefs and ombudsmen for six different types of elder mistreatment. One-hundred nineteen police chiefs from four states and 203 ombudsmen from 26 states were surveyed by mail. The survey described six scenarios of abuse, including incidents of institutional abuse and neglect as well as incidents of street crime and fraud. Respondents were asked to rank order the perceived appropriateness of four sanctions, ranging from administrative reprimand to fines, probation and jail time. They were also asked to rank order the severity of the offenses. While ombudsmen rated patient offenses as most serious, police chiefs rated street crimes as most severe. In addition, they were also asked for agreement or disagreement on five statements regarding policy in addressing elder abuse. While both groups appear to support the criminalization of elder abuse and agree that it should be a priority of the criminal justice system, they differed as to what sanctions were most appropriate for most offenses. Policy implications are considered.
Rantz, M. et al.
Nursing Home Quality, Cost, Staffing, and Staff Mix
The Gerontologist; Vol. 44 (1), 24-38; 2004.
This study examines elements of quality of institutional care in a sample of Missouri nursing homes. Ninety-two nursing homes were randomly selected and classified as having good, average or poor resident outcomes according to quality indicators (QI) recorded on the Minimum Data Sets (MDS). Processes of care, care costs, organizational characteristics, staffing levels and staffing mix were analyzed. Cost and staffing information was obtained from Medicaid records, and care processes were directly observed. Good-resident outcomes appeared associated with requisite organizational attributes: effective and consistent leadership among nurses and administrators; group and team approaches to management and service delivery; and ongoing quality improvement initiatives. With these attributes in place, staff was able to deliver core care services consistently and effectively (assistance with ambulation, nutrition and hydration, toileting/bowel regimens, pain management, and skin care). There were no significant associations among costs, staffing levels and staff mix, and resident outcomes. Poor-outcome groups had a slightly higher resident cost per day than the good-outcome groups. The only facility characteristic that appeared associated with outcome was number of beds; facilities with fewer beds (60 or less) were linked to higher resident outcome ratings. This suggests that consistent leadership with a focus on quality improvement and a team approach is essential for higher quality of care, and that good care may cost less than poor care.
Rennison, C. & Rand, M.
Nonlethal Intimate Partner Violence - A Comparison of Three Age Cohorts
Violence Against Women; Vol. 9 (12), 1417-1428; December 2003.
This article provides a comparison of data from the National Crime Victimization Survey (NCVS, 1993-2001) regarding the prevalence and incidence estimates of nonlethal intimate partner violence (IPV) among three age cohorts: women aged 55 and over, those aged 25 to 54, and those aged 12 to 24. Females aged 12 to 24 had the highest rate of intimate partner victimization (12.3 per 1000), those aged 25 to 54 were victimized at a rate of 8.7 per 1000, and women aged 55 and older were victimized at a rate of .44 per 1000. Older women were most often victimized by a current spouse (62 percent), and nearly half of this group indicated that their abuser was under the influence of alcohol or drugs. Ninety-four percent of the IPV of older women occurred in their homes. Only 52 percent of the nonlethal IPV perpetrated against older women was reported to the police. Reasons for poor reporting rates among older women are considered.
Reiboldt, W. & Vogel, R.
A Critical Analysis of Telemarketing Fraud in a Gated Senior Community
Journal of Elder Abuse & Neglect; Vol. 13 (4), 21-38; 2001.*
After providing an overview of the literature on telemarketing fraud involving seniors, this article discusses findings from a random sample survey of older residents of a gated community that had a reported problem with this activity. A 10.4 percent rate of victimization was demonstrated among the study's 240 participants. The researchers assessed the beliefs that participants held regarding the truthfulness of the telemarketers, the comfort level they had in conducting business on the telephone, the level of isolation that they felt, and their mobility level. Using logistic regression, only one variable appeared significantly correlated to victimization: the tendency to believe the telemarketer's "pitch." The research suggests that there is not one "typical" fraud victim profile.
Roberto, K., Teaster, P. & Duke, J.
Older Women Who Experience Mistreatment: Circumstances and Outcomes
Journal of Women & Aging; Vol. 16 (1/2), 3-17; 2004.
Ninety-five substantiated elder abuse cases opened by Virginia Adult Protective Services (APS) were examined in order to develop a victim profile of elderly female abuse victims. The study also analyzed the circumstances in which the abuse occurred, and the outcomes of the cases. The participants were predominantly White, aged 61 to 98, and nearly half lived in their own homes. Most of the victims required assistance with ambulation and with financial management. Neglect was the most commonly reported mistreatment (44 percent), followed by financial exploitation (14 percent) and physical abuse (12 percent); and 18 percent experienced multiple types of abuses. Most women were victimized in their own homes, and mistreatment was typically reported by health care or social service professionals. The abuser was most commonly a family member (65 percent) although 15 percent were abused by long-term care staff members. Of the outcomes, only four perpetrators were prosecuted, 18 percent of the victims were relocated, and 80 percent received APS services (including counseling, case management, health care services, community based services, etc.). Seventy percent of the cases remained open for the three month study period, and 59 per cent of the victims were still considered "at risk" for mistreatment.
Saliga, S., Adamowicz, C., Logue, A. & Smith, K.
Physical Therapists' Knowledge of Physical Elder Abuse - Signs, Symptoms, Laws, and Facility Protocols
Journal of Geriatric Physical Therapy; Vol. 27 (1), 1-10; April 2004.
In this study, 400 randomly selected licensed physical therapists from Michigan were surveyed regarding their knowledge of elder abuse signs and symptoms, current state laws, and the protocols in place at their work site to address the handling of suspected abuse. One-hundred-eighteen surveys were returned and completed, representing a response rate of 31 percent. One-quarter of the sample had suspected a client had been abused, but less than half reported their concerns. Fifty-eight percent reported that their facility did not provide any training or information on elder abuse, and only 44.1 percent were aware of their facility's protocol for addressing suspected abuse. Twenty-one percent were unaware of their legal mandate to report. Facility training appears to have a significant impact upon knowledge of legal responsibilities to report, and also demonstrates trends towards greater awareness of clinical signs and symptoms of physical abuse. The article discusses the importance of the recent APTA's publication entitled, "Guidelines for Recognizing and Providing Care for Victims of Elder Abuse."
Dementia and Aggressiveness: Stimulated Recall Interviews with Caregivers after Video-Recorded Interactions
Journal of Clinical Nursing; Vol. 13, 515-525; 2004.
The purpose of this study was to develop insight into the differences between caregivers who reported difficulties with aggressive dementia patients and those who did not. Video recordings of care provision were later reviewed by those paid caregivers involved, who then participated in stimulated recall interviews. Upon review, those caregivers who were more likely to experience problems appeared more focused on task completion (such as bathing) without consideration of the effect of the process upon the resident. Those caregivers who maintained a more positive interaction appeared more spontaneous during the process of providing care. Researchers suggest that an increase in creativity and support for the caregivers would likely reduce the perception of difficulty in assisting such residents.
Shields, L., Hunsaker, D. & Hunsaker, J.
Abuse and Neglect: A Ten-Year Review of Mortality and Morbidity in our Elders in a Large Metropolitan Area
Journal of Forensic Science; Vol. 49 (1), 122-127; January 2004.
This article reports upon a ten-year retrospective study of mortality and morbidity of elders whose deaths were attributed to homicide or suspected neglect. Data was drawn from the State Medical Examiner's Office (serving a metropolitan region of Kentucky and Indiana) and the Office's Clinical Forensic Medicine Program, which completes examinations of living abuse victims. In all, 74 deaths of victims aged 60 and over had been evaluated through medicolegal autopsies (1992 through 2001) and identified as due to homicide (n=52) or neglect (n=22). Causes of homicide were gunshot wounds, assaults (stabbing and beating), and asphyxia. The most common cause of death in neglect cases was found to be bronchopneumonia. In 45 percent of the cases, the perpetrator was undetermined; in 31.8 percent the perpetrator was the spouse; in four percent it was another family member; and in one percent it was an acquaintance. Decubitus ulcers were found on 21 of the 22 neglect victims. Of the 22 cases involving elders that had been referred to the Clinical Forensic Medicine Program, 19 were identified as being victims of physical and/or sexual abuse and three were identified as neglected. The article includes a detailed case study of a 75 year old White woman who lived with her son and a paid caregiver. The autopsy indicates that neglect by the son and caregiver significantly contributed to her death, and both were sentenced based upon the forensic evidence. The importance of multidisciplinary/interdisciplinary and multi-agency collaboration, and the role of the forensic pathologist, is stressed when investigating cases of elder deaths under suspicious circumstances.
Sievers, V., Murphy, S. & Miller, J.
Sexual Assault Evidence Collection More Accurate When Completed by Sexual Assault Nurse Examiners: Colorado's Experience
Journal of Emergency Medicine; Vol. 29 (6), 511-514; December 2003.
This research addresses the question: Are Sexual Assault Nurse Examiners (SANEs) more effective at evidence collection than non-SANE nurses and physicians? Five-hundred fifteen evidence kits (279 completed by SANEs and 236 by non-SANES), collected from October 1999 through April 2002 in Colorado, were audited by crime laboratory analysts from the Colorado Bureau of Investigation. Overall, kits collected by SANE practitioners were more complete and accurate. For example, kits collected by SANEs documented a completed chain of evidence at a 92 percent rate, while those collected by non-SANEs were at 81 percent, and SANEs were more likely to collect sufficient amounts of pubic hair, head hair, swabs and blood tubes. (Note: Although this article does not address elder sexual assault specifically, it contains information on best practices relevant to elder sexual assault investigation, evidence collection and documentation.)
Stek, M. et al.
Prevalence, Correlates and Recognition of Depression in the Oldest Old: The Leiden 85-plus Study
Journal of Affective Disorders; Vol. 78 (3), 193-200; 2004.
Little research regarding the prevalence of depression in the oldest old (aged 85 and over) has been conducted, in part because of the difficulties of studying depression in the presence of multiple physical and psychiatric diseases. This study assessed depression in a sample of 599 of the 705 residents of the Netherlands, born between 1912 and 1914, who were participating in the Leiden 85-plus health study. Researchers used the 15-item Geriatric Depression Scale (GDS-S) and also the Mini Mental Status Exam (MMSE). Demographic, health-related and functional correlates were also collected. The prevalence rate of depressive symptomotology was 15.4 percent. Depression was correlated with loneliness, impaired cognition, impaired daily functioning, self-described poor health, poor mobility and being institutionalized. Although 90 percent of the depressed participants had been seen by their physicians during the past year, only 25 percent of these individuals were identified as depressed by their doctor, and only one participant had been prescribed antidepressant medication. The prevalence rate is compared with findings from other oldest old studies.
Teaster, P. & Roberto, K.
Sexual Abuse of Older Women Living in Nursing Homes
Journal of Gerontological Social Work; Vol. 40 (4), 105-119; 2003.
Elder sexual abuse is the least recognized and reported form of elder mistreatment, representing less than one percent of mistreatment reported in the U.S. This article presents data on the sexual abuse of older female nursing home residents reported to the Virginia Adult Protective Services Program from July 1996 through June 2001. Fifty cases of sexual abuse of female residents were substantiated during this time period. Half of those abused were aged 70 to 79 and the other half were 80 to 89. Among the victim characteristics, 73 percent were not oriented to time and 58 percent were not oriented to place; 72 percent were unable to ambulate without assistance; and 94 percent were unable to manage their financial affairs without assistance. Seventy-six percent of the abuse involved sexualized kissing and fondling, and 38 percent involved unwelcome sexual interest in the victim's body. Other forms of sexual abuse that occurred with less frequency included unwanted descriptions of sexual activity, sexualized jokes, oral-genital contact, vaginal rape and digital penetration. In 90 percent of the cases, the alleged perpetrator was a male resident of the same facility, and typically 70 years of age or older. Twenty-eight percent had untreated psychiatric illness and 12 percent abused substances. No staff members were identified as perpetrators. The women were relocated in 16 percent of the cases, and 12 percent received physical or psychological treatment. In 68 percent of the cases, action was taken regarding the perpetrator; in 34 percent of the cases he was relocated and in 14 percent he received psychiatric treatment.
Texas Health and Human Services Commission
Preliminary Report - Implementation of Executive Order RP33 April 14, 2004 Relating to Reforming the Adult Protective Services Program
Texas Health and Human Services Commission; May 19 2004.
As a result of several high profile controversial cases in Texas, the state's Health and Human Services Commission (HHCS) conducted a systematic review of the Adult Protective Services (APS) program of the Department of Family and Protective Services (DFPS). A survey team reviewed 1,200 cases involving 200 clients in El Paso. The deficiencies identified suggest fundamental and systemic problems with the APS program. Of the preliminary findings, it was determined serious problems in casework include poor assessment, inadequate documentation, and inadequate follow-up. In 35 percent of the cases reviewed, allegations of abuse and/or neglect were not fully addressed; in 30 percent the service plans did not adequately address the abuse, neglect or exploitation; and in 41 percent of the cases, adequate prevention measures were not taken. Of note, in 41 percent of the cases, the client was determined to have mental illness, yet further steps (such as referral) were only taken in less than half of these cases. Capacity was considered questionable in nearly half of the cases evaluated. Performance levels in this region compared poorly to statewide averages. Corrective actions required based on this survey include training in the use of appropriate capacity tools, additional staffing and supervision, strengthened judicial relationships and technology integration. (Note: This report is available online at http://www.hhsc.state.tx.us/pubs/051904_PR_RP33.html .)
Unutzer, J. et al.
Collaborative Care Management of Late-Life Depression in the Primary Care Setting - A Randomized Controlled Trial
JAMA/Journal of the American Medical Association; Vol. 288 (22), 2836-2845; December 2003.
This randomized controlled trial was designed to evaluate the effectiveness of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) management program. Project IMPACT provides an integrative care model for the treatment of geriatric depression. A sample of 1801 patients aged 60 and over, participated throughout 18 primary care clinics across five states (July 1999-Autust 2001). Seventeen percent of the participants were diagnosed with major depression, 30 percent were diagnosed with dysthymic disorder, and 53 percent were diagnosed with both. Nine-hundred and six patients were randomly assigned to the IMPACT intervention and the remaining 895 were assigned to usual care. Components of the IMPACT intervention include one year's access to a depression care manager (under the supervision of a psychiatrist and a liaison primary care physician), psychoeducation, anti-depressant medication and brief psychotherapy (Problem Solving Treatment in Primary Care or PST-PC). Outcomes were assessed three, six and 12 month intervals. Of the major findings, IMPACT interventions were more likely to access medication and therapy, and at the 12 month assessment, 45 percent of the intervention patients had experienced at least a 50 percent reduction in depressive symptoms as compared to 19 percent in the usual care group. The annual par patient cost of the IMPACT intervention was estimated at $553.00.
Watson, L. & Pignone, M.
Screening Accuracy for Late-Life Depression in Primary Care: A Systematic Review
Journal of Family Practice; Vol. 52 (12), 956-964; December 2003.
The purpose of this literature survey is to review the accuracy of depression screening instruments for use with older adults in the primary care setting. Among the nine assessment tools surveyed, the Geriatric Depression Scale (GDS), the Center for Epidemiological Studies Depression Scale (CES-D), and the SelfCARE (D) are identified as both sensitive and specific and appropriate for use in this setting. The CES-D and Cornell Scale for Depression in Dementia (CSDD) appear accurate for identifying depression in dementia patients with an average Mini-Mental Status Exam (MMSE) score of 19, although more research is needed in this area. Tables include summaries of studies reviewed.
Dilemmas and Ethics: Social Work Practice in the Detection and Management of Abused Older Women and Men
Journal of Elder Abuse and Neglect; Vol. 14 (1), 79-94; 2002.*
This article presents the themes identified throughout the interviews with social workers serving older clients of the assessment and care management department of a U.K. social service area. Twenty-four open-ended interviews were conducted with front line social workers and first line managers (approximately half of the staff) regarding their observations, understanding of, and attitudes towards elder abuse. Dominant themes identified include shortage of resources and mistrust of residential care. All participants expressed a superficial awareness of elder mistreatment. Discussions suggest that there is a lack of awareness of differences and diversity, and that the complexity of these cases seem to be unappreciated.
Wetherell, J. et al.
Quality of Life in Geriatric Generalized Anxiety Disorder: A Preliminary Investigation
Journal of Psychiatric Research; Vol. 38 (3), 305-312; 2004.
Generalized anxiety disorder (GAD) is currently defined as a condition lasting six months or longer, wherein an individual experiences difficult to control, excessive worrying most of the time. It is usually accompanied by sleep disturbance, irritability and impaired concentration among other symptoms. In this study, researchers assessed the impact of GAD upon health-related quality of life of older adults. Seventy-five older individuals (median age 68) presenting with GAD (including 39 who had a co-morbid psychiatric diagnosis) were interviewed and completed the Medical Outcomes Study short form, the Beck Anxiety Inventory, and the Beck Depression Inventory. Results were compared with 32 participants who were not reporting any current psychiatric symptoms. GAD patients with and without co-morbid psychiatric symptoms did not differ on any quality of life variable, however, both groups experiencing GAD reported a poorer quality of life for all domains, including the physical health-related domains. When compared with national norms, older individuals experiencing GAD reported an overall quality of life worse than patients who recently experienced myocardial infarction or type II diabetes.
Wood, S. & Stephens, M.
Vulnerability to Elder Abuse and Neglect in Assisted Living Facilities
The Gerontologist; Vol. 43 (5), 753-757; 2003.
Assisted living is the fastest growing segment of long-term care in the U.S. It has long been believed that it is a consumer driven market, and that consumers (residents) receiving substandard care would "vote with their feet" by choosing alternative placements. This descriptive study explores the vulnerability of assisted living residents to elder abuse and neglect. Twenty-seven relatively cognitively intact residents participated in this research. The mean age was 87, and 24 of the residents were female. Participants were initially interviewed for a baseline assessment of their knowledge of adult supportive services, including Ombudsman programs. They next viewed a video of 19 scenarios depicting various types of abuse and neglect while receiving care at the facility (two scenarios depicted appropriate care). Following the video, they were asked to develop their own strategies should they be similarly victimized. Of the findings, the participants demonstrated a poor awareness of adult protective services and other supportive services. While they were able to identify abusive situations 54 percent of the time, when asked how they would address abusive situations, 78 percent appeared unable to generate a plan without consulting with family. Among the implications is the need for educating residents regarding adult supportive services and abuse and neglect issues. It is likely that residents vulnerable to poor treatment would be unable to change their residence easily.
Yan, E. & So-Kum Tang, C.
Proclivity to Elder Abuse - A Community Study on Hong Kong Chinese
Journal of Interpersonal Violence; Vol. 18 (9), 999-1017; 2003.
As in other cultures, it is believed that while elder abuse exists in Chinese societies, it is under-reported. The researchers involved in this project suggest that studying the proclivity rates of elder abuse may provide additional information regarding the nature and scope of the problem. The study was designed to determine the proclivity rates of elder abuse in Hong Kong as well as to explore possible associations between attitudinal variables and childhood experiences of abuse and proclivity. Based upon the intergenerational theory of violence, researchers hypothesized that those participants exposed to family violence as children would report higher levels of proclivity towards various types of elder mistreatment. Based upon the ecological theory, they also hypothesized that participants with negative attitudes towards the elderly, modernity, and filial piety would also demonstrate greater proclivity. A convenience sample (drawn from community centers, professional organizations and college students) of 464 Chinese residents of Hong Kong, aged 18-70, completed this mailed survey. The Revised Conflict Tactics Scale (CTS2), The Modernity subscale of the Chinese Personality Assessment Inventory, the Filial Piety and Ancestral Worship subscale of the Chinese Individual Traditionality Scale, and a portion of the Revised Kogan Attitudes Toward Older People Scale were the instruments used. Among the results, there was a 20 percent proclivity rate towards verbal abuse (including spiteful statements, insults and shouting), a 2.4 percent proclivity towards physical abuse. A high level of childhood experience of abuse and negative attitudes towards the elderly were the most salient predictors for proclivity to elder abuse.
Yeaw, E. & Burlingame, P.
Identifying High-Risk Patients from the Emergency Department to the Home
Home Healthcare Nurse; Vol. 21 (7), 473-480; July 2003.
This article discusses the development of the High Risk Discharge Assessment Instrument (HRDAI) for use in the emergency department (ED) as well as in home care services. It was based upon the High Risk Fall Model (HRFM) since the retrospective study of medical records from an ED revealed that 65 percent of the admissions of patients 65 and over were due to falls. The tool identifies eight areas of potential risk: impaired mobility, living alone, mental status changes, the possibility of domestic violence or elder abuse, substance abuse, non-compliance, inadequate resources and repeat visits to the emergency room (ER). Composite scores indicate the suggested level of intervention, which range from further inquiry to social service referral (prior to or post-discharge) to the need for temporary nursing home placement. Early results indicate that the tool is effective in identifying patients in need of post discharge services, as researchers continue to test the tool in the Rhode Island hospital where it was developed. A copy of the HRDAI is included, along with guidelines for the adaptation of this process to home care nursing services.
Zeisel, J. et al.
Environmental Correlates to Behavioral Health Outcomes in Alzheimer's Special Care Units
The Gerontologist; Vol. 43 (5), 697-711; 2003.
In this study, researchers analyzed the association between behavioral health outcomes and environmental design features of nursing home special care units (SCUs) for residents with Alzheimer's disease. Agitation, aggression, psychotic symptoms, depression and social withdrawal were evaluated as dependent variables of specific proximal physical environmental factors. Fifteen SCUs were selected based on distinct environmental conditions to allow for increased statistical power of analysis. Environmental characteristics studied were exit control, walking paths, individual space, common space, outdoor freedom, residential character, sensory comprehension, and autonomy support. Nonenvironmental variables controlled for included resident characteristics (such as cognition, ADL skills, length of stay on the SCU, and prescription drug use) and facility characteristics (facility size and organizational status). Each design factor appeared correlated to behavioral outcomes. Among the findings, residents in facilities with more privacy generally scored lower on anxiety, aggression and psychotic problems scales. Facilities with greater variability in common areas appeared associated with lower rates of social withdrawal, and depression was negatively associated with facilities with camouflaged exits and silent electronic locks. This research supports earlier findings that environmental interventions may have a significant impact upon behavioral outcomes, and quality of care, of residents with dementia.
Zhang, X. & Grabowski, D.
Nursing Home Staffing and Quality Under the Nursing Home Reform Act
The Gerontologist; Vol. 44 (1), 13-23; 2004.
The purpose of this study was to determine whether the Nursing Home Reform Act (NHRA - part of the Omnibus Budget Reconciliation Act of 1987 or OBRA) has been effective in improving staffing and quality of care in nursing homes. Drawing upon secondary data sets from over 5,000 nursing homes collected through the 1987 Medicaid Automated Certification System (MMACS) and the 1993 Online Survey, Certification, and Reporting System (OSCAR), researchers examined the incidence of pressure ulcers, use of physical restraints, and the use of urinary catheters. Of the findings, there was an initial increase of staffing levels from 1987 through 1993. Using a first-difference fixed effects model, researchers examined whether staffing increases were associated with changes in quality of care. Overall, increases in staffing were not directly related to improved quality of care; however, increases in registered nurses' staffing appeared associated with improved care among facilities that were particularly deficient prior to the NHRA.
Zink, T., Regan, S., Jacobson, C. & Pabst, S.
Cohort, Period, and Aging Effects
Violence Against Women; Vol. 9 (12), 1429-1441; 2003.
This qualitative research examines the reasons that older women remain in relationships characterized by intimate partner violence. Thirty-six women aged 55 and over, participated in semi-structured interviews regarding the nature, frequency and patterns of the abuse, their relationships with their abusers, and reasons for maintaining or leaving their relationships. They were also asked to describe efforts to gain support, formally and informally. The audiotaped interviews were then analyzed and coded by a multidisciplinary research team to identify common themes. Although less than half of the participants remained in abusive relationships, most had been victimized for many years before deciding to leave. The decision to leave the relationship was typically catalyzed by a severe physical assault or another extramarital affair. Cohort effects that impacted upon the decision to leave included limited means of financial independence (including a lack of financial resources, minimal job skills or limited education). In addition, many women who stayed experienced psychological dependence and poor self-esteem. The length of the abuse appeared to intensify the shame experienced by these older women as compared to younger women. Other effects contributing to this decision include individual and institutional ignorance regarding the power and control dynamics of domestic violence. Physical limitations of both the women and their abusers were a significant aging effect that immobilized many of the participants. Researchers emphasize that these factors, unique to older women, need to be considered when developing and implementing interventions.
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