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Risk Assessment Instruments

by Rosalie Wolf, Ph.D.
Special Research Review Section
National Center on Elder Abuse NewsletterSeptember 2000

Introduction

Since elder abuse first appeared as a social and health problem, researchers have been seeking ways to create a tool to identify the elder at risk of abuse, neglect, and exploitation that is reliable (scores are consistent over time), valid (instrument measures what it is supposed to measure), and generalizable (instrument can be used in other locations and on other populations). Unfortunately, most elder abuse screening tools in use do not meet these standards because producing such a tool requires a rigorous research process that is very expensive.

Risk assessment instruments for elder abuse can be grouped into two categories: the first are screening tools whose purpose is to identify abused elders and elders at risk of abuse (primary prevention); the second are instruments whose purpose is to assess an existing case of elder abuse for future risk (secondary prevention). Examples of these two types are presented below.

Screening Instruments

A team from McMaster University, in a study of screening instruments, identified 90 articles in the English literature that discussed risk factors. Of these, 18 included a screening tool but only six provided information regarding the reliability and validity of the instrument (Fulmer & O'Malley, 1987; Hamilton, 1989; Hwalek & Sengstock, 1986; Reis & Nahmiash, 1995a; Reis & Nahmiash, 1995b; and Reis & Nahmiash, 1998) (Shott et al., 1999). It is interesting to note that the first three were done in the late 80s. The latter three were carried out as part of one Canadian study of risk factors in the late 90s. Two of these instruments -- the recently re-analyzed Hwalek-Sengstock instrument and a new tool that was developed under more rigorous application of research methodology than some others -- are discussed below.

Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). These researchers pooled over 1000 items from existing elder abuse assessment protocols to develop a 15 item tool which measured three aspects of abuse: (1) violation of personal rights or direct abuse, (2) characteristics of vulnerability, and (3) potentially abusive situations. It was designed to be completed by older people themselves and is the only self-report measure in the above group. Although preliminary validation was reported, work on the tool was not extended beyond the original validated samples. Eventually, using discriminant analysis, the authors found that the following set of six items discriminated as effectively between the abuse and non-abuse groups as did the original 15 items (Neale et. al., 1991):
  1. Has anyone close to you tried to hurt or harm you recently?
  2. Do you feel uncomfortable with anyone in your family?
  3. Does anyone tell you that you give them too much trouble?
  4. Has anyone forced you to do things that you didn't want to do?
  5. Do you feel that nobody wants you around?
  6. Who makes decisions about your life... like how you should live or where you should live?

The instrument is limited because of the small unrepresentative samples used to test it, the low internal consistency, and a relatively high false negative rate, suggesting that some cases of actual abuse may be missed.

Very recently, the original 15-item H-S/EAST screening tool has been the subject of further analysis by the Australian Women's Health Survey (Schofield, 1999). Two additional items were added: "Has anyone close to you called you names or put you down or made you feel bad recently?" and "Are you afraid of anyone in your family?" Then the survey group examined the reliability and validity of the resultant instrument on a nationally representative community-based sample of older Australian women (n=12,340). Their exploratory analyses led to the deletion of five of the 15 items from the H-S/EAST. The remaining 12 factors were divided into four categories which they labeled: vulnerability, dependence, dejection, and coercion. Further investigation revealed that "dependence" had more to do with autonomy than abuse and "dejection," with depression and mental health issues. The authors suggest that responses to the six remaining items could provide a simple screening tool for elder abuse:
  1. Are you afraid of anyone in your family?
  2. Has anyone close to you tried to hurt or harm you recently?
  3. Has anyone close to you called you names or put you down or made you feel bad recently?
  4. Does someone in your family make you stay in bed or tell you you're sick when you know you aren't?
  5. Has anyone forced you to do things you didn't want to do?
  6. Has anyone taken things that belong to you without your OK?

Indicators of Abuse Screen (Reis & Nahmiash, 1998). This tool is very different from the one just described because it is completed by trained professionals, usually after a 2-3 hour comprehensive assessment (filling out the form itself takes about 20 minutes). The study isolated 29 abuse indicators from a preliminary checklist of 48 problems and 12 background/demographic items that related both to the caregiver and care recipient, scored on a 5-point rating scale. The 29 items could be organized into three categories:
  1. Caregiver intrapersonal problems/ issues (e.g. mental health, behavioral, and alcohol or other substance abuse difficulties);
  2. Caregiver interpersonal problems (e.g. marital and family conflict and poor relationships generally with the care receiver, etc.); and
  3. Care receiver social support shortages and past abuse.

The strengths of the tool include its demonstrated reliability and validity and successful identification of 78-84% of senior abuse cases entering a health and social service agency.

Extent of Future Risk

A 1995 survey of state APS programs indicated that 18 states used a risk assessment tool that described the client's current level of risk for future abuse, neglect, and exploitation (Goodrich, 1997). Only three states had tested the form for reliability and validity; a fourth state tested for validity only. Determination of risk was carried out at varied times in the process of case investigation and care planning: during the initial assessment, at the substantiation decision point, periodically while the case was open, at case closure, and all of the above. Such tools generally contain a list of indicators or conditions which were rated with regard to the level of risk for the victim or the abuser. The Illinois form is an example. They included 33 items categorized as follows:
  1. Client characteristics (e.g., age, gender, physical or functional health, confusion, deteriorating emotional health, etc.);
  2. Environmental risk factors (e.g., health violations, structural soundness of victim's home, home location, termination of utilities in the home, etc.);
  3. Support services (e.g., availability of needed community services, adequacy of formal supportive services, and adequacy of informal support network, etc.);
  4. Current and historical abuse factors (e.g., previous history of abuse, severity or escalating pattern of abuse, etc.); and
  5. Abuser factors (e.g., physical or functional limitations, caregiver skills and knowledge, active alcoholism and other substance abuse, mental health problems, emotional or financial dependency, chronic fatigue).

The APS caseworker then rated the victim's level of risk for each factor using the following categories: no risk/low risk: situation had a low likelihood of reoccurring; medium/intermediate risk: situation may continue or possibly escalate; and high risk: situation will very likely continue and probably escalate. For each of the 33 items, at each level of risk, a description is given to guide the caseworker in making a decision. In trying to quantify the assessment, Illinois assigned a numerical value of 1-3. However, there was no formula for measuring overall risk; that was still based on the clinical judgment of the caseworker and supervisor. The state of Illinois analyzed their FY1994 data and found that at intake 18.4% of substantiated cases were at low risk, 60.2% were at medium risk, and 21.4% were at high risk. At case closure, the respective percentages were 63.9%, 27.7%, and 8.4%. After several years in use, the Illinois form is being modified. One of the issues raised by the caseworkers was the need to extend the range from 1-3 to 1-5 or 1-7 to help them make decisions.

Another type of assessment tool is used in Colorado. Using field staff, the Colorado APS developed a risk assessment tool based on the case worker's and supervisor's clinical judgment after an ongoing assessment and management of the case. The rating consisted of: Immediate (high risk), Preventive (moderate risk), and None (low risk). The assessment form consists of 175 different indicators. Much of the information has now been incorporated into their new APS data management system, which will replace the assessment tool.

It does not appear that much progress has been made in quantifying or standardizing the process of risk assessment. It is still basically a qualitative process that reflects clinical judgment. The states do not have the resources to develop an instrument that would meet psychometric properties and established researchers as yet have not expressed an interest on working on the problem. However, with the development of data management systems, APS programs will be in a better position to monitor cases and to produce data that will allow for quantification of risk and measurement of outcomes.

References

Fulmer, T.T. & O'Malley, T.A. (1987). Inadequate care of the elderly: A health care perspective on abuse and neglect. New York: Springer.
Goodrich, C. S. (1997). Results of a national survey of state protective services programs: Assessing risk and defining victim outcomes. Journal of Elder Abuse & Neglect, 9(1), 69-86.
Hamilton, G.P. (1989). Using a family systems approach: Prevent elder abuse. Journal of Gerontological Nursing, 15(3), 21-26.
Hwalek, M.A. & Sengstock, M. C. (1986). Assessing the probability of abuse in the elderly: Toward development of a clinical screening instrument. Journal of Applied Gerontology, 5(2), 153-173.
Neale, AV, Hwalek, MA, Scott, RO, Sengstock, MC, and Stahl, C. (1991). Validation of the Hwalek-Sengstock elder abuse screening test. Journal of Applied Gerontology, 10(4), 406-418.
Reis, M. & Nahmiash, D. (1995a). Validation of the caregiver abuse screen (CASE). Canadian Journal on Aging, 14(sup2), 45-60.
Reis, M. & Nahmiash, D. (1995b). When seniors are abused: An intervention model. The Gerontologist, 35, 666-671.
Reis, M. & Nahmiash, D. (1998). Validation of the indicators of abuse (IOA) screen. The Gerontologist, 38(4), 471-480.
Scofield, M., Reynolds, R., Mishra, G., Powers, P. & Dobson, A..(1999). Vulnerability to abuse, powerlessness and psychological stress among older women: Unpublished report. Callaghan, NSW, University of Newcastle: Women's Health Australia Study.
Shott, P., Ploeg, J. & Hutchison, B. (1999). Systematic overview of screening tools in elder abuse. Unpublished report. Hamilton, Ontario: McMaster University.

Last Updated: May 26, 2003  Top

     
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