Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients Under Guardianships

Palliative care clinicians often help facilitate coordination of care, complex serious illness, and end-of-life medical decision-making. However, the clinical and legal issues related to guardianship can complicate the decision-making process, care delivery, outcomes, and the role of the palliative care clinician. Adult patients who have a guardian have been found by a court to be unable to make some or all decisions for themselves. Providing care for patients under guardianship is where medicine overlaps with legal rights. It is crucial to be familiar with the patients' rights and the guardians' responsibilities to clarify medical decision-making processes and identify necessary authorities. This article uses an interprofessional approach to leverage the expertise of physicians, nurses, lawyers, and guardians and to guide palliative care clinicians to optimally support patients under guardianship.

Motivations Behind Dog Walking in Older Adults: Insights From Guided Walks and Interviews

For many older adults, physical activity declines with age, contributing to chronic disease and social isolation. Companionship from dogs can help mitigate isolation and promote physical activity. Outdoor environments aligned with the abilities of older adults can encourage walking habits and socialization. To understand how neighborhood features influence dog walking, we adapted a Photovoice approach and photographed 12 older adults walking their dog. Photographs were presented during in-person interviews to facilitate discussions about environmental features. Thematic coding revealed that interactions with nature were key. Participants valued choices in walking path type and conveniently placed dog waste stations. Opportunities to socialize with neighbors were also important. Safety from falling, other animals, and motorized traffic were concerns but were not enough to prevent walking. Our findings suggest that walking environments intended for older adults with dogs should include experiences with nature, diverse path designs, and dog-specific amenities.

Ageism as a Source of Global Mental Health Inequity

Ageism manifests as stereotyping of or discrimination against people-usually older adults-because of their age. Since ageism contributes to global mental health inequity among older people, responding to their needs should be a clinical, ethical, and policy priority. This article suggests how relatively simple, low-cost, high-yield interventions can be implemented globally and domestically to improve the well-being and quality of life of older individuals.

Financial Fraud of Older Adults During the Early Months of the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) created a "perfect storm" for financial fraud targeting older adults. Guided by the Contextual Theory of Elder Abuse, we focused on individual and systemic contexts to examine how older adults became prey to financial fraud.

RESEARCH DESIGN AND METHODS

In July 2020, 998 adults who were 60-98 years of age (93% White; 64% female) completed an online survey about experiences with financial fraud. Participants were recruited from gerontology research registries at Florida State University, University of Pittsburg, Virginia Tech, and Wayne State University.

RESULTS

Over half (65.9%) of the respondents experienced a COVID-19-related scam attempt, with charity contributions (49%) and COVID-19 treatments (42%) being the most common. Perpetrators commonly contacted older adults electronically (47%) two or more times (64%). Although most respondents ignored the request (i.e., hung up the phone and deleted text/e-mail), 11.3% sent a requested payment, and 5.3% provided personal information. Predictors of vulnerability included contentment with financial situation, concern about finances in the aftermath of the pandemic, and wishing to talk to someone about financial decisions. Respondents targeted for a non-COVID-19 scam attempt were less likely to be targets of a COVID-19-related scam.

DISCUSSION AND IMPLICATIONS

Older adults who were financially secure, worried about their financial situation, or wished they could speak with someone about their financial decisions appeared susceptible to falling victim to a fraud attempt. The high number of attempts indicates a need for a measurable and concerted effort to prevent the financial fraud of older adults.

The Context of Elder Maltreatment: an Opportunity for Prevention Science

Elder maltreatment (EM) has been understood as a worldwide major public health threat for decades, yet it remains a form of victimization receiving limited attention, resources, and research. EM, which includes caregiver neglect and self-neglect, has far-reaching and long-lasting impacts on older adults, their families, and communities. Rigorous prevention and intervention research has significantly lagged in proportion to the magnitude of this problem. With rapidly growing population aging, the coming decade will be transformative: by 2030, one in six people worldwide will be aged 60 or older, and approximately 16% will experience at least one form of maltreatment (World Health Organization, 2021). The goal of this paper is to raise awareness of the context and complexities of EM, provide an overview of current intervention strategies based on a scoping review, and discuss opportunities for further prevention research, practice, and policy within an ecological model applicable to EM.

Exploration and Comparison of Contextual Characteristics and Mistreatment Prevalence Among Older American Indian and Alaska Native Respondents: Secondary Analysis of the National Elder Mistreatment Study

Limited research on elder abuse among American Indians and Alaska Natives (AIANs) suggests a higher prevalence of abuse. Using data from the National Elder Mistreatment Study (NEMS), we compared contextual characteristics and elder mistreatment prevalence rates from a community-based sample of AIAN (n = 195) and Black (n = 437) and White (n = 5,013) respondents. There were differences in the prevalence of 16 abuse types and the 23 contextual variables. AIAN respondents had more similarities compared with Black respondents than White respondents, though differences existed. The cumulative prevalence of emotional, physical, and sexual mistreatment in the past year, neglect, and financial abuse by a family member for the AIAN group was 33%, almost double the 17.1% reported in the NEMS study. Over their lifetime, 29.7% of AIAN respondents reported experiencing two or more types of neglect, exploitation, or mistreatment. Almost one fourth of AIAN respondents reported emotional abuse since 60 years of age (the most commonly occurring abuse type)-nearly double that of White respondents. This is the first study to offer comparative prevalence of elder abuse for both AIAN older males and females that draws from a nationally representative sample. The study also provides descriptive analysis of important contextual information within the AIAN population, an underrepresented racial group in elder abuse research. Disaggregating nonmajority racial groups to examine contextual variables and the prevalence of elder mistreatment in the NEMS data set specific to AIAN respondents fills a knowledge gap. Known prevalence of various abuse typologies among AIAN elders can be useful in setting priorities for community planning and response, and in prioritization of funding for future research on causative mechanisms by abuse type, screening, and interventions at various levels. Findings may facilitate development of culturally specific evidence-based prevention and intervention practices aimed at needs specific to AIAN older adults.

Unrepresented Adults Face Adverse Healthcare Consequences: The Role of Guardians, Public Guardianship Reform, and Alternative Policy Solutions

Persons without family or friends to serve as healthcare agents may become "unrepresented" in healthcare, with no one to serve as healthcare agents when decisional support is needed. Surveys of clinicians (N = 81) and attorneys/guardians (N = 23) in Massachusetts reveal that unrepresented adults experience prolonged hospital stays (66%), delays in receiving palliative care (52%), delays in treatment (49%), and other negative consequences. Clinicians say guardianship is most helpful in resolving issues related to care transitions, medical treatment, quality of life, housing, finances, and safety. However, experiences with guardianship are varied, with delays often/always in court appointments (43%) and actions after appointments (24%). Policy solutions include legal reform, education, and alternate models.

Characteristics of Socially Isolated Residents in Long-Term Care: A Retrospective Cohort Study

Objectives: To identify socially isolated long-term care residents and to compare their demographic characteristics, functional status, and health conditions to residents who are not isolated. Methods: We conducted a retrospective cohort study using the Resident Assessment Instrument, Minimum Data Set, 2.0 (RAI-MDS) data, from residents in 34 long-term care homes in Alberta, Canada (2008–2018). Using logistic regression, we compared the characteristics, conditions, and functional status of residents who were socially isolated (no contact with family/friends) and non-socially isolated residents. Results: Socially isolated residents were male, younger, and had a longer length of stay in the home, than non-socially isolated residents. Socially isolated residents lacked social engagement and exhibited signs of depression. Discussion: Socially isolated residents had unique care concerns, including psychiatric disorders, and co-morbid conditions. Our approach, using a single item in an existing data source, has the potential to assist clinicians in screening for socially isolated long-term care residents.

Challenges in Caring for Unbefriended Residents in Long-term Care Homes: A Qualitative Study

OBJECTIVES

This study examined challenges experienced by long-term care staff in caring for unbefriended residents who are incapacitated and alone. These residents often are estranged from or have no living family or live geographically distant from them and require a public guardian as their surrogate decision-maker. To date, research on unbefriended older adults has focused on those living in acute care and community settings. Little is known about those living in long-term care homes.

METHOD

We conducted semi-structured interviews with 39 long-term care staff (e.g., registered nurses, care aides, social workers) and 3 public guardians. Staff were sampled from seven long-term care homes in Alberta, Canada. We analyzed interview transcripts using content analysis and then using the theoretical framework of complex adaptive systems.

RESULTS

Long-term care staff experience challenges unique to unbefriended residents. Guardians' responsibilities did not fulfill unbefriended residents' needs, such as shopping for personal items or accompanying residents to appointments. Consequently, the guardians rely on long-term care staff, particularly care aides, to provide increased levels of care and support. These additional responsibilities, and organizational messages dissuading staff from providing preferential care, diminish quality of work life for staff.

DISCUSSION

Long-term care homes are complex adaptive systems. Within these systems, we found organizational barriers for long-term care staff providing care to unbefriended residents. These barriers may be modifiable and could improve the quality of care for unbefriended residents and quality of life of staff. Implications for practice include adjusting public guardian scope of work, improving team communication, and compensating staff for additional care.

Experiences With Involuntary Nursing Home Relocation: The Staff Perspective

Although involuntary nursing home closures for operational and care-related reasons occur infrequently, few studies have examined the centrality of the actions of staff to facilitate residents' relocation adjustment. We interviewed 18 administrators and 43 staff working at 27 facilities about the relocation process for residents from two facilities that lost their Medicare and State Medicaid certification due to ongoing care deficiencies. Thematic analysis revealed three major themes throughout each aspect of the relocation process: (a) staff expectations were not met, (b) barriers/challenges were persistent, and (c) resident/family involvement was minimal. We offer proactive participant-derived recommendations for policy and practice to strengthen involuntary relocation processes to ensure a cooperative work environment and residents' well-being, regardless of the cause for involuntary closure.

A First (and Disturbing) Look at the Relationship Between the Opioid Epidemic and Elder Abuse: Insights of Human Service Professionals

This study explored the relationship between the opioid epidemic and elder abuse. Twenty professionals from four states with working knowledge of elder abuse cases participated in focus groups. Thematic analysis revealed four themes characterizing the relationship between opioid misuse and elder abuse: (a) Opioid-Related Elder Abuse is an Escalating Problem; (b) Vulnerable Older Adults are Prisoners in Their Own Home; (c) Health Care Professionals Perpetrate Opioid-Related Elder Abuse; and (d) Older Adults Abuse and Deal Opiates. In addition, all participants noted the lack of reliable, retrievable data to address cases of elder abuse when opioids are involved. Findings lay the groundwork for further research to understand the breadth and depth of the opioid-elder abuse relationship that can ultimately be used to develop prevention and intervention strategies and policies to address this hidden but widespread concern.

ELDER FINANCIAL ABUSE IN FAMILIES: EXPANDING THEORY AND RESEARCH

Elder family financial exploitation (EFFE) is widespread and increasing. The effect is devastating, causing significant financial losses, reducing health and well-being of elders, and disrupting family systems. Research reveals that most (90%) perpetrators are family members or trusted others and researchers typically focus on identification of the problem, rather than understanding how and why exploitation occurs within the family unit. Furthermore, limited consensus exists regarding a theoretical understanding of the complexities of EFFE. Theory-driven, empirical explanations of how and why EFFE transpires are urgently needed to enhance and deepen intervention and prevention efforts. In this symposium, we extend both theory and research by using a common theoretical lens to present research findings from three distinct EFFE studies. The first paper reviews the current literature on EFFE and theory and introduces Bronfennbrenner’s bioecological Process-Person-Context-Time (PPCT) model as an under-utilized, but useful framework for understanding EFFE. The second paper reports on findings from in-depth interviews with non-perpetrator family members who experienced EFFE and will highlight complex intergenerational family systems processes in PPCT. The third paper highlights findings from a national study of substantiated and investigated cases of EFFE in which family member perpetrators were designated as surrogate decision makers. The fourth paper shares results from a qualitative study of family member POAs and how components of the PPCT model can be interpreted for use by helping professionals assisting families. We will also focus on the opportunities and challenges of developing theoretically sound EFFE research and the implications for improving practice and policy.

THE USE OF ELDERCARING COORDINATION FOR RESOLVING CASES INVOLVING OLDER ADULTS AND HIGH-CONFLICT FAMILY DYNAMICS

The Association for Conflict Resolution and The Florida Chapter of the Association of Family and Conciliation Courts developed a model of Eldercaring Coordination for use in guardianship/probate cases involving high-conflict family dynamics that interfere with the well-being and safety of an older adult, limit adherence to court orders, impede court processes, or detract from the efficacy of guardianship and other appointments by the court. Developed by 40 organizations and entities in the United States and Canada, Eldercaring Coordination focuses on improving family dynamics so that the older adult, family members, and other involved parties can better work together and with professionals to make thoughtful and informed decisions and to support each other during times of transition. The purpose of this research was to gather information about participant experiences with Eldercaring Coordination. A pre-post test design was employed in which data were collected from older adults or their surrogates, family members and other court-ordered participants, judges and court administrators, and the Eldercaring Coordinators themselves. Findings from post-tests of 23 judges and court administrators revealed that the most common advantages of Eldercaring Coordination were that the intervention prioritized the older adults’ needs and improved family relationships. Post-test surveys from 17 Eldercaring Coordinators indicated some positive outcomes for older adults and their families, but also a need for enhanced authority, greater support from attorneys, and more cooperation from participants. Preliminary findings support the assertion that Eldercaring Coordination holds promise for intervening in high-conflict court cases involving older adults.

STAFF PERCEPTIONS OF INVOLUNTARY NURSING HOME CLOSURE AND RELOCATION PROCESSES

Involuntary nursing home closures happens infrequently, but when they do occur, they impact residents, their family, and facility staff. During the transition, residents’ care needs are of primary concern, yet few studies have examined the centrality of the actions of staff to residents’ relocation adjustment. This paper examined staff perceptions of the involuntary relocation process for 132 residents after a facility lost its Medicaid certification because of low quality performance. Interviews were conducted with 34 staff (e.g., administrators, nurses, social workers) from 21 receiving facilities. Using content analysis, we identified challenges that hindered relocation and affected resident/family experiences. Receiving facility staff perceived undue distress and hardship on residents and family members because of inadequate notification about the situation. Limited, untimely, and poor communication led to residents being uninformed or unprepared for moving. The efficiency and effectiveness of the resident discharge process was also viewed as unacceptable. Minimal documentation in residents’ charts hampered the coordination of resident moves. Receiving facility staff offered recommendations for decertified facilities and receiving facilities to improve the relocation experience including the need for open communication, thoughtful and early engagement in the process, and transparent and timely interactions. Findings suggest that staff are well-positioned for active involvement in the relocation process and should facilitate deliberate and strategic planning, decision-making, and communication with residents and their relatives. Resident-centered policies are needed to improve the involuntary relocation process and give voice to remaining/receiving staff, both of whom are integral to residents’ support system.

THE INTERSECTION OF ETHICS AND VULNERABLE ELDERS

Researchers, practitioners and policymakers are daily confronted with multiple and competing situations regarding vulnerable older adults and the complex issues that they face in all aspects of their lives. Challenges can arise in the provision of social services, dispensing justice, conducting research, or addressing legal issues. The purpose of this symposium is to discuss dilemmas that vulnerable older adults and concerned others face by elucidating current and future challenges facing this population, particularly in the realms of compromised health (cognitive impairment); effective status (gender); care arrangements (home and community-based services); and abuse, neglect, and exploitation. Teaster and Anetzberger discuss relevant ethical theories and principles as well as a definition of vulnerability. Santos and Nichols-Hadeed report on ethical issues embedded in vulnerable elders’ cognitive status. Bowland and Halaas highlight the intersection of ethics, gender and vulnerable elders. Niles-Yokum and Beaumaster discuss the nexus of ethics and the provision of home and community based services for vulnerable older adults. Heisler considers vulnerabilities of older adults and ethical challenges when addressing elder abuse. Throughout the papers, we weave the ethical principles of autonomy, beneficence, nonmaleficence, and justice.

ELDER ABUSE AMID THE OPIOID EPIDEMIC: APS CASES IN RURAL AMERICA

Older adults are hidden victims of the opioid crises, suffering abuse at the hands of those who seek resources to support their addiction. Using APS data from 2015-2017 provided by the Kentucky Department for Community-Based Services, we used a logistic regression model with robust standard errors to examine whether substantiated cases of elder abuse were associated with opioid misuse by perpetrators. Overall, 9% of the 462 substantiated cases over the three-year period involved perpetrators were substance users. The percentage of these cases rose from 5% in 2015 to 13% in 2016 before dropping to 7% of elder abuse cases in 2017. Opioid use was most prevalent among perpetrators of financial abuse of older adults with cognitive and/or physical care needs. The current study offers a first look at empirical linkages between opioid misuse and elder abuse and revealed consistencies across cases that call for further investigation.

ELDER ABUSE AND THE OPIOID CRISIS: PERPETRATORS WHO ARE SUBSTANCE USERS

Substance abuse, particularly the diversion/abuse of prescription drugs along with illicit opioid deviates by alleged perpetrators has been identified as is a risk factor for elder abuse. The purpose of this study was to characterize cases of elder abuse substantiated by APS in which the perpetrator used opioids and related substances. Guided by the Contextual Theory of Elder Abuse, we conducted a within-case/across-cases thematic analysis of Kentucky APS caseworkers’ notes on 40 substantiated cases of elder abuse. Financial exploitation was the most commonly identified type of abused associated with perpetrators who abuse opioids. Findings revealed that most cases of elder abuse occurred when the perpetrators’ substance abuse intersected with employment status, complex family relationships, and a history of altercations with the law. Findings provide new insights into a more elaborate conception of the ways in which the opioid epidemic is contributing to the perpetration of elder abuse today.

Victim, Allegation, and Investigation Characteristics Associated With Substantiated Reports of Sexual Abuse of Adults in Residential Care Settings

The purpose of this study was to identify characteristics of investigations of sexual abuse concerning vulnerable adults residing in facility settings that were associated with case substantiation. Data on 410 reports of sexual abuse were collected prospectively from Adult Protective Services (APS) and state licensure agency staff in New Hampshire, Oregon, Tennessee, Texas, and Wisconsin over a six-month period. Specifically, we examined differences between reports that were substantiated and those that were not by comparing characteristics of alleged victims, alleged perpetrators, and aspects of investigation using logistic regression. We found that a relatively low proportion of cases (18%) were substantiated overall. Compared to cases that were not substantiated, cases that were substantiated were more likely to feature nursing home residents, older victims, female victims, and allegations of physical contact between the alleged perpetrator and victim. Despite the high proportion of alleged perpetrators who were facility staff (51%) compared to resident perpetrators (25%), cases with resident-to-resident allegations of abuse were much more likely to be substantiated, accounting for 63% of substantiated cases. In light of these findings, we believe it is important that investigators are trained to handle sexual abuse cases appropriately and that they are able to investigate the case thoroughly, promptly, and with as much information as possible. It is also critical that investigators make substantiation decisions using the appropriate standard for confirmation (e.g., preponderance of the evidence, beyond a reasonable doubt, clear and convincing evidence) as state law dictates.

Assessing the Federal Response to Elder Abuse, While the Opioid Crisis Rages On

The opioid crisis directly connects to elder abuse: grandparents may be caring for grandchildren of parents addicted to opioids; and family members, caregivers, and older adults may misuse opioids. The Elder Justice Act, the Older Americans Act, the Omnibus Reconciliation Act of 1981, and the Elder Abuse Prevention and Prosecution Act dictate responses to such opioid misuse. The Administration for Community Living, the Administration on Aging, the Office of Community Services, and the Department of Justice administer these laws. This article describes the laws, their status, and programs these agencies authorize.