A model intervention for elder abuse and dementia

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Detection of Elder Abuse Among Orthopedic Patients

Approximately 10% of US adults experience elder abuse, which often manifests as musculoskeletal and soft tissue injuries. The goal of our study was to determine the rate of elder abuse among orthopedic surgery patients and characterize which patients may be at an increased risk. National Inpatient Sample Healthcare Cost and Utilization Project data from 2001 to 2015 were parsed with the Clinical Classifications Software tool. Patients 60 years and older were identified by International Classification of Diseases, Ninth Revision (ICD-9), code for elder abuse. Primary orthopedic procedures and subsequent inpatient diagnoses and comorbidities were used to develop a binary logistic regression model to predict an elder's risk of abuse. Of a total of 20,532,211 admissions for an orthopedic procedure, 0.010% (2084) were classified as elder abuse. Patients with a classification of abuse more commonly were women (74.8% vs 60.6%) and from the lowest socioeconomic quartile by income (28.5% vs 21.7%). In addition, these patients had hospital stays that were twice as long (10.2 vs 5.3 days) and had higher admission mortality rates (4.4% vs 1.2%). No primary orthopedic procedures were associated with a higher risk of elder abuse. Nonorthopedic diagnoses made during admission that were associated with increased risk of abuse included superficial injury or contusion (odds ratio [OR], 3.252), chronic skin ulcer (OR, 3.119), nutritional deficiency (OR, 3.418), fluid and electrolyte disturbances (OR, 1.729), and delirium or dementia (OR, 2.210). The incidence of elder abuse among orthopedic surgery patients is significantly lower than national estimates. This finding warrants further investigation to determine whether it is a function of underreporting or differences in patient populations, given the 4-fold increase in mortality risk. [Orthopedics. 2022;45(1):50-56.].

Abuse of Older Persons With Dementia: A Review of the Literature

In view of the rapidly aging population, increasing attention has been paid to studying persons with dementia. Factors associated with its onset, prognosis, and treatment as well as ways to support caregivers in the community have been extensively studied. Despite the fact that older persons with dementia are at higher risk of abuse compared to their cognitively unimpaired counterparts in institutions and the community, however, relatively little attention has been paid to understanding such abuse. This review summarizes the available literature on abuse of older persons with dementia. It compares methodologies used across studies and highlights the implications of using different informants, sampling strategies, and abuse subtypes in studying abuse of persons with dementia and discussed the relevant cultural considerations for research. The results of this review provide important information for researchers, policy makers, and practitioners.

The Effectiveness of Educational Programs to Improve Recognition and Reporting of Elder Abuse and Neglect: A Systematic Review of the Literature

Health professionals often lack adequate protocols or knowledge to detect, manage, and prevent elder maltreatment. This systematic review describes and evaluates existing literature on the effectiveness of educational interventions to improve health professionals' recognition and reporting of elder abuse and neglect. Fourteen articles described 22 programs ranging from brief didactics to experiential learning and targeted a variety of health and social service audiences. Most evaluations were limited to satisfaction measures. These programs may result in increased awareness, collaboration, and improved case finding. However, using the published literature to guide new program planning is constrained by lack of details and limited evaluations.

State of the science on prevention of elder abuse and lessons learned from child abuse and domestic violence prevention: Toward a conceptual framework for research

The goal of this review is to discuss the state of the science in elder abuse prevention. Findings from evidence-based programs to reduce elder abuse are discussed, drawing from findings and insights from evidence-based programs for child maltreatment and domestic/intimate partner violence. A conceptual measurement model for the study of elder abuse is presented and linked to possible measures of risk factors and outcomes. Advances in neuroscience in child maltreatment and novel measurement strategies for outcome assessment are presented.

Interventions for preventing abuse in the elderly

BACKGROUND

Maltreatment of older people (elder abuse) includes psychological, physical, sexual abuse, neglect and financial exploitation. Evidence suggests that 10% of older adults experience some form of abuse, and only a fraction of cases are actually reported or referred to social services agencies. Elder abuse is associated with significant morbidity and premature mortality. Numerous interventions have been implemented to address the issue of elder maltreatment. It is, however, unclear which interventions best serve to prevent or reduce elder abuse.

OBJECTIVES

The objective of this review was to assess the effectiveness of primary, secondary and tertiary intervention programmes used to reduce or prevent abuse of the elderly in their own home, in organisational or institutional and community settings. The secondary objective was to investigate whether intervention effects are modified by types of abuse, types of participants, setting of intervention, or the cognitive status of older people.

SEARCH METHODS

We searched 19 databases (AgeLine, CINAHL, Psycinfo, MEDLINE, Embase, Proquest Central, Social Services Abstracts‎, ASSIA, Sociological Abstracts, ProQuest Dissertations & Theses Global, Web of Science, LILACS, EPPI, InfoBase, CENTRAL, HMIC, Opengrey and Zetoc) on 12 platforms, including multidisciplinary disciplines covering medical, health, social sciences, social services, legal, finance and education. We also browsed related organisational websites, contacted authors of relevant articles and checked reference lists. Searches of databases were conducted between 30 August 2015 and 16 March 2016 and were not restricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised trials, and quasi-RCTs, before-and-after studies, and interrupted time series. Only studies with at least 12 weeks of follow-up investigating the effect of interventions in preventing or reducing abuse of elderly people and those who interact with the elderly were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the studies' risk of bias. Studies were categorised as: 1) education on elder abuse, 2) programmes to reduce factors influencing elder abuse, 3) specific policies for elder abuse, 4) legislation on elder abuse, 5) programmes to increase detection rate on elder abuse, 6) programmes targeted to victims of elder abuse, and 7) rehabilitation programmes for perpetrators of elder abuse. All studies were assessed for study methodology, intervention type, setting, targeted audience, intervention components and intervention intensity.

MAIN RESULTS

The search and selection process produced seven eligible studies which included a total of 1924 elderly participants and 740 other people. Four of the above seven categories of interventions were evaluated by included studies that varied in study design. Eligible studies of rehabilitation programmes, specific policies for elder abuse and legislation on elder abuse were not found. All included studies contained a control group, with five of the seven studies describing the method of allocation as randomised. We used the Cochrane 'Risk of bias' tool and EPOC assessment criteria to assess risk of bias. The results suggest that risk of bias across the included body of research was high, with at least 40% of the included studies judged as being at high risk of bias. Only one study was judged as having no domains at high risk of bias, with two studies having two of 11 domains at high risk. One study was judged as being at high risk of bias across eight of 11 domains.All included studies were set in high-income countries, as determined by the World Bank economic classification (USA four, Taiwan one, UK two). None of the studies provided specific information or analysis on equity considerations, including by socio-economic disadvantage, although one study was described as being set in a housing project. One study performed some form of cost-effectiveness analysis on the implementation of their intervention programmes, although there were few details on the components and analysis of the costing.We are uncertain whether these interventions reduce the occurrence or recurrence of elder abuse due to variation in settings, measures and effects reported in the included studies, some of which were very small and at a high risk of bias (low- and very low-quality evidence).Two studies measured the occurrence of elder abuse. A high risk of bias study found a difference in the post-test scores (P value 0.048 and 0.18). In a low risk of bias study there was no difference found (adjusted odds ratio (OR) =0.48, 95% 0.18 to 1.27) (n = 214). For interventions measuring abuse recurrence, one small study (n = 16) reported no difference in post-test means, whilst another found higher levels of abuse reported for the intervention arms (Cox regression, combined intervention hazard ratio (HR) = 1.78, alpha level = 0.01).It is uncertain whether targeted educational interventions improve the relevant knowledge of health professionals and caregivers (very low-quality evidence), although they may improve detection of resident-to-resident abuse. The concept of measuring improvement in detection or reporting as opposed to measuring the occurrence or recurrence of abuse is complicated. An intervention of public education and support services aimed at victims may also improve rates of reporting, however it is unclear whether this was due to an increase in abuse recurrence or better reporting of abuse.The effectiveness of service planning interventions at improving the assessment and documentation of related domains is uncertain. Unintended outcomes were not reported in the studies.

AUTHORS' CONCLUSIONS

There is inadequate trustworthy evidence to assess the effects of elder abuse interventions on occurrence or recurrence of abuse, although there is some evidence to suggest it may change the combined measure of anxiety and depression of caregivers. There is a need for high-quality trials, including from low- or middle-income countries, with adequate statistical power and appropriate study characteristics to determine whether specific intervention programmes, and which components of these programmes, are effective in preventing or reducing abuse episodes among the elderly. It is uncertain whether the use of educational interventions improves knowledge and attitude of caregivers, and whether such programmes also reduce occurrence of abuse, thus future research is warranted. In addition, all future research should include a component of cost-effectiveness analysis, implementation assessment and equity considerations of the specific interventions under review.

Development of a comprehensive hospital-based elder abuse intervention: an initial systematic scoping review

Introduction

Elder abuse, a universal human rights problem, is associated with many negative consequences. In most jurisdictions, however, there are no comprehensive hospital-based interventions for elder abuse that address the totality of needs of abused older adults: psychological, physical, legal, and social. As the first step towards the development of such an intervention, we undertook a systematic scoping review.

Objectives

Our primary objective was to systematically extract and synthesize actionable and applicable recommendations for components of a multidisciplinary intersectoral hospital-based elder abuse intervention. A secondary objective was to summarize the characteristics of the responses reviewed, including methods of development and validation.

Methods

The grey and scholarly literatures were systematically searched, with two independent reviewers conducting the title, abstract and full text screening. Documents were considered eligible for inclusion if they: 1) addressed a response (e.g., an intervention) to elder abuse, 2) contained recommendations for responding to abused older adults with potential relevance to a multidisciplinary and intersectoral hospital-based elder abuse intervention; and 3) were available in English.

Analysis

The extracted recommendations for care were collated, coded, categorized into themes, and further reviewed for relevancy to a comprehensive hospital-based response. Characteristics of the responses were summarized using descriptive statistics.

Results

649 recommendations were extracted from 68 distinct elder abuse responses, 149 of which were deemed relevant and were categorized into 5 themes: Initial contact; Capacity and consent; Interview with older adult, caregiver, collateral contacts, and/or suspected abuser; Assessment: physical/forensic, mental, psychosocial, and environmental/functional; and care plan. Only 6 responses had been evaluated, suggesting a significant gap between development and implementation of recommendations.

Discussion

To address the lack of evidence to support the recommendations extracted in this review, in a future study, a group of experts will formally evaluate each recommendation for its inclusion in a comprehensive hospital-based response.

Elder abuse and dementia: a review of the research and health policy

Older adults with dementia may be at high risk for abuse, but the topic has not been well studied. We conducted a literature review to examine the relationships between elder abuse and dementia. We found that psychological abuse was the most common form of abuse among older adults, with estimates of its prevalence ranging from 27.9 percent to 62.3 percent. Physical abuse was estimated to affect 3.5-23.1 percent of older adults with dementia. We also found that many older adults experienced multiple forms of abuse simultaneously, and the risk of mortality from abuse and self-neglect may be higher in older adults with greater levels of cognitive impairment. We summarize programs and policies related to the abuse of older adults with dementia, including adult protective services, mandatory elder abuse reporting, and the Long-Term Care Ombudsman Program. We also summarize aspects of the National Alzheimer's Project Act, the Older Americans Act, and the Elder Justice Act. In spite of a recent increase in research and policy developments on elder abuse, challenges such as insufficient funding, limited knowledge about elder abuse, a lack of funding for the implementation of federal and state programs relevant to elder abuse and dementia, and a lack of dementia-specific training for front-line health care staff persist. Stronger programs targeting the well-being of older adults with dementia are needed.

Physical mistreatment in persons with Alzheimer's disease

Physical mistreatment has been estimated to affect 2 million older persons each year and dramatically affects health outcomes. While researchers have attempted to examine risk factors for specific forms of abuse, many have been able to focus on only victim or perpetrator characteristics, or a limited number of psychosocial variables at any one time. Additionally, data on risk factors for subgroups such as persons with Alzheimer's disease who may have heightened and/or unique risk profiles has also been limited. This paper examines risk for physical violence in caregiver/patient dyads who participated in the Aggression and Violence in Community-Based Alzheimer's Families Grant. Data were collected via in-person interview and mailed survey and included demographics as well as measures of violence, physical and emotional health, and health behaviors. Logistic regression analysis indicated that caregivers providing care to elders with high levels of functional impairment or dementia symptoms, or who had alcohol problems, were more likely to use violence as a conflict resolution strategy, as were caregivers who were providing care to elders who used violence against them. By contrast, caregivers with high self-esteem were less likely to use violence as a conflict resolution strategy. Significant interaction effects were also noted.

Risk and ageing populations: practice development research through an international research network

Background.  Risk theories derive from a range of disciplines, with nursing traditionally concentrating on scientific medical perspectives. However, for older people, risk perception and management is filled with complexity and paradox, and the threat of focusing on physical safety only to the detriment of the well-being of the older person. Method.  An international collaborative research network on risk in ageing populations has been developed, with 22 members in six countries (Britain, USA, India, South Africa, Australia and Northern Ireland). The network supports several independent projects, many of which have developed as a result of the network. An annual workshop for members has provided the opportunity to share and synthesize methodological experiences and to identify a developing model of risk for older people. Findings.  The developing model highlights the importance for older people of engaging with risk in a positive way, and describes patterns of risk-philic and risk-phobic activity. The inter-relationship of the individual older person with their community, with practitioners and with society is specific to the context of different countries. Conclusion.  Socio-critical practice development research can be a vehicle for advancing an understanding of risk theory for older people. Risk underpins concepts of choice and capacity to execute decisions. It is influenced by society, policy, health and social care services, and has a profound impact on the experiences of older people.

Developing an empirical profile for elder abuse research in Canada

The aging population of Canada and the associated caregiving demands highlight the need for elder abuse research. The objectives of this article are to provide a review of literature while identifying recommendations and directions for future research. Significant gaps in the knowledge base are identified that preclude the development of effective programming and policies. Future research directions include prevalence studies in community and institutional settings; studies on correlates, risk, and protective factors; research to clarify definitional issues and to develop psychometrically sound measurements; qualitative studies; and the need to support elder abuse research through capacity building and appropriate resource strategies.

Educational support group in changing caregivers' psychological elder abuse behavior toward caring for institutionalized elders

Institutionalized elderly who are frail and dependent are vulnerable to be abused by overwhelmed caregivers especially caregiver psychological abusive behavior is a growing but hidden problem with few evidence-based interventions. The purpose of this study was to examine the effectiveness of an educational support group in alleviating caregiver's psychological abusive behavior, reducing work stress and promoting knowledge of geriatric care-giving among a group of caregivers. A quasi-experimental design using a case control pre-post test approach was conducted. A total of 100 participants completed the study with 50 caregivers in each group. The research instruments included the Caregiver Psychological Elder Abuse Behavior Scale (CPEAB), the Work Stressors Inventory (WSI), and the Knowledge of Gerontology Nursing Scale (KGNS). The results showed that the intervention had significant effects in alleviating caregiver psychological abuse behavior and increasing care-giving knowledge in the experimental group (p = .048; .018). However, the intervention had no measurable effect on work stress (p = .66). Findings have important implications for education and programming for facility administers and long-term care policy makers when planning quality improvement for elderly care.

Caregiver Burden, Dementia, and Elder Abuse in South Korea

The purpose of this study is to identify characteristics that would increase the likelihood that a Korean older adult with dementia being cared for by a family caregiver is at risk of being abused. This analysis was based on a sample of 481 primary family caregivers from the data of Comprehensive Study for the Elderly Welfare Policy in Seoul (2003). Multiple regression analysis was used to examine predictors among the demographic characteristics of caregivers and care recipients, the severity of cognitive impairment, functional ability, caregiver burden, and social support for the degree of elder abuse. The degree of elder abuse was significantly associated with caregiver burden, mental impairment, dependency of daily living of care recipient, and use of formal services.

Beyond Zero Tolerance: a varied approach to workplace violence

Violence in the health- and social-care workplace remains unexplored, with a knowledge base which is often ambiguous or incomplete. However, the issue has attracted increasing attention over the last two decades as indicated by an expanding range of policy initiatives and growing research literature. Additionally, a proliferation of training programmes for healthcare staff has appeared. This paper will explore the reasons for an observed tendency for interventions to focus on training as the primary response, which suggests a misperception of the problem of violence as principally a function of interpersonal conflict. It argues that a radical cultural shift is needed, which recognises the organizational and societal roots of violence, and that adopts and applies the principles of a public health approach.

Interventions from Home-Based Geriatric Assessments of Adult Protective Service Clients Suffering Elder Mistreatment

OBJECTIVES

To describe the interventions for adult protective service (APS) clients referred for geriatric assessment.

DESIGN

Retrospective cohort study.

SETTING

In-home geriatric assessments conducted in two New Jersey counties.

PARTICIPANTS

Two hundred eleven APS clients; 74% female; mean age 77.

MEASUREMENTS

Cognition, affect, nutrition, prevalence of selected medical diagnoses and functional conditions, and categories of interventions.

RESULTS

Home health agency services were initiated for 46% of APS clients suffering from all forms of mistreatment. Institutional placements (36%) and guardianship interventions (36%) were correlated with caregiver neglect, especially in female APS clients and those diagnosed with dementia. Urgent medications (25%) were prescribed across all mistreatment classifications, and acute hospitalization (20%) was correlated with circumstances of physical abuse.

CONCLUSION

An in-home geriatric assessment service was able to contribute at least one relevant intervention for 81% of referred APS clients to collaboratively help mitigate elder mistreatment circumstances.

Dementia and Elder Abuse

Dementia and elder abuse are relatively common and under-diagnosed geriatric syndromes. A unique relationship is observed when the two entities coexist. Special issues can confound the care of the dementia patient suspected of being abused. Impaired language or motor abilities to communicate abusive situations to a third party, lack of decisional capacity to address the abusive situation, disinhibited behavior that contributes to a cycle of violence, and coincident depression of the abused elder complicate the diagnosis and management of elder abuse. Education of the caregiver and attention to caregiver stress, including depression, may prevent onset and perpetuation of abuse.

Medical Implications of Elder Abuse and Neglect

Recognition of elder abuse and neglect among health care professionals has been a relatively recent phenomenon. Each year, millions of elderly persons suffer as the result of abuse and neglect. Their quality of life is severely jeopardized in the form of worsened functional status and progressive dependency, poorly rated self-health, feelings of helplessness, and from the vicious cycle of social isolation, stress and further psychologic decline. Other medical implications of abuse and neglect include higher health systems use in the form of frequent ER visits, higher hospitalization, and higher nursing home placement; most importantly, it is an independent predictor for higher mortality. Physicians are well situated in detecting and reporting suspected cases and taking care of the frail elders who are victims of abuse and neglect, but there are barriers on the individual level, and there is a broader need for system change. Through education, training, and reinforcement, there are strategies to get health care professionals more involved and provide effective management protocols and guidelines for us to advocate for our patients in the current epidemic of elder abuse and neglect.

Elder abuse

Elder abuse has received increasing attention over the past decade as a common problem with serious consequences for the health and wellbeing of old people. Our aim is to assist clinicians by summarising recent international research and clinical findings about elder abuse, and to assess their quality, relevance, and feasibility for health-care providers in clinical practice. This seminar includes issues of definition and frequency of elder abuse and a summary of major known risk factors. The advantages and disadvantages of screening for elder abuse are discussed. We review clinical manifestations and diagnosis of elder abuse, and propose a protocol for medical assessment of a patient with confirmed or suspected abuse. Suggestions for treatment are offered on the basis that elder abuse is multifactorial and needs individual medical and social intervention strategies, preferably in the context of a multidisciplinary team.

Elder abuse: the role of the orthopaedic surgeon in diagnosis and management

Increased awareness of elder abuse has led to the recognition that mistreatment of individuals over the age of 65 years is a widespread public health problem. It is estimated that the prevalence of elder abuse is 32 cases per 1,000 persons and is increasing with the growing elderly population. Elder abuse is suspected to be a major source of morbidity and mortality, representing a high economic burden to society. The diagnosis of elder abuse is seldom straightforward due to social issues, cognitive impairment, and comorbid conditions, and requires careful correlation of historical and clinical findings. Comprehensive evaluation, including a detailed history, systematic physical examination, and appropriate laboratory and radiographic assessment, is essential. The orthopaedic surgeon consulted to evaluate an elderly individual with musculoskeletal injuries must be cognizant of the potential for elder abuse, especially when circumstances are suspect. The role of the orthopaedic surgeon is often fundamental to establishing whether musculoskeletal injuries are consistent with the stated mechanism of injury. Due to the variety of presentations, there are no fracture patterns considered pathognomonic of elder abuse. Rather, the nature and pattern of injury must be viewed in the context of the general health and psychosocial environment of the patient to determine whether abuse has occurred. Once the diagnosis of elder abuse has been made, a comprehensive, multidisciplinary long-term care plan must be formulated to ensure patient safety while respecting the autonomy of a competent individual. Physicians have an ethical and legal responsibility to protect patients from suspected abuse, and most states mandate reporting by health-care personnel.