Elder Abuse Workshop: The System Response to Elder Abuse - Reports from Current or Recently Completed Research Projects

Panel Presentations:

Frederick Newman — Testing a Model of Elder Mistreatment and Barriers to Help Seeking

Goals:

  • To test the full structural equation model.
  • To test factor invariance by type of abuse, ethnicity, age clusters and first-order interactions.
  • To hold community workshops on a coordinated community plan.

Study Design: A total of 450 women of varying ethnicities individually completing a three-part survey on barriers and types of abuse, conflict tactics scale and demographics. Follow up with unstructured interviews with nine victims who sought help and nine who did not. Analysis includes unified coding strategy, individual coding and constant comparison method, results confirmed by multiple groups and respondents.

Observations: The people the study focuses on are not in the system. If anything we code is not in two or more people or in two or more groups, it is not included.

Conclusions: In relation to the Barriers to Help Seeking model we will look at covariance structure as to how these things relate to each other and across groups. This is more in the area of preventive intervention. We will work with authorities in the community to see if the results of the study can help them. We are working at the statistical and change level.

Shelly Jackson — Financial Abuse of the Elderly Versus Other Forms of Elder Abuse - Assessing the Dynamics, Risk Factors and Society's Response

Goals:

  • Compare risk factors associated with various forms of elder mistreatment.
  • Compare the outcomes of the various forms of elder abuse.
  • Compare the elder person's and caseworker's perceptions of the case.
  • Consider whether the current APS model is an appropriate way of responding to financial exploitation.

Study Design:

  • Conduct triangulated interviews [APS caseworker (N = 240); elder (N = 240); caregiver, residential partner or other (N = 120)].
  • Use four types of cases [financial (n = 60), physical (n = 60), neglect by other (n = 60), hybrid (n = 60)].
  • Eligibility - incident (not necessarily substantiated, but not invalidated) occurred within last 18 months to an elderly person over the age of 59 who was living in his or her home at the time, and the APS investigation is closed.

Observations: All participants will be asked about the incident during the interview. The APS response and outcome will be noted and all caseworkers will be asked about their opinion and experience. The IRB required that the interview be limited to 90 minutes, but the investigators have discretion to continue longer if the elder person seems to want to extend the interview. The elder person and the caregiver each receive $75 compensation; we are not allowed to compensate APS workers. Virginia APS indicators of financial exploitation will be used. Lawyers will use the Lawyer Assessment of Capacity to evaluate whether the volunteer has the capacity to be interviewed. Data collection will take 18 months.

Conclusions: None yet.

Meghan Slipka — How Protective Behaviors and Risk Factors Affect the Course of Abuse Over Time

Goals:

  • To determine the proportion of cases in which abuse escalates, maintains or desists.
  • To determine the risk factors associated with the onset of abuse and its persistence.
  • To determine which victims receive assistance from police and other service providers and why.
  • To determine how reporting abuse and/or other protective measures taken by victims affect the course of the abuse.

Study Design: Population is either elderly victims for whom the Chicago Police Department's elder abuse unit responded to a call or elderly residents in Chicago overall. Sampling strategy includes extensive telephone interviews of 150 elders who have filed a police complaint, and 150 victims and 150 non-victims in the general population of Chicago.

Observations: The victim survey is moving slowly.

Conclusions: None yet. The non-victim community sample is complete. There are 30 complete interviews from the community victim sample and 30 complete interviews from the police sample. The six-month follow-up surveys will begin in the next few months.

Andy Klein — A Statewide Analysis of Elder Abuse of Older Women and the Criminal Justice Response in Rhode Island

Observations: Women were classified as "older" (50-59) or "elder" (60+). Women who are 60 and older can use APS, not just law enforcement.

Conclusions: Some of the results included:

  • In Rhode Island, a greater percentage of whites were victimized.
  • The suspects were 90 percent intimate partners for younger women, 30 percent intimate partners for older women, with the rest family members, and they were all family members for elder women.
  • Victim relationship — a finding that the abuser was a relative was significantly higher for 60+ victims.
  • The profile of the family member suspected of abuse versus the intimate partner suspect indicates that those suspected of abusing elder women are younger male members of the family with a criminal history.
  • The incidence of calling the police was not related to the age of the victim.
  • Within two years, 23 percent were re-victimized, but not necessarily by the same suspect.
  • Family member abusers were more likely to be back in court for re-abuse than were intimate-partner abusers.
  • Referrals - police made very few referrals to the Department of Elder Affairs because they contended that APS doesn't do anything. Only three APS cases were referred to the police.

Lori Stiegel — A Multisite Assessment of Court-Focused Elder Abuse Initiatives

Goal: To provide judges, court administrators, policy makers and funders with evidence-based knowledge about the structure, process and outcomes of these initiatives so that they can make informed decisions about whether and how to spend limited resources, to enhance courts' approaches and activities to protect elder abuse victims, and to hold perpetrators accountable.

Study Design: Two-year project (begun October 2007) with five sites, using data sources (informant surveys, stakeholder surveys, randomly selected case file reviews and observation of court proceedings, if possible) to make a quantitative and qualitative assessment of court-focused elder abuse initiatives.

Observations: Is there a conflict of interest for courts that are acting as both decision makers and service providers? Areas to be considered include:

  • Redundancy - are courts duplicating efforts?
  • Training - do key people have training in elder abuse?
  • Court leadership and support, and is there compliance with the mission?
  • Institutionalizing projects so that if people leave, the project moves on.
  • Time of case processing - is it too slow?
  • Interaction with other community services.
  • Costs.
  • Is there any follow-up with victims?

Conclusions: None yet.

Carmel Dyer — Factors That Impact the Determination by Medical Examiners of Elder Mistreatment as a Cause of Death in Older Persons

Overview: Elders reported to APS have nearly triple the mortality rates of those never reported, but elder abuse is rarely identified as a cause of death. Why?

Results of Studies Conducted:

Summary and Conclusions of Phase I:

  • Medical examiners (ME) infrequently determine elder mistreatment as a cause of death in older decedents. Chronic diseases and features of old age confound the picture. Medical records and other information, including scene investigation reports, are often inadequate.

Summary and Conclusions of Phase II:

  • MEs are not versed in the standard of care for older persons. It seems more appropriate for geriatricians to review the records and to render opinions about the standard of care, as well as the presence or absence of elder mistreatment. There is little information concerning the effects of collaboration between MEs and geriatricians.

Summary and Conclusions of Phase III:

  • Scene investigation is not geared to the detection of forensic markers and risk factors. Training of investigators in elder mistreatment may be helpful. Consider the use of standardized investigation forms that prompt the investigators to look for signs of elder mistreatment.

Phase IV: To compare variables regarding scene investigation, medical records, toxicology, and daily workloads in the case of persons ages 65 years or older whose cause of death was elder mistreatment with those from cases of deaths whose cause was not elder mistreatment. A pilot study indicated that APS cases were sharply different in terms of finding elder mistreatment. The questions are: Could APS predict some deaths if they had data available? Could MEs make elder mistreatment diagnoses at autopsy?

  • New study design asked how to determine lethality factors. How can we be sure that the death was due to elder mistreatment? Begin by looking at causes of death once referred to APS, i.e., if you come in from APS, what are the risk factors?

Summary and Conclusions of Phase IV:

  • Documented dementia or skin findings were more likely to trigger an autopsy and more likely to have been an APS case. Other issues include ME access to APS records and performing autopsies in targeted cases.

A goal is to develop lethality risk factors. This is an important issue and any suggestions would be welcome.

Discussant, Kathleen Quinn

Ms. Quinn noted how much everyone has learned at this conference and how honored she was to be a part of it. She thanked NIJ, NIA, the Archstone Foundation and Ms. Connolly for providing the leadership for this meeting.

Ms. Quinn reviewed the research projects. She praised Dr. Newman's research for developing a tool to help prevent elder abuse based on the voices of the victims themselves. This experience will shape our outreach. Dr. Jackson's research into financial exploitation is of critical importance to give us insight into a form of abuse that was not initially recognized. Experience would lead us to believe that financial exploitation is a motivating factor behind neglect, and it is important to find out. Again, this is based on the victims' voices. Ms. Slipka's study will identify risk factors and clarify things that work in protecting victims, as well as give insight into the effect of reporting. Dr. Klein's work in Rhode Island gives us numbers that could influence criminal victim surveys. It substantiates what we see in the field with the adult son, and the criminal background issue was very interesting. It is also important to note that APS is different across states, and we should be cautious about generalizations. Ms. Steigel's work is so important in terms of educating the judges, and it will help show what really works and what is considered ethical and legal. Dr. Dyer's work is critical, for what is more important than finding out how many people are murdered by abuse and neglect? In summary, we have miles to go, but it is encouraging to see the excitement and interest and get the sense that we are starting to catch up. It is wonderful to hear the victims' voices through this research and to see the emphasis, first and foremost, on victim safety. We need to consider how to use these data to increase awareness and influence other systems like law enforcement and health care to join this awareness and shape their responses accordingly. We need to address the endless logistical problems and delays — and we can learn from each other some ways to ease this barrier. Finally, and very significantly, we need to consider how to attract other private foundations beyond Archstone to join this effort.

Question/Answer/Comment Period

Dr. Anetzberger asked how to increase private funding and wondered about calling a special session to address the issue. Ms. Laura Giles from the Archstone Foundation stressed the need for continued networking, noting that Archstone was paired with other foundations at recent meetings, which provided valuable opportunities to spread the message. She added that Archstone is on the agenda at an upcoming conference and will be able to bring this issue to the attention of other foundations and funders. Ms. Brenda Uekert noted that the Pew Foundation is going to address elder issues and have an end-of-life agenda, as well. Dr. Hawes suggested that a problem with funding for elder abuse is that it is not a "feel good" topic, and no one wants to fund such an ugly issue, including CMS. An approach is needed that attracts funders, and research should be packaged to show that not only is there a problem, there is a solution. If it is not possible to persuade federal agencies of this need, we should be prepared to go to Congress. Ms. Quinn pointed out that domestic violence isn't pretty, and yet it gets funded. Dr. Hawes noted that the difference is that domestic violence victims speak out. Dr. Maggie Baker recounted a difficulty in getting funding for a study to review medical records in the long-term care setting, then realized that the title of study was not resonating with funders who wanted to see more a health promotion theme. This problem could be addressed by changing the title because the study was always geared to promoting safety in the facility. The research must be framed in a way that will receive the best reception. Dr. Anetzberger opined that it is systems failures, whether they are real or perceived, that attract funding. Dr. Newman stressed the importance of meeting with agencies to ask what the results of the research mean to them in terms of their policies and procedures, and what research we need to do next.

Dr. Mosqueda asked Dr. Jackson about APS barriers to follow-up once a case is closed, noting that her researchers have not been allowed to do follow-up. She wondered if this was a matter of state law or policy and asked for guidance on how to handle this. Dr. Jackson replied that she particularly wanted to work with closed cases in her research and that APS allowed her to work on these cases and do it with verbal consent, so it has not been a problem. But, she stressed, this is not considered reopening a closed case. Dr. Dyer suggested that Dr. Mosqueda obtain consent from the client before the case is closed. Ms. Connolly suggested that perhaps NAPSA might prepare some guidance on this issue. Dr. Newman observed that as researchers gain more experience working with IRBs and APS, they might view the barriers as opportunities to spread the word and communicate the message of research to a broader audience so that ultimately these barriers will break down.

Dr. Stahl, referencing the earlier research of Dr. Mark Lachs, asked Dr. Dyer whether she had any estimate of the incidence of deaths due to elder abuse. Dr. Dyer replied that Dr. Lachs used death certificate data from ME records in his research. However, she said, death certificates are notoriously inaccurate, and no one is going to write "died of elder abuse" as the cause of death. Based on chart reviews she said her best guesstimate is 11-22 percent. Dr. Hawes suggested that a worthwhile project would be to study the ME's decision to sign off on so many deaths as natural. An elderly person who is scalded to death in a bathtub has not died of natural causes. Ms. Connolly asked Dr. Patricia McFeeley about the handling of elder deaths. Dr. McFeeley explained that there is a triage between the coroner and the ME, and often someone with no medical knowledge is handling the investigation. She said that basically death certificates are useless even when signed by the ME. Dr. Solomon Liao noted that not only do physicians fill out death certificates incorrectly, but also many deaths are not even attended by physicians, who get secondhand information about the death from the nurse. He suggested that more training is needed for these nurses.

Ms. Stiegel suggested two projects:

  1. Assess the effect of fatality review teams on ME reports.
  2. Do a fatality assessment in terms of what we can learn.

Dr. Mulford said that Dr. Klein's study had influenced her thinking about theory development, particularly in light of the predatory offspring findings. Dr. Klein noted that Rhode Island is one of the states that mandates treatment for domestic violence and suggested that the state is diverting cases into the wrong resource. Dr. Jackson also expressed interest in Dr. Klein's findings about psychopathological behavior of family members, saying that model may fit for financial abuse cases.

Next Session: VISION Report.

Date Created: August 11, 2008