Comprehensive Older Adult and Caregiver Help (COACH): A person-centered caregiver intervention prevents elder mistreatment.

BACKGROUND: Elder mistreatment (EM) harms individuals, families, communities, and society as a whole. Yet research on interventions is lagging, and no rigorous studies demonstrating effective prevention have been published. This pilot study examines whether a first-of-its-kind coaching intervention reduced the experience of EM among older adults with chronic health conditions, including dementia. METHODS: We used a double-blind, randomized controlled trial to test a strengths-based person-centered caregiver support intervention, developed from evidence-based approaches used in other types of family violence. Participants (n = 80), family caregivers of older adults who were members of Kaiser Permanente, completed surveys at baseline, post-test, and 3-month follow-up. The primary outcome was caregiver-reported EM; additional proximal outcomes were caregiver burden, quality-of-life, anxiety, and depression. Nonparametric tests (Mann-Whitney U, Fisher's Exact, Wilcoxon Signed Rank, and McNemar's) were used to make comparisons between treatment and control groups and across time points. RESULTS: The treatment group had no EM after intervention completion (assessed at 3-month follow-up), a significantly lower rate than the control group (treatment = 0%, control = 23.1%, p = 0.010). CONCLUSIONS: In this pilot study, we found that the COACH caregiver support intervention successfully reduced EM of persons living with chronic illness, including dementia. Next steps will include: (1) testing the intervention's mechanism in a fully powered RCT and (2) scaling the intervention for testing in a variety of care delivery systems.

The Mediating Role of Sense of Control in the Associations Between Remote Contacts and Loneliness Among Older Adults.

This study explored whether a sense of control over social life mediated the associations between using remote contact (phone calls, letters/emails, social media) and loneliness for socially isolated older adults. We used path analysis with the 2014 and 2016 Health and Retirement Study datasets (N = 3767). Results showed that more frequent phone calls and letters/emails were associated with lower levels of loneliness through sense of control. However, sense of control did not mediate the association between social media and loneliness. Findings suggest that promoting sense of control over social life by remote contact, particularly phone calls and letters/emails, may be effective in alleviating loneliness for isolated older adults.

Improving forensics: Characterizing injuries among community-dwelling physically abused older adults.

BACKGROUND: Physical elder abuse affects a substantial number of older adults, leaving victims at increased risk for negative health outcomes. Improved detection of abuse-related injuries may increase victim access to professional support, but providers report difficulties distinguishing between accidental and abuse-related injuries, due in part to victims' pre-existing health conditions and medication use. OBJECTIVES: To describe the spectrum and characteristics of injuries among physically abused older adults and identify injury characteristics associated with abuse. DESIGN: Case-control study. SETTING: Physically abused adult protective services clients were interviewed in their home; non-abused comparison group participants were interviewed in an outpatient geriatrics clinic. PARTICIPANTS: Sample included 156 community-dwelling adults aged 65 and older, including 57 physically abused and 99 non-abused individuals. Self-reported abuse history was confirmed through independent case assessment by a LEAD (Longitudinal, Expert All-Data) panel of clinicians with family violence expertise. MEASUREMENTS: Full-body assessments were conducted, documenting injury incidence, diagnosis, and location. We also collected sociodemographic characteristics, level of social support, functional ability, medical history, and medication use. RESULTS: Physically abused older adults were more likely to be injured upon assessment (79.0% vs 63.6%; p < 0.05) and have a greater number of injuries ( x¯=2.9 vs x¯=2.0 , p < 0.05). Injuries seen more often among abused individuals included: upper extremity ecchymoses (42.1% vs 26.3%; p < 0.05), abrasions (31.6% vs 11.1%; p < 0.01), and areas of tenderness (8.8% vs 0.0%; p < 0.01); and head/neck/maxillofacial ecchymoses (15.8% vs 2.0%; p < 0.01) and tenderness (15.8% vs 0.0%; p < 0.001). Lower extremity abrasions (12.3%) were common but unrelated to abuse status. CONCLUSION: While physical abuse does not always result in physical injury, victims more commonly display head/neck/maxillofacial ecchymoses or tenderness and upper extremity abrasions, ecchymoses, or tenderness. Detection of these injuries among older adults warrants further interview and examination.

Who is in the revolving door? Policy and practice implications of recurrent reports to adult protective services.

Repeat referral to adult protective services APS (recurrence) is a much-discussed topic among APS agencies as it may indicate ongoing harm, yet there is limited research examining prevalence or causes. This paper provides a foundational investigation of recurrence within a California APS county program. Drawing from thirty-three months of de-identified reports, we used logistic regression to examine the impact of intake report characteristics on repeat referral within one year after baseline case closure. One-fifth of the sample was recurrent (19.9%, n=987/4,958), with self-neglect being the most common type of report to recur (14.3%, n=307/2,141). Overall recurrence was predicted by female gender, older age, living alone, and multiple elder abuse, neglect, and exploitation (ANE) types reported at baseline, and report placed by social service provider, friends, family, landlords, and victim self-reports. Reporters personally related to the victim and social service providers are potential partners in identifying ANE, and alternate intervention approaches may be necessary.

Elder Abuse Characteristics Based on Calls to the National Center on Elder Abuse Resource Line.

Characterizing the types of elder abuse and identifying the characteristics of perpetrators are critically important. This study examined the types of elder abuse reported to the National Center on Elder Abuse (NCEA) resource line. Calls were coded with regard to whether abuse was reported, types of abuse alleged, whether multiple abuse subtypes occurred, and who perpetrated the alleged abuse. Of the 1,939 calls, 818 (42.2%) alleged abuse, with financial abuse being the most commonly reported (449 calls, 54.9%). A subset of calls identified multiple abuse types (188, 23.0%) and multiple abusers (149, 18.2%). Physical abuse was most likely to co-occur with another abuse type (61/93 calls, 65.6%). Family members were the most commonly identified perpetrators (309 calls, 46.8%). This study reports the characteristics of elder abuse from a unique source of frontline data, the NCEA resource line. Findings point to the importance of supportive resources for elder abuse victims and loved ones.

Toward a better understanding of the elder abuse forensic center model: comparing and contrasting four programs in California.

Resolving elder abuse, neglect, and self-neglect often requires the authority and expertise of multiple providers. Prior research of the elder abuse forensic center (FC) model, although limited, has indicated strong member support, increases in prosecution of abusers, and increases in conservatorship for those lacking capacity. This study expands on previous single-site research by conducting a cross-site multimethod evaluation of four established FCs to better describe the model and inform its replication with fidelity. Data were compiled from FC administrative data, site visits completed from 2011-2012, and a follow-up telephone interviews conducted in 2018. Site characteristics, processes, desired outcomes, and long-term sustainability were compared. All FCs had dedicated staff who convened a multidisciplinary team (MDT) of medical, legal, and social services providers to jointly engage in case review, consultation, and provision of supportive professional services. Similar results were observed across all sites in team effectiveness and member-perceived improvements in personal practice and inter-agency relationships. While three programs had unified philosophies and practice approaches, one employed a distinct model and was no longer in operation at follow-up. Commonalities in case characteristics, program structure, processes, and outcomes provide insight into the core model components and a foundation for continued program replication and standardization.

What Are the Characteristics of Caregivers Logging in for Support Services?

BACKGROUND AND OBJECTIVES: Online service delivery options have the potential to increase access to informational resources among caregivers to older adults. However, it is unknown which caregivers will use online-delivered services over usual service delivery modes (e.g., by phone) when both options are available in social service settings. This is important for service providers to know when making decisions that best serve their communities. RESEARCH DESIGN AND METHODS: Guided by Andersen's model of health service utilization, we used step-wise logistic regression models to compare the characteristics of caregivers who used an online information service called FCA CareJourney (FCA CJ) with those who accessed the same services using the usual mode of service delivery (N = 540). Online and usual-care services were available through two social service organizations in California. RESULTS: In all, 13.7% of clients used FCA CJ to receive services online. Enabling characteristics were the main predictors of using online-delivered services. Caregivers employed part-time had 3.82 times the odds of using online-delivered services compared to those employed full-time (odds ratio [OR] = 3.82; 95% confidence interval [CI]: 1.58-9.22). Caregivers who learned about services from health care providers had 2.91 times the odds of using FCA CJ as those who learned about services through social services (OR = 2.91; 95% CI: 1.28-6.62). Even among those who learned about services online, 62.2% still accessed services using usual delivery modes. DISCUSSION AND IMPLICATIONS: Based on differences in the characteristics of caregivers using different service delivery modes and the low uptake of online-delivered services, we suggest online service delivery should supplement, not replace, usual delivery modes in social service settings. At the same time, user rates of online service delivery are likely modifiable. Given the potential for online-delivered programming to expand access to information services for caregivers, we recommend further examination into the effects of marketing online service delivery options to caregivers in novel ways.

What Can Elder Mistreatment Researchers Learn About Primary Prevention From Family Violence Intervention Models?

Elder mistreatment (EM) is a public health problem that harms millions of older Americans each year. Despite growing recognition of its occurrence, there are no evidence-based primary prevention programs. Although EM is distinct from other areas of family violence, including child maltreatment and intimate partner violence, common risk factors and theoretical underpinnings point to opportunities for prevention strategies. Drawing on evidence-based best practices found in other fields of family violence, we identify approaches that could be tested to prevent EM at the hands of family caregivers, who are among the most likely to commit mistreatment. Specifically, we examine home visiting approaches primarily used in the child maltreatment field and identify components that have potential to inform EM interventions, including prevention. We conclude that there is enough information to begin testing a prevention intervention for EM that targets caregivers.

The Prevalence of Self-Reported Elder Abuse Among Older Women in Community Settings: A Systematic Review and Meta-Analysis.

The abuse of older women appears to be a significant problem. Developing a better understanding of the extent of the problem is an important step toward preventing it. We conducted a global systematic review and meta-analysis of existing prevalence studies, in multiple languages, that occurred in the community settings from inception to June 26, 2015, in order to determine the extent of abuse against women aged 60 years and over. To disentangle the wide variations in prevalence estimates, we also investigated the associations between prevalence estimates and studies' demographic and methodological characteristics. A total of 50 studies were included in the meta-analysis. The combined prevalence for overall elder abuse in the past year was 14.1% (95% confidence interval (CI) [11.0, 18.0]). Pooled prevalence for psychological abuse was 11.8% (95% CI [9.2%, 14.9%]), neglect was 4.1% (95% CI [2.7%, 6.3%]), financial abuse was 3.8% (95% CI [2.5%, 5.5%]), sexual abuse was 2.2% (95% CI [1.6%, 3.0%]), and physical abuse was 1.9% (95% CI [1.2%, 3.1%]). The studies included in the meta-analysis for overall abuse were heterogeneous indicating that significant differences among the prevalence estimates exist. Significant associations were found between prevalence estimates and the following covariates: World Health Organization-defined regions, countries' income classification, and sample size. Together, these covariates explained 37% of the variance. Although robust prevalence studies are sparse in low- and middle-income countries, about 1 in 6, or 68 million older women experience abuse worldwide. More work is needed to understand the variation in prevalence rates and implications for prevention.

Research Protocol for Systematic Review and Meta-Analysis of Elder Abuse Prevalence Studies.

Elder abuse is an important public health and human rights issue, yet its true extent is not well understood. To address this, we will conduct a systematic review and meta-analysis of elder abuse prevalence studies from around the world. This protocol describes the methodological approach to be adopted for conducting this systematic review and meta-analysis. In particular, the protocol describes the search strategies and eligibility criteria to be used to identify and select studies and how data from the selected studies will be extracted for analysis. The protocol also describes the analytical approach that will be used to calculate pooled prevalence estimates and discusses the use of meta-regression to assess how studies' characteristics influence the prevalence estimates. This protocol conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analysis - or PRISMA - guidelines and has been registered with the PROSPERO International Prospective Register of systematic reviews.

Elder abuse prevalence in community settings: a systematic review and meta-analysis.

BACKGROUND: Elder abuse is recognised worldwide as a serious problem, yet quantitative syntheses of prevalence studies are rare. We aimed to quantify and understand prevalence variation at the global and regional levels. METHODS: For this systematic review and meta-analysis, we searched 14 databases, including PubMed, PsycINFO, CINAHL, EMBASE, and MEDLINE, using a comprehensive search strategy to identify elder abuse prevalence studies in the community published from inception to June 26, 2015. Studies reporting estimates of past-year abuse prevalence in adults aged 60 years or older were included in the analyses. Subgroup analysis and meta-regression were used to explore heterogeneity, with study quality assessed with the risk of bias tool. The study protocol has been registered with PROSPERO, number CRD42015029197. FINDINGS: Of the 38 544 studies initially identified, 52 were eligible for inclusion. These studies were geographically diverse (28 countries). The pooled prevalence rate for overall elder abuse was 15·7% (95% CI 12·8-19·3). The pooled prevalence estimate was 11·6% (8·1-16·3) for psychological abuse, 6·8% (5·0-9·2) for financial abuse, 4·2% (2·1-8·1) for neglect, 2·6% (1·6-4·4) for physical abuse, and 0·9% (0·6-1·4) for sexual abuse. Meta-analysis of studies that included overall abuse revealed heterogeneity. Significant associations were found between overall prevalence estimates and sample size, income classification, and method of data collection, but not with gender. INTERPRETATION: Although robust prevalence studies are sparse in low-income and middle-income countries, elder abuse seems to affect one in six older adults worldwide, which is roughly 141 million people. Nonetheless, elder abuse is a neglected global public health priority, especially compared with other types of violence. FUNDING: Social Sciences and Humanities Research Council of Canada and the WHO Department of Ageing and Life Course.

Community Discharge of Nursing Home Residents: The Role of Facility Characteristics.

OBJECTIVE: Using a socio-ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long-term services and supports systems. DATA SOURCE: Data were drawn from the Minimum Data Set, the federal Online Survey, Certification, and Reporting (OSCAR) database, the Area Health Resource File, and the LTCFocUs.org database for all free-standing, certified nursing homes in California (n = 1,127) and Florida (n = 657) from July 2007 to June 2008. STUDY DESIGN: Hierarchical generalized linear models were used to examine the impact of facility characteristics on the probability of transitioning to the community. PRINCIPAL FINDINGS: Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge but differed by state and whether the discharge occurred after a short or long stay. CONCLUSION: Short- and long-stay nursing home discharge to the community is affected by resident, facility, and sometimes market characteristics, with Medicaid consistently influencing discharge in both states.

Nursing Home Residents' Preferences on Physician Orders for Life Sustaining Treatment.

PURPOSE OF THE STUDY: Previous studies examining preferences documented in Physician Orders for Life Sustaining Treatment (POLST) have found that most sampled POLSTs show a preference to limit care. These studies were conducted in states that are relatively ethnically homogeneous. This study investigated the POLST preferences of nursing home residents in an ethnically diverse state-California-that requires nursing homes to document whether residents execute POLST. DESIGN AND METHODS: Data were collected from POLST forms executed by 941 residents in a convenience sample of 13 nursing homes in Southern California. The study analyzed data from 4 POLST form items: signatory (resident vs. surrogate decision-maker) and care preferences related to: (a) resuscitation; (b) medical intervention; and (c) artificially administered nutrition. Descriptive, comparative, and regression analyses are reported at both individual and facility levels. RESULTS: Of reviewed POLSTs, 46.8% documented a preference for "do not resuscitate" (DNR); 47.3% documented limits on medical intervention; and 52% documented limits on artificially administered nutrition. Residents in nursing homes serving comparatively larger populations of older residents and White residents had lower odds of electing the full care option for each of the POLST's 3 care items; those in nursing homes serving comparatively larger populations of Hispanic residents had higher odds of electing long-term artificially administered nutrition. IMPLICATIONS: This study found lower rates of POLST choices limiting care than previous studies, possibly because the sampled nursing homes served a more ethnically- and age-diverse population. California's requirement that nursing homes document whether residents execute POLST also may have indirectly influenced choice patterns.

Protecting victims of elder financial exploitation: the role of an Elder Abuse Forensic Center in referring victims for conservatorship.

OBJECTIVES: The aim of this study was to examine the extent to which an Elder Abuse Forensic Center protects financial exploitation (FE) victims through referral to the Office of the Public Guardian (PG) for investigation and possible conservatorship (called 'guardianship' in many states). METHOD: Los Angeles County Elder Abuse Forensic Center cases involving adults aged 65 and older (April 2007-December 2009) were matched using one-to-one propensity-score matching to 33,650 usual care Adult Protective Services (APS) cases. The final analysis sample consisted of 472 FE cases. RESULTS: Compared to usual care, Forensic Center cases were more likely to be referred to the PG for investigation (30.6%, n = 72 vs. 5.9%, n = 14, p < .001). The strongest predictors of PG referral were suspected cognitive impairment, as identified by APS (odds ratio [OR] = 11.69, confidence intervals [CI]: 3.50-39.03), and Forensic Center review (OR = 7.85, CI: 3.86-15.95). Among referred cases, the court approved conservatorship at higher rates - though not statistically significant - for Forensic Center cases than usual care (52.9%, n = 36/68 vs. 41.7%, n = 5/12). CONCLUSION: Conservatorship may be a necessary last resort to improve safety for some FE victims, and the Forensic Center appears to provide a pathway to this service. These findings suggest modification to the Elder Abuse Forensic Center conceptual model and contribute to an emerging body of evidence on the role of the Forensic Center in addressing elder abuse.

Who transitions to the community from nursing homes? Comparing patterns and predictors for short-stay and long-stay residents.

Little is known about characteristics of those who transition to the community after long stays in nursing facilities. Yet this information is highly relevant to efforts to reduce preventable nursing facility use. This study identifies and compares community transition among short-stay (1-90 days) and long-stay residents (91-365 days) aged 65 + using Kaplan-Meier survival estimates and logistic regression to analyze 3,762 episodes of care in Southern California. Over 90% of community discharges occurred in the first 90 days, and few characteristics predicted discharge after 90 days. The findings inform transition programs' efforts to identify and effectively target residents after 90-day stays.

Holding abusers accountable: an elder abuse forensic center increases criminal prosecution of financial exploitation.

PURPOSE: Despite growing awareness of elder abuse, cases are rarely prosecuted. The aim of this study was to examine the effectiveness of an elder abuse forensic center compared with usual care to increase prosecution of elder financial abuse. DESIGN AND METHODS: Using one-to-one propensity score matching, cases referred to the Los Angeles County Elder Abuse Forensic Center (the Forensic Center) between April 2007 and December 2009 for financial exploitation of adults aged 65 and older (n = 237) were matched to a population of 33,650 cases that received usual care from Adult Protective Services (APS). RESULTS: 1 Significantly, more Forensic Center cases were submitted to the District Attorney's office (DA) for review (22%, n = 51 vs. 3%, n = 7 usual care, p < .001). Among the cases submitted, charges were filed by the DA at similar rates, as was the proportion of resultant pleas and convictions. Using logistic regression, the strongest predictor of case review and ultimate filing and conviction was whether the case was presented at the Forensic Center, with 10 times greater odds of submission to the DA (Odds ratio = 11.00, confidence interval = 4.66-25.98). IMPLICATIONS: Previous studies have not demonstrated that elder abuse interventions impact outcomes; this study breaks new ground by showing that an elder abuse multidisciplinary team increases rates of prosecution for financial exploitation. The elder abuse forensic center model facilitates cooperation and group problem solving among key professionals, including APS, law enforcement, and the DA and provides additional resources such as neuropsychological testing, medical record review, and direct access to the Office of the Public Guardian.

Determining prevalence and correlates of elder abuse using promotores: low-income immigrant Latinos report high rates of abuse and neglect.

Low-income Latino immigrants are understudied in elder abuse research. Limited English proficiency, economic insecurity, neighborhood seclusion, a tradition of resolving conflicts within the family, and mistrust of authorities may impede survey research and suppress abuse reporting. To overcome these barriers, promotores, local Spanish-speaking Latinos, were recruited and trained to interview a sample of Latino adults aged 66 and older residing in low-income communities. The promotores conducted door-to-door interviews in randomly selected census tracts in Los Angeles to assess the frequency of psychological, physical, and sexual abuse; financial exploitation; and caregiver neglect. Overall, 40.4% of elderly Latino adults had experienced some form of abuse or neglect within the previous year. Nearly 25% reported psychological abuse, 10.7% physical assault, 9% sexual abuse, and 16.7% financial exploitation, and 11.7% were neglected by their caregivers. Younger age, higher education, and experiencing sexual or physical abuse before age 65 were significant risk factors for psychological, physical, and sexual abuse. Years lived in the United States, younger age, and prior abuse were associated with greater risk of financial exploitation. Years spent living in the United States was a significant risk factor for caregiver neglect. Abuse prevalence was much higher in all mistreatment domains than findings from previous research on community-dwelling elderly adults, suggesting that low-income Latino immigrants are highly vulnerable to elder mistreatment or that respondents are more willing to disclose abuse to promotores who represent their culture and community.

Conversion diversion: participation in a social HMO reduces the likelihood of converting from short-stay to long-stay nursing facility placement.

OBJECTIVES: To determine the effect of a Social Health Maintenance Organization (S/HMO) on diverting older adults admitted into a nursing facility from converting to long-stay placement. DESIGN: Members of the SCAN S/HMO and those in Medicare Fee-For-Service were compared on successful discharge to the community after being admitted to nursing facilities between January 1, 2001, and December 31, 2003. SETTING: Skilled nursing facilities in 4 counties in Southern California (Los Angeles, Orange, San Bernardino, Riverside). PARTICIPANTS: Data (N = 4635) were extracted from Minimum Data Set (MDS) 2.0 records for nursing facility residents in the S/HMO or the Medicare Fee-for-Service 5% sample who were aged 65 and older with an episode of care greater than 14 days. MEASUREMENTS: Predisposing, enabling, and need measures were used to predict successful discharge to the community within 90 days. RESULTS: After controlling for selected sociodemographics, comorbidities, behavioral issues, mental health conditions, and other risk factors, being enrolled in the S/HMO increased the likelihood of successful discharge by 26%. CONCLUSION: With systemic increases in short-stay patients, research on diversion must look past the avoidance of unnecessary entry to nursing facilities, to the successful transition of short-stay residents to the community. As described in this study, the S/HMO model is an important but largely unaddressed method of avoiding the conversion to long-stay.

Who are the Latino baby boomers? Demographic and economic characteristics of a hidden population.

The United States is confronting two simultaneous demographic shifts with profound implications for public policy: population aging and increasing diversity. These changes are accelerating during a dramatic economic downturn, placing entitlement reform prominently on the national policy agenda. Using decennial census data from 2000, this paper examines the nexus of these trends by examining characteristics of Latino baby boomers. In the census data, Latinos constituted 10% of the 80 million boomers; roughly one-third of Latino boomers (37%) were born in the United States or abroad to a U.S. parent; 6% were born in a U.S. territory; 21% were naturalized citizens; and 36% were noncitizens. Compared to non-Latinos, Latino baby boomers had lower levels of education, home ownership, and investment income and higher rates of material hardship and poverty; however, there was considerable variation based on citizenship status. A better understanding of Latino baby boomers will help policy makers anticipate the retirement needs of baby boomers as the United States prepares for the aging of a racially and ethnically diverse population.