The Importance of Investigating Abuser Characteristics in Elder Emotional/Psychological Abuse: Results from Adult Protective Services Data.

OBJECTIVES: Elder emotional/psychological abuse is the infliction of mental anguish on older adults through verbal or non-verbal acts. Using indicators based on existing literature, theoretically important abuser characteristics and victim vulnerabilities were collected using the Elder Abuse Decision Support System (EADSS) to test a theory of emotional/psychological abuse. METHOD: Eight-hundred-and-ten alleged emotional/psychological abuse cases were investigated by caseworkers in six Illinois adult protective services (APS) agencies; 466 individuals endorsed at least one item on the Older Adult Psychological Abuse Measure (OAPAM). RESULTS: Bivariate ordinary linear regression results established that all abuser characteristics were predictive of emotional/psychological abuse scores. In the hierarchical regression model where abuser characteristics were entered after victim vulnerabilities, abuser characteristics predicted emotional/psychological abuse above and beyond victim vulnerabilities (ΔR2 = 0.349, p < .001). Abuser risk and abuser's negative attitudes towards victims remained as significant predictors in the final model. Post hoc analysis identified significant items of abuser risk and negative attitudes, including: an emotionally draining relationship between abuser and victim, abuser's poor temper control, and abuser's angry feelings towards victims. DISCUSSION: Abuser weaknesses and strengths as highlighted in the theoretical framework should be further investigated for future prevention and intervention in cases of emotional/psychological abuse.

Validation of the MedUseQ: A Self-Administered Screener for Older Adults to Assess Medication Use Problems.

BACKGROUND: Older adults taking multiple prescription and nonprescription drugs are at risk for medication use problems, yet there are few brief, self-administered screening tools designed specifically for them. OBJECTIVE: The study objective was to develop and validate a patient-centered screener for community-dwelling older adults. METHODS: In phase 1, a convenience sample of 57 stakeholders (older adults, pharmacists, nurses, and physicians) participated in concept mapping, using Concept System® Global MAXTM, to identify items for a questionnaire. In phase 2, a 40-item questionnaire was tested with a convenience sample of 377 adults and a 24-item version was tested with 306 older adults, aged 55 and older, using Rasch methodology. In phase 3, stakeholder focus groups provided feedback on the format of questionnaire materials and recommended strategies for addressing problems. RESULTS: The concept map contained 72 statements organized into 6 conceptual clusters or domains. The 24-item screener was unidimensional. Cronbach's alpha was .87, person reliability was acceptable (.74), and item reliability was high (.96). CONCLUSION: The MedUseQ is a validated, patient-centered tool targeting older adults that can be used to assess a wide range of medication use problems in clinical and community settings and to identify areas for education, intervention, or further assessment.

Examining the Role of Substance Abuse in Elder Mistreatment: Results From Mistreatment Investigations.

Substance abuse has long been identified as a risk factor for elder mistreatment, yet research on the topic remains sparse. This study tested hypotheses whether perpetrator and victim substance use problems were associated with financial exploitation, physical abuse, emotional abuse, and neglect versus no abuse. Cross-sectional data were collected on 948 cases with yes/no substantiation decisions where 357 cases had no abuse in elder mistreatment investigations. Hypotheses were tested using odds ratios, bivariate, and multiple linear regression analyses including a control for victim vulnerability. Of 948 alleged victims, 42 (4.4%) exhibited signs of substance use problems. Among the 323 alleged perpetrators, 87 (26.9%) were reported to have substance use problems. Substance use problems by alleged perpetrators were associated ( p < .01) with financial exploitation, physical abuse, and emotional abuse but not neglect. Substance use problems by alleged victims were associated with neglect, but not the other types. Alleged perpetrators with substance use problems tended to commit multiple forms of abuse, were male and not caregivers. Except for the findings on neglect, the associations with elder mistreatment were stronger for alleged perpetrators with substance use problems, than for alleged victims. Clarification of the role of perpetrator risk factors such as substance abuse should improve risk identification and subsequent intervention.

Development of short-form measures to assess four types of elder mistreatment: Findings from an evidence-based study of APS elder abuse substantiation decisions.

Improving the standardization and efficiency of adult protective services (APS) investigations is a top priority in APS practice. Using data from the Elder Abuse Decision Support System (EADSS), we developed short-form measures of four types of elder abuse: financial, emotional/psychological, physical, and neglect. The EADSS data set contains 948 elder abuse cases (age 60+) with yes/no abuse substantiation decisions for each abuse type following a 30-day investigation. Item sensitivity/specificity analyses were conducted on long-form items with the substantiation decision for each abuse type as the criterion. Validity was further tested using receiver-operator characteristic (ROC) curve analysis, correlation with long forms and internal consistency. The four resulting short-form measures, containing 36 of the 82 original items, have validity similar to the original long forms. These short forms can be used to standardize and increase efficiency of APS investigations, and may also offer researchers new options for brief elder abuse assessments.

Elder Abuse Decision Support System: Field test outcomes, abuse measure validation, and lessons learned.

The Elder Abuse Decision Support System was designed to meet the critical need for improved methods for assessment and substantiation of elder mistreatment, using a web-based system with standardized measures. Six Illinois agencies participated in the field test. One-year pre/post analyses assessed substantiation results, using Illinois' standard investigation procedure as a comparison. Pre/post acceptability was assessed with caseworkers in focus groups with adult protective service staff. Validity of measures was assessed using Cronbach's alpha and receiver operator characteristic curve analyses with final substantiation decision as a criterion. Increased substantiation of abuse was found. Regarding acceptability, the two systems were found to have differing strengths and weaknesses. Outcome measures had high validity estimates, while focus groups indicated directions for improvement. This study was a successful proof of concept that data collected in the field would be useful for clinical purposes as well as for research.

A Person-Centered Approach to Financial Capacity Assessment: Preliminary Development of a New Rating Scale.

Financial exploitation and financial capacity issues often overlap when a gerontologist assesses whether an older adult's financial decision is an autonomous, capable choice. Our goal is to describe a new conceptual model for assessing financial decisions using principles of person-centered approaches and to introduce a new instrument, the Lichtenberg Financial Decision Rating Scale (LFDRS). We created a conceptual model, convened meetings of experts from various disciplines to critique the model and provide input on content and structure, and select final items. We then videotaped administration of the LFDRS to five older adults and had 10 experts provide independent ratings. The LFDRS demonstrated good to excellent inter-rater agreement. The LFDRS is a new tool that allows gerontologists to systematically gather information about a specific financial decision and the decisional abilities in question.

Observational measure of elder self-neglect.

The purpose of this study was to improve measurement of elder self-neglect by testing the psychometric properties of the Elder Self-Neglect Assessment (ESNA). Social workers, case managers, and adult protective services providers from 13 Illinois agencies completed a 77-item assessment for 215 clients suffering from self neglect. Analyses used Rasch item response theory and traditional validation approaches to test for dimensionality, model fit, and additional construct validation, resulting in a 62-item assessment. The ESNA met Rasch fit criteria with good internal consistency, item reliability, and construct validity. A 25-item short form also met Rasch criteria. A hierarchy of items associated with severity of abuse was produced by frequency of occurrence. ESNA indicators of self-neglect align into two broad categories: behavioral characteristics and environmental factors, which must be accounted for in a comprehensive evaluation. Theoretical refinements developed using the empirically generated item hierarchy may help to improve assessment and intervention.

Developing a faith-based caregiver support partnership.

Caring Together, Living Better (CTLB), a partnership of nonprofit and faith-based organizations, developed a culturally appropriate regional network of supportive caregiver services in the south suburbs of Chicago, IL. This article describes the findings of a mixed-methods evaluation that included network analysis to track network growth and development, tracking of service delivery, assessment of caregiver-related outcomes using standardized pre-post measures, and analysis of change stories elicited from project partners. Results include documentation of network expansion and statistically significant improvements in caregiving self-efficacy and adequacy of help. Story themes highlight participants' positive experiences with CTLB and improved caregiver quality of life.

Creating a quality of life assessment measure for residents in long term care.

OBJECTIVES: The objectives of this study were to (1) gain an empirical understanding of how stakeholder (residents, family members, staff) groups view quality of life (QoL) for residents in long term care; (2) create a visual map of the domain of QoL and describe differences in importance of key elements; and (3) identify key elements of QoL that could be used to develop a standardized assessment instrument for use in person-centered care planning. DESIGN: This is a descriptive study, using a mixed-method, qualitative/quantitative approach called "concept mapping." SETTING: The study was conducted at a 240-bed skilled nursing facility located in a major metropolitan area. It is part of a not-for-profit religiously affiliated social service organization. PARTICIPANTS: A convenience sample included 3 groups of participants: staff members, family members of residents, and residents. Fifty-three people participated in the brain-storming sessions, and 45 people completed sorting and rating tasks. Sample sizes varied by group and by task. MEASUREMENTS: Statements about the elements of QoL for residents in long term care were elicited during 14 brain-storming sessions. Sorting and rating activities were completed using a final list of 88 items. RESULTS: A visual map was generated, with 5 clusters of elements representing 5 conceptual areas within QoL. Importance ratings of elements were similar for family members and staff members, and a set of elements rated as high in importance but requiring attention to implementation was produced. CONCLUSIONS: Family members and staff produced similar conceptual models of QoL, and their views on the importance of the various elements were consistent. There was a high degree of consensus regarding elements considered least important and those considered most important. Elements considered most important addressed quality of care, autonomy and respect, and aspects of daily life, including food and sleep. There was less concern with the physical appearance of the facility, the amenities offered, and issues related to independence; however, all items scored above the mean of 2.5 on the 5-point rating scale. This project has shown that it is possible to use concept mapping methodology to obtain facility-specific information about stakeholders' QoL perceptions in the long term care setting, and that residents' views can be assessed and incorporated.

Conceptual model and map of financial exploitation of older adults.

This article describes the processes and outcomes of three-dimensional concept mapping to conceptualize financial exploitation of older adults. Statements were generated from a literature review and by local and national panels consisting of 16 experts in the field of financial exploitation. These statements were sorted and rated using Concept Systems software, which grouped the statements into clusters and depicted them as a map. Statements were grouped into six clusters, and ranked by the experts as follows in descending severity: (a) theft and scams, (b) financial victimization, (c) financial entitlement, (d) coercion, (e) signs of possible financial exploitation, and (f) money management difficulties. The hierarchical model can be used to identify elder financial exploitation and differentiate it from related but distinct areas of victimization. The severity hierarchy may be used to develop measures that will enable more precise screening for triage of clients into appropriate interventions.

Conceptual model and map of psychological abuse of older adults.

Psychological abuse of older adults is a hidden and pervasive problem that is not well conceptualized nor well measured. Goals. The goals were to (a) conceptualize psychological abuse using three-dimensional concept maps, and (b) develop theoretical models. Methods. Statements describing the construct were generated by local and national panels. These were sorted and rated using Concept Systems software whereby the concepts were depicted as a map. Results. The concept maps guided development of theoretical hierarchies. Significance. Theoretical models may help to develop measures to estimate prevalence better and may enable more precise screening for triage into appropriate interventions.

A direct comparison of popular models of normal memory loss and Alzheimer's disease in samples of African Americans, Mexican Americans, and refugees and immigrants from the former Soviet Union.

OBJECTIVES: To understand how people differentiate normal memory loss from Alzheimer's disease (AD) by investigating cultural models of these conditions. DESIGN: Ethnographic interviews followed by a survey. Cultural consensus analysis was used to test for the presence of group models, derive the "culturally correct" set of beliefs, and compare models of normal memory loss and AD. SETTING: Chicago, Illinois. PARTICIPANTS: One hundred eight individuals from local neighborhoods: African Americans, Mexican Americans, and refugees and immigrants from the former Soviet Union. MEASUREMENTS: Participants responded to yes-or-no questions about the nature and causes of normal memory loss and AD and provided information on ethnicity, age, sex, acculturation, and experience with AD. RESULTS: Groups held a common model of AD as a brain-based disease reflecting irreversible cognitive decline. Higher levels of acculturation predicted greater knowledge of AD. Russian speakers favored biological over psychological models of the disease. Groups also held a common model of normal memory loss, including the important belief that "normal" forgetting involves eventual recall of the forgotten material. CONCLUSION: Popular models of memory loss and AD confirm that patients and clinicians are speaking the same "language" in their discussions of memory loss and AD. Nevertheless, the presence of coherent models of memory loss and AD, and the unequal distribution of that knowledge across groups, suggests that clinicians should include wider circles of patients' families and friends in their consultations. These results frame knowledge as distributed across social groups rather than simply the possession of individual minds.

Self-report measure of psychological abuse of older adults.

PURPOSE: This study tested key psychometric properties of the Older Adult Psychological Abuse Measure (OAPAM), one self-report scale of the Older Adult Mistreatment Assessment (OAMA). DESIGN AND METHODS: Items and theory were developed in a prior concept mapping study. Subsequently, the measures were administered to 226 substantiated clients by 22 elder abuse staff from 7 agencies in a full-scale field test. The resulting database was used to estimate the psychometric properties of the OAPAM using the Rasch item response theory model and traditional validation techniques. Analyses included tests for dimensionality, model fit, and theoretical construct validation. Results from the OAPAM client report were validated against the adult protective services substantiation decision of abuse and the elder abuse staff assessment of psychological abuse (PA). RESULTS: The client self-report measures met stringent Rasch analysis fit and unidimensionality criteria and had high person (internal consistency) and item reliability. The validity results supported the usefulness of the client measures and led to reconsideration of aspects of the hypothesized theoretical hierarchy. A short form was developed. Cut-points were proposed to distinguish levels of PA. IMPLICATIONS: The measure is now available to aid in the assessment of PA of older adults by both clinicians and researchers. Theoretical refinements developed using the Rasch item hierarchy may help to improve assessment and intervention.

Seeking a diagnosis for memory problems: the experiences of caregivers and families in 5 limited English proficiency communities.

Limited data exist on how members of different cultures understand dementia. The Northwestern Cognitive Neurology and Alzheimer's Disease Center in collaboration with Coalition of Limited English Speaking Elderly and Alzheimer's Association-Greater Illinois Chapter collaborated to raise awareness in 5 limited English proficiency (LEP) communities (Assyrian, Arabic, Bosnian, Hindi, and Urdu) during 2005 to 2008 through a grant from the Administration on Aging Alzheimer's Disease Demonstration Grants to States. After the second year of the program, 267 individuals with cognitive impairment were identified with cognitive impairment and enrolled; however, only 13% of those sought a medical evaluation to obtain a diagnosis or further help for their memory problems. This project sought to: (1) understand how these LEP community groups conceptualize dementia and (2) understand reasons LEP communities sought or did not seek a diagnosis. Using a community-based participatory research approach, ethnic community leaders conducted 48 interviews in a convenience sample of persons enrolled in the previous Administration on Aging demonstration grant. These interviews were conducted with family members of identified persons with dementia in their native language. Interview notes were translated and subjected to thematic analysis. The majority view memory loss as explainable and normative--due to aging, reaction to medication or trauma experienced by war, family problems, or the immigration experience. This conceptualization and the perception that a doctor cannot help influenced whether they sought an evaluation. Those who saw a doctor were looking for medical treatment and help with difficult behaviors. Experience in the doctor's office was variable. Discussion of analysis with ethnic communities revealed the significance of stigma in the data gathering. Continued community-based participatory research approaches with LEP communities could further highlight needs for culturally relevant education and intervention.

Self-report measure of financial exploitation of older adults.

PURPOSE: this study was designed to improve the measurement of financial exploitation (FE) by testing psychometric properties of the older adult financial exploitation measure (OAFEM), a client self-report instrument. DESIGN AND METHODS: rasch item response theory and traditional validation approaches were used. Questionnaires were administered by 22 adult protective services investigators from 7 agencies in Illinois to 227 substantiated abuse clients. Analyses included tests for dimensionality, model fit, and additional construct validation. Results from the OAFEM were also compared with the substantiation decision of abuse and with investigators' assessments of FE using a staff report version. Hypotheses were generated to test hypothesized relationships. RESULTS: the OAFEM, including the original 79-, 54-, and 30-item measures, met stringent Rasch analysis fit and unidimensionality criteria and had high internal consistency and item reliability. The validation results were supportive, while leading to reconsideration of aspects of the hypothesized theoretical hierarchy. Thresholds were suggested to demonstrate levels of severity. IMPLICATIONS: the measure is now available to aid in the assessment of FE of older adults by both clinicians and researchers. Theoretical refinements developed using the empirically generated item hierarchy may help to improve assessment and intervention.

The development of a conceptual model for understanding elder self-neglect.

PURPOSE: Elder self-neglect (ESN) represents half or more of all cases reported to adult protective services. ESN directly affects older adults and also their families, neighbors, and the larger communities around them. ESN has public health implications and is associated with higher than expected mortality rates, hospitalizations, long-term care placements, and localized environmental and safety hazards. This article describes results from a study using concept mapping to create a conceptual model of ESN. DESIGN AND METHODS: Two brainstorming sessions were convened with senior services program supervisors, geriatricians, local policy analysts and program planners, elder law practitioners, and university-based researchers (n = 20), and a list of 73 ESN indicators was generated. Using Concept Systems software, the 20 original panelists and an additional 30 practitioners, including case managers and supervisors from local agencies, social workers specializing in working with older adults, and elder abuse investigators, sorted the 73 items and rated them along the dimension of importance for the concept of self-neglect. RESULTS: Using hierarchical cluster analysis and multidimensional scaling, a conceptual map with 7 clusters was produced. Clusters with the highest importance ratings were Physical Living Conditions and Mental Health. Clusters were highly interrelated, with the exception of the Physical Living Conditions cluster. IMPLICATIONS: This research presents a conceptualization of ESN, identifies the constituent domains, and proposes a conceptual model based on the importance for assessing symptoms and indicators. Findings may help focus programmatic and research efforts, leading to the development of measures that open the field for further research and theory generation.

The effectiveness of an online mind-body intervention for older adults with chronic pain.

UNLABELLED: The Self-care Pain Management Project assessed the feasibility and efficacy of delivering online mind-body self-care techniques to 78 adults aged 55 and older with chronic pain. To assess feasibility, the study monitored use of the intervention and documented participant satisfaction. A randomized trial with intervention (n = 41) and waiting list comparison groups (n = 37) was used to assess changes in pain intensity, limitations due to pain, pain self-efficacy, depression, anxiety, and awareness of responses to pain from baseline to follow-up at 6 weeks. There were statistically significant results for between-group difference in awareness of responses to pain, improvements in pain intensity and pain interference for both groups, and increases in confidence with using nonmedical self-care techniques to manage pain for the intervention group. Reductions in mean pain scores reported by the intervention group at log on and log off also suggest that the intervention may have an immediate impact on reducing pain. Findings document the feasibility of a relatively short-term, online mind-body pain management intervention that can have benefits for participants. The characteristics of those who volunteered for an online self-care pain management intervention also have implications for identifying target populations for such interventions. PERSPECTIVE: This article documents the outcomes of an Internet-based self-care pain management intervention that focused on mind-body exercises. The study suggests that the Internet can be an efficient mode for delivering self-care education to older adults with chronic pain and has potential benefits that complement clinical care.

Postmenopausal women with minimal trauma fractures are unapprised of the existence of low bone mass or osteoporosis.

OBJECTIVES: To explore barriers to medical care for osteoporosis following a minimal trauma fracture (MTF). MTFs occur from a fall while in a seated, recumbent or standing position; during normal walking, or from a height less than 4 feet. METHODS: Prospective study and focus groups of women with MTF performed in Chicago from June to December of 2003. Study protocol approved by Institutional Review Board (IRB) and all participants signed consent forms. Focus groups were audiotaped and transcribed, transcripts analyzed using Atlas.ti. Survey results analyzed with SPSS 11.5. RESULTS: Twenty nine participants recruited with average age of 74+/-16 years. MTF occurred at the mean age of 61+/-8 years, with fifteen (15/29) reporting more that one prior MTF. The age distribution was 40-49 years 2 (2/29) participants, 50-59 years 2 (2/29), 60-69 years 6 (6/29), 70-79 years 10 (10/29), 80 and above 9 (9/29). Most participants (21/29, 70%) reported knowledge about osteoporosis obtained from written media. Osteoporotic fractures were rated on a single item Likert Scale (1=not important to 5=most important) as 2.5 (compared with breast cancer 2.3, and myocardial infarction 2.8). Half (16/29) had osteoporosis counseling with their PCP and 9 were receiving medications for bone loss. We observed a positive correlation between osteoporosis counseling and BMD testing (r=0.6, p<0.001), and a trend toward osteoporosis treatment (r=0.372, p=0.09). Half of the participants had reported the occurrence of MTF to their PCP (14/29), however this did not lead to counseling, BMD testing (r=0.07, p=0.78), or treatment (r=-0.14, p=0.53). None of the women believed that low BMD or osteoporosis had contributed to their fracture. Women studied believed that they were "too young" (12/29) to have osteoporosis. CONCLUSION: Women are not receiving adequate information about osteoporosis; they remain unaware of the connection between MTFs and osteoporosis. Post-menopausal women with MTF do not identify osteoporosis as a cause for the fracture, may exhibit ageism and thereby fail to seek adequate medical care.

Nurses' perspectives on the distinctive aspects of providing nursing care in a congregational setting.

As the number of parish nurses grow, it is important to understand the unique attributes of providing nursing care in a congregation. Through a focus group and interviews, this qualitative research study explored this question with 17 parish nurses participating in a hospital-sponsored, volunteer health ministry program. Content analysis revealed the nurses felt they had the greatest impact through health promotion and prevention, advocacy, health education, and health counseling, including psychosocial support and spiritual care. The nurses appreciated the unique opportunities afforded by the congregational setting including integrating faith and health in nursing practice, the more relaxed environment, the opportunity for long-term relationships, and the level of professional autonomy. Challenges were experienced from the client's autonomy, the impact of religious beliefs, the nurse's worship experience, and time constraints. This study demonstrates that parish nurses can provide a valuable adjunct to the traditional care system as they practically and conceptually integrate faith and health.

Health promotion attitudes and strategies in older adults.

The purpose of this study was to describe older adults' attitudes and beliefs regarding wellness, self-care, and participation in health promotion activities. Six focus groups were conducted with 45 men and women aged 62 to 91. The White Crane Model of Healthy Lives for Older Adults was developed based on the focus group themes. Being healthy incorporates multiple components, including functional independence, self-care and management of illness, positive outlook, and personal growth and social contribution. Being healthy is determined by self-evaluation in the context of chronic illness or disability and the social and/or physical environment. Strategies for maintaining health and motivation for healthy behavior are identified. Socialization and social support are central to participation in programs, and interpersonal engagement is particularly important. Flexibility in choice and structure of programs contribute to seniors' sense of control over their health. Programs should be challenging and tailored to older adults' needs and expectations.