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.

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.

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 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.

Using Latent Class Analysis to Identify Profiles of Elder Abuse Perpetrators.

Objectives: Research suggests that abuser risk factors differ across elder mistreatment types, but abuse interventions are not individualized. To move away from assumptions of perpetrator homogeneity and to inform intervention approaches, this study classifies abusers into subtypes according to their behavior profiles. Method: Data are from the Older Adult Mistreatment Assessment administered to victims by Adult Protective Service (APS) in Illinois. Latent class analysis was used to categorize abusers (N = 336) using victim and caseworker reports on abusers' harmful and supportive behaviors and characteristics. Multinomial logistic regression was then used to determine which abuser profiles are associated with 4 types of mistreatment-neglect, physical, emotional, and financial-and other sociodemographic characteristics. Results: Abusers fall into 4 profiles descriptively labeled "Caregiver," "Temperamental," "Dependent Caregiver," and "Dangerous." Dangerous abusers have the highest levels of aggression, financial dependency, substance abuse, and irresponsibility. Caregivers are lowest in harmful characteristics and highest in providing emotional and instrumental support to victims. The 4 profiles significantly differ in the average age and gender of the abuser, the relationship to victims, and types of mistreatment committed. Discussion: This is the first quantitative study to identify and characterize abuser subtypes. Tailored interventions are needed to reduce problem behaviors and enhance strengths specific to each abuser profile.

Knowledge About and Perceptions of Advance Care Planning and Communication of Chinese-American Older Adults.

Although advance care planning (ACP) is associated with better care at the end of life, better quality of death, and less psychological distress in survivors, ethnic disparities in ACP completion rates have been documented and may be attributable to lack of knowledge about ACP or differences in cultural values and preferences. Despite rapid increases in the size of the Asian-American population, little is known about ACP preferences of Chinese Americans. The purpose of this study is to explore the knowledge, attitudes, and preferences of older Chinese Americans toward ACP. Focus groups with Chinese older adults (n = 34) were conducted in Mandarin, Cantonese, and English, and transcripts were analyzed using a grounded theory approach. Identified themes included knowledge and experience with ACP and end-of-life care options, health as a factor in timing of ACP and communication, and communication of end-of-life care preferences. Knowledge of and experience with ACP and end-of-life decision-making varied according to focus group, although few participants had an advance directive. Findings suggest that Chinese older adults prefer to use indirect communication strategies, such as commenting on the circumstances of others rather than directly stating their wishes, and informal contexts, such as during a family dinner rather than formal meeting, to convey their care preferences to loved ones and may employ similar tactics when communicating with clinicians. This is particularly important given the recent decision by the Centers for Medicare and Medicaid Services to provide reimbursement to physicians for engaging in advance care planning conversations.

Knowledge and perceptions of hospice care of Chinese older adults.

Despite dramatic increases in hospice enrollment, ethnic disparities persist. With rapidly growing populations of Asian Americans, research is needed to elucidate factors that contribute to hospice underenrollment in subgroups of Asian populations. The purpose of this study was to explore older Chinese Americans' knowledge, understanding, and perceptions of hospice care. Three focus groups were conducted, one each in English, Mandarin, and Cantonese, all recruited from a Chinese social service agency. Focus groups were audiotaped and transcribed and then coded for themes. Thirty-four Chinese Americans participated in the groups, all but one reporting primary language other than English. Themes included lack of knowledge, death timing, burden (financial, emotional, physical toward family or government), peaceful death (relief of suffering), and quality of care (and its influence on perception of best care location). Findings indicate the need for hospice education and outreach to Chinese Americans. Additionally, to address concerns about burden and death in the home, efforts to improve access to hospice facilities are needed. Findings from this study provide direction for healthcare providers to address potential barriers to increasing access to hospice of Chinese Americans.