Once the tool was ready, we tested its usability and acceptability with 14 older adults. Results and discussion: Focus group participants supported use of a tablet-based tool to screen for EM, indicating that digital screening benefits from feelings of privacy and anonymity. Prominent suggestions made by older adults included using a female voice for the tool narrator, larger font size, more multimedia, headphones for privacy; and having someone available during screening for assistance if needed.
Participants indicated that it is difficult for older adults experiencing EM to ask for help and that any type of mistreatment screening would be helpful. They also highlighted the need to explain community resources available to older adults once EM is disclosed, especially resources offering help to the caregiver. Participants of the usability evaluation rated the tool a mean score of Did you notice any of these today or in the past 12 months? Yaffe ac. Additional information about the Elder Abuse Suspicion Index is available at www.
Other screening and assessment instruments for elder abuse include the Indicators of Abuse Screen, a item checklist of problems that requires a two- to three-hour home visit by a trained health care provider not necessarily a physician , which discriminated With the exception of the Elder Abuse Suspicion Index, none of these instruments has been validated in the primary care setting.
The most recent recommendations from the Canadian Task Force on Preventive Health Care are from , at which time the task force found poor evidence to include case-finding for elder abuse in, or to exclude it from, the periodic health examination.
Whenever possible, assessments of elder abuse should occur in private, as the presence of caregivers may hinder disclosure of abuse. The task force also suggested an advocacy approach to prevent further abuse, whereby physicians direct the older person to community resources. Interventions can be categorized by the target the abuser, the abused elderly person or the situation see Appendix 1, Part 4.
All of the studies we identified 36 — 45 were heterogeneous and had substantial limitations, and it is therefore difficult to recommend any of the studied interventions. The most promising model is that of multidisciplinary teams that include physicians, nurses, mental health care providers, protective services and professionals within the justice system.
However, there has been only one study demonstrating a statistically significant measurable outcome for a multidisciplinary team. This study addressed only financial abuse, however, and its results cannot be extrapolated to other types of abuse that may be harder to prove in the justice system. More fundamentally, it remains unclear what should be considered an effective outcome and whether abused elderly people view prosecution in a positive way.
Despite the lack of robust evidence to support recommendations, clinicians still need an approach to this relatively common problem. We encourage physicians to be aware of potential risk factors and clinical manifestations of elder abuse while recognizing the limitations of the research in this area.
In the US, all but five states have some sort of mandatory reporting of elder abuse to adult protective services. For example, Nova Scotia and Newfoundland and Labrador mandate that any person suspecting elder abuse is to report it without discriminating between capable or incapable older adults, whereas other provinces limit reporting to professional persons or have laws that vary according to whether the abused older person lives in a health care facility.
Although there is no comparable Canadian statement, the Department of Health for England has issued a government policy statement on safeguarding vulnerable adults, 48 which highlights six principles: empowerment presumption of person-led decisions and informed consent , prevention it is better to take action before harm occurs , proportionality proportionate and least intrusive response appropriate to the risk presented , protection support and representation for those in greatest need , partnership local solutions through services working with their communities and accountability accountability and transparency in delivery of safeguarding.
With these principles in mind and on the basis of our experience and review of the literature, we propose the approach outlined in Figure 1. This approach has not been tested. Suggested approach to intervening in cases of suspected elder abuse. Assessment of suspected elder abuse should begin with an assessment of capacity. We believe that management strategies for elder abuse should be handled similarly to other medical treatment decisions with regard to capacity, namely whether the patient is able to understand and appreciate the consequences of the proposed treatment.
If it is determined that the abused older person is capable, we suggest that the physician present his or her concerns about abuse to the patient, educate the patient about elder abuse and the tendency for it to increase in frequency and severity, and direct the patient to local resources, including day programs, home care, respite care, legal services, shelters and government-supported elder abuse consultants.
In Canada, additional resources include the Advocacy Centre for the Elderly www. Imminent safety should be assessed and any concerns clearly communicated to the patient, including creation of an emergency safety plan. In the case of an incapable older person who is experiencing abuse, we suggest identifying the person who has power of attorney and offering the same resources.
An important caveat would be to ensure that the incapable patient does not have reversible medical causes of incapacity that could be addressed before seeking guardianship. All abused older adults should be offered more frequent medical follow-up. Evidence regarding the risk factors for, assessment of and interventions to address elder abuse is limited. Although multidisciplinary teams have existed for several decades, only one study has demonstrated a measurable effect of such teams, and it was limited to financial abuse.
Future research is needed to clarify the risk factors for each type of abuse, to determine screening or case-finding thresholds, to define effective outcome measures and to test the efficacy of clinically feasible interventional approaches.
There is insufficient evidence to recommend screening all older people for elder abuse and insufficient evidence to recommend any one intervention. However, physicians still need to address this relatively common health issue. An advocacy approach for suspected elder abuse is recommended. Following an assessment of capacity, physicians should educate the patient about elder abuse and direct him or her to local resources, including home care and respite agencies, legal services, shelters and government-supported elder-abuse and police services.
CMAJ Podcasts: author interview at soundcloud. Competing interests: None declared. Disclaimer: Sharon Straus is an associate editor for the CMAJ and was not involved in the editorial decisionmaking process for this article. This article has been peer reviewed. Contributors: Xuyi Mimi Wang was involved in the conception and design of the review, literature search, abstract review, full-text review, data abstraction, and drafting and editing of the manuscript.
Sarah Brisbin was involved in the abstract review, full-text review, data abstraction and manuscript editing. Tenneille Loo was involved in abstract review and manuscript editing. Sharon Straus was involved in the conception and design of the review, literature search and manuscript editing. All of the authors gave final approval of the version to be published and agree to act as guarantors of the work. National Center for Biotechnology Information , U. Author information Copyright and License information Disclaimer.
Correspondence to: Xuyi Mimi Wang, ac. This article has been cited by other articles in PMC. Box 1: Evidence for this review. How is elder abuse defined? What are the risk factors for elder abuse? What are the clinical manifestations of elder abuse? Are there recommendations for screening or case-finding for elder abuse? Box 3: Elder Abuse Suspicion Index What evidence supports interventions to combat elder abuse?
How can physicians intervene in clinical practice? Open in a separate window. Figure Conclusion Evidence regarding the risk factors for, assessment of and interventions to address elder abuse is limited. References 1. Dong X, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. Adult protective service use and nursing home placement. Gerontologist ; 42 : —9. The mortality of elder mistreatment.
JAMA ; — Prevalence of and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health ; —7. The prevalence of elder abuse and neglect: a systematic review. Age Ageing ; 37 : — Several tools have been tested; some have demonstrated a moderate to good internal consistency and some have been validated to allow an early identification.
None have been evaluated against measurable violence or health outcomes. Relevance to clinical practice: Nurses and all healthcare providers should screen patients routinely. However, we are not able to recommend a single tool as the selection and implementation has to be appropriate to the setting. Furthermore, the study population and the possibility of using multiple tools in combination should be taken into consideration, to assess all the aspects of violence.
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