Enhancing and evaluating the capacity of elder abuse fatality review teams to assist victim services.

Fatality review teams (FRTs) have been historically helpful in identifying systemic issues that may lead to child and domestic violence deaths to improve responses, guide prevention efforts, and better serve victims. More recently, these teams have formed to address similar concerns in elder abuse matters. The American Bar Association Commission on Law and Aging received an early grant to study elder abuse fatality review teams (EAFRTs) and in 2005 created its first Replication Guide. The current study reports on a subsequent national survey of EAFRTs, conducted 14 years later to identify important similarities and differences in team operations, impact and sustainability. EAFRTs are growing nationally in numbers, have positive impacts on member elder abuse and victim services knowledge, skills and confidence, but experience challenges to impact evaluability and sustainability due to low funding and membership time, turnover and commitment. Recommendations for supporting newly developing and currently functioning EAFRTs are provided.

Medical implications of elder abuse: self-neglect.

Self-neglect, the most common form of elder mistreatment seen by Adult Protective Service Agencies across the United States, is an often unrecognized geriatric syndrome characterized by squalor and unsafe living circumstances. It is a result of medical, neurologic, or psychiatric disorders coupled with lack of capacity for self-care and self-protection in the absence of necessary services or medical care, and leads to increased morbidity and mortality. Clinicians should evaluate self-neglecters and plan interventions based on comprehensive geriatric assessment and capacity assessment. State and federal policies are needed to address the pressing needs of this vulnerable population of seniors.

Future research: a prospective longitudinal study of elder self-neglect.

In almost every U.S. jurisdiction, elder self-neglect is the most common allegation addressed by Adult Protective Service (APS) agencies. Not only is self-neglect common, but this form of mistreatment is an independent risk factor for death. A lack of understanding of the precipitating factors and root causes and of the effect on social and medical systems persists in this field. Research in this area has been limited, because the needs of these vulnerable elderly people are complex and diverse. Moreover, these factors encompass interrelated medical, psychiatric, economic, social, and functional problems. In 2004, the National Institutes of Health Interdisciplinary Roadmap Initiative provided the means for preliminary exploration of elder self-neglect through the formation of the Consortium for Research in Elder Self-neglect of Texas (CREST). The goals of CREST include to conduct pilot studies, form interdisciplinary working groups, convene a national research conference, and appoint a national external advisory board. CREST orchestrated the work of 35 interdisciplinary investigators to achieve these goals. CREST researchers have begun to characterize the population of vulnerable elderly people who were reported to APS for neglecting themselves. The pilot studies provided a snapshot of 100 elderly people who had neglected themselves. A proposed next phase could involve a prospective longitudinal study of elderly people with severe self-neglect. This study of the clinical course, the death rate, the causes of death, the occurrence of acute and chronic medical or mental illness, and the costs to the healthcare and social systems would greatly inform the field of elder mistreatment.

Healthcare costs and utilization of vulnerable elderly people reported to Adult Protective Services for self-neglect.

OBJECTIVES: To assess differences between diagnoses, healthcare utilization, and healthcare costs of vulnerable elderly people reported to Adult Protective Services for self-neglect and those of matched controls. DESIGN: A case-control study of 131 self-neglect cases and 131 matched controls. SETTING: All participants were patients in a public hospital geriatrics program. PARTICIPANTS: Adult Protection Services referred the self-neglect cases to an interdisciplinary geriatric medicine team. The controls were patients who used the same source of geriatric medical services and were matched on race or ethnicity, sex, and age. MEASUREMENTS: Diagnoses, healthcare utilization, and Medicare reimbursable costs were compared in cases and controls for 1 year before and 1 year after the case medical referral. RESULTS: Mental disorders were diagnosed more frequently in the self-neglect group than in the control group. Self-neglecters had lower healthcare utilization and medical costs than controls in the year before the medical referral, but utilization and costs were similar in the two groups in the year after the referral. CONCLUSION: This study provides evidence that, once self-neglecters are brought into the healthcare system, they are no more expensive than other similar patients. This result has important public policy implications and fills an important gap, because there is no published literature describing the financial effect of self-neglect on the healthcare system.

Self-neglect among the elderly: a model based on more than 500 patients seen by a geriatric medicine team.

OBJECTIVES: We sought to identify the functional, cognitive, and social factors associated with self-neglect among the elderly to aid the development of etiologic models to guide future research. METHODS: A cross-sectional chart review was conducted at Baylor College of Medicine Geriatrics Clinic in Houston, Tex. Patients were assessed using standardized comprehensive geriatric assessment tools. RESULTS: Data analysis was performed using the charts of 538 patients; the average patient age was 75.6 years, and 70% were women. Further analysis in 460 persons aged 65 years and older showed that 50% had abnormal Mini Mental State Examination scores, 15% had abnormal Geriatric Depression Scale scores, 76.3% had abnormal physical performance test scores, and 95% had moderate-to-poor social support per the Duke Social Support Index. Patients had a range of illnesses; 46.4% were taking no medications. CONCLUSIONS: A model of self-neglect was developed wherein executive dyscontrol leads to functional impairment in the setting of inadequate medical and social support. Future studies should aim to provide empirical evidence that validates this model as a framework for self-neglect. If validated, this model will impart a better understanding of the pathways to self-neglect and provide clinicians and public service workers with more effective prevention and intervention strategies.

Do medical examiners determine elder mistreatment as a cause of death?

This study examines the decision-making process of medical examiners in determining elder mistreatment in cases that present to the county morgue. Harris County Medical Examiners were surveyed about factors that influence the determination whether elder abuse or neglect was a contributor to the cause of death. At the time of the survey, all 11 Harris County Medical Examiners participated. Of these, 8 did not determine elder abuse or neglect as contributing to the cause of death in the 12 months prior to the survey, 6 reported that medical records were helpful "all the time", 3 reported "most of the time", and 2, indicated that the records were "some-times helpful". The survey also indicated that information that assists medical examiners in identifying the potential for abuse or neglect ranged from "present most of the time" to "never present". Multiple factors including autopsy findings, medical compliance, inconsistency in injury findings, and malnutrition were reported as helpful in determining elder abuse or neglect. Further studies are needed to determine additional factors that would provide medical examiners with the ability to more readily identify signs of elder abuse or neglect.

Severe self-neglect: an epidemiological and historical perspective.

Older adults with severe self-neglect have multiple deficits in various social, functional and physical domains, and often live insqualor. These individuals often present with poor personal hygiene, domestic squalor and hoarding which results in a threat to their own health as well as personal and public safety. Severe self-neglect occurs along a continuum with older adults often having cognitive and affective disorders compared with younger individuals presenting with psychiatric illnesses. In cases of severe self-neglect with hoarding, evidence has shown this behavior occurs in diverse social strata and not among the wealthy and professionals alone as believed earlier. Due to the multiple conditions associated with severe self-neglect, this population will require an interdisciplinary, multidimensional approach to reduce morbidity and mortality rates including nursing home placement. Research on this group has been limited and is rarely described in the medical and nursing literature. Future research is needed to provide practitioners with effective screening instruments and interventions on cases of severe self-neglect.

The making of a self-neglect severity scale.

BACKGROUND: Research in elder self-neglect has lagged behind that of other forms of mistreatment, despite the fact that self-neglect is the most common allegation reported to Adult Protective Service agencies throughout the US. The lack of a gold standard to measure self-neglect has hampered efforts to study this phenomenon. METHODS: Researchers designed the Self-Neglect Severity Scale (SSS) based on interviews with Adult Protective Service workers and a national expert panel. The SSS is based on observation and interview and is administered in the home to include an environmental assessment. It was piloted, extensively field tested and then revised. RESULTS: The CREST SSS was developed using survey data and consultation with experts in the field. This instrument utilizes observer ratings, interview responses, and assesses subjects' physical and environmental domains. It also assesses functional status as it relates to health and safety issues. After field and pilot testing, the SSS was finalized and is currently undergoing reliability and validity testing. CONCLUSIONS: The CREST SSS was developed as a state scale to provide a common language for describing cases of self-neglect. It is the first self-neglect severity scale available to researchers. If found to be both reliable and valid, it may be used in future intervention studies.

What is the association between self-neglect, depressive symptoms and untreated medical conditions?

OBJECTIVE: There have been no studies describing the occurrence of untreated medical condition(s) in elders with depression who self-neglect. This study compares the prevalence of depression as indicated by an abnormal score ( > or = 5) on the Geriatric Depression Scale-Short Form (GDS-SF) between self-neglecters and matched non self-neglecting community-dwelling elders. It also describes the relationship between untreated medical condition(s) associated with self-neglect and abnormal scores on the GDS-SF. METHODS: The two samples consisted of 50 self-neglect cases validated by Adult Protective Services and 50 matched non-self-neglecters recruited from a hospital geriatric unit. The cases and controls were matched on age, gender, ethnicity and socio-economic status when possible. All were assessed in their home. Each participant received a comprehensive geriatric assessment, which included the Geriatric Depression Scale-Short Form, the Mini-Mental State Exam, the Self-Rated Health and Mortality question, and the Physical Performance Test. A laboratory blood analysis was also conducted. Untreated medical condition(s) was determined during the assessment by a geriatric nurse practitioner. RESULTS: There was a statistically significant difference in the distribution of abnormal GDS-SF scores between the self-neglect (n = 25, 51%) versus the control group (n = 14, 28%; X2 = 5.49, df = 1, p = .019). Self-neglecters with scores indicative of depression were also significantly more likely (56% vs. 21%) to have untreated medical condition(s) compared to self-neglecters scoring normal on the GDS-SF (OR = 4.84, 95% CI = 1.37-17.09). CONCLUSION: Clinicians should anticipate untreated medical condition(s) in elderly patients with depressive symptomatology who self-neglect.

Social networks: a profile of the elderly who self-neglect.

BACKGROUND: Self-neglect is an independent risk factor for early mortality in older people and has been linked to depression and the occurrence of mental and physical decline. Sound social networks have been shown to slow the process of decline in the elderly, and currently little is known about the social networks associated with elder self-neglect. The aim of this study was to explore the social networks associated with elder self-neglect compared with a matched-control group. METHODS: Ninety-one Adult Protective Services-validated cases of elder self-neglect were compared on formal and informal social network factors with 91controls matched for age, race, gender, and socio-economic status. RESULTS: Elders in the self-neglect group were significantly less likely to (1) Live with a spouse, (2) Live with others, (3) Have weekly contact with children or siblings, (4) Visit with neighbors and friends and (5) Participate in religious activities. CONCLUSIONS: Less adequate social resources related to family, friends, and religious affiliations are significantly associated with elder self-neglect.

Is pain a significant factor in elder self-neglect?

PURPOSE: Pain is a worldwide health concern leading to cognitive impairments, depression, and decline in activities of daily living when poorly controlled. Self-neglect is also a serious public health issue being the most common allegation reported to Adult Protective Services (APS). The purpose of this analysis is to determine whether self-reported pain is associated with validated cases of self-neglect compared with matched controls. METHODS: This is a cross-sectional study of 80 (APS) validated cases of self-neglect aged 65 years and older and 80 control participants recruited from a geriatric clinic at Harris County Hospital District. Control participants were matched for age, race, gender, and zip code. Both groups were administered the Wong-Baker FACES rating scale and the Mini-Mental State Examination in their homes by a geriatric nurse practitioner and a research assistant. SUMMARY OF RESULTS: Self-reported pain was noted in 43% of the self-neglect group compared with only 28% in the control group (X2 = 3.85, df = 1, p = .05). This difference became non-significant after stratifying for MMSE scores of 19 or greater (X2 = 3.38, df = 1, p = .066). The self-neglecting elderly also reported significantly higher levels of pain compared with the matched controls (t = 2.5, df = 143, p = .014). This mean difference remained significant after stratifying by MMSE scores of 19 or greater (t = 2.6, df = 124, p = .009). CONCLUSION: The data provide preliminary support for the relationship between self-reported pain and elder self-neglect. Research is needed to determine whether pain is a causal or associated factor in self-neglect and whether therapeutic intervention can improve the syndrome of self-neglect.

Vitamin D deficiency associated with self-neglect in the elderly.

BACKGROUND: Vitamin D deficiency is common in elders. However, little is known about the implications of vitamin D deficiency in elder self-neglect. SPECIFIC AIMS: To characterize a group of self-neglecting elders with vitamin D deficiency based on clinical, cognitive, and functional status. Participants. Forty-four self-neglecting elders referred by the Adult Protective Services. METHODS: Vitamin D status of the self-neglecting elders was based upon serum levels of 25-hydroxyvitamin D (25-OHD). Demographics, cognitive, and functional characteristics of vitamin D deficient self-neglecting elders were described and compared to those without vitamin D deficiency. RESULTS: Vitamin D deficiency (25-OHD < 25 nmol/L) was detected in 16 out of 44 self-neglecting elders (36%). Self-neglecting elders with vitamin D deficiency had lower scores in the Physical Performance Test and higher scores in the Kohlman Evaluation of Living Skills, compared with those who were not vitamin D deficient (p = 0.014 and p = 0.018 respectively). CONCLUSIONS: Vitamin D deficiency is common in elder self-neglect. Self-neglecting elders with vitamin D deficiency have impaired physical performance and inadequate living skills, which can be potentially improved by treating vitamin D deficiency.

Assessing capacity in the setting of self-neglect: development of a novel screening tool for decision-making capacity.

Compared with older adults with disabilities and those who autonomously choose to live in squalor, self-neglect syndrome arises from a predicate state of vulnerability in frail older adults. This state of vulnerability is characteristically associated with a decline in decision-making capacity regarding the ability to care for and protect oneself. We developed the COMP Screen to evaluate vulnerable older adults to identify potential gaps in decision-making capacity using a screening tool. A total of 182 older adults were evaluated and consistent declines in cognitive ability and decision-making processes were present in this population. However, there were no significant differences between elders referred for self-neglect and matched older adults. These findings suggest that declines in decision-making processes are not uncommon in vulnerable older adults but traditional conceptualizations of decision-making capacity may be inadequate for differentiating the capacity for self-care and protection in elders who self-neglect.

Enhancing victim safety through collaboration.

Elder abuse is associated with morbid and lethal outcomes. In some cases of elder abuse, particularly involving domestic violence, uninformed or improperly executed interventions can result in serious harm to the victims. Professionals from various disciplines may themselves be at risk during encounters with perpetrators. This chapter provides an overview of potentially dangerous scenarios of elder abuse such as homicide, homicide/suicide, strangulation, and stalking. Intervention strategies such as lethality assessments and safety planning are described. A case scenario illustrates the value of an interdisciplinary response to enhance victim safety. This chapter reviews potential lethality factors and the steps that can be taken to enhance the safety of victims, their families, and the professionals who serve them.

The hidden health menace of elder abuse. Physicians can help patients surmount intimate partner violence.

As many as 2 million elderly persons in the United States experience physical, psychologic, or sexual abuse each year. Nationally spouses or intimate partners commit between 13% and 50% of elder abuse.1 Physicians can be instrumental in preventing and intervening in intimate partner violence in their elderly patients.

Frail older patient care by interdisciplinary teams: a primer for generalists.

Frail older patients-unlike younger persons in the health care system or even well elders-require complex care. Most frail older patients have multiple chronic illnesses. Optimum care cannot be achieved by following the paradigm of ongoing traditional health care, which emphasizes disease and cure. Because no one health care professional can possibly have all of the specialized skills required to implement such a model of health care delivery, interdisciplinary team care has evolved. This paper describes the roles of the participating team members in the context of interdisciplinary care for frail older adults. In addition, the challenges that occur when Geriatric Interdisciplinary (ID) Teams involved in providing care to frail older patients are identified and discussed.