Different Definitions of Elder Mistreatment and Mortality: A Prospective Cohort Study From 2011 to 2017.

OBJECTIVES: To investigate the relationship between different definitions and subtypes of elder mistreatment (EM) and yearly mortality. DESIGN: Population-based epidemiological study. SETTING: Greater Chicago area. PARTICIPANTS: Chinese Americans aged 60 and older (N=3,157). MEASUREMENTS: Data were collected from 2011 to 2017, with mortality data collected over the subsequent 4 years. Face-to-face in-home interviews were conducted. EM was measured using a brief screening tool (10 items) and a detailed assessment (56 items) and defined using different criteria for overall and specific subtypes of EM. Mortality was ascertained during follow-up. Cox proportional hazards models were used. RESULTS: Four hundred seventy-five (15.2%) participants reported EM. Severe and moderate EM were associated with greater risk of 1-year (hazard ratio (HR)=2.51, 95% confidence interval (CI)=1.04-6.03; HR=2.55, 95% CI=1.08-6.03), 2-year (HR=1.68, 95% CI=1.01-2.78; HR=1.69, 95% CI=1.04-2.74), 3-year (HR=1.73, 95% CI=1.17-2.55; HR=1.73, 95% CI=1.19-2.51) and 4-year (HR=1.51, 95% CI=1.08-2.10; HR=1.48, 95% CI=1.08-2.04) mortality. A broad definition of EM was associated with greater risk of 3-year and 4-year mortality. With respect to subtypes of EM, psychological mistreatment and caregiver neglect were associated with greater mortality risk, whereas the relationships between psychological mistreatment, caregiver neglect and mortality risk varied according to definitional criteria. DISCUSSION: Different definitions and subtypes of EM had different associations with mortality in Chinese-American older adults. This study challenges assumptions about consequences of EM and calls for customized interventions for EM in minority populations. J Am Geriatr Soc 67:S506-S512, 2019.

Consequences of Elder Abuse and Neglect: A Systematic Review of Observational Studies.

This article presents the results of a systematic review of the consequences of elder abuse and neglect (EAN). A systematic search was conducted in seven electronic databases and three sources of gray literature up to January 8, 2016, supplemented by scanning of citation lists in relevant articles and contact with field experts. All observational studies investigating elder abuse as a risk factor for adverse health outcomes, mortality, and health-care utilization were included. Of 517 articles initially captured, 19 articles met our inclusion criteria and were analyzed. Two reviewers independently performed abstract screening, full-texts appraisal, and quality assessment using the Newcastle-Ottawa Scale. Across 19 studies, methodological heterogeneity was a prominent feature; seven definitions of EAN and nine measurement tools for abuse were employed. Summary of results reveals a wide range of EAN outcomes, from premature mortality to increased health-care consumption and various forms of physical and psychological symptoms. Higher risks of mortality emerged as the most credible outcome, while the majority of morbidity outcomes originated from cross-sectional studies. Our findings suggest that there is an underrepresentation of older adults from non-Western populations and developing countries, and there is a need for more population-based prospective studies in middle- and low-income regions. Evidence gathered from this review is crucial in upgrading current practices, formulating policies, and shaping the future direction of research.

[The diagnostic criteria for the improper care of the elderly subjects and their forensic medical significance]. / Diagnosticheskie kriterii nenadlezhashchego ukhoda za liud'mi preklonnogo vozrasta i ikh sudebno-meditsinskoe znachenie.

The demographic ageing of the population is accompanied by the gradual increase in the number of the people of the advanced age both in Russia and in other countries all over the world. This situation enhances the probability of violence and the improper care of the elderly subjects both in their families and in the specialized socio-medical facilities. The objective of the present work was to study the experience of the foreign specialists dealing with the problem of the improper care for the elderly subjects with a view to the identification of the diagnostic criteria for the application in the forensic medical practice. The improper care of the elderly subjects is one of the most widespread forms of violence because the associated inadequate actions or the absence of thereof are likely to be a cause of high morbidity and mortality among the persons of this age group as a result of infectious diseases. In the case of the lethal outcomes, the measures of investigation have the purpose not only to elucidate the cause of death but also to establish the relationship between the fact of death and the form of violence including the improper care. The latter can be manifested as the poor hygienic conditions, untidiness of attire, marked dehydration, nutritional dystrophy, injuries and skin burns, persistent and/or refractory cutaneous eruption in the anogenital and inguinal regions, inadequately treated decubital sore of atypical localization. The most dangerous complication of decubital ulcers in the elderly subjects is the systemic infection making up the commonest case of death. Such lethal outcomes are considered to be accidents and sometimes are qualified as murder. The report of the careful forensic medical examination is indispensable for the reliable evaluation of the circumstances of death and the quality of the medical treatment provided for the elderly subjects. Not infrequently it is of crucial importance in the civil and criminal procedures.

The circumstances surrounding the death of 105 elders as a result of resident-to-resident incidents in dementia in long-term care homes.

Resident-to-resident incidents in dementia in long-term care homes resulting in deaths represent a growing concern among residents, family members, care providers, care advocacy organizations, and policy makers. Despite these concerns and experts' predictions by which injurious and fatal incidents will increase in the coming years due to the projected growth in the number of people with dementia, no studies have been conducted in North America on these fatal incidents. This exploratory pilot study makes first steps towards bridging this major gap in research and practice. Using publicly available information (primarily newspaper articles and death review reports), practically useful patterns were identified pertaining to the circumstances surrounding the death of 105 elders as a result of these incidents. The findings could inform various efforts to prevent future deaths in similar circumstances, keep vulnerable and frail residents safe, and encourage researchers to examine risk and protective factors for these incidents.

Medico-legal aspects of deaths related to neglect and abandonment in the elderly.

As life expectancy increases, the phenomenon of the neglect of elderly persons is becoming increasingly relevant in the fields of both medicine and social care. This work analyses the cases of two subjects whose deaths initially seemed to have been attributable to natural causes. The autopsy findings and the analysis of clinical data, however, were able to establish that neglect had played a determining role in their deaths. These cases highlight the need for healthcare workers to be more alert to the clinical signs of neglect. Finally, in cases of death, the forensic pathologist must conduct a meticulous post-mortem examination to detect the physical signs of neglect and to establish if abuse has been responsible for the death.

Mortality among elder abuse victims in rural Malaysia: A two-year population-based descriptive study.

Our study aims at describing mortality among reported elder abuse experiences in rural Malaysia. This is a population-based cohort study with a multistage cluster sampling method. Older adults in Kuala Pilah (n = 1,927) were interviewed from November 2013 to May 2014. Mortality was traced after 2 years using the National Registration Department database. Overall, 139 (7.2%) respondents died. Fifteen (9.6%) abuse victims died compared to 124 (7.0%) not abused. Mortality was highest with financial abuse (13%), followed by psychological abuse (10.8%). There was a dose-response relationship between mortality and clustering of abuse: 7%, 7.7%, and 14.0% for no abuse, one type, and two types or more, respectively. Among abuse victims, 40% of deaths had ill-defined causes, 33% were respiratory-related, and 27% had cardiovascular and metabolic origin. Results suggest a link between abuse and mortality. Death proportions varied according to abuse subtypes and gender.

Elder mistreatment in a community dwelling population: the Malaysian Elder Mistreatment Project (MAESTRO) cohort study protocol.

INTRODUCTION: Despite being now recognised as a global health concern, there is still an inadequate amount of research into elder mistreatment, especially in low and middle-income regions. The purpose of this paper is to report on the design and methodology of a population-based cohort study on elder mistreatment among the older Malaysian population. The study aims at gathering data and evidence to estimate the prevalence and incidence of elder mistreatment, identify its individual, familial and social determinants, and quantify its health consequences. METHODS AND ANALYSIS: This is a community-based prospective cohort study using randomly selected households from the national census. A multistage sampling method was employed to obtain a total of 2496 older adults living in the rural Kuala Pilah district. The study is divided into two phases: cross-sectional study (baseline), and a longitudinal follow-up study at the third and fifth years. Elder mistreatment was measured using instrument derived from the previous literature and modified Conflict Tactic Scales. Outcomes of elder mistreatment include mortality, physical function, mental health, quality of life and health utilisation. Logistic regression models are used to examine the relationship between risk factors and abuse estimates. Cox proportional hazard regression will be used to estimate risk of mortality associated with abuse. Associated annual rate of hospitalisation and health visit frequency, and reporting of abuse, will be estimated using Poisson regression. ETHICS AND DISSEMINATION: The study has been approved by the Medical Ethics Committee of the University of Malaya Medical Center (MEC Ref 902.2) and the Malaysian National Medical Research Register (NMRR-12-1444-11726). Written consent was obtained from all respondents prior to baseline assessment and subsequent follow-up. Findings will be disseminated to local stakeholders via forums with community leaders, and health and social welfare departments, and published in appropriate scientific journals and presented at conferences.

A systematic review and meta-analysis of interventions designed to prevent or stop elder maltreatment.

BACKGROUND: elder maltreatment is a major risk for older adults' mental health, quality of life, health, institutionalisation and even mortality. OBJECTIVES: to perform a systematic review and meta-analysis of interventions designed to prevent or stop elder abuse. METHODS: Studies that were posted between January 2000 and December 2014, written in English, specifically designed to prevent or stop elder maltreatment were included. RESULTS: overall, 24 studies (and four records reporting on the same participants) were kept for the systematic review and the meta-analysis. Studies were broadly grouped into three main categories: (i) interventions designed to improve the ability of professionals to detect or stop elder maltreatment (n = 2), (ii) interventions that target older adults who experience elder maltreatment (n = 3) and (iii) interventions that target caregivers who maltreat older adults (n = 19). Of the latter category, one study targeted family caregivers, five targeted psychological abuse among paid carers and the remaining studies targeted restraint use. The pooled effect of randomised controlled trials (RCTs)/cluster-RCTs that targeted restraint use was significant, supporting the effectiveness of these interventions in reducing restraint use: standardised mean difference: -0.24, 95% confidence interval = -0.38 to -0.09. INTERPRETATION: the most effective place to intervene at the present time is by directly targeting physical restraint by long-term care paid carers. Specific areas that are still lacking evidence at the present time are interventions that target (i) elder neglect, (ii) public awareness, (iii) older adults who experience maltreatment, (iv) professionals responsible for preventing maltreatment, (v) family caregivers who abuse and (vi) carers who abuse.

Five-year all-cause mortality rates across five categories of substantiated elder abuse occurring in the community.

Elder abuse increases the likelihood of early mortality, but little is known regarding which types of abuse may be resulting in the greatest mortality risk. This study included N = 1,670 cases of substantiated elder abuse and estimated the 5-year all-cause mortality for five types of elder abuse (caregiver neglect, physical abuse, emotional abuse, financial exploitation, and polyvictimization). Statistically significant differences in 5-year mortality risks were found between abuse types and across gender. Caregiver neglect and financial exploitation had the lowest survival rates, underscoring the value of considering the long-term consequences associated with different forms of abuse. Likewise, mortality differences between genders and abuse types indicate the need to consider this interaction in elder abuse case investigations and responses. Further mortality studies are needed in this population to better understand these patterns and implications for public health and clinical management of community-dwelling elder abuse victims.

Effectiveness of START psychological intervention in reducing abuse by dementia family carers: randomized controlled trial.

BACKGROUND: Family carers of people with dementia frequently report acting abusively toward them and carer psychological morbidity predicts this. We investigated whether START (STrAtegies for RelaTives), a psychological intervention which reduces depression and anxiety in family carers also reduces abusive behavior in carers of people living in their own homes. We also explored the longitudinal course of carer abusive behavior over two year. METHODS: We included self-identified family carers who gave support at least weekly to people with dementia referred in the previous year to three UK mental health services and a neurological dementia service. We randomly assigned these carers to START, an eight-session, manual-based coping intervention, or treatment as usual (TAU). Carer abusive behavior (Modified Conflict Tactic Scale (MCTS) score ≥2 representing significant abuse) was assessed at baseline, 4, 8, 12, and 24 months. RESULTS: We recruited 260 carers, 173 to START and 87 to TAU. There was no evidence that abusive behavior levels differed between randomization groups or changed over time. A quarter of carers still reported significant abuse after two years, but those not acting abusively at baseline did not become abusive. CONCLUSION: There was no evidence that START, which reduced carer anxiety and depression, reduced carer abusive behavior. For ethical reasons, we frequently intervened to manage concerning abuse reported in both groups, which may have disguised an intervention effect. Future dementia research should include elder abuse as an outcome, and consider carefully how to manage detected abuse.

Análise sobre as políticas públicas de enfrentamento a violência contra o idoso / Assessment of the public policies to cope with violence against the elderly / Análisis de las políticas públicas de enfrentamiento a la violencia contra las personas mayores

Objetivo: refletir sobre as políticas públicas de enfrentamento a violência contra o idoso no Brasil. Método: estudo descritivo de cunho teórico-reflexivo, com prévia revisão da literatura especializada na temática. As informações foram analisadas possibilitando com que emergissem como pontos norteadores de reflexão, dois eixos temáticos: Epidemiologia da violência contra a pessoa idosa e Políticas públicas de enfrentamento a violência contra idosos no Brasil. Resultados: evidencia-se que o Brasil, atualmente possui suficientes recursos legais para o enfrentamento da violência contra o idoso. Contudo, apenas a produção de instrumentos legais não é suficiente para mudar a situação de violência a que está submetida a população idosa no país. Conclusão: a violência contra pessoa idosa constitui, portanto, uma violação dos Direitos Humanos e requer ações estratégicas por parte do poder público e da sociedade, tanto no âmbito da prevenção quanto do enfrentamento, a fim de resgatar e garantir a dignidade desse segmento.(AU)

Objective: to reflect on the public policies to cope with violence against the elderly in Brazil. Method: Descriptive theoretical-reflexive study, with previous review of the literature specialized on the topic. The information was assessed, and brought up two theme axis as reflexion guides: Epidemiology of the violence against the elderly and Public policies to cope with violence against the elderly in Brazil. Results: it is shown that Brazil currently has sufficient legal resources to cope with violence against the elderly. However, only producing legal instruments is not enough to change the violence situation to which the elderly population in country is submitted. Conclusion: violence against elderly constitutes, therefore, a Human Rights violation and requires strategic actions by the public power and the society, in prevention and coping areas, in order to rescue and ensure the dignity of this segment.(AU)

Objetivo: reflexionar sobre las políticas públicas de enfrentamiento a la violencia contra las personas mayores en Brasil. Método: estudio descriptivo de cuño teórico-reflexivo, con previa revisión de la literatura especializada en el tema. Las informaciones se analizaron, posibilitando la emergencia de puntos rectores de reflexión, dos ejes temáticos: Epidemiologia de la violencia contra la persona mayor y las políticas públicas de enfrentamiento a violencia contra las personas mayores en Brasil. Resultados: se evidencia que Brasil, en la actualidad, dispone de recursos legales suficientes para el enfrentamiento de la violencia contra las personas mayores. Sin embargo, apenas la producción de instrumentos legales no es suficiente para cambiar la situación de violencia a que está sujeta da populación anciana en el país. Conclusión: la violencia contra la persona mayor constituye, así, una violación de los Derechos Humanos e requiere acciones estratégicas de lo poder público e de la sociedad, en materia de prevención y enfrentamiento, con el fin de rescatar y garantir la dignidad de este segmento.(AU)

"Death Is Better Than Misery": Elders' Accounts of Abuse and Neglect in Ethiopia.

As the proportion of elders in developing nations increases and the ability of families to meet their needs is stretched thin, the risk of elder abuse will grow. This study examined the types and nature of abuse and neglect from the perspective of elders in Ethiopia who experienced abuse in noninstitutional settings. A qualitative design guided by hermeneutic phenomenology was used to explore the lived experiences of abuse and neglect of 15 Ethiopian elders. Nine women and six men ranging in age from 64 to 93 years were interviewed. Most were victims of multiple forms of abuse, especially financial exploitation, emotional abuse, and neglect. Economic vulnerability was a clear underlying factor contributing to elders' risk for encountering abuse. Effective prevention efforts must address the societal level factors that ultimately contribute to elder abuse while also holding individuals responsible for their harmful behaviors against elders.

Care of the victim.

The number of elder abuse cases is expected to rise as the number of persons older than age 65 doubles over the next 20 years. Patients affected by elder abuse present in all care settings, including inpatient and outpatient clinical care, emergency rooms, long-term care facilities, and home care. Victims have significant medical consequences, physical and psychological, and often need additional resources, including legal guidance. Health care professionals need additional training to be effective advocates for survivors of elder abuse. Care of the victim must also be recognized as an equally important topic for research and education.

A description of cases of severe physical abuse in the elderly and 1-year mortality.

We conducted a case-control study to evaluate severe physical abuse of the elderly treated in two Chicago area Level I trauma centers. This report details whether physicians are adequately reporting cases of abuse to Adult Protective Services (APS), and assesses 1 year. The failure to report two-thirds of the cases and the substantially higher risk of death during the first year after hospitalization indicates the need for improved identification, reporting, and intervention. It is important that clinicians understand the complexity of elder abuse in order to better identify suspected victims and report these cases to professionals in APS.

Mortality and disability outcomes of self-reported elder abuse: a 12-year prospective investigation.

OBJECTIVES: To determine whether elder abuse can predict mortality and disability over the ensuing 12 years. DESIGN: Population-based prospective cohort study of women aged 70 to 75 in 1996; survival analysis. SETTING: Australia. PARTICIPANTS: Twelve thousand sixty-six women with complete data on elder abuse. MEASUREMENTS: Elder abuse was assessed using the 12-item Vulnerability to Abuse Screening Scale (VASS) subscales: vulnerability, coercion, dependence, and dejection. Outcomes were death and disability (defined as an affirmative response to "Do you regularly need help with daily tasks because of long-term illness, disability or frailty?"). RESULTS: In 1996, 8% reported vulnerability, 6% coercion, 18% dependence, and 22% dejection. By October 2008, 3,488 (29%) had died. Mortality was associated with coercion (hazard ratio (HR) = 1.21, 95% confidence interval (CI) = 1.06-1.40) and dejection (HR = 1.12, 95% CI = 1.03-1.23), after controlling for demographic characteristics, social support, and health behavior but not after adding chronic conditions to the coercion model. Over the 12 years, 2,158 of 11,027 women who had reported no disability in 1996 reported disability. Women who reported vulnerability (HR = 1.25, 95% CI = 1.06-1.49) or dejection (HR = 1.55, 95% CI = 1.38-1.73) were at greater risk of disability, after controlling for demographic characteristics, social support, and health behavior. The relationship remained significant for dejection when chronic conditions and mental health were included in the model (HR = 1.40, 95% CI = 1.24-1.58). CONCLUSION: Specific components of vulnerability to elder abuse were differently associated with rates of disability and mortality over the ensuing 12 years.

Elder abuse.

Five types of elder abuse (physical, psychological, sexual, neglect and financial) are recognized. They are not new, occur worldwide and are associated with persistent morbidity and mortality. The forensic clinician has responsibilities to: (i) the patient, with competent history taking and examination, (ii) interpret findings and recognize patterns of harm and (iii) promulgate this issue in wider professional and public forums. Research into elder abuse is relatively recent; standardized terminology remains unsettled, and small-scale, local studies are hard to generalize. Cross-sectional, population-based studies of elder abuse should be possible, and standardized endpoints will require forensic science contributions.

A prospective population-based study of differences in elder self-neglect and mortality between black and white older adults.

BACKGROUND: Self-neglect is the behavior of an elderly person that threatens his or her own health and safety, and it is associated with increased morbidity and mortality. Although report of self-neglect is more common among black older adults, the racial/ethnic differences in mortality remain unclear. METHODS: The Chicago Healthy Aging Project is a population-based cohort study conducted from 1993 to 2005. A subset of these participants were suspected to self-neglect and were reported to a social services agency. Mortality was ascertained during follow-up and from the National Death Index. Cox proportional hazards models were used to assess the mortality risk. RESULTS: In the total cohort, there were 5,963 black and 3,475 white older adults, and of these, 1,479 were reported for self-neglect (21.7% in black and 5.3% in white older adults). In multivariable analyses with extensive adjustments, the interaction term indicated that impact of self-neglect on mortality was significantly stronger in black than in white older adults (parameter estimate, 0.54, SE, 0.14, p < .001). This difference persisted over time. In race/ethnicity-stratified analyses, at 6 months after report of self-neglect, the hazard ratio for black older adults was 5.00 (95% confidence interval, 4.47-5.59) and for white older adults was 2.75 (95% confidence interval, 2.19-3.44). At 3 years after report, the hazard ratios were 2.61 (95% confidence interval, 2.25-3.04) and 1.47 (95% confidence interval, 1.10-1.96) for black older adults and white older adults, respectively. CONCLUSIONS: Future studies are needed to qualify the casual mechanisms between self-neglect and mortality in black and white older adults in order to devise targeted prevention and intervention strategies.

Elder abuse and mortality: the role of psychological and social wellbeing.

BACKGROUND: Elder abuse is a pervasive human right and public health issue. OBJECTIVES: We aimed to examine the mortality associated with elder abuse across levels of psychological and social factors. METHODS: The Chicago Health and Aging Project (CHAP) is a prospective population-based cohort study that began in 1993. A subset of these participants enrolled between 1993 and 2005 had elder abuse reported to social services agencies (n = 113). Mortality was ascertained during follow-up and with the National Death Index. Psychosocial factors (depression, social network and social engagement) were assessed during the CHAP interview. Cox proportional hazard models were used to assess the mortality of elder abuse across levels of psychosocial factors using time-varying covariate analyses. RESULTS: The median follow-up time for the cohort (n = 7,841) was 7.6 years (interquartile range 3.8-12.4 years). In multivariate analyses, those with highest (hazard ratio (HR) 2.60, 95% CI 1.58-4.28) and middle levels (HR 2.18, 95% CI 1.19-3.99) of depressive symptoms had an increased mortality risk associated with elder abuse. For social network, those with lowest (HR 2.50, 95% CI 1.62-3.87) and middle levels (HR 2.65, 95% CI 1.52-4.60) of social network had increased mortality risk associated with elder abuse. For social engagement, those with lowest (HR 2.32, 95% CI 1.47-3.68) and middle levels (HR 2.59, 95% CI 1.65-5.45) of social engagement had increased mortality risk associated with elder abuse. Among those with lowest levels of depressive symptoms, highest levels of social network and social engagement, there was no significant effect of reported or confirmed elder abuse on mortality risk. CONCLUSION: Mortality risk associated with elder abuse was most prominent among those with higher levels of depressive symptoms and lower levels of social network and social engagement.

Elder self-neglect and abuse and mortality risk in a community-dwelling population.

CONTEXT: Both elder self-neglect and abuse have become increasingly prominent public health issues. The association of either elder self-neglect or abuse with mortality remains unclear. OBJECTIVE: To examine the relationship of elder self-neglect or abuse reported to social services agencies with all-cause mortality among a community-dwelling elderly population. DESIGN, SETTING, AND PARTICIPANTS: Prospective, population-based cohort study (conducted from 1993 to 2005) of residents living in a geographically defined community of 3 adjacent neighborhoods in Chicago, Illinois, who were participating in the Chicago Health and Aging Project (CHAP; a longitudinal, population-based, epidemiological study of residents aged > or = 65 years). A subset of these participants had suspected elder self-neglect or abuse reported to social services agencies. MAIN OUTCOME MEASURES: Mortality ascertained during follow-up and by use of the National Death Index. Cox proportional hazard models were used to assess independent associations of self-neglect or elder abuse reporting with the risk of all-cause mortality using time-varying covariate analyses. RESULTS: Of 9318 CHAP participants, 1544 participants were reported for elder self-neglect and 113 participants were reported for elder abuse from 1993 to 2005. All CHAP participants were followed up for a median of 6.9 years (interquartile range, 7.4 years), during which 4306 deaths occurred. In multivariable analyses, reported elder self-neglect was associated with a significantly increased risk of 1-year mortality (hazard ratio [HR], 5.82; 95% confidence interval [CI], 5.20-6.51). Mortality risk was lower but still elevated after 1 year (HR, 1.88; 95% CI, 1.67-2.14). Reported elder abuse also was associated with significantly increased risk of overall mortality (HR, 1.39; 95% CI, 1.07-1.84). Confirmed elder self-neglect or abuse also was associated with mortality. Increased mortality risks associated with either elder self-neglect or abuse were not restricted to those with the lowest levels of cognitive or physical function. CONCLUSION: Both elder self-neglect and abuse reported to social services agencies were associated with increased risk of mortality.