A case and intervention for older adult sexual mistreatment.

BACKGROUND: The sexual mistreatment of older adults is a significant public health issue; like other forms of sexual violence, it is more prevalent than officially reported. Survivors often hesitate to speak out due to feelings of embarrassment, fear, or potential cognitive impairments. Moreover, the concealment of such mistreatment, coupled with societal stigmas surrounding aging and sexuality, creates challenges in recognizing sexual mistreatment during routine or emergency room visits. PURPOSE: This paper provides a framework for informing physicians, psychiatrists, and other healthcare providers on best practices screening, detection, and management of sexual mistreatment in older adults. METHODS: A literature review of older adult sexual mistreatment articles between 2005-2024 was conducted. RESULTS: Medical professionals and psychiatrists are well-positioned to raise awareness and identify sexual mistreatment in older adults and manage such situations when suspected. CONCLUSION: Assessing suspected sexual mistreatment can improve detection, responsiveness, and patient safety for older adults through an interprofessional approach.

Perspectives on elder mistreatment screening and responding in emergency departments: A qualitative study with survivors.

OBJECTIVE: Elder Mistreatment (EM) occurs in approximately 10% of older adults and is associated with trauma-related outcomes including depression, anxiety, posttraumatic stress disorder, and early mortality. Low screening and older adult self-reporting, especially within emergency departments, represent missed opportunities for identify and mitigate future EM occurrences and consequences. To date, no studies have obtained EM survivors' perspectives on EM screening and response practices in emergency departments. METHODS: Semi-structured interviews with 19 EM survivors of those with Adult Protective Services validated EM were completed in older adults' homes. The Elder Mistreatment Emergency Department Screening and Response Tool (EM-SART) was used to guide the interview questions. All interviews were recorded, transcribed, and analyzed using qualitative thematic analyses. RESULTS: The participants were mostly female (63%) and white (58%) with an average age of 74 years. Physical abuse accounted for 67% of the EM incidents. Three themes emerged indicating the survivor preference for (1) building rapport and approaching the older adult with compassion and care, (2) setting the context before asking the EM questions, and (3) allowing mutuality, collaborative work, and shared decision-making during the response. CONCLUSIONS: Older adults are agreeable and willing to self-report and actively engage in the EM screening and response practices in the emergency department if trauma-informed care principles are utilized.

Social connection and self-neglect: A case for broader exploration.

OBJECTIVE: Self-neglect (SN) is the most common report to Adult Protective Services (APS) and is associated with significant morbidity and mortality risks for older adults. Lack of instrumental support is a well-evidenced etiologic factor in the development and continuation of SN, but little is known about other modifiable social connection characteristics. The social connection framework provides evidence-based characteristics across structure, function, and quality missing from SN studies that could be identified if explored. These factors could provide prevention and intervention targets related to poor health. METHODS: A narrative case study is presented using quantitative and qualitative data to explore social connection across structure, function, and quality in the context of SN. RESULTS: The findings highlight the complexity of social connection that may be observed in SN cases reported to APS. Strategic utilization of direct and indirect social interventions to support social connection in this case are presented. CONCLUSION: The results from this case give rise to considerations that may be generalizable to other SN cases. Recommendations for future research on social connection in this population are provided.

Building resilience: A specialty clinic tailored to older adults at risk for violence and abuse.

OBJECTIVE: Both structural (e.g., ageism) and personal (e.g., stigma) barriers hinder older adults' access to and engagement with mental health care. These barriers are particularly problematic for those vulnerable to interpersonal violence and abuse (e.g., due to social isolation). This study presents a quality improvement program aimed at older adults who have experienced significant stressful events, particularly elder mistreatment, within a larger trauma specialty clinic. Leveraging home-based telemedicine, the clinic provides evidence-based psychotherapy tailored to the needs of older adults. METHODS: From 2021 through 2023, the authors retrospectively examined treatment initiation, engagement, completion, and clinical outcomes among 231 older adults age 60+ who reported trauma that met DSM-5 criterion A criteria for post-traumatic stress disorder, depression, or other mental health comorbid conditions related to their traumatic event. The clinic uses an automated measurement-based care approach that facilitates Quality Improvement projects, allowing the tracking of treatment initiation, engagement, completion, and clinical outcomes for all patients. RESULTS: The results indicated high treatment completion, high engagement with telemedicine-delivered interventions, and, most importantly, significant changes in clinical outcomes. CONCLUSION: These findings highlight the importance of expanding telemedicine-based mental health services for older adults, challenging ageist norms, and prioritizing older adults' mental health needs by providing tailored services to this patient population.

A collaboration between adult protective services and forensic accounting examiners to investigate complex financial exploitation: formative evaluation findings.

Financial exploitation (FE) is one of the most common reports to Adult Protective Services (APS) and the cases are often complex. Consequently, APS caseworkers report FE investigations to be among the most difficult while simultaneously reporting low confidence in productive outcomes for these investigations. This necessitates finding ways to support APS FE investigations. This paper describes the structure, process, and formative findings of a collaboration between forensic accounting examiners and APS workers to investigate complex cases of FE. Among the 77 FE cases completed, forensic examiners reviewed multiple years of financial records which included over 101,000 transactions, totaling over $213,000,000.00 in finances, and identified over $8,000,000 in questionable activity. Scores on the 8-item Client Satisfaction Questionnaire were high indicating high program satisfaction by APS workers, subject matter experts, and forensic examiners. These findings support the feasibility and acceptability of forensic accounting and APS collaborations to investigate complex cases of FE.

Victimization in Unethical Unlicensed Small Residential Care Homes in the United States: The Case for Whole System Disruption.

In the United States, small residential care homes provide affordable community-based care for disabled older adults. Also called adult foster care homes, residential care facilities, group homes, or board and care homes, small residential care homes are typically private, small businesses operating in single-family dwellings that provide round-the-clock care in a home-like setting in residential neighborhoods. While most states license small residential care homes they also exist, legally and illegally, as unlicensed and unregulated operations. The quality of care in some unlicensed and unregulated small residential care homes can be questionable. Disabled older adults are targeted and victimized by unethical small residential care home operators for financial gain. This commentary highlights the need for whole system disruption to end victimization in unethical unlicensed and unregulated small residential care homes through case studies of the abuse and neglect of residents living in unethical unlicensed operations and recommends ambitious goals centered on reducing secondary financial gains and medically neglectful practices. These recommendations are at federal, state, and local levels, and include creating a federal definition of small residential care homes, increasing and coupling government incomes with state registration and employee misconduct registry checks, increasing oversight and assessment, improving temporary guardianship processes, providing avenues for reporting abuse, and developing older adult fatality review teams.

Racial/Ethnic Group Differences in Older Adults' Involvement with Adult Protective Services.

This paper represents the first study to focus on quantifying racial/ethnic group differences in older adults' involvement with adult protective services (APS).  Across 3 independent county programs, the rate of APS reports was about twice as high for Black older adults compared to White older adults.  These differences were greater for clients who were older and male but remained similar across allegation type.  The percent of reports validated was slightly but consistently lower for Black clients than for White clients, and a lower percentage of Black clients' cases were closed due to investigation or service refusal. Findings for Hispanic clients differed by county, so it was impossible to generalize about their APS experience.  Researchers should distinguish racial/ethnic group differences that persist across multiple programs from those that are program-specific.  Further studies with larger data sets are needed to guide APS practice and ensure equity for all clients served. .

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.

Socioecological indicators of senior financial exploitation: an application of data science to 8,800 substantiated mistreatment cases.

Senior financial exploitation (FE) is prevalent and harmful. Its often insidious nature and co-occurrence with other forms of mistreatment make detection and substantiation challenging. A secondary data analysis of N = 8,800 Adult Protective Services substantiated senior mistreatment cases, using machine learning algorithms, was conducted to determine when pure FE versus hybrid FE was occurring. FE represented N = 2514 (29%) of the cases with 78% being pure FE. Victim suicidal ideation and threatening behaviors, injuries, drug paraphernalia, contentious relationships, caregiver stress, and burnout and victims needing assistance were most important for differentiating FE vs non-FE-related mistreatment. The inability to afford housing, medications, food, and medical care as well as victims suffering from intellectual disability disorder(s) predicted hybrid FE. This study distinguishes socioecological factors strongly associated with the presence of FE during protective service investigations. These findings support existing and new indicators of FE and could inform protective service investigation practices.

Capacity evaluations for adult protective services: videoconference or in-person interviews.

The Geriatrician clinicians of the Texas Elder Abuse and Mistreatment Institute - Forensic Assessment Center Network (TEAM-FACN) in Houston, have many years of experience providing capacity assessment services for Adult Protective Services (APS) and Texas courts. A process has developed which is efficient, consistent, and evidence-informed. In the last two years, telecommunication has been added to this process to conduct assessments of APS clients in areas of Texas remote from the Houston area. Of the 545 capacity assessments TEAM-FACN has completed across the state of Texas over the first two years of adding telecommunication, 211 (39%) were conducted with in-person interviews and 334 (61%) were conducted using videoconference interviews. APS and the courts in remote areas of Texas have embraced the use of the videoconference assisted capacity assessments. This article describes this evidence-informed process and how telecommunication technology is incorporated to expand the reach of the service.

Pilot testing the detection of elder abuse through emergency care technicians (DETECT) screening tool: results from the DETECT pilot project.

OBJECTIVE: To pilot test the feasibility of implementing an elder abuse (EA) screening tool (DETECT) designed for medics. METHODS: Testing occurred between September 17th, 2015 and October 26th, 2015. MedStar Mobile Healthcare medics completed the DETECT tool when responding to calls for community-dwelling patients 65 years of age or older. RESULTS: The DETECT tool was used 1,248 times by 97% of medics responding to an eligible 911 call. Medics responded affirmatively to at least one screening item on 209 of the completed screenings (16.8%). Immediately following the introduction of the DETECT tool, there was an increase of 5.4 (226% above baseline) reports per month (p = 0.0056). CONCLUSIONS: The DETECT tool was easily incorporated into medic's field-based practice and resulted in an increase in medic generated reports of EA to APS. Future research designed to evaluate the tool's validity and reliability are warranted.

Assessment of older adults' satisfaction with adult protective services investigation and assistance.

This study examined elder self-neglect client satisfaction with services provided by an Adult Protective Services (APS) program. A total of 77 community-dwelling older adults with APS-substantiated self-neglect responded to the standardized and widely used 8-item Client Satisfaction Questionnaire. Approximately 75% of the participants reported being satisfied with the overall services. They felt that the services provided were responsive to their need(s) and helped them deal with their problem(s). Greater than 80% responded that they would refer a friend, would utilize APS in the future if necessary, and were at least satisfied with the amount of help received. The extent to which their needs were met received the lowest satisfaction scores. Future studies are needed to examine elder self-neglect client satisfaction in relation to specific services.

Feasibility of intervention in elder self-neglecters: Setting the stage for future research.

OBJECTIVES: Interventions are critical to improving clinical outcomes in elder self-neglecters. This study assessed feasibility of a randomized controlled trial of oral vitamin D in Adult Protective Services-substantiated self-neglect clients ≥65 years. METHODS: Participants were directly observed to consume ergocalciferol 50,000 IU (treatment) or ergocalciferol 400 IU (control), once a month, for 10 months. For months 6-10, half the control group randomly crossed into the treatment group (crossover). Intervention feasibility was measured by number of potential participants who agreed to participate and by retention rates during the study. RESULTS: Ninety-four referrals were received and 59 (63%) agreed to participate. Forty-nine participants were enrolled after prescreening and 35 completed the two-phase trial for a 72% retention rate. The participants' average age was 75.2 ± 6.8 years, mainly female (59%), African-American (47%), and living alone (41%). DISCUSSION: Despite assumptions that self-neglecters are resistant to care, we have successfully conducted the first clinical intervention in this vulnerable population.

Frailty in self-neglecting older adults: A secondary analysis.

Self-neglect (SN) and frailty in older adults is associated with increased disability and mortality. Despite these commonalities, there have been no studies objectively assessing frailty in older adults who SN. This secondary analysis classified frailty in N = 37 older adults with Adult Protective Services validated SN using the Fried Frailty Phenotype (FFP) of weight loss, weakness, exhaustion, activity level, and walking speed. Overall, 3% were classified as robust, 62% as prefrail, and 35% as frail. Most (72%) were overweight/obese, with clinically significant decreases in activity level (60%) and walking speed (97%). Compared to the original FFP population, older adults who SN exhibit important differences in frailty phenotypes, and finding that the largest percentage of older adults who SN were prefrail may indicate a critical opportunity for intervening in this population to reduce future functional decline and mortality.

Correlates of depression in self-neglecting older adults: A cross-sectional study examining the role of alcohol abuse and pain in increasing vulnerability.

Self-neglect among older adults results in increased morbidity and mortality rates. Depression is strongly linked to self-neglect and when untreated, severely complicates management of health and functional outcomes. The study aims to identify factors correlated with depression to inform approaches to service recruitment and retention that improve long-term outcomes. The sample included urban community-dwelling older adults (n = 96) 65 years of age and older with Adult Protective Services-substantiated self-neglect. All participants completed a range of validated cognitive, functional, and self-report demographic and clinical measures around health and mental health functioning. A secondary data analysis using multivariable logistic regression revealed that a positive screen for alcohol abuse, low self-rated health, and higher self-reported pain were associated with significantly higher odds of self-reported depression. Further research is needed to understand the temporality between these correlates and depression and to inform prevention and intervention practices for self-neglecting older adults.

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.

Development of an Acute Stroke Care Seeking Framework.

ABSTRACT: BACKGROUND: A multitude of variables influence an individual's decision to seek care in emergency situations. By recognizing these variables and their impact on the timeline of an individual seeking care for a stroke, nurses have an opportunity to positively affect the outcomes of stroke within the community. The purpose of this narrative review was to develop a research framework describing the variables involved in care seeking during an acute stroke. METHODS: Using a theory synthesis methodology that included variable identification and the establishment of relationships between variables based on existing literature, a framework describing variables relevant to acute stroke care seeking behavior was developed. RESULTS: Fourteen recently published studies reported significant variables related to seeking emergency medical care during the hyperacute phase of a stroke. Eight variables were identified and characterized as either promoters or distractors. Promoters led an individual to seek acute stroke care earlier, such as perceived symptom severity, stroke knowledge, and the presence of others. Distractors led an individual to delay seeking acute stroke care and resulted in later hospital arrival times, such as a lack of social network or resources, comorbid conditions, and incongruity with the local health system. CONCLUSION: Although individual decision making is exceedingly complex and varies by individual and situation, the developed acute stroke care seeking framework may provide a basis on which to develop stroke awareness programs and interventions targeted at individuals at risk for delayed acute stroke care.

Meeting the challenges in conducting research in vulnerable older adults with self-neglect-notes from a field team.

Gaining a systematic understanding of possible ways to increase the quality and lifespan of older adults experiencing self-neglect has unique challenges. These challenges include identifying self-neglect in the community and navigating levels of cognitive, physical, and/or psychological difficulties in this population that impact recruitment, consent, and accurate data collection. Conducting quality research under some of the environmental self-neglect conditions such as squalor, animal and insect infestations and no utilities can also challenge planned study protocols and study validity. This manuscript presents details of these overarching challenges and some of the workable solutions noted and implemented by research field-team members who have enrolled over 300 adults experiencing self-neglect for various studies. Usual research methodology must overcome these barriers to work to create consciousness about the self-neglect population. The classic series of cases is still a good alternative when describing self-neglect. Considerations for conducting future self-neglect research are presented.

Racial/ethnic disparities in use of surveillance mammogram among breast cancer survivors: a systematic review.

BACKGROUND: Increasing number of breast cancer survivors in the USA have led to greater focus on the long-term health outcomes and surveillance care among these women. However limited evidence exists of use of surveillance mammography among breast cancer survivors and how it varies across racial/ethnic groups. METHODS: We conducted a systematic review of the literature to explore disparities in use of surveillance mammogram among women breast cancer survivors by searching for relevant studies published between 2000 and 2020 from Medline (Ovid), PubMed (National Library of Medicine), and PsycINFO (Ovid) bibliographic databases. Two authors independently screened titles, abstracts, and full texts of all articles that reported surveillance mammography use across racial/ethnic groups. Data on study design, screening eligibility, sample size, operational definition, and/or measure of the use of a surveillance mammogram among breast cancer survivors and the association between race/ethnicity and use of a surveillance mammogram were summarized in the evidence tables. RESULTS: We identified 1544 records from the three databases, and 30 studies examined the use of surveillance mammograms among breast cancer survivors across race/ethnic groups. Of these, 21 provided adjusted estimates of racial/ethnic disparities in use of surveillance mammograms, and 15 of these reported statistically significant disparities. In summary, most studies reported that non-white women (mainly Blacks and Hispanics) were less likely to receive a timely surveillance mammogram compared to White. CONCLUSION: This study extends the evidence of racial/ethnic disparities beyond completion of initial treatment by finding similar disparities in receipt of surveillance mammograms among breast cancer survivors. IMPLICATION FOR CANCER SURVIVORS: Our findings identify a need to improve efforts to increase post-treatment use of surveillance mammography among racial/ethnic minority women to reduce these gaps and improve overall clinical and quality of life outcomes.

A statewide elder mistreatment virtual assessment program: Legal, ethical, and practical issues.

Telecommunication assisted forensic assessments of capacity and mistreatment by geriatricians with expertise in elder abuse and self-neglect are helping to meet the demand for such forensic services for Adult Protective Services (APS) clients in remote and underserved areas of Texas. The use of synchronous audiovisual assisted interviews instead of in-person interviews with clients to provide capacity assessments has become more important with the arrival of the COVID-19 pandemic. There is growing interest in establishing similar programs in other states using geriatrician faculty from medical schools to serve the clients of their state Adult Protective Services agencies. The arrangement between APS and the geriatricians at McGovern Medical School in Houston, Texas is novel. The structure of the arrangement is important for the success of the program. Legal, ethical, and practical considerations are discussed in this article, including approaches to the Health Insurance Portability and Accountability Act, physician liability, state law, and resource limitations. It is hoped that sharing how one such collaboration has addressed these important issues will suggest approaches for the structuring of similar programs.