Risk Factors for Elder Mistreatment Among Older Korean Americans.

Using data from a sample of older Korean Americans (n = 2,150), we examined the prevalence and associated factors of physical, emotional, and financial mistreatment. Given the importance of contextual factors, we examined the effect of immigration-related (years in the U.S. and acculturation) and interpersonal/community-related (family solidarity, social network, and ethnic community social cohesion) factors in addition to sociodemographic and health-related characteristics. The rate of experiencing physical, emotional, and financial mistreatment during the past year was 3%, 37.9%, and 16.1%, respectively. Younger age and lower family solidarity were common risk factors for emotional and financial mistreatment. The experience of emotional mistreatment was also more likely among females and those with higher level of acculturation, smaller social networks, and lower ethnic community social cohesion. Chronic disease was an additional risk factor for financial mistreatment. The findings suggest targeted prevention and intervention strategies for elder mistreatment.

The Role of Social Isolation on Mediating Depression and Anxiety among Primary Family Caregivers of Older Adults: A Two-Wave Mediation Analysis.

BACKGROUND: Primary family caregivers of older people with chronic care conditions are highly vulnerable to social isolation and psychological strains such as depression and anxiety due to their demanding responsibilities. This study examines how social isolation mediates the relationship between caregiving stress and mental health symptoms of primary family caregivers. METHODS: The analytic sample included 881 primary caregivers of older adults from the 2015 and 2017 National Study of Caregiving (NSOC). Social isolation was measured using a composite structure that includes objective social disconnectedness and subjective loneliness. Two-wave mediation models were estimated to examine longitudinally if social isolation mediated the relationship between caregiving stress (subjective & objective stress) and mental health symptoms (depression & anxiety) of primary caregivers. RESULTS: The study findings indicate that both subjective (ß = 0.32, p < 0.001) and objective stress (ß = 0.21, p = 0.003) have direct effects on depression among primary caregivers. Social isolation was found to only mediate the relationship between objective stress and depression (ß = 0.18, p < 0.001). In contrast, no significant direct and indirect pathway was found in the anxiety model. CONCLUSIONS: The study demonstrates the internal mechanism where objective strains of caregiving make family caregivers socially isolated, which in turn leads to increased symptoms of depression. Future interventions and practices aimed at improving the psychological well-being of family caregivers should prioritize strategies aimed at increasing social engagement, particularly for those with heavy caregiver burdens.

How do family caregivers of older adults cope with relationship strain?

OBJECTIVE: Studies of families' experiences with caregiving to older adults most often focus on overall burden and stress. Yet, caregiving is also a type of relationship, and the onset of caregiving can contribute to relationship strain between care partners. Despite implications for both care partners, little is known about how caregivers cope with caregiving relationship strain. METHODS: The authors conducted nine focus groups and 8 interviews with a purposeful sample of racially and ethnically diverse family caregivers in Los Angeles. Conventional content analysis was applied to transcripts to identify how caregivers cope with relationship strain. RESULTS: Analyses revealed four overall coping approaches to manage relationship strain: (1) Self-Care; (2) Adapting Behaviors, (3) Adapting Feelings and Cognitions, and (4) Help and Support. Selected strategies likely vary by care recipient condition. For example, caregivers for persons living with dementia emphasize adapting their own behaviors and feelings, rather than trying to change their loved one's behaviors. CONCLUSIONS: Findings suggest that caregivers cope with relationship strain using both interpersonal tension and care management strategies. We also identified possible variations by care recipient condition and caregiver race and ethnicity. These results suggest a need for interventions focused on caregiver coping should also be tested for effects on relationship strain.

Elder abuse in the COVID-19 era based on calls to the National Center on Elder Abuse resource line.

BACKGROUND: The COVID-19 pandemic has exacerbated circumstances that place older adults at higher risk for abuse, neglect, and exploitation. Identifying characteristics of elder abuse during COVID-19 is critically important. This study characterized and compared elder abuse patterns across two time periods, a one-year period during the pandemic, and a corresponding one-year period prior to the start of the pandemic. METHODS: Contacts (including social media contacts, and email; all referred to as "calls" for expediency) made to the National Center on Elder Abuse (NCEA) resource line were examined for differences in types of reported elder abuse and characteristics of alleged perpetrators prior to the pandemic (Time 1; March 16, 2018 to March 15, 2019) and during the pandemic (Time 2; March 16, 2020 to March 15, 2021). Calls were examined for whether or not abuse was reported, the types of reported elder abuse, including financial, physical, sexual, emotional, and neglect, and characteristics of callers, victims, and alleged perpetrators. Chi-square tests of independence compared frequencies of elder abuse characteristics between time periods. RESULTS: In Time 1, 1401 calls were received, of which 795 calls (56.7%) described abuse. In Time 2, 1009 calls were received, of which 550 calls (54.5%) described abuse. The difference between time periods in frequency of abuse to non-abuse calls was not significant ([Formula: see text]). Time periods also did not significantly differ with regard to caller, victim, and perpetrator characteristics. Greater rates of physical abuse ([Formula: see text] and emotional abuse ([Formula: see text] were reported during Time 2 after adjustment for multiple comparisons. An increased frequency of multiple forms of abuse was also found in Time 2 compared to Time 1 ([Formula: see text]. CONCLUSIONS: Findings suggest differences in specific elder abuse subtypes and frequency of co-occurrence between subtypes between time periods, pointing to a potential increase in the severity of elder abuse during COVID-19.

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 Are Strategies to Advance Policies Supporting Family Caregivers? Promising Approaches From a Statewide Task Force.

Family caregivers are the cornerstone of the long-term supports and services infrastructure in the United States, yet they often contend with many challenges related to this role. Public policy has been slow to change, leaving many caregivers vulnerable to health and economic consequences. Using models of policy making, we identify barriers to advancing policies that support family caregivers and overcome policy drift. We draw on discussions from the California Task Force on Family Caregiving as it prepares state policy recommendations. Identified strategies include identification of caregivers in health care and workplace settings to promote political consciousness raising, collecting and reporting on data that frame caregiving as a policy problem, borrowing policies and language from overlapping fields to emulate their policy successes, and presenting supportive caregiver policies as solutions to other policy problems. By presenting specific strategic approaches to advance caregiving policies, we provide tools to address the growing gap between caregiver needs and policy responses.

Developing an undue influence screening tool for Adult Protective Services.

The study purpose was to develop and pilot an undue influence screening tool for California's Adult Protective Services (APS) personnel based on the definition of undue influence enacted into California law January 1, 2014. Methods included four focus groups with APS providers (n = 33), piloting the preliminary tool by APS personnel (n = 15), and interviews with four elder abuse experts and two APS administrators. Social service literature-including existing undue influence models-was reviewed, as were existing screening and assessment tools. Using the information from these various sources, the California Undue Influence Screening Tool (CUIST) was developed. It can be applied to APS cases and potentially adapted for use by other professionals and for use in other states. Implementation of the tool into APS practice, policy, procedures, and training of personnel will depend on the initiative of APS management. Future work will need to address the reliability and validity of CUIST.

The Forensic Lens: Bringing Elder Neglect Into Focus in the Emergency Department.

We present 2 case studies of older patients who were brought to the emergency department (ED) in severely debilitated states. Both presented with severe malnutrition, contractures, and decubitus ulcers, and were nonverbal, with histories of dementia and end-stage disease. Their primary caregivers, adult children, were uncooperative with Adult Protective Services and disregarded treatment recommendations. Although both elders had signs suspicious for neglect, a comprehensive review revealed many layers of complexity. We use these cases to illustrate an approach to the assessment of possible elder neglect in ED settings and how to intervene to ensure patient safety. We begin with a discussion of the differences between willful, unintentional, and unsubstantiated neglect by a caregiver and then describe when to suspect neglect by evaluating the elder, interviewing the caregiver and first responders, assessing the caregiver's ability to meet the elder's needs, and, if possible, obtaining medical history and information about the home care environment. These cases illustrate the importance of careful documentation in cases of suspected neglect to assist investigative agencies, reduce the risk of further harm, and improve patient outcomes.

Protecting victims of elder financial exploitation: the role of an Elder Abuse Forensic Center in referring victims for conservatorship.

OBJECTIVES: The aim of this study was to examine the extent to which an Elder Abuse Forensic Center protects financial exploitation (FE) victims through referral to the Office of the Public Guardian (PG) for investigation and possible conservatorship (called 'guardianship' in many states). METHOD: Los Angeles County Elder Abuse Forensic Center cases involving adults aged 65 and older (April 2007-December 2009) were matched using one-to-one propensity-score matching to 33,650 usual care Adult Protective Services (APS) cases. The final analysis sample consisted of 472 FE cases. RESULTS: Compared to usual care, Forensic Center cases were more likely to be referred to the PG for investigation (30.6%, n = 72 vs. 5.9%, n = 14, p < .001). The strongest predictors of PG referral were suspected cognitive impairment, as identified by APS (odds ratio [OR] = 11.69, confidence intervals [CI]: 3.50-39.03), and Forensic Center review (OR = 7.85, CI: 3.86-15.95). Among referred cases, the court approved conservatorship at higher rates - though not statistically significant - for Forensic Center cases than usual care (52.9%, n = 36/68 vs. 41.7%, n = 5/12). CONCLUSION: Conservatorship may be a necessary last resort to improve safety for some FE victims, and the Forensic Center appears to provide a pathway to this service. These findings suggest modification to the Elder Abuse Forensic Center conceptual model and contribute to an emerging body of evidence on the role of the Forensic Center in addressing elder abuse.

Neuropsychological profiles of victims of financial elder exploitation at the los angeles county elder abuse forensic center.

The current article examines neuropsychological correlates of financial elder exploitation in a sample of older adults who have been documented victims of financial elder exploitation. The purpose of this exploratory study was twofold. First, a subsample of the referrals at the Los Angeles County Elder Abuse Forensic Center (LACEAFC) was compared to community dwelling adults in terms of the specific cognitive domains linked to financial capacity including memory, calculation, and executive functioning. Next, the correlation between presence of neuropsychological data and the likelihood of filing a case with the LA County's District Attorney office was examined. Twenty-seven LACEAFC cases and 32 controls were assessed. Overall, the forensic center group performed worse than a community-based age-matched control group on the MMSE, calculation, and executive functioning (ps < .01). The presence of neuropsychological data was significantly correlated to an increased likelihood of a case being filed.

Exploring Staffing Levels in Adult Day Services: Does Profit Status Matter?

OBJECTIVE: For more than 4 decades, adult day service centers (ADSCs) have provided long-term care services and socialization to hundreds of thousands of people in the United States. An important part of the long-term care continuum, ADSCs serve older adults and adults with disabilities, many of whom have low incomes and are racial and ethnic minorities. Yet, little is known about the quality of ADSCs. To better understand ADSC quality, we examined staffing levels, a key aspect of organizational structure. Staffing levels are an established quality measure associated with resident outcomes in nursing homes. Our study compares ADSC staffing levels between for-profit and nonprofit or government-operated ADSCs. DESIGN: Cross-sectional secondary data analysis using a nationally representative survey of ADSCs. SETTING AND PARTICIPANTS: Adult day service center (n = 573) directors completed a survey as part of the 2018 National Study of Long-Term Care Providers. METHODS: Bivariate comparisons and multivariate linear regression were used to compare staffing, measured as hours per participant day in nonprofit and for-profit ADSCs. RESULTS: Approximately 60% of ADSCs in the sample were nonprofit or government-operated and the remainder were for-profit. For-profit ADSC staffing averaged 1.5 hours per participant day and nonprofit or government-operated ADSC staffing averaged 1.9 hours per participant day. For-profit ADSCs had 15.8% (P = .047) lower hours per participant day compared with nonprofit ADSCs after controlling for center characteristics, such as Medicaid use, participant acuity, and ADSC size. CONCLUSION AND IMPLICATIONS: We found that for-profit ADSCs have lower staffing levels compared with nonprofit and government-operated ADSCs. Future research is needed to understand how staffing levels relates to the quality of care in for-profit and nonprofit ADSCs and how these relationships vary by participant characteristics, such as income, race/ethnicity, and acuity.

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.

Who transitions to the community from nursing homes? Comparing patterns and predictors for short-stay and long-stay residents.

Little is known about characteristics of those who transition to the community after long stays in nursing facilities. Yet this information is highly relevant to efforts to reduce preventable nursing facility use. This study identifies and compares community transition among short-stay (1-90 days) and long-stay residents (91-365 days) aged 65 + using Kaplan-Meier survival estimates and logistic regression to analyze 3,762 episodes of care in Southern California. Over 90% of community discharges occurred in the first 90 days, and few characteristics predicted discharge after 90 days. The findings inform transition programs' efforts to identify and effectively target residents after 90-day stays.

Conceptualizing Person-Centered Care in Elder Mistreatment Intervention: Use of a Well-Being Framework.

BACKGROUND AND OBJECTIVES: Person-centered care (PCC) applied to elder mistreatment interventions is an approach to include victim priorities. Although PCC may improve outcomes by supporting choice, victim preferences are often difficult to support, especially in high-risk situations. We studied the adaptation of PCC structures and process to a pilot intervention, aimed at including client preferences in a multidisciplinary team's plans to address complex elder mistreatment. RESEARCH DESIGN AND METHODS: Case study analysis was used to examine the process of integrating client priorities into a risk-reduction plan. A well-being framework was used to understand the relationship between safety and preferences. Purposive sampling identified a case study of a high-risk victim with history of refusing help who agreed to work with the Service Advocate, a member of a multidisciplinary team. RESULTS: PCC required a relationship of trust, honed over several weeks by prioritizing the clients' perspective. Client preferences included remaining at home, continuing the relationship with the abuser, and maintaining a sense of mastery. Individualized definitions of "safety" were unrelated to elder mistreatment risk. Assistance included working with the suspected perpetrator, which is not offered by most elder mistreatment interventions, and resulted in some risk reduction. Reasons for refusing help were a desire for control and fear of loss of well-being assets. DISCUSSION AND IMPLICATIONS: Individualized definitions of well-being should be considered in measuring intervention success. Future research could determine guidelines on what levels of elder mistreatment risk are acceptable, and how to monitor clients for safety while supporting autonomy.

Identifying risk of hospital readmission among Medicare aged patients: an approach using routinely collected data.

Readmission provisions in the Patient Protection and Affordable Care Act of March 2010 have created urgent fiscal accountability requirements for hospitals, dependent upon a better understanding of their specific populations, along with development of mechanisms to easily identify these at-risk patients. Readmissions are disruptive and costly to both patients and the health care system. Effectively addressing hospital readmissions among Medicare aged patients offers promising targets for resources aimed at improved quality of care for older patients. Routinely collected data, accessible via electronic medical records, were examined using logistic models of sociodemographic, clinical, and utilization factors to identify predictors among patients who required rehospitalization within 30 days. Specific comorbidities and discharge care orders in this urban, nonprofit hospital had significantly greater odds of predicting a Medicare aged patient's risk of readmission within 30 days.

The Differential Effects of Caregiving Intensity on Overnight Hospitalization.

This study aims to examine how caregiving for a spouse affects caregivers' likelihood of overnight hospitalization. Using data from the Health and Retirement Study, we examine the odds of spousal caregivers experiencing an overnight hospitalization in the previous two years according to caregiving status, intensity, and change in caregiving intensity. Caregivers were no more likely to experience an overnight hospitalization than noncaregivers (OR = .92; CI [.84, 1.00]). Effects varied by intensity of care. Compared to noncaregivers, caregivers who reported providing no assistance with activities of daily living were less likely to experience overnight hospitalization (OR = .77; CI [.66, .89]); however, caregivers who provided care to someone living with dementia for 4 to <6 years had 2.11 times the odds of experiencing an overnight hospitalization (CI [1.16, 3.85]). Although caregivers overall experience overnight hospitalization at a similar rate as noncaregivers, there are differences between caregivers by the intensity of care.

The Effect of Support From Secondary Caregiver Network on Primary Caregiver Burden: Do Men and Women, Blacks and Whites Differ?

OBJECTIVES: Many older adults receive informal care from multiple caregivers, including support from a primary caregiver and a secondary caregiver network (SCN). This study examined the association between SCN support and primary caregiver burden, and whether the association varies across women and men, Black and White. METHODS: Data came from the 2015 National Health and Aging Trend Study and the National Study of Caregiving, including non-Hispanic White and Black men and women who were identified as primary caregivers (n = 967) and their secondary caregivers (n = 2,253). SCN support was indicated by (a) care domain overlap and (b) proportion of caregiving by SCN. Multiple regression models were estimated for the analyses. RESULTS: Both SCN support variables were found to reduce primary caregiver burden, and the effect of proportion of caregiving by SCN was found to vary by gender-race groups. With the increase of the proportion of caregiving by SCN, both Black and White women caregivers tend to experience faster decrease in caregiver burden than Black men. DISCUSSION: Our findings support the role of SCN in reducing primary caregiver burden and demonstrate that the benefit of SCN support varies across the 4 gender-race groups. The results indicate that it is imperative to further examine caregiving experience and protective mechanisms of SCN support using an intersectional perspective.

Voices of Experience: What Do Low-Income Older Adults Tell Us About Mobility, Technology, and Social Participation?

Mobility and technology can facilitate in-person and virtual social participation to help reduce social isolation, but issues exist regarding older adults' access, feasibility, and motivation to use various forms of mobility and technology. This qualitative study explores how a diverse group of low-income, urban-living older adults use mobility and technology for social participation. We conducted six focus groups (N = 48), two each in English, Spanish, and Korean at a Los Angeles senior center. Three major themes emerged from thematic analysis: using technology for mobility; links between mobility and social participation; and technology-mediated social participation. Cost, perceived safety, (dis)ability, and support from family and friends were related to mobility and technology use. This study demonstrates the range of mobility and technology uses among older adults and associated barriers. The findings can help establish a pre-COVID-19 baseline on how to make mobility and technology more accessible for older adults at risk of isolation.