The Context of Elder Maltreatment: an Opportunity for Prevention Science.

Elder maltreatment (EM) has been understood as a worldwide major public health threat for decades, yet it remains a form of victimization receiving limited attention, resources, and research. EM, which includes caregiver neglect and self-neglect, has far-reaching and long-lasting impacts on older adults, their families, and communities. Rigorous prevention and intervention research has significantly lagged in proportion to the magnitude of this problem. With rapidly growing population aging, the coming decade will be transformative: by 2030, one in six people worldwide will be aged 60 or older, and approximately 16% will experience at least one form of maltreatment (World Health Organization, 2021). The goal of this paper is to raise awareness of the context and complexities of EM, provide an overview of current intervention strategies based on a scoping review, and discuss opportunities for further prevention research, practice, and policy within an ecological model applicable to EM.

Unrepresented Adults Face Adverse Healthcare Consequences: The Role of Guardians, Public Guardianship Reform, and Alternative Policy Solutions.

Persons without family or friends to serve as healthcare agents may become "unrepresented" in healthcare, with no one to serve as healthcare agents when decisional support is needed. Surveys of clinicians (N = 81) and attorneys/guardians (N = 23) in Massachusetts reveal that unrepresented adults experience prolonged hospital stays (66%), delays in receiving palliative care (52%), delays in treatment (49%), and other negative consequences. Clinicians say guardianship is most helpful in resolving issues related to care transitions, medical treatment, quality of life, housing, finances, and safety. However, experiences with guardianship are varied, with delays often/always in court appointments (43%) and actions after appointments (24%). Policy solutions include legal reform, education, and alternate models.

Characteristics and unmet care needs of unbefriended residents in long-term care: a qualitative interview study.

Objectives: This study explored the impact of being 'unbefriended' for residents in Canadian long-term care (LTC) homes. Residents are 'unbefriended' if they lack decision-making capacity and family or friends to act as their legal representative. Research suggests that unbefriended individuals may have unmet needs and experience poor quality of care due to their limited social support. Our specific objectives were to identify resident characteristics, their unmet care needs, and implications for quality of care and quality of life.Methods: We conducted semi-structured interviews with 39 LTC staff and 3 public guardians. Interviews took place between March 2017 and September 2017. All interviews were audio recorded and transcribed verbatim. We analyzed the interviews using content analysis.Results: We found two groups of unbefriended LTC residents: (1) individuals with no living conjugate partner or children and (2) individuals with histories of substance use, homelessness, and estrangement from family. Unbefriended residents have no one to help meet needs for social interaction and engagement or to assist in purchasing needed personal items and uninsured services. LTC staff report significant care issues with unbefriended residents at end of life, including more aggressive behaviors and inappropriate care practices.Conclusion: Our findings demonstrate alarming issues in quality of life and quality of care for unbefriended residents. Unbefriended residents had limited social support and difficulty accessing even basic personal items. We discuss implications for policy and practice.

Assessing the Federal Response to Elder Abuse, While the Opioid Crisis Rages On.

The opioid crisis directly connects to elder abuse: grandparents may be caring for grandchildren of parents addicted to opioids; and family members, caregivers, and older adults may misuse opioids. The Elder Justice Act, the Older Americans Act, the Omnibus Reconciliation Act of 1981, and the Elder Abuse Prevention and Prosecution Act dictate responses to such opioid misuse. The Administration for Community Living, the Administration on Aging, the Office of Community Services, and the Department of Justice administer these laws. This article describes the laws, their status, and programs these agencies authorize.

A framework for polyvictimization in later life.

This article provides a context and overview for what is known about polyvictimization in later life. Drawing from previous literature, the article includes a definition of the phenomenon, as well as theoretical constructs by which it may be understood. We place other forms of polyvictimization within the context of elder abuse, recognize frameworks for conceptualizing polyvictimization in later life, and distinguish between polyvictimization at younger ages and polyvictimization in later life. The paper concludes with implications of the framework for research, practice, and policy.

Ethical Concerns and Procedural Pathways for Patients Who are Incapacitated and Alone: Implications from a Qualitative Study for Advancing Ethical Practice.

Adults who are incapacitated and alone, having no surrogates, may be known as "unbefriended." Decision-making for these particularly vulnerable patients is a common and vexing concern for healthcare providers and hospital ethics committees. When all other avenues for resolving the need for surrogate decision-making fail, patients who are incapacitated and alone may be referred for "public guardianship" or guardianship of last resort. While an appropriate mechanism in theory, these programs are often under-staffed and under-funded, laying the consequences of inadequacies on the healthcare system and the patient him or herself. We describe a qualitative study of professionals spanning clinical, court, and agency settings about the mechanisms for resolving surrogate consent for these patients and problems therein within the state of Massachusetts. Interviews found that all participants encountered adults who are incapacitated and without surrogates. Four approaches for addressing surrogate needs were: (1) work to restore capacity; (2) find previously unknown surrogates; (3) work with agencies to obtain surrogates; and (4) access the guardianship system. The use of guardianship was associated with procedural challenges and ethical concerns including delays in care, short term gains for long term costs, inabilities to meet a patient's values and preferences, conflicts of interest, and ethical discomfort among interviewees. Findings are discussed in the context of resources to restore capacity, identify previously unknown surrogates, and establish improved surrogate mechanisms for this vulnerable population.

The Sexual Victimization of Older Women Living in Nursing Homes.

This study examined 64 cases of sexual victimization of women ages 65+ (mean = 81) living in facilities that were investigated by APS and regulatory agencies in five states over a six-month period. Typically, abuse involved molestation (53%) and unwelcome sexual interest in the body (20%). Abilities and needs of women in substantiated and unsubstantiated cases were comparable. Resident perpetrators were more likely to be substantiated than staff or any other perpetrator (p = 0.008). Our results underscore the need to evaluate differences associated with gender, age, and residence, and to train on reporting and intervention by disciplines serving victims.

An ecological systems examination of elder abuse: a week in the life of adult protective services.

Using Bronfenbrenner's ecological systems model, this study examined allegations of elder abuse made to Kentucky Adult Protective Services (APS) and the investigation that followed, in order to understand how APS addressed the needs of abused elders. Elder abuse allegations made to APS during the study week were collected using 3 study tools. Allegations and resulting investigations were analyzed. During the study week, APS received 1,002 calls alleging elder abuse. Of these, 483 were categorized as reports needing protective services, with 177 reports screened in for investigation and 167 actually investigated. Results describe characteristics of abuse calls, investigations, victims, perpetrators, and total investigation times. Substantiation ratio, recidivism, and whether investigation increased or decreased the risk of abuse were also assessed. An examination of APS casework through the lens of nested systems frames the study findings and discussion. Such an examination has the potential to improve the quality of services provided to older adults.

Motivations Behind Dog Walking in Older Adults: Insights From Guided Walks and Interviews.

For many older adults, physical activity declines with age, contributing to chronic disease and social isolation. Companionship from dogs can help mitigate isolation and promote physical activity. Outdoor environments aligned with the abilities of older adults can encourage walking habits and socialization. To understand how neighborhood features influence dog walking, we adapted a Photovoice approach and photographed 12 older adults walking their dog. Photographs were presented during in-person interviews to facilitate discussions about environmental features. Thematic coding revealed that interactions with nature were key. Participants valued choices in walking path type and conveniently placed dog waste stations. Opportunities to socialize with neighbors were also important. Safety from falling, other animals, and motorized traffic were concerns but were not enough to prevent walking. Our findings suggest that walking environments intended for older adults with dogs should include experiences with nature, diverse path designs, and dog-specific amenities.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients Under Guardianships.

Palliative care clinicians often help facilitate coordination of care, complex serious illness, and end-of-life medical decision-making. However, the clinical and legal issues related to guardianship can complicate the decision-making process, care delivery, outcomes, and the role of the palliative care clinician. Adult patients who have a guardian have been found by a court to be unable to make some or all decisions for themselves. Providing care for patients under guardianship is where medicine overlaps with legal rights. It is crucial to be familiar with the patients' rights and the guardians' responsibilities to clarify medical decision-making processes and identify necessary authorities. This article uses an interprofessional approach to leverage the expertise of physicians, nurses, lawyers, and guardians and to guide palliative care clinicians to optimally support patients under guardianship.

Elder abuse and neglect: a survey of clergy awareness, knowledge, and intervention preferences.

This article explores the research question: What is the perceived level of elder abuse and neglect awareness and knowledge among Protestant clergy members in Kentucky? Of the 300 clergy contacted, 160 participated, for a response rate of 53.3%. Pearson Chi-Square analyses were used to determine statistical significance, and phi coefficient correlations examined the strength of the associations between variables. Findings indicate that approximately 44% of clergy members in this study report some "awareness" of elder abuse and neglect. However, 56% of clergy respondents do not know that Kentucky is an "any person" mandatory reporting state. Specifically, participating clergy appear poorly informed about legal requirements for reporting elder abuse and neglect and perceive types of abuse differently. Untrained clergy with little formal training indicate a willingness to provide therapy to victims despite reporting that they do not feel qualified to do so.

Ageism as a Source of Global Mental Health Inequity.

Ageism manifests as stereotyping of or discrimination against people-usually older adults-because of their age. Since ageism contributes to global mental health inequity among older people, responding to their needs should be a clinical, ethical, and policy priority. This article suggests how relatively simple, low-cost, high-yield interventions can be implemented globally and domestically to improve the well-being and quality of life of older individuals.

Financial Fraud of Older Adults During the Early Months of the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) created a "perfect storm" for financial fraud targeting older adults. Guided by the Contextual Theory of Elder Abuse, we focused on individual and systemic contexts to examine how older adults became prey to financial fraud. RESEARCH DESIGN AND METHODS: In July 2020, 998 adults who were 60-98 years of age (93% White; 64% female) completed an online survey about experiences with financial fraud. Participants were recruited from gerontology research registries at Florida State University, University of Pittsburg, Virginia Tech, and Wayne State University. RESULTS: Over half (65.9%) of the respondents experienced a COVID-19-related scam attempt, with charity contributions (49%) and COVID-19 treatments (42%) being the most common. Perpetrators commonly contacted older adults electronically (47%) two or more times (64%). Although most respondents ignored the request (i.e., hung up the phone and deleted text/e-mail), 11.3% sent a requested payment, and 5.3% provided personal information. Predictors of vulnerability included contentment with financial situation, concern about finances in the aftermath of the pandemic, and wishing to talk to someone about financial decisions. Respondents targeted for a non-COVID-19 scam attempt were less likely to be targets of a COVID-19-related scam. DISCUSSION AND IMPLICATIONS: Older adults who were financially secure, worried about their financial situation, or wished they could speak with someone about their financial decisions appeared susceptible to falling victim to a fraud attempt. The high number of attempts indicates a need for a measurable and concerted effort to prevent the financial fraud of older adults.

Exploration and Comparison of Contextual Characteristics and Mistreatment Prevalence Among Older American Indian and Alaska Native Respondents: Secondary Analysis of the National Elder Mistreatment Study.

Limited research on elder abuse among American Indians and Alaska Natives (AIANs) suggests a higher prevalence of abuse. Using data from the National Elder Mistreatment Study (NEMS), we compared contextual characteristics and elder mistreatment prevalence rates from a community-based sample of AIAN (n = 195) and Black (n = 437) and White (n = 5,013) respondents. There were differences in the prevalence of 16 abuse types and the 23 contextual variables. AIAN respondents had more similarities compared with Black respondents than White respondents, though differences existed. The cumulative prevalence of emotional, physical, and sexual mistreatment in the past year, neglect, and financial abuse by a family member for the AIAN group was 33%, almost double the 17.1% reported in the NEMS study. Over their lifetime, 29.7% of AIAN respondents reported experiencing two or more types of neglect, exploitation, or mistreatment. Almost one fourth of AIAN respondents reported emotional abuse since 60 years of age (the most commonly occurring abuse type)-nearly double that of White respondents. This is the first study to offer comparative prevalence of elder abuse for both AIAN older males and females that draws from a nationally representative sample. The study also provides descriptive analysis of important contextual information within the AIAN population, an underrepresented racial group in elder abuse research. Disaggregating nonmajority racial groups to examine contextual variables and the prevalence of elder mistreatment in the NEMS data set specific to AIAN respondents fills a knowledge gap. Known prevalence of various abuse typologies among AIAN elders can be useful in setting priorities for community planning and response, and in prioritization of funding for future research on causative mechanisms by abuse type, screening, and interventions at various levels. Findings may facilitate development of culturally specific evidence-based prevention and intervention practices aimed at needs specific to AIAN older adults.

Experiences With Involuntary Nursing Home Relocation: The Staff Perspective.

Although involuntary nursing home closures for operational and care-related reasons occur infrequently, few studies have examined the centrality of the actions of staff to facilitate residents' relocation adjustment. We interviewed 18 administrators and 43 staff working at 27 facilities about the relocation process for residents from two facilities that lost their Medicare and State Medicaid certification due to ongoing care deficiencies. Thematic analysis revealed three major themes throughout each aspect of the relocation process: (a) staff expectations were not met, (b) barriers/challenges were persistent, and (c) resident/family involvement was minimal. We offer proactive participant-derived recommendations for policy and practice to strengthen involuntary relocation processes to ensure a cooperative work environment and residents' well-being, regardless of the cause for involuntary closure.

A First (and Disturbing) Look at the Relationship Between the Opioid Epidemic and Elder Abuse: Insights of Human Service Professionals.

This study explored the relationship between the opioid epidemic and elder abuse. Twenty professionals from four states with working knowledge of elder abuse cases participated in focus groups. Thematic analysis revealed four themes characterizing the relationship between opioid misuse and elder abuse: (a) Opioid-Related Elder Abuse is an Escalating Problem; (b) Vulnerable Older Adults are Prisoners in Their Own Home; (c) Health Care Professionals Perpetrate Opioid-Related Elder Abuse; and (d) Older Adults Abuse and Deal Opiates. In addition, all participants noted the lack of reliable, retrievable data to address cases of elder abuse when opioids are involved. Findings lay the groundwork for further research to understand the breadth and depth of the opioid-elder abuse relationship that can ultimately be used to develop prevention and intervention strategies and policies to address this hidden but widespread concern.

Kentucky's Local Elder Abuse Coordinating Councils: a model for other states.

In 1998 Kentucky's Local Coordinating Councils on Elder Abuse (LCCEAs) were established to intervene in cases of elder abuse in local communities. As of 2008 there were 39 LCCEAs in the state, covering 112 of Kentucky's 120 counties. This study was an attempt to understand a concerted statewide multidisciplinary team (MDT) effort related to elder abuse. Survey questions examined the roles, processes, varieties, and accomplishments of these councils. Nearly half of the councils have been in existence for less than 3 years. Councils provided a range of services from expert consultation to service provided for keeping members up to date about services, programs, and legislation. Roles for the councils included identifying service gaps and systemic problems and advocating for change. Half the councils conducted case reviews, and of those, most examined all types of cases. Lack of funding was a major problem for all councils. Funding came from a patchwork of sources, which suggested that it was inadequate and unreliable. The LCCEAs appear to function largely as community educators. To ensure the long-term viability of the LCCEAs and to better integrate and unify their efforts, LCCEAs need committed staffs, constant funding, clear vision and goals, and uniform and consistent outcome measures.

A glass half full: the dubious history of elder abuse policy.

This article highlights the brief 30-year history of major U.S. policies that address elder abuse. The history of elder abuse policy is checkered and incomplete, reflecting a lack of comprehensive federal legislation. We begin our review by discussing the scope of elder abuse policy and, in particular, the Social Security Block Grant, which has become the sole source of federal aid for Adult Protective Services programs. The other source of federal aid, typically for helping efforts by Area Agencies on Aging, is the Older Americans Act. We document the incremental but increasing attention paid to elder abuse by chronicling key initiatives, including early congressional reports and hearings; White House Conferences on Aging; and efforts by pioneers such as Mario Biaggi, Claude Pepper, John Breaux, and Orin Hatch-efforts that we believe have led to the various introductions of the Elder Justice Act.

Future directions for social policy and elder abuse: through the looking glass of generational characteristics.

The future directions for social policy and elder abuse are forecast using the characteristics of three contiguous generations: Baby Boomers, Gen Xers, and Nexters. The results suggest greater potential victimization for the Boomers than previous generations, particularly neglect and exploitation. Gen Xers may experience more self-neglect. Social policy will continue to emphasize the criminalization of elder abuse, reflecting Boomer self-righteousness and severity. Elder abuse victimization will have a medical hue, given the Boomer obsession with health and wellness. Although Gen Xers are less cynical than Boomers, they will be more concerned about their immediate lives and pass the elder abuse policy torch to the Nexters, who will elevate it in deference to the Boomers and in quest for a higher moral order.

WorldView Environmental Scan on Elder Abuse.

In response to a growing and worldwide recognition of elder abuse, the WorldView Environmental Scan on Elder Abuse was undertaken. It represented an attempt to collect both information on the nature of the problem of elder abuse and responses to it from a global perspective. The first of its kind, the Scan gathered information about elder abuse as well as on related legislation and policy, services and programs, educational resources and needs, training, and past and ongoing research. A total of 53 countries responded to the survey questionnaire, with 362 respondents representing the six world regions designated by the World Health Organization. Findings revealed that factors contributing to elder abuse include changing social and economic structures, isolation of victims, inadequate knowledge of laws and services, intergenerational conflict, and poverty. Barriers to seeking resources to intervene and protect older adults include the culture of the country, language issues, literacy, stigma, lack of mobility, lack of funding, and insufficient familiarity with and access to the internet. The data serve as a catalyst to take action, both globally and nationally, while emphasizing the changes necessary to protect the rights and dignity of older adults.