Chapter Four

Mental health professionals contribute in important ways to both the clinical and ethical issues raised by cases of elder mistreatment. Their clinical competencies contribute to improving quality of life by diminishing psychological suffering and the symptoms of mental illness. They are also used for managing the ethical issues raised by these cases. The ethics of mental health care are based on the values of beneficence, nonmaleficence, autonomy, and justice. The value of autonomy in mental health care gives priority to an individual's long-term ability to act as independently, rationally, and fully in all aspects of life as possible. The concepts of legal and clinical competence also aid in managing the ethical problems represented by cases of elder mistreatment. The ethical protocols of mental health professionals may be distinguished from some other disciplines by the premium given to long-term autonomy and by the aim of insuring treatment for all persons involved in cases of elder mistreatment, rather than limiting treatment responsibilities to the victim.     

Screening Elders in the Emergency Department at Risk for Mistreatment: A Pilot Study

Impaired functional status is associated with risk of elder mistreatment. Screening for functional impairment in elderly patients admitted to emergency departments could be performed to identify patients at risk for elder mistreatment who might benefit from further evaluation. This study utilized a modified Identification of Seniors at Risk (ISAR) screening tool to identify the proportion of elderly at risk for mistreatment due to functional difficulties presenting to two emergency departments in southeastern Virginia, one urban, the other rural. Of a 180-patient cohort (90 per site), 82 screened positive (46%), ISAR > 2 (range 0–6), indicating nearly half of all patients enrolled are at risk for mistreatment. Patients presenting to the urban emergency departments were potentially more at risk than their rural counterparts (p < 0.01). Health care professionals, particularly in urban settings, should consider screening seniors with a simple tool to identify patients at risk of elder mistreatment.     

Elder Mistreatment in U.S. Residential Care Facilities: The Scope of the Problem

Many in the United States believe elder mistreatment in long-term care is serious and widespread, but until recently few studies focused on the problem. This study was designed to describe the scope of mistreatment in assisted living facilities (ALFs) in Arizona during a 3-year period. Findings showed that receiving citations for elder mistreatment was relatively rare. However, analysis of narrative reports from only 7% of facilities showed 598 allegations of mistreatment in complaint investigations, of which 372 (62.2%) were substantiated and given citations for something other than mistreatment. Results show that elder mistreatment in ALFs is seriously underidentified, even by state inspectors.     

Three Case Studies of Elder Mistreatment:

Three case studies involving ethical issues in elder mistreatment are presented. They were created from a variety of actual situations to illustrate the range and complexity of ethical issues that professionals encounter in elder mistreatment and to serve as the basis for discussion of ethical issues by professionals from a variety of disciplines in subsequent chapters of the publication. Problems of physical and mental disability, relational loss, and mistreatment in institutional settings are illustrated. Elements of self neglect as well as neglect and abuse by others are contained in the cases, and intentional and unintentional mistreatment are portrayed. The author highlights some of the ethical dilemmas presented by each of the three cases.     

The conceptualization of mistreatment by older American Indians

The problem of how to conceptualize elder mistreatment goes back several decades, and is especially important for ethnic minority populations, who may have perspectives that differ from the dominant society. This community-based participatory research study, which examined perceptions of mistreatment by family among 100 urban and rural older American Indians, permits a rare glimpse into how Native elders themselves understand this issue. Here, good treatment was conceptualized in terms of being taken care of, having one’s needs met, and being respected. We found relatively high standards for how elders should be treated—such as the belief that an elder’s needs should be anticipated and met without the elder needing to ask—in the face of widespread accounts of the mistreatment of elders within the community, largely through various acts of financial exploitation and neglect. Substance abuse and culture loss were blamed formuch of the elder mistreatment occurring in contemporary Native communities.     

Chapter Three

Elder mistreatment is explored from the perspective of the health care professional, beginning with a brief review of relevant values and ethical concepts. These include beneficence, non-maleficence, autonomy, confidentiality, paternalism, filial piety, and justice. The chapter then raises several ethical dilemmas faced by health care professionals in evaluating, reporting, and caring for cases of elder mistreatment. These include the difficulty in balancing patient autonomy with the obligation to prevent them from harm, the problem of confidentiality and reporting requirements, the impact of reporting on relationships with patients and other professionals, and the problems in working with patients and their families. Approaches to developing appropriate institutional responses are suggested. The chapter concludes with a discussion of the three cases.     

Readability and content of elder abuse instruments

Since elder abuse was first acknowledged as a health care and social problem, incidence and prevalence of mistreatment has been assessed sparingly in the United States and other countries around the world. Standardized instruments for determining the prevalence of elder abuse have not been developed and other instruments measuring a person's function and spousal violence have been adapted for the measurement of elder abuse prevalence. The purposes of this paper are to (1) ascertain the reading grade level of the most frequently used elder abuse prevalence instrument's text and (2) determine the content validity of the instruments with respect to the types of elder abuse included in them. A review of the instruments used to measure elder abuse prevalence was completed and a questionnaire was developed to measure the reading grade level and type of elder abuse content in four instruments. The Fry Readability, Flesch Reading Ease, and McLaughlin Grading formulas were used to determine reading grade level. A questionnaire regarding content validity was sent to 69 faculty and staff in one university department and a 59% return was achieved. The Conflict Tactics Scale and the Hwalek-Sengstock Elder Abuse-Screening Test had the lowest mean score at the 6th grade reading level. Results of content analysis for types of elder abuse demonstrated none of the instruments are comprehensive. Instruments to measure the prevalence are needed which balance readability and content validity.     

A social capital approach to the prevention of elder mistreatment

The current demographic landscape features an increasing number of elderly individuals in the care of some trusted other. Being cared for by a trusted other raises the potential for mistreatment of the elder by that trusted other. The goal of this paper is to explore the possibility of preventing elder mistreatment by increasing the bridging and bonding social capital available to caretakers. Attending to social capital lets researchers expand their focus toward areas rarely examined through current stress-outcome models (e.g., interpersonal interactions). First, elder mistreatment and social capital are defined and discussed. Then, a model is forwarded that details how social capital might mitigate the effects of caretaker stress and decrease the probability that caretakers will engage in elder mistreatment in both home and long-term care institutional settings. Finally, implications for future research and practical intervention are discussed.     

Combating elder and dependent adult mistreatment: the role of the clinical psychologist

Among the many different professionals who work to address elder and dependent adult mistreatment, the clinical psychologist performs a function that is not well documented. The experiences of a clinical psychologist attached to a medical response team and an elder abuse forensic center provide insight into this complex and multifaceted role. Case examples from an elder abuse forensic center illustrate the breadth of referral questions that a clinical psychologist addresses. This information may be of use to those who would argue that these services be made widely available to elder abuse professionals such as social workers, public guardians, and those in the criminal justice system. The case studies also may be useful for training purposes.     

The prevalence and incidence of intimate partner and interpersonal mistreatment in older women in primary care offices

Self-report information about mistreatment experiences and perpetrators were collected from a large sample of women over 55 years of age who sought care from Midwestern primary care offices. A significantly larger proportion of women had experienced sexual mistreatment since turning 55 that was perpetrated by an intimate partner than committed by an interpersonal perpetrator. The women experienced significantly more threats, physical mistreatment, and caregiver mistreatment since turning 55, and more threats and caregiver mistreatment within the last year by an interpersonal perpetrator than by an intimate partner. Several women described different types of perpetrators who had threatened or mistreated them. Few women reported the mistreatment to anyone. Implications for elder service providers and advocates are discussed.     

Combating Elder and Dependent Adult Mistreatment: The Role of the Clinical Psychologist

ABSTRACT

Among the many different professionals who work to address elder and dependent adult mistreatment, the clinical psychologist performs a function that is not well documented. The experiences of a clinical psychologist attached to a medical response team and an elder abuse forensic center provide insight into this complex and multifaceted role. Case examples from an elder abuse forensic center illustrate the breadth of referral questions that a clinical psychologist addresses. This information may be of use to those who would argue that these services be made widely available to elder abuse professionals such as social workers, public guardians, and those in the criminal justice system. The case studies also may be useful for training purposes.     

Elder Abuse Decision Support System: Field test outcomes,abuse measure validation,and lessons learned

The Elder Abuse Decision Support System was designed to meet the critical need for improved methods for assessment and substantiation of elder mistreatment, using a web-based system with standardized measures. Six Illinois agencies participated in the field test. One-year pre/post analyses assessed substantiation results, using Illinois’ standard investigation procedure as a comparison. Pre/post acceptability was assessed with caseworkers in focus groups with adult protective service staff. Validity of measures was assessed using Cronbach’s alpha and receiver operator characteristic curve analyses with final substantiation decision as a criterion. Increased substantiation of abuse was found. Regarding acceptability, the two systems were found to have differing strengths and weaknesses. Outcome measures had high validity estimates, while focus groups indicated directions for improvement. This study was a successful proof of concept that data collected in the field would be useful for clinical purposes as well as for research.     

Prevention of Elder Mistreatment in Nursing Homes: Competencies for Direct-Care Staff

Existing training on elder mistreatment in nursing homes focuses on detection and reporting of abuse, with little training specifically targeted toward prevention of mistreatment before it occurs. We used qualitative interviews with nursing home staff, policy makers, and related professionals to identify training needs. Based on participant accounts, we drafted a number of competencies essential for caregiver training to prevent mistreatment in nursing homes. Competencies include those dealing with definitions and policies, risks for mistreatment, communication and respect in relationships with residents, and development of a cooperative work environment. Competencies are discussed along with illustrative examples, and implications for practice and policy are addressed.     

Preventing and combating elder mistreatment in flanders (belgium): general overview

In Flanders, the state that comprises the Dutch-speaking part of Belgium, the structural attention given to the problem of elder mistreatment has grown slowly throughout the last decade. Equivalent to the evolution in most other western countries, there is nevertheless still a great lack of scientific research, and several governments (federal, regional, supralocal, and local) are still very reluctant to provide sufficient means in order to prevent and combat elder mistreatment. This article aims to present a general overview of the current state of affairs in the regional state of Flanders to address elder mistreatment. More concretely, it will highlight the history of the Flemish Reporting Point for Elder Abuse, what its aims are, and what definition and typology of elder mistreatment it uses in its daily activities. Because of the importance of well-conducted scientific research and excellent academic support in order for policymakers and social services to deal efficiently with elder mistreatment, the lack of scientific research in Flanders also will be briefly highlighted.     

Prevalence and correlates of elder mistreatment in Singapore

The current study attempts to identify the prevalence rate of and risk factors associated with elder mistreatment in Singapore, a multi-ethnic nation in South-East Asia. Information on elder mistreatment was collected from 400 non-randomly selected cognitively intact older adults in a residential area of Singapore. Items on mistreatment were adopted from the Hwalek-Sengstock Elder Abuse Screening Test and the Vulnerability to Abuse Screening Scale. Standardized scales on activities of daily living, loneliness, and items on violence between family members were administered. The prevalence rate of mistreatment was 8.3%. A family environment characterized by psychological and physical abuse between family members and a social environment characterized by loneliness increased the vulnerability of older adults to mistreatment. Older adults who were mistreated reported more depression symptoms than those who were not.     

Preventing and Combating Elder Mistreatment in Flanders (Belgium): General Overview

In Flanders, the state that comprises the Dutch-speaking part of Belgium, the structural attention given to the problem of elder mistreatment has grown slowly throughout the last decade. Equivalent to the evolution in most other western countries, there is nevertheless still a great lack of scientific research, and several governments (federal, regional, supralocal, and local) are still very reluctant to provide sufficient means in order to prevent and combat elder mistreatment. This article aims to present a general overview of the current state of affairs in the regional state of Flanders to address elder mistreatment. More concretely, it will highlight the history of the Flemish Reporting Point for Elder Abuse, what its aims are, and what definition and typology of elder mistreatment it uses in its daily activities. Because of the importance of well-conducted scientific research and excellent academic support in order for policymakers and social services to deal efficiently with elder mistreatment, the lack of scientific research in Flanders also will be briefly highlighted.     

Mistreatment of Older People in the United Kingdom: Findings from the First National Prevalence Study

There have been few national studies of the prevalence of elder mistreatment (abuse and neglect) in private households. This article provides an overview of the UK National Prevalence Study of Elder Mistreatment that took place in 2006. It addressed 2,111 respondents in four countries who answered a face-to-face survey questionnaire. The achieved sample was weighted to be representative of the UK older population. Of respondents, 2.6% reported mistreatment by family members, close friends, or care workers. The predominant type of reported mistreatment was neglect (1.1%) followed by financial abuse (0.6%), with 0.4% of respondents reporting psychological abuse, 0.4% physical abuse, and 0.2% sexual abuse. Women were significantly more likely to have experienced mistreatment than men, but there were gender differences according to type of abuse and perpetrator characteristics. Divergent patterns were found for neglect, financial, and interpersonal abuse. Further analysis of the data indicated that the likelihood of mistreatment varied with socioeconomic position and health status.     

Self-neglect: Implications for prosecutors

Historically, the view of elder mistreatment in the United States has been similar to that of child abuse and has been detrimental to the understanding of elder mistreatment. Until recently, there was little understanding of the complexity of elder mistreatment and the legal system lacked appropriate laws with which to handle this growing problem. Over the last two decades, legislation, laws, and criminal codes of conduct have been developed to tackle the problem of elder mistreatment. However, little knowledge or understanding of the public health problems and legal implications related to the most common form of elder mistreatment referred to Adult Protective Services (APS), elder self-neglect, is available. The growth of this national problem has expanded the role of the legal system and pushed the development of interdisciplinary research with the intent of defining and understanding the problem of self-neglect and with the ultimate goal of expanding intervention strategies. The Consortium for Research in Elder Self-Neglect of Texas (CREST) is the leader in this field and the pilot study suggests numerous medical and legal implications for both intervention and future research.     

Differentiating self-neglect as a type of elder mistreatment: how do these cases compare to traditional types of elder mistreatment?

Official estimates suggest that self-neglect is the most common type of elder mistreatment. Interestingly, very few researchers have empirically assessed self-neglect as a type of elder mistreatment. In the current study, attention is given to how self-neglect cases handled by adult protective services agencies compare to other types of elder mistreatment. Comparisons are made between the needs of self-neglect clients and other protective services clients as well as the role of stress in the different types of abuse. Findings suggest that self-neglect clients are less likely to need help with certain functional activities. In addition, those who are married and those who have completed fewer years of education are less likely to be labeled as experiencing self-neglect. City differences in rates of self-neglect were also found. Not surprisingly, self-neglect clients were more likely than other protective services clients to refuse services. Implications are provided.     

Self-Neglect: Implications for Prosecutors

ABSTRACT

Historically, the view of elder mistreatment in the United States has been similar to that of child abuse and has been detrimental to the understanding of elder mistreatment. Until recently, there was little understanding of the complexity of elder mistreatment and the legal system lacked appropriate laws with which to handle this growing problem. Over the last two decades, legislation, laws, and criminal codes of conduct have been developed to tackle the problem of elder mistreatment. However, little knowledge or understanding of the public health problems and legal implications related to the most common form of elder mistreatment referred to Adult Protective Services (APS), elder self-neglect, is available. The growth of this national problem has expanded the role of the legal system and pushed the development of interdisciplinary research with the intent of defining and understanding the problem of self-neglect and with the ultimate goal of expanding intervention strategies. The Consortium for Research in Elder Self-Neglect of Texas (CREST) is the leader in this field and the pilot study suggests numerous medical and legal implications for both intervention and future research.