Amber Selwood

The prevalence of elder abuse and neglect: a systematic review

OBJECTIVE to perform a systematic review of studies measuring the prevalence of elder abuse or neglect, either reported by older people themselves, or family and professional caregivers or investigated using objective measures. METHODS we conducted a comprehensive literature search of multiple databases up to October 2006, supplemented by a search of the references of all relevant articles. Validity of studies was graded by two authors independently using a standardised checklist. RESULTS forty-nine studies met our inclusion criteria, of which only seven used measures for which reliability and validity had been assessed. In the general population studies, 6% of older people reported significant abuse in the last month and 5.6% of couples reported physical violence in their relationship in the last year. In studies using valid instruments involving vulnerable elders, nearly a quarter reported significant levels of psychological abuse. Five per cent of family caregivers reported physical abuse towards care recipients with dementia in a year, and a third reported any significant abuse. Sixteen per cent of care home staff admitted significant psychological abuse. Rates of abuse recorded using objective measures (5%) or reported to home management or adult protective services (APS) (1-2%) were low. CONCLUSION one in four vulnerable elders are at risk of abuse and only a small proportion of this is currently detected. Elders and family and professional caregivers are willing to report abuse and should be asked about it routinely. Valid, reliable measures and consensus on what constitutes an adequate standard for validity of abuse measures are needed.

Abuse of people with dementia by family carers: representative cross sectional survey.

Objective To determine the prevalence of abusive behaviours by family carers of people with dementia. Design Representative cross sectional survey Setting Community mental health teams in Essex and London. Participants 220 family carers of people newly referred to secondary psychiatric services with dementia who were living at home. Main outcome measure Psychological and physical abuse (revised modified conflict tactics scale). Results 115 (52%, 95% confidence interval 46% to 59%) carers reported some abusive behaviour and 74 (34%, 27% to 40%) reported important levels of abuse. Verbal abuse was most commonly reported. Only three (1.4%) carers reported occasional physical abuse. Conclusions Abusive behaviour by family carers towards people with dementia is common, with a third reporting important levels of abuse and half some abusive behaviour. We found few cases of physical or frequent abuse, although those with the most abusive behaviour may have been reluctant to report it.

The determinants of family carers' abusive behaviour to people with dementia: Results of the CARD study

BACKGROUND Although dementia and elder abuse prevention are political priorities, there are no evidence-based interventions to reduce abuse by family carers. We have limited understanding of why some family carers, but not others in similar circumstances, behave abusively. We aimed to test our hypothesis, that more anxious dementia carers report more abusive behaviours, and dysfunctional coping strategies and carer burden mediate this relationship. METHOD We interviewed 220 family/friend dementia carers from Essex and London Community Mental Health Teams. We used the revised Modified Conflict Tactics Scale to measure abuse. RESULTS More anxious and depressed carers reported more abuse; this relationship was mediated by using dysfunctional coping strategies and higher burden. Abuse was predicted by: spending more hours caring, experiencing more abusive behaviour from care recipients and higher burden. LIMITATIONS This was a cross-sectional study so we cannot confirm directions of causality. While many carers were willing to report abusive actions, some may not have been and our numbers may be an underestimate. CONCLUSION Anxious and depressed carers are particularly likely to report abusive behaviour when asked. Testing interventions directed at reducing carer anxiety, depression or changing unhelpful coping strategies, and/or reducing care recipient aggression where possible, is a logical and urgent next step.

The sensitivity and specificity of the Modified Conflict Tactics Scale for detecting clinically significant elder abuse

BACKGROUND A third of family carers of people with dementia describe acting abusively in research studies, but far fewer cases of abuse are currently detected in clinical situations. This discrepancy may be explained by inadequate detection by health professionals, or disagreement regarding what constitutes elder abuse. This study was undertaken to determine the sensitivity and specificity of the revised Modified Conflict Tactics Scale (MCTS) for detecting clinically significant abuse. METHODS We interviewed 220 family carers of people consecutively referred to psychiatric services with dementia in Essex and London (U.K.), using the MCTS to measure abuse. We defined abuse cases using (1) the MCTS conventional scoring system; (2) the Pillemer criteria; and (3) clinical judgment of an expert panel. RESULTS Our panel judged that 15 (6.8%) of carers reported potentially clinical concerning abusive behavior; but 47 (21%) were cases according to the Pillemer criteria and 74 (34%) using the MCTS conventional scoring system. We developed a weighted MCTS scoring system, with high sensitivity and specificity for detecting clinically concerning abuse. CONCLUSIONS The MCTS could be used routinely in clinical practice with carers of people with dementia to detect clinically concerning cases of abuse, many of which are currently being missed.

Long term cognitive dysfunction in older people after non-cardiac surgery

Outcomes from various studies differ, and no definite conclusion is possible Half of all people reaching the age of 65 subsequently have one or more operations,1 but despite substantial research on short term cognitive dysfunction within the first week after the operation little research has been undertaken into the potential long term effects on cognition. The exception is cardiac surgery, where cognitive dysfunction has been well documented and has usually been attributed to the adverse effects of cardiopulmonary bypass on the brain.2 3 Various risk factors for long term (defined as three months or more) postoperative cognitive dysfunction have been investigated, including type of anaesthetic agent, general versus regional anaesthesia, use of anticholinergic agents such as atropine, or the physiological effects of the anaesthetic such as hypoxia, hypotension, or hyper-ventilation. The multicentre International Study of Post-Operative Cognitive Dysfunction (ISPOCD1) compared 1218 patients aged 60 years and older undergoing major surgery with a control group (n = 321) of a similar age.4 At three months after …

What would help me stop abusing? The family carer's perspective.

BACKGROUND A third of family members caring for people with dementia report acting abusively towards them, but there are currently no evidence-based interventions to reduce or prevent such behavior. Family carers who act abusively have not previously been consulted about what may help to reduce abuse. METHOD We prospectively recruited a consecutive sample of 220 family carers of people with dementia referred to secondary psychiatric services. We asked carers who reported any abusive behavior in the previous three months to select from a list of services and potential interventions those that they thought might help to reduce or prevent this abusive behavior. Carers were also asked to suggest other interventions that might help prevent abuse. RESULTS 113/115 carers who reported any abusive behavior answered questions about possible interventions. The three most frequently endorsed interventions were: medication to help the care recipients memory (n = 54; 48.2%); written advice on understanding memory problems and what to do (n = 48; 42.9%) and more information from professionals caring for the person with dementia (n = 45; 40.2%). When asked which interventions were most important, medication to help memory (n = 21; 18.6%), home care (n = 17; 15.0%), residential respite and sitting services (both n = 12; 10.6%) were most frequently endorsed. CONCLUSION To prevent abuse, family carers prioritized medication for memory, good communication from professionals, written advice on memory problems, home care, residential respite and sitting services. As no interventions to reduce abuse by family carers have yet been formally evaluated, a good starting point may be the expressed wishes of family carers.

Antidementia drugs: prescription by level of cognitive impairment or by socio-economic group?

Objectives: We aimed to investigate for the first time whether cholinesterase inhibitor prescription was associated with economic status in a population of people with dementia. Method: We recruited 215 people with dementia, living independently, who were consecutively referred to five Community Mental Health Teams in London and Essex. We tested our hypothesis that home owners were more likely to be prescribed cholinesterase inhibitors than those who rented their accommodation. Results: People who owned their home were four times more likely to be prescribed cholinesterase inhibitors (OR 4.2, 1.8–9.8; p = 0.001). Younger age, fewer neuropsychiatric symptoms, having a dementia diagnosis for which cholinesterase inhibitors were recommended and longer time since diagnosis also predicted prescription, but severity of cognitive impairment did not. Conclusion: Despite high-profile guidelines that NHS cholinesterase prescribing should be restricted to people with moderate dementia, being a home owner was a strong predictor of prescription, while dementia severity was not. We recommend that health services should be audited to ensure that access to treatment increases in those who are socioeconomically disadvantaged.

Abuse of people with dementia

Summary People with dementia are particularly vulnerable to abuse. It is inherently difficult to study as it is a hidden offence, perpetrated against vulnerable people with memory impairment, by those on whom they depend. In the general population, 6% of older people have experienced abuse in the last month and this rises to approximately 25% in vulnerable populations such as people with dementia. We know that various factors in the carer and the care recipient can predispose to a higher rate of abuse and this knowledge can be harnessed to try and improve prevention. There are also valid and reliable scales available to help detect abuse in vulnerable older adults. All health and social care professionals have a responsibility to act on any suspicion or evidence of significant abuse or neglect in order to ensure that appropriate management is taken.

Involving service users in the development of the Support at Home:interventions to enhance life in Dementia Carer Supporter Programme for family carers of people with dementia

Involving service users in research can be an effective way of improving the practicalities and acceptability of interventions for target end users.