Kathleen H. Wilber

Elder abuse prevalence in community settings: a systematic review and meta-analysis

BACKGROUND Elder abuse is recognised worldwide as a serious problem, yet quantitative syntheses of prevalence studies are rare. We aimed to quantify and understand prevalence variation at the global and regional levels. METHODS For this systematic review and meta-analysis, we searched 14 databases, including PubMed, PsycINFO, CINAHL, EMBASE, and MEDLINE, using a comprehensive search strategy to identify elder abuse prevalence studies in the community published from inception to June 26, 2015. Studies reporting estimates of past-year abuse prevalence in adults aged 60 years or older were included in the analyses. Subgroup analysis and meta-regression were used to explore heterogeneity, with study quality assessed with the risk of bias tool. The study protocol has been registered with PROSPERO, number CRD42015029197. FINDINGS Of the 38 544 studies initially identified, 52 were eligible for inclusion. These studies were geographically diverse (28 countries). The pooled prevalence rate for overall elder abuse was 15·7% (95% CI 12·8-19·3). The pooled prevalence estimate was 11·6% (8·1-16·3) for psychological abuse, 6·8% (5·0-9·2) for financial abuse, 4·2% (2·1-8·1) for neglect, 2·6% (1·6-4·4) for physical abuse, and 0·9% (0·6-1·4) for sexual abuse. Meta-analysis of studies that included overall abuse revealed heterogeneity. Significant associations were found between overall prevalence estimates and sample size, income classification, and method of data collection, but not with gender. INTERPRETATION Although robust prevalence studies are sparse in low-income and middle-income countries, elder abuse seems to affect one in six older adults worldwide, which is roughly 141 million people. Nonetheless, elder abuse is a neglected global public health priority, especially compared with other types of violence. FUNDING Social Sciences and Humanities Research Council of Canada and the WHO Department of Ageing and Life Course.

Determining Prevalence and Correlates of Elder Abuse Using Promotores: Low‐Income Immigrant Latinos Report High Rates of Abuse and Neglect

Low‐income Latino immigrants are understudied in elder abuse research. Limited English proficiency, economic insecurity, neighborhood seclusion, a tradition of resolving conflicts within the family, and mistrust of authorities may impede survey research and suppress abuse reporting. To overcome these barriers, promotores, local Spanish‐speaking Latinos, were recruited and trained to interview a sample of Latino adults aged 66 and older residing in low‐income communities. The promotores conducted door‐to‐door interviews in randomly selected census tracts in Los Angeles to assess the frequency of psychological, physical, and sexual abuse; financial exploitation; and caregiver neglect. Overall, 40.4% of elderly Latino adults had experienced some form of abuse or neglect within the previous year. Nearly 25% reported psychological abuse, 10.7% physical assault, 9% sexual abuse, and 16.7% financial exploitation, and 11.7% were neglected by their caregivers. Younger age, higher education, and experiencing sexual or physical abuse before age 65 were significant risk factors for psychological, physical, and sexual abuse. Years lived in the United States, younger age, and prior abuse were associated with greater risk of financial exploitation. Years spent living in the United States was a significant risk factor for caregiver neglect. Abuse prevalence was much higher in all mistreatment domains than findings from previous research on community‐dwelling elderly adults, suggesting that low‐income Latino immigrants are highly vulnerable to elder mistreatment or that respondents are more willing to disclose abuse to promotores who represent their culture and community.

Holding Abusers Accountable: An Elder Abuse Forensic Center Increases Criminal Prosecution of Financial Exploitation

PURPOSE Despite growing awareness of elder abuse, cases are rarely prosecuted. The aim of this study was to examine the effectiveness of an elder abuse forensic center compared with usual care to increase prosecution of elder financial abuse. DESIGN AND METHODS Using one-to-one propensity score matching, cases referred to the Los Angeles County Elder Abuse Forensic Center (the Forensic Center) between April 2007 and December 2009 for financial exploitation of adults aged 65 and older (n = 237) were matched to a population of 33,650 cases that received usual care from Adult Protective Services (APS). RESULTS 1 Significantly, more Forensic Center cases were submitted to the District Attorneys office (DA) for review (22%, n = 51 vs. 3%, n = 7 usual care, p < .001). Among the cases submitted, charges were filed by the DA at similar rates, as was the proportion of resultant pleas and convictions. Using logistic regression, the strongest predictor of case review and ultimate filing and conviction was whether the case was presented at the Forensic Center, with 10 times greater odds of submission to the DA (Odds ratio = 11.00, confidence interval = 4.66-25.98). IMPLICATIONS Previous studies have not demonstrated that elder abuse interventions impact outcomes; this study breaks new ground by showing that an elder abuse multidisciplinary team increases rates of prosecution for financial exploitation. The elder abuse forensic center model facilitates cooperation and group problem solving among key professionals, including APS, law enforcement, and the DA and provides additional resources such as neuropsychological testing, medical record review, and direct access to the Office of the Public Guardian.

Person-Centered Care for Older Adults with Chronic Conditions and Functional Impairment: A Systematic Literature Review.

Person‐centered care (PCC) shifts focus away from the traditional biomedical model in favor of embracing personal choice and autonomy for people receiving health services. It has become an important avenue for improving primary care, and older adults remain a priority target for PCC because they are more likely to have complex care needs than younger individuals. Nevertheless, despite a growing body of evidence regarding its use, PCC still lacks an agreed‐upon definition. A literature review was conducted to explore extant scholarship on PCC for older adults, assess corresponding definitions of PCC, and identify important elements of quality PCC. Nearly 3,000 articles published between 1990 and 2014 were identified. Excluding search results outside the parameters of this study, the final review comprised 132 nonduplicate sources focused on patient‐centered care or PCC in older adults. Fifteen descriptions of PCC were identified, addressing 17 central principles or values. The six most‐prominent domains of PCC were holistic or whole‐person care, respect and value, choice, dignity, self‐determination, and purposeful living. The body of evidence reviewed suggests that PCC is an important area of growing interest. Although multiple definitions and elements of PCC abound—with many commonalities and some overlap—the field would benefit from a consensus definition and list of essential elements to clarify how to operationalize a PCC approach to health care and services for older adults. This work guided the development of a separate American Geriatrics Society expert panel statement presenting a standardized definition and a list of PCC elements for older adults with chronic conditions or functional impairment.

Ethnic variation in site of death of older adults dually eligible for Medicaid and Medicare.

This is a retrospective study using secondary data to investigate variation in site of death by ethnicity and to determine how hospice enrollment affects site of death. Data for this study were obtained between 1996 and 2000 from linked Medi‐Cal and Medicare claims from 18 California counties participating in a state legislated effort to improve chronic care services in California. Subjects examined in this study included 38,519 decedents aged 65 and older who died between 1997 and 2000 and were dually eligible the entire year immediately before death. Demographic variables were site of death, cause of death, hospice use, and care setting in the year before death. Results revealed that blacks and Latinos were significantly more likely than whites to die at home, although being black or Asian was negatively associated with hospice use. This variation did not change when hospice use was controlled. Thus, although minorities were more likely to die at home, they were less likely to receive hospice care. Because patients dying at home without hospice care report higher rates of pain than those who have hospice care, physicians must work to ensure that minority patients understand all end‐of‐life care options, including hospice, and how these care options can be delivered in a culturally competent manner.

Do Sedentary Older Adults Benefit From Community-Based Exercise? Results From the Active Start Program

PURPOSE This study assessed the effectiveness of Active Start, a community-based behavior change and fitness program, designed to promote physical activity among sedentary community-dwelling older adults. DESIGN AND METHODS A quasi-experimental design was used. Data were analyzed using a within-group pretest-post-test design to calculate changes in the intervention group and changes in the waitlist comparison group. Further analyses were conducted after the comparison group completed the intervention. Paired t tests were employed to analyze unadjusted mean changes in physical performance measures from pretest to post-test. Repeated measures analysis of covariance (using SAS Proc Mixed) was then conducted to calculate the adjusted mean change for the intervention group. RESULTS Significant improvement was found on all performance measures (strength, flexibility, and balance) for the intervention group as a whole. Similar improvements were found among subgroups (Whites, African Americans, and Hispanics). No significant changes were found in the comparison group when they were in the control condition; however, they significantly improved on all measures after completing the intervention. IMPLICATIONS This study suggests that a community-based physical activity program benefits sedentary, racially, and ethnically diverse older adults by coupling a behavioral change support group and fitness classes.

Conceptual model and map of financial exploitation of older adults

This article describes the processes and outcomes of three-dimensional concept mapping to conceptualize financial exploitation of older adults. Statements were generated from a literature review and by local and national panels consisting of 16 experts in the field of financial exploitation. These statements were sorted and rated using Concept Systems software, which grouped the statements into clusters and depicted them as a map. Statements were grouped into six clusters, and ranked by the experts as follows in descending severity: (a) theft and scams, (b) financial victimization, (c) financial entitlement, (d) coercion, (e) signs of possible financial exploitation, and (f) money management difficulties. The hierarchical model can be used to identify elder financial exploitation and differentiate it from related but distinct areas of victimization. The severity hierarchy may be used to develop measures that will enable more precise screening for triage of clients into appropriate interventions.

Using interagency collaboration to serve older adults with chronic care needs: the Care Advocate Program.

Summary: This article describes the Care Advocate Program, an interagency collaborative effort that involved health care organizations, social service agencies, and an academic research center to improve chronic care service delivery to older adults. The article discusses existing barriers to effective chronic care delivery as well as concepts for successful collaboration. The article describes the multiple and often competing demands of stakeholders who undertake collaborative projects. It concludes with lessons learned when partners from different settings work together to design and implement a demonstration program.

Prevalence of Potential Medication Problems among Dually Eligible Older Adults in Medicaid Waiver Services

Background: Methods for identifying potential medication problems among older adults at risk for nursing home placement have generally not included clinical risk factors in addition to medication lists. Objective: To assess the prevalence of potential medication problems for older adults enrolled in a Medicaid waiver service using tested Home Health Criteria that combine medication use and clinical risk factors for screening drug regimens. Methods: A cross-sectional survey screened 615 community-dwelling, dually eligible, functionally impaired adults aged 65 years and older enrolled in a Medi-Cal (Californias Medicaid) waiver care management program, Californias Multipurpose Senior Services Program (MSSP). Measures included prevalence and predictors of having 1 of 4 potential medication problems: unnecessary therapeutic duplication, use of psychotropic drugs with concurrent falls or confusion, cardiovascular medication problems, and use of nonsteroidal antiinflammatory drugs with risk of peptic ulcer complications. Results: Forty-nine percent of the sample had a potential medication problem, with unnecessary therapeutic duplication being most prevalent (24%). Nearly 20% of patients screened had 2 or more potential problems. Independent predictors of any potential medication problem were age (OR 1.029; 95% CI 1.01 to 1.05), new MSSP enrollment (OR 1.634; 95% CI 1.14 to 2.35), and number of medications (OR 1.183; 95% CI 1.13 to 1.24). Conclusions: Prevalence of potential medication problems in MSSP was markedly higher than reported in the original home healthcare sample used to test the Home Health Criteria. The prevalence rate for older adults at risk for nursing home placement necessitates expanded screening and medication therapy management interventions, especially upon initial enrollment and for those taking multiple medications. Interventions are needed to increase medication problem identification and resolution while promoting collaboration among physicians, consultant pharmacists, and waiver service providers.

Reductions in Costly Healthcare Service Utilization: Findings from the Care Advocate Program

OBJECTIVES: To determine whether a telephone care‐management intervention for high‐risk Medicare health maintenance organization (HMO) health plan enrollees can reduce costly medical service utilization.