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This article presents recommendations from expert practitioners and researchers regarding future directions for research on elder abuse prevention. Using the Research-to-Practice Consensus Workshop model, participants critiqued academic research on the prevention of elder mistreatment and identified practice-based suggestions for a research agenda on this topic. The practitioners’ critique resulted in 10 key recommendations for future research that include the following priority areas: defining elder abuse, providing researchers with access to victims and abusers, determining the best approaches in treating abusers, exploiting existing data sets, identifying risk factors, understanding the impact of cultural factors, improving program evaluation, establishing how cognitive impairment affects legal investigations, promoting studies of financial and medical forensics, and improving professional reporting and training. It is hoped that these recommendations will help guide future research in such a way as to make it more applicable to community practice.
Elder mistreatment is a pervasive and growing problem and the scientific literature on the topic is growing. Several incidence and prevalence studies have been conducted throughout the world and more reliable and valid research instruments have been developed (Cooper, Selwood, & Livingston, 2008). Longitudinal research has demonstrated that experiencing elder mistreatment raises the risk of nursing home placement and mortality (Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998; Lachs, Williams, O’Brien, & Pillemer, 2002). Elder abuse now is seen as a topic worthy of serious study interest by social scientists, epidemiologists, and clinical and health service researchers.
Within the field, however, there is universal consensus that strenuous attempts are needed to improve the conduct of research. The past four decades have seen more dramatic advances in our knowledge about other types of interpersonal abuse than has occurred with elder mistreatment. A number of major population surveys on wife abuse, physical child abuse, and child sexual abuse have helped establish reliable prevalence estimates of these problems. Scientifically conducted case-control studies have more definitively specified risk factors for such maltreatment. That similar progress has not occurred in the field of elder abuse is widely acknowledged (Ingram, 2003; Lachs & Pillemer, 2004; National Research Council, 2003). Although speculative discussions of elder abuse abound, rigorous research evidence is still relatively scarce.
The lack of scientifically credible research is not just an academic concern. The paucity of firm findings regarding elder mistreatment makes an organized, comprehensive approach to prevention nearly impossible. Indeed, better research is key to all steps in such a comprehensive process: defining the magnitude of the problem, identifying causes, developing and testing interventions, and implementing interventions and measuring effectiveness (Doll, Bonzo, Mercy, & Sleet, 2008; Ingram, 2003). It is not an exaggeration to say that from a public health perspective, better research is a necessary first step in creating practical solutions to elder mistreatment.
Several attempts have been made to create research agendas for elder mistreatment. Most notably, a National Academy of Sciences panel was convened to assess the state of research in elder mistreatment (National Research Council, 2003). This panel, consisting predominantly of scientific experts, made a variety of suggestions for improving elder mistreatment research. What has been lacking in such efforts, however, has been the voice of the practice community. Scientists have been involved in generating priorities for research on elder mistreatment, but such individuals are typically removed from the day-to-day experience of abuse and neglect.
It is the working hypothesis of this article that, following principles of community-based participatory research (Israel, Eng, Schulz, & Parker, 2005), the eventual end-users of elder mistreatment research should be consulted regarding research priorities – those practitioners who will use research knowledge and evidence-based practices to assist victims and their families. This article reports on the results of a “research-to-practice” consensus workshop that generated research recommendations for the field of elder mistreatment, based on practitioner and researcher dialogue.
The Cornell Institute for Translational Research on Aging (CITRA) has created a program of “Research-to-Practice Consensus Workshops” on issues of importance to the practice community. As its name implies, a major goal of CITRA is to “translate” the findings of research studies to individuals who can use them in their work with older persons. All too often, research findings are published in ways that are of interest only to other scientists. The aim of CITRA is to create “research you can use” for practitioners in a variety of formats.
The CITRA consensus workshop model acknowledges that practitioners often have too little voice in what scientists study, and that scientists can benefit greatly by having practitioners help shape their research agendas. The goal of each Research-to-Practice Consensus Workshop is to help bridge the gap between “science and service,” by bringing the research and practice communities together on specific topics. An important outcome of the workshops is reaching consensus on a set of recommendations for future studies that then are disseminated to researchers. CITRA consensus conferences have been held on a variety of topics, including fall prevention, social isolation, and chronic pain (see Sabir et al., 2006, for a detailed description of the CITRA consensus conference model; a manual for conducting workshops is available by contacting the first author). Based on the joint interests of CITRA’s community partners and researchers, a consensus workshop on elder mistreatment was held in New York City.
Prior to holding each consensus workshop, a research review paper is prepared. In this case, the research review was a summary of recent studies on the topic of preventing elder mistreatment. Although written in non-technical language, the research review focuses on studies that meet rigorous scientific standards. Thus, this report is not a summary of “best practices” or of reports about elder abuse prevention programs that people working in the field have found to be useful without subjecting them to scientific tests. Instead, it highlights findings using research methods that scientists believe are reliable and valid. Practitioners in the consensus conference are encouraged to critique existing research reviewed in the paper, including selection of topics, methods used, and implications.
In brief, the research review for the elder mistreatment consensus conference covered the topics of the extent of elder mistreatment, risk factors, and types of interventions. The review noted that prevalence rates range from 3.2 – 8 percent depending on the definition of abuse and whether abuse included material exploitation and theft. With prevalence rates this high, clinicians are likely to see at least clinical or sub-clinical victims of elder abuse frequently. Probable risk factors include living in a shared living environment; older persons living alone are at lower risk. Older people with poor social networks and those who suffer from dementia are at greater risk. In abusers, psychological problems such as depression and alcohol abuse are common and often abusers are dependent on their elder victims.
The research review described several types of interventions, as follows; however, few of these have been studied empirically. Screening for abuse may be challenging, because older people may hide abuse or injuries could be due to falls or other accidents. Caregiver support interventions may help prevent re-victimization by alleviating caregiver stress and burn-out. Reporting elder abuse is mandatory in most states, but definitions differ by state. All states offer adult protective services, but a few studies found a negative impact of protective services. Educating professionals increases awareness and knowledge. Finally, educating potential victims proves difficult, since victims may not self-identify as being at risk for elder abuse. Throughout the review, it was made clear that studies of effectiveness of these interventions have not been conducted.
The CITRA consensus conference uses a standard format that has been refined over several years. A group of approximately 25 practitioners who have interest and expertise in the topic is invited to the consensus conference. Three academic research experts and three practitioner experts on the topic are selected as presenters. Each of those individuals provides a five-minute critique of the research review, raising questions and issues for discussion. Following these brief presentations, there is an open discussion of the research review, with a focus on what gaps exist in the literature from a practice point of view. In the final portion of the conference, recommendations for needed future research are proposed and prioritized.
After the workshop, the research review is revised and updated to include the recommendations from the consensus conference. Approximately one month later, a follow-up roundtable is held to which all consensus workshop participants are invited. This two-hour session examines the recommendations, grouping similar ideas and reducing the list as necessary. A final set of recommendations is determined, and a report then is produced and disseminated.
In May 2007, CITRA convened the elder mistreatment consensus workshop to discuss the topic and arrive at recommendations for the future research agenda. The invited practitioners represented the five boroughs of New York City and the range of available elder mistreatment services, including senior centers, social services, adult protective services, criminal justice, guardianship services, law enforcement, dentistry, civil law, victim advocacy, housing, forensics (including a medical examiner), medicine, and nursing. A total of 31 individuals participated in the consensus conference and 16 in the follow-up roundtable. The discussions in both sessions were taped and transcribed.
The Elder Mistreatment Prevention Consensus Workshop generated 41 recommendations covering 14 domains. From this information, the roundtable discussion refined the list to 10 priorities for research that participants believe would lead to improved prevention of elder mistreatment. In some cases, these recommendations reflected primary prevention – ways of preventing the first incident of mistreatment. In other cases, recommendations centered on secondary and tertiary prevention – that is, preventing reoccurrence of mistreatment or its negative outcomes. It is important to note that what distinguishes these recommendations is that they were generated by practitioners based on their exposure to elder mistreatment research and dialogue with scientific experts on the topic. We review the areas recommended for research and provide additional detail on specific research questions that were suggested.
Ten priority areas for research on elder mistreatment were identified: defining elder abuse, providing researchers with access to victims and abusers, determining the best approaches in treating abusers, utilizing existing data sets, identifying risk factors, understanding the impact of cultural factors, improving program evaluation, establishing how cognitive impairment affects legal investigations, promoting studies of financial and medical forensics, and improving professional reporting and training.
Over the past 20 years, efforts have been made to clarify the definition of elder mistreatment. However, practitioners continue to grapple with the question of what, precisely, falls under this term. Participants raised the issue of whether all crimes against older people constitute elder mistreatment, asking to what degree a difference exists between elder abuse victims and crime victims. They also expressed uncertainty regarding the issue of the relationship of perpetrator to victim: Is it elder abuse if the mistreatment is caused by a stranger, rather than by a relative or other person in a position of trust? Further, who can be considered in a “position of trust,” and under what circumstances?
Another issue raised by participants relates to the question: At what age are people considered to be “older” adults? For example, in some states a person is considered an older adult at age 60, whereas in other states a person is considered an older adult at age 65. They noted that there is no standard age cut-off for “elder” mistreatment, and that it would be helpful if there were one. In addition, they asked: Should we even use age as a way to determine elder status or instead consider other characteristics such as functional status to determine the at-risk population?
The consensus workshop participants recommended that researchers work to resolve the definitional issue and attempt to achieve some form of consensus for empirical studies. They noted that their own attempts to apply research findings to practice are hindered by the definitional disarray in published articles, and that this makes it difficult to draw conclusions from research. At a minimum, researchers should be extremely careful in detailing how elder mistreatment is defined, and they should attempt to adhere to standard definitions (e.g., that used in the National Research Council report) to the greatest degree possible.
It was acknowledged that one of the most significant barriers to better elder mistreatment research is lack of access to victims and abusers. Often victims and abusers are socially isolated, “suffering in silence” until the problem is discovered by a health or social service professional. Elder victims may not want the abuse discovered for fear that they will be removed from their own home and placed in a nursing home. Victims may be frail, cognitively impaired, and not receptive to investigation or treatment. They may be accompanied to the doctor by their abuser and thus may try to hide their abuse during a potential screening. Further, agency administrators often are concerned that research may violate their clients’ privacy or be disturbing to them (or to an abusive family member).
Thus, researcher access to victims and abusers for studies has been limited. This situation is in contrast to the fields of child abuse and intimate partner abuse, in which researchers have had much greater ability to conduct interview studies (in part through obtaining samples from treatment programs). The result of the lack of access has been the proliferation of studies that rely on agency records or on surveys of service providers in the elder abuse field.
The consensus workshop recommended much closer interaction between researchers and service providers. It is interesting that the practitioners rated this recommendation very highly, acknowledging that assistance in obtaining research participants is a key to improving empirical studies. They suggested that graduate students in training to be researchers intern at local elder mistreatment service programs, so that they can gain first-hand experience in front-line elder abuse work. Trainees would thereby both gain experience in coordinating with service providers and gain access to elder abuse victims and abusers.
In the field of intimate partner abuse, interventions are common with abusers. The participants noted that such is clearly not the case with elder mistreatment. Only one major intervention study with alleged abusers has been conducted in the field of elder mistreatment, and this study had surprisingly negative outcomes (Davis and Medina-Ariza, 2001). This is clearly a line of research that must be pursued.
The consensus workshop acknowledged that programs for elder abusers require careful evaluation before they can be promoted as prevention strategies. They suggested testing a range of services, including having support groups in which perpetrators receive counseling and learn anger management and coping strategies. Such programs, they recommended, could take place in conjunction with support (and possibly emergency shelter) for the victims. Another important issue identified by the consensus workshop was intervention strategies targeting grandchildren who are mistreating grandparents (a phenomenon perceived as on the rise in urban environments).
The consensus workshop participants recommended that researchers should exploit existing data sets to study elder mistreatment. In doing so, they acknowledged the expense and time required to collect original data on this topic. Practitioners noted that police departments may have data, as do numerous municipal and state agencies. Researchers must work closely with government officials and agency practitioners, such that agency officials understand the need for the data and how it will be used. Potentially complex human subjects approval issues also will need to be addressed in such efforts.
Although research has identified several risk factors (Pillemer, Mueller-Johnson, Mock, Suitor, & Lachs, 2006), practitioners argued that more work was necessary. The consensus workshop participants noted that their work greatly would be facilitated by improved risk profiles for both victims and abusers. Further, prevention programs are difficult to plan in the absence of meaningful risk factor data.
Participants argued that cultural groups may differ in how they define, excuse, or prohibit elder abuse. They suggested that much greater knowledge is needed about the nature and dynamics of elder abuse in minority communities. Ethnic and racial minority elders are often at a greater risk of poor health, social isolation, and poverty, which may increase their risk of elder abuse. Because the number of ethnic and racial minority persons in the older population is growing (especially in urban areas), it is increasingly important that cultural considerations in the delivery of services to elder mistreatment victims be understood. In addition, the group recommended that researchers develop and test culturally-specific public awareness and educational campaigns, to discover what the best ways are to promote help-seeking behaviors among minority victims and their families.
The consensus workshop participants endorsed the use of evidence-based strategies for preventing and treating elder mistreatment. However, they noted that there is a near absence of rigorously tested elder mistreatment interventions. They strongly recommended that intensive evaluation research be conducted to determine what kinds of programs work. Further, they recommended that researchers examine what types of programs work best with specific categories of older people (e.g., young-old versus old-old, disabled versus nondisabled), so that interventions can be targeted better. It also was recommended that cost-benefit analysis needs to be done to determine the effectiveness of programs. In particular, they suggested studying the cost-effectiveness of publicly-funded programs across the nation.
Practitioners noted a cognitive impairment as a key issue that arises in many cases of elder mistreatment, and in particular around investigation of suspected mistreatment situations. They pointed out that their investigations rely on the testimony of victims; however, the individuals who are providing the accounts or accusations of elder mistreatment may have sometimes significant cognitive impairment. Therefore, determining the accuracy of the memory of suspected elder mistreatment victims is a critical component of investigation, as is that of the possible abuser. This is, of course, true in legal settings, but also for social workers, medical professionals, and others who screen for or investigate mistreatment. Practitioners expressed frustration at the lack of tools or methods for determining the validity of older persons’ reports of elder mistreatment, and suggested this be a high priority for research.
Participants suggested that research and evidence-based techniques used in forensics be applied to elder mistreatment. First, they suggested that investigators develop software programs and algorithms in collaboration with the financial services industry to alert appropriate individuals to the possibility that an older adult is being financially exploited. The recommendation derived from the fact that cases of financial exploitation often are discovered long after the older person’s resources have been depleted. In terms of medical forensics, participants also agreed on the need for a better understanding as to whether or not certain injuries could reflect abuse or neglect with a more robust scientific foundation. Examples include fractures that could have resulted from a fall versus assault, or malnutrition or dehydration that could have resulted from chronic or acute illnesses, rather than intentional neglect.
Participants recommended that training programs be developed and carefully evaluated to determine if: a) training improves the effectiveness of professionals and gatekeepers to detect and help victims; and b) if training about cognitive impairment in older adults improves elder abuse investigations. In addition, participants recommended that researchers create and test new training methods.
This Research-to-Practice Consensus Workshop provided practitioners with research-based information on the prevention of elder mistreatment as well as access to scientific experts in the field. In response, participants created a set of research priorities designed to increase the likelihood of relevance to practice. These recommendations emerged from their front-line experience assisting elder abuse victims and working with their families. It is therefore likely that research attention to these themes will pay dividends in the world of practice. Several insights emerged from this process that are worthy of note.
The consensus workshop demonstrated considerable support on the part of practitioners for research efforts; indeed, many participants reported that they look to research for guidance in elder abuse prevention. Further, there was considerable understanding on the part of practitioners regarding the challenges inherent in elder mistreatment research. Interestingly, several of the strongest recommendations involve ways to facilitate research and to assist investigators in their studies – most notably, endorsement of strategies to provide researchers with better access to victims and abusers and allowing access to agency data sets. Participants clearly recognized barriers to sound research and believe that governmental and voluntary agencies need to step up efforts to create a research-friendly environment in this field.
Academic discussions of research priorities in elder mistreatment frequently point to studies of the prevalence and incidence of the problem. In contrast, the consensus workshop participants felt that although prevalence data are important, existing data on the extent of elder mistreatment may be adequate for practice and policy purposes. Studies of the etiology of mistreatment and of interventions were felt to be of the most immediate value to people in the field.
We have found in our previous experience with Research-to-Practice Consensus Workshops that participants become mobilized by the process to take action. In this case, a group of practitioners from the roundtable decided to follow-up with the idea to improve data-mining in the financial industry to uncover possible financial abuse. This workgroup included, in addition to select roundtable members, a gerotechnology expert, a financial industry computer systems consultant, an Assistant District Attorney (DA) with expertise in financial exploitation, a medical researcher and social workers from the elder abuse social services network. This group’s extensive follow-up research determined that this data-mining software already exists but that the larger problem is that the financial industry does not have: 1) established protocols for how to handle cases they find; or 2) established relationships and referral mechanisms with community resources, law enforcement, or the DAs offices to ensure proper interventions and follow-up. The group identified potential funders to pursue this work.
The major goal of the CITRA consensus workshops is to generate and publicize practitioner-based recommendations for research. However, the model can also be used on the local level as a way of clarifying community priorities and creating interest in evidence-based approaches to elder mistreatment intervention. Although this consensus workshop model may have applicability to many communities, there are some possible limitations to expanding the model. In this case, New York City has a well-defined and informed elder abuse network, as well as a rich supply of elder abuse research and practitioner experts to convene a consensus conference on elder mistreatment. Other communities may not have ready access to such resources. Second, academic resources may be needed to prepare a background paper on research. It is possible, however, to use an already-published paper as the springboard for discussion. Third, there are some modest costs associated with the workshop, including meeting space, refreshments, and organizational time. Where possible, however, conducting a Research-to-Practice Consensus Workshop on elder mistreatment may help communities to spur researcher-practitioner collaborations on this topic on the local level.
In conclusion, elder mistreatment is gaining international recognition as an extensive problem, and both researchers and practitioners are vigorously seeking solutions. It is clear that improvements need to be made in the way research is conducted. The most compelling approach to this community-based problem is the direct participation of providers who treat elder abuse in the conceptualization, design, and implementation of the research. Ultimately, community-based participatory research principles suggest that these efforts also should include victims and their families to invoke a truly comprehensive picture. The Research-to-Practice Consensus Workshop findings are a meaningful first step in that direction.
KARL PILLEMER, Department of Human Development, Cornell University, Ithaca, New York, USA.
RISA BRECKMAN, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, New York, USA.
CHARLOTTE D. SWEENEY, Department of Human Development, Cornell University, Ithaca, New York, USA.
PATRICIA BROWNELL, Graduate School of Social Service, Fordham University, New York, New York, USA.
TERRY FULMER, College of Nursing, New York University, New York, New York, USA.
JACKIE BERMAN, City Department for the Aging, New York, New York, USA.
EARAMICHIA BROWN, Office of the Inspector General of the MTA, New York, New York, USA.
EVELYN LAUREANO, Neighborhood SHOPP, Bronx, New York, USA.
MARK S. LACHS, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, New York, USA.