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American Academy of Nursing on Policy| Volume 63, ISSUE 5, P610-613, September 2015

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Elder justice: Preventing and intervening in elder mistreatment

        Introduction

        In the United States, as many as 1 in 10 older adults and 47% of persons with dementia living at home experience some form of mistreatment (IOM, 2014). Elder mistreatment results in diminished well-being and quality of life, and violates the rights of older adults to be safe and free from violence. Elder mistreatment can occur anywhere–in the home, in care and residential facilities and in the community. It can also be malignantly contagious within settings and families and across the lifespan (
        • Dong X.
        Elder abuse and the contagion of violence: One size doesn't fit all.
        ). With the rapid growth of the US population of older adults, now estimated to reach 84 million by the year 2050 (
        • Ortman J.M.
        • Velkoff V.A.
        • Hogan H.
        An aging nation: The older population in the United States.
        ), the issue of elder mistreatment is a major national health concern.
        The American Academy of Nursing's Strategic Goal #3 (2014–2017) – to lead change to improve health and healthcare and drive policy – is especially related to this issue. Health care professionals in regular contact with vulnerable older adults–including the nation's 3 million nurses–are in an ideal position to identify and report suspected cases of mistreatment; they are, however, among the least likely to do so (
        • Schmeidel A.N.
        • Daly J.M.
        • Rosenbaum M.E.
        • Schmuch G.A.
        • Jogerst G.J.
        Healthcare professionals’ perspectives on barriers to elder abuse detection and reporting in primary care settings.
        ). This policy brief summarizes some of the most relevant information in the field of elder mistreatment and recommends partnered action by health professions organizations and other stakeholders to promote elder justice and improve overall health and well-being of this vulnerable group.

        Background

        The successful legislation of the Elder Justice Act in 2010 as a part of the Patient Protection and Affordable Care Act (
        United States. Congress. Senate. Committee on Finance
        Elder Justice Act: Report (to accompany S.2010).
        ) has done much to accelerate nationally the deserved attention that elder mistreatment in all of its forms demands. Unfortunately, to date, no funds have been appropriated by Congress to carry out the important provisions of this Act or its earlier iteration (

        Older American's Act Amendments of 2006, Public Law 109–365 (October 17, 2006).

        ) related to direct services, education or policy and resource development for elder justice. The American Academy of Nursing is committed to justice for all individuals and especially those who are frail, disadvantaged, and potentially incapable of defending themselves in the presence of elder mistreatment. Two of the Academy's special interest groups—Aging and Psychiatric, Mental Health & Substance Abuse—stand ready to bring to bear their collective resources and talents to help address this serious and potentially fatal syndrome.
        There is currently no overarching theory or conceptual framework for elder mistreatment, although several borrowed from other fields (Ecological Model, Sociocultural Model, Cycle of Violence Theory, Life Course Perspective as examples) have been used (IOM, 2013). And, while there is no universally accepted definition, the Elder Justice Roadmap Project (
        • Connolly M.-T.
        • Brandl B.
        • Brekman R.
        Elder justice roadmap report.
        ) has defined it broadly as physical, sexual, or psychological abuse, as well as neglect, abandonment, and financial exploitation of an older person by another person or entity, that occurs in any setting (e.g., home, community, or facility), either in a relationship where there is an expectation of trust and/or when an older person is targeted based on age or disability. Elder justice recognizes an older person's rights and his or her ability to be free of abuse, neglect, and exploitation. The Elder Justice Act defines elder justice activities as “efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy” (
        United States. Congress. Senate. Committee on Finance
        Elder Justice Act: Report (to accompany S.2010).
        ).
        A number of risk factors for elder mistreatment and its subsequent health outcomes create opportunities for prevention or intervention. These include: increased physical dependency of frail elders on caregivers; fewer family members living in the same geographic region or caregivers being elderly or impaired themselves; substance abuse, cognitive impairment and mental illness among caregivers and/or the mistreated as well as poverty, age, race, functional disability, frailty, loneliness and low education (
        • Fulmer T.
        Mistreatment of older adults.
        ). For the elder, the experience of mistreatment itself, in any of its forms, often also results in behavioral health symptoms including depression, risk of suicide, anxiety, cognitive dysfunction and sleep difficulty; self-treatment with drugs and alcohol; injuries and morbidities resulting in higher use of emergency department, hospital and nursing home services, and greater mortality (
        • Dong X.
        Elder abuse: Research, practice, and health policy: The 2012 GSA Maxwell Pollack Award lecture.
        ). Thus, elder mistreatment is not only harmful to individuals but is also detrimental to social, legal and health systems (
        • Vognar L.
        • Gibbs L.M.
        Care of the victim.
        ).
        There is growing interest in and commitment to the prevention and treatment of elder mistreatment among national agencies and institutes whose collaboration could achieve greater impact. The recent release of the Elder Justice Roadmap (
        • Connolly M.-T.
        • Brandl B.
        • Brekman R.
        Elder justice roadmap report.
        ), developed with support from the Department of Justice (DOJ) and the Department of Health and Human Services (HHS), provides impetus and guidance for advancing strategic policy, practice, education and research initiatives that can help move forward components of the recently enacted Elder Justice Act and recommendations from the IOM's 2013 Forum on Global Violence workshop (
        IOM
        Forum on global violence prevention: Elder abuse and its prevention.
        ). Furthermore, the 2015 White House Conference on Aging (WHCoA) has identified four themes, of which Elder Justice is one. Elder justice is also a priority area for the American Academy of Nursing which has a broad and deep reach in national policy and can play a critical role in helping to advance the recommendations from these initiatives. All nurses and other health professional groups must capitalize on the opportunities created by these recent initiatives to contribute to the national conversation. Their input and feedback can help shape the aging policy landscape through a variety of mechanisms, including listening sessions, regional forums, social media and the WHCoA website. In addition, they can help to educate legislators and their policy staff by sharing this policy brief.

        Recommendations

        Health professionals, and especially nurses, play an extraordinarily important role in the advancement of our understanding of and response to the complex phenomenon of elder mistreatment. As the largest professional healthcare workforce, nurses serve at the frontline in the prevention, assessment and management of elder mistreatment. Partnered organizational support of efforts related to prevention, recognition and treatment, education and training and research will make important inroads in solving this critical problem. The following recommendations align with those found in the Elder Justice Roadmap (
        • Connolly M.-T.
        • Brandl B.
        • Brekman R.
        Elder justice roadmap report.
        ).

        Prevention

        Nurses and other health professionals should support elder mistreatment prevention by aligning with existing efforts to shore up community-based networks and resources that buttress and sustain older adults and their families. Programs currently gaining momentum include Age Friendly Communities and the Village Movement, both aimed at enhancing safe and healthy aging-in-place.

        The Academy Recommends

        • Encouragement of all health professionals, including nurses, to use opportunities like social media, online resources, and public service messaging to combat ageism and raise the public's awareness of elder mistreatment and its severity, identifying high risk situations and the need to intervene before mistreatment arises or escalates.
        • Engagement of state and Area Agency on Aging efforts to provide supports, improve awareness of at-risk elders, and facilitate effective preventive resources.
        • Heightened attention to needs of underserved, isolated, or vulnerable populations at highest risk for mistreatment, e.g., a partnership with National Indigenous Elder Justice Initiative housed at the University of North Dakota's Center for Rural Health among others.
        • Increased awareness of the activities and products of the International Network for the Prevention of Elder Abuse, a non-governmental organization affiliated with the United Nations.
        • Better preparation of older adults and adult children who will take care of their aging parents through public awareness and caregiver education and training.

        Recognition & Treatment

        Health professions societies and academies should advocate broader use of efforts to recognize and intervene in elder mistreatment. These include integrated care models (
        IOM
        The mental health and substance use workforce for older adults: In whose hands?.
        ), routine screening, and use of related evidence-based intervention models.

        The Academy Recommends

        • A campaign to encourage nurses and others in primary care settings to ask privately–of every client age 65 and older–the screening question, ‘Do you feel safe at home?’
        • Expansion of Medicare/Medicaid reimbursement to better cover screening and basic first level mental health services by primary care provider staff. This will enhance inclusion of routine screening for mistreatment, substance use and mental health problems as part of the annual Medicare health promotion visit.
        • Recognition by the National Quality Forum of elder mistreatment assessment as a quality indicator across healthcare settings, thus, enhancing adoption of the practice.
        • Advocacy for scaling up use in primary care settings of depression and substance use intervention models that work, such as IMPACT or SBIRT.
        • Support for the Administration on Aging's National Center on Elder Abuse (NCEA) to heighten awareness and serve as a resource for policy makers, social service and health care practitioners, the justice system, researchers, advocates and families.

        Education & Training

        The Health Resources and Services Administration, in concert with the AoA's National Center for Elder Abuse, should convene a group to determine key training models and materials that would address attention to mistreatment in clinical practice and make recommendations for health sciences curricula and continuing education. This collaborative effort will also enhance broad-based learning for advocates, caregivers, community leaders, financial services industry personnel and legal/law enforcement workers as well as health care professionals and social service providers.

        The Academy Recommends

        • Interprofessional training to address ageism, mistreatment and behavioral health at pre- and post-professional levels.
        • Mandatory continuing education for nurses on elder abuse, similar to the recent National Council of State Boards of Nursing requirement for child abuse education; this model could also be used by other health professions.
        • A requirement by the National Academies of Practice that all distinguished practitioners have an awareness of and plan for addressing all forms of family violence, including elder mistreatment.
        • Contribute, use, disseminate and review training materials for the Elder Abuse Training Repository of the NCEA, a national resource center dedicated to the provision of information to professionals and the public, technical assistance and training to state and community-based organizations.

        Research

        The National Institute for Nursing Research, in partnership with the National Institute on Aging, the Substance Abuse and Mental Health Services Administration and the Department of Justice together with its Elder Justice Steering Committee and non-governmental funding agencies, should establish guidelines for setting priorities and securing funding to advance a RESEARCH AND PROGRAM EVALUATION AGENDA that addresses recommendations from the Elder Justice Roadmap.

        The Academy Recommends

        • Prioritization of research on elder mistreatment in all its forms, as this emphasis is crucial to fostering quality of life for older adults and a just and healthier society.
        • Strategic promotion of prevention research priorities and evaluation strategies identified in the Elder Justice Roadmap, as well as Adult Protective Services intervention studies and recruitment to the elder justice field researchers with expertise in studying prevention.
        • Assurance that critical research foci include epidemiology of this multidimensional and complex problem, especially psychological abuse.
        • Demonstration of effectiveness of preventive, early recognition, surveillance, intervention (including legal) and rehabilitative programs in diverse individuals, including those with cognitive impairment, across settings.
        • Inclusion of projects that result in recommendations for promoting and protecting resilience, mental health and coping and that empower older people, their families, and their communities.

        Acknowledgment

        This policy brief was prepared by the Expert Panel on Aging and the Psychiatric, Mental Health & Substance Abuse Expert Panel on behalf of the American Academy of Nursing. We gratefully recognize Terry Fulmer, PhD, RN, FAAN, Lois Evans, PhD, RN, FAAN, Kitty Buckwalter, PhD, RN, FAAN, Marie Boltz, PhD, RN, CRNP, FAAN, and Tara Cortes PhD, RN, FAAN, for their contributions in authoring this policy brief.

        References

          • Connolly M.-T.
          • Brandl B.
          • Brekman R.
          Elder justice roadmap report.
          U.S. Department of Justice, Washington, DC2014
          • Dong X.
          Elder abuse: Research, practice, and health policy: The 2012 GSA Maxwell Pollack Award lecture.
          The Gerontologist. 2014; 54: 153-162
          • Dong X.
          Elder abuse and the contagion of violence: One size doesn't fit all.
          Institute of Medicine, Washington, DC2012
          • Fulmer T.
          Mistreatment of older adults.
          in: Durso S. Sullivan G. Geriatric review syllabus: A core curriculum in geriatric medicine. 8th ed. American Geriatrics Society, New York2013: 104-108
          • IOM
          Forum on global violence prevention: Elder abuse and its prevention.
          (pp. 59–66) National Research Council, Washington, DC2014
          • IOM
          The mental health and substance use workforce for older adults: In whose hands?.
          National Academies Press, Washington, DC2012
        1. Older American's Act Amendments of 2006, Public Law 109–365 (October 17, 2006).

          • Ortman J.M.
          • Velkoff V.A.
          • Hogan H.
          An aging nation: The older population in the United States.
          (Current Population Reports) U.S. Census Bureau, Washington, DC2014
          • Schmeidel A.N.
          • Daly J.M.
          • Rosenbaum M.E.
          • Schmuch G.A.
          • Jogerst G.J.
          Healthcare professionals’ perspectives on barriers to elder abuse detection and reporting in primary care settings.
          Journal of Elder Abuse & Neglect. 2012; 24: 17-36
          • United States. Congress. Senate. Committee on Finance
          Elder Justice Act: Report (to accompany S.2010).
          U.S. GPO, Washington, DC2006
          • Vognar L.
          • Gibbs L.M.
          Care of the victim.
          Clinics in Geriatric Medicine. 2014; 30: 869-880