a systematic review of interventions for elder abuse
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This article was downloaded by: [University of Windsor]On: 12 November 2014, At: 06:47Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Elder Abuse & NeglectPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wean20
A Systematic Review of Interventions forElder AbuseJenny Ploeg RN PhD a , Jana Fear MLIS a , Brian Hutchison MD b ,Harriet MacMillan MD c & Gale Bolan RN BScN da School of Nursing , McMaster University , Hamilton, Ontario,Canadab Professor Emeritus, Department of Family Medicine and ClinicalEpidemiology and Biostatistics , McMaster University , Hamilton,Ontario, Canadac Department of Psychiatry and Behavioural Neurosciences andPediatrics , McMaster University , Hamilton, Ontario, Canadad Hamilton Niagara Haldimand Brant Community Care AccessCentre , Hamilton, Ontario, CanadaPublished online: 09 Jul 2009.
To cite this article: Jenny Ploeg RN PhD , Jana Fear MLIS , Brian Hutchison MD , Harriet MacMillan MD& Gale Bolan RN BScN (2009) A Systematic Review of Interventions for Elder Abuse, Journal of ElderAbuse & Neglect, 21:3, 187-210, DOI: 10.1080/08946560902997181
To link to this article: http://dx.doi.org/10.1080/08946560902997181
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Journal of Elder Abuse & Neglect, 21:187–210, 2009 Copyright © Taylor & Francis Group, LLC ISSN: 0894-6566 print/1540-4129 onlineDOI: 10.1080/08946560902997181
WEAN0894-65661540-4129Journal of Elder Abuse & Neglect, Vol. 21, No. 3, May 2009: pp. 1–34Journal of Elder Abuse & Neglect
A Systematic Review of Interventions for Elder Abuse
Interventions for Elder AbuseJ. Ploeg et al.
JENNY PLOEG, RN, PhD and JANA FEAR, MLISSchool of Nursing, McMaster University, Hamilton, Ontario, Canada
BRIAN HUTCHISON, MDProfessor Emeritus, Department of Family Medicine and Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, Ontario, Canada
HARRIET MACMILLAN, MDDepartment of Psychiatry and Behavioural Neurosciences and Pediatrics,
McMaster University, Hamilton, Ontario, Canada
GALE BOLAN, RN, BScNHamilton Niagara Haldimand Brant Community Care Access Centre,
Hamilton, Ontario, Canada
The purpose of this study was to use rigorous systematic reviewmethods to summarize the effectiveness of interventions for elderabuse. Only eight studies met our inclusion criteria. Evidenceregarding the recurrence of abuse following intervention was lim-ited, but the interventions for which this outcome was reportedfailed to reduce, and may have even increased, the likelihood ofrecurrence. Elder abuse interventions had no significant effect oncase resolution and at-risk caregiver outcomes, and had mixedresults regarding professional knowledge and behavior related toelder abuse. The included studies had important methodologicallimitations that limit our ability to draw conclusions about theeffectiveness of these interventions.
KEYWORDS elder abuse, systematic review, intervention studies
This research was supported by the Canadian Institutes of Health Research (CIHR)Institutes of Gender and Health; Aging; Human Development, Child and Youth Health;Neurosciences, Mental Health and Addiction; and Population and Public Health. Dr. Ploeg helda CIHR/St. Josephs Healthcare Hamilton career investigator award while conducting this study.
Address correspondence to Jenny Ploeg, School of Nursing, Room HSc3N28G, McMasterUniversity, 1200 Main Street West, Hamilton, ON, Canada L8N 3Z5. E-mail: [email protected]
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Elder abuse is a significant and growing problem in our society. A recentsystematic review of the prevalence of elder abuse and neglect found that6% of older people in general population studies reported significant abusein the previous month, and this is probably an underestimate because somepeople are reluctant to report abuse (Cooper, Selwood, & Livingston, 2008).The problem of elder abuse is particularly troubling in view of the expecteddoubling of the number of older adults worldwide from 1995 to 2025 (Krug,Dahlberg, Mercy, Zwi, & Lozano, 2002).
Little rigorous research has been conducted to determine the conse-quences of elder abuse (Comijs, Pot, Smit, Bouter, & Jonker, 1998; Kruget al., 2002). Elder abuse has been associated with a more than three-fold increased likelihood of mortality (odds ratio, 3.1; 95% confidenceinterval [CI], 1.4–6.7) (Lachs, Williams, O’Brien, Pillemer, & Charlson,1998).
Given the increasing number of older adults likely to experience elderabuse and the negative impacts associated with abuse, it is particularlyimportant to develop and implement effective prevention and managementstrategies. Authors of published reviews of the elder abuse literature suggest avariety of approaches for the detection, assessment, and management of elderabuse (All, 1994; Baumhover, Beall, & Pieroni, 1990; Gorbien & Eisenstein,2005; Kleinschmidt, 1997; Lachs & Pillemer, 2004; McCreadie & Tinker,1993; Nahmiash, 1998; O’Connor & Rowe, 2005; Wieland, 2000; Wolf, 1997).Lachs and Pillemer (2004), for example, suggest that interventions should becontext specific and preferably involve a multidisciplinary team. Theauthors of most reviews, however, acknowledge the limited number ofhigh-quality primary studies of elder abuse interventions on which to baserecommendations. Few of these reviews involved a systematic assessmentof the methods of the studies, including design, procedures, and outcomesof intervention studies for elder abuse.
In a systematic review of prevention and treatment programs for familyviolence, Chalk and King (1998) found only two studies of elder abuseinterventions (Filinson, 1993; Scogin et al., 1989) that met their inclusion cri-teria (i.e., experimental or quasiexperimental design, comparison group,evaluation conducted between 1980 and 1996), compared to 78 studies ofchild maltreatment interventions and 34 studies of domestic violence inter-ventions. The authors emphasized the need for more rigorous research onelder abuse interventions, in particular designs that include comparisongroups.
There is a need for a systematic and critical review of the benefits andpossible harms associated with intervention for elder abuse that includesrecent research. The purpose of this study was to critically appraise thequality of existing studies in the elder abuse field and to summarize the cur-rent state of knowledge related to the effectiveness of interventions for elderabuse.
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Interventions for Elder Abuse 189
METHODS
Literature Search and Eligibility Criteria
We searched Ageline, CINAHL, EMBASE, MEDLINE, PsycINFO, PubMed,Sociological Abstracts, and Social Science Abstracts from the start date ofeach database to February 2008 using appropriate database-specific subjectheadings and keywords such as “elder abuse” and “elder neglect.”
The searches were conducted by an investigator (JF) with an educa-tional background in library science who was skilled in literature searching.Specific volumes of the Journal of Elder Abuse & Neglect were handsearched. In our search for primary studies of elder abuse interventions, wealso searched specifically for systematic reviews of the elder abuse literatureusing Canadian Medical Association INFOBASE, Cochrane Library, NationalHealth Services Database of Abstracts of Reviews of Effectiveness, andNational Guideline Clearinghouse from the respective database start dates toFebruary 2008. The reference lists of all retrieved articles and systematicreviews were manually searched for additional studies.
We searched for unpublished articles only to supplement the dataobtained in published papers. The complete texts of all potentially relevantarticles were reviewed using the following inclusion criteria: (a) the articleaddresses abuse of persons aged 60 and older; (b) the article describes anintervention that addresses one or more of the following types of elderabuse: physical, psychological, financial, or neglect; (c) the article describesan intervention that is designed to be provided to individual clients (abusedpersons or perpetrators), professionals who care for older persons, or thecommunity; (d) the article includes assessment of client, professional, and/or community outcomes; (e) the article is a primary study; (f) the study usesquantitative methods; (g) the study includes a comparison group (compari-son with usual care or another intervention); and (h) the study is publishedin English. Studies were excluded if they only addressed self-neglect or ifthey were conducted in a developing country.
Studies were eligible if they (a) included a limited or no intervention com-parison group or if they (b) compared two or more interventions. Thus, thisreview addresses two questions: Are elder abuse interventions effective? (inter-vention versus limited or no intervention), and Are some elder abuse interven-tions more effective than others? (intervention A versus intervention B).
Two investigators (JP, JF) independently reviewed the searches and thereference lists of all articles retrieved. Discrepancies were resolved throughdiscussion.
Data Extraction
For each study, two investigators (JP, JF) independently extracted dataon the study setting, sample, and characteristics of the intervention. One
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investigator extracted information on the study outcomes and a secondinvestigator compared the extracted data to the original data source.Because of the diversity of study designs (randomized controlled trials[RCT], nonequivalent comparison group studies), we assessed the quality ofeach study with selected criteria appropriate to the study design, and madecomments on the data extraction forms related to study limitations. Forexample, for RCTs, we assessed the randomization procedure, blinding, andloss to follow-up. We did not exclude any studies based on quality becausethere were only a small number of studies meeting the inclusion criteria.Because of the heterogeneity of samples, interventions, and outcomesacross studies, meta-analysis was not conducted.
RESULTS
Identification of Eligible Studies
We reviewed 1,253 abstracts and excluded 1,070 that did not indicate anelder abuse intervention or an eligible study sample (see Figure 1). Weretrieved and reviewed 183 full-text articles and reports. Of these, 173 wereexcluded because they did not meet the inclusion criteria: 45 interventionstudies were excluded because they had no comparison group (list ofnonincluded intervention studies available from authors). We included 10full-text articles and reports that met our inclusion criteria for a total of eightseparate studies (Brownell & Heiser, 2006; Brownell & Wolden, 2002; Davis,Medina, & Avitabile, 2001; Davis & Medina-Ariza, 2001; Filinson, 1993;
FIGURE 1 Identification of eligible studies.
1,253 potentiallyrelevant abstracts
identified
183 full-text articlesand reports retrieved for
detailed evaluation
1,070 abstracts excluded(no elder abuse
intervention, sample noteligible)
10 full-text articlesand reports (8
studies) included
173 articles and reportsexcluded
(45 were interventionsbut did not meet criteria)
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Interventions for Elder Abuse 191
Jogerst & Ely, 1997; Richardson, Kitchen, & Livingston, 2002, 2004; Scoginet al., 1989; Sengstock, Hwalek, & Stahl, 1991).
Study Characteristics
Characteristics of the eight intervention studies are shown in Table 1. Fourstudies involved interventions targeted at older adults who were abused(Brownell & Heiser, 2006; Brownell & Wolden, 2002; Davis et al., 2001;Davis & Medina-Ariza, 2001; Filinson, 1993), one study included programstargeted primarily at abused persons and to a lesser degree at perpetrators(Sengstock et al., 1991), one study included a program aimed at caregiversat risk of abusing older family members (Scogin et al., 1989), and two stud-ies were focused on health professionals who provide care to older adultswho have been abused (Jogerst & Ely, 1997; Richardson et al., 2002, 2004).
Of these eight studies, four included a limited or no interventioncontrol group (Davis et al., 2001; Davis & Medina-Ariza, 2001; Filinson,1993; Jogerst & Ely, 1997; Scogin et al., 1989), and four compared two ormore different interventions (Brownell & Heiser, 2006; Brownell & Wolden,2002; Richardson et al., 2002, 2004; Sengstock et al., 1991).
Three studies were RCTs (Brownell & Heiser, 2006; Davis et al., 2001;Davis & Medina-Ariza, 2001; Richardson et al., 2002, 2004) and the otherswere nonequivalent comparison group studies. All studies except for one(Richardson et al., 2002, 2004) were conducted in the United States. A rangeof interventions targeted at abused older adults were studied including: apsychoeducational support group (Brownell & Heiser, 2006); two commu-nity-based elder abuse case management programs, one focused on legalinterventions and the other on social services (Brownell & Wolden, 2002);education related to elder abuse and home visits by a domestic violencecounselor and police (Davis et al., 2001; Davis & Medina-Ariza, 2001);volunteer visitors who provided assistance, support, and advocacy in theuse of the criminal justice system (Filinson, 1993); and case managementand other services including a law-oriented program and an advocacy-based program (Sengstock et al., 1991).
One study examined an educational intervention for at-risk caregivers(Scogin et al., 1989). Interventions for professionals included a home visittraining program as part of a geriatrics rotation for family practice residents(Jogerst & Ely, 1997) and an educational course for nursing staff, care assis-tants, care managers, and social workers (Richardson et al., 2002, 2004).
In most studies, there were important methodological issues that limitthe validity of the findings (see Tables 2, 3, and 4). Some of the most impor-tant study limitations included: (a) few studies with rigorous RCT designs;(b) failure in some RCTs to describe randomization procedures, allocationconcealment procedures, or blinding of outcome assessors and data analysts;(c) studies with small sample sizes and missing sample size estimations and
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TA
BLE
1Su
mm
ary
of In
terv
entio
n S
tudie
s fo
r A
buse
of O
lder
Per
sons
Auth
or
(yea
r), co
untry
Des
ign
Settin
g/par
ticip
ants
/ty
pe
of ab
use
Inte
rven
tion
Com
men
ts r
elat
ed to
inte
rven
tion
Bro
wnel
l an
d H
eise
r (2
006)
, U
nite
d S
tate
sPilo
t RCT
Sett
ing:
Pro
fess
ional
soci
al
work
agi
ng
serv
ices
in
New
York
City
Pa
rtic
ipa
nts
: W
om
en a
ge 6
0 an
d o
lder
, vi
ctim
s of
mis
trea
tmen
t by
fam
ily
mem
ber
s an
d s
ignific
ant
oth
ers
for
whom
they
wer
e pro
vidin
g ca
regi
ver su
pport
(n =
16)
; IG
n =
9; CG
n =
6A
buse
: Phys
ical
, fin
anci
al, an
d
psy
cholo
gica
l
IG: Eld
er a
buse
psy
choed
uca
tional
support
group m
eetin
g fo
r 2
hours
per
wee
k fo
r 8
wee
ks. Conte
nt in
cluded
: dom
estic
vi
ole
nce
, ab
use
and n
egle
ct o
f old
er
wom
en, trouble
d fam
ilies
, fa
mily
his
tories
, en
han
cing
self-e
stee
m, dea
ling
with
dep
ress
ion, an
xiet
y, s
tres
s,
subst
ance
abuse
, ga
mblin
g, c
opin
g w
ith
loss
and c
han
ge in r
elat
ionsh
ips
and
stra
tegi
es for
chan
ge, an
d s
ervi
ce
reso
urc
es. Se
ssio
ns
faci
litat
ed b
y re
tired
pro
fess
ional
soci
al w
ork
er a
nd g
raduat
e so
cial
work
stu
den
t.
Par
ticip
ants
in b
oth
gr
oups
rece
ived
soci
al
serv
ice
support p
rior to
an
d d
uring
the
study.
Bro
wnel
l an
d W
old
en
(200
2), U
nite
d S
tate
sN
oneq
uiv
alen
t co
mpar
ison
group
Sett
ing:
Quee
ns,
New
York
, co
mm
unity
-bas
ed p
rogr
amP
art
icip
an
ts: Ran
dom
sam
ple
of ca
ses
close
d in 2
001;
age
60
and o
lder
; 77
% fem
ale
IG#1: 27
rec
eive
d e
lder
se
rvic
es (
ES)
pro
gram
IG#2: 29
rec
eive
d c
rim
e vi
ctim
s boar
d (
CV
B)
pro
gram
Abu
se: Phys
ical
, fin
anci
al, an
d
psy
cholo
gica
l or
neg
lect
, in
cludin
g se
lf-n
egle
ct
Tw
o c
om
munity
-bas
ed e
lder
abuse
cas
e m
anag
emen
t pro
gram
s: C
VB
pro
gram
pro
vided
leg
al s
ervi
ces
to v
ictim
s of
crim
es o
r al
lege
d c
rim
es; ES
pro
gram
pro
vided
soci
al s
ervi
ces
to e
lder
abuse
vi
ctim
s an
d fam
ilies
when
the
abuse
did
not ap
pea
r to
be
a cr
ime
as d
efin
ed b
y N
ew Y
ork
Sta
te P
enal
Code;
soci
al
serv
ices
incl
uded
counse
ling,
ref
erra
l, lin
kage
to h
ealth
and m
enta
l hea
lth
serv
ices
, as
sist
ance
in o
bta
inin
g en
title
men
ts a
nd o
ther
in-h
om
e an
d
com
munity
-bas
ed s
ervi
ces,
and h
ousi
ng
assi
stan
ce; le
gal se
rvic
es incl
uded
ap
ply
ing
for
ord
ers
of pro
tect
ion in
fam
ily o
r cr
imin
al c
ourt, en
gagi
ng
law
en
forc
emen
t, w
ork
ing
with
dis
tric
t at
torn
eys’ o
ffic
es to p
rose
cute
an a
buse
r.
Soci
al a
nd leg
al s
ervi
ces
wer
e re
ceiv
ed b
y both
in
terv
entio
n g
roups;
49
case
s go
t so
cial
se
rvic
e in
terv
entio
ns;
25
cas
es s
erve
d b
y ES
and 2
4 se
rved
by
CV
B;
17 c
ases
rec
eive
d leg
al
inte
rven
tions,
13
from
CV
B a
nd 4
fro
m E
S.
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193
Dav
is a
nd M
edin
a-A
riza
(20
01); D
avis
, M
edin
a, a
nd
Avi
tabile
(20
01),
Unite
d S
tate
s
Nes
ted R
CT
Sett
ing:
Public
housi
ng
pro
ject
s fr
om
thre
e polic
e se
rvic
e ar
eas
in M
anhat
tan,
sorted
into
pai
rs, m
atch
ed
on in
com
e, rac
e, a
nd fam
ily
com
posi
tion
Pa
rtic
ipa
nts
: In
terv
entio
n 1
: ra
ndom
ass
ignm
ent of
30/6
0 N
ew Y
ork
City
public
housi
ng
pro
ject
s to
rec
eive
ed
uca
tion a
bout fa
mily
vi
ole
nce
Inte
rven
tion
2: In
all
60
housi
ng
pro
ject
s,
403
house
hold
s re
portin
g el
der a
buse
in n
ext 1
0 m
onth
s to
polic
e w
ere
random
ly
assi
gned
to follo
w-u
p h
om
e vi
sits
by
polic
e an
d
dom
estic
vio
lence
co
unse
lor
or
only
the
usu
al
polic
e pat
rol re
sponse
and
letter
; vi
ctim
s, 8
1% fem
ale;
m
edia
n a
ge 6
5 ye
ars
Abu
se: phys
ical
, ver
bal
, fam
ily
dis
pute
s, m
isdem
eanor
offen
ses
Inte
rven
tion
1: H
ousi
ng
pro
ject
s re
ceiv
ed
educa
tion a
bout fa
mily
vio
lence
thro
ugh
co
mm
unity
mee
tings
and flie
rs;
pre
sente
rs d
escr
ibed
eld
er a
buse
and
expla
ined
role
of polic
e an
d v
ictim
se
rvic
es sen
ior sp
ecia
lists
, dis
cuss
ed c
ourt
pro
cedure
s an
d o
rder
s of pro
tect
ion.
Con
trol
1: N
o inte
rven
tion.
Inte
rven
tion
2: H
ouse
hold
s re
portin
g el
der
ab
use
to p
olic
e re
ceiv
ed let
ters
and
phone
calls
reg
ardin
g upco
min
g hom
e vi
sit,
two a
ttem
pts
mad
e to
vis
it; h
om
e vi
sits
mad
e by
polic
e an
d d
om
estic
vi
ole
nce
counse
lor; c
ounse
lor
info
rmed
vi
ctim
s of le
gal optio
ns,
polic
e pro
cedure
s, a
nd s
ervi
ces
avai
lable
to
assi
st them
(e.
g., re
loca
tion a
ssis
tance
, finan
cial
ass
ista
nce
, co
unse
ling)
; en
coura
ged to c
all polic
e if r
epea
t vi
ole
nce
occ
urr
ed; lin
ked v
ictim
s an
d
abuse
rs to s
oci
al s
ervi
ces,
hea
lth c
are
assi
stan
ce, or
antih
aras
smen
t m
easu
res;
in
<5%
of vi
sits
the
abuse
r w
as p
rese
nt
and p
olic
e sp
oke
of th
e in
tent to
monito
r th
e house
hold
; dura
tion o
f hom
e vi
sit
varied
but m
ost
wer
e < 2
0 m
inute
s.C
ontr
ol 2
: U
sual
polic
e pat
rol re
sponse
.
Difficu
lty im
ple
men
ting
inte
rven
tion: only
6%
of el
der
ly r
esid
ents
at
targ
eted
housi
ng
pro
ject
s at
tended
ed
uca
tional
ses
sions;
only
50%
tar
gete
d
house
hold
s re
ceiv
ed
full
hom
e vi
sit
inte
rven
tion, on
aver
age
56 d
ays
afte
r th
e in
itial
cal
l to p
olic
e,
inst
ead o
f in
tended
fe
w d
ays
afte
r in
itial
polic
e co
nta
ct;
additi
onal
23%
of
house
hold
s re
ceiv
ed
som
e co
nta
ct (
e.g.
, phone)
; in
rem
ainder
, hom
e vi
sit te
am lef
t a
letter
and b
roch
ure
.
(Con
tin
ued
)
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TA
BLE
1(C
onti
nu
ed)
Auth
or
(yea
r), co
untry
Des
ign
Settin
g/par
ticip
ants
/ty
pe
of ab
use
Inte
rven
tion
Com
men
ts r
elat
ed to
inte
rven
tion
Filin
son (
1993
), U
nite
d
Stat
esN
oneq
uiva
lent
co
mpar
ison
gr
oups
Sett
ing:
Com
munity
in R
hode
Isla
nd
Pa
rtic
ipa
nts
: IG
, 42
cas
es o
f el
der
abuse
usi
ng
the
pro
gram
CG
, 42
cas
es
inve
stig
ated
by
Dep
artm
ent
of Eld
erly
Affai
rs b
ut not
refe
rred
to p
rogr
am; g
roups
mat
ched
by
gender
of
vict
im a
nd p
erpet
rato
r, typ
e of ab
use
, an
d a
ge a
nd r
ace
of vi
ctim
Abu
se: Phys
ical
, psy
cholo
gica
l, finan
cial
, se
xual
, se
lf-n
egle
ct, an
d
com
bin
atio
n o
f ty
pes
Pro
gram
goal
s w
ere
to p
rovi
de
assi
stan
ce,
support, an
d a
dvo
cacy
in the
use
of th
e cr
imin
al ju
stic
e sy
stem
; vo
lunte
er
coord
inat
or
and c
om
munity
cas
e m
anag
er d
evel
oped
goal
s an
d o
bje
ctiv
es
for
the
volu
nte
er; vo
lunte
ers
met
with
cl
ients
a m
inim
um
of 2
hours
per
wee
k,
pro
vided
info
rmat
ion a
nd e
nco
ura
gem
ent
in p
ress
ing
char
ges,
obta
inin
g a
rest
rain
ing
ord
er, p
rovi
ded
tra
nsp
ortat
ion
or
acco
mpan
imen
t to
polic
e st
atio
n o
r co
urt, as
sist
ed c
lient w
ith c
om
ple
tion o
f re
ports
or
form
s; v
olu
nte
er c
oord
inat
or
monito
red c
ases
by
revi
ewin
g m
onth
ly
volu
nte
er r
eports.
Auth
or
note
d that
ex
tensi
ve r
ecord
ke
epin
g by
volu
nte
ers
was
difficu
lt so
much
of in
terv
entio
n
dyn
amic
s w
ere
not
reco
rded
.A
uth
or
note
d that
ther
e w
as p
robab
ly a
te
nden
cy to r
efer
cl
ients
who w
ere
more
re
ceptiv
e to
in
terv
entio
n to the
pro
ject
.
Joge
rst an
d E
ly (
1997
),
Unite
d S
tate
sN
oneq
uiv
alen
t co
mpar
ison
groups
Sett
ing:
Fam
ily p
ract
ice
resi
den
cy p
rogr
am;
pote
ntia
l ab
use
cas
es
reported
to A
rizo
na’
s A
dult
Pro
tect
ive
Serv
ices
(A
PS)
in
the
Phoen
ix a
rea
Pa
rtic
ipa
nts
: Tw
o c
ohorts
of
fam
ily p
ract
ice
resi
den
t gr
aduat
es
IG: gr
aduat
es fro
m 1
985
to 1
992
(n =
43)
CG
: gr
aduat
es fro
m 1
977
to
1984
(n =
28)
Abu
se: N
egle
ct, ex
plo
itatio
n,
phys
ical
, se
xual
IG: H
om
e vi
sit trai
nin
g pro
gram
as
par
t of
required
3-y
ear
geriat
rics
rota
tions
to
eval
uat
e pote
ntia
l ab
use
vic
tims
reported
to
APS;
res
iden
ts m
ade
an a
vera
ge
of 3.
7 vi
sits
during
the
3 ye
ars
of
resi
den
cy; re
siden
ts p
rese
nte
d
info
rmat
ion g
ained
at th
e hom
e vi
sit to
th
e phys
icia
n fac
ulty
mem
ber
; th
e re
siden
t an
d fac
ulty
pre
par
ed w
ritten
ev
aluat
ions
follo
win
g ea
ch h
om
e vi
sit.
CG
: N
o s
pec
ific
tra
inin
g in
ger
iatric
s, n
o
hom
e vi
sit trai
nin
g.
Com
par
ison g
roup w
as
from
diffe
rent tim
e co
hort.
Dow
nloa
ded
by [
Uni
vers
ity o
f W
inds
or]
at 0
6:47
12
Nov
embe
r 20
14
195
Ric
har
dso
n e
t al
., (2
002,
200
4),
Unite
d K
ingd
om
RCT
Sett
ing:
North L
ondon, U
nite
d
Kin
gdom
Pa
rtic
ipa
nts
: Em
plo
yees
of
loca
l co
mm
unity
hea
lth
trust
or
soci
al s
ervi
ces
who
work
ed w
ith o
lder
peo
ple
, nurs
ing
staf
f, c
are
assi
stan
ts,
care
man
ager
s, a
nd s
oci
al
work
ers
IG n
= 4
4CG
n =
42
Abu
se: N
egle
ct, ve
rbal
, phys
ical
, finan
cial
IG: Educa
tional
cours
e ta
rget
ed
iden
tific
atio
n a
nd m
anag
emen
t of al
l ty
pes
of ab
use
; pro
gram
s w
ere
bas
ed o
n
the
polic
y, p
ract
ice
guid
ance
, an
d
pro
cedure
s fo
r re
spondin
g to
abuse
and
inad
equat
e ca
re o
f vu
lner
able
adults
, w
hic
h w
as o
per
atio
nal
in b
oth
hea
lth a
nd
soci
al s
ervi
ces;
cours
e co
mm
issi
oned
by
the
emplo
ying
Nat
ional
Hea
lth S
ervi
ce
trust
and s
oci
al s
ervi
ces.
CG
: Rec
eive
d r
eadin
g m
ater
ial w
ith the
sam
e co
nte
nt as
the
cours
e.
Min
imal
info
rmat
ion
give
n reg
ardin
g le
ngt
h,
dura
tion, an
d c
onte
nt
of th
e co
urs
e.
Scogi
n e
t al
. (1
989)
, U
nite
d S
tate
sN
oneq
uiv
alen
t co
mpar
ison
groups
Sett
ing:
Men
tal hea
lth c
ente
rs
or
senio
rs c
ente
rs in fiv
e la
rge
citie
s in
Ala
bam
aP
art
icip
an
ts: C
areg
iver
s at
ris
k fo
r ab
usi
ng
fam
ily m
ember
ag
e 55
and o
lder
and w
ho
had
no k
now
n p
sych
ose
s an
d d
id n
ot re
ceiv
e psy
chia
tric
tre
atm
ent;
most
ca
regi
vers
wer
e fe
mal
e (a
lmost
90%
), m
id-5
0s, an
d
self-r
efer
red; ca
re rec
ipie
nts
w
ere
most
ly fem
ale,
av
erag
e ag
e 75
Thre
e gr
oups
: Im
med
iate
trai
nin
g gr
oup (
IG)
n =
56;
w
ait lis
t co
ntrol
n =
16;
nontrai
nin
g co
ntrols
n =
23
IG: Eig
ht w
eekl
y trai
nin
g se
ssio
ns
appro
xim
atel
y 2
hours
eac
h; trai
nin
g m
ethods
incl
uded
com
bin
atio
n o
f did
actic
pre
senta
tions,
gro
up d
iscu
ssio
n,
role
pla
ying,
guid
ed p
ract
ice;
conte
nt
area
s in
cluded
agi
ng
pro
cess
, pro
ble
m
solv
ing,
stres
s an
d a
nge
r m
anag
emen
t, an
d u
se o
f co
mm
unity
res
ourc
es.
Inte
rven
ers:
Mas
ter’s
leve
l m
enta
l hea
lth
clin
icia
ns
with
exp
erie
nce
in p
rovi
din
g se
rvic
es to loca
l cl
ients
and lea
din
g gr
oups.
(Con
tin
ued
)
Dow
nloa
ded
by [
Uni
vers
ity o
f W
inds
or]
at 0
6:47
12
Nov
embe
r 20
14
196
TA
BLE
1(C
onti
nu
ed)
Auth
or
(yea
r), co
untry
Des
ign
Settin
g/par
ticip
ants
/ty
pe
of ab
use
Inte
rven
tion
Com
men
ts r
elat
ed to
inte
rven
tion
Sengs
tock
et al
. (19
91);
Unite
d S
tate
sN
oneq
uiv
alen
t co
mpar
ison
groups
Sett
ing:
Four
Eld
er A
buse
D
emonst
ratio
n p
rogr
ams
in
diffe
rent ar
eas
of Illin
ois
fr
om
198
5 to
198
7:La
w-o
rien
ted
pro
gra
m g
rou
ps:
Gro
up 1
: M
andat
ed r
eportin
g in
rura
l ar
ea (
n =
80)
Gro
up 2
: Le
gal in
terv
entio
n in
suburb
an a
rea
(n =
74)
Ad
voca
cy s
ervi
ce g
rou
ps:
Gro
up 3
: Rura
l ar
ea (
n =
25)
Gro
up 4
: Su
burb
an a
rea
(n =
25)
Pa
rtic
ipa
nts
: 20
4 el
der
abuse
ca
ses
seen
in 1
986
Abu
se: Phys
ical
, co
nfinem
ent,
dep
riva
tion, finan
cial
, neg
lect
, se
lf-n
egle
ct
Inte
rven
tion 1
: M
andat
ory
rep
ortin
gIn
terv
entio
n 2
: Le
gal in
terv
entio
nIn
terv
entio
n 3
: A
dvo
cacy
model
invo
lvin
g w
ork
er a
dvo
catin
g fo
r bro
ad u
se o
f fo
rmal
and info
rmal
ser
vice
s to
ass
ist
vict
imSi
mila
ritie
s in
pro
gram
s: a
gency
initi
ated
co
nta
ct w
ith a
llege
d v
ictim
of el
der
abuse
w
ithin
24
hours
; ag
ency
req
uired
to
man
age
the
case
, dev
elop c
are
pla
n,
sele
ct s
ervi
ce v
endor, m
onito
r pro
gres
s m
onth
ly
20 d
iffe
rent ty
pes
of se
rvic
es u
sed to
vary
ing
deg
rees
in e
ach p
rogr
am, 13
w
ere
gener
al h
ealth
or so
cial
ser
vice
s an
d
7 w
ere
lega
l an
d c
risi
s se
rvic
es
Serv
ices
pro
vided
to b
oth
abuse
d a
nd
per
pet
rato
r in
leg
al inte
rven
tion g
roup
(34%
), m
andat
ory
rep
ortin
g gr
oup (
4%),
and a
dvo
cacy
gro
ups
(6%
)
Age
nci
es r
esponsi
ble
for
case
man
agem
ent w
ere
hig
hly
div
erse
, in
cluded
sen
ior se
rvic
e ag
enci
es, vi
sitin
g nurs
es, fa
mily
soci
al
serv
ices
, dom
estic
vi
ole
nce
age
nci
es, an
d
so o
n.
Cas
e dis
posi
tion r
ecord
s in
dic
ate
that
10.
3% o
f al
l ca
ses
refu
sed initi
al
asse
ssm
ent,
and a
fu
rther
13.
8% o
f al
l ca
ses
refu
sed m
ore
as
sist
ance
.Pro
gram
s w
ere
pro
vided
in
diffe
rent ge
ogr
aphic
ar
eas
(urb
an, ru
ral)
mak
ing
com
par
isons
difficu
lt.
Not
es: IG
= inte
rven
tion g
roup; CG
= c
ontrol or
com
par
ison g
roup.
Dow
nloa
ded
by [
Uni
vers
ity o
f W
inds
or]
at 0
6:47
12
Nov
embe
r 20
14
197
TA
BLE
2Su
mm
ary
of Clie
nt O
utc
om
es o
f In
terv
entio
ns
Studie
s of A
buse
of O
lder
Per
sons
Auth
or
(yea
r),
country
Dat
a co
llect
ion
Outc
om
e m
easu
res
Res
ults
Com
men
ts a
nd s
tudy
limita
tions
Bro
wnel
l an
d
Hei
ser (2
006)
, U
nite
d S
tate
s
In-p
erso
n p
re-
and
post
inte
rven
tion
inte
rvie
ws
conduct
ed 2
m
onth
s bef
ore
and a
fter
th
e in
terv
entio
n p
erio
d
with
inte
rven
tion a
nd
control par
ticip
ants
.
Phys
ical
and n
onphys
ical
ab
use
exp
erie
nce
d
(Har
tford
Stu
dy
Abuse
Su
bsc
ales
)D
epre
ssio
n (
CES-
D10
) G
uilt
(M
ulti
-Pro
ble
m
Scre
enin
g In
vento
ry,
Guilt
subsc
ale)
Self-e
stee
m (
Rose
nber
g Se
lf-E
stee
m S
cale
)Fa
mily
rel
atio
ns
(Har
tford
Fa
mily
Rel
atio
nsh
ip
Pro
ble
ms
Subsc
ale)
Post
-tes
t phys
ical
abuse
: IG
13%
; CG
0%
(p
= 0
.41)
;N
onphys
ical
abuse
: IG
83%
; CG
75%
(p
= 0
.75)
No s
tatis
tical
ly s
ignific
ant diffe
rence
s bet
wee
n g
roups
for
dep
ress
ion
(p= 0
.49)
, gu
ilt (
p = 0
.72)
, se
lf-e
stee
m (
p-va
lue
not sp
ecifie
d),
fam
ily rel
atio
ns
pro
ble
ms
(p =
0.2
2)
at s
tudy
end
Inad
equat
e sa
mple
siz
eN
o info
rmat
ion o
n
random
izat
ion p
roce
dure
or
conce
alm
ent of al
loca
tion;
no info
rmat
ion r
elat
ed to
psy
chom
etric
pro
per
ties
of
Har
tford
Stu
dy
Abuse
Su
bsc
ales
; par
ticip
ants
had
hig
h s
elf-es
teem
, re
lativ
ely
low
dep
ress
ion, st
rong
soci
al n
etw
ork
supports,
an
d h
igh s
elf-su
ffic
iency
bef
ore
inte
rven
tion
Bro
wnel
l an
d
Wold
en
(200
2), U
nite
d
Stat
es
Ret
rosp
ectiv
e ch
art r
evie
w
of cl
ose
d c
ases
co
nduct
ed b
y re
sear
cher
Succ
essf
ul r
esolu
tion e
qual
s sa
fety
outc
om
es a
chie
ved
(num
ber
res
olv
ed a
nd
unre
solv
ed in e
ach
group)
Eld
er s
ervi
ces
(ES)
pro
gram
: 17
cas
es
(63%
) su
cces
sful r
esolu
tion (16
due
to inte
rven
tion); 1
0 ca
ses
unre
solv
ed o
r unsu
cces
sful
outc
om
e (n
ine
case
s cl
ose
d a
t re
ques
t of vi
ctim
, one
close
d a
s vi
ctim
could
no longe
r be
loca
ted)
Crim
e vi
ctim
s boar
d (
CV
B)
pro
gram
: 18
cas
es (
62%
) su
cces
sful
reso
lutio
n (
14 d
ue
to inte
rven
tion);
11 c
ases
unsu
cces
sful outc
om
e (s
even
cas
es c
lose
d a
t re
ques
t of
vict
im, fo
ur
close
d a
s vi
ctim
could
no longe
r be
loca
ted); (
for
com
par
ison o
f su
cces
sful
reso
lutio
n b
etw
een g
roups,
p
= 0
.582
)
Smal
l num
ber
of ca
ses
studie
d; ca
ses
from
only
one
com
munity
age
ncy
.Pro
gram
s had
diffe
rent
adm
issi
on c
rite
ria
No d
iscu
ssio
n o
f re
liabili
ty o
f dat
a ex
trac
tion for
char
t re
view
Diffe
rence
s in
bas
elin
e ch
arac
terist
ics
of gr
oups
Both
pro
gram
s re
solv
ed
maj
ority
of ca
ses
revi
ewed
in
the
study
(Con
tin
ued
)
Dow
nloa
ded
by [
Uni
vers
ity o
f W
inds
or]
at 0
6:47
12
Nov
embe
r 20
14
198
TA
BLE
2(C
onti
nu
ed)
Auth
or
(yea
r),
country
Dat
a co
llect
ion
Outc
om
e m
easu
res
Res
ults
Com
men
ts a
nd s
tudy
limita
tions
For finan
cial
abuse
, CV
B inte
rven
tion
resu
lted in m
ore
cas
es s
ucc
essf
ully
re
solv
ed (
67%
) th
an E
S in
terv
entio
n (
17%
) (p
= 0
.043
)Fo
r psy
cholo
gica
l ab
use
, CV
B
inte
rven
tion r
esulte
d in 4
6% o
f ca
ses
succ
essf
ully
res
olv
ed
com
par
ed w
ith 5
5% in E
S in
terv
entio
n (
p = 0
.50)
Dav
is a
nd
Med
ina-
Ariza
(2
001)
; D
avis
, M
edin
a,
and A
vita
bile
(2
001)
, U
nite
d S
tate
s
Polic
e re
cord
s ch
ecke
d
and v
ictim
s in
terv
iew
ed
most
ly b
y phone
at
6w
eeks
and 6
and
12m
onth
s af
ter
trig
ger
inci
den
t; co
mple
tion
rate
was
67%
at
6w
eeks
, 69
% a
t 6
month
s, 6
7% a
t 12
month
s
Freq
uen
cy a
nd s
ever
ity o
f ab
use
(m
odifie
d C
onflic
t Tac
tics
Scal
e)Fr
equen
cy o
f ca
lling
polic
eK
now
ledge
of el
der
abuse
an
d a
war
enes
s of
serv
ices
Self-e
stee
m (
Rose
nber
g Se
lf-E
stee
m S
cale
)Psy
cholo
gica
l w
ell-bei
ng
(Bra
dburn
Affec
t Bal
ance
Sc
ale)
New
inci
den
ts o
f ab
use
(m
ean,
SD):
hom
e vi
sit plu
s public
educa
tion
group h
ad h
igher
counts
than
co
ntrol gr
oup a
t 6
month
s (1
2.63
, 25
.96
vs. 5.
87, 12
.63
resp
ectiv
ely,
p
< 0
.05)
and a
t 12
month
s (8
.58,
23
.32
vs. 5.
36, 8.
67 r
espec
tivel
y,
not si
gnific
ant); no s
ignific
ant
diffe
rence
s bet
wee
n p
ublic
ed
uca
tion–o
nly
gro
up o
r hom
e vi
sit–
only
gro
up a
nd c
ontrol gr
oup
House
hold
s th
at rec
eive
d h
om
e vi
sits
an
d h
om
e vi
sits
plu
s public
ed
uca
tion c
alle
d p
olic
e si
gnific
antly
more
often
than
co
ntrols
at 6
month
sN
o d
iffe
rence
s bet
wee
n g
roups
at
6or
12 m
onth
s on k
now
ledge
of
elder
abuse
and a
war
enes
s of
serv
ices
, sel
f-es
teem
, psy
cholo
gica
l w
ell-bei
ng
Indiv
idual
leve
l ran
dom
izat
ion
was
quas
i-ra
ndom
ized
(o
dd/e
ven);
Min
imal
info
rmat
ion rel
ated
to
conce
alm
ent of al
loca
tion
Inte
rvie
w n
onco
mple
tion
varied
sig
nific
antly
by
group; at
12
month
s, 2
9.7%
of hom
e vi
sit gr
oup d
id n
ot
com
ple
te s
urv
ey c
om
par
ed
to 3
9.7%
of co
ntrol gr
oup
(p =
0.0
3)In
terv
entio
n 2
(hom
e vi
sit)
an
d c
ontrol gr
oups
wer
e diffe
rent at
bas
elin
e on
ethnic
ity o
f vi
ctim
and
abuse
r, a
nd g
ender
of
abuse
r
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12
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14
199
Filin
son (
1993
),
Unite
d S
tate
sPro
ject
direc
tor
indep
enden
tly
com
ple
ted d
ata
colle
ctio
n inst
rum
ent
for al
l 42
case
s; 2
8 ca
ses
coded
by
both
in
vest
igat
or
and p
roje
ct
direc
tor
but re
liabili
ty
chec
k not done
Cas
ework
ers
from
D
epar
tmen
t of Eld
erly
Affai
rs E
lder
Abuse
Unit
com
ple
ted the
dat
a co
llect
ion form
s fo
r co
ntrol ca
ses
they
in
vest
igat
ed
Rec
urr
ence
of ab
use
Soci
al iso
latio
nSe
rvic
es a
cces
sed
Lengt
h o
f tim
e ca
ses
wer
e ac
tive
Pro
portio
n o
f ca
ses
consi
der
ed c
lose
dPro
portio
n o
f ca
ses
relo
cate
dPro
portio
n o
f per
pet
rato
rs
relo
cate
d
Rec
urr
ence
of ab
use
was
sig
nific
antly
hig
her
in the
IG (
24%
) th
an in the
CG
(17
%)
(p =
0.0
06); I
G m
ore
lik
ely
to h
ave
dim
inis
hed
soci
al
isola
tion (
43%
) co
mpar
ed to C
G
(17%
) (p
= 0
.02)
; more
IG
acc
esse
d
serv
ices
(55
%)
com
par
ed to C
G
(24%
) (p
= 0
.007
); n
o s
tatis
tical
ly
sign
ific
ant diffe
rence
s in
: le
ngt
h o
f tim
e ca
ses
wer
e ac
tive
bet
wee
n IG
an
d C
G; pro
portio
n o
f ca
ses
consi
der
ed c
lose
d b
etw
een I
G
(36%
) an
d C
G (60
%); p
roportio
n o
f ab
use
d p
erso
ns
relo
cate
d b
etw
een
IG (
19%
) an
d C
G (
14%
);
pro
portio
n o
f per
pet
rato
rs
relo
cate
d b
etw
een I
G (
24%
) an
d
CG
(19
%)
Smal
l sa
mple
siz
eN
o r
andom
allo
catio
n o
f per
sons
to IG
and C
GSo
me
bas
elin
e diffe
rence
s in
tw
o g
roups,
for
exam
ple
, pro
ject
cas
es h
ad m
ore
cl
ients
who w
ere
old
er,
few
er c
lients
with
multi
ple
ty
pes
of ab
use
Diffe
rent outc
om
e as
sess
ors
fo
r th
e tw
o g
roups.
Rel
iabili
ty o
f outc
om
e dat
a m
ay b
e co
mpro
mis
ed:
Inci
den
ce o
f re
curr
ence
of
abuse
unkn
ow
n b
y ca
sew
ork
ers
in m
uch
lar
ger
pro
portio
n o
f CG
cas
es
(43%
) th
an IG
inte
rven
tion
case
s (1
2%)
Sengs
tock
et al
. (1
991)
; Unite
d
Stat
es
87 c
ases
clo
sed d
uring
per
iod o
f stu
dy
asse
ssed
(2
9 in
Gro
up 1
; 21
in
Gro
up 2
; 18
in G
roup 3
; 15
in G
roup 4
)Cas
ework
ers
asse
ssed
ca
se d
isposi
tion
Ca
se d
ispo
siti
onSa
fe a
nd s
table
Inst
itutio
nal
pla
cem
ent
Mis
cella
neo
us
No s
tatis
tical
ly s
ignific
ant diffe
rence
bet
wee
n g
roups
on c
ase
dis
posi
tion
Per
centa
ge o
f ca
ses
consi
der
ed s
afe
and s
table
wer
e: G
roup 1
, 21
%;
Gro
up 2
, 38
%; G
roups
3 an
d 4
, 33
% (
p = 0
.36)
Per
centa
ge o
f ca
ses
ente
ring
long-
term
car
e w
ere:
Gro
up 1
, 14
%;
Gro
up 2
, 14
%; G
roups
3 an
d 4
, 15
% (
p = 0
.99)
Per
centa
ge o
f ca
ses
consi
der
ed a
s m
isce
llaneo
us
dis
posi
tion w
ere:
G
roup 1
, 10
%; G
roup 2
, 14
%;
Gro
ups
3 an
d 4
, 21
% (
p = 0
.49)
Larg
e num
ber
of w
ork
ers
ove
r bro
ad g
eogr
aphic
are
a in
volv
ed in d
ata
colle
ctio
nD
ata
wer
e no
t co
llect
ed for
re
sear
ch p
urpos
es s
o m
odifi
catio
ns w
ere
nece
ssar
y to
ada
pt da
ta for
ana
lysis
Auth
ors
note
d that
cat
egories
of ca
se d
isposi
tion p
rovi
de
little
under
stan
din
g of th
e ef
fect
iven
ess
of
inte
rven
tions
It is
pro
ble
mat
ic that
sec
ond
most
fre
quen
tly r
eported
dis
posi
tion o
f ca
ses
is
“mis
cella
neo
us”
Not
e: I
G =
inte
rven
tion g
roup; CG
= c
ontrol or
com
par
ison g
roup.
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14
200
TA
BLE
3Su
mm
ary
of At-Ris
k Car
egiv
er O
utc
om
es o
f an
Inte
rven
tion S
tudy
Rel
ated
to A
buse
of O
lder
Per
sons
Auth
or
(yea
r),
country
Dat
a co
llect
ion
Outc
om
e m
easu
res
Res
ults
Com
men
ts a
nd s
tudy
limita
tions
Scogi
n e
t al.
(198
9),
Unite
d S
tate
sD
ata
wer
e co
llect
ed
twic
e fo
r ea
ch
group a
t an
inte
rval
of ap
pro
xim
atel
y 8
wee
ks
Ange
r (A
nge
r In
vento
ry [AI])
Self-e
stee
m (
Rose
nber
g Se
lf-E
stee
m S
cale
[RSE
S])
Car
egiv
er b
urd
en (
Cost
of Car
e In
dex
[CO
CI])
Gen
eral
men
tal hea
lth (
Brief
Sy
mpto
m I
nve
nto
ry [B
SI] )
No s
tatis
tical
ly
sign
ific
ant d
iffe
rence
bet
wee
n g
roups
on
CO
CI (p
= 0
.2), B
SI
(p =
0.1
3), A
I, o
r RSE
S
No info
rmat
ion rel
ated
to p
ow
er
of st
udy
Bas
elin
e dat
a pro
vided
for
101
per
sons
in im
med
iate
tra
inin
g gr
oup, 25
per
sons
in d
elay
ed
trai
nin
g co
ntrol gr
oup, an
d
48per
sons
in n
ontrai
nin
g co
ntrol,
not fo
r th
e par
ticip
ants
(n =
56,
16,
23
resp
ectiv
ely)
who c
om
ple
ted
the
study;
the
thre
e gr
oups
who c
om
ple
ted the
study
may
hav
e bee
n d
iffe
rent at
bas
elin
e.
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201
TA
BLE
4Su
mm
ary
of Pro
fess
ional
Outc
om
es o
f In
terv
entio
ns
Studie
s Rel
ated
to A
buse
of O
lder
Per
sons
Auth
or
(yea
r),
country
Dat
a co
llect
ion
Outc
om
e m
easu
res
Res
ults
Com
men
ts a
nd s
tudy
limita
tions
Joge
rst an
d E
ly
(199
7), U
nite
d
Stat
es
Tw
o m
ailin
gs o
f su
rvey
s to
fam
ily p
ract
ice
resi
den
cy g
raduat
es;
ove
rall
resp
onse
rat
e of 79
%; IG
res
ponse
ra
te 9
3.5%
; CG
re
sponse
rat
e 63
.6%
Self-a
sses
smen
t of use
fuln
ess
of
geriat
ric
trai
nin
g, c
onfiden
ce
with
eva
luat
ion o
f th
e hom
e en
viro
nm
ent,
com
fort in
dia
gnosi
ng
elder
abuse
Self-r
eport o
f hav
ing
pro
vided
st
atem
ents
for
guar
dia
nsh
ips
and h
avin
g dia
gnose
d e
lder
ab
use
IG rat
ed the
use
fuln
ess
of the
ger
iatric
trai
ning
hig
her th
an C
G (
p <
0.01
),
repor
ted
mor
e co
nfid
ence
with
ev
alua
tion
of the
hom
e en
viro
nmen
t (p
< 0
.04)
; CG
mor
e lik
ely
to h
ave
mad
e ho
me
visits (
p =
0.03
1) a
nd to
have
pro
vide
d stat
emen
ts c
once
rnin
g gu
ardi
ansh
ip (
p =
0.01
2) tha
n IG
; no
stat
istic
ally
sig
nific
ant d
iffer
ence
bet
wee
n gr
oups
on c
omfo
rt in
dia
gnos
ing
elde
r ab
use
(p =
0.1
0), a
bilit
y to
eva
luat
e el
derly
for ca
pac
ity (
p =
0.17
), o
r pro
por
tion
who
had
dia
gnos
ed e
lder
ab
use
(p-v
alue
not
rep
orte
d)
Low
er r
esponse
rat
e am
ong
CG
(63
.6%
) th
an I
G (
93.5
%)
Pow
er o
f st
udy
not
reported
Psy
chom
etric
pro
per
ties
of to
ols
not re
ported
IG a
nd C
G n
ot
conte
mpora
neo
us
Ric
har
dso
n e
t al.
(200
2, 2
004)
, U
nite
d
Kin
gdom
Par
ticip
ants
com
ple
ted
ques
tionnai
re b
efore
an
d a
fter
the
inte
rven
tion;
64 o
f 86
par
ticip
ants
ra
ndom
ized
co
mple
ted follo
w-u
p
(74%
);70
.4%
com
ple
tion in I
G
and 7
8.6%
in C
G
Know
ledge
and m
anag
emen
t of
abuse
(K
AM
A)
bas
ed o
n
hyp
oth
etic
al v
ignet
tes
Burn
out (M
asla
ch B
urn
out
Inve
nto
ry [M
BI])
Attitu
de
(Attitu
de
of H
ealth
Car
e Per
sonnel
tow
ards
Dem
ente
d
Pat
ients
[A
HCPD
P])
Stat
istic
ally
sig
nific
ant d
iffe
rence
bet
wee
n
groups
on K
AM
A s
core
s w
ith those
in
IG
im
pro
ving
and those
in C
G
det
erio
ratin
g (p
= 0
.000
)N
o s
tatis
tical
ly s
ignific
ant diffe
rence
s bet
wee
n g
roups
on M
BI
or
AD
HCPD
PReg
ress
ion a
nal
ysis
rev
eale
d tw
o
variab
les
as s
ignific
ant in
pre
dic
ting
lear
nin
g: a
lloca
tion to e
duca
tional
co
urs
e (O
R =
6.8
; 95
% C
I 1.
9, 2
4.5;
p
= 0
.003
) an
d low
bas
elin
e K
AM
A s
core
s (O
R =
4.8
, 95
%
CI
1.4,
16.
9; p
= 0
.015
)
Follo
w-u
p p
erio
d w
as
short; do n
ot kn
ow
if
impro
vem
ent w
ould
be
mai
nta
ined
Ther
e w
as a
cei
ling
effe
ct o
n k
now
ledge
sc
ore
s w
ith those
kn
ow
ing
more
at
bas
elin
e hav
ing
little
ro
om
for
impro
vem
ent
Ther
e w
as n
o
asse
ssm
ent of
pro
fess
ional
beh
avio
r direc
tly r
elat
ed to
iden
tific
atio
n o
r m
anag
emen
t of el
der
ab
use
as
an o
utc
om
e
Not
e: I
G =
inte
rven
tion g
roup; CG
= c
ontrol or
com
par
ison g
roup.
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202 J. Ploeg et al.
power analyses; (d) measures with limited or no information related to psy-chometric properties; (e) follow-up rates of less than 80%; (f) lack of adjust-ment for baseline differences between groups; and (g) outcome assessmentcompleted by caseworkers, not independent assessors. Study results are sum-marized by category of outcome in the following sections: (a) client out-comes, (b) at-risk caregiver outcomes, and (c) professional outcomes.
Client Outcomes
Many different client outcomes were assessed in the six studies that exam-ined interventions targeted at abused older persons (see Table 2). Threeoutcomes were addressed by more than one study and will be describedfirst: recurrence of abuse, case resolution, and relocation.
RECURRENCE OF ABUSE
Two studies examined recurrence of abuse after the intervention (Daviset al., 2001; Davis & Medina-Ariza, 2001; Filinson, 1993). Surprisingly, bothstudies found that the intervention groups (IG) had higher rates of recur-rence of abuse than the control groups (CG). In the first study, volunteervisitors provided assistance, support, and advocacy in the use of the crimi-nal justice system (Filinson, 1993). This study found a recurrence rate of24% in the IG compared to 17% in the CG (p = 0.006). However, there wereimportant study limitations related to outcome assessment. Caseworkerscompleted the data collection forms for the control cases they investigated,and the incidence of recurrence of abuse was unknown by the caseworkersin 43% of the controls compared to 12% of the intervention cases. Further,the project director completed the data collection tool for the interventioncases, and while some data were coded by both the project director and theinvestigator, no reliability check of the data was completed.
The second study found that participants in the experimental group whoreceived the home visit plus public education had higher rates of repeatabuse than the CG; these effects were statistically significant at 6 months butnot at 12 months (Davis et al., 2001; Davis & Medina-Ariza, 2001). No statis-tically significant differences were found on abuse recurrence between thepublic education–only group or the home visit–only group and the CG.Study limitations included significant baseline group differences, less than80% follow-up at 12 months, and statistically significant differences in rateof follow-up between groups at 12 months. Other study limitations wererelated to the very low proportion of IG participants who actually receivedthe interventions and problems with protocol adherence by service providers.Only 6% of residents at the targeted housing projects attended the educa-tional sessions, and only 50% of the targeted households received the home
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Interventions for Elder Abuse 203
visit intervention, on average 56 days after the initial call to the police ratherthan the intended few days after initial police contact.
CASE RESOLUTION
Four studies examined the impact of elder abuse interventions on case reso-lution (Brownell & Heiser, 2006; Brownell & Wolden, 2002; Filinson, 1993;Sengstock et al., 1991). In all four studies, there were no statistically signifi-cant differences between groups on case resolution. There were differencesin how case resolution was defined and measured between studies. In theirevaluation of a psychoeducational support group, Brownell and Heiser(2006) conducted pre- and post-test interviews with older adults to assessphysical and nonphysical abuse. At pre-test, the percentages of IG and CGparticipants with self-reported physical abuse were 22 and 43 (p = 0.33),respectively, and for nonphysical abuse were 100 and 83 (p = 0.67), respec-tively. At post-test, the percentages of IG and CG participants with self-reported physical abuse were 13 and 0 (p = 0.41), respectively, and fornonphysical abuse were 83 and 75 (p = 0.75), respectively. However, thisstudy was limited by an inadequate sample size and lack of informationrelated to the psychometric properties of the Hartford Study Abuse scalesused in the study.
Using a retrospective chart audit, Brownell and Wolden (2002)compared the outcomes of a legal services program to a social servicesprogram. They found no statistically significant differences between groupsin percentage of cases successfully resolved, that is, where safety wasachieved through successful implementation of the service plan (63% and62%, respectively). For financial abuse, the legal services program resultedin more cases successfully resolved than the social services program (67%and 17%, respectively; p = 0.043). Only 56 cases were assessed in this study,all from the same agency.
In a study of the effectiveness of volunteer visitors, Filinson (1993)found that the percentage of cases considered closed was higher in the CG(60%) compared to the IG (36%), but this was not statistically significant.Limitations of this study have been previously described.
In the study by Sengstock et al. (1991) outcomes of three programswere assessed: Group 1, mandated reporting; Group 2, legal intervention;Groups 3 and 4, advocacy services. Caseworkers determined if the case wasconsidered safe and stable at closure. Study findings indicated that therewas no statistically significant difference between groups in percentages ofcases considered safe and stable: Group 1, 21%; Group 2, 38%; Groups 3and 4, 33% (p = 0.36). A major problem for interpreting the findings fromthis study is the lack of a no-intervention control group. Two additionallimitations were that: (a) a large number of caseworkers over a broad geo-graphic area assessed case disposition, and (b) the data were not collected
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204 J. Ploeg et al.
for research purposes so the categories of case disposition are difficult tointerpret with respect to effectiveness of these interventions.
RELOCATION
One study examined the impact of an elder abuse intervention on nursinghome placement and one study examined the impact on relocation in gen-eral. Filinson (1993) found that 19% of intervention cases were relocatedcompared to 14% of the control group, but the study did not specify if caseswere relocated to nursing homes or other settings. Sengstock et al. (1991)found that there was no statistically significant difference between rates ofrelocation to long-term care among the mandated reporting (14%), legalintervention (14%), and advocacy intervention groups (15%) (p = 0.99).Because there was no control group that did not receive the intervention,we do not know if the relocation rates are higher with or without theinterventions.
SOCIAL-PSYCHOLOGICAL OUTCOMES
Studies assessed the impact of the programs on a number of social andpsychological client outcomes. Most studies found no statistically significantdifferences between groups on these outcomes. Brownell and Heiser (2006)found no statistically significant differences between groups for depression(p = 0.49), guilt (p = 0.72), self-esteem (p-value not specified), and familyrelationship problems (p = 0.22). Davis and Medina-Ariza (2001) found nodifferences between groups at 6 or 12 months on psychological well-being orself-esteem. Filinson (1993) found that intervention cases were more likely tohave diminished social isolation compared to control cases (p = 0.02).
OTHER OUTCOMES
Davis and Medina-Ariza (2001) and Davis et al. (2001) found no statisticallysignificant difference between groups on knowledge of elder abuse andawareness of services.
AT-RISK CAREGIVER OUTCOMES
Only one study examined the impact of an intervention targeted at caregiversat risk of abusing older family members (Scogin et al., 1989) (see Table 3).The three study groups included an immediate training group (n = 56), await-list CG (n = 16) and a nontraining CG (n = 23). Caregivers receivedeight weekly training sessions provided by experienced mental health clini-cians related to aging, problem solving, stress and anger management, and
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community resources. At the end of 8 weeks, there were no statisticallysignificant differences between the groups on the outcomes of anger, self-esteem, caregiver burden, or general mental health. However, no informa-tion was provided as to whether the study was adequately powered todetect a statistically significant difference. Sociodemographic data are pre-sented for the starting sample not, as one would expect, only for those whocompleted the study and for whom outcome measures were calculated. It ispossible that the three groups (IG, CG, and wait-list CG) who completed thestudy were different at baseline. Finally, this study included caregivers atrisk for abusing older family members, not those actually confirmed to haveabused them.
PROFESSIONAL OUTCOMES
Two studies examined the impact of elder abuse interventions for healthcare professionals and demonstrated mixed findings (Jogerst & Ely, 1997;Richardson et al., 2002, 2004) (see Table 4). In one study, the IG of familypractice residents received an educational course targeting identificationand management of abuse, while the CG, an earlier cohort of residents, hadnot received this education (Jogerst & Ely, 1997). The IG of residents madean average of 3.7 home visits during the 3 years of residency to potentiallyabused older adults who had been reported to Adult Protective Services(APS). The residents obtained written evaluations after the home visits froma faculty member. The IG reported more confidence with evaluation of thehome environment (p < 0.04) compared to the CG. A higher proportion ofthe CG than the IG reported having made home visits (p = 0.031) andhaving provided statements for guardianship (p = 0.012). There were nostatistically significant differences between groups on their self-reportedcomfort level in diagnosing elder abuse (p = 0.10) and the proportion whohad diagnosed elder abuse. Study limitations included the lack of informa-tion related to psychometric properties of the measurement tools and a 74%follow-up rate.
The second study of elder abuse interventions for health professionalsinvolved an RCT of an educational course for nursing staff, care assistants,care managers, and social workers of a community health trust or social ser-vices agencies in London, United Kingdom (Richardson et al., 2002, 2004).The CG received reading materials with the same content as the course.Those in the educational course showed significant improvement in scoreson the instrument Knowledge and Management of Abuse (KAMA) whilethose in the CG deteriorated in scores (p = 0.000); however, the CG had sta-tistically significant higher baseline KAMA scores. As noted by the authors,there was a ceiling effect with respect to the knowledge score, with thosewho knew more at baseline having little room for improvement of theirscores. There were no statistically significant differences between groups on
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measures of burnout and attitude toward demented persons. There was noassessment of behavior directly related to identification or management ofelder abuse in this study.
DISCUSSION
Findings of this systematic review of elder abuse interventions suggest thatthere is currently insufficient evidence to support any particular interventionrelated to elder abuse targeting clients, perpetrators, or health care profes-sionals. More than 10 years ago, Wolf (1997) indicated that the elder abuseliterature was particularly lacking in “reliable data on the effectiveness ofinterventions” (p. 81) and this situation is unfortunately still true today. Arecent systematic review of database citations on elder abuse until January2006 found that of 398 references, only 8% were related to agency or pro-gram development and/or evaluation and only 6.5% were related to detec-tion, assessment, and/or intervention (Erlingsson, 2007). The review offamily violence interventions by Chalk and King (1998) described previ-ously underscores how little high-quality elder abuse intervention researchhas been completed compared to the areas of child abuse and domesticviolence.
Not only are there few published primary studies evaluating elderabuse interventions, but most of the published studies have importantmethodological limitations. Only eight studies met our inclusion criteria;most published reports of elder abuse interventions are descriptive in natureand do not include comparison groups. Even the studies that did meet ourinclusion criteria had important methodological limitations that preclude usfrom drawing firm conclusions about the effectiveness of the interventionsstudied. Only four of the included studies had a limited or no interventioncomparison group.
In terms of client outcomes, it is troubling that both studies assessingrecurrence of abuse found that the intervention groups had higher rates ofrecurrence of abuse than did the limited or no intervention control groups(Davis et al., 2001; Davis & Medina-Ariza, 2001; Filinson, 1993). It is possi-ble, however, that these findings were the result of the methodologicallimitations of the studies and not the harmful effects of the programsthemselves.
In terms of case resolution, the one study with a usual care comparisongroup found no statistically significant difference between intervention andcontrol group (Filinson, 1993). The three studies comparing different inter-ventions found no statistically significant differences between groups on caseresolution (Brownell & Heiser, 2006; Brownell & Wolden, 2002; Sengstocket al., 1991). Again, these results may have been, at least in part, the result ofthe methodological limitations of the studies.
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The relatively high rates of relocation of abused older adults associatedwith intervention programs is also troubling. Although relocation mayremove the abused person from harm’s way, it does so at the cost of place-ment in unfamiliar surroundings and probable reduction in autonomy anddisruption of social relationships.
Only one study examined the impact of a training program for at-risk car-egivers and found no difference between intervention and control groups(Scogin et al., 1989). Finally, the two studies that examined the impact of elderabuse education and training programs for health care professionals demon-strated mixed results (Jogerst & Ely, 1997; Richardson et al., 2002, 2004).
The results of this review do not tell us which elder abuse interventionsare most effective, in what circumstances, and with which target groups. Infact, the results suggest that there may be negative consequences associatedwith some elder abuse interventions. Researchers suggest that despite thegaps in knowledge with respect to treatment of elder abuse, cliniciansshould still take an active role in its identification and management (Lachs &Pillemer, 2004). We argue that given this situation, further high-qualityresearch is absolutely vital in the area of elder abuse interventions.
Implications for Future Research
The results of this systematic review highlight the need for high-qualityresearch in the area of elder abuse interventions. Our literature searchfound 45 studies of elder abuse interventions that did not meet our inclu-sion criteria; most of these studies were descriptive in nature. These studiesaddressed a broad scope of elder abuse interventions such as case manage-ment, home-based geriatric assessment, support groups, adult protectiveservices, multiservice programs, partnerships with faith communities, andprofessional education, to name a few. These interventions have the poten-tial to have a positive impact on the complex issue of elder abuse but mustbe evaluated more rigorously. Further, innovative new approaches toaddress elder abuse at individual, family, community, and system-widelevels should be developed and evaluated.
It has been argued that the best data on whether an intervention doesmore good than harm comes from experimental designs or RCTs (Streiner &Norman, 1998). Where possible, experimental or quasiexperimental designsshould be conducted in the field of elder abuse interventions. Further, thestudy limitations found in this review should be addressed, including:(a) appropriate sample size; (b) for RCTs, description of the randomizationprocedures and allocation concealment procedures; (c) the use of measure-ment tools with established psychometric properties; (d) where possible,blinding of outcome assessors and data analysts; (e) follow-up rates of morethan 80%; and (f) appropriate adjustment for baseline differences betweengroups. Mixed-methods studies, studies that include both quantitative and
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qualitative components, may help us to determine not only the effectivenessof interventions but also to understand why some interventions are success-ful or not and the perspectives of recipients who receive those interventions(Creswell & Clark, 2007).
Our review of the studies of elder abuse interventions underscores theimportant challenges of conducting research in this field. Authors ofincluded studies discussed the challenges in accessing, recruiting, andretaining participants; obtaining comparison groups; and addressing ethicalchallenges in accessing client data. While we recognize these challenges,particularly as they relate to the use of experimental designs, it is only as weconduct rigorously designed studies that we will have strong evidence onwhich to base decisions on the best use of scarce and costly health andsocial services. MacMillan and Wathen (2005) suggest that family violenceresearch could benefit from closer collaboration of those working in theareas of child maltreatment, intimate partner violence, and elder abuse. Inthe area of child maltreatment, for example, while research methods are stillproblematic, they have improved and RCTs have been used to assess inter-ventions such as home visits (Olds, 2002). It is vital that clinicians, research-ers, and policymakers promote and support rigorous research in all areas offamily violence, including elder abuse, and apply the results to the develop-ment of effective interventions. Appropriate funding for such high-qualityresearch on elder abuse interventions must be a priority.
Study Limitations
There were a number of limitations of this systematic review. First, we didnot search specifically for unpublished research reports, although we didobtain and review unpublished reports listed in the reference lists ofretrieved articles. We did not contact experts in the field for other studies,and we only included English-language articles. Nevertheless, we did con-duct a comprehensive search of existing databases.
While we did not conduct a formal quality assessment of the includedarticles, the inclusion criteria imposed quality standards in that all studieshad to have a comparison group (not before-after) and had to report out-comes. The most important limitation of this review is a reflection of thecurrent state of the literature itself, specifically, the limited number of rigor-ous studies examining the effectiveness of elder abuse interventions.
CONCLUSION
While elder abuse is an increasingly important issue internationally, there islittle high-quality research on the effectiveness of interventions. This reviewhighlights the limited number and quality of empirical research studies in
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the field. Further, the review suggests that there may be both positive andnegative consequences of elder abuse interventions. The need for high-quality research in the field is critical not only to ensure health and qualityof life for older adults but also to ensure wise use of scarce and costlyhealth and social service resources.
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