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        Best-Practice Guideline on the Prevention of Abuse and Neglect of Older Adults
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Abstract

A systematic review of the literature was conducted to identify effective approaches to preventing and addressing abuse and neglect of older adults within health care settings in Canada. The review was conducted using databases searched from January 2000–April-May 2013. Additionally, expert panel members submitted article citations from personal archives. Two research associates (NRA) screened each title and abstract for inclusion. After inter-rater reliability was determined between the NRAs (Kappa score of 0.76), the records were divided, appraised, and data extracted independently. The review resulted in 62 studies that focused on identifying, assessing, and responding to abuse and neglect of older adults; education, prevention, and health promotion strategies; and organizational and system-level supports to prevent and respond to abuse and neglect. Abuse and neglect of older adults remains under-explored in terms of evidence-based studies; consequently, further research in all of the areas described in the results is needed.

Background

The past few decades have seen a substantial increase in the awareness and understanding, and the personal and societal costs, related to the abuse and neglect of older adults in Canadian society. Supporting this has been substantial growth in research studies, specific to the incidence, prevalence, causation, and detection of abuse and neglect of older adults. In Canada, it is currently estimated that the prevalence of abuse and neglect ranges from between 4 and 10 per cent among those aged 65 and older, although some researchers believe this may still underestimate an often hidden issue within our society (Brennan, 2009; Canadian Centre for Justice Statistics, 2002; Podnieks, Pillemer, Nicholson, Shillington, & Frizze, 1990; Pottie-Bunge, 2000).

The World Health Organization (WHO) (2000a, 2000b) has been influential in establishing a commonly used definition of abuse: “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (p. 126). The United Nations International Plan of Action (2002) adopted in Madrid recognized the importance of addressing abuse and neglect of older adults and incorporated it within its framework for universal human rights.

Authorities or key stakeholder organizations in every Canadian jurisdiction, with the exception of Nunavut, have adopted a definition of abuse and neglect of older adults. The National Seniors Council of Canada (2007) identified that abuse may take numerous forms: financial, physical, emotional or psychological, sexual, systemic, spiritual, and neglect. Subsequently, the National Initiative for the Care of the Elderly (2012) in Canada developed through consensus building the following definition, “Mistreatment of older adults refers to actions/behaviours or lack of actions/behaviours that cause harm or risk of harm within a trust relationship” (McDonald, L., Beaulieu, M. et al. 2012, p. 4).

Although health care providers are well positioned to recognize abuse and neglect against older adults, the level of reporting of these types of cases is believed to be substantially lower than its true incidence (Almogue, Weiss, Marcus, & Beloosesky, 2010; Bond & Butler, 2013; Polkastro & Payne, 2014; Schmeidel, Daly, Rosenbaum, Schmuch, & Jogerst, 2012). Potential barriers to recognizing and reporting abuse and neglect of older adults include their reluctance to acknowledge the abuse, health care professionals’ limited knowledge, a lack of protocols to identify abuse, fear of liability, and the small number of services available to support older adults in these situations (Rodriguez, Wallace, Woolf, & Mangione, 2006; Taylor, Bachuwa, Evans, & Jackson-Johnson, 2006; Wei & Herbers, 2004).

Furthermore, until recently, there existed no comprehensive clinical guidelines for preventing and addressing abuse and neglect of older adults applicable to the Canadian context. One of the reasons for this deficit is that the current body of research in this area is underdeveloped, related to the lack of development of theoretical models to understand abuse and neglect of older adults. A theory provides an explanation of why something happens the way it does; abuse and neglect are complex and multilayered experiences that require robust theoretical frameworks to guide an understanding as well as actions to address these concerns. Explanations as to why the field of abuse and neglect of older adults has been devoid of guiding theories include the fact that (a) abuse and neglect of older adults has only within the past several decades gained national attention, (b) recognition is limited at organizational and governmental levels of a need to support theory development, and (c) the field has tended to support the belief that caregiver stress sufficiently explains the occurrence of abuse and neglect in this population group.

In this article, we present the findings from a systematic review that we conducted to synthesize current research evidence on effective approaches to address and prevent abuse and neglect of older adults. The purpose of the review was to inform the development of a best-practice guideline specific to this health challenge. Linking evidence-based guidelines to practice facilitates high-quality nursing and health care for older clients. The purpose of this guideline is to disseminate evidence-based recommendations to clinicians in health care settings that are providing services to older adults, as well as health system administrators and policy makers.

Methods

Developing a search strategy requires a structured approach. As Gillespie and Gillespie (2003) wrote, “Start by framing a simple question … this can be refined to specify all the concepts of interest to the … condition” (p. 139). The question will influence the selection of the search terms.

Expert Panel Creation and Selection of Guiding Questions for the Systematic Review

In 2012, the Registered Nurses’ Association of Ontario (RNAO) invited a broad group of experts to serve on an expert panel that would help inform and guide the development of the best-practice guideline. In total, 12 subject matter experts ranging from fields as diverse as nursing, medicine, social work, law, patient advocacy, education, and research formed the expert panel. The panel helped derive the following questions to guide the subsequent literature search that informed the systematic review.

  1. 1. What are the most effective ways for nurses (and other health care providers) to identify and assess for abuse and neglect of older adults?

  2. 2. What are the most effective ways for nurses (and other health care providers) to respond to the abuse and neglect of older adults?

  3. 3. What education do nurses (and other health care providers) need to effectively address abuse and neglect of older adults?

  4. 4. What prevention and health promotion strategies are recommended regarding abuse and neglect of older adults?

  5. 5. What organizational policies and system level supports are required to effectively prevent and address abuse and neglect of older adults (living in facilities and community settings)?

Data Sources and Search Strategy

A comprehensive search strategy was developed through an iterative process between a health sciences librarian and the RNAO’s research team consisting of two nursing research associates (NRA) and a master’s-level-prepared nurse manager. Two literature searches were conducted by the librarian in the following databases: Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Controlled Trials (CT), Cochrane Systematic Reviews (SR), Database of Abstracts of Reviews of Effectiveness (DARE), Embase, Joanna Briggs Institute, Medline, Medline in Progress, Ovid Healthstar, and PsycINFO. We conducted the first search to select literature published between January 2000 and April 2013 and focused on the question, What are the most effective ways for nurses (and other health care providers) to identify, assess, and respond to abuse and neglect of older adults? The second search was conducted from January 2000–May 2013 and focused on the question, what are the most effective ways to prevent and address abuse and neglect of older adults (living in facilities and community settings)?

Keywords and subject headings relating to the abuse and neglect of older adults were used in each database. Search terms included but were not limited to the following: older adult, mistreatment, risk factor, screening, abuse, education, and best practices. As a generic term, “abuse” was selected because it was more generic in scope versus individual types of abuse being used as search terms. Terms were used alone and in combination. Expert panel members were also asked to review personal libraries to identify records. These were included if the two NRAs independently determined that the records had not been identified by the literature search and met the inclusion criteria. Results from all databases and records submitted were exported into bibliographic management software and merged to form a single database; duplicate citations were removed.

Study Selection and Quality Appraisal Process

The research team, in collaboration with the expert panel, developed inclusion and exclusion criteria . Inclusion criteria included (a) primary focus on abuse and neglect of older adults; (b) population aged 55 and older; (c) published in English or French in a peer-reviewed journal; (d) relevant to the scope of nursing, any health setting, or sector; and (e) records accessible for retrieval, any study type. Commentaries, dissertations, letters to the editor, editorials, papers less than one page in length, and study designs protocols were excluded.

Two NRAs independently screened each title and abstract of the records retrieved according to inclusion and exclusion criteria. Full text of the included records was then assessed for relevance according to the same a priori criteria used for the initial review. Any discrepancies arising throughout the screening process (between NRAs) were resolved by the program manager. The NRA determined inter-rater reliability by independently quality appraising 10 per cent of the included full-text records. Once a sufficient kappa score (κ = 0.76) was achieved, the remaining studies were divided equally between the NRA for independent quality appraisal and data extraction (Fleiss, Levin, & Paik, 2003).

Appraisal tools were selected based on study design and included Critical Appraisal Skills Programme (CASP) for randomized control trials, qualitative studies, and observational studies; Assessing the Methodological Quality of Systematic Reviews (AMSTAR) for systematic reviews; Quasi-experimental Tool adapted from Cochrane Public Health (n.d.) for quasi-experimental studies; and Evaluation Tool for Mixed Methods studies for studies employing more than one type of research method (Long, Godfrey, Randall, Brettle, & Grant, 2002). Using the appropriate tool, we scored each study and gave it an overall score that reflected the study’s quality. Quality ratings included strong, moderate, or weak (see Table 1). Although quality rating tools as measures of article merit are still evolving, they nonetheless provide a method of quality assurance to the systematic review process.

Table 1: Quality rating of evidence specific to research question

a Studies (n = 62) that are applicable to multiple thematic categories

TOTAL QA SCORES:

Weak = 21

Moderate = 31

Strong = 10

Data Extraction and Analysis

From all records selected for full-text review, we extracted data for information on authors, study type, purpose, data collection methods, measures, data analysis, results, conclusions, and limitations. Data extraction tables were organized according to the identified search question and further organized by study type (see Table 1). The results of all studies were grouped into a thematic table, which we used to organize and summarize findings. The table outlined the main findings found among the results, conclusions of the study, and an explanation of the findings that aligned with the research question.

Results

Identification of Eligible Studies

The literature search returned 20,475 records, including 12 records submitted by the panel members. This was reduced to 13,064 records after removing duplicates, and further reduced to 816 records after we applied the inclusion and exclusion criteria to the abstracts.

Review of these articles resulted in 84 records that met the inclusion criteria, of which an additional 22 records were excluded based on their lack of applicability to the initial search questions. Of the 62 studies that met the overall inclusion criteria, quality appraisals resulted in 10 rated as strong, 31 as moderate, and 21 as weak. Weak studies were included in the review if the findings aligned with stronger studies and together formed a common theme, or to support the discussions of recommendations in the best-practice guideline (see Table 2). Figure 1 summarizes the records analysed as part of the review process.

Table 2: Summary of research questions, citations, and quality rating specific to the research questions explored in the study

n = 62 citations (some studies are applicable to multiple research questions)

Figure 1: Identification of the 62 eligible studies found in the literature review for determining a best-practice guideline for preventing the abuse and neglect of older adults. Flow diagram adapted from “Preferred Reporting Items for Systematic Reviews and Meta-analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and The PRISMA Group, 2009, British Medical Journal, 339, p. b2535

The following is a summary of results according to the five guiding questions

Identifying and Assessing For Abuse and Neglect of Older Adults

Descriptive/observational and qualitative studies form the bulk of studies and reviews for identifying and assessing abuse and neglect. Six studies identified various markers, types, and risk factors associated with abuse and neglect of older adults (Davies et al., 2011; Goergen, 2004; Lindbloom, Brandt, Hough, & Meadows, 2007; Murphy, Waa, Jaffer, Sauter, & Chan, 2013; Perez-Carceles et al., 2009; Wiglesworth et al., 2009). The main approaches to identify and assess for abuse and neglect of older adults (a) use combined and multi-faceted approaches to assess for abuse and neglect (Cohen, 2011; Cohen, Levin, Gagin, & Friedman, 2007; Fulmer et al., 2003; Sandmoe, 2007); (b) conduct screening in acute (e.g., emergency department) and subacute (e.g., rehabilitation care) health care settings (Joubert & Posenelli, 2009); (c) routinely ask about abuse with direct questioning (Cohen, Halevy-Levin, Gagin, Prilutzky, & Friedman, 2010; Tetterton & Farnsworth, 2011); and (d) utilize the skills of an expert assessment team (Fulmer et al., 2003). One study indicated that there is a lack of evidence to determine if screening for abuse reduces harm (Caldwell, Gilden, & Mueller, 2013). The majority of the studies specific to this question were of weak quality.

Responding to the Abuse and Neglect of Older Adults

Despite the fact that two studies indicated insufficient evidence to support any particular intervention for nurses and other health care providers to respond to abuse and neglect of older adults (Cooper, Blanchard, Selwood, Walker, & Livingston, 2010; Ploeg, Fear, Hutchison, MacMillan, & Bolan, 2009), three important features did emerge, including (a) individualizing the intervention to the older adult (Sandmoe & Kirkevold, 2013; Sandmoe, Kirkevold, & Ballantyne (2011); (b) utilizing multipronged and varied strategies (e.g., education and referrals) (Begley, O’Brien, Anand, Killick, & Taylor, 2012; Zink, Jacobson, Regan, & Pabst, 2004); and (c) implementing interventions acceptable to the older adult, family, and caregivers (Nahmiash & Reis, 2000; Selwood, Cooper, Owens, Blanchard, & Livingston, 2009; Vladescu, Eveleigh, Ploeg, & Patterson, 2000). Emotionally supportive, culturally considerate, and patient-centred approaches with a harm reduction focus were favoured in the literature (Beaulieu & Leclerc, 2006; Cripps, 2001; Lithwick, Beaulieu, Gravel, & Straka, 2000; Tetterton & Farnsworth, 2011). Effectively responding to the abuse and neglect of older adults requires an interprofessional, collaborative, and coordinated approach (Clancy, McDaid, O’Neill, & O’Brien, 2011; Harbison, Coughlan, Karabanow, & VanderPlaat, 2005; Heath, Kobylarz, Brown, & Castano, 2005; Killick & Taylor, 2009; Wiglesworth, Mosqueda, Burnight, Younglove, & Jeske, 2006). Overall, the majority of the studies specific to this question were of moderate to weak quality.

Education Needed to Effectively Address Abuse and Neglect of Older Adults

Three issues we identified that related to the education of health care providers were (a) a knowledge and training deficit around the abuse and neglect of older adults (i.e., how to recognize abuse, how to respond appropriately, laws related to reporting abuse) (Almogue et al., 2010; Podnieks, Anetzberger, Wilson, Teaster, & Wangmo, 2010; Richardson, Kitchen, & Livingston, 2002; Saliga, Adamowicz, Logue, & Smith, 2004); (b) a hesitancy to report abuse and neglect even after education is provided (McCool, Jogerst, Daly, & Xu, 2009); and (c) a gap between knowledge and practice in that education may increase knowledge about abuse but may not affect health ca1re provider behaviour (i.e., asking about or responding to abuse) (Jogerst, Daly, Dawson, Brinig, & Schmuch, 2003). The literature on older adult abuse education programs have shown mixed results regarding their effectiveness, mainly whether the education programs lead to an increase in knowledge, assessment skills, and reporting of abuse and neglect by health care providers (Alt, Nguyen, & Meurer, 2011; Jogerst et al., 2003; Mills et al., 2012; Teresi et al., 2013; Wong & Marr, 2002).

Despite these limitations and challenges, it is agreed in the literature that effective educational programs are needed so that health care providers have the knowledge to address abuse and neglect of older adults (Ko & Koh, 2012; Meeks-Sjostrom, 2013). Specifically, education programs should address four key elements: (1) discuss ethical issues involved with abuse (Beaulieu & Leclerc, 2006; Rodriguez et al., 2006; Winterstein (2012); (2) specify professional and legal responsibilities of health care providers when abuse and neglect is suspected or known (Killick & Taylor, 2009; Malmedal, Hammervold, & Saveman, 2009; Schmeidel et al., 2012); (3) use various training strategies focused on increasing knowledge in addressing abuse (Dow et al., 2013; Cooper, Selwood, & Livingston, 2009; Zink et al., 2004), and (4) modify attitudes that condone abuse (Shinan-Altman & Cohen, 2009). The majority of the studies specific to this question were of moderate quality.

Prevention and Health Promotion Strategies

Prevention and health promotion strategies targeted the older adult, the abusive caregiver, and the public. Strategies concerning older adults included community activities and supports that enable older people to disclose concerns and access assistance if needed. Examples include (a) implementing a rights-focused advocacy model to empower older adults to overcome abuse and (b) arranging for home-based supportive services, volunteer/buddy advocates, and the involvement of faith communities, community outreach, and support groups (Begley et al., 2012; Cripps, 2001; Nahmiash & Reis, 2000; Proehl, 2012; Wolf, 2001). Strategies for the abusive caregiver included programs specifically targeting abusers (i.e., counselling to minimize stress, education, anger management), and education about caregiving for older adults with cognitive impairments such as dementia (Hsieh, Wang, Yen, & Liu, 2009; Koch & Nay, 2003; Reay & Browne, 2002). Finally, suggested prevention strategies addressed public education about abuse and neglect of older adults, the rights of older adults, how to protect oneself from abuse, and awareness campaigns about abuse and neglect of older adults (Jogerst, Daly, & Ingram, 2001). The majority of the studies specific to this question were of moderate quality.

Organizational Policies and System Level Supports

Six strategies emerged that underline how organizations and government systems can target abuse and neglect of older adults. These were (a) developing abuse/neglect of older adults assessment teams (Fulmer et al., 2003; Heath et al., 2005; Lawrence & Banerjee, 2010; Mosqueda, Burnight, Liao, & Kemp, 2004; Teaster, Nerenberg, & Stansbury, 2003; Wiglesworth et al., 2006); (b) improving working conditions in nursing homes (Goergen, 2004; Shinan-Altman & Cohen, 2009); (c) supporting the supervision, tracking, and monitoring of abuse in nursing homes (Lindbloom et al., 2007; Malmedal et al., 2009; McCool et al., 2009; Phillips & Ziminski, 2012; Schmeidel et al., 2012); (d) providing funding for abuse programs/services (Jogerst et al., 2001; Podnieks et al., 2010); (e) developing policies and protocols for responding and for training; and (f) creating supports for health care providers (Buzgova & Ivanova, 2009; Ko, & Koh, 2012; Sandmoe & Kirkevold, 2013; Sandmoe et al., 2011).The literature pointed out the challenges and outcomes of mandatory reporting laws and policies (Saliga et al., 2004). Health care providers are not always aware of mandatory reporting laws and policies or how to enforce them. However, even after education is provided, not all providers comply for various reasons (e.g., not wanting to tell on a colleague) (Jogerst et al., 2003; Rodriguez et al., 2006). The majority of the studies specific to this question were of moderate quality.

Discussion

When reviewing a substantive body of evidence on a particular topic, it is important that the reviewers understand there is often a large degree of variability in the quality of existing research studies. Indeed, for our systematic review, the quality of the studies we reviewed significantly varied across the results, with only a few appraised as strong studies. The majority of these high-quality studies focused on describing abuse and neglect of older adults; very few focused on what could be done at the individual practitioner level and none at the organization level. This contributes to a number of concerns regarding the evidence that can inform us concerning this important issue.

There was no clear consensus on the definition and measurement of abuse among older adults. Differences in the prevalence of abuse or neglect and its components using the various definitions, both within and between populations of older adults, indicate that caution is required when comparing findings from different studies. Determining the significance of these differences will require prospective outcome studies. This lack of consistency will contribute to whether older adults are recognized as being abused. Indeed, a lack of consistent identification methods means that some older adults will not be identified and referred to appropriate services even as the abuse may continue.

Our review further indicated a lack of evidence to determine if screening for abuse actually reduces its occurrence; this was supported by the U.S. Preventive Services Task Force recommendation statement (2013), based on a systematic review of screening tools, that there is insufficient evidence about the benefits and harms of screening tools and raises doubts about their accuracy and effectiveness. Insufficient evidence also exists supporting the effectiveness of interventions to respond to abuse and neglect. There is a growing interest in providing intervention services for older victims of abuse along the lines of those developed for abused women. Emergency shelters and support groups specifically aimed at older abused adults are relatively new. However, few intervention programs have been formally evaluated, and it is not possible to say which approaches have been most effective.

Perhaps the most hurtful form of abuse against older adults, found in our review, lies generally in the negative attitudes held towards them. As long as older people are devalued by society, they will remain highly susceptible to all forms of abuse. Public awareness campaigns and educational initiatives are key to educating Canadians about abuse and neglect of older adults. Education is a fundamental preventive strategy and should be targeted to practitioners in the various relevant disciplines and to the public. Yet very little is known about the effectiveness of professional education and even less about public awareness campaigns to increase awareness and prevent abuse and neglect of older adults.

To continue to strengthen research evidence and related programs and policies, intervention strategies should be embedded in a rigorous research agenda. Future research should focus on understanding the effectiveness of different tools used to identify and assess for abuse and neglect and intervention approaches, and what works best in addressing this issue among the diversity of cultural groups in Canada.

Arising from the findings are areas rich for further investigation specific to abuse and neglect of older adults. Efforts to mobilize social action against this serious concern at an organizational, provincial/territorial, and national level – and efforts to develop legislation and policy initiatives – are at varying stages of development. However, there is no evidence to support their effectiveness or to indicate the true extent of the problem. Findings indicate a significant lack of available data to inform health policy. The determinants of health might provide a broad and inclusive framework in which to situate awareness, prevention, early detection, and effective intervention specific to the abuse and neglect of older adults, since economic and social factors contribute to their occurrence.

It is the authors’ perspective that enhanced understanding of the causes and consequences of abuse and neglect of older adults will contribute to its eventual elimination. Intergenerational practices that develop from abuse and neglect experiences within families need to be explored: Do they contribute to the experiences, or do they prevent them from developing? Children and youth are part of families, and we observed that clearly missing from the literature was an understanding of young people’s experiences with abuse and neglect of older family members, as well as around opportunities to engage them in ways that limit abuse and neglect.

Limitations of this Systematic Review

The methodology in conducting this systematic review is consistent with others published in recent years. Despite reviewing 13,064 English and French language records and relying on our expert panel to suggest others that we may have missed, the possibility remains that other records related to abuse and neglect of older adults were not identified and reviewed. Although the grey literature, including reporting guidelines, may have provided an alternative means for thinking about abuse and neglect, it was beyond the scope of this systematic literature review.

Conclusion

Abuse and neglect of older adults is a health and societal problem that occurs across a diverse range of settings and is likely more prevalent than is officially reported. It places a significant burden on older adults, in addition to that which is placed on health care providers, the health care system, and governments. This systematic review identified current evidence on effective approaches for addressing and preventing the abuse and neglect of older adults. However, it is clear that further research is needed to continue to articulate the evidence upon which actions must be taken to address abuse and neglect of older adults.

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