Adult Protective Services Clients Research Articles

Abuse of and Intervention for Older Adults During the COVID-19 Pandemic

Beginning in the United States in 2020, SARS-CoV-2 lead to unprecedented changes in the lives of both younger and older people. Efforts to mitigate the spread of the novel coronavirus, which included physical distancing and self-quarantine not only upended the lives of many people but also created natural laboratory conditions for the mistreatment of older adults. Exploring the mistreatment of older adults during the pandemic presented an unprecedented opportunity to examine perspectives of service providers and affected older adults. This symposium offers four perspectives on this subject. Dr. Karen Roberto and colleagues will present changes and challenges that COVID-19 brought for Adult Protectives Service staff and the vulnerable adults whom they serve. Ms. Lori Smetanka and colleagues will present changes and challenges that COVID-19 created for state and local Long-Term Care Ombudsman. Dr. Holly Ramsey-Klawsnik and Ms. Tammy Seaver will report on how the pandemic affected Nevada Adult Protective Services clients, casework, and staff. Finally, Dr. Pamela Teaster and colleagues will discuss how older adults experienced exploitation attempts during the early months of the pandemic. Dr. Cory Bolkan will begin the discussion, highlighting how conditions brought about by COVID-19 both enabled and thwarted efforts to address elder abuse.

Improving forensics: Characterizing injuries among community-dwelling physically abused older adults.

Physical elder abuse affects a substantial number of older adults, leaving victims at increased risk for negative health outcomes. Improved detection of abuse-related injuries may increase victim access to professional support, but providers report difficulties distinguishing between accidental and abuse-related injuries, due in part to victims' pre-existing health conditions and medication use. To describe the spectrum and characteristics of injuries among physically abused older adults and identify injury characteristics associated with abuse. Case-control study. Physically abused adult protective services clients were interviewed in their home; non-abused comparison group participants were interviewed in an outpatient geriatrics clinic. Sample included 156 community-dwelling adults aged 65 and older, including 57 physically abused and 99 non-abused individuals. Self-reported abuse history was confirmed through independent case assessment by a LEAD (Longitudinal, Expert All-Data) panel of clinicians with family violence expertise. Full-body assessments were conducted, documenting injury incidence, diagnosis, and location. We also collected sociodemographic characteristics, level of social support, functional ability, medical history, and medication use. Physically abused older adults were more likely to be injured upon assessment (79.0% vs 63.6%; p < 0.05) and have a greater number of injuries ( vs , p < 0.05). Injuries seen more often among abused individuals included: upper extremity ecchymoses (42.1% vs 26.3%; p < 0.05), abrasions (31.6% vs 11.1%; p < 0.01), and areas of tenderness (8.8% vs 0.0%; p < 0.01); and head/neck/maxillofacial ecchymoses (15.8% vs 2.0%; p < 0.01) and tenderness (15.8% vs 0.0%; p < 0.001). Lower extremity abrasions (12.3%) were common but unrelated to abuse status. While physical abuse does not always result in physical injury, victims more commonly display head/neck/maxillofacial ecchymoses or tenderness and upper extremity abrasions, ecchymoses, or tenderness. Detection of these injuries among older adults warrants further interview and examination.

Evaluating an Integrated APS–Elder Advocate Intervention Model in the State of Maine

Despite recommendations to include a distinct intervention phase in Adult Protective Services (APS), most APS programs close cases following investigation/substantiation phases without engaging in a defined intervention phase. This study implements and evaluates a novel APS service planning/intervention model in the state of Maine. Using an experimental efficacy trial design with stratified random sampling at the level of Maine APS offices, this study compares standard APS care with an enhanced/integrated APS intervention model involving “elder advocates”. Advocates were trained in motivational interviewing, supported decision-making, teaming, restorative justice, and goal attainment scaling to develop capacity to work with both the older adult victim and perpetrator and to strengthen the family and social systems surrounding the victim-perpetrator dyad. This presentation will present results on the efficacy of this integrated APS/elder advocate model and discuss the challenges and successes in conducting elder abuse intervention research in collaboration with APS and APS clients. Part of a symposium sponsored by Abuse, Neglect and Exploitation of Elderly People Interest Group.

Pent-up demand for care among dual-eligible victims of elder financial exploitation in Maine

ABSTRACT Elder financial exploitation (EFE), the misuse of a vulnerable adult’s property or resources for personal gain, is a form of elder abuse. This study addresses whether dual-eligible EFE victims were experiencing pent-up demand for health services alleviated through investigation by Adult Protective Services (APS). A quasi-experimental design addressed health service utilization and costs for 131 dual-eligible Maine APS clients over age 60 with substantiated allegations of EFE relative to comparable non-APS controls. APS case files spanning 2007–2012 were linked to 2006–2014 Medicare and Medicaid claims data. Service utilization and costs were analyzed 1 year prior, during, and 2 years after the initial APS investigation. Difference in differences logistic regression and generalized linear models addressed the likelihood of incurring costs and expenditure levels relative to matched controls, respectively. Victims of EFE had higher overall odds of using inpatient and long-term services and supports (LTSS) and higher odds of using LTSS post-investigation than controls. Higher overall levels of outpatient and prescriptions expenditures and higher inpatient expenditures during the APS event year contributed toward APS clients incurring $1,142 higher PMPM total costs than controls. Victims of EFE were experiencing significant pent-up demand for health services post-APS involvement.

Capacity evaluations for adult protective services: videoconference or in-person interviews

ABSTRACT The Geriatrician clinicians of the Texas Elder Abuse and Mistreatment Institute – Forensic Assessment Center Network (TEAM-FACN) in Houston, have many years of experience providing capacity assessment services for Adult Protective Services (APS) and Texas courts. A process has developed which is efficient, consistent, and evidence-informed. In the last two years, telecommunication has been added to this process to conduct assessments of APS clients in areas of Texas remote from the Houston area. Of the 545 capacity assessments TEAM-FACN has completed across the state of Texas over the first two years of adding telecommunication, 211 (39%) were conducted with in-person interviews and 334 (61%) were conducted using videoconference interviews. APS and the courts in remote areas of Texas have embraced the use of the videoconference assisted capacity assessments. This article describes this evidence-informed process and how telecommunication technology is incorporated to expand the reach of the service.

Clock Copying Predicts Mortality in Adult Protective Services Clients

The objective of this study was to determine if a clock copying task predicts 18-month mortality in an Adult Protective Services (APS) sample referred for a decision-making capacity assessment. The authors performed a retrospective medical record review of clients (N = 233) referred by APS for a decision-making capacity assessment during a 3-year time period. Information extracted included demographic data and neuropsychological performance on a battery sensitive to executive function, visuospatial ability, depression, memory, and general cognition. A Cox proportional hazards models was constructed to determine the relationship between Executive Clock Drawing Task Part 2 (CLOX2) performance and survival. Poor clock copying, as measured by CLOX2, predicted 18-month mortality when covaried for age, education, sex, rural dwelling status, depression, and general cognition. Clock copying is an easily administered visuospatial task that may inform survival in this vulnerable population.

Perceived Stress and Elder Abuse: A Population-Based Study of Adult Protective Services Cases in Chicago.

To characterize the relationship between perceived stress and Adult Protective Services (APS) elder abuse cases in a population-based sample. Cross-sectional. Chicago. community-dwelling, older adults (N = 8,558; mean age 74 ± 7, 62% female, 64% African American). Perceived Stress Scale (PSS), APS database linkage. Bivariate and adjusted analyses showed that perceived stress was significantly higher in APS clients than in participants without any APS interaction for various subtypes of abuse (e.g., abuse from a perpetrator and self-neglect). This relationship was strongest for those with a confirmed history of abuse from a perpetrator, with a medium-large effect size (t = -5.8, P < .001, Cohen D = -0.6). Those in the highest stress tertile had a likelihood of having confirmed history of abuse from a perpetrator that was nearly three times as great as that of those in lower stress tertiles (odds ratio = 2.7, 95% confidence interval = 1.2-6.2). Analyses of individual PSS items revealed a robust relationship between distress items and APS involvement. Items reflecting coping were inconsistently associated with elder abuse. Clients of APS have higher levels of perceived stress, and abuse from a perpetrator strengthens this relationship. Therefore, victims of abuse from a perpetrator may be at the highest risk of stress-related consequences and should be targeted for intervention efforts that enhance empowerment and effective coping strategies.

Executive Function Impairment and Recidivism in Adult Protective Services Clients Referred for a Decision Making Capacity Assessment

The objective of this study was to determine if recidivistic Adult Protective Services (APS) cases referred for a decision-making capacity assessment were more cognitively impaired than nonrecidivistic cases. A retrospective medical record review of neuropsychological and demographic data was gathered during decisional capacity assessments. Recidivistic clients were those referred to APS more than once; those with a single open case were nonrecidivistic. Mean neuropsychological test scores were compared between recidivistic (n = 138) and nonrecidivistic (n = 95) subjects. No significant differences were found for age, gender, ethnicity, education, or dwelling status. Both recidivistic and nonrecidivistic cases performed poorly in all cognitive domains. Recidivistic clients performed significantly worse on measures of executive function (CLOX1, EXIT25). Executive function impairments seem to be one risk factor for recidivism in APS referrals. With 60% of cases referred for decision capacity assessments being recidivistic, identifying risk factors may help identify when targeted interventions are indicated to preclude recurrence of abuse.

Cognitive Profiles of Elder Adult Protective Services Clients Living in Squalor

The purpose of this study was to determine whether squalor-dwelling Adult Protective Services (APS) clients were more cognitively impaired than non–squalor-dwelling APS clients referred for decision-making capacity assessments. The authors performed a retrospective medical record review of neuropsychological and demographic data gathered during decisional capacity assessments. Squalor dwelling was defined by unsanitary living conditions that posed a danger to the occupant’s health or safety. Mean neuropsychological test scores were compared between squalor-dwelling (n = 50) and non–squalor-dwelling (n = 180) subjects. Squalor-dwelling clients were significantly younger than non–squalor-dwelling clients. There were no distribution differences among gender, education, race, or rural-dwelling status. Although both groups performed poorly on each neuropsychological measure, squalor dwellers demonstrated better memory and general cognitive performance. Cognition, depression, gender, race, education, dementia diagnosis, and rural-dwelling status seem insufficient to explain squalor-dwelling behaviors. Other biological and psychosocial variables should be considered.

Multidimensional Measurement Within Adult Protective Services: Design and Initial Testing of the Tool for Risk, Interventions, and Outcomes

This study describes the development, field utility, reliability, and validity of the multidimensional Tool for Risk, Interventions, and Outcomes (TRIO) for use in Adult Protective Services (APS). The TRIO is designed to facilitate consistent APS practice and collect data related to multiple dimensions of typical interactions with APS clients, including the investigation and assessment of risks, the provision of APS interventions, and associated health and safety outcomes. Initial tests of the TRIO indicated high field utility, social worker “relevance and buy-in,” and inter-rater reliability. TRIO concurrent validity was demonstrated via appropriate patterns of TRIO item differentiation based on the type of observed confirmed abuse or neglect; and predictive validity was demonstrated by prediction of the risk of actual APS recurrence. The TRIO is a promising new tool that can help meet the challenges of providing and documenting effective APS practices and identifying those at high risk for future APS recurrence.

Adult Protective Services Clients Confirmed for Self-Neglect: Characteristics and Service Use

Self-neglect is a complex and inadequately understood phenomenon that accounts for the majority of Adult Protective Services cases. This retrospective, record-based study of the characteristics of 210 older adults who were reported to Adult Protective Services and confirmed for self-neglect revealed that common health problems included nutritional frailty, arthritis, and incontinence. Comparisons based upon length of service showed differences in worker-rated social environment risk, client capacity, and activities of daily living performance. Comparisons of findings with those of other studies of self-neglect underscore the need for systematic research on this population.

Executive Function in Self-Neglecting Adult Protective Services Referrals Compared With Elder Psychiatric Outpatients

Psychometric performance, with an emphasis on executive function, was compared between adult protective services (APS) clients referred for a decision-making capacity consultation and elders seen in an outpatient geriatric psychiatry clinic. The authors performed a retrospective medical records review extracting general, executive, and visuospatial cognitive performance and depression symptom burden in APS referrals (N = 63) and geriatric psychiatry outpatients (N = 58). After adjusting for age and education, APS clients had worse mean executive performance as measured by the Executive Interview (24.3 [SD 6.4] versus 17.3 [SD 7.6], F[1, 87] 15.7, p <0.001) and CLOX1 (7.4 [SD 4.0] versus 9.3 [SD 4.2], F[1, 92] 4.79, p = 0.03). There were no differences in visuospatial or general cognitive abilities. The self-neglect subgroup had worse cognitive performance on each measure than other APS referrals. Compared with routine geriatric psychiatry patients, APS referrals are more likely to be executively impaired but less depressed. General cognitive screens do not distinguish these two groups.

A National Study of Involuntary Protective Services to Adult Protective Services Clients

ABSTRACT A questionnaire was sent to state administrators of Adult Protective Services Programs (APS) to learn about involuntary protective services provided by APS to vulnerable adults at risk of abuse, neglect, or exploitation. Data were obtained on criteria used to assess the need for involuntary services, types of services provided, sources of authority for involuntary intervention, the nature and extent of public concern about involuntary services, and the protection of the rights of incapacitated clients. Based on responses from 43 states, less than 10 percent of APS recipients receive services without their consent; and all states providing services involuntarily take steps to ensure the protection of rights. Available information from the study does not support the general belief that adults who self-neglect are more likely than other APS clients to have protective services imposed.