Elder Abuse Forensic Research Articles

Using Latent Class Analysis to Identify Types of Elder Abuse: Multidisciplinary Team Interventions

Elder abuse is a complex, multifaceted problem that can devastate the lives of older adults, and overwhelm medical, legal, and social service providers. To address this problem, the Elder Abuse Multidisciplinary Team (MDT) is an oft-utilized intervention that brings individuals from various professional disciplines together to address elder abuse. With the passage of the Elder Justice Act of 2010, the Federal Government included budgetary provisions in support of a particularly promising model of MDT: The Elder Abuse Forensic Center (EAFC). Although the EAFC model has been implemented at four sites in California with promising outcomes, the specific structures, processes, and practices that currently define this model have not been validated with rigorous research of other MDTs in the United States. In this study, we surveyed 81 elder abuse MDT key informants across the country, using instruments guided by the most current EAFC model (Yonashiro-Cho et al., 2019). We then used Latent Class Analysis (LCA) to group these teams based on EAFC model characteristics. We hypothesized that elder abuse MDTs would fall on a spectrum: those that were identical or nearly identical to the EAFC model, those that had some EAFC qualities, and those that were not identical. Results of the LCA supported our hypothesis and revealed three types of elder abuse MDTs: EAFCs (n=26), Semi-EAFCs (n=24), and Non-EAFCs (n=31). Policy makers, advocates, and professionals seeking to form new teams or support existing teams can draw on these findings to make decisions about MDT creation and sustainability.

Development and Evaluation of an Elder Abuse Forensic Nurse Examiner e-Learning Curriculum.

In Ontario, Canada, there is a need for an easily accessible training for forensic nurse examiners on the provision of care for abused older adults. In this study, our objective was to develop and evaluate a novel elder abuse nurse examiner e-learning curriculum focused on improving the care provided to older adults. The curriculum was launched on an online learning management system to forensic nurses working across Ontario’s hospital-based violence treatment centers in June 2019 and evaluated using pre- and post-training questionnaires that measured self-assessed changes in knowledge and skills-based competence related to providing elder abuse care. There were significant improvements pre- to post-training in self-reported knowledge and competence across all core content domains: Older Adults and Abuse; Documentation, Legal, and Legislative Issues; Interview with Older Adult, Caregiver, and Other Relevant Contacts; Initial Assessment; Medical and Forensic Examination; and Case Summary, Discharge Plan, and Follow-Up Care. As the curriculum enhanced the knowledge and skills associated with caring for abused older adults, it may have implications for training forensic nurse examiners and associated staff working in more than 25 countries internationally.

Prosecutors' Perspectives on Elder Justice Using an Elder Abuse Forensic Center.

Prosecution is a rare outcome in elder financial exploitation. Previous studies have shown that elder abuse forensic centers-multidisciplinary teams that help investigate and respond to elder mistreatment-increase prosecution rates by enhancing teamwork across agencies. Research is needed to identify what aspects of this intervention model lead to better elder justice outcomes. Six District Attorneys (DAs) were interviewed about their experiences working with other agencies at an elder abuse forensic center (the "Center") and how participating in case discussions influenced their professional perspectives on elder abuse. Transcripts were analyzed qualitatively revealing three themes: (1) "goal-driven" versus "mission-driven" professional orientations; (2) role blurring; and (3) value added from participating in the Center team. Important factors for increasing rates of prosecution were: (1) having key decision-makers present at the meeting; (2) the forensic expertise provided by the geriatrician and neuropsychologist; and (3) cross-discipline learning. Influenced by the other disciplines, DAs sought goals beyond prosecution as the default approach to resolving elder financial abuse and advocated for interventions that could best respond to the victim's needs, such as restitution or protection.

Inside the Black Box: The Case Review Process of an Elder Abuse Forensic Center.

Preliminary evidence suggests that elder abuse forensic centers improve victim welfare by increasing necessary prosecutions and conservatorships and reducing the recurrence of protective service referrals. Center team members gather information and make decisions designed to protect clients and their assets, yet the collective process of how these case reviews are conducted remains unexamined. The purpose of this study is to present a model describing the interprofessional approach of investigation and response to financial exploitation (FE), a frequent and complex type of abuse of vulnerable adults. To develop an understanding of the case review process at the Los Angeles County Elder Abuse Forensic Center (Center), a quasi-Delphi field study approach was used involving direct observations of meetings, surveying team members, and review from the Center's Advisory Council. The goal of this iterative analysis was to understand the case review process for suspected FE in Los Angeles County. A process map of key forensic center elements was developed that may be useful for replication in other settings. The process map includes: (a) multidisciplinary data collection, (b) key decisions for consideration, and (c) strategic actions utilized by an interprofessional team focused on elder justice. Elder justice relies on a complex system of providers. Elder abuse forensic centers provide a process designed to efficiently address client safety, client welfare, and protection of assets. Study findings provide a process map that may help other communities replicate an established multidisciplinary team, one experienced with justice system outcomes designed to protect FE victims.

Protecting victims of elder financial exploitation: the role of an Elder Abuse Forensic Center in referring victims for conservatorship

Objectives: The aim of this study was to examine the extent to which an Elder Abuse Forensic Center protects financial exploitation (FE) victims through referral to the Office of the Public Guardian (PG) for investigation and possible conservatorship (called ‘guardianship’ in many states).Method: Los Angeles County Elder Abuse Forensic Center cases involving adults aged 65 and older (April 2007–December 2009) were matched using one-to-one propensity-score matching to 33,650 usual care Adult Protective Services (APS) cases. The final analysis sample consisted of 472 FE cases.Results: Compared to usual care, Forensic Center cases were more likely to be referred to the PG for investigation (30.6%, n = 72 vs. 5.9%, n = 14, p < .001). The strongest predictors of PG referral were suspected cognitive impairment, as identified by APS (odds ratio [OR] = 11.69, confidence intervals [CI]: 3.50–39.03), and Forensic Center review (OR = 7.85, CI: 3.86–15.95). Among referred cases, the court approved conservatorship at higher rates – though not statistically significant – for Forensic Center cases than usual care (52.9%, n = 36/68 vs. 41.7%, n = 5/12).Conclusion: Conservatorship may be a necessary last resort to improve safety for some FE victims, and the Forensic Center appears to provide a pathway to this service. These findings suggest modification to the Elder Abuse Forensic Center conceptual model and contribute to an emerging body of evidence on the role of the Forensic Center in addressing elder abuse.

Neuropsychological Profiles of Victims of Financial Elder Exploitation at the Los Angeles County Elder Abuse Forensic Center

The current article examines neuropsychological correlates of financial elder exploitation in a sample of older adults who have been documented victims of financial elder exploitation. The purpose of this exploratory study was twofold. First, a subsample of the referrals at the Los Angeles County Elder Abuse Forensic Center (LACEAFC) was compared to community dwelling adults in terms of the specific cognitive domains linked to financial capacity including memory, calculation, and executive functioning. Next, the correlation between presence of neuropsychological data and the likelihood of filing a case with the LA County’s District Attorney office was examined. Twenty-seven LACEAFC cases and 32 controls were assessed. Overall, the forensic center group performed worse than a community-based age-matched control group on the MMSE, calculation, and executive functioning (ps < .01). The presence of neuropsychological data was significantly correlated to an increased likelihood of a case being filed.

Holding Abusers Accountable: An Elder Abuse Forensic Center Increases Criminal Prosecution of Financial Exploitation

Despite growing awareness of elder abuse, cases are rarely prosecuted. The aim of this study was to examine the effectiveness of an elder abuse forensic center compared with usual care to increase prosecution of elder financial abuse. Using one-to-one propensity score matching, cases referred to the Los Angeles County Elder Abuse Forensic Center (the Forensic Center) between April 2007 and December 2009 for financial exploitation of adults aged 65 and older (n = 237) were matched to a population of 33,650 cases that received usual care from Adult Protective Services (APS). 1 Significantly, more Forensic Center cases were submitted to the District Attorney's office (DA) for review (22%, n = 51 vs. 3%, n = 7 usual care, p < .001). Among the cases submitted, charges were filed by the DA at similar rates, as was the proportion of resultant pleas and convictions. Using logistic regression, the strongest predictor of case review and ultimate filing and conviction was whether the case was presented at the Forensic Center, with 10 times greater odds of submission to the DA (Odds ratio = 11.00, confidence interval = 4.66-25.98). Previous studies have not demonstrated that elder abuse interventions impact outcomes; this study breaks new ground by showing that an elder abuse multidisciplinary team increases rates of prosecution for financial exploitation. The elder abuse forensic center model facilitates cooperation and group problem solving among key professionals, including APS, law enforcement, and the DA and provides additional resources such as neuropsychological testing, medical record review, and direct access to the Office of the Public Guardian.

The Bet Tzedek Legal Services Model: How a Legal Services Model Addresses Elder Abuse and Neglect

Bet Tzedek, Hebrew for the “House of Justice,” provides free legal assistance to older adults in Los Angeles County. Their civil attorneys work alongside prosecutors and service providers for the elderly as members of multidisciplinary teams to assist older adults with complicated elder abuse and neglect cases. Case examples demonstrate how civil attorneys collaborate with the Los Angeles County Elder Abuse Forensic Center to address financial abuse, real estate fraud, and self-neglect issues. Cooperation among the courts, Bet Tzedek, and other county agencies has resulted in more user-friendly processes to expedite filing of conservatorships and elder abuse restraining orders.

Do We Really Need Another Meeting? Lessons From the Los Angeles County Elder Abuse Forensic Center

Elder abuse cases are often time consuming and complex, requiring interagency cooperation from a diverse array of professionals. Although multidisciplinary teams (MDTs) offer a potentially powerful approach to synergizing the efforts of different providers, there has been little research on elder abuse MDTs in general or elder abuse forensic centers in particular. This article draws on our experience with the development of an innovative elder abuse MDT model by describing the structure, process, and outcomes of the Los Angeles County Elder Abuse Forensic Center (the Center). We use a logic model to provide the framework for discussing the Center's components and de-identified client records to report key characteristics of the cases reviewed (n = 313). We summarize surveys of core team members' evaluations of team effectiveness (n = 37) and case presenters' assessments of the Center effectiveness (n = 108). During its first 3 years, the Center reviewed 2-4 cases per week and gained active and regular participation among core team members. Both team members' and presenters' evaluations were highly favorable. Process outcomes indicate that busy professionals found the model extremely valuable, with added consultation and services aiding elder abuse prevention, protection, and prosecution. The logic model offers structure, process, and outcomes with which to replicate and individualize the elder abuse forensic center model according to the needs and resources in each community.

Findings From an Elder Abuse Forensic Center

The first Elder Abuse Forensic Center (EAFC) in the United States was instituted in 2003. People from a variety of disciplines, including Adult Protective Services social workers, law enforcement, the district attorney's office, a medical response team, public guardian deputies, ombudsmen, mental health services, a victim advocate, and a domestic violence expert work cooperatively on cases of elder and dependent-adult mistreatment. Researchers conducted an assessment of the EAFC's impact on the efficiency and effectiveness of the collaboration. Mixed quantitative and qualitative methods included statistical analysis of data from outcome surveys of EAFC collaborators and illustrative case studies developed from case files and structured interviews. Mean survey scores evaluating the efficiency and effectiveness of the collaboration were significantly better than neutral responses. Case studies show efficient and effective case management through cooperation of the collaborating agencies. Survey results clearly support perceptions exemplified in case studies. An EAFC enhances the efficiency and effectiveness of those who address elder abuse in one community, which in turn leads to improved outcomes. Continued analysis to identify strengths, weaknesses, and cost effectiveness of the EAFC model is ongoing.

Elder Abuse at End of Life

Advances in health care and changing demographics have led to an aging population whose care at the end of life has become complex. Patients at the end of life, by the nature of their clinical and social circumstances, are at high risk for elder abuse. Underreporting of elder abuse is a growing concern. The clinical presentation of abuse may overlap with the natural dying process, further compounding the problem. Articles were obtained through a PubMed search using the terms "elder abuse" and "elder mistreatment" and from the University of California, Irvine's Elder Abuse Forensic Center library. Additional references were followed through these first set of articles and also from colleagues expert in this field. Multidisciplinary teams have been shown to be the most effective intervention for the assessment and prevention of abuse. Most abuse occurs at home by family members; the hospice team may be the only outside professionals coming into the home. Caregiver stress and victim dependency increase the risk for abuse. Although physical abuse is the most commonly envisioned, neglect is the most common form of abuse. Financial abuse is often the underlying motivation for other forms of abuse. Health professionals have an ethical and legal responsibility to both report and work to prevent suspected abuse. The interdisciplinary team can make a significant impact on elder abuse, a major detriment on quality of life.