A Review of Elder Abuse Screening Tools for Use in the Irish Context
A Review of Elder Abuse Screening Tools for Use in the Irish Context
A Review of Elder Abuse Screening Tools for Use in the Irish Context
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A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong><br />
<strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong><br />
Amanda Phelan and Margaret P. Treacy
NCPOP Board <strong>of</strong> Programme Directors<br />
Pr<strong>of</strong>essor Margaret P. Treacy, Pr<strong>of</strong>essor Gerard Fealy, Pr<strong>of</strong>essor Denis Cusack, Pr<strong>of</strong>essor Cecily Kelleher, Pr<strong>of</strong>essor Colm<br />
Harmon, Ms. Anne O’Loughl<strong>in</strong>, Dr. Amanda Phelan, Pr<strong>of</strong>essor Suzanne Qu<strong>in</strong>.<br />
This study was funded by <strong>the</strong> Health Service Executive as part <strong>of</strong> <strong>the</strong> work <strong>of</strong> <strong>the</strong> National Centre <strong>for</strong> <strong>the</strong> Protection <strong>of</strong><br />
Older People (NCPOP) at University College Dubl<strong>in</strong>.<br />
This report should be cited as:<br />
Phelan, A., Treacy, M.P. (2011) A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong>, NCPOP, School <strong>of</strong> Nurs<strong>in</strong>g, Midwifery and<br />
Health Systems, University College Dubl<strong>in</strong><br />
National Centre <strong>for</strong> <strong>the</strong> Protection <strong>of</strong> Older People (NCPOP)<br />
UCD School <strong>of</strong> Nurs<strong>in</strong>g, Midwifery and Heath Systems<br />
Health Sciences Centre<br />
University College Dubl<strong>in</strong><br />
Belfield, Dubl<strong>in</strong> 4, Ireland<br />
Tel: +353 (0)1 716 6467 Fax: +353 (0)1 716 6498<br />
Email: ncpop@ucd.ie Web: www.ncpop.ie<br />
© UCD and HSE, 2011
Acknowledgements<br />
The National Centre <strong>for</strong> <strong>the</strong> Protection <strong>of</strong> Older People gratefully acknowledges <strong>the</strong> <strong>in</strong>valuable support and<br />
contribution to <strong>the</strong> work <strong>of</strong>:<br />
• Pr<strong>of</strong>essor Mark Yaffe, Department <strong>of</strong> Family Medic<strong>in</strong>e McGill University/St. Mary’s Hospital Center, Montreal<br />
• Pr<strong>of</strong>essor Mark Lachs, The Weill Medical College <strong>of</strong> Cornell University/ Director <strong>of</strong> Geriatrics, New York<br />
Presbyterian Health System<br />
• Pr<strong>of</strong>essor Karl Pillemer, Cornell Institute <strong>for</strong> Translational Research on Age<strong>in</strong>g (NCPOP International Advisory<br />
Committee)<br />
• The Health Service Executive (HSE) which funds <strong>the</strong> NCPOP and <strong>the</strong> programme <strong>of</strong> research <strong>of</strong> which this work<br />
is part; <strong>the</strong> NCPOP HSE Steer<strong>in</strong>g Committee and <strong>the</strong> NCPOP HSE Management Group.<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 1
Contents<br />
Abbreviations 3<br />
1. Introduction 4<br />
1.1 Rationale <strong>for</strong> this review 4<br />
1.2 Method 4<br />
2. <strong>Context</strong>: population 5<br />
2.1 The extent <strong>of</strong> elder abuse 5<br />
2.2 Risk factors <strong>for</strong> elder abuse 5<br />
3. <strong>Screen<strong>in</strong>g</strong> 6<br />
3.1 <strong>Screen<strong>in</strong>g</strong> <strong>in</strong> family violence 6<br />
3.2 Us<strong>in</strong>g technology to screen 7<br />
3.3 <strong>Screen<strong>in</strong>g</strong> <strong>for</strong> elder abuse 7<br />
3.3.1 <strong>Screen<strong>in</strong>g</strong> tools and validation 10<br />
a) The Hwalek-Sengstock <strong>Elder</strong> <strong>Abuse</strong> 10<br />
<strong>Screen<strong>in</strong>g</strong> Test<br />
b) The Vulnerability <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Scale 11<br />
c) The <strong>Elder</strong> Assessment Instrument 12<br />
d) The Indicators <strong>of</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Tool 13<br />
e) Brief <strong>Abuse</strong> Screen <strong>for</strong> <strong>the</strong> <strong>Elder</strong>ly 14<br />
f) The Caregiver <strong>Abuse</strong> Screen 14<br />
g) The <strong>Elder</strong> <strong>Abuse</strong> Suspicion Index 14<br />
h) Caregivers Psychological <strong>Elder</strong> <strong>Abuse</strong> 16<br />
Behaviour Scale<br />
i) <strong>Elder</strong> Psychological <strong>Abuse</strong> Scale 16<br />
j) The Older Adult Psychological <strong>Abuse</strong> Measure 17<br />
k) The Older Adult F<strong>in</strong>ancial Exploitation Measure 17<br />
3.4 Assessment guidel<strong>in</strong>es 18<br />
4. Discussion 20<br />
5. Conclusion and Recommendations 21<br />
References 22<br />
2<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong>
Abbreviations<br />
AAT<br />
AMA<br />
BASE<br />
CABS<br />
CAS<br />
CPEABS<br />
EAI<br />
EASI<br />
EASI-sa<br />
EPAS<br />
H-S EAST<br />
IOA<br />
OAPAM<br />
OAFEM<br />
RAT<br />
SAT<br />
STRP<br />
VASS<br />
Actual <strong>Abuse</strong> Tool<br />
American Medical Association<br />
The Brief <strong>Abuse</strong> Screen <strong>for</strong> <strong>the</strong> <strong>Elder</strong>ly<br />
Care Giver’s Burden Scale<br />
The Caregiver <strong>Abuse</strong> Screen<br />
Caregivers Psychological <strong>Elder</strong> <strong>Abuse</strong><br />
Behaviour Scale<br />
The <strong>Elder</strong> Assessment Instrument<br />
The <strong>Elder</strong> <strong>Abuse</strong> Suspicion Index<br />
The <strong>Elder</strong> <strong>Abuse</strong> Suspicion Index - self<br />
adm<strong>in</strong>istered<br />
<strong>Elder</strong> Psychological <strong>Abuse</strong> Scale<br />
The Hwalek-Sengstock <strong>Elder</strong> <strong>Abuse</strong><br />
<strong>Screen<strong>in</strong>g</strong> Test<br />
The Indicators <strong>of</strong> <strong>Abuse</strong> Screen<br />
Older Adult Psychological <strong>Abuse</strong><br />
Measure<br />
The Older Adult F<strong>in</strong>ancial Exploitation<br />
Measure<br />
Risk <strong>of</strong> <strong>Abuse</strong> Tool<br />
Suspected <strong>Abuse</strong> Tool<br />
<strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> and Referral Protocol<br />
Vulnerability <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Scale<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 3
1. Introduction<br />
This review presents a discussion <strong>of</strong> a selection <strong>of</strong> tools<br />
designed to highlight <strong>the</strong> potential <strong>for</strong> elder abuse and it<br />
exam<strong>in</strong>es <strong>the</strong>m <strong>for</strong> possible use with<strong>in</strong> <strong>the</strong> <strong>Irish</strong> context.<br />
These tools while referred to as screen<strong>in</strong>g tools, <strong>in</strong><br />
general, highlight suspicion <strong>of</strong> elder abuse ra<strong>the</strong>r than<br />
giv<strong>in</strong>g rise to a def<strong>in</strong>itive diagnosis <strong>of</strong> abuse. The <strong>Irish</strong><br />
policy document (DOHC 2002), recommended that <strong>the</strong><br />
basic report<strong>in</strong>g assessment <strong>of</strong> elder abuse should <strong>in</strong>volve<br />
<strong>the</strong> detection <strong>of</strong> elder abuse. <strong>Elder</strong> abuse screen<strong>in</strong>g tools<br />
have been suggested as a method <strong>of</strong> assist<strong>in</strong>g<br />
practitioners to detect <strong>the</strong> risk <strong>of</strong> elder abuse (Fulmer et<br />
al. 2005) and <strong>the</strong>se screen<strong>in</strong>g tools may <strong>of</strong>fer <strong>the</strong> capacity<br />
to highlight potential abuse which can lead to fur<strong>the</strong>r<br />
<strong>in</strong>vestigation. The capacity <strong>of</strong> screen<strong>in</strong>g tools to detect<br />
potential abuse is particularly important as many<br />
pr<strong>of</strong>essionals struggle to recognise elder abuse (Heath et<br />
al. 2005; Kennedy 2005; Newton 2005; Cooper et al.<br />
2008a,b; Perel-Lev<strong>in</strong> 2008; Killick and Taylor 2009). The<br />
paper presents <strong>the</strong> aims, <strong>the</strong> background rational and <strong>the</strong><br />
approach adopted <strong>for</strong> <strong>the</strong> review. This is followed by a<br />
brief <strong>in</strong>troduction to <strong>the</strong> context <strong>of</strong> elder abuse with<strong>in</strong><br />
<strong>the</strong> <strong>Irish</strong> population, risk factors <strong>for</strong> elder abuse,<br />
challenges <strong>in</strong> screen<strong>in</strong>g <strong>for</strong> potential elder abuse,<br />
discussion <strong>of</strong> a number <strong>of</strong> elder abuse screen<strong>in</strong>g tools<br />
and recommendations.<br />
The aims <strong>of</strong> this review are:<br />
1. To exam<strong>in</strong>e elder abuse screen<strong>in</strong>g tools<br />
<strong>in</strong>ternationally and identify a tool(s) <strong>of</strong> particular<br />
merit <strong>for</strong> potential use <strong>in</strong> <strong>the</strong> <strong>Irish</strong> context<br />
2. To identify issues related to <strong>the</strong> use <strong>of</strong> elder<br />
abuse screen<strong>in</strong>g tools <strong>in</strong>ternationally<br />
3. To make recommendations regard<strong>in</strong>g <strong>the</strong> use <strong>of</strong><br />
elder abuse screen<strong>in</strong>g tools <strong>in</strong> <strong>the</strong> <strong>Irish</strong> context.<br />
1.1 Rationale <strong>for</strong> this review<br />
Various <strong>Irish</strong> reports have identified <strong>the</strong> need to facilitate<br />
mechanisms which will assist <strong>in</strong> <strong>the</strong> early identification <strong>of</strong><br />
elder abuse (DOHC 2002; National Council on Age<strong>in</strong>g<br />
and Older People 2009). Consequently, screen<strong>in</strong>g tools<br />
may <strong>of</strong>fer a method <strong>of</strong> identify<strong>in</strong>g older people who may<br />
be at risk <strong>of</strong> abuse or have a greater probability <strong>of</strong> be<strong>in</strong>g<br />
subjected to abuse. This is particularly relevant <strong>in</strong> an<br />
age<strong>in</strong>g <strong>Irish</strong> population (Layte 2009; Layte et al. 2009) <strong>in</strong><br />
terms <strong>of</strong> negative experiences and outcomes <strong>for</strong> older<br />
people who are subjected to abuse (Lachs et al. 1998;<br />
Lachs et al. 2002; Dong et al. 2009; WHO 2011). This<br />
review exam<strong>in</strong>es elder abuse screen<strong>in</strong>g tools and sets out<br />
to identify tools which have <strong>the</strong> potential to transfer <strong>for</strong><br />
use <strong>in</strong> <strong>the</strong> <strong>Irish</strong> sett<strong>in</strong>g. If available, <strong>the</strong> use <strong>of</strong> a<br />
standardised, reliable and valid screen<strong>in</strong>g tool(s) will<br />
facilitate more generic understand<strong>in</strong>g and <strong>in</strong>ter-rater<br />
reliability giv<strong>in</strong>g rise to more clarity <strong>in</strong> recognis<strong>in</strong>g<br />
potential elder abuse. However, prior to us<strong>in</strong>g any tool<br />
adequate tra<strong>in</strong><strong>in</strong>g and education must be provided <strong>for</strong><br />
healthcare pr<strong>of</strong>essionals who may use <strong>the</strong> tool <strong>in</strong><br />
practice.<br />
1.2 Method<br />
A literature search was undertaken <strong>in</strong> CINAHL and<br />
PUBMED us<strong>in</strong>g <strong>the</strong> terms ‘elder abuse and screen<strong>in</strong>g<br />
tools’ and ‘elder abuse detection’ <strong>for</strong> <strong>the</strong> years 1980-2010.<br />
Grey literature was searched through a review <strong>of</strong> <strong>in</strong>ternet<br />
websites us<strong>in</strong>g <strong>the</strong> same search terms. In addition,<br />
consultation took place with experts who had published<br />
work <strong>in</strong> relation to screen<strong>in</strong>g tools which have<br />
demonstrated merit <strong>in</strong> terms <strong>of</strong> reliability and validity.<br />
4<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong>
2. <strong>Context</strong>: population<br />
The world’s population is age<strong>in</strong>g. In Ireland,<br />
demographics <strong>in</strong>dicate that approximately 11.5 percent<br />
<strong>of</strong> <strong>the</strong> population is aged 65 years or older (CSO 2006).<br />
However, due to advances <strong>in</strong> areas such as healthcare,<br />
pharmaceuticals, welfare protection and changes <strong>in</strong><br />
<strong>in</strong>fertility rates, <strong>the</strong> volume <strong>of</strong> older people will <strong>in</strong>crease.<br />
The Economic and Social Research Institute (Morgenroth<br />
2009) estimate that older people <strong>in</strong> Ireland will rise from<br />
11.5 percent <strong>in</strong> 2006 to 15.1 percent <strong>in</strong> 2021.<br />
Fur<strong>the</strong>rmore, <strong>the</strong> number <strong>of</strong> old persons (65 years and<br />
over) is projected to almost double <strong>in</strong> every geographical<br />
region <strong>in</strong> Ireland between 2011-2020 (CSO 2008). With<strong>in</strong><br />
<strong>the</strong> context <strong>of</strong> a ris<strong>in</strong>g older person population, it is<br />
anticipated that most older people will reside <strong>in</strong> <strong>the</strong><br />
community (Duggan and Murphy 2009).<br />
2.1 The extent <strong>of</strong> elder abuse<br />
<strong>Elder</strong> abuse is a significant issue <strong>in</strong> societies globally<br />
(Fulmer and O’Malley 1987; Mellor and Brownell 2006;<br />
Brandl et al. 2007; Phelan 2010). From its <strong>for</strong>mal<br />
recognition (Baker 1975), <strong>the</strong>re have been particular<br />
challenges <strong>in</strong> def<strong>in</strong><strong>in</strong>g precisely what constitutes elder<br />
abuse (Johnson 1986; Bennett et al. 1997) due to its<br />
complex, multi-factorial contexts (Lachs and Pillemer<br />
2004; Bomba 2006) and vary<strong>in</strong>g cultural <strong>in</strong>terpretations.<br />
<strong>Elder</strong> abuse prevalence studies <strong>in</strong>dicate that between two<br />
to five percent <strong>of</strong> community dwell<strong>in</strong>g older people<br />
experience some <strong>for</strong>m <strong>of</strong> abuse. A recent study <strong>in</strong> Ireland<br />
(Naughton et al. 2010) <strong>in</strong>dicated a prevalence <strong>of</strong> 2.2<br />
percent <strong>in</strong> community dwell<strong>in</strong>g older people, and this<br />
rose to 2.9 percent when <strong>the</strong> def<strong>in</strong>ition <strong>in</strong>cluded abuse by<br />
neighbours or acqua<strong>in</strong>tances (Naughton et al. 2010). This<br />
broadly concurs with o<strong>the</strong>r <strong>in</strong>ternational studies on elder<br />
abuse prevalence (Wetzels 1996; Pillemer and F<strong>in</strong>kelhor<br />
1998; Comijis 1998a,1998b; O’Keefe et al. 2007), however,<br />
some prevalence studies have identified a much higher<br />
rate, <strong>for</strong> example <strong>in</strong> Israel (18.4% exclud<strong>in</strong>g neglect)<br />
(Eisikovits et al. 2005; Lowenste<strong>in</strong> et al. 2009) and <strong>the</strong><br />
United States (11.4%) (Acierno et al. 2010). While<br />
prevalence studies seek to enumerate <strong>the</strong> extent <strong>of</strong> elder<br />
abuse <strong>in</strong> society, many <strong>of</strong> <strong>the</strong>se studies represent<br />
‘impressionistic estimates’ (Bonnie and Wallace 2003:21).<br />
It has been observed that elder abuse prevalence<br />
statistics are likely to be underestimates <strong>of</strong> true figures, a<br />
phenomenon which has been referred to as <strong>the</strong> ‘iceberg<br />
<strong>the</strong>ory’ (Tatara et al. 1998; Rhodes 2005). The National<br />
<strong>Elder</strong> <strong>Abuse</strong> Incidence Study (NEAIS) (Tatara et al. 1998)<br />
estimated that <strong>for</strong> every one reported case <strong>of</strong> elder<br />
abuse, up to 5.3 cases are not reported. Fulmer (2003)<br />
argues that it is more likely that at least one <strong>in</strong> ten cases<br />
do not come to <strong>the</strong> attention <strong>of</strong> <strong>of</strong>ficial bodies and that<br />
<strong>the</strong> lack <strong>of</strong> pr<strong>of</strong>essional report<strong>in</strong>g is due to <strong>the</strong> absence <strong>of</strong><br />
appropriate screen<strong>in</strong>g <strong>in</strong>struments.<br />
The detection <strong>of</strong> elder abuse <strong>in</strong> Ireland is highlighted as<br />
be<strong>in</strong>g particularly important when <strong>Irish</strong> prevalence figures<br />
(Naughton et al. 2010) are compared to referrals <strong>of</strong> elder<br />
abuse to <strong>the</strong> HSE elder abuse service (HSE 2011). Despite<br />
ef<strong>for</strong>ts to <strong>for</strong>mally address <strong>the</strong> issue <strong>of</strong> elder abuse <strong>in</strong><br />
Ireland through dedicated services and staff tra<strong>in</strong><strong>in</strong>g,<br />
referrals rema<strong>in</strong> low compared to prevalence statistics. In<br />
this context, <strong>the</strong> availability and use <strong>of</strong> screen<strong>in</strong>g tools<br />
may <strong>of</strong>fer a greater pathway to detection <strong>of</strong> potential<br />
abuse and consequently, <strong>the</strong> fur<strong>the</strong>r development <strong>of</strong><br />
responses to elder abuse. Effective service provision is<br />
dependent on efficient assessment techniques (Imbody<br />
and Vandsburger 2011).<br />
2.2 Risk factors <strong>for</strong> elder abuse<br />
<strong>Screen<strong>in</strong>g</strong> tools are generally based on a review <strong>of</strong> risk<br />
factors associated with a higher probability <strong>of</strong> a disease/<br />
disorder. Particular elder abuse risk factors have been<br />
suggested but additional research is required due to<br />
conflict<strong>in</strong>g f<strong>in</strong>d<strong>in</strong>gs. However, some risk factors have ga<strong>in</strong>ed<br />
moderate support and have been showed to predict abuse<br />
(Cohen et al. 2007) as well as facilitat<strong>in</strong>g <strong>the</strong> detection <strong>of</strong><br />
abuse (Nagpaul 2001). For example, studies <strong>in</strong>dicate that<br />
liv<strong>in</strong>g with ano<strong>the</strong>r person <strong>in</strong>creases risk (Lachs et al. 1997;<br />
Hansberry et al. 2005; Naughton et al. 2010). Cognitive<br />
impairment <strong>of</strong> <strong>the</strong> older person (Compton et al. 1997; Naik<br />
et al. 2010) or <strong>the</strong> caregiver (Miller et al. 2006) also<br />
<strong>in</strong>creases risk as does alcohol dependence (Campbell Reay<br />
and Browne 2001; WHO 2006). Past childhood abuse<br />
(Campbell Reay and Browne 2001), cognitive and<br />
functional impairment (Lachs et al. 1997; Shugarman et al.<br />
2003; Laumann et al. 2008), caregiver stress (Wang et al.<br />
2009), and mental health problems health problems<br />
(K<strong>in</strong>gston and Penhale 1995) are also identified as risk<br />
factors.<br />
In addition, <strong>in</strong>tergenerational violence (Pillemer 1986;<br />
Erl<strong>in</strong>gsson et al. 2005), dependency (Kruger and Moon<br />
1999; Erl<strong>in</strong>gsson et al. 2005; Buri et al. 2006) gender, be<strong>in</strong>g<br />
<strong>in</strong> <strong>the</strong> older old group (Buri et al. 2006; Naughton et al.<br />
2010), social isolation (Carp 2000; Buri et al. 2006), poor<br />
social support (Shugarman et al. 2003) and a history <strong>of</strong><br />
volatile <strong>in</strong>trapersonal relationships (Acer<strong>in</strong>o 2003;<br />
Erl<strong>in</strong>gsson et al. 2005) suggest susceptibility to abuse. Some<br />
risk factors have been proposed as <strong>the</strong>oretical frameworks<br />
to expla<strong>in</strong> elder abuse, however, no <strong>the</strong>ory has adequately<br />
expla<strong>in</strong>ed, with empirical evidence, <strong>the</strong> complexity <strong>of</strong> elder<br />
abuse.<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 5
3. <strong>Screen<strong>in</strong>g</strong><br />
The concept <strong>of</strong> screen<strong>in</strong>g or case f<strong>in</strong>d<strong>in</strong>g comes from<br />
epidemiology. Its purpose is <strong>the</strong> early identification <strong>of</strong> risk<br />
<strong>of</strong> a disease or disorder so that early treatment may be<br />
<strong>in</strong>itiated result<strong>in</strong>g <strong>in</strong> a decrease <strong>in</strong> <strong>the</strong> disease related<br />
mortality and morbidity rates (United States Preventative<br />
Services Task Force 1996; Petersen 1997). As such,<br />
screen<strong>in</strong>g represents a major <strong>in</strong>strument <strong>in</strong> public health<br />
and is an important element <strong>in</strong> current <strong>Irish</strong> health<br />
policies (DOHC 2001a; 2001b). While screen<strong>in</strong>g tools are<br />
not diagnostic, <strong>the</strong>y do highlight cases which have a<br />
higher statistical probability <strong>of</strong> a disease or disorder<br />
(Stampfer et al. 2004; Kettles et al. 2004). In relation to<br />
elder abuse Yaffe notes that screen<strong>in</strong>g tools can draw<br />
attention to cases which warrant fur<strong>the</strong>r <strong>in</strong>vestigation by<br />
a practitioner (Yaffe et al. 2011).<br />
The concept <strong>of</strong> screen<strong>in</strong>g may appear simple but is<br />
<strong>in</strong>fluenced by <strong>the</strong> presence <strong>of</strong> classic screen<strong>in</strong>g criteria<br />
(Wilson and Junger 1968). <strong>Screen<strong>in</strong>g</strong> may be universal,<br />
such as <strong>the</strong> newborn metabolic screen<strong>in</strong>g test<strong>in</strong>g or<br />
selective, <strong>in</strong> populations deemed at risk, <strong>for</strong> example,<br />
screen<strong>in</strong>g <strong>for</strong> cognitive impairment <strong>in</strong> older people.<br />
However, as noted by Wilson and Junger (1968:7), ‘<strong>in</strong><br />
<strong>the</strong>ory, screen<strong>in</strong>g is an admirable method <strong>of</strong> combat<strong>in</strong>g<br />
disease…In practice <strong>the</strong>re are snags’. In <strong>the</strong> case <strong>of</strong><br />
screen<strong>in</strong>g <strong>for</strong> elder abuse, its complexity has been noted<br />
by Lachs (2004) who po<strong>in</strong>ts out that <strong>the</strong> traditional<br />
paradigm <strong>of</strong> screen<strong>in</strong>g programmes is unrealistic <strong>for</strong> elder<br />
abuse if a traditional disease–model analysis is applied. In<br />
particular, issues such as abuser <strong>in</strong>volvement <strong>in</strong> care,<br />
active ef<strong>for</strong>ts to hide <strong>the</strong> abuse and possible limited<br />
access to <strong>the</strong> older person may preclude screen<strong>in</strong>g (Lachs<br />
and Pillemer 2004).<br />
3.1 <strong>Screen<strong>in</strong>g</strong> <strong>in</strong> family violence<br />
The spectrum <strong>of</strong> family violence may be divided <strong>in</strong>to<br />
<strong>in</strong>timate partner violence, child protection and elder<br />
abuse. The issue <strong>of</strong> screen<strong>in</strong>g <strong>for</strong> family violence has<br />
been subject to debate and while generic screen<strong>in</strong>g tools<br />
do hold some merit, variations <strong>in</strong> <strong>the</strong> three doma<strong>in</strong>s<br />
necessitate specific screen<strong>in</strong>g foci. For example, trauma<br />
<strong>in</strong> older people differs from o<strong>the</strong>r generations (Brown et<br />
al. 2004). One <strong>of</strong> <strong>the</strong> most common tools to identify<br />
family violence is <strong>the</strong> Conflict Tactics Scales (CTS) (Straus<br />
1979) and this has shown some utility <strong>in</strong> elder abuse<br />
assessment with cognitively <strong>in</strong>tact older people (Beech et<br />
al. 2005; Cooper et al. 2008a; 2009a). Although elder<br />
abuse screen<strong>in</strong>g tools have potential to trigger<br />
pr<strong>of</strong>essional <strong>in</strong>tervention <strong>in</strong> both prevent<strong>in</strong>g elder abuse<br />
and identify<strong>in</strong>g elder abuse, <strong>the</strong> United States<br />
Preventative Service Task Force on Family Violence (1996;<br />
2004) stated that <strong>the</strong>re was <strong>in</strong>sufficient empirical<br />
evidence to recommend <strong>for</strong> or aga<strong>in</strong>st screen<strong>in</strong>g tools <strong>in</strong><br />
<strong>the</strong> doma<strong>in</strong> <strong>of</strong> family violence (which <strong>in</strong>cludes elder<br />
abuse). For example, concerns focus on whe<strong>the</strong>r<br />
screen<strong>in</strong>g tools equate to improved outcomes (Waalen et<br />
al. 2000) and <strong>the</strong>re is limited empirical data regard<strong>in</strong>g <strong>the</strong><br />
potential ill-effects <strong>of</strong> screen<strong>in</strong>g (Rab<strong>in</strong> et al. 2009).<br />
The <strong>for</strong>ego<strong>in</strong>g concern concurs with conclusions from a<br />
recent systematic review which exam<strong>in</strong>ed screen<strong>in</strong>g tools<br />
<strong>for</strong> <strong>in</strong>timate partner violence (Rab<strong>in</strong> et al. 2009). F<strong>in</strong>d<strong>in</strong>gs<br />
revealed a lack <strong>of</strong> consensus <strong>in</strong> appropriate comparison<br />
measures <strong>for</strong> test<strong>in</strong>g sensitivity and specificity, a wide<br />
variance <strong>of</strong> sensitivities and specificities and <strong>the</strong> need <strong>for</strong><br />
additional reliability and validity test<strong>in</strong>g (Rab<strong>in</strong> et al.<br />
2009). Despite varied perspectives, many medical<br />
organisations advocate screen<strong>in</strong>g (American Medical<br />
Association (AMA) 1992, Programme <strong>of</strong> Action <strong>for</strong><br />
Children 2004) as a standard <strong>in</strong> rout<strong>in</strong>e care as await<strong>in</strong>g<br />
evidence <strong>of</strong> improved screen<strong>in</strong>g outcomes could result <strong>in</strong><br />
risk exposure <strong>for</strong> an abused person (Halpern et al. 2005).<br />
Fur<strong>the</strong>rmore, although <strong>the</strong> impact <strong>of</strong> <strong>in</strong>ter-personal<br />
violence is significant <strong>in</strong> terms <strong>of</strong> mortality and morbidity,<br />
detection rates by healthcare pr<strong>of</strong>essionals rema<strong>in</strong><br />
relatively low (Feldhaus et al. 1997). While some work has<br />
been undertaken <strong>in</strong> <strong>the</strong> assessment <strong>of</strong> <strong>in</strong>terpersonal<br />
violence and recommendations <strong>for</strong> rout<strong>in</strong>e screen<strong>in</strong>g<br />
(Ramsey et al. 2002), <strong>the</strong> World Health Organisation<br />
(2008) has noted that, compared to o<strong>the</strong>r age cohorts,<br />
assess<strong>in</strong>g abuse <strong>in</strong> older people is not as advanced. The<br />
benefits <strong>of</strong> screen<strong>in</strong>g transcend <strong>the</strong> <strong>in</strong>dividual older<br />
person as screen<strong>in</strong>g can lead to rationalisation <strong>of</strong><br />
resource allocation, improved education and improved<br />
responses; although case <strong>in</strong>vestigation should not take<br />
weaken a focus on protection (Bonnie and Wallace 2003).<br />
Consideration needs to be given to <strong>the</strong> m<strong>in</strong>imisation <strong>of</strong><br />
bias when screen<strong>in</strong>g <strong>for</strong> abuse. In us<strong>in</strong>g a screen<strong>in</strong>g tool,<br />
caution has been urged to ensure that respondents are<br />
not primed towards particular answers through <strong>the</strong><br />
discussion on <strong>the</strong> purpose <strong>of</strong> <strong>the</strong> screen<strong>in</strong>g tool or <strong>the</strong><br />
discursive orientation <strong>of</strong> <strong>the</strong> questions (Bonnie and<br />
Wallace 2003). The importance <strong>of</strong> <strong>the</strong> orientation <strong>of</strong><br />
questions was noted by Acer<strong>in</strong>o et al. (2010) where<br />
culturally neutral open ended questions were considered<br />
to maximise disclosure <strong>of</strong> elder abuse. Thus, it is<br />
6<br />
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suggested that screen<strong>in</strong>g questions <strong>in</strong> abuse are<br />
contextualised with<strong>in</strong> social behaviours and nonthreaten<strong>in</strong>g<br />
language (Laumann et al. 2008). However, it<br />
is suggested that follow<strong>in</strong>g general questions which<br />
contextualise <strong>the</strong> older person’s reality, direct queries are<br />
essential to establish <strong>the</strong> precise nature <strong>of</strong> <strong>the</strong> abuse<br />
(Lachs and Pillemer 2004; Oswald et al. 2004). Ano<strong>the</strong>r<br />
important issue is <strong>the</strong> development <strong>of</strong> rapport between<br />
<strong>in</strong>terviewer and <strong>in</strong>terviewee which can allow open and<br />
honest disclosure (Phelan 2010). This is pert<strong>in</strong>ent <strong>for</strong><br />
engagement with both <strong>the</strong> older person and <strong>the</strong> alleged<br />
perpetrator as a non-judgemental, empa<strong>the</strong>tic attitude is<br />
fundamental to facilitat<strong>in</strong>g difficult discussions.<br />
Concerns have been articulated regard<strong>in</strong>g gender and<br />
screen<strong>in</strong>g <strong>for</strong> elder abuse. Some authors have argued that<br />
a particular focus should be af<strong>for</strong>ded to gender based<br />
screen<strong>in</strong>g (Reeves et al. 2007; Yaffe et al. 2007; Paranjape<br />
et al. 2009) as older men’s experiences may be<br />
marg<strong>in</strong>alised (Reeves et al. 2007; Yaffe et al. 2007).<br />
Equally, it has been noted that gender issues which<br />
transcend <strong>the</strong> <strong>in</strong>terpersonal violence doma<strong>in</strong> have been<br />
neglected (Paranjape et al. 2009).<br />
The method <strong>of</strong> screen<strong>in</strong>g has also been subject to debate<br />
as self-completed questionnaires have been shown to be<br />
preferable <strong>in</strong> <strong>in</strong>timate partner violence (MacMillan et al.<br />
2006), whilst telephone <strong>in</strong>terviews have shown<br />
comparable results to face-to-face <strong>in</strong>terviews (Acierno et<br />
al. 2003). However, screen<strong>in</strong>g methods that are not<br />
face-to-face prohibit direct observation <strong>for</strong> non-verbal<br />
cues <strong>in</strong> <strong>the</strong> participant’s responses, such as elicit<strong>in</strong>g<br />
understand<strong>in</strong>g <strong>of</strong> <strong>the</strong> question or facial reactions. For<br />
self-completed questionnaires, <strong>the</strong>re is an <strong>in</strong>herent<br />
assumption <strong>of</strong> literacy and comprehension skills which<br />
may be problematic <strong>for</strong> older people (Daly and Jogerst<br />
2005; Lalor et al. 2009). However, Yaffe et al. 2011 have<br />
used a self-complete elder abuse screen<strong>in</strong>g tool which<br />
has demonstrated some success. Never<strong>the</strong>less, it has<br />
been argued that face to-face <strong>in</strong>terview<strong>in</strong>g can be <strong>the</strong><br />
most effective method <strong>of</strong> screen<strong>in</strong>g (Chuang and<br />
Liebschutz 2002). It can <strong>in</strong>crease <strong>the</strong> degree <strong>of</strong> empathy<br />
af<strong>for</strong>ded <strong>the</strong> person be<strong>in</strong>g screened <strong>for</strong> abuse (Acierno et<br />
al. 2003) and improve <strong>the</strong> validity <strong>of</strong> <strong>the</strong> screen<strong>in</strong>g (WHO<br />
2008). What is essential is that privacy is af<strong>for</strong>ded to <strong>the</strong><br />
older person to disclose abuse <strong>in</strong> a safe environment.<br />
Thus, care should be taken to <strong>in</strong>terview <strong>the</strong> older person<br />
alone. In relation to confidentiality, it has been suggested<br />
that when privacy to complete is facilitated, selfcompleted<br />
questionnaires (Hawk<strong>in</strong>s et al. 2009), and<br />
telephone screen<strong>in</strong>g us<strong>in</strong>g a yes/no response <strong>for</strong>mat may<br />
heighten confidentiality (Acierno et al. 2003).<br />
3.2 Us<strong>in</strong>g technology to screen<br />
Some ef<strong>for</strong>ts have been made <strong>in</strong> <strong>the</strong> use <strong>of</strong> computerised<br />
<strong>in</strong>terpersonal violence screen<strong>in</strong>g (McNutt et al. 2005;<br />
Hawk<strong>in</strong>s et al. 2009). McNutt et al. (2005) exam<strong>in</strong>ed <strong>the</strong><br />
use <strong>of</strong> computers to self-screen <strong>for</strong> <strong>in</strong>terpersonal violence<br />
immediately prior to a scheduled physician visit. Results<br />
<strong>of</strong> <strong>the</strong> screen <strong>the</strong>n accompanied <strong>the</strong> patient <strong>in</strong>to <strong>the</strong><br />
face-to-face visit. In contrast, Hawk<strong>in</strong>s et al. (2009)<br />
created specific s<strong>of</strong>tware, (Po<strong>in</strong>t <strong>of</strong> In<strong>for</strong>mation Systems<br />
(PCIS), <strong>for</strong> use by health care pr<strong>of</strong>essionals with <strong>the</strong>ir<br />
personal digital assistant (PDA). Both methods <strong>of</strong><br />
screen<strong>in</strong>g demonstrated some promis<strong>in</strong>g results, such as<br />
speed<strong>in</strong>g up <strong>the</strong> process <strong>for</strong> referrals and <strong>the</strong> elim<strong>in</strong>ation<br />
<strong>of</strong> duplicate documentation. However, <strong>the</strong>re are some<br />
issues which relate to us<strong>in</strong>g <strong>the</strong>se on older adults, such as<br />
competency with computers and <strong>the</strong> adm<strong>in</strong>istration <strong>of</strong><br />
generic screen<strong>in</strong>g tools ra<strong>the</strong>r than those specific to elder<br />
abuse.<br />
3.3 <strong>Screen<strong>in</strong>g</strong> <strong>for</strong> elder abuse<br />
In review<strong>in</strong>g approaches to screen<strong>in</strong>g tools, a variety <strong>of</strong><br />
terms are used to convey <strong>the</strong> purpose <strong>of</strong> <strong>the</strong> <strong>in</strong>strument.<br />
These terms range from <strong>in</strong>dexes <strong>of</strong> abuse, <strong>in</strong>struments to<br />
identify risk <strong>of</strong> abuse, elder abuse questionnaires, elder<br />
abuse screen<strong>in</strong>g tools, elder abuse screen<strong>in</strong>g test,<br />
algorithms, protocols and elder abuse assessment. The<br />
fundamental function <strong>of</strong> any assessment <strong>in</strong>strument is to<br />
guide practitioners through a standardised screen<strong>in</strong>g<br />
process and to ensure that signs <strong>of</strong> abuse are not missed<br />
(Anetzberger 2001; Peral-Lev<strong>in</strong> 2008). For <strong>the</strong> purposes <strong>of</strong><br />
this discussion, <strong>the</strong> term screen<strong>in</strong>g tool is used to<br />
describe <strong>in</strong>struments developed to ‘screen’ <strong>for</strong> potential<br />
abuse, while <strong>the</strong> terms guidel<strong>in</strong>es and protocols are used<br />
to describe any o<strong>the</strong>r approaches to review<strong>in</strong>g an older<br />
person <strong>for</strong> potential elder abuse.<br />
An important part <strong>of</strong> <strong>the</strong> management <strong>of</strong> elder abuse is<br />
its early identification, and screen<strong>in</strong>g <strong>for</strong> elder abuse has<br />
been advocated as fundamental to <strong>the</strong> rout<strong>in</strong>e<br />
assessment <strong>of</strong> older people (Aravanis et al. 1993,<br />
American Medical Association 1992; Lachs and Pillemer<br />
2004) particularly due to its prevalence (O’ Brien 1996).<br />
However, as early as 1988, Kosberg identified a failure <strong>of</strong><br />
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pr<strong>of</strong>essionals to detect abuse or to be aware <strong>of</strong> its<br />
occurrence. Many pr<strong>of</strong>essionals struggle to recognise<br />
elder abuse (Heath et al. 2005; Kennedy 2005; Newton<br />
2005; Mandiracioglu et al. 2005; Cooper et al. 2008b;<br />
Killick and Taylor 2009; Caciula et al. 2010; Hempton et<br />
al. 2010), which makes screen<strong>in</strong>g tools attractive <strong>in</strong> <strong>the</strong>ir<br />
potential ability to detect <strong>the</strong> risk <strong>of</strong> elder abuse <strong>in</strong><br />
diverse sett<strong>in</strong>gs. Identification <strong>of</strong> elder abuse may be<br />
h<strong>in</strong>dered by issues such as ageism (Gutman and Spencer<br />
2010; Phelan 2011), a lack <strong>of</strong> direct observation <strong>of</strong> abuse<br />
(Bonnie and Wallace 2003), family privacy (Kosberg 1988;<br />
Phelan 2010), complacency (WHO 2002), complexity<br />
(Antzeberger 2001), sensitivity <strong>of</strong> <strong>the</strong> assessor (Shefet et<br />
al. 2007), service sett<strong>in</strong>g (O Brien 1996), time constra<strong>in</strong>ts<br />
(Jones et al. 1997), a lack <strong>of</strong> knowledge or education and<br />
tra<strong>in</strong><strong>in</strong>g <strong>in</strong> elder abuse (WHO 2002; Fulmer et al. 2004).<br />
A number <strong>of</strong> o<strong>the</strong>r factors <strong>in</strong> pr<strong>of</strong>essionals’ failure to<br />
identify elder abuse <strong>in</strong>clude confusion as to whe<strong>the</strong>r<br />
present<strong>in</strong>g symptoms are associated with age related<br />
changes or abuse (Kimball 1995; Bonnie and Wallace<br />
2003; Lachs and Pillemer 2004), and <strong>the</strong> subtlety <strong>of</strong><br />
present<strong>in</strong>g symptoms (Fulmer et al. 1984; Alibhai et al.<br />
2005). Apathy towards positive <strong>in</strong>tervention pathways<br />
(Anetzberger 2001; Selwood et al. 2007), a lack <strong>of</strong> time<br />
and unstable def<strong>in</strong>itions <strong>of</strong> abuse (Jones et al. 1997),<br />
ethical dilemmas (Bergeron and Gray 2003; Donovan and<br />
Regehr 2010) and <strong>the</strong> <strong>in</strong>visibility <strong>of</strong> elder abuse (Reis and<br />
Nahmiash 1998) are also suggested as reasons why many<br />
pr<strong>of</strong>essionals struggle to recognise elder abuse. Moreover,<br />
Anetzberger (2001) argues that elder abuse is not equal<br />
<strong>in</strong> terms <strong>of</strong> categorical assessment as its various <strong>for</strong>ms<br />
may have different standards <strong>of</strong> recognisability.<br />
Acknowledg<strong>in</strong>g <strong>the</strong>se difficulties, Bomba (2006:111)<br />
argues that elder abuse should be constructed as a<br />
geriatric syndrome as this approach ‘provides a<br />
conceptual start<strong>in</strong>g po<strong>in</strong>t from which <strong>the</strong> physician and<br />
health care pr<strong>of</strong>essional can beg<strong>in</strong> to address<br />
mistreatment from screen<strong>in</strong>g to management’ stages.<br />
However, employ<strong>in</strong>g <strong>the</strong> term ‘syndrome’ may have <strong>the</strong><br />
effect <strong>of</strong> medicalis<strong>in</strong>g a problem which is essentially an<br />
issue immersed <strong>in</strong> complex <strong>in</strong>trapersonal, <strong>in</strong>terpersonal<br />
and societal dynamics.<br />
The WHO (2008) po<strong>in</strong>ts out that older people do not<br />
generally wish to disclose abuse and as many as 80<br />
percent <strong>of</strong> cases may not be diagnosed. Older people<br />
<strong>the</strong>mselves may not disclose due to cognitive impairment<br />
(Nelson et al. 2004; Laumann et al. 2008), embarrassment<br />
(Bergeron 2006), <strong>the</strong> perpetrator be<strong>in</strong>g a family member<br />
with negative unsupportive attitudes (Z<strong>in</strong>k et al. 2004),<br />
<strong>the</strong> taboo nature <strong>of</strong> elder abuse (Krueger and Patterson<br />
1997; Kosberg 1998; Twomey et al. 2005), abuse be<strong>in</strong>g<br />
normalised (Qu<strong>in</strong>n and Tomita 1997) or fear <strong>of</strong><br />
repercussions and fur<strong>the</strong>r abuse (Mowlam et al. 2007). In<br />
addition, if <strong>the</strong> older person is <strong>in</strong> some way dependent on<br />
<strong>the</strong> abuser, <strong>the</strong> removal <strong>of</strong> <strong>the</strong> abuser may, <strong>in</strong> reality or <strong>in</strong><br />
<strong>the</strong> older person’s perception, mean changes <strong>in</strong> <strong>the</strong>ir<br />
liv<strong>in</strong>g arrangements or be<strong>in</strong>g placed <strong>in</strong> long-term care.<br />
Consequently, elder abuse is generally identified by a<br />
third party (Fulmer et al. 2004; Phelan 2009). This may be<br />
difficult as it is suggested that perpetrators are careful to<br />
cover up abuse and to provide plausible explanations <strong>for</strong><br />
any present<strong>in</strong>g problems and <strong>of</strong>ten isolate <strong>the</strong> older<br />
person (Carp 2000). Fur<strong>the</strong>rmore, older people have<br />
reduced social <strong>in</strong>teraction mandates and contact with<br />
health care pr<strong>of</strong>essionals can provide a valuable<br />
opportunity to identify potential elder abuse (Cohen et<br />
al. 2006).<br />
If elder abuse is not identified early, <strong>in</strong>tervention is<br />
delayed or prevented. The Diagnostic and Treatment<br />
Guidel<strong>in</strong>es on <strong>Elder</strong> <strong>Abuse</strong> and Neglect (American Medical<br />
Association 1992) recommend that screen<strong>in</strong>g <strong>for</strong> elder<br />
abuse be a fundamental part <strong>of</strong> all cl<strong>in</strong>ical sett<strong>in</strong>gs where<br />
older people <strong>in</strong>terface with healthcare pr<strong>of</strong>essionals.<br />
Thus, elder abuse case identification is central to <strong>the</strong> care<br />
<strong>of</strong> older people. Identification has an impact on issues<br />
such as <strong>the</strong> rationale <strong>for</strong> specific fund<strong>in</strong>g <strong>for</strong> care <strong>of</strong> older<br />
people, <strong>the</strong> development <strong>of</strong> responsive services and also<br />
highlights <strong>the</strong> need <strong>for</strong> both pr<strong>of</strong>essional and public<br />
awareness and education (Bonnie and Wallace 2003). In<br />
tandem with <strong>the</strong> need to improve methods <strong>of</strong> detection,<br />
it is <strong>the</strong> necessity to have sufficient tra<strong>in</strong><strong>in</strong>g and support<br />
<strong>for</strong> pr<strong>of</strong>essionals to address suspected cases <strong>of</strong> elder<br />
abuse (WHO 2008). Despite this, research <strong>in</strong> elder abuse<br />
screen<strong>in</strong>g tools has progressed slowly (Fulmer et al. 2004)<br />
and substantial research is required to support <strong>the</strong><br />
development <strong>of</strong> universal screen<strong>in</strong>g <strong>for</strong> elder abuse<br />
(Bonnie and Wallace 2003; United States Task Force on<br />
Preventative Violence 2004). Fulmer (2008) <strong>in</strong>dicates that<br />
issues <strong>of</strong> culture, cognitive impairment, cl<strong>in</strong>ician fear <strong>of</strong><br />
false positives, <strong>in</strong>tentional versus un<strong>in</strong>tentional abuse and<br />
exploitation can present challenges to screen<strong>in</strong>g <strong>the</strong><br />
older person <strong>for</strong> abuse. Moreover, concerns persist<br />
regard<strong>in</strong>g <strong>the</strong> effectiveness <strong>of</strong> <strong>in</strong>terventions <strong>for</strong> elder<br />
abuse which could worsen <strong>the</strong> abuse situation (Lachs and<br />
Pillemer 2004). Despite this, <strong>the</strong> identification <strong>of</strong> elder<br />
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abuse is greater when us<strong>in</strong>g a specific screen<strong>in</strong>g tool than<br />
is reported <strong>in</strong> prevalence studies (Cohen et al. 2006, Yaffe<br />
et al. 2008).<br />
Bonnie and Wallace (2003) explored a framework <strong>for</strong><br />
elder mistreatment screen<strong>in</strong>g and case identification<br />
which encompassed four levels. It proposes firstly that,<br />
appropriate sett<strong>in</strong>gs with<strong>in</strong> which to screen <strong>the</strong> older<br />
person are identified, such as accident and emergency<br />
departments or <strong>the</strong> person’s home. Secondly, a prescreen<strong>in</strong>g<br />
process is proposed which would identify and<br />
target particularly vulnerable older people who<br />
demonstrate an <strong>in</strong>creased risk to abuse. Thirdly, it<br />
proposes <strong>the</strong> <strong>in</strong>itiation <strong>of</strong> <strong>the</strong> screen<strong>in</strong>g process and, if <strong>the</strong><br />
screen<strong>in</strong>g test is positive, <strong>the</strong> fourth level encompasses a<br />
recommendation <strong>for</strong> case identification <strong>in</strong>vestigation.<br />
<strong>Screen<strong>in</strong>g</strong> tools can also be related to <strong>the</strong> context <strong>of</strong> <strong>the</strong>ir<br />
utilisation. For example, brief screen<strong>in</strong>g tools are more<br />
appropriate <strong>for</strong> busy, high turnover areas, such as<br />
accident and emergency units, whilst, longer, more<br />
comprehensive screen<strong>in</strong>g tools are more suitable <strong>for</strong><br />
areas such as <strong>in</strong>-patient units and community contexts<br />
(Fulmer et al. 2004). Some assessment tools advocate <strong>the</strong><br />
<strong>in</strong>clusion <strong>of</strong> a medical exam<strong>in</strong>ation (American Medical<br />
Association 1992; Lachs and Pillemer 2004), while o<strong>the</strong>rs<br />
<strong>in</strong>volve verbal assessment only (Fulmer et al. 1984;<br />
Sengstock and Hwalek 1987; Wang et al. 2007; Yaffe et al.<br />
2008). However, <strong>the</strong> World Health Organisation (2008)<br />
suggests that screen<strong>in</strong>g tools <strong>for</strong> <strong>the</strong> primary health care<br />
sett<strong>in</strong>g are critical as <strong>the</strong>y have <strong>the</strong> ability to raise<br />
awareness <strong>of</strong> <strong>the</strong> issue <strong>of</strong> elder abuse and can assist <strong>in</strong><br />
develop<strong>in</strong>g competencies <strong>in</strong> <strong>the</strong> management <strong>of</strong> elder<br />
abuse. Consequently, <strong>the</strong> choice <strong>for</strong> an appropriate<br />
screen<strong>in</strong>g tool must take <strong>in</strong>to account <strong>the</strong> balance<br />
between brevity and comprehensiveness (Rab<strong>in</strong> et al.<br />
2009) while also demonstrat<strong>in</strong>g accuracy and ease <strong>of</strong> use<br />
(Bonnie and Wallace 2003). In addition, pr<strong>of</strong>essional<br />
perspectives may result <strong>in</strong> subtle differences and it has<br />
been suggested that elder abuse education <strong>in</strong>cludes a<br />
sensitisation <strong>of</strong> <strong>in</strong>terdiscipl<strong>in</strong>ary predispositions so that<br />
holistic approaches to elder abuse may be improved<br />
(Yaffe et al. 2009). As discussed previously, ano<strong>the</strong>r<br />
important factor <strong>in</strong> screen<strong>in</strong>g <strong>for</strong> elder abuse is that, as<br />
far as possible, it should be undertaken <strong>in</strong> private with<br />
<strong>the</strong> older person to allow a candid discussion. Most<br />
importantly, skilled communication strategies are<br />
necessary to facilitate <strong>the</strong> disclosure <strong>of</strong> sensitive<br />
<strong>in</strong><strong>for</strong>mation <strong>in</strong> <strong>the</strong> screen<strong>in</strong>g encounter and are essential<br />
when communicat<strong>in</strong>g results both to <strong>the</strong> older person<br />
and <strong>the</strong>ir family (Fulmer 2008; WHO 2008).<br />
<strong>Elder</strong> abuse screen<strong>in</strong>g tools <strong>for</strong> long term care facilities<br />
are lack<strong>in</strong>g. Institutional abuse differs from abuse <strong>in</strong> <strong>the</strong><br />
community due to issues <strong>of</strong> an expectation <strong>of</strong> <strong>for</strong>mal<br />
caregivers. <strong>Abuse</strong> <strong>in</strong> long term care may be constituted<br />
by abusive behaviour, abusive attitudes and abuse<br />
practices (Gilleard 1994). Abusive behaviour may also be<br />
related to nurs<strong>in</strong>g staff burn-out and shortages (Saveman<br />
et al. 1999; Goergen 2001; Sh<strong>in</strong>an-Altman and Cohen<br />
2009; Post et al. 2010), <strong>the</strong> physical conditions <strong>of</strong> <strong>the</strong><br />
nurs<strong>in</strong>g home (Millard and Roberts 1991), and <strong>in</strong>tr<strong>in</strong>sic<br />
managerial fail<strong>in</strong>gs (Bennett et al. 1997). O<strong>the</strong>r challenges<br />
<strong>in</strong>clude a general low report<strong>in</strong>g rate <strong>of</strong> elder abuse. For<br />
example, <strong>in</strong> one study <strong>in</strong>cident rates <strong>of</strong> report<strong>in</strong>g abuse<br />
to nurs<strong>in</strong>g home staff were as low as 20.7 per 1,000<br />
residents, while <strong>for</strong>mal reports to adult protective<br />
services constituted 18.4 per 1,000 residents (Jogerst et<br />
al. 2006). Studies vary from 11 percent to 91 percent <strong>of</strong><br />
staff observ<strong>in</strong>g abuse, while 2 percent to 87 percent<br />
disclosed <strong>the</strong>ir perpetration <strong>of</strong> abuse (Pillemer and<br />
Moore 1989, Goergan 2001, Malmedal et al. 2009). Larger<br />
<strong>in</strong>stitutions with larger volume <strong>of</strong> older people may<br />
<strong>in</strong>crease risk (Jogerst et al. 2006).<br />
The potential <strong>for</strong> an older person with impaired mental<br />
capacity to experience abuse is noted (Compton et al.<br />
1997; Choi and Mayer 2000; Cooney et al. 2006; Naik et<br />
al. 2010). Older people with dementia are particularly<br />
prone to abuse (Cooper et al. 2008a, Wiglesworth et al.<br />
2010, Yan and Kwok 2011) which may be due to higher<br />
care requirements and behavioural challenges (Cooper et<br />
al. 2008a). In a study <strong>of</strong> car<strong>in</strong>g <strong>for</strong> a relative with<br />
dementia (CARD) over half reported physical or<br />
psychological abuse and one third met <strong>the</strong> criteria <strong>of</strong><br />
significant abuse (Cooper et al. 2009b) However,<br />
screen<strong>in</strong>g <strong>for</strong> elder abuse when an older person is<br />
cognitively impaired is problematic as self-report<strong>in</strong>g may<br />
be unreliable or <strong>the</strong> older person may not be able to<br />
report abuse (Cooney et al. 2006; Selwood et al. 2007).<br />
Laumann et al. (2008:2) argue that ‘screen<strong>in</strong>g <strong>for</strong><br />
impairment is key to modell<strong>in</strong>g and understand<strong>in</strong>g elder<br />
mistreatment’. This is significant as dementia can be<br />
unrecognised, particularly <strong>in</strong> nurs<strong>in</strong>g homes (MacDonald<br />
and Carpenter 2003; Cahill et al. 2010) where behavioural<br />
disturbances <strong>of</strong> <strong>the</strong> older person can lead to abusive<br />
contexts (Bredthauer et al. 2005). Despite concerns<br />
relat<strong>in</strong>g to elder abuse <strong>in</strong> older people with dementia,<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 9
3. <strong>Screen<strong>in</strong>g</strong><br />
<strong>the</strong>re is a paucity <strong>of</strong> <strong>in</strong><strong>for</strong>mation on validated screen<strong>in</strong>g<br />
tools related to older people with dementia (Yan and<br />
Kwok 2011). Yet, <strong>the</strong> use <strong>of</strong> generic elder abuse screen<strong>in</strong>g<br />
tools can pose particular challenges <strong>for</strong> <strong>the</strong> health care<br />
pr<strong>of</strong>essional as capacity cannot be ascerta<strong>in</strong>ed dur<strong>in</strong>g<br />
ord<strong>in</strong>ary conversation (Naik et al. 2007; Naik et al. 2008).<br />
Thus, any elder abuse screen<strong>in</strong>g method <strong>for</strong> older people<br />
who have capacity challenges must be sensitive and<br />
specific enough to discrim<strong>in</strong>ate abuse while concurrently<br />
tak<strong>in</strong>g <strong>the</strong> potential presence <strong>of</strong> dementia <strong>in</strong>to account.<br />
Although <strong>the</strong>re are a number <strong>of</strong> screen<strong>in</strong>g tools available,<br />
<strong>the</strong>re is scant knowledge or widespread use <strong>of</strong> <strong>the</strong>se tools<br />
(Bonnie and Wallace 2003). Many tools have been used<br />
<strong>for</strong> research purposes only where issues <strong>of</strong> sensitivity and<br />
specificity are not addressed and have low efficiency <strong>in</strong><br />
cl<strong>in</strong>ical sett<strong>in</strong>gs. O<strong>the</strong>r concerns centre on <strong>the</strong> vocabulary<br />
used <strong>in</strong> <strong>the</strong> tools as well as <strong>the</strong> time necessary to<br />
complete (WHO 2008). <strong>Screen<strong>in</strong>g</strong> tools may be<br />
completed on <strong>the</strong> basis <strong>of</strong> direct question<strong>in</strong>g <strong>of</strong> <strong>the</strong> older<br />
person or caregiver. They may also be completed as<br />
self-reports by <strong>the</strong> older person or caregiver (Cohen et al.<br />
2007). For screen<strong>in</strong>g tools that require responses from <strong>the</strong><br />
older person, challenges arise <strong>in</strong> <strong>the</strong> context <strong>of</strong> <strong>the</strong>ir<br />
ability to respond competently as <strong>the</strong>re may be concerns<br />
regard<strong>in</strong>g mental <strong>in</strong>capacity, frailty, high anxiety, fear or<br />
o<strong>the</strong>r factors. <strong>Screen<strong>in</strong>g</strong> tools which require <strong>the</strong> caregiver<br />
to respond may be complicated by <strong>in</strong>accurate answers<br />
(Bonnie and Wallace 2003). In addition, some<br />
commentators have highlighted that elder abuse<br />
screen<strong>in</strong>g tools need to be flexible enough to take<br />
cultural issues <strong>in</strong>to account (Wang et al. 2006; Wang et al.<br />
2007; WHO 2008; Yan and Kwok 2011).<br />
3.3.1 <strong>Screen<strong>in</strong>g</strong> tools and validation<br />
<strong>Screen<strong>in</strong>g</strong> tools <strong>for</strong> elder abuse should meet <strong>the</strong><br />
epidemiological criteria which support <strong>the</strong> use <strong>of</strong> a<br />
validated <strong>in</strong>strument used <strong>for</strong> screen<strong>in</strong>g purposes (Wilson<br />
and Junger 1968). What is important is that a screen<strong>in</strong>g<br />
tool has <strong>the</strong> ability to demonstrate psychometric<br />
properties <strong>in</strong> <strong>the</strong> context <strong>of</strong> reliability and validity. This<br />
translates to <strong>the</strong> ability <strong>of</strong> an <strong>in</strong>dicator or item on a scale<br />
to represent a <strong>the</strong>oretical concept. A screen<strong>in</strong>g test must<br />
also demonstrate a high sensitivity to and specificity <strong>in</strong><br />
test<strong>in</strong>g <strong>for</strong> elder abuse. Thus, a screen<strong>in</strong>g tool <strong>for</strong> elder<br />
abuse must be ‘practical, be easy to adm<strong>in</strong>ister, have<br />
appropriate and clear word<strong>in</strong>g suitable <strong>for</strong> different<br />
contexts, and show a high sensitivity rate’ (WHO 2008: 6).<br />
Given <strong>the</strong> <strong>for</strong>ego<strong>in</strong>g considerations, <strong>the</strong> elder abuse<br />
screen<strong>in</strong>g tools <strong>in</strong> <strong>the</strong> discussion which follows represent<br />
those which have been subject to psychometric test<strong>in</strong>g,<br />
specifically used <strong>for</strong> elder abuse, and have been reported<br />
<strong>in</strong> peer reviewed publications. Bear<strong>in</strong>g <strong>in</strong> m<strong>in</strong>d that<br />
screen<strong>in</strong>g tools <strong>for</strong> elder abuse do not provide def<strong>in</strong>itive<br />
identification <strong>of</strong> abuse but ra<strong>the</strong>r highlight <strong>the</strong> risk <strong>of</strong> or<br />
potential <strong>for</strong> abuse and must be used with this <strong>in</strong> m<strong>in</strong>d,<br />
<strong>the</strong> follow<strong>in</strong>g screen<strong>in</strong>g tools are discussed:<br />
• The Hwalek-Sengstock <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong><br />
Test<br />
• Vulnerability <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Scale<br />
• The <strong>Elder</strong> Assessment Instrument<br />
• The Indicators <strong>of</strong> <strong>Abuse</strong> Screen<br />
• The Brief <strong>Abuse</strong> Screen <strong>for</strong> <strong>the</strong> <strong>Elder</strong>ly<br />
• The Caregiver <strong>Abuse</strong> Screen<br />
• The <strong>Elder</strong> <strong>Abuse</strong> Suspicion Index<br />
• <strong>Elder</strong> Psychological <strong>Abuse</strong> Scale<br />
• Caregivers Psychological <strong>Elder</strong> <strong>Abuse</strong> Behaviour<br />
Scale<br />
• Older Adult Psychological <strong>Abuse</strong> Measure<br />
• The Older Adult F<strong>in</strong>ancial Exploitation Measure<br />
The Hwalek-Sengstock <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Test<br />
Recognis<strong>in</strong>g <strong>the</strong> lack <strong>of</strong> uni<strong>for</strong>mity and comprehensive<br />
approach <strong>in</strong> how pr<strong>of</strong>essionals identified elder abuse,<br />
Sengstock and Hwalek (1987) developed <strong>the</strong> Hwalek-<br />
Senstock <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Test (H-S EAST) to<br />
identify an older person at risk <strong>of</strong> abuse. Prelim<strong>in</strong>ary<br />
reviews <strong>of</strong> both published and unpublished literature on<br />
elder abuse and child abuse identified seven <strong>in</strong>dexes<br />
which were analysed <strong>for</strong> <strong>in</strong>clusion and exclusion criteria<br />
<strong>in</strong> relation to types <strong>of</strong> abuse. Six categories resulted<br />
which <strong>in</strong>cluded <strong>the</strong> capacity to screen <strong>for</strong> physical abuse,<br />
psychological neglect, material abuse, and violation <strong>of</strong><br />
personal rights. Sengstock and Hwalek (1987) also<br />
<strong>in</strong>cluded a category <strong>of</strong> risk <strong>in</strong>dicators, which could<br />
contribute to <strong>the</strong> potential <strong>for</strong> elder abuse to occur. The<br />
H-S EAST (Sengstock and Hwalek 1987) was developed<br />
from a larger study that <strong>in</strong>volved pool<strong>in</strong>g and rat<strong>in</strong>g 1,000<br />
items by an expert, five person panel who were members<br />
10<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong>
3. <strong>Screen<strong>in</strong>g</strong><br />
<strong>of</strong> <strong>the</strong> Institute <strong>of</strong> Gerontology at Wayne State University.<br />
This resulted <strong>in</strong> a 15 item <strong>in</strong>strument which screens <strong>for</strong><br />
three factors: violation <strong>of</strong> personal rights, contextual<br />
factors contribut<strong>in</strong>g to <strong>the</strong> older person’s vulnerability<br />
and potential abusive circumstances (Neale et al. 1991).<br />
Construct validity was demonstrated as a score <strong>of</strong> three<br />
or more reflected a risk <strong>of</strong> abuse, exploitation or neglect<br />
(Neale et al. 1991). Fur<strong>the</strong>r discrim<strong>in</strong>ate analysis<br />
demonstrated that six <strong>of</strong> <strong>the</strong> fifteen items were predictive<br />
<strong>of</strong> <strong>the</strong> potential presence <strong>of</strong> elder abuse. As such, <strong>the</strong><br />
(H-S EAST) is a brief screen<strong>in</strong>g tool which is suitable <strong>for</strong><br />
use <strong>in</strong> multiple environments.<br />
Psychometric support <strong>for</strong> this tool was also demonstrated<br />
<strong>in</strong> two fur<strong>the</strong>r studies (Neale et al. 1991; Moody et al.<br />
2000). Neale et al. (1991) used three groups <strong>of</strong> older<br />
people to test <strong>the</strong> H-S EAST and f<strong>in</strong>d<strong>in</strong>gs supported <strong>the</strong><br />
construct validity <strong>of</strong> <strong>the</strong> <strong>in</strong>strument. Moody et al. (2000)<br />
also used <strong>the</strong> H-S EAST <strong>in</strong> a study <strong>of</strong> 100 African<br />
American, Hispanic, and white older people liv<strong>in</strong>g <strong>in</strong><br />
public hous<strong>in</strong>g <strong>in</strong> <strong>the</strong> US. Study results demonstrated that<br />
pr<strong>in</strong>cipal components factor analysis supported <strong>the</strong> H-S<br />
EAST tool structure <strong>for</strong> a total <strong>of</strong> 10 items (factor load<strong>in</strong>gs<br />
= 0.4 or >), expla<strong>in</strong><strong>in</strong>g 38 percent <strong>of</strong> <strong>the</strong> variance. A<br />
discrim<strong>in</strong>ant function analysis showed that 6 items were as<br />
effective as <strong>the</strong> 9-item model <strong>in</strong> classify<strong>in</strong>g cases (71.4%)<br />
as abuse. Despite <strong>the</strong> H-S EAST demonstrat<strong>in</strong>g some value<br />
<strong>in</strong> screen<strong>in</strong>g <strong>for</strong> elder abuse <strong>in</strong> this study, o<strong>the</strong>r studies<br />
have raised questions regard<strong>in</strong>g <strong>the</strong> tool’s discrim<strong>in</strong>atory<br />
abuse, particularly <strong>in</strong> relation to cognitive impairment<br />
(Buri et al. 2009). Fur<strong>the</strong>rmore, Fulmer et al. (2004)<br />
suggest that <strong>the</strong> H-S EAST requires additional ref<strong>in</strong>ement<br />
to discrim<strong>in</strong>ate abuse from o<strong>the</strong>r types <strong>of</strong> elder<br />
mistreatment. Fur<strong>the</strong>r test<strong>in</strong>g to ref<strong>in</strong>e <strong>the</strong> psychometric<br />
properties is also needed (Anthony et al. 2009).<br />
In summary, <strong>the</strong> H-S EAST tool (Sengstock and Hwalek<br />
1987) is a brief <strong>in</strong>strument which has demonstrated some<br />
promis<strong>in</strong>g results <strong>in</strong> screen<strong>in</strong>g <strong>for</strong> elder abuse. However,<br />
<strong>the</strong>re have been some concerns regard<strong>in</strong>g its ability to<br />
discrim<strong>in</strong>ate between abuse and non–abuse, <strong>the</strong> types <strong>of</strong><br />
abuse manifestation and <strong>the</strong> need <strong>for</strong> fur<strong>the</strong>r ref<strong>in</strong>ement<br />
<strong>of</strong> <strong>the</strong> psychometric properties <strong>of</strong> <strong>the</strong> tool has been<br />
noted.<br />
The Vulnerability <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Scale<br />
The Vulnerability to <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Scale (VASS) was<br />
developed <strong>in</strong> <strong>the</strong> context <strong>of</strong> an Australian Longitud<strong>in</strong>al<br />
Study on Women’s Health (Women’s Health Study<br />
(WHS)) (Sch<strong>of</strong>ield et al. 2002), which exam<strong>in</strong>ed <strong>the</strong><br />
health and well-be<strong>in</strong>g <strong>of</strong> three age cohorts <strong>of</strong> women;<br />
18-23 years, 45-50, and 70-75 years over a 20 year period.<br />
The VASS represents an adaptation <strong>of</strong> <strong>the</strong> H-S EAST<br />
(Sengstock and Hwalek 1987) as fur<strong>the</strong>r questions were<br />
added. The two additional questions demonstrated high<br />
face validity with one based on <strong>the</strong> Conflict Tactics Scale<br />
(CTS) (Strauss 1979) and <strong>the</strong> second based on a<br />
screen<strong>in</strong>g tool developed <strong>for</strong> <strong>the</strong> assessment <strong>of</strong> abuse<br />
dur<strong>in</strong>g pregnancy (McFarlane et al. 1992). The third<br />
question, ‘Have you ever been <strong>in</strong> a violent relationship<br />
with a spouse/partner?’ was added by <strong>the</strong> study<br />
researchers (Sch<strong>of</strong>ield et al. 2002). In an ef<strong>for</strong>t to establish<br />
construct validity, factor analysis and correlation with a<br />
wide range <strong>of</strong> o<strong>the</strong>r variables were used. Two o<strong>the</strong>r<br />
measurement scales were used <strong>in</strong> <strong>the</strong> study: <strong>the</strong> Medical<br />
Outcomes Study Health Survey Short Form (SF-36)<br />
(Ware, Kos<strong>in</strong>ski and Keller 1994) and <strong>the</strong> Duke Social<br />
Support Index (Koenig et al. 1993). In addition,<br />
participants were also questioned about <strong>the</strong> amount <strong>of</strong><br />
chronic, acute health problems, visits to <strong>the</strong> family<br />
doctors, alternative medic<strong>in</strong>e practitioners, hospital<br />
admissions or await<strong>in</strong>g hospital admissions, medications<br />
and o<strong>the</strong>r health traits. Social supports, assistance with<br />
activities <strong>of</strong> daily liv<strong>in</strong>g and life satisfaction were also<br />
elicited. Acknowledg<strong>in</strong>g <strong>the</strong> lack <strong>of</strong> a gold standard to<br />
test sensitivity and specificity <strong>of</strong> <strong>the</strong> H-S EAST, f<strong>in</strong>d<strong>in</strong>gs<br />
from this study <strong>of</strong> 12,340 older women aged 70-75 years<br />
did not support <strong>the</strong> <strong>in</strong>clusion <strong>of</strong> dimensions <strong>of</strong> violation<br />
<strong>of</strong> personal rights or direct abuse, characteristics <strong>of</strong><br />
vulnerability and potentially abusive situations. The<br />
researchers concluded that a screen<strong>in</strong>g tool which<br />
focuses on vulnerability and coercion could provide a<br />
simple and more ref<strong>in</strong>ed system to elicit <strong>the</strong> potential <strong>for</strong><br />
elder abuse (Sch<strong>of</strong>ield et al. 2002).<br />
Follow<strong>in</strong>g <strong>the</strong> <strong>in</strong>itial study (Sch<strong>of</strong>ield et al. 2002), <strong>the</strong><br />
revised tool, <strong>the</strong> VASS, consisted <strong>of</strong> four factors:<br />
vulnerability, dependence, dejection and coercion<br />
(Sch<strong>of</strong>ield and Mishra 2003). Each <strong>of</strong> <strong>the</strong> factors<br />
conta<strong>in</strong>ed three sub-items. The tool was tested over a<br />
subsequent three year follow-up period with<strong>in</strong> <strong>the</strong><br />
Australian Longitud<strong>in</strong>al Study on Women’s Health (WHS).<br />
The sample <strong>for</strong> <strong>the</strong> VASS study comprised 10,421 older<br />
people aged between 73-78 years. Concurrent<br />
measurements were also used to assess stress, life events<br />
(modified from Norbeck 1984), social support (Koenig et<br />
al. 1993), dependence (Dom<strong>in</strong>o and Affonso 1990,<br />
Pollack and Duffy 1990, Scheier et al. 1994), health (Ware<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 11
3. <strong>Screen<strong>in</strong>g</strong><br />
et al. 1994), acute and chronic illnesses, use <strong>of</strong> health<br />
services, medication use, body mass <strong>in</strong>dex and<br />
demographic details. Cronbach’s alpha <strong>for</strong> <strong>the</strong> four factors<br />
were: Dependence (.74), Dejection (.44), Vulnerability<br />
(.45) and Coercion (.31). Consequently, <strong>the</strong> VASS<br />
demonstrated moderate to good <strong>in</strong>ternal consistency as a<br />
brief screen<strong>in</strong>g tool. In terms <strong>of</strong> <strong>the</strong> four factors, construct<br />
validity considered <strong>the</strong> relationship between <strong>the</strong> four<br />
factors and <strong>the</strong> psychosocial variables hypo<strong>the</strong>sised as<br />
associated with abuse.<br />
Vulnerability was closely related to stress, particularly<br />
with<strong>in</strong> close relationships, while negatively associated<br />
with social support (Sch<strong>of</strong>ield and Mishra 2003). A<br />
negative association was found <strong>in</strong> <strong>the</strong> relationship <strong>of</strong><br />
coercion and <strong>the</strong> ability to depend on o<strong>the</strong>rs as well as<br />
<strong>the</strong> belief that conflict could be resolved by discussion.<br />
Dejection was associated with low social support,<br />
unstable dependence on o<strong>the</strong>rs, less control <strong>of</strong> health,<br />
stress regard<strong>in</strong>g liv<strong>in</strong>g relationships and <strong>in</strong>terpersonal<br />
conflict with children. Dependence was correlated with<br />
areas such as better physical health, lower stress, and<br />
lower health service use.<br />
Sch<strong>of</strong>ield and Mishra (2003) suggest that dependence<br />
may provide a protective element aga<strong>in</strong>st poorer health<br />
as dependent older people are generally <strong>in</strong> receipt <strong>of</strong><br />
care. Some additional support <strong>of</strong> <strong>the</strong> VASS factors was<br />
recently demonstrated <strong>in</strong> a Ch<strong>in</strong>ese study (Dong et al.<br />
2011) where 411 older people over 60 years were<br />
assessed us<strong>in</strong>g <strong>the</strong> VASS, a modified Geriatric Depression<br />
Scale (Yesavage et al. 1983) and <strong>the</strong> Social Support Index<br />
(Berkman et al. 1992). Depression was associated with<br />
<strong>in</strong>creased risk <strong>of</strong> report<strong>in</strong>g elder abuse, although social<br />
supports are proposed as hav<strong>in</strong>g a modifiable effect on<br />
<strong>the</strong> abusive environment.<br />
While <strong>the</strong> VASS has shown some promis<strong>in</strong>g psychometric<br />
results, <strong>the</strong> authors (Sch<strong>of</strong>ield and Mischra 2003)<br />
acknowledge that issues rema<strong>in</strong> <strong>in</strong> relation to <strong>the</strong><br />
reliability and <strong>in</strong>ternal consistency <strong>of</strong> <strong>the</strong> coercion factor.<br />
A particular concern was <strong>the</strong> difficulty <strong>in</strong> establish<strong>in</strong>g<br />
predictive validity <strong>of</strong> <strong>the</strong> test and additional qualitative<br />
research is recommended to generate knowledge on<br />
abusive experiences <strong>of</strong> older people. When Buri et al.<br />
(2009) used <strong>the</strong> VASS as one <strong>of</strong> <strong>the</strong> elder abuse screen<strong>in</strong>g<br />
tools <strong>in</strong> Iowa <strong>in</strong> <strong>the</strong> United States, f<strong>in</strong>d<strong>in</strong>gs from <strong>the</strong>ir<br />
telephone study <strong>of</strong> 44 older people who were referred to<br />
a social service agency <strong>in</strong>dicated that <strong>the</strong> discrim<strong>in</strong>atory<br />
ability <strong>of</strong> <strong>the</strong> VASS could be <strong>in</strong>fluenced by issues such as<br />
mental capacity status and refusal to complete <strong>the</strong><br />
screen. Thus, although <strong>the</strong> VASS has expanded <strong>the</strong> H-S<br />
EAST and it has been used with a large sample, it rema<strong>in</strong>s<br />
relatively untested and additional work needs to be<br />
undertaken <strong>in</strong> determ<strong>in</strong><strong>in</strong>g predictive value (Sch<strong>of</strong>ield<br />
and Mishra 2003).<br />
The <strong>Elder</strong> Assessment Instrument<br />
The <strong>Elder</strong> Assessment Instrument (EAI) was first<br />
<strong>in</strong>troduced <strong>in</strong> 1984 (Fulmer et al. 1984) and has been<br />
adapted to different cl<strong>in</strong>ical areas (Fulmer 2008). It is<br />
completed by a healthcare pr<strong>of</strong>essional who undertakes a<br />
one-to-one <strong>in</strong>terview and physical assessment <strong>of</strong> <strong>the</strong><br />
older person to determ<strong>in</strong>e if abuse may have occurred.<br />
The test takes between 12-15 m<strong>in</strong>utes to complete and<br />
encompasses both subjective and objective assessment.<br />
The constituents <strong>of</strong> <strong>the</strong> screen<strong>in</strong>g tool are derived from<br />
<strong>the</strong> literature which proposes causative factors <strong>in</strong> elder<br />
abuse but also accommodates <strong>in</strong>dicators from o<strong>the</strong>r<br />
doma<strong>in</strong>s <strong>in</strong> <strong>the</strong> family violence spectrum. The tool is<br />
composed <strong>of</strong> 41 non-scor<strong>in</strong>g items which are sub-divided<br />
<strong>in</strong>to seven sections: general assessment, possible abuse<br />
<strong>in</strong>dicators, possible neglect <strong>in</strong>dicators, possible<br />
exploitation <strong>in</strong>dicators, possible abandonment <strong>in</strong>dicators,<br />
and a summary section. Each item is completed based on<br />
a five po<strong>in</strong>t scale rang<strong>in</strong>g from ‘no evidence’ to ‘def<strong>in</strong>ite<br />
evidence’ (1-4) and <strong>the</strong> fifth po<strong>in</strong>t allows <strong>for</strong> a ‘<strong>in</strong>ability to<br />
assess’. Neglect is also reviewed under <strong>the</strong> section<br />
‘general assessment’ (Cohen 2011). The 41 items are<br />
graded accord<strong>in</strong>g to a likert-type scale and <strong>the</strong> f<strong>in</strong>al<br />
summary section attempts to identify evidence <strong>of</strong> elder<br />
abuse. The tool conta<strong>in</strong>s a f<strong>in</strong>al commentary section<br />
which allows <strong>the</strong> assessor to ‘expla<strong>in</strong> why she or he is<br />
<strong>in</strong>terpret<strong>in</strong>g a cl<strong>in</strong>ical sign or symptom <strong>in</strong> a particular way’<br />
(Fulmer 2008: 54).<br />
The EAI functions to provide a risk <strong>in</strong>dicator <strong>for</strong> abuse<br />
and can underp<strong>in</strong> <strong>the</strong> need <strong>for</strong> fur<strong>the</strong>r review and referral<br />
<strong>of</strong> <strong>the</strong> older person. Referral is warranted if <strong>the</strong>re are<br />
positive <strong>in</strong>dicators <strong>of</strong> abuse without sufficient cl<strong>in</strong>ical<br />
explanation, if <strong>the</strong> older person discloses abuse or if <strong>the</strong>re<br />
is high risk <strong>of</strong> probable abuse, neglect, exploitation or<br />
abandonment (Fulmer 2003). In terms <strong>of</strong> validity and<br />
reliability, a study <strong>of</strong> 501 older people <strong>in</strong> an emergency<br />
department showed an <strong>in</strong>ternal consistency reliability<br />
(Cronbach’s alpha) <strong>of</strong> 0.84 and a test/retest reliability <strong>of</strong><br />
0.83 (P
3. <strong>Screen<strong>in</strong>g</strong><br />
also shown to have a sensitivity <strong>of</strong> 71 percent, a<br />
specificity <strong>of</strong> 93 percent and a content validity <strong>in</strong>dex <strong>of</strong><br />
0.83 (Fulmer et al. 2004). The EAI does have some merit<br />
<strong>in</strong> test<strong>in</strong>g <strong>for</strong> elder abuse but does not give a score on<br />
probability <strong>of</strong> abuse (Cohen 2011). The tool has<br />
demonstrated some promis<strong>in</strong>g results <strong>in</strong> identify<strong>in</strong>g elder<br />
abuse, but is victim focused and does not capture an<br />
assessment <strong>of</strong> <strong>the</strong> caregiver or perpetrator (Imbody and<br />
Vandsburger 2011) and although <strong>the</strong> EAI has<br />
demonstrated some success fur<strong>the</strong>r empirical test<strong>in</strong>g is<br />
required.<br />
The Indicators <strong>of</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Tool<br />
The Indicators <strong>of</strong> <strong>Abuse</strong> (IOA) screen (Reis and Nahmiash<br />
1998) is adm<strong>in</strong>istered by a tra<strong>in</strong>ed pr<strong>of</strong>essional to<br />
discrim<strong>in</strong>ate potential abusive and non-abusive<br />
situations. The test takes approximately two to three<br />
hours to complete and is focused on <strong>the</strong> home<br />
environment. The IOA was developed from <strong>the</strong><br />
compilation <strong>of</strong> a 60-itemed prelim<strong>in</strong>ary checklist, with 48<br />
items drawn from possible <strong>in</strong>dicators and 12 focuss<strong>in</strong>g on<br />
background and demographic details (Reis 2000). The<br />
sixty items were tested with<strong>in</strong> a larger study (PROJECT<br />
CARE) (Reis and Nahmiash 1995a,b,c) with<strong>in</strong> a residential<br />
area <strong>of</strong> a North American city us<strong>in</strong>g 341 participants. The<br />
study used participants from <strong>the</strong> age <strong>of</strong> 55 years, who had<br />
unpaid caregivers. From this study 29 items were isolated<br />
which could predict whe<strong>the</strong>r abuse was potentially<br />
occurr<strong>in</strong>g. The items focus on mental and psychosocial<br />
features <strong>in</strong> <strong>the</strong> caregiver characteristics, <strong>the</strong> care-receiver<br />
characteristics and <strong>the</strong> <strong>in</strong>terpersonal care receivercaregiver<br />
context. Measurements on <strong>the</strong> IOA scale range<br />
from an evaluation <strong>of</strong> <strong>the</strong> item’s ‘non-existence’ to ‘yes/<br />
severe’ with cod<strong>in</strong>g accommodated <strong>for</strong> items which were<br />
not applicable or were not determ<strong>in</strong>able dur<strong>in</strong>g <strong>the</strong><br />
screen<strong>in</strong>g test. True positives <strong>for</strong> abuse were identified <strong>in</strong><br />
78 to 84.4 percent <strong>of</strong> screened older people while<br />
non-abuse cases were identified <strong>in</strong> 99.2 percent <strong>of</strong> those<br />
screened (Reis and Nahmiash 1998). Reliability was<br />
determ<strong>in</strong>ed by <strong>the</strong> IOA’s high <strong>in</strong>ternal consistency<br />
(Cronbach alpha coefficient .91-.92). However, although<br />
<strong>the</strong> IOA has <strong>the</strong> capability to identify risk <strong>of</strong> abuse, its<br />
content is based on <strong>in</strong>dicators and <strong>in</strong>terviewers’ skills<br />
may impact on <strong>the</strong> use <strong>of</strong> <strong>the</strong> tool (Cohen et al. 2006,<br />
Cohen 2011).<br />
In 2006, Cohen and colleagues expanded <strong>the</strong> IOA scale<br />
(E-IOA) by <strong>in</strong>troduc<strong>in</strong>g a series <strong>of</strong> sub-<strong>in</strong>dicators (Cohen<br />
et al. 2006). These were based on high risk and were<br />
drawn from literature on psychiatric disorders (American<br />
Psychiatric Association’s 1994, Goldman 1994) and a<br />
model <strong>of</strong> bio-psychosocial assessment social work relat<strong>in</strong>g<br />
to older people (Greene 2000). Four <strong>in</strong>dicators were<br />
removed from <strong>the</strong> orig<strong>in</strong>al IOL. These <strong>in</strong>dicators related<br />
to past poor relationships as this was correlated to poor<br />
current relationships; <strong>the</strong> existence <strong>of</strong> falls was<br />
considered a possible sign <strong>of</strong> abuse ra<strong>the</strong>r than a high<br />
risk <strong>in</strong>dicator; ‘no permanent doctor’ was considered not<br />
applicable to <strong>the</strong> Israeli context and ‘suffered abuse <strong>in</strong><br />
<strong>the</strong> past’ was removed as this was seen as demonstrat<strong>in</strong>g<br />
a high certa<strong>in</strong>ty <strong>of</strong> abuse <strong>in</strong> <strong>the</strong> present. Fur<strong>the</strong>r<br />
assessment <strong>in</strong>cluded a determ<strong>in</strong>ation based on evident<br />
signs and symptoms <strong>of</strong> abuse which were elicited from<br />
<strong>the</strong> physical, mental, sexual, and <strong>the</strong> economic signs <strong>of</strong><br />
abuse and neglect developed by Mount S<strong>in</strong>ai Hospital<br />
(Ansen and Breckman 1988). Evaluation <strong>of</strong> <strong>the</strong> list <strong>of</strong><br />
signs <strong>of</strong> abuse ranged from 1= ‘to a great extent’ to 5=<br />
‘not at all’ or ‘not possible to receive <strong>in</strong><strong>for</strong>mation’. In a<br />
pre-test sample, Cronbach alpha <strong>for</strong> <strong>the</strong> E-IOA was .78 to<br />
.91. In a sample <strong>of</strong> 108 (Cohen et al. 2006) and a fur<strong>the</strong>r<br />
sample <strong>of</strong> 730 older people from <strong>the</strong> age <strong>of</strong> 65 years<br />
(Cohen et al. 2007), <strong>the</strong> tool discerned 92.9 percent <strong>of</strong><br />
older people as be<strong>in</strong>g at risk <strong>of</strong> abuse and 97.9 percent <strong>of</strong><br />
older people who were probably not abused. Fur<strong>the</strong>r<br />
test<strong>in</strong>g <strong>of</strong> 1,317 older people over 70 years <strong>of</strong> age also<br />
demonstrated good validity and reliability (Cohen et al.<br />
2010).<br />
In summary, <strong>the</strong> IOA does show some strength <strong>in</strong> terms<br />
<strong>of</strong> validity and reliability and is easy to score (Meeks-<br />
Sjostrom 2004) however; <strong>the</strong> tool requires completion by<br />
a tra<strong>in</strong>ed pr<strong>of</strong>essional and is based on <strong>the</strong> pr<strong>of</strong>essional’s<br />
subjective score <strong>in</strong> relation to each item (Imbody and<br />
Vandsburger 2011, Cohen 2011). Fur<strong>the</strong>rmore, <strong>the</strong> time<br />
to complete <strong>the</strong> screen may prohibit its use <strong>in</strong> cl<strong>in</strong>ical<br />
practice (Fulmer et al. 2004). Although, <strong>the</strong> IOA has been<br />
tested by Reis and Nahmiash (1998) <strong>in</strong> <strong>the</strong> home<br />
environment and <strong>the</strong> E-IOA by Cohen et al. (2006) <strong>in</strong> <strong>the</strong><br />
acute hospital environment, nei<strong>the</strong>r have been used <strong>in</strong><br />
long term care facilities <strong>for</strong> older people. Fur<strong>the</strong>rmore,<br />
E-IOA tools are weak <strong>in</strong> identify<strong>in</strong>g areas <strong>of</strong> f<strong>in</strong>ancial<br />
abuse (Cohen et al. 2006).<br />
Brief <strong>Abuse</strong> Screen <strong>for</strong> <strong>the</strong> <strong>Elder</strong>ly<br />
Reis and Nahmiash (1995c) developed <strong>the</strong> Brief <strong>Abuse</strong><br />
Screen <strong>for</strong> <strong>the</strong> <strong>Elder</strong>ly (BASE) as part <strong>of</strong> PROJECT CARE.<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 13
3. <strong>Screen<strong>in</strong>g</strong><br />
This tool conta<strong>in</strong>s five questions to sensitise those who<br />
use <strong>the</strong> tool to <strong>the</strong> possibility <strong>of</strong> elder abuse. It has <strong>the</strong><br />
advantage <strong>of</strong> tak<strong>in</strong>g approximately one m<strong>in</strong>ute to<br />
complete by a tra<strong>in</strong>ed pr<strong>of</strong>essional. Questions focus on<br />
<strong>the</strong> suspicion level, <strong>the</strong> abuse type and <strong>the</strong> immediacy <strong>of</strong><br />
response, however, it does not assess <strong>for</strong> specific risk<br />
factors or signs <strong>of</strong> abuse or neglect (Imbody and<br />
Vandsburger 2011). Psychometric test<strong>in</strong>g (n=492)<br />
demonstrated predictive validity which ranged from 89-91<br />
percent (Reis and Nahmiash 1995c). While <strong>the</strong> BASE has<br />
some merit as a screen<strong>in</strong>g <strong>in</strong>strument, its use is limited as<br />
it should be adm<strong>in</strong>istered <strong>in</strong> conjunction with <strong>the</strong> IOA<br />
tool (Reis and Nahmiash 1998) ra<strong>the</strong>r than as a standalone<br />
assessment. This complicates <strong>the</strong> screen<strong>in</strong>g process<br />
and can elongate assessment.<br />
The Caregiver <strong>Abuse</strong> Screen<br />
Developed <strong>in</strong> <strong>the</strong> context <strong>of</strong> a large scale elder abuse and<br />
<strong>in</strong>tervention research project (PROJECT CARE) (Reis and<br />
Nahmiash 1995a, b, c), <strong>the</strong> CAS focuses on current<br />
physical, psychological, or f<strong>in</strong>ancial abuse as well as<br />
neglect. It encompasses eight questions which screen <strong>the</strong><br />
caregiver <strong>of</strong> <strong>the</strong> older person giv<strong>in</strong>g <strong>the</strong> option <strong>of</strong> a ‘yes’<br />
or ‘no’ answer. Questions are orientated towards elicit<strong>in</strong>g<br />
a suspicion <strong>of</strong> one <strong>of</strong> <strong>the</strong> abuse types without specific<br />
reference to particular abuse behaviours. The screen<br />
takes between one to two m<strong>in</strong>utes to complete.<br />
Theoretical l<strong>in</strong>ks are made by <strong>the</strong> authors <strong>in</strong> relation to<br />
an external locus <strong>of</strong> control and <strong>the</strong> neutralisation <strong>the</strong>ory,<br />
which expla<strong>in</strong>s abuse as <strong>in</strong>volv<strong>in</strong>g particular<br />
rationalisations <strong>of</strong> <strong>the</strong> caregiver’s behaviour. Such<br />
rationalisations are not challenged with<strong>in</strong> <strong>the</strong> context <strong>of</strong><br />
<strong>the</strong> screen<strong>in</strong>g tool (Reis and Nahmiash 1995a).<br />
Psychometric test<strong>in</strong>g <strong>of</strong> <strong>the</strong> <strong>in</strong>strument was undertaken<br />
with 44 abusive caregivers receiv<strong>in</strong>g <strong>the</strong> PROJECT CARE<br />
abuse <strong>in</strong>tervention model. Two contrast groups were also<br />
recruited. The first conta<strong>in</strong>ed a sample <strong>of</strong> 45 non-abusive<br />
caregivers receiv<strong>in</strong>g assistance from <strong>the</strong> health and social<br />
care services. The second group consisted <strong>of</strong> 50 nonabusive<br />
caregivers recruited from <strong>the</strong> same or similar<br />
geographical area who were not <strong>in</strong> receipt or any external<br />
health or social care assistance.<br />
Three abuse/aggression scales were used to exam<strong>in</strong>e<br />
convergent validity: <strong>the</strong> IOA (Reis and Nahmiash 1998),<br />
two Ryden Agression Subscales (Ryden 1988a, b) and <strong>the</strong><br />
H-S EAST (Neale et al. 1991). In addition, personality<br />
traits were measured us<strong>in</strong>g a number <strong>of</strong> scales or<br />
sub-scales which were adm<strong>in</strong>istered <strong>in</strong> <strong>the</strong> context <strong>of</strong> <strong>the</strong><br />
<strong>in</strong>terview. Concurrent validity was supported by <strong>the</strong> fact<br />
that ‘known’ abusers scored much higher that <strong>the</strong> two<br />
non-abus<strong>in</strong>g groups, thus <strong>in</strong>dicat<strong>in</strong>g <strong>the</strong> tool’s ability to<br />
dist<strong>in</strong>guish between abusive and non-abusive caregivers.<br />
There were no differences between <strong>the</strong> two non-abus<strong>in</strong>g<br />
groups. Internal consistency <strong>of</strong> <strong>the</strong> tool measured at<br />
Cronbach’s alpha 0.71. Statistical correlations were also<br />
found us<strong>in</strong>g <strong>the</strong> three abuse/aggression scales with a cut<br />
<strong>of</strong>f significance <strong>of</strong> p
3. <strong>Screen<strong>in</strong>g</strong><br />
questions with three older people, an additional subquestion<br />
was added to elicit <strong>the</strong> frequency <strong>of</strong> <strong>the</strong> abuse<br />
type. The study (Yaffe et al. 2008) suggested elim<strong>in</strong>at<strong>in</strong>g<br />
<strong>the</strong> question on frequency as it did not impact on <strong>the</strong><br />
sensitivity <strong>of</strong> <strong>the</strong> tool nor was frequency considered<br />
essential by <strong>the</strong> World Health Organisation (2008) review.<br />
F<strong>in</strong>ally, a sixth question was added to articulate <strong>the</strong> need<br />
to <strong>in</strong>clude physician observation <strong>of</strong> <strong>the</strong> older person. The<br />
f<strong>in</strong>al items on <strong>the</strong> tool focused on closed, behaviourally<br />
specific questions, preface statements which were<br />
contextually orientated and <strong>the</strong> assessment <strong>of</strong> active<br />
abuse by people with whom <strong>the</strong> older person has contact<br />
with (WHO 2008).<br />
A sample <strong>of</strong> 953 cognitively <strong>in</strong>tact older people was<br />
screened with <strong>the</strong> EASI and three weeks later <strong>the</strong> Social<br />
Worker Evaluation (SWE) was completed on <strong>the</strong> same<br />
population. The SWE is a standardised assessment which<br />
allows <strong>in</strong>-depth evaluation <strong>of</strong> older people at risk <strong>of</strong> be<strong>in</strong>g<br />
abused and takes an average <strong>of</strong> 66 m<strong>in</strong>utes to complete<br />
(WHO 2008). Social workers who undertook <strong>the</strong> SWE<br />
were bl<strong>in</strong>ded to <strong>the</strong> result <strong>of</strong> <strong>the</strong> EASI. The EASI was<br />
identified as hav<strong>in</strong>g a relatively high specificity and<br />
sensitivity. The sensitivity <strong>of</strong> each <strong>of</strong> <strong>the</strong> six questions<br />
ranged from 0.03-0.23, whilst <strong>the</strong> specificity ranged from<br />
0.72-0.99. However, it was noted that when <strong>the</strong> first<br />
question, which addressed risk, was removed <strong>the</strong><br />
sensitivity reduced from 0.47 to 0.32. The authors (Yaffe<br />
et al. 2008) suggest that <strong>the</strong> first question is important as<br />
a primer <strong>for</strong> o<strong>the</strong>r EASI responses and such questions<br />
may be necessary to encourage full disclosure (Acierno et<br />
al. 2003). Overall <strong>the</strong> correlation <strong>of</strong> <strong>the</strong> EASI and <strong>the</strong> SWE<br />
<strong>in</strong>dicated a sensitivity rate <strong>of</strong> 0.44 and a specificity rate <strong>of</strong><br />
0.77 (Yaffe et al. 2008).<br />
The EASI does have potential <strong>for</strong> use <strong>in</strong> <strong>the</strong> practice<br />
sett<strong>in</strong>g <strong>in</strong> terms <strong>of</strong> brevity with 69.2 percent <strong>of</strong> physicians<br />
who completed <strong>the</strong> post-study survey <strong>in</strong>dicat<strong>in</strong>g that <strong>the</strong><br />
EASI took two m<strong>in</strong>utes or less to complete (Yaffe et al.<br />
2008). In addition, 95.8 percent <strong>of</strong> physicians <strong>in</strong>dicated<br />
that <strong>the</strong> questions were ‘very easy’ or ‘somewhat easy’<br />
(Yaffe et al. 2008). However, it is noted that older people<br />
who have been subject to repeated abuse may require a<br />
more <strong>in</strong>-depth screen to identify abuse.<br />
In 2008, <strong>the</strong> WHO used <strong>the</strong> EASI as a basis <strong>for</strong> develop<strong>in</strong>g<br />
an elder abuse screen<strong>in</strong>g tool that would be culturally<br />
and geographically acceptable <strong>in</strong> areas outside <strong>of</strong><br />
Canada. Focus groups from eight participat<strong>in</strong>g countries<br />
(Australia, Brazil, Chile, Costa Rica, Kenya, S<strong>in</strong>gapore,<br />
Spa<strong>in</strong> and Switzerland) were used. Each participat<strong>in</strong>g<br />
country convened three focus groups comprised <strong>of</strong> older<br />
people and four focus groups comprised <strong>of</strong> primary<br />
health care pr<strong>of</strong>essionals. Fur<strong>the</strong>r workshops considered<br />
<strong>the</strong> concept <strong>of</strong> <strong>the</strong> SWE, local understand<strong>in</strong>gs and<br />
<strong>in</strong>terventions related to elder abuse and <strong>the</strong> efficacy <strong>of</strong><br />
<strong>the</strong> Pan American Health Organisation (2002) guidel<strong>in</strong>es<br />
on elder abuse and neglect. F<strong>in</strong>d<strong>in</strong>gs from this study<br />
<strong>in</strong>dicate that <strong>the</strong> EASI tool was simple to complete,<br />
covered <strong>the</strong> important categories <strong>of</strong> elder abuse and<br />
although <strong>the</strong>re were m<strong>in</strong>or issues <strong>in</strong> relation to local<br />
cultural <strong>in</strong>terpretations, <strong>the</strong> tool was culturally<br />
transferable. Comments also <strong>in</strong>dicated that neglect was<br />
not addressed sufficiently. The WHO (2008) suggested<br />
some alterations to <strong>the</strong> six questions with<strong>in</strong> <strong>the</strong> EASI<br />
screen<strong>in</strong>g tool, but, to date, <strong>the</strong> revised tool has not been<br />
piloted <strong>in</strong> cl<strong>in</strong>ical practice. Although <strong>the</strong> EASI tool was<br />
developed <strong>for</strong> physician use, <strong>the</strong> WHO (2008) suggests as<br />
an alternative nurses could adm<strong>in</strong>ister <strong>the</strong> tool.<br />
Currently, <strong>the</strong> EASI has been translated <strong>in</strong>to Spanish,<br />
French, Japanese, German, Hebrew and Arabic (Yaffe M.<br />
Personal communication 5/12/10). Recently, <strong>the</strong> EASI has<br />
been adapted <strong>for</strong> self-completion by older people (Yaffe<br />
et al. 2011). The first five questions were reta<strong>in</strong>ed but <strong>the</strong><br />
sixth question, which was orig<strong>in</strong>ally focused on physician<br />
observation, was elim<strong>in</strong>ated. This decision was<br />
considered supported by psychometric evaluation as<br />
when <strong>the</strong> sixth question was elim<strong>in</strong>ated, sensitivity<br />
decreased by 0.01, while specificity <strong>in</strong>creased by a similar<br />
quantity (Yaffe at al. 2008). The response options were<br />
reduced to ‘yes’ or ‘no’ as ‘did not answer’ was removed.<br />
The revised EASI, referred to as EASI-sa, was completed<br />
by 210 cognitively <strong>in</strong>tact older people who were stratified<br />
<strong>in</strong>to eight groups to evaluate <strong>the</strong> screen<strong>in</strong>g tool (Yaffe et<br />
al. 2011). Readability and acceptability <strong>of</strong> <strong>the</strong> tool was<br />
positively evaluated and <strong>the</strong> refusal rate to complete was<br />
low. Completion time ranged from two to five m<strong>in</strong>utes<br />
with <strong>the</strong> tool act<strong>in</strong>g as an elder abuse awareness tra<strong>in</strong><strong>in</strong>g<br />
method <strong>for</strong> <strong>the</strong> older people <strong>in</strong> 27.2 percent <strong>of</strong> cases as<br />
well as <strong>in</strong>creas<strong>in</strong>g understand<strong>in</strong>g <strong>of</strong> <strong>the</strong> manifestations <strong>of</strong><br />
elder abuse. Yaffe and colleagues (2011) <strong>in</strong>dicate that<br />
fur<strong>the</strong>r validation studies will focus on compar<strong>in</strong>g<br />
outcomes from <strong>the</strong> EASI and <strong>the</strong> EASI-sa.<br />
Although <strong>the</strong> EASI does not assess <strong>the</strong> caregiver, it has<br />
particular merit <strong>in</strong> be<strong>in</strong>g a rapid assessment which<br />
assesses <strong>for</strong> potential abuse and allows practitioners to<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 15
3. <strong>Screen<strong>in</strong>g</strong><br />
<strong>in</strong>corporate <strong>the</strong>ir subjective assessment. As a tool, it<br />
provides <strong>for</strong> <strong>the</strong> identification <strong>of</strong> older people at potential<br />
risk <strong>of</strong> elder abuse and highlights <strong>in</strong>dividuals whose case<br />
may require fur<strong>the</strong>r prob<strong>in</strong>g and, if deemed necessary,<br />
referral to elder abuse services. The tool appears to be<br />
culturally transferable, suitable <strong>for</strong> use <strong>in</strong> multiple<br />
sett<strong>in</strong>gs, to have <strong>the</strong> potential to be used by pr<strong>of</strong>essions<br />
o<strong>the</strong>r than physicians (WHO 2008) and has demonstrated<br />
acceptability and value <strong>in</strong> <strong>the</strong> context <strong>of</strong> self-completion<br />
by <strong>the</strong> older person.<br />
Caregivers Psychological <strong>Elder</strong> <strong>Abuse</strong> Behaviour Scale<br />
In Taiwan, Wang et al. (2006) developed two elder abuse<br />
screen<strong>in</strong>g tools which focused on identify<strong>in</strong>g <strong>the</strong> potential<br />
<strong>for</strong> psychological abuse. Wang et al. (2005; 2006) noted<br />
that although psychological abuse is <strong>the</strong> most common<br />
<strong>for</strong>m <strong>of</strong> abuse, it is generally underestimated due to a<br />
lack <strong>of</strong> evidence or a m<strong>in</strong>imisation <strong>of</strong> <strong>the</strong> significance <strong>of</strong><br />
elder abuse. The Caregivers Psychological <strong>Elder</strong> <strong>Abuse</strong><br />
Behaviour Scale (CPEABS) takes ten m<strong>in</strong>utes to complete<br />
and focuses on elicit<strong>in</strong>g <strong>in</strong><strong>for</strong>mation from <strong>the</strong> caregiver.<br />
The CPEABS consists <strong>of</strong> 20 items which are rated on a<br />
one to four likert scale, rang<strong>in</strong>g from “1=never behave<br />
this way”, to “4 =<strong>of</strong>ten behave this way”.<br />
The CPEABS has been tested <strong>in</strong> both long term care<br />
(Wang 2005) and <strong>in</strong> <strong>the</strong> home environment (Wang et al.<br />
2006). Caregivers <strong>in</strong> long term care environment<br />
completed <strong>the</strong> scale which was used <strong>in</strong> conjunction with<br />
<strong>the</strong> Caregiver’s Burden Scale (CBS) (adapted from Wu<br />
1995). Results <strong>in</strong>dicated that caregivers with higher levels<br />
<strong>of</strong> education, higher work burdens and those who lacked<br />
specialist geriatric tra<strong>in</strong><strong>in</strong>g were more prone to potentially<br />
abuse. Psychological abuse was also more associated<br />
with younger caregivers ra<strong>the</strong>r than <strong>the</strong>ir older<br />
counterparts. In test<strong>in</strong>g <strong>the</strong> CPEABS <strong>in</strong> <strong>the</strong> home<br />
environment, Wang et al. (2006) also used <strong>the</strong> CBS.<br />
Scores were added and could range between 20-80, with<br />
a higher score demonstrat<strong>in</strong>g a higher possibility to<br />
abuse. Reported psychometric results <strong>in</strong>dicate a content<br />
validity <strong>of</strong> .95 and a Cronbach’s alpha <strong>of</strong> .85. The testretest<br />
reliability was established .64, (p< .001) over a two<br />
week period (Wang et al. 2006).<br />
While <strong>the</strong> CPEABS (Wang et al. 2006) has <strong>the</strong> ability to<br />
probe <strong>in</strong>to psychological abuse and has been tested <strong>in</strong><br />
both community and long term sett<strong>in</strong>gs, it is specific to<br />
one typology. Although psychological abuse is a prevalent<br />
type <strong>of</strong> elder abuse, it <strong>of</strong>ten co-exists with o<strong>the</strong>r<br />
typologies, and us<strong>in</strong>g this tool alone would not illum<strong>in</strong>ate<br />
such co-morbidity. A generic screen<strong>in</strong>g tool <strong>for</strong> all<br />
typologies should be used as <strong>the</strong> front-l<strong>in</strong>e assessment<br />
while <strong>the</strong> CPEABS (Wang et al. 2006) could facilitate<br />
fur<strong>the</strong>r <strong>in</strong>vestigation <strong>of</strong> psychological abuse with<strong>in</strong> a<br />
specialised referral service. Fur<strong>the</strong>rmore, additional<br />
empirical test<strong>in</strong>g and a review <strong>of</strong> cultural transferability<br />
are required.<br />
<strong>Elder</strong> Psychological <strong>Abuse</strong> Scale<br />
The <strong>Elder</strong> Psychological <strong>Abuse</strong> Scale (EPAS) was<br />
developed by Wang et al. (2007) <strong>in</strong> Taiwan. Follow<strong>in</strong>g a<br />
review <strong>of</strong> <strong>the</strong> literature and <strong>in</strong>-depth focus group<br />
<strong>in</strong>terviews which discussed <strong>the</strong> concept <strong>of</strong> psychological<br />
abuse <strong>of</strong> older people, <strong>the</strong> items were reviewed by<br />
experts <strong>in</strong> <strong>the</strong> area <strong>of</strong> gerontology (academic and<br />
cl<strong>in</strong>ical). This resulted <strong>in</strong> a 32 item scale which focuses on<br />
discussion with <strong>the</strong> older person (Q 1-7), active<br />
observation (Q8-13) and an <strong>in</strong>terview with <strong>the</strong> caregiver<br />
(Q14-32). Concurrent validity was tested us<strong>in</strong>g <strong>the</strong><br />
Bar<strong>the</strong>l Index (BI) <strong>for</strong> activities <strong>of</strong> daily liv<strong>in</strong>g and <strong>the</strong><br />
Short Portable Mental State Questionnaire (SPMSQ)<br />
(Pfeiffer 1975).<br />
The EPAS was tested on 195 older people over 60 years<br />
<strong>of</strong> age who were resident <strong>in</strong> <strong>in</strong>stitutional care sett<strong>in</strong>gs and<br />
Wang et al. (2007) report an average <strong>of</strong> 5-10 m<strong>in</strong>utes <strong>for</strong><br />
completion. Reliability was established <strong>in</strong> a K-R20<br />
co-efficient <strong>of</strong> 0.82 <strong>for</strong> <strong>in</strong>ternal consistency. Concurrent<br />
validity was obta<strong>in</strong>ed by evaluat<strong>in</strong>g <strong>the</strong> relationship with<br />
<strong>the</strong> BI and SPMSQ with an overall correlation <strong>of</strong> -0.32<br />
(p
3. <strong>Screen<strong>in</strong>g</strong><br />
The Older Adult Psychological <strong>Abuse</strong> Measure<br />
As part <strong>of</strong> a study to develop scales <strong>for</strong> a comprehensive<br />
Older Adult Mistreatment Assessment (OAMA), Conrad<br />
and colleagues (2010a) developed <strong>the</strong> Older Adult<br />
Psychological <strong>Abuse</strong> Measure (OAPAM) and <strong>the</strong> Older<br />
Adult F<strong>in</strong>ancial Exploitation Measure (described below).<br />
Trochim’s (1989) three dimensional concept mapp<strong>in</strong>g<br />
approach was used to conceptualise psychological abuse<br />
<strong>of</strong> older people (Conrad et al. 2010a). Statements from<br />
<strong>the</strong> literature on <strong>the</strong> topic <strong>of</strong> psychological abuse and<br />
those developed by a national panel <strong>of</strong> 16 experts <strong>in</strong> this<br />
area were rated us<strong>in</strong>g a severity score from 1-5 and <strong>the</strong>n<br />
clustered us<strong>in</strong>g Concept Systems s<strong>of</strong>tware. Results<br />
comprised a hierarchy <strong>of</strong> severity 1) isolation, 2)<br />
<strong>in</strong>sensitivity and disrespect 3) sham<strong>in</strong>g and blam<strong>in</strong>g 4)<br />
threats and <strong>in</strong>timidation and 5) trusted o<strong>the</strong>r risk factors.<br />
Statements were <strong>the</strong>n generated <strong>for</strong> questionnaires and<br />
developed <strong>for</strong> both third party review and self-report<br />
(Conrad et al. 2010a). The questionnaires were <strong>the</strong>n<br />
reviewed by n<strong>in</strong>e focus groups comprised <strong>of</strong> both staff<br />
members from adult protective services and older<br />
people. A fur<strong>the</strong>r four cognitive <strong>in</strong>terviews were<br />
conducted with four older people with substantiated<br />
elder abuse. This resulted <strong>in</strong> a 31 item client-self report<br />
measure, <strong>the</strong> OAPAM. Us<strong>in</strong>g 22 staff <strong>in</strong> Adult Protective<br />
Services <strong>in</strong> <strong>the</strong> Chicago area, 226 older people, who were<br />
substantiated <strong>for</strong> at least one abuse type, were recruited<br />
to participate <strong>in</strong> <strong>the</strong> study, all <strong>of</strong> whom consented to <strong>the</strong><br />
study and demonstrated a M<strong>in</strong>i-Mental State Exam<strong>in</strong>ation<br />
(MMSE) score <strong>of</strong> at least 17. Statistical analysis was<br />
conducted us<strong>in</strong>g <strong>the</strong> Rasch measurement module (Rasch<br />
1960), which has <strong>the</strong> ability to test use an item hierarchy<br />
and contributes to <strong>the</strong>ory build<strong>in</strong>g and test construct<br />
validity. The test construct dimensionality raw variance<br />
was 43.1 percent which supported <strong>the</strong> unidimensionality<br />
<strong>of</strong> <strong>the</strong> tool. The Rasch person reliability was .86, which is<br />
equivalent to a Cronbach’s Alpha <strong>of</strong> .92, and item<br />
reliability was demonstrated as high at .97. A shorter from<br />
<strong>of</strong> <strong>the</strong> OAPAM us<strong>in</strong>g 18 items was also developed and<br />
met str<strong>in</strong>gent Rasch analysis (Rasch person reliability .78<br />
correspond<strong>in</strong>g to a Cronbach’s alpha <strong>of</strong> .87, item reliability<br />
was .96).<br />
The OAPAM (Conrad et al. 2010a) has been<br />
demonstrated as a useful tool <strong>in</strong> screen<strong>in</strong>g <strong>for</strong> potential<br />
psychological abuse <strong>of</strong> older people and has also<br />
identified relevant graduations <strong>of</strong> severity <strong>of</strong><br />
psychological abuse. Fur<strong>the</strong>r validity test<strong>in</strong>g <strong>in</strong> o<strong>the</strong>r<br />
populations would contribute to <strong>the</strong> ability <strong>of</strong> <strong>the</strong> OAPAM<br />
to elicit suspicion <strong>of</strong> psychological abuse and to<br />
potentialise <strong>the</strong> effectiveness <strong>of</strong> service response <strong>in</strong><br />
prevention and amelioration.<br />
The Older Adult F<strong>in</strong>ancial Exploitation Measure<br />
The only validated f<strong>in</strong>ancial abuse screen<strong>in</strong>g tool<br />
reported <strong>in</strong> <strong>the</strong> literature is <strong>the</strong> Older Adult F<strong>in</strong>ancial<br />
Exploitation Measure (OAFEM) (Conrad et al. 2010b),<br />
which represents part <strong>of</strong> <strong>the</strong> developmental work by<br />
Conrad and colleagues with<strong>in</strong> <strong>the</strong> Older Adult<br />
Mistreatment Assessment (OAMA) research. The OAFEM<br />
identifies <strong>in</strong>dividual components <strong>of</strong> f<strong>in</strong>ancial abuse and a<br />
related severity hierarchy. Us<strong>in</strong>g statements on f<strong>in</strong>ancial<br />
abuse from <strong>the</strong> literature and bra<strong>in</strong>-storm<strong>in</strong>g with expert<br />
panels, a list was produced which reflected aspects <strong>of</strong><br />
f<strong>in</strong>ancial abuse. The list was <strong>the</strong>n arranged <strong>in</strong>to a<br />
conceptual framework us<strong>in</strong>g Trochim’s (1989) concept<br />
mapp<strong>in</strong>g and components rated <strong>for</strong> severity by <strong>the</strong> expert<br />
panel.<br />
The concept mapp<strong>in</strong>g and expert review work resulted <strong>in</strong><br />
six clusters and gave rise to an 82 item scale, which was<br />
fur<strong>the</strong>r reduced to 79 items. The clusters focused on;<br />
<strong>the</strong>ft and scams, f<strong>in</strong>ancial victimisation, f<strong>in</strong>ancial<br />
entitlement, coercion, signs <strong>of</strong> possible f<strong>in</strong>ancial<br />
exploitation and money management. Possible responses<br />
to <strong>the</strong> questions on <strong>the</strong> OAFEM <strong>in</strong>clude a positive,<br />
negative, suspected or not-applicable response <strong>for</strong> <strong>the</strong><br />
specific <strong>for</strong>ms <strong>of</strong> f<strong>in</strong>ancial abuse listed. Initial<br />
psychometric test<strong>in</strong>g by 22 tra<strong>in</strong>ed staff on 227 older<br />
people who had substantiated abuse demonstrated<br />
enhanced pr<strong>of</strong>essional decision mak<strong>in</strong>g <strong>in</strong> suspected<br />
cases <strong>of</strong> f<strong>in</strong>ancial abuse. Adequate cognitive capacity is<br />
required to complete <strong>the</strong> OAFEM. Consequently,<br />
completion requires a M<strong>in</strong>i-Mental Status Exam score <strong>of</strong><br />
17 or above or competent <strong>in</strong>vestigator judgment (Conrad<br />
et al. 2009). Fur<strong>the</strong>r psychometric test<strong>in</strong>g ref<strong>in</strong>ed <strong>the</strong> tool<br />
to a 30 item scale which has demonstrated validity.<br />
With<strong>in</strong> <strong>the</strong> sample, 173 people endorsed one or more<br />
items on <strong>the</strong> 30 item scale which uses different cut-<strong>of</strong>f<br />
po<strong>in</strong>ts, but it has <strong>the</strong> potential to <strong>in</strong>dicate more serious<br />
f<strong>in</strong>ancial abuse (Conrad et al. 2010b). The latest version<br />
<strong>of</strong> <strong>the</strong> OAFEM has been reduced to a 25 item tool<br />
(personal communication with Conrad 2011), which<br />
addresses <strong>the</strong> issue <strong>of</strong> a lengthy completion time<br />
compared to <strong>the</strong> 79 item tool.<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 17
3. <strong>Screen<strong>in</strong>g</strong><br />
The OAFEM (Conrad et al. 2010b) has demonstrated<br />
specific merit <strong>in</strong> identify<strong>in</strong>g potential f<strong>in</strong>ancial abuse <strong>of</strong><br />
older people; <strong>in</strong> addition <strong>the</strong> reduction <strong>of</strong> items on <strong>the</strong><br />
tool has decreased <strong>the</strong> time required <strong>for</strong> completion. The<br />
OAFEM screens specifically <strong>for</strong> f<strong>in</strong>ancial abuse and may<br />
have particular value <strong>in</strong> <strong>the</strong> context <strong>of</strong> screen<strong>in</strong>g if a<br />
practitioner’s suspicion <strong>of</strong> f<strong>in</strong>ancial abuse is aroused and<br />
may also be useful when o<strong>the</strong>r abuse types have been<br />
identified. Identification <strong>of</strong> potential f<strong>in</strong>ancial abuse is<br />
particularly relevant <strong>in</strong> <strong>the</strong> context <strong>of</strong> recent studies<br />
which have identified f<strong>in</strong>ancial abuse as <strong>the</strong> most<br />
common <strong>for</strong>m <strong>of</strong> elder abuse (Naughton et al. 2010,<br />
Acierno et al. 2010, Lifespan <strong>of</strong> Greater Rochester Inc. et<br />
al. 2011).<br />
3.4 Assessment guidel<strong>in</strong>es<br />
In addition to screen<strong>in</strong>g tools, a number <strong>of</strong> assessment<br />
protocols and guidel<strong>in</strong>es have been developed to assist<br />
assessment <strong>of</strong> elder abuse. While screen<strong>in</strong>g tools<br />
generally have a specific closed response to particular<br />
focussed questions, assessment protocols and guidel<strong>in</strong>es<br />
are generally comprised <strong>of</strong> open-ended questions<br />
(Anthony et al. 2009). Such guidel<strong>in</strong>es <strong>in</strong>clude <strong>the</strong><br />
American Medical Association’s Diagnostic and Treatment<br />
Guidel<strong>in</strong>es on <strong>Elder</strong> <strong>Abuse</strong> and Neglect (1992) which<br />
recommends that assessment <strong>for</strong> elder abuse is<br />
<strong>in</strong>corporated <strong>in</strong>to a rout<strong>in</strong>e geriatric practice. Thus, it can<br />
be a lengthy process but is underp<strong>in</strong>ned by <strong>the</strong> practical<br />
support <strong>of</strong> a flow chart (Fulmer et al. 2004). The use <strong>of</strong><br />
flow charts or algorithms has been considered a priority<br />
<strong>for</strong> elder abuse detection and management (Kreuger et<br />
al. 1997) and <strong>the</strong>y allow a simple and clear pathway <strong>for</strong><br />
decision mak<strong>in</strong>g. O<strong>the</strong>r guidel<strong>in</strong>es use a broad qualitative<br />
approach (Johnson 1981; Rathbone- McCuan 1980;<br />
Tomita 1982) while Bomba (2006) has developed a s<strong>in</strong>gle<br />
page assessment and management tool <strong>for</strong> elder abuse<br />
<strong>in</strong>corporat<strong>in</strong>g assessment (adapted from Lachs 1998),<br />
best practice guidel<strong>in</strong>es (adapted from <strong>the</strong> National<br />
Association <strong>of</strong> Adult Protective Services Adm<strong>in</strong>istrators<br />
consensus statement), screen<strong>in</strong>g (adapted from a<br />
modified H-S EAST (Scholfield 1999), suspicion <strong>of</strong> abuse<br />
(Modified Ohio <strong>Elder</strong> <strong>Abuse</strong> and DVLL <strong>Screen<strong>in</strong>g</strong> tool<br />
(Ejaz 2001) and abuse management and monitor<strong>in</strong>g<br />
(modified AMA 1992). Although <strong>the</strong>se assessment<br />
protocols and guidel<strong>in</strong>es do raise practitioners’ sensitivity<br />
to elder abuse, <strong>the</strong> majority have not been validated. Two<br />
screen<strong>in</strong>g protocols were identified as be<strong>in</strong>g commonly<br />
cited <strong>in</strong> <strong>the</strong> literature and are reviewed below.<br />
The American Medical Association Diagnostic and<br />
Treatment Guidel<strong>in</strong>es on <strong>Elder</strong> <strong>Abuse</strong> and Neglect<br />
Although <strong>the</strong> United States Task Force on Preventative<br />
Violence (2004) did not support <strong>the</strong> rout<strong>in</strong>e use <strong>of</strong><br />
screen<strong>in</strong>g tools <strong>for</strong> elder abuse, <strong>the</strong> AMA (American<br />
Medical Association 1992) recommends that n<strong>in</strong>e<br />
questions related to elder abuse are <strong>in</strong>terwoven <strong>in</strong>to<br />
assessment <strong>of</strong> <strong>the</strong> older person. Questions focus on<br />
establish<strong>in</strong>g <strong>the</strong> safety <strong>of</strong> <strong>the</strong> older person, functional and<br />
cognitive assessment, general health, social connections,<br />
f<strong>in</strong>ance, psychological status and, if identified, a<br />
description <strong>of</strong> <strong>the</strong> abuse. The guidel<strong>in</strong>es <strong>in</strong>clude a<br />
flowchart which identifies care pathways and referral<br />
resources. Although, <strong>the</strong> guidel<strong>in</strong>es do provide some<br />
guidance, assessment is lengthy, neglect is not<br />
considered and <strong>the</strong> discrim<strong>in</strong>ation between disease and<br />
maltreatment is not differentiated (Fulmer et al. 2004).<br />
Consequently, Fulmer et al. (2004) report that <strong>the</strong>y are<br />
not well utilised by practic<strong>in</strong>g cl<strong>in</strong>icians. In 2009, Buri et<br />
al. tested <strong>the</strong> sensitivity and specificity <strong>of</strong> <strong>the</strong> AMA<br />
guidel<strong>in</strong>es <strong>in</strong> comparison with elder abuse screen<strong>in</strong>g<br />
tools. Results <strong>in</strong>dicate that <strong>the</strong> AMA had a test-retest<br />
reliability <strong>of</strong> 0.825 (p
3. <strong>Screen<strong>in</strong>g</strong><br />
<strong>Screen<strong>in</strong>g</strong> Tool and Risk <strong>of</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> Tool (Bass et<br />
al. 2001). The <strong>in</strong>troduction centres on provid<strong>in</strong>g <strong>the</strong><br />
practitioner with a preamble to <strong>the</strong> topic <strong>of</strong> elder abuse<br />
and focuses on rais<strong>in</strong>g awareness regard<strong>in</strong>g <strong>the</strong> topic,<br />
through <strong>in</strong><strong>for</strong>mation and case examples. As legal<br />
report<strong>in</strong>g is mandated <strong>in</strong> <strong>the</strong> United States, <strong>the</strong><br />
<strong>in</strong>troduction also gives a description <strong>of</strong> <strong>the</strong> pert<strong>in</strong>ent<br />
state laws. The referral protocol conta<strong>in</strong>s a one page<br />
decision mak<strong>in</strong>g flow chart <strong>for</strong> identify<strong>in</strong>g, report<strong>in</strong>g and<br />
referral <strong>of</strong> <strong>the</strong> problem. Decision mak<strong>in</strong>g and subsequent<br />
actions are assisted through use <strong>of</strong> <strong>the</strong> screen<strong>in</strong>g tools<br />
which accompany <strong>the</strong> STRP. The protocol is divided <strong>in</strong>to<br />
pathways <strong>for</strong> risk <strong>of</strong> abuse or actual/suspected abuse<br />
situations.<br />
The Actual <strong>Abuse</strong> Tool (AAT) asks if <strong>the</strong>re has been a<br />
reliable report <strong>of</strong> abuse and provides a list (nonexhaustive)<br />
<strong>of</strong> <strong>the</strong> prom<strong>in</strong>ent types <strong>of</strong> abuse and neglect<br />
and <strong>the</strong>ir behavioural manifestations. The AAT also<br />
conta<strong>in</strong>s a decision/action sheet which supports decision<br />
mak<strong>in</strong>g <strong>in</strong> <strong>the</strong> case. The Suspected <strong>Abuse</strong> Tool (SAT) is<br />
used when actual abuse is not reliably reported.<br />
Common signs and symptoms <strong>of</strong> abuse are considered <strong>in</strong><br />
a check-list <strong>for</strong>mat. Positive responses <strong>in</strong>dicate that <strong>the</strong><br />
case requires follow-up. This part <strong>of</strong> <strong>the</strong> STRP also<br />
conta<strong>in</strong>s a decision mak<strong>in</strong>g section to <strong>in</strong>dicate how<br />
particular conclusions were justified. When <strong>the</strong>re is an<br />
absence <strong>of</strong> actual abuse and <strong>the</strong> practitioner cannot<br />
identify related signs <strong>of</strong> abuse when <strong>the</strong>re is suspicion <strong>of</strong><br />
abuse, <strong>the</strong> Risk <strong>of</strong> <strong>Abuse</strong> Tool (RAT) is completed. This<br />
tool evaluates <strong>the</strong> presence <strong>of</strong> risk factors that are<br />
commonly associated with abuse. Thus, <strong>the</strong> RAT assesses<br />
<strong>the</strong> heightened risk <strong>of</strong> abuse ra<strong>the</strong>r than its presence or<br />
possible presence. It has sections which focus on both<br />
<strong>the</strong> older person and <strong>the</strong> person who may be susceptible<br />
to abus<strong>in</strong>g. Five risk factors are accorded particular<br />
importance: alcohol use, activities <strong>of</strong> daily liv<strong>in</strong>g<br />
dependencies, <strong>in</strong>strumental activities <strong>of</strong> daily<br />
dependencies, cognitive impairment and depression and<br />
are supported by fur<strong>the</strong>r guidance <strong>in</strong> what <strong>the</strong> authors<br />
entitle ‘extended tools’ (Bass et al. 2001). Psychometric<br />
test<strong>in</strong>g has not been recorded.<br />
The STRP (Bass et al. 2001) provides a template <strong>for</strong><br />
screen<strong>in</strong>g <strong>for</strong> abuse, particularly alert<strong>in</strong>g <strong>the</strong> practitioner<br />
to <strong>in</strong><strong>for</strong>mation on elder abuse and guidance on<br />
procedural pathways and assessment <strong>in</strong> <strong>the</strong> context <strong>of</strong><br />
actual, suspected and risk <strong>of</strong> elder abuse. However, its<br />
lack <strong>of</strong> empirical test<strong>in</strong>g is a major limitation and fur<strong>the</strong>r<br />
work is required to demonstrate its psychometric<br />
properties and value <strong>in</strong> be<strong>in</strong>g a valid and reliable tool <strong>in</strong><br />
screen<strong>in</strong>g <strong>for</strong> elder abuse.<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 19
4. Discussion<br />
The debate <strong>of</strong> whe<strong>the</strong>r screen<strong>in</strong>g tools are a valid and<br />
reliable method <strong>of</strong> assess<strong>in</strong>g potential elder abuse<br />
cont<strong>in</strong>ues. This is a particular issue <strong>in</strong> both <strong>the</strong> medical<br />
and legal doma<strong>in</strong>s as reasonable certa<strong>in</strong>ty <strong>of</strong> <strong>the</strong><br />
occurrence <strong>of</strong> elder abuse rema<strong>in</strong>s elusive <strong>in</strong> some cases<br />
(McNamee and Murphy 2006, Imbody and Vandsburger<br />
2011). A major complicat<strong>in</strong>g factor <strong>in</strong> <strong>the</strong> development <strong>of</strong><br />
screen<strong>in</strong>g methods is <strong>the</strong> diverse <strong>in</strong>terpretations <strong>of</strong> elder<br />
abuse. In addition, as Lachs (2004) notes, traditional<br />
disease orientated approaches to screen<strong>in</strong>g do not<br />
readily apply to elder abuse. <strong>Screen<strong>in</strong>g</strong> tools can raise<br />
practitioner awareness to <strong>the</strong> possibility <strong>of</strong> elder abuse<br />
and may raise <strong>the</strong> <strong>in</strong>dex <strong>of</strong> suspicion, particularly <strong>in</strong> cases<br />
where <strong>the</strong> signs <strong>of</strong> maltreatment are observable (Bomba<br />
2006). However, <strong>the</strong> items with<strong>in</strong> some screen<strong>in</strong>g tools<br />
are <strong>of</strong>ten based on overt signs <strong>of</strong> abuse which makes <strong>the</strong><br />
recognition <strong>of</strong> subtle abuse challeng<strong>in</strong>g (Anthony et al.<br />
2009). Moreover, although screen<strong>in</strong>g tools do require<br />
cultural sensitivity, cultural norms are not an excuse to<br />
ignore abuse (WHO 2008).<br />
While progress has been made <strong>in</strong> screen<strong>in</strong>g older people<br />
<strong>for</strong> potential elder abuse, <strong>the</strong> validated tools exam<strong>in</strong>ed <strong>in</strong><br />
this discussion require fur<strong>the</strong>r ref<strong>in</strong>ement. For <strong>in</strong>stance,<br />
Antzberger (2001) <strong>in</strong>dicated that exist<strong>in</strong>g tools do not<br />
adequately discrim<strong>in</strong>ate between actual abuse, signs <strong>of</strong><br />
suspected abuse and risk <strong>in</strong>dicators <strong>of</strong> abuse.<br />
Fur<strong>the</strong>rmore, some tools have only been tested on<br />
relatively small sample sizes, which limit <strong>the</strong>ir<br />
generalisability. O<strong>the</strong>r concerns focus on an exam<strong>in</strong>ation<br />
<strong>of</strong> domestic violence <strong>in</strong> older people as an element <strong>of</strong><br />
elder abuse as well as clear del<strong>in</strong>eations <strong>of</strong> legal and<br />
cl<strong>in</strong>ical parameters. Tak<strong>in</strong>g <strong>in</strong>to account <strong>the</strong> complexity <strong>of</strong><br />
elder abuse, it may be argued that rais<strong>in</strong>g practitioner<br />
awareness through education may override a reliance on<br />
screen<strong>in</strong>g tools (Lachs and Pillemer 2004). From an<br />
ethical po<strong>in</strong>t <strong>of</strong> view, any system <strong>of</strong> <strong>in</strong>creas<strong>in</strong>g practitioner<br />
awareness or systematic screen<strong>in</strong>g <strong>of</strong> elder abuse<br />
demands appropriate and flexible <strong>in</strong>tervention pathways.<br />
Moreover, screen<strong>in</strong>g tools need to be ‘fit <strong>for</strong> purpose’ <strong>for</strong><br />
<strong>the</strong> environment <strong>in</strong> which <strong>the</strong>y are utilised (Bomba 2006).<br />
This is a particular issue when screen<strong>in</strong>g older people<br />
who have mental capacity challenges as no screen<strong>in</strong>g<br />
tool has <strong>in</strong>dicated validity or reliability <strong>in</strong> detect<strong>in</strong>g<br />
potential elder abuse with this group.<br />
screen<strong>in</strong>g assessment. There<strong>for</strong>e, it is unlikely that any<br />
one elder abuse screen<strong>in</strong>g tool will meet all <strong>the</strong><br />
requirements <strong>for</strong> universal sett<strong>in</strong>g (Anthony et al. 2009).<br />
A notable absence <strong>of</strong> screen<strong>in</strong>g tools is <strong>in</strong> <strong>the</strong> doma<strong>in</strong> <strong>of</strong><br />
residential care as most screen<strong>in</strong>g tools focus on <strong>the</strong><br />
dyadic relationship <strong>of</strong> abuse with<strong>in</strong> <strong>the</strong> home<br />
environment. Although <strong>the</strong> EAI (Fulmer 1984) has been<br />
identified as useful <strong>for</strong> assessment <strong>of</strong> abuse <strong>in</strong> residential<br />
care (Meeks-Sjostrom 2004), any screen<strong>in</strong>g tool which<br />
focuses on residential abuse would need to consider <strong>the</strong><br />
contextual differences relat<strong>in</strong>g to elder abuse, such as<br />
systems <strong>of</strong> care challenges. Some tentative ef<strong>for</strong>ts have<br />
been made (Cohen et al. 2010), but fur<strong>the</strong>r development<br />
and ref<strong>in</strong>ement is required. In particular, a screen<strong>in</strong>g tool<br />
<strong>for</strong> elder abuse <strong>in</strong> residential care would need to address<br />
context issues <strong>in</strong>herent <strong>in</strong> <strong>the</strong> systems <strong>of</strong> care as well as<br />
<strong>in</strong>terpersonal dynamics. Overall, what must be borne <strong>in</strong><br />
m<strong>in</strong>d is that <strong>the</strong> focus <strong>of</strong> screen<strong>in</strong>g tools <strong>in</strong> elder abuse<br />
has been to raise practitioners’ suspicion <strong>of</strong> abuse and to<br />
help <strong>the</strong>m identify potential abuse with a view to fur<strong>the</strong>r<br />
<strong>in</strong>vestigation and referral.<br />
The target sett<strong>in</strong>g <strong>for</strong> complet<strong>in</strong>g a screen<strong>in</strong>g tool is also<br />
an issue. Busy areas demand a brief tool, while o<strong>the</strong>r<br />
doma<strong>in</strong>s may have <strong>the</strong> capacity to engage <strong>in</strong> a lengthier<br />
20<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong>
5. Conclusion and Recommendations<br />
Conclusion<br />
In conclusion, screen<strong>in</strong>g tools <strong>for</strong> elder abuse may have<br />
<strong>the</strong> ability to provide a systematic, standardised, multidiscipl<strong>in</strong>ary<br />
objective assessment to detect potential<br />
elder abuse. However, fur<strong>the</strong>r test<strong>in</strong>g <strong>of</strong> screen<strong>in</strong>g<br />
<strong>in</strong>struments is fundamental to ref<strong>in</strong><strong>in</strong>g <strong>the</strong> validity and<br />
reliability <strong>of</strong> such tools. Although some screen<strong>in</strong>g tools<br />
have shown some promise, particular categories <strong>of</strong> abuse<br />
may have been omitted, particularly <strong>the</strong> area <strong>of</strong> sexual<br />
abuse. With<strong>in</strong> <strong>the</strong> context <strong>of</strong> <strong>the</strong> screen<strong>in</strong>g tools reviewed<br />
<strong>in</strong> this discussion, it is proposed that two tools<br />
demonstrate particular merit <strong>for</strong> possible use <strong>in</strong> <strong>the</strong> <strong>Irish</strong><br />
context namely, <strong>the</strong> EASI and <strong>the</strong> OAFEM. The EASI has<br />
<strong>the</strong> ability to screen <strong>for</strong> all abuse manifestations. The EASI<br />
has and cont<strong>in</strong>ues to be used <strong>in</strong> differ<strong>in</strong>g cultures and has<br />
been subject to WHO (2008) review and support. It is a<br />
relatively rapid screen<strong>in</strong>g <strong>in</strong>strument, is easily completed<br />
and has <strong>the</strong> capacity to be practitioner adm<strong>in</strong>istered and,<br />
more recently, self-adm<strong>in</strong>istered. Most importantly, it<br />
addresses all categories <strong>of</strong> elder abuse and measures<br />
potential abuse with<strong>in</strong> <strong>the</strong> preced<strong>in</strong>g twelve month<br />
period.<br />
Recommendations<br />
In relation to <strong>the</strong> OAFEM, f<strong>in</strong>ancial abuse is a particular<br />
concern with<strong>in</strong> <strong>the</strong> <strong>Irish</strong> context and <strong>the</strong> OAFEM appears<br />
to have potential <strong>in</strong> terms <strong>of</strong> target<strong>in</strong>g identification <strong>of</strong><br />
<strong>the</strong> possible presence <strong>of</strong> f<strong>in</strong>ancial abuse. As f<strong>in</strong>ancial<br />
abuse is <strong>the</strong> most common <strong>for</strong>m abuse <strong>in</strong> Ireland<br />
(Naughton et al. 2010) and <strong>the</strong> second most common<br />
abuse among HSE referrals <strong>for</strong> <strong>the</strong> elder abuse service<br />
(HSE 2011), <strong>the</strong> use <strong>of</strong> a specific tool to detect f<strong>in</strong>ancial<br />
abuse is likely to be important. Although, this tool has<br />
only been tested <strong>in</strong> a limited way with older people,<br />
psychometric results to date demonstrate positive results<br />
<strong>in</strong> terms <strong>of</strong> validity and reliability, <strong>the</strong>re<strong>for</strong>e OAFEM as a<br />
tool to lead to <strong>the</strong> detection <strong>of</strong> f<strong>in</strong>ancial abuse warrants<br />
fur<strong>the</strong>r exam<strong>in</strong>ation.<br />
The follow<strong>in</strong>g recommendations are <strong>of</strong>fered bear<strong>in</strong>g <strong>in</strong><br />
m<strong>in</strong>d that no def<strong>in</strong>itive screen<strong>in</strong>g tool <strong>for</strong> <strong>the</strong> detection <strong>of</strong><br />
elder abuse exists, and that screen<strong>in</strong>g tools <strong>for</strong> elder<br />
abuse are not diagnostic but ra<strong>the</strong>r can identify <strong>the</strong><br />
potential presence <strong>of</strong> abuse and highlight cases which<br />
may warrant fur<strong>the</strong>r <strong>in</strong>vestigation and referral.<br />
• That consideration be given to pilot<strong>in</strong>g <strong>the</strong> <strong>Elder</strong><br />
<strong>Abuse</strong> Suspicion Index (EASI) <strong>in</strong> <strong>the</strong> <strong>Irish</strong> context<br />
and that it be subjected to fur<strong>the</strong>r psychometric<br />
test<strong>in</strong>g. It is recommended that pilot<strong>in</strong>g should<br />
encompass a multi-discipl<strong>in</strong>ary and multi-sett<strong>in</strong>g<br />
approach and that participants <strong>in</strong> <strong>the</strong> pilot study<br />
should receive tra<strong>in</strong><strong>in</strong>g on <strong>the</strong> issue <strong>of</strong> elder<br />
abuse and <strong>the</strong> use <strong>of</strong> <strong>the</strong> EASI.<br />
• That <strong>the</strong> OAFEM be <strong>the</strong> subject <strong>of</strong> fur<strong>the</strong>r study<br />
<strong>for</strong> potential validation.<br />
A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong> 21
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A <strong>Review</strong> <strong>of</strong> <strong>Elder</strong> <strong>Abuse</strong> <strong>Screen<strong>in</strong>g</strong> <strong>Tools</strong> <strong>for</strong> <strong>Use</strong> <strong>in</strong> <strong>the</strong> <strong>Irish</strong> <strong>Context</strong>
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