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
Amanda Phelan and Margaret P. Treacy

NCPOP Board of Programme Directors
Professor Margaret P. Treacy, Professor Gerard Fealy, Professor Denis Cusack, Professor Cecily Kelleher, Professor Colm
Harmon, Ms. Anne O’Loughlin, Dr. Amanda Phelan, Professor Suzanne Quin.
This study was funded by the Health Service Executive as part of the work of the National Centre for the Protection of
Older People (NCPOP) at University College Dublin.
This report should be cited as:
Phelan, A., Treacy, M.P. (2011) A Review of Elder Abuse Screening Tools, NCPOP, School of Nursing, Midwifery and
Health Systems, University College Dublin
National Centre for the Protection of Older People (NCPOP)
UCD School of Nursing, Midwifery and Heath Systems
Health Sciences Centre
University College Dublin
Belfield, Dublin 4, Ireland
Tel: +353 (0)1 716 6467 Fax: +353 (0)1 716 6498
Email: ncpop@ucd.ie Web: www.ncpop.ie
© UCD and HSE, 2011

Acknowledgements
The National Centre for the Protection of Older People gratefully acknowledges the invaluable support and
contribution to the work of:
• Professor Mark Yaffe, Department of Family Medicine McGill University/St. Mary’s Hospital Center, Montreal
• Professor Mark Lachs, The Weill Medical College of Cornell University/ Director of Geriatrics, New York
Presbyterian Health System
• Professor Karl Pillemer, Cornell Institute for Translational Research on Ageing (NCPOP International Advisory
Committee)
• The Health Service Executive (HSE) which funds the NCPOP and the programme of research of which this work
is part; the NCPOP HSE Steering Committee and the NCPOP HSE Management Group.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 1

Contents
Abbreviations 3
1. Introduction 4
1.1 Rationale for this review 4
1.2 Method 4
2. Context: population 5
2.1 The extent of elder abuse 5
2.2 Risk factors for elder abuse 5
3. Screening 6
3.1 Screening in family violence 6
3.2 Using technology to screen 7
3.3 Screening for elder abuse 7
3.3.1 Screening tools and validation 10
a) The Hwalek-Sengstock Elder Abuse 10
Screening Test
b) The Vulnerability Abuse Screening Scale 11
c) The Elder Assessment Instrument 12
d) The Indicators of Abuse Screening Tool 13
e) Brief Abuse Screen for the Elderly 14
f) The Caregiver Abuse Screen 14
g) The Elder Abuse Suspicion Index 14
h) Caregivers Psychological Elder Abuse 16
Behaviour Scale
i) Elder Psychological Abuse Scale 16
j) The Older Adult Psychological Abuse Measure 17
k) The Older Adult Financial Exploitation Measure 17
3.4 Assessment guidelines 18
4. Discussion 20
5. Conclusion and Recommendations 21
References 22
2
A Review of Elder Abuse Screening Tools for Use in the Irish Context

Abbreviations
AAT
AMA
BASE
CABS
CAS
CPEABS
EAI
EASI
EASI-sa
EPAS
H-S EAST
IOA
OAPAM
OAFEM
RAT
SAT
STRP
VASS
Actual Abuse Tool
American Medical Association
The Brief Abuse Screen for the Elderly
Care Giver’s Burden Scale
The Caregiver Abuse Screen
Caregivers Psychological Elder Abuse
Behaviour Scale
The Elder Assessment Instrument
The Elder Abuse Suspicion Index
The Elder Abuse Suspicion Index - self
administered
Elder Psychological Abuse Scale
The Hwalek-Sengstock Elder Abuse
Screening Test
The Indicators of Abuse Screen
Older Adult Psychological Abuse
Measure
The Older Adult Financial Exploitation
Measure
Risk of Abuse Tool
Suspected Abuse Tool
Screening Tools and Referral Protocol
Vulnerability Abuse Screening Scale
A Review of Elder Abuse Screening Tools for Use in the Irish Context 3

1. Introduction
This review presents a discussion of a selection of tools
designed to highlight the potential for elder abuse and it
examines them for possible use within the Irish context.
These tools while referred to as screening tools, in
general, highlight suspicion of elder abuse rather than
giving rise to a definitive diagnosis of abuse. The Irish
policy document (DOHC 2002), recommended that the
basic reporting assessment of elder abuse should involve
the detection of elder abuse. Elder abuse screening tools
have been suggested as a method of assisting
practitioners to detect the risk of elder abuse (Fulmer et
al. 2005) and these screening tools may offer the capacity
to highlight potential abuse which can lead to further
investigation. The capacity of screening tools to detect
potential abuse is particularly important as many
professionals struggle to recognise elder abuse (Heath et
al. 2005; Kennedy 2005; Newton 2005; Cooper et al.
2008a,b; Perel-Levin 2008; Killick and Taylor 2009). The
paper presents the aims, the background rational and the
approach adopted for the review. This is followed by a
brief introduction to the context of elder abuse within
the Irish population, risk factors for elder abuse,
challenges in screening for potential elder abuse,
discussion of a number of elder abuse screening tools
and recommendations.
The aims of this review are:
1. To examine elder abuse screening tools
internationally and identify a tool(s) of particular
merit for potential use in the Irish context
2. To identify issues related to the use of elder
abuse screening tools internationally
3. To make recommendations regarding the use of
elder abuse screening tools in the Irish context.
1.1 Rationale for this review
Various Irish reports have identified the need to facilitate
mechanisms which will assist in the early identification of
elder abuse (DOHC 2002; National Council on Ageing
and Older People 2009). Consequently, screening tools
may offer a method of identifying older people who may
be at risk of abuse or have a greater probability of being
subjected to abuse. This is particularly relevant in an
ageing Irish population (Layte 2009; Layte et al. 2009) in
terms of negative experiences and outcomes for older
people who are subjected to abuse (Lachs et al. 1998;
Lachs et al. 2002; Dong et al. 2009; WHO 2011). This
review examines elder abuse screening tools and sets out
to identify tools which have the potential to transfer for
use in the Irish setting. If available, the use of a
standardised, reliable and valid screening tool(s) will
facilitate more generic understanding and inter-rater
reliability giving rise to more clarity in recognising
potential elder abuse. However, prior to using any tool
adequate training and education must be provided for
healthcare professionals who may use the tool in
practice.
1.2 Method
A literature search was undertaken in CINAHL and
PUBMED using the terms ‘elder abuse and screening
tools’ and ‘elder abuse detection’ for the years 1980-2010.
Grey literature was searched through a review of internet
websites using the same search terms. In addition,
consultation took place with experts who had published
work in relation to screening tools which have
demonstrated merit in terms of reliability and validity.
4
A Review of Elder Abuse Screening Tools for Use in the Irish Context

2. Context: population
The world’s population is ageing. In Ireland,
demographics indicate that approximately 11.5 percent
of the population is aged 65 years or older (CSO 2006).
However, due to advances in areas such as healthcare,
pharmaceuticals, welfare protection and changes in
infertility rates, the volume of older people will increase.
The Economic and Social Research Institute (Morgenroth
2009) estimate that older people in Ireland will rise from
11.5 percent in 2006 to 15.1 percent in 2021.
Furthermore, the number of old persons (65 years and
over) is projected to almost double in every geographical
region in Ireland between 2011-2020 (CSO 2008). Within
the context of a rising older person population, it is
anticipated that most older people will reside in the
community (Duggan and Murphy 2009).
2.1 The extent of elder abuse
Elder abuse is a significant issue in societies globally
(Fulmer and O’Malley 1987; Mellor and Brownell 2006;
Brandl et al. 2007; Phelan 2010). From its formal
recognition (Baker 1975), there have been particular
challenges in defining precisely what constitutes elder
abuse (Johnson 1986; Bennett et al. 1997) due to its
complex, multi-factorial contexts (Lachs and Pillemer
2004; Bomba 2006) and varying cultural interpretations.
Elder abuse prevalence studies indicate that between two
to five percent of community dwelling older people
experience some form of abuse. A recent study in Ireland
(Naughton et al. 2010) indicated a prevalence of 2.2
percent in community dwelling older people, and this
rose to 2.9 percent when the definition included abuse by
neighbours or acquaintances (Naughton et al. 2010). This
broadly concurs with other international studies on elder
abuse prevalence (Wetzels 1996; Pillemer and Finkelhor
1998; Comijis 1998a,1998b; O’Keefe et al. 2007), however,
some prevalence studies have identified a much higher
rate, for example in Israel (18.4% excluding neglect)
(Eisikovits et al. 2005; Lowenstein et al. 2009) and the
United States (11.4%) (Acierno et al. 2010). While
prevalence studies seek to enumerate the extent of elder
abuse in society, many of these studies represent
‘impressionistic estimates’ (Bonnie and Wallace 2003:21).
It has been observed that elder abuse prevalence
statistics are likely to be underestimates of true figures, a
phenomenon which has been referred to as the ‘iceberg
theory’ (Tatara et al. 1998; Rhodes 2005). The National
Elder Abuse Incidence Study (NEAIS) (Tatara et al. 1998)
estimated that for every one reported case of elder
abuse, up to 5.3 cases are not reported. Fulmer (2003)
argues that it is more likely that at least one in ten cases
do not come to the attention of official bodies and that
the lack of professional reporting is due to the absence of
appropriate screening instruments.
The detection of elder abuse in Ireland is highlighted as
being particularly important when Irish prevalence figures
(Naughton et al. 2010) are compared to referrals of elder
abuse to the HSE elder abuse service (HSE 2011). Despite
efforts to formally address the issue of elder abuse in
Ireland through dedicated services and staff training,
referrals remain low compared to prevalence statistics. In
this context, the availability and use of screening tools
may offer a greater pathway to detection of potential
abuse and consequently, the further development of
responses to elder abuse. Effective service provision is
dependent on efficient assessment techniques (Imbody
and Vandsburger 2011).
2.2 Risk factors for elder abuse
Screening tools are generally based on a review of risk
factors associated with a higher probability of a disease/
disorder. Particular elder abuse risk factors have been
suggested but additional research is required due to
conflicting findings. However, some risk factors have gained
moderate support and have been showed to predict abuse
(Cohen et al. 2007) as well as facilitating the detection of
abuse (Nagpaul 2001). For example, studies indicate that
living with another person increases risk (Lachs et al. 1997;
Hansberry et al. 2005; Naughton et al. 2010). Cognitive
impairment of the older person (Compton et al. 1997; Naik
et al. 2010) or the caregiver (Miller et al. 2006) also
increases risk as does alcohol dependence (Campbell Reay
and Browne 2001; WHO 2006). Past childhood abuse
(Campbell Reay and Browne 2001), cognitive and
functional impairment (Lachs et al. 1997; Shugarman et al.
2003; Laumann et al. 2008), caregiver stress (Wang et al.
2009), and mental health problems health problems
(Kingston and Penhale 1995) are also identified as risk
factors.
In addition, intergenerational violence (Pillemer 1986;
Erlingsson et al. 2005), dependency (Kruger and Moon
1999; Erlingsson et al. 2005; Buri et al. 2006) gender, being
in the older old group (Buri et al. 2006; Naughton et al.
2010), social isolation (Carp 2000; Buri et al. 2006), poor
social support (Shugarman et al. 2003) and a history of
volatile intrapersonal relationships (Acerino 2003;
Erlingsson et al. 2005) suggest susceptibility to abuse. Some
risk factors have been proposed as theoretical frameworks
to explain elder abuse, however, no theory has adequately
explained, with empirical evidence, the complexity of elder
abuse.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 5

3. Screening
The concept of screening or case finding comes from
epidemiology. Its purpose is the early identification of risk
of a disease or disorder so that early treatment may be
initiated resulting in a decrease in the disease related
mortality and morbidity rates (United States Preventative
Services Task Force 1996; Petersen 1997). As such,
screening represents a major instrument in public health
and is an important element in current Irish health
policies (DOHC 2001a; 2001b). While screening tools are
not diagnostic, they do highlight cases which have a
higher statistical probability of a disease or disorder
(Stampfer et al. 2004; Kettles et al. 2004). In relation to
elder abuse Yaffe notes that screening tools can draw
attention to cases which warrant further investigation by
a practitioner (Yaffe et al. 2011).
The concept of screening may appear simple but is
influenced by the presence of classic screening criteria
(Wilson and Junger 1968). Screening may be universal,
such as the newborn metabolic screening testing or
selective, in populations deemed at risk, for example,
screening for cognitive impairment in older people.
However, as noted by Wilson and Junger (1968:7), ‘in
theory, screening is an admirable method of combating
disease…In practice there are snags’. In the case of
screening for elder abuse, its complexity has been noted
by Lachs (2004) who points out that the traditional
paradigm of screening programmes is unrealistic for elder
abuse if a traditional disease–model analysis is applied. In
particular, issues such as abuser involvement in care,
active efforts to hide the abuse and possible limited
access to the older person may preclude screening (Lachs
and Pillemer 2004).
3.1 Screening in family violence
The spectrum of family violence may be divided into
intimate partner violence, child protection and elder
abuse. The issue of screening for family violence has
been subject to debate and while generic screening tools
do hold some merit, variations in the three domains
necessitate specific screening foci. For example, trauma
in older people differs from other generations (Brown et
al. 2004). One of the most common tools to identify
family violence is the Conflict Tactics Scales (CTS) (Straus
1979) and this has shown some utility in elder abuse
assessment with cognitively intact older people (Beech et
al. 2005; Cooper et al. 2008a; 2009a). Although elder
abuse screening tools have potential to trigger
professional intervention in both preventing elder abuse
and identifying elder abuse, the United States
Preventative Service Task Force on Family Violence (1996;
2004) stated that there was insufficient empirical
evidence to recommend for or against screening tools in
the domain of family violence (which includes elder
abuse). For example, concerns focus on whether
screening tools equate to improved outcomes (Waalen et
al. 2000) and there is limited empirical data regarding the
potential ill-effects of screening (Rabin et al. 2009).
The foregoing concern concurs with conclusions from a
recent systematic review which examined screening tools
for intimate partner violence (Rabin et al. 2009). Findings
revealed a lack of consensus in appropriate comparison
measures for testing sensitivity and specificity, a wide
variance of sensitivities and specificities and the need for
additional reliability and validity testing (Rabin et al.
2009). Despite varied perspectives, many medical
organisations advocate screening (American Medical
Association (AMA) 1992, Programme of Action for
Children 2004) as a standard in routine care as awaiting
evidence of improved screening outcomes could result in
risk exposure for an abused person (Halpern et al. 2005).
Furthermore, although the impact of inter-personal
violence is significant in terms of mortality and morbidity,
detection rates by healthcare professionals remain
relatively low (Feldhaus et al. 1997). While some work has
been undertaken in the assessment of interpersonal
violence and recommendations for routine screening
(Ramsey et al. 2002), the World Health Organisation
(2008) has noted that, compared to other age cohorts,
assessing abuse in older people is not as advanced. The
benefits of screening transcend the individual older
person as screening can lead to rationalisation of
resource allocation, improved education and improved
responses; although case investigation should not take
weaken a focus on protection (Bonnie and Wallace 2003).
Consideration needs to be given to the minimisation of
bias when screening for abuse. In using a screening tool,
caution has been urged to ensure that respondents are
not primed towards particular answers through the
discussion on the purpose of the screening tool or the
discursive orientation of the questions (Bonnie and
Wallace 2003). The importance of the orientation of
questions was noted by Acerino et al. (2010) where
culturally neutral open ended questions were considered
to maximise disclosure of elder abuse. Thus, it is
6
A Review of Elder Abuse Screening Tools for Use in the Irish Context

3. Screening
suggested that screening questions in abuse are
contextualised within social behaviours and nonthreatening
language (Laumann et al. 2008). However, it
is suggested that following general questions which
contextualise the older person’s reality, direct queries are
essential to establish the precise nature of the abuse
(Lachs and Pillemer 2004; Oswald et al. 2004). Another
important issue is the development of rapport between
interviewer and interviewee which can allow open and
honest disclosure (Phelan 2010). This is pertinent for
engagement with both the older person and the alleged
perpetrator as a non-judgemental, empathetic attitude is
fundamental to facilitating difficult discussions.
Concerns have been articulated regarding gender and
screening for elder abuse. Some authors have argued that
a particular focus should be afforded to gender based
screening (Reeves et al. 2007; Yaffe et al. 2007; Paranjape
et al. 2009) as older men’s experiences may be
marginalised (Reeves et al. 2007; Yaffe et al. 2007).
Equally, it has been noted that gender issues which
transcend the interpersonal violence domain have been
neglected (Paranjape et al. 2009).
The method of screening has also been subject to debate
as self-completed questionnaires have been shown to be
preferable in intimate partner violence (MacMillan et al.
2006), whilst telephone interviews have shown
comparable results to face-to-face interviews (Acierno et
al. 2003). However, screening methods that are not
face-to-face prohibit direct observation for non-verbal
cues in the participant’s responses, such as eliciting
understanding of the question or facial reactions. For
self-completed questionnaires, there is an inherent
assumption of literacy and comprehension skills which
may be problematic for older people (Daly and Jogerst
2005; Lalor et al. 2009). However, Yaffe et al. 2011 have
used a self-complete elder abuse screening tool which
has demonstrated some success. Nevertheless, it has
been argued that face to-face interviewing can be the
most effective method of screening (Chuang and
Liebschutz 2002). It can increase the degree of empathy
afforded the person being screened for abuse (Acierno et
al. 2003) and improve the validity of the screening (WHO
2008). What is essential is that privacy is afforded to the
older person to disclose abuse in a safe environment.
Thus, care should be taken to interview the older person
alone. In relation to confidentiality, it has been suggested
that when privacy to complete is facilitated, selfcompleted
questionnaires (Hawkins et al. 2009), and
telephone screening using a yes/no response format may
heighten confidentiality (Acierno et al. 2003).
3.2 Using technology to screen
Some efforts have been made in the use of computerised
interpersonal violence screening (McNutt et al. 2005;
Hawkins et al. 2009). McNutt et al. (2005) examined the
use of computers to self-screen for interpersonal violence
immediately prior to a scheduled physician visit. Results
of the screen then accompanied the patient into the
face-to-face visit. In contrast, Hawkins et al. (2009)
created specific software, (Point of Information Systems
(PCIS), for use by health care professionals with their
personal digital assistant (PDA). Both methods of
screening demonstrated some promising results, such as
speeding up the process for referrals and the elimination
of duplicate documentation. However, there are some
issues which relate to using these on older adults, such as
competency with computers and the administration of
generic screening tools rather than those specific to elder
abuse.
3.3 Screening for elder abuse
In reviewing approaches to screening tools, a variety of
terms are used to convey the purpose of the instrument.
These terms range from indexes of abuse, instruments to
identify risk of abuse, elder abuse questionnaires, elder
abuse screening tools, elder abuse screening test,
algorithms, protocols and elder abuse assessment. The
fundamental function of any assessment instrument is to
guide practitioners through a standardised screening
process and to ensure that signs of abuse are not missed
(Anetzberger 2001; Peral-Levin 2008). For the purposes of
this discussion, the term screening tool is used to
describe instruments developed to ‘screen’ for potential
abuse, while the terms guidelines and protocols are used
to describe any other approaches to reviewing an older
person for potential elder abuse.
An important part of the management of elder abuse is
its early identification, and screening for elder abuse has
been advocated as fundamental to the routine
assessment of older people (Aravanis et al. 1993,
American Medical Association 1992; Lachs and Pillemer
2004) particularly due to its prevalence (O’ Brien 1996).
However, as early as 1988, Kosberg identified a failure of
A Review of Elder Abuse Screening Tools for Use in the Irish Context 7

3. Screening
professionals to detect abuse or to be aware of its
occurrence. Many professionals struggle to recognise
elder abuse (Heath et al. 2005; Kennedy 2005; Newton
2005; Mandiracioglu et al. 2005; Cooper et al. 2008b;
Killick and Taylor 2009; Caciula et al. 2010; Hempton et
al. 2010), which makes screening tools attractive in their
potential ability to detect the risk of elder abuse in
diverse settings. Identification of elder abuse may be
hindered by issues such as ageism (Gutman and Spencer
2010; Phelan 2011), a lack of direct observation of abuse
(Bonnie and Wallace 2003), family privacy (Kosberg 1988;
Phelan 2010), complacency (WHO 2002), complexity
(Antzeberger 2001), sensitivity of the assessor (Shefet et
al. 2007), service setting (O Brien 1996), time constraints
(Jones et al. 1997), a lack of knowledge or education and
training in elder abuse (WHO 2002; Fulmer et al. 2004).
A number of other factors in professionals’ failure to
identify elder abuse include confusion as to whether
presenting symptoms are associated with age related
changes or abuse (Kimball 1995; Bonnie and Wallace
2003; Lachs and Pillemer 2004), and the subtlety of
presenting symptoms (Fulmer et al. 1984; Alibhai et al.
2005). Apathy towards positive intervention pathways
(Anetzberger 2001; Selwood et al. 2007), a lack of time
and unstable definitions of abuse (Jones et al. 1997),
ethical dilemmas (Bergeron and Gray 2003; Donovan and
Regehr 2010) and the invisibility of elder abuse (Reis and
Nahmiash 1998) are also suggested as reasons why many
professionals struggle to recognise elder abuse. Moreover,
Anetzberger (2001) argues that elder abuse is not equal
in terms of categorical assessment as its various forms
may have different standards of recognisability.
Acknowledging these difficulties, Bomba (2006:111)
argues that elder abuse should be constructed as a
geriatric syndrome as this approach ‘provides a
conceptual starting point from which the physician and
health care professional can begin to address
mistreatment from screening to management’ stages.
However, employing the term ‘syndrome’ may have the
effect of medicalising a problem which is essentially an
issue immersed in complex intrapersonal, interpersonal
and societal dynamics.
The WHO (2008) points out that older people do not
generally wish to disclose abuse and as many as 80
percent of cases may not be diagnosed. Older people
themselves may not disclose due to cognitive impairment
(Nelson et al. 2004; Laumann et al. 2008), embarrassment
(Bergeron 2006), the perpetrator being a family member
with negative unsupportive attitudes (Zink et al. 2004),
the taboo nature of elder abuse (Krueger and Patterson
1997; Kosberg 1998; Twomey et al. 2005), abuse being
normalised (Quinn and Tomita 1997) or fear of
repercussions and further abuse (Mowlam et al. 2007). In
addition, if the older person is in some way dependent on
the abuser, the removal of the abuser may, in reality or in
the older person’s perception, mean changes in their
living arrangements or being placed in long-term care.
Consequently, elder abuse is generally identified by a
third party (Fulmer et al. 2004; Phelan 2009). This may be
difficult as it is suggested that perpetrators are careful to
cover up abuse and to provide plausible explanations for
any presenting problems and often isolate the older
person (Carp 2000). Furthermore, older people have
reduced social interaction mandates and contact with
health care professionals can provide a valuable
opportunity to identify potential elder abuse (Cohen et
al. 2006).
If elder abuse is not identified early, intervention is
delayed or prevented. The Diagnostic and Treatment
Guidelines on Elder Abuse and Neglect (American Medical
Association 1992) recommend that screening for elder
abuse be a fundamental part of all clinical settings where
older people interface with healthcare professionals.
Thus, elder abuse case identification is central to the care
of older people. Identification has an impact on issues
such as the rationale for specific funding for care of older
people, the development of responsive services and also
highlights the need for both professional and public
awareness and education (Bonnie and Wallace 2003). In
tandem with the need to improve methods of detection,
it is the necessity to have sufficient training and support
for professionals to address suspected cases of elder
abuse (WHO 2008). Despite this, research in elder abuse
screening tools has progressed slowly (Fulmer et al. 2004)
and substantial research is required to support the
development of universal screening for elder abuse
(Bonnie and Wallace 2003; United States Task Force on
Preventative Violence 2004). Fulmer (2008) indicates that
issues of culture, cognitive impairment, clinician fear of
false positives, intentional versus unintentional abuse and
exploitation can present challenges to screening the
older person for abuse. Moreover, concerns persist
regarding the effectiveness of interventions for elder
abuse which could worsen the abuse situation (Lachs and
Pillemer 2004). Despite this, the identification of elder
8
A Review of Elder Abuse Screening Tools for Use in the Irish Context

3. Screening
abuse is greater when using a specific screening tool than
is reported in prevalence studies (Cohen et al. 2006, Yaffe
et al. 2008).
Bonnie and Wallace (2003) explored a framework for
elder mistreatment screening and case identification
which encompassed four levels. It proposes firstly that,
appropriate settings within which to screen the older
person are identified, such as accident and emergency
departments or the person’s home. Secondly, a prescreening
process is proposed which would identify and
target particularly vulnerable older people who
demonstrate an increased risk to abuse. Thirdly, it
proposes the initiation of the screening process and, if the
screening test is positive, the fourth level encompasses a
recommendation for case identification investigation.
Screening tools can also be related to the context of their
utilisation. For example, brief screening tools are more
appropriate for busy, high turnover areas, such as
accident and emergency units, whilst, longer, more
comprehensive screening tools are more suitable for
areas such as in-patient units and community contexts
(Fulmer et al. 2004). Some assessment tools advocate the
inclusion of a medical examination (American Medical
Association 1992; Lachs and Pillemer 2004), while others
involve verbal assessment only (Fulmer et al. 1984;
Sengstock and Hwalek 1987; Wang et al. 2007; Yaffe et al.
2008). However, the World Health Organisation (2008)
suggests that screening tools for the primary health care
setting are critical as they have the ability to raise
awareness of the issue of elder abuse and can assist in
developing competencies in the management of elder
abuse. Consequently, the choice for an appropriate
screening tool must take into account the balance
between brevity and comprehensiveness (Rabin et al.
2009) while also demonstrating accuracy and ease of use
(Bonnie and Wallace 2003). In addition, professional
perspectives may result in subtle differences and it has
been suggested that elder abuse education includes a
sensitisation of interdisciplinary predispositions so that
holistic approaches to elder abuse may be improved
(Yaffe et al. 2009). As discussed previously, another
important factor in screening for elder abuse is that, as
far as possible, it should be undertaken in private with
the older person to allow a candid discussion. Most
importantly, skilled communication strategies are
necessary to facilitate the disclosure of sensitive
information in the screening encounter and are essential
when communicating results both to the older person
and their family (Fulmer 2008; WHO 2008).
Elder abuse screening tools for long term care facilities
are lacking. Institutional abuse differs from abuse in the
community due to issues of an expectation of formal
caregivers. Abuse in long term care may be constituted
by abusive behaviour, abusive attitudes and abuse
practices (Gilleard 1994). Abusive behaviour may also be
related to nursing staff burn-out and shortages (Saveman
et al. 1999; Goergen 2001; Shinan-Altman and Cohen
2009; Post et al. 2010), the physical conditions of the
nursing home (Millard and Roberts 1991), and intrinsic
managerial failings (Bennett et al. 1997). Other challenges
include a general low reporting rate of elder abuse. For
example, in one study incident rates of reporting abuse
to nursing home staff were as low as 20.7 per 1,000
residents, while formal reports to adult protective
services constituted 18.4 per 1,000 residents (Jogerst et
al. 2006). Studies vary from 11 percent to 91 percent of
staff observing abuse, while 2 percent to 87 percent
disclosed their perpetration of abuse (Pillemer and
Moore 1989, Goergan 2001, Malmedal et al. 2009). Larger
institutions with larger volume of older people may
increase risk (Jogerst et al. 2006).
The potential for an older person with impaired mental
capacity to experience abuse is noted (Compton et al.
1997; Choi and Mayer 2000; Cooney et al. 2006; Naik et
al. 2010). Older people with dementia are particularly
prone to abuse (Cooper et al. 2008a, Wiglesworth et al.
2010, Yan and Kwok 2011) which may be due to higher
care requirements and behavioural challenges (Cooper et
al. 2008a). In a study of caring for a relative with
dementia (CARD) over half reported physical or
psychological abuse and one third met the criteria of
significant abuse (Cooper et al. 2009b) However,
screening for elder abuse when an older person is
cognitively impaired is problematic as self-reporting may
be unreliable or the older person may not be able to
report abuse (Cooney et al. 2006; Selwood et al. 2007).
Laumann et al. (2008:2) argue that ‘screening for
impairment is key to modelling and understanding elder
mistreatment’. This is significant as dementia can be
unrecognised, particularly in nursing homes (MacDonald
and Carpenter 2003; Cahill et al. 2010) where behavioural
disturbances of the older person can lead to abusive
contexts (Bredthauer et al. 2005). Despite concerns
relating to elder abuse in older people with dementia,
A Review of Elder Abuse Screening Tools for Use in the Irish Context 9

3. Screening
there is a paucity of information on validated screening
tools related to older people with dementia (Yan and
Kwok 2011). Yet, the use of generic elder abuse screening
tools can pose particular challenges for the health care
professional as capacity cannot be ascertained during
ordinary conversation (Naik et al. 2007; Naik et al. 2008).
Thus, any elder abuse screening method for older people
who have capacity challenges must be sensitive and
specific enough to discriminate abuse while concurrently
taking the potential presence of dementia into account.
Although there are a number of screening tools available,
there is scant knowledge or widespread use of these tools
(Bonnie and Wallace 2003). Many tools have been used
for research purposes only where issues of sensitivity and
specificity are not addressed and have low efficiency in
clinical settings. Other concerns centre on the vocabulary
used in the tools as well as the time necessary to
complete (WHO 2008). Screening tools may be
completed on the basis of direct questioning of the older
person or caregiver. They may also be completed as
self-reports by the older person or caregiver (Cohen et al.
2007). For screening tools that require responses from the
older person, challenges arise in the context of their
ability to respond competently as there may be concerns
regarding mental incapacity, frailty, high anxiety, fear or
other factors. Screening tools which require the caregiver
to respond may be complicated by inaccurate answers
(Bonnie and Wallace 2003). In addition, some
commentators have highlighted that elder abuse
screening tools need to be flexible enough to take
cultural issues into account (Wang et al. 2006; Wang et al.
2007; WHO 2008; Yan and Kwok 2011).
3.3.1 Screening tools and validation
Screening tools for elder abuse should meet the
epidemiological criteria which support the use of a
validated instrument used for screening purposes (Wilson
and Junger 1968). What is important is that a screening
tool has the ability to demonstrate psychometric
properties in the context of reliability and validity. This
translates to the ability of an indicator or item on a scale
to represent a theoretical concept. A screening test must
also demonstrate a high sensitivity to and specificity in
testing for elder abuse. Thus, a screening tool for elder
abuse must be ‘practical, be easy to administer, have
appropriate and clear wording suitable for different
contexts, and show a high sensitivity rate’ (WHO 2008: 6).
Given the foregoing considerations, the elder abuse
screening tools in the discussion which follows represent
those which have been subject to psychometric testing,
specifically used for elder abuse, and have been reported
in peer reviewed publications. Bearing in mind that
screening tools for elder abuse do not provide definitive
identification of abuse but rather highlight the risk of or
potential for abuse and must be used with this in mind,
the following screening tools are discussed:
• The Hwalek-Sengstock Elder Abuse Screening
Test
• Vulnerability Abuse Screening Scale
• The Elder Assessment Instrument
• The Indicators of Abuse Screen
• The Brief Abuse Screen for the Elderly
• The Caregiver Abuse Screen
• The Elder Abuse Suspicion Index
• Elder Psychological Abuse Scale
• Caregivers Psychological Elder Abuse Behaviour
Scale
• Older Adult Psychological Abuse Measure
• The Older Adult Financial Exploitation Measure
The Hwalek-Sengstock Elder Abuse Screening Test
Recognising the lack of uniformity and comprehensive
approach in how professionals identified elder abuse,
Sengstock and Hwalek (1987) developed the Hwalek-
Senstock Elder Abuse Screening Test (H-S EAST) to
identify an older person at risk of abuse. Preliminary
reviews of both published and unpublished literature on
elder abuse and child abuse identified seven indexes
which were analysed for inclusion and exclusion criteria
in relation to types of abuse. Six categories resulted
which included the capacity to screen for physical abuse,
psychological neglect, material abuse, and violation of
personal rights. Sengstock and Hwalek (1987) also
included a category of risk indicators, which could
contribute to the potential for elder abuse to occur. The
H-S EAST (Sengstock and Hwalek 1987) was developed
from a larger study that involved pooling and rating 1,000
items by an expert, five person panel who were members
10
A Review of Elder Abuse Screening Tools for Use in the Irish Context

3. Screening
of the Institute of Gerontology at Wayne State University.
This resulted in a 15 item instrument which screens for
three factors: violation of personal rights, contextual
factors contributing to the older person’s vulnerability
and potential abusive circumstances (Neale et al. 1991).
Construct validity was demonstrated as a score of three
or more reflected a risk of abuse, exploitation or neglect
(Neale et al. 1991). Further discriminate analysis
demonstrated that six of the fifteen items were predictive
of the potential presence of elder abuse. As such, the
(H-S EAST) is a brief screening tool which is suitable for
use in multiple environments.
Psychometric support for this tool was also demonstrated
in two further studies (Neale et al. 1991; Moody et al.
2000). Neale et al. (1991) used three groups of older
people to test the H-S EAST and findings supported the
construct validity of the instrument. Moody et al. (2000)
also used the H-S EAST in a study of 100 African
American, Hispanic, and white older people living in
public housing in the US. Study results demonstrated that
principal components factor analysis supported the H-S
EAST tool structure for a total of 10 items (factor loadings
= 0.4 or >), explaining 38 percent of the variance. A
discriminant function analysis showed that 6 items were as
effective as the 9-item model in classifying cases (71.4%)
as abuse. Despite the H-S EAST demonstrating some value
in screening for elder abuse in this study, other studies
have raised questions regarding the tool’s discriminatory
abuse, particularly in relation to cognitive impairment
(Buri et al. 2009). Furthermore, Fulmer et al. (2004)
suggest that the H-S EAST requires additional refinement
to discriminate abuse from other types of elder
mistreatment. Further testing to refine the psychometric
properties is also needed (Anthony et al. 2009).
In summary, the H-S EAST tool (Sengstock and Hwalek
1987) is a brief instrument which has demonstrated some
promising results in screening for elder abuse. However,
there have been some concerns regarding its ability to
discriminate between abuse and non–abuse, the types of
abuse manifestation and the need for further refinement
of the psychometric properties of the tool has been
noted.
The Vulnerability Abuse Screening Scale
The Vulnerability to Abuse Screening Scale (VASS) was
developed in the context of an Australian Longitudinal
Study on Women’s Health (Women’s Health Study
(WHS)) (Schofield et al. 2002), which examined the
health and well-being of three age cohorts of women;
18-23 years, 45-50, and 70-75 years over a 20 year period.
The VASS represents an adaptation of the H-S EAST
(Sengstock and Hwalek 1987) as further questions were
added. The two additional questions demonstrated high
face validity with one based on the Conflict Tactics Scale
(CTS) (Strauss 1979) and the second based on a
screening tool developed for the assessment of abuse
during pregnancy (McFarlane et al. 1992). The third
question, ‘Have you ever been in a violent relationship
with a spouse/partner?’ was added by the study
researchers (Schofield et al. 2002). In an effort to establish
construct validity, factor analysis and correlation with a
wide range of other variables were used. Two other
measurement scales were used in the study: the Medical
Outcomes Study Health Survey Short Form (SF-36)
(Ware, Kosinski and Keller 1994) and the Duke Social
Support Index (Koenig et al. 1993). In addition,
participants were also questioned about the amount of
chronic, acute health problems, visits to the family
doctors, alternative medicine practitioners, hospital
admissions or awaiting hospital admissions, medications
and other health traits. Social supports, assistance with
activities of daily living and life satisfaction were also
elicited. Acknowledging the lack of a gold standard to
test sensitivity and specificity of the H-S EAST, findings
from this study of 12,340 older women aged 70-75 years
did not support the inclusion of dimensions of violation
of personal rights or direct abuse, characteristics of
vulnerability and potentially abusive situations. The
researchers concluded that a screening tool which
focuses on vulnerability and coercion could provide a
simple and more refined system to elicit the potential for
elder abuse (Schofield et al. 2002).
Following the initial study (Schofield et al. 2002), the
revised tool, the VASS, consisted of four factors:
vulnerability, dependence, dejection and coercion
(Schofield and Mishra 2003). Each of the factors
contained three sub-items. The tool was tested over a
subsequent three year follow-up period within the
Australian Longitudinal Study on Women’s Health (WHS).
The sample for the VASS study comprised 10,421 older
people aged between 73-78 years. Concurrent
measurements were also used to assess stress, life events
(modified from Norbeck 1984), social support (Koenig et
al. 1993), dependence (Domino and Affonso 1990,
Pollack and Duffy 1990, Scheier et al. 1994), health (Ware
A Review of Elder Abuse Screening Tools for Use in the Irish Context 11

3. Screening
et al. 1994), acute and chronic illnesses, use of health
services, medication use, body mass index and
demographic details. Cronbach’s alpha for the four factors
were: Dependence (.74), Dejection (.44), Vulnerability
(.45) and Coercion (.31). Consequently, the VASS
demonstrated moderate to good internal consistency as a
brief screening tool. In terms of the four factors, construct
validity considered the relationship between the four
factors and the psychosocial variables hypothesised as
associated with abuse.
Vulnerability was closely related to stress, particularly
within close relationships, while negatively associated
with social support (Schofield and Mishra 2003). A
negative association was found in the relationship of
coercion and the ability to depend on others as well as
the belief that conflict could be resolved by discussion.
Dejection was associated with low social support,
unstable dependence on others, less control of health,
stress regarding living relationships and interpersonal
conflict with children. Dependence was correlated with
areas such as better physical health, lower stress, and
lower health service use.
Schofield and Mishra (2003) suggest that dependence
may provide a protective element against poorer health
as dependent older people are generally in receipt of
care. Some additional support of the VASS factors was
recently demonstrated in a Chinese study (Dong et al.
2011) where 411 older people over 60 years were
assessed using the VASS, a modified Geriatric Depression
Scale (Yesavage et al. 1983) and the Social Support Index
(Berkman et al. 1992). Depression was associated with
increased risk of reporting elder abuse, although social
supports are proposed as having a modifiable effect on
the abusive environment.
While the VASS has shown some promising psychometric
results, the authors (Schofield and Mischra 2003)
acknowledge that issues remain in relation to the
reliability and internal consistency of the coercion factor.
A particular concern was the difficulty in establishing
predictive validity of the test and additional qualitative
research is recommended to generate knowledge on
abusive experiences of older people. When Buri et al.
(2009) used the VASS as one of the elder abuse screening
tools in Iowa in the United States, findings from their
telephone study of 44 older people who were referred to
a social service agency indicated that the discriminatory
ability of the VASS could be influenced by issues such as
mental capacity status and refusal to complete the
screen. Thus, although the VASS has expanded the H-S
EAST and it has been used with a large sample, it remains
relatively untested and additional work needs to be
undertaken in determining predictive value (Schofield
and Mishra 2003).
The Elder Assessment Instrument
The Elder Assessment Instrument (EAI) was first
introduced in 1984 (Fulmer et al. 1984) and has been
adapted to different clinical areas (Fulmer 2008). It is
completed by a healthcare professional who undertakes a
one-to-one interview and physical assessment of the
older person to determine if abuse may have occurred.
The test takes between 12-15 minutes to complete and
encompasses both subjective and objective assessment.
The constituents of the screening tool are derived from
the literature which proposes causative factors in elder
abuse but also accommodates indicators from other
domains in the family violence spectrum. The tool is
composed of 41 non-scoring items which are sub-divided
into seven sections: general assessment, possible abuse
indicators, possible neglect indicators, possible
exploitation indicators, possible abandonment indicators,
and a summary section. Each item is completed based on
a five point scale ranging from ‘no evidence’ to ‘definite
evidence’ (1-4) and the fifth point allows for a ‘inability to
assess’. Neglect is also reviewed under the section
‘general assessment’ (Cohen 2011). The 41 items are
graded according to a likert-type scale and the final
summary section attempts to identify evidence of elder
abuse. The tool contains a final commentary section
which allows the assessor to ‘explain why she or he is
interpreting a clinical sign or symptom in a particular way’
(Fulmer 2008: 54).
The EAI functions to provide a risk indicator for abuse
and can underpin the need for further review and referral
of the older person. Referral is warranted if there are
positive indicators of abuse without sufficient clinical
explanation, if the older person discloses abuse or if there
is high risk of probable abuse, neglect, exploitation or
abandonment (Fulmer 2003). In terms of validity and
reliability, a study of 501 older people in an emergency
department showed an internal consistency reliability
(Cronbach’s alpha) of 0.84 and a test/retest reliability of
0.83 (P

3. Screening
also shown to have a sensitivity of 71 percent, a
specificity of 93 percent and a content validity index of
0.83 (Fulmer et al. 2004). The EAI does have some merit
in testing for elder abuse but does not give a score on
probability of abuse (Cohen 2011). The tool has
demonstrated some promising results in identifying elder
abuse, but is victim focused and does not capture an
assessment of the caregiver or perpetrator (Imbody and
Vandsburger 2011) and although the EAI has
demonstrated some success further empirical testing is
required.
The Indicators of Abuse Screening Tool
The Indicators of Abuse (IOA) screen (Reis and Nahmiash
1998) is administered by a trained professional to
discriminate potential abusive and non-abusive
situations. The test takes approximately two to three
hours to complete and is focused on the home
environment. The IOA was developed from the
compilation of a 60-itemed preliminary checklist, with 48
items drawn from possible indicators and 12 focussing on
background and demographic details (Reis 2000). The
sixty items were tested within a larger study (PROJECT
CARE) (Reis and Nahmiash 1995a,b,c) within a residential
area of a North American city using 341 participants. The
study used participants from the age of 55 years, who had
unpaid caregivers. From this study 29 items were isolated
which could predict whether abuse was potentially
occurring. The items focus on mental and psychosocial
features in the caregiver characteristics, the care-receiver
characteristics and the interpersonal care receivercaregiver
context. Measurements on the IOA scale range
from an evaluation of the item’s ‘non-existence’ to ‘yes/
severe’ with coding accommodated for items which were
not applicable or were not determinable during the
screening test. True positives for abuse were identified in
78 to 84.4 percent of screened older people while
non-abuse cases were identified in 99.2 percent of those
screened (Reis and Nahmiash 1998). Reliability was
determined by the IOA’s high internal consistency
(Cronbach alpha coefficient .91-.92). However, although
the IOA has the capability to identify risk of abuse, its
content is based on indicators and interviewers’ skills
may impact on the use of the tool (Cohen et al. 2006,
Cohen 2011).
In 2006, Cohen and colleagues expanded the IOA scale
(E-IOA) by introducing a series of sub-indicators (Cohen
et al. 2006). These were based on high risk and were
drawn from literature on psychiatric disorders (American
Psychiatric Association’s 1994, Goldman 1994) and a
model of bio-psychosocial assessment social work relating
to older people (Greene 2000). Four indicators were
removed from the original IOL. These indicators related
to past poor relationships as this was correlated to poor
current relationships; the existence of falls was
considered a possible sign of abuse rather than a high
risk indicator; ‘no permanent doctor’ was considered not
applicable to the Israeli context and ‘suffered abuse in
the past’ was removed as this was seen as demonstrating
a high certainty of abuse in the present. Further
assessment included a determination based on evident
signs and symptoms of abuse which were elicited from
the physical, mental, sexual, and the economic signs of
abuse and neglect developed by Mount Sinai Hospital
(Ansen and Breckman 1988). Evaluation of the list of
signs of abuse ranged from 1= ‘to a great extent’ to 5=
‘not at all’ or ‘not possible to receive information’. In a
pre-test sample, Cronbach alpha for the E-IOA was .78 to
.91. In a sample of 108 (Cohen et al. 2006) and a further
sample of 730 older people from the age of 65 years
(Cohen et al. 2007), the tool discerned 92.9 percent of
older people as being at risk of abuse and 97.9 percent of
older people who were probably not abused. Further
testing of 1,317 older people over 70 years of age also
demonstrated good validity and reliability (Cohen et al.
2010).
In summary, the IOA does show some strength in terms
of validity and reliability and is easy to score (Meeks-
Sjostrom 2004) however; the tool requires completion by
a trained professional and is based on the professional’s
subjective score in relation to each item (Imbody and
Vandsburger 2011, Cohen 2011). Furthermore, the time
to complete the screen may prohibit its use in clinical
practice (Fulmer et al. 2004). Although, the IOA has been
tested by Reis and Nahmiash (1998) in the home
environment and the E-IOA by Cohen et al. (2006) in the
acute hospital environment, neither have been used in
long term care facilities for older people. Furthermore,
E-IOA tools are weak in identifying areas of financial
abuse (Cohen et al. 2006).
Brief Abuse Screen for the Elderly
Reis and Nahmiash (1995c) developed the Brief Abuse
Screen for the Elderly (BASE) as part of PROJECT CARE.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 13

3. Screening
This tool contains five questions to sensitise those who
use the tool to the possibility of elder abuse. It has the
advantage of taking approximately one minute to
complete by a trained professional. Questions focus on
the suspicion level, the abuse type and the immediacy of
response, however, it does not assess for specific risk
factors or signs of abuse or neglect (Imbody and
Vandsburger 2011). Psychometric testing (n=492)
demonstrated predictive validity which ranged from 89-91
percent (Reis and Nahmiash 1995c). While the BASE has
some merit as a screening instrument, its use is limited as
it should be administered in conjunction with the IOA
tool (Reis and Nahmiash 1998) rather than as a standalone
assessment. This complicates the screening process
and can elongate assessment.
The Caregiver Abuse Screen
Developed in the context of a large scale elder abuse and
intervention research project (PROJECT CARE) (Reis and
Nahmiash 1995a, b, c), the CAS focuses on current
physical, psychological, or financial abuse as well as
neglect. It encompasses eight questions which screen the
caregiver of the older person giving the option of a ‘yes’
or ‘no’ answer. Questions are orientated towards eliciting
a suspicion of one of the abuse types without specific
reference to particular abuse behaviours. The screen
takes between one to two minutes to complete.
Theoretical links are made by the authors in relation to
an external locus of control and the neutralisation theory,
which explains abuse as involving particular
rationalisations of the caregiver’s behaviour. Such
rationalisations are not challenged within the context of
the screening tool (Reis and Nahmiash 1995a).
Psychometric testing of the instrument was undertaken
with 44 abusive caregivers receiving the PROJECT CARE
abuse intervention model. Two contrast groups were also
recruited. The first contained a sample of 45 non-abusive
caregivers receiving assistance from the health and social
care services. The second group consisted of 50 nonabusive
caregivers recruited from the same or similar
geographical area who were not in receipt or any external
health or social care assistance.
Three abuse/aggression scales were used to examine
convergent validity: the IOA (Reis and Nahmiash 1998),
two Ryden Agression Subscales (Ryden 1988a, b) and the
H-S EAST (Neale et al. 1991). In addition, personality
traits were measured using a number of scales or
sub-scales which were administered in the context of the
interview. Concurrent validity was supported by the fact
that ‘known’ abusers scored much higher that the two
non-abusing groups, thus indicating the tool’s ability to
distinguish between abusive and non-abusive caregivers.
There were no differences between the two non-abusing
groups. Internal consistency of the tool measured at
Cronbach’s alpha 0.71. Statistical correlations were also
found using the three abuse/aggression scales with a cut
off significance of p

3. Screening
questions with three older people, an additional subquestion
was added to elicit the frequency of the abuse
type. The study (Yaffe et al. 2008) suggested eliminating
the question on frequency as it did not impact on the
sensitivity of the tool nor was frequency considered
essential by the World Health Organisation (2008) review.
Finally, a sixth question was added to articulate the need
to include physician observation of the older person. The
final items on the tool focused on closed, behaviourally
specific questions, preface statements which were
contextually orientated and the assessment of active
abuse by people with whom the older person has contact
with (WHO 2008).
A sample of 953 cognitively intact older people was
screened with the EASI and three weeks later the Social
Worker Evaluation (SWE) was completed on the same
population. The SWE is a standardised assessment which
allows in-depth evaluation of older people at risk of being
abused and takes an average of 66 minutes to complete
(WHO 2008). Social workers who undertook the SWE
were blinded to the result of the EASI. The EASI was
identified as having a relatively high specificity and
sensitivity. The sensitivity of each of the six questions
ranged from 0.03-0.23, whilst the specificity ranged from
0.72-0.99. However, it was noted that when the first
question, which addressed risk, was removed the
sensitivity reduced from 0.47 to 0.32. The authors (Yaffe
et al. 2008) suggest that the first question is important as
a primer for other EASI responses and such questions
may be necessary to encourage full disclosure (Acierno et
al. 2003). Overall the correlation of the EASI and the SWE
indicated a sensitivity rate of 0.44 and a specificity rate of
0.77 (Yaffe et al. 2008).
The EASI does have potential for use in the practice
setting in terms of brevity with 69.2 percent of physicians
who completed the post-study survey indicating that the
EASI took two minutes or less to complete (Yaffe et al.
2008). In addition, 95.8 percent of physicians indicated
that the questions were ‘very easy’ or ‘somewhat easy’
(Yaffe et al. 2008). However, it is noted that older people
who have been subject to repeated abuse may require a
more in-depth screen to identify abuse.
In 2008, the WHO used the EASI as a basis for developing
an elder abuse screening tool that would be culturally
and geographically acceptable in areas outside of
Canada. Focus groups from eight participating countries
(Australia, Brazil, Chile, Costa Rica, Kenya, Singapore,
Spain and Switzerland) were used. Each participating
country convened three focus groups comprised of older
people and four focus groups comprised of primary
health care professionals. Further workshops considered
the concept of the SWE, local understandings and
interventions related to elder abuse and the efficacy of
the Pan American Health Organisation (2002) guidelines
on elder abuse and neglect. Findings from this study
indicate that the EASI tool was simple to complete,
covered the important categories of elder abuse and
although there were minor issues in relation to local
cultural interpretations, the tool was culturally
transferable. Comments also indicated that neglect was
not addressed sufficiently. The WHO (2008) suggested
some alterations to the six questions within the EASI
screening tool, but, to date, the revised tool has not been
piloted in clinical practice. Although the EASI tool was
developed for physician use, the WHO (2008) suggests as
an alternative nurses could administer the tool.
Currently, the EASI has been translated into Spanish,
French, Japanese, German, Hebrew and Arabic (Yaffe M.
Personal communication 5/12/10). Recently, the EASI has
been adapted for self-completion by older people (Yaffe
et al. 2011). The first five questions were retained but the
sixth question, which was originally focused on physician
observation, was eliminated. This decision was
considered supported by psychometric evaluation as
when the sixth question was eliminated, sensitivity
decreased by 0.01, while specificity increased by a similar
quantity (Yaffe at al. 2008). The response options were
reduced to ‘yes’ or ‘no’ as ‘did not answer’ was removed.
The revised EASI, referred to as EASI-sa, was completed
by 210 cognitively intact older people who were stratified
into eight groups to evaluate the screening tool (Yaffe et
al. 2011). Readability and acceptability of the tool was
positively evaluated and the refusal rate to complete was
low. Completion time ranged from two to five minutes
with the tool acting as an elder abuse awareness training
method for the older people in 27.2 percent of cases as
well as increasing understanding of the manifestations of
elder abuse. Yaffe and colleagues (2011) indicate that
further validation studies will focus on comparing
outcomes from the EASI and the EASI-sa.
Although the EASI does not assess the caregiver, it has
particular merit in being a rapid assessment which
assesses for potential abuse and allows practitioners to
A Review of Elder Abuse Screening Tools for Use in the Irish Context 15

3. Screening
incorporate their subjective assessment. As a tool, it
provides for the identification of older people at potential
risk of elder abuse and highlights individuals whose case
may require further probing and, if deemed necessary,
referral to elder abuse services. The tool appears to be
culturally transferable, suitable for use in multiple
settings, to have the potential to be used by professions
other than physicians (WHO 2008) and has demonstrated
acceptability and value in the context of self-completion
by the older person.
Caregivers Psychological Elder Abuse Behaviour Scale
In Taiwan, Wang et al. (2006) developed two elder abuse
screening tools which focused on identifying the potential
for psychological abuse. Wang et al. (2005; 2006) noted
that although psychological abuse is the most common
form of abuse, it is generally underestimated due to a
lack of evidence or a minimisation of the significance of
elder abuse. The Caregivers Psychological Elder Abuse
Behaviour Scale (CPEABS) takes ten minutes to complete
and focuses on eliciting information from the caregiver.
The CPEABS consists of 20 items which are rated on a
one to four likert scale, ranging from “1=never behave
this way”, to “4 =often behave this way”.
The CPEABS has been tested in both long term care
(Wang 2005) and in the home environment (Wang et al.
2006). Caregivers in long term care environment
completed the scale which was used in conjunction with
the Caregiver’s Burden Scale (CBS) (adapted from Wu
1995). Results indicated that caregivers with higher levels
of education, higher work burdens and those who lacked
specialist geriatric training were more prone to potentially
abuse. Psychological abuse was also more associated
with younger caregivers rather than their older
counterparts. In testing the CPEABS in the home
environment, Wang et al. (2006) also used the CBS.
Scores were added and could range between 20-80, with
a higher score demonstrating a higher possibility to
abuse. Reported psychometric results indicate a content
validity of .95 and a Cronbach’s alpha of .85. The testretest
reliability was established .64, (p< .001) over a two
week period (Wang et al. 2006).
While the CPEABS (Wang et al. 2006) has the ability to
probe into psychological abuse and has been tested in
both community and long term settings, it is specific to
one typology. Although psychological abuse is a prevalent
type of elder abuse, it often co-exists with other
typologies, and using this tool alone would not illuminate
such co-morbidity. A generic screening tool for all
typologies should be used as the front-line assessment
while the CPEABS (Wang et al. 2006) could facilitate
further investigation of psychological abuse within a
specialised referral service. Furthermore, additional
empirical testing and a review of cultural transferability
are required.
Elder Psychological Abuse Scale
The Elder Psychological Abuse Scale (EPAS) was
developed by Wang et al. (2007) in Taiwan. Following a
review of the literature and in-depth focus group
interviews which discussed the concept of psychological
abuse of older people, the items were reviewed by
experts in the area of gerontology (academic and
clinical). This resulted in a 32 item scale which focuses on
discussion with the older person (Q 1-7), active
observation (Q8-13) and an interview with the caregiver
(Q14-32). Concurrent validity was tested using the
Barthel Index (BI) for activities of daily living and the
Short Portable Mental State Questionnaire (SPMSQ)
(Pfeiffer 1975).
The EPAS was tested on 195 older people over 60 years
of age who were resident in institutional care settings and
Wang et al. (2007) report an average of 5-10 minutes for
completion. Reliability was established in a K-R20
co-efficient of 0.82 for internal consistency. Concurrent
validity was obtained by evaluating the relationship with
the BI and SPMSQ with an overall correlation of -0.32
(p

3. Screening
The Older Adult Psychological Abuse Measure
As part of a study to develop scales for a comprehensive
Older Adult Mistreatment Assessment (OAMA), Conrad
and colleagues (2010a) developed the Older Adult
Psychological Abuse Measure (OAPAM) and the Older
Adult Financial Exploitation Measure (described below).
Trochim’s (1989) three dimensional concept mapping
approach was used to conceptualise psychological abuse
of older people (Conrad et al. 2010a). Statements from
the literature on the topic of psychological abuse and
those developed by a national panel of 16 experts in this
area were rated using a severity score from 1-5 and then
clustered using Concept Systems software. Results
comprised a hierarchy of severity 1) isolation, 2)
insensitivity and disrespect 3) shaming and blaming 4)
threats and intimidation and 5) trusted other risk factors.
Statements were then generated for questionnaires and
developed for both third party review and self-report
(Conrad et al. 2010a). The questionnaires were then
reviewed by nine focus groups comprised of both staff
members from adult protective services and older
people. A further four cognitive interviews were
conducted with four older people with substantiated
elder abuse. This resulted in a 31 item client-self report
measure, the OAPAM. Using 22 staff in Adult Protective
Services in the Chicago area, 226 older people, who were
substantiated for at least one abuse type, were recruited
to participate in the study, all of whom consented to the
study and demonstrated a Mini-Mental State Examination
(MMSE) score of at least 17. Statistical analysis was
conducted using the Rasch measurement module (Rasch
1960), which has the ability to test use an item hierarchy
and contributes to theory building and test construct
validity. The test construct dimensionality raw variance
was 43.1 percent which supported the unidimensionality
of the tool. The Rasch person reliability was .86, which is
equivalent to a Cronbach’s Alpha of .92, and item
reliability was demonstrated as high at .97. A shorter from
of the OAPAM using 18 items was also developed and
met stringent Rasch analysis (Rasch person reliability .78
corresponding to a Cronbach’s alpha of .87, item reliability
was .96).
The OAPAM (Conrad et al. 2010a) has been
demonstrated as a useful tool in screening for potential
psychological abuse of older people and has also
identified relevant graduations of severity of
psychological abuse. Further validity testing in other
populations would contribute to the ability of the OAPAM
to elicit suspicion of psychological abuse and to
potentialise the effectiveness of service response in
prevention and amelioration.
The Older Adult Financial Exploitation Measure
The only validated financial abuse screening tool
reported in the literature is the Older Adult Financial
Exploitation Measure (OAFEM) (Conrad et al. 2010b),
which represents part of the developmental work by
Conrad and colleagues within the Older Adult
Mistreatment Assessment (OAMA) research. The OAFEM
identifies individual components of financial abuse and a
related severity hierarchy. Using statements on financial
abuse from the literature and brain-storming with expert
panels, a list was produced which reflected aspects of
financial abuse. The list was then arranged into a
conceptual framework using Trochim’s (1989) concept
mapping and components rated for severity by the expert
panel.
The concept mapping and expert review work resulted in
six clusters and gave rise to an 82 item scale, which was
further reduced to 79 items. The clusters focused on;
theft and scams, financial victimisation, financial
entitlement, coercion, signs of possible financial
exploitation and money management. Possible responses
to the questions on the OAFEM include a positive,
negative, suspected or not-applicable response for the
specific forms of financial abuse listed. Initial
psychometric testing by 22 trained staff on 227 older
people who had substantiated abuse demonstrated
enhanced professional decision making in suspected
cases of financial abuse. Adequate cognitive capacity is
required to complete the OAFEM. Consequently,
completion requires a Mini-Mental Status Exam score of
17 or above or competent investigator judgment (Conrad
et al. 2009). Further psychometric testing refined the tool
to a 30 item scale which has demonstrated validity.
Within the sample, 173 people endorsed one or more
items on the 30 item scale which uses different cut-off
points, but it has the potential to indicate more serious
financial abuse (Conrad et al. 2010b). The latest version
of the OAFEM has been reduced to a 25 item tool
(personal communication with Conrad 2011), which
addresses the issue of a lengthy completion time
compared to the 79 item tool.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 17

3. Screening
The OAFEM (Conrad et al. 2010b) has demonstrated
specific merit in identifying potential financial abuse of
older people; in addition the reduction of items on the
tool has decreased the time required for completion. The
OAFEM screens specifically for financial abuse and may
have particular value in the context of screening if a
practitioner’s suspicion of financial abuse is aroused and
may also be useful when other abuse types have been
identified. Identification of potential financial abuse is
particularly relevant in the context of recent studies
which have identified financial abuse as the most
common form of elder abuse (Naughton et al. 2010,
Acierno et al. 2010, Lifespan of Greater Rochester Inc. et
al. 2011).
3.4 Assessment guidelines
In addition to screening tools, a number of assessment
protocols and guidelines have been developed to assist
assessment of elder abuse. While screening tools
generally have a specific closed response to particular
focussed questions, assessment protocols and guidelines
are generally comprised of open-ended questions
(Anthony et al. 2009). Such guidelines include the
American Medical Association’s Diagnostic and Treatment
Guidelines on Elder Abuse and Neglect (1992) which
recommends that assessment for elder abuse is
incorporated into a routine geriatric practice. Thus, it can
be a lengthy process but is underpinned by the practical
support of a flow chart (Fulmer et al. 2004). The use of
flow charts or algorithms has been considered a priority
for elder abuse detection and management (Kreuger et
al. 1997) and they allow a simple and clear pathway for
decision making. Other guidelines use a broad qualitative
approach (Johnson 1981; Rathbone- McCuan 1980;
Tomita 1982) while Bomba (2006) has developed a single
page assessment and management tool for elder abuse
incorporating assessment (adapted from Lachs 1998),
best practice guidelines (adapted from the National
Association of Adult Protective Services Administrators
consensus statement), screening (adapted from a
modified H-S EAST (Scholfield 1999), suspicion of abuse
(Modified Ohio Elder Abuse and DVLL Screening tool
(Ejaz 2001) and abuse management and monitoring
(modified AMA 1992). Although these assessment
protocols and guidelines do raise practitioners’ sensitivity
to elder abuse, the majority have not been validated. Two
screening protocols were identified as being commonly
cited in the literature and are reviewed below.
The American Medical Association Diagnostic and
Treatment Guidelines on Elder Abuse and Neglect
Although the United States Task Force on Preventative
Violence (2004) did not support the routine use of
screening tools for elder abuse, the AMA (American
Medical Association 1992) recommends that nine
questions related to elder abuse are interwoven into
assessment of the older person. Questions focus on
establishing the safety of the older person, functional and
cognitive assessment, general health, social connections,
finance, psychological status and, if identified, a
description of the abuse. The guidelines include a
flowchart which identifies care pathways and referral
resources. Although, the guidelines do provide some
guidance, assessment is lengthy, neglect is not
considered and the discrimination between disease and
maltreatment is not differentiated (Fulmer et al. 2004).
Consequently, Fulmer et al. (2004) report that they are
not well utilised by practicing clinicians. In 2009, Buri et
al. tested the sensitivity and specificity of the AMA
guidelines in comparison with elder abuse screening
tools. Results indicate that the AMA had a test-retest
reliability of 0.825 (p

3. Screening
Screening Tool and Risk of Abuse Screening Tool (Bass et
al. 2001). The introduction centres on providing the
practitioner with a preamble to the topic of elder abuse
and focuses on raising awareness regarding the topic,
through information and case examples. As legal
reporting is mandated in the United States, the
introduction also gives a description of the pertinent
state laws. The referral protocol contains a one page
decision making flow chart for identifying, reporting and
referral of the problem. Decision making and subsequent
actions are assisted through use of the screening tools
which accompany the STRP. The protocol is divided into
pathways for risk of abuse or actual/suspected abuse
situations.
The Actual Abuse Tool (AAT) asks if there has been a
reliable report of abuse and provides a list (nonexhaustive)
of the prominent types of abuse and neglect
and their behavioural manifestations. The AAT also
contains a decision/action sheet which supports decision
making in the case. The Suspected Abuse Tool (SAT) is
used when actual abuse is not reliably reported.
Common signs and symptoms of abuse are considered in
a check-list format. Positive responses indicate that the
case requires follow-up. This part of the STRP also
contains a decision making section to indicate how
particular conclusions were justified. When there is an
absence of actual abuse and the practitioner cannot
identify related signs of abuse when there is suspicion of
abuse, the Risk of Abuse Tool (RAT) is completed. This
tool evaluates the presence of risk factors that are
commonly associated with abuse. Thus, the RAT assesses
the heightened risk of abuse rather than its presence or
possible presence. It has sections which focus on both
the older person and the person who may be susceptible
to abusing. Five risk factors are accorded particular
importance: alcohol use, activities of daily living
dependencies, instrumental activities of daily
dependencies, cognitive impairment and depression and
are supported by further guidance in what the authors
entitle ‘extended tools’ (Bass et al. 2001). Psychometric
testing has not been recorded.
The STRP (Bass et al. 2001) provides a template for
screening for abuse, particularly alerting the practitioner
to information on elder abuse and guidance on
procedural pathways and assessment in the context of
actual, suspected and risk of elder abuse. However, its
lack of empirical testing is a major limitation and further
work is required to demonstrate its psychometric
properties and value in being a valid and reliable tool in
screening for elder abuse.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 19

4. Discussion
The debate of whether screening tools are a valid and
reliable method of assessing potential elder abuse
continues. This is a particular issue in both the medical
and legal domains as reasonable certainty of the
occurrence of elder abuse remains elusive in some cases
(McNamee and Murphy 2006, Imbody and Vandsburger
2011). A major complicating factor in the development of
screening methods is the diverse interpretations of elder
abuse. In addition, as Lachs (2004) notes, traditional
disease orientated approaches to screening do not
readily apply to elder abuse. Screening tools can raise
practitioner awareness to the possibility of elder abuse
and may raise the index of suspicion, particularly in cases
where the signs of maltreatment are observable (Bomba
2006). However, the items within some screening tools
are often based on overt signs of abuse which makes the
recognition of subtle abuse challenging (Anthony et al.
2009). Moreover, although screening tools do require
cultural sensitivity, cultural norms are not an excuse to
ignore abuse (WHO 2008).
While progress has been made in screening older people
for potential elder abuse, the validated tools examined in
this discussion require further refinement. For instance,
Antzberger (2001) indicated that existing tools do not
adequately discriminate between actual abuse, signs of
suspected abuse and risk indicators of abuse.
Furthermore, some tools have only been tested on
relatively small sample sizes, which limit their
generalisability. Other concerns focus on an examination
of domestic violence in older people as an element of
elder abuse as well as clear delineations of legal and
clinical parameters. Taking into account the complexity of
elder abuse, it may be argued that raising practitioner
awareness through education may override a reliance on
screening tools (Lachs and Pillemer 2004). From an
ethical point of view, any system of increasing practitioner
awareness or systematic screening of elder abuse
demands appropriate and flexible intervention pathways.
Moreover, screening tools need to be ‘fit for purpose’ for
the environment in which they are utilised (Bomba 2006).
This is a particular issue when screening older people
who have mental capacity challenges as no screening
tool has indicated validity or reliability in detecting
potential elder abuse with this group.
screening assessment. Therefore, it is unlikely that any
one elder abuse screening tool will meet all the
requirements for universal setting (Anthony et al. 2009).
A notable absence of screening tools is in the domain of
residential care as most screening tools focus on the
dyadic relationship of abuse within the home
environment. Although the EAI (Fulmer 1984) has been
identified as useful for assessment of abuse in residential
care (Meeks-Sjostrom 2004), any screening tool which
focuses on residential abuse would need to consider the
contextual differences relating to elder abuse, such as
systems of care challenges. Some tentative efforts have
been made (Cohen et al. 2010), but further development
and refinement is required. In particular, a screening tool
for elder abuse in residential care would need to address
context issues inherent in the systems of care as well as
interpersonal dynamics. Overall, what must be borne in
mind is that the focus of screening tools in elder abuse
has been to raise practitioners’ suspicion of abuse and to
help them identify potential abuse with a view to further
investigation and referral.
The target setting for completing a screening tool is also
an issue. Busy areas demand a brief tool, while other
domains may have the capacity to engage in a lengthier
20
A Review of Elder Abuse Screening Tools for Use in the Irish Context

5. Conclusion and Recommendations
Conclusion
In conclusion, screening tools for elder abuse may have
the ability to provide a systematic, standardised, multidisciplinary
objective assessment to detect potential
elder abuse. However, further testing of screening
instruments is fundamental to refining the validity and
reliability of such tools. Although some screening tools
have shown some promise, particular categories of abuse
may have been omitted, particularly the area of sexual
abuse. Within the context of the screening tools reviewed
in this discussion, it is proposed that two tools
demonstrate particular merit for possible use in the Irish
context namely, the EASI and the OAFEM. The EASI has
the ability to screen for all abuse manifestations. The EASI
has and continues to be used in differing cultures and has
been subject to WHO (2008) review and support. It is a
relatively rapid screening instrument, is easily completed
and has the capacity to be practitioner administered and,
more recently, self-administered. Most importantly, it
addresses all categories of elder abuse and measures
potential abuse within the preceding twelve month
period.
Recommendations
In relation to the OAFEM, financial abuse is a particular
concern within the Irish context and the OAFEM appears
to have potential in terms of targeting identification of
the possible presence of financial abuse. As financial
abuse is the most common form abuse in Ireland
(Naughton et al. 2010) and the second most common
abuse among HSE referrals for the elder abuse service
(HSE 2011), the use of a specific tool to detect financial
abuse is likely to be important. Although, this tool has
only been tested in a limited way with older people,
psychometric results to date demonstrate positive results
in terms of validity and reliability, therefore OAFEM as a
tool to lead to the detection of financial abuse warrants
further examination.
The following recommendations are offered bearing in
mind that no definitive screening tool for the detection of
elder abuse exists, and that screening tools for elder
abuse are not diagnostic but rather can identify the
potential presence of abuse and highlight cases which
may warrant further investigation and referral.
• That consideration be given to piloting the Elder
Abuse Suspicion Index (EASI) in the Irish context
and that it be subjected to further psychometric
testing. It is recommended that piloting should
encompass a multi-disciplinary and multi-setting
approach and that participants in the pilot study
should receive training on the issue of elder
abuse and the use of the EASI.
• That the OAFEM be the subject of further study
for potential validation.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 21

References
Acerino R., Hernandez M.A., Amstadter A.B., Resnick
H.S., Steve K., Muzzy W. and Kilpatrick D.G. (2010)
Prevalence and correlates of emotional, physical, sexual
and financial abuse and potential neglect in the United
States: The national elder mistreatment study, American
Journal of Public Health, 100(2), 292-297.
Acerino R., Resnick H., Kilpatrick D. and Stark-Reimer W.
(2003) Assessing elder victimisation: Demonstration of a
methodology, Social Psychiatry and Psychiatric
Epidemiology, 38(11), 644–653.
Alibhai S.M., Greenwood C. and Payette H. (2005) An
approach to the management of unintentional weight
loss in elderly people, Canadian Medical Association
Journal, 172(6), 773-780.
American Medical Association (1992) Diagnostic and
treatment guidelines on elder abuse and neglect. American
Medical Association, Chicago, Illinois.
American Psychiatric Association (1994) Diagnostic and
statistical manual of mental disorders, (4th ed.), APD,
Washington DC.
Anetzberger G.J. (2001) Elder abuse identification and
referral: The importance of screening tools and referral
protocols, Journal of Elder Abuse and Neglect, 13(2), 3-22.
Ansen P. and Breckman R. (1988) Elder mistreatment
guidelines for health care professionals: Detection,
assessment and interventions. Mount Sinai, New York.
Anthony E.K., Lehning A.J., Austin M.J., and Peck M.D.
(2009) Assessing elder mistreatment: Instrument
development and implications for adult protective
services, Journal of Adult Protective Services, 52(8),
815-836.
Aravanis S.C., Adelman R.D., Breckman R., Fulmer T.,
Holder E., Lacks M., O’Brien J.G. and Saunder A.B. (1993)
Diagnostic and treatment guidelines on elder abuse and
neglect, Archives of Family Medicine, 2(4), 371-388.
Baker A.A. (1975) Granny bashing, Modern Geriatrics, 8,
20-24.
Bass D.M, Anetzberger G.J., Ejaz F.K. and Nagpaul K.
(2001) Screening tools and referral protocol for stopping
abuse against older Ohioans: a guide for service
providers, Journal of Elder Abuse and Neglect, 13(2),
23-38.
Beech S.R., Schulz R., Williamson G.M., Miller L.S., Weiner
M.F. and Lance C.E. (2005) Risk factors for potentially
harmful informal caregiver behavior, Journal of the
American Geriatric Society, 53(2), 255-261.
Bennett G., Kingston P. and Penhale B. (1997) The
Dimensions of Elder Abuse: Perspectives for Practitioners.
Macmillan, Basingstoke.
Bergeron L.R. (2006) Self-determination and elder abuse
do we know enough? Journal of Gerontological Social
Work, 46(3-4), 81-102.
Bergeron L.R. and Gray B. (2003) Ethical dilemmas of
reporting elder abuse, Social Work, 48(1), 96-105.
Berkman L.F., Leo-Summers L. and Horwitz R.I. (1992)
Emotional support and survival after myocardial
infarction, Annals of Internal Medicine, 117(12), 1003-
1010.
Bomba P.A. (2006) Use of a single page elder abuse
assessment and management tool, Journal of
Gerontological Social Work, 46(3), 103-122.
Bonnie R.J. and Wallace R. (2003) A theoretical model of
elder abuse. In Elder mistreatment: Abuse, neglect and
exploitation in an aging America (Bonnie R.J. and Wallace
R. eds). The National Academy Press, Washington, 60-70.
Brandyl B., Bitondo Dyer C., Heisler C.J., Marlatt Otto J.,
Stiegel L.A. and Thomas R.W. (2007) Elder abuse detection
and intervention: A collaborative approach. Springer
Publishing, New York.
Bredhauer D., Becker C., Eicher B., Koczy P., and Nikolaus
T. (2005) Factors relating to the use of physical restraints
in psychogeriatric care: a paradigm for elder abuse,
Zeitschrift für Gerontologie und Geriatric, 38(1), 10-18.
Brown K., Streubert G.E. and Burgess A.W. (2004)
Effectively detect and manage elder abuse, Nurse
Practitioner, 29(8), 22-31.
Buri H., Daly J.M., Hartz A.J. and Jogerst G.J. (2006)
Factors associated with self-reported elder mistreatment
in Iowa’s frailest elders, Research on Aging, 28(5) 562-581.
Buri H.M., Daly J.M. and Jogerst G.J. (2009) Elder abuse
telephone screen reliability and validity, Journal of Elder
Abuse and Neglect, 21(1), 58-73.
22
A Review of Elder Abuse Screening Tools for Use in the Irish Context

References
Caciula I., Livingston G., Caciula R. and Cooper C. (2010)
Recognition of elder abuse by home care workers and
older people in Romania, International Psychogeriatrics,
22(3), 403-408.
Cahill S., Diaz-Ponse A.M., Coen R.F. and Walsh C. (2010)
The underdetection of cognitive impairment in nursing
homes in the Dublin area. The need for on-going
cognitive assessment, Age and Ageing, 39(1) 128-131.
Campbell-Reay A.M. and Brown K.D. (2001) Risk factor
characteristics in carers who physically abuse or neglect
their elderly dependents, Ageing and Mental Health, 5(1),
56-62.
Carp F.M. (2000) Elder Abuse in the Family. Springer
Publishing Company, New York.
Central Statistics Office (2006) Population by age 2006.
Accessed on-line: http://www.cso.ie/Quicktables/
GetQuickTables.aspx?FileName=CNA15.aspandTableNa
me=Population+by+Age+2006andStatisticalProduct=
DB_CN
Central Statistics Office (2008) Population projections
2011-2021. Accessed on-line: http://www.cso.ie/
releasespublications/documents/population/2008/
tablesA-Q.xls
Choi N.G. and Mayer J. (2000) Elder abuse, neglect and
exploitation: risk factors and prevention strategies,
Journal of Gerontological Social Work, 33(2), 5-15.
Chuang C.H. and Liebschutz J.M. (2002) Screening for
intimate partner violence in the primary care setting: a
critical review, Journal of Clinical Outcomes Management,
9(10), 565-571.
Cohen M., Halevi-Levin S., Gagin R. and Friedman G.
(2006) Development of a screening tool for identifying
elderly people at risk of abuse by their caregivers, Journal
of Aging and Health, 18(5), 660-685.
Cohen M., Halevey-Levin S., Gagin R. and Friedman G.
(2007) Elder abuse: disparities between older people’s
disclosure of abuse, evident signs of abuse, and high risk
of abuse, Journal of the American Geriatric Society, 55,
1224-1230.
Cohen M., Halevy-Levin S., Gagin R., Priltuzky D. and
Friedman G. (2010) Elder abuse in long-term care
residences and the risk indicators, Ageing and Society,
30(6), 1027-1040.
Cohen M. (2011) Screening tools for the identification of
elder abuse, Journal of Clinical Outcomes Management,
18(6), 261-270.
Comijs H., Pot A.M., Smit H.H., Bouter L.M. and Jonker C.
(1998a) Elder abuse in the community: Prevalence and
consequences, Journal of the American Geriatric Society,
46, 885-888.
Comijs H., Pot A.M., Smit H.H., Bouter L.M. and Jonker C.
(1998b) Risk indicators of elder mistreatment in the
community, Journal of Elder Abuse and Neglect, 9(4),
67-76.
Compton S.A., Flanagan P. and Gregg W. (1997) Elder
abuse in people with dementia in Northern Ireland:
Prevalence and predictors in cases referred to a
psychiatry of old age service, International Journal of
Geriatric Psychiatry, 12(6), 632-635.
Conrad K. (2011) Personal Communication. 21/10/11.
Conrad K.J., Iris M. and Ridings J.W. (2009)
Conceptualising and measuring financial exploitation and
psychological abuse of the elderly. Accessed on-line:
https://www.ncjrs.gov/pdffiles1/nij/grants/228632.pdf.
Conrad K.J., Iris M., Ridings J.W., Langley K. and
Anetzberger G.J. (2010a) Self-report measure of
psychological abuse of older adults, Gerontologist, 51(3),
354-366.
Conrad K.J., Iris M., Ridings J.W., Langley K. and Wilber
K.H. (2010b) Self-report measure of financial exploitation
of older adults, Gerontologist, 50(6), 758-773.
Cooney C., Howard R. and Lawlor B. (2006) Abuse of
vulnerable people with dementia by their caregivers: can
we identify those most at risk, International Journal of
Geriatric Psychiatry, 21(6), 564-571.
Cooper C., Manela M., Katona C. and Livingston G.
(2008a) Screening for elder abuse in dementia in the
LASER-AD study: Prevalence, correlates and validation of
instruments, International Journal of Geriatric Psychiatry,
23(3), 283-288.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 23

References
Cooper C., Selwood A. and Livingston G. (2008b) The
prevalence of elder abuse and neglect: a systematic
review, Age and Ageing, 37(2), 151-160.
Cooper C., Maxim K., Selwood A., Blanchard M. and
Livingston G. (2009a) The sensitivity and specificity of the
Modified Conflict Tactics Scale for detecting clinically
significant elder abuse, International Psychogeriatrics,
21(4), 774-778.
Cooper C., Selwood A., Blanchard M., Walker Z., Blizard
R. and Livingston G. (2009b) Abuse of people with
dementia by family caregivers: Representative crosssectional
survey, British Medical Journal, 338, b155.
Daly J.M. and Jogerst G.J. (2005) Readability and content
of elder abuse instruments, Journal of Elder Abuse and
Neglect, 17(4), 31-52.
Department of Health and Children (2001a) Quality and
Fairness. Stationery Office, Dublin.
Department of Health and Children (2001b) A Primary
Health Care Strategy. Stationery Office, Dublin.
Department of Health and Children (2002) Protecting our
Future. Stationery Office, Dublin.
Domino G. and Affonso D.D. (1990) A personality
measure of Erikson’s life stages: The inventory of
psychosocial balance, Journal of Personality Assessment,
53(3-4), 576-588.
Dong Q.I., Simon M., Mendes de Leon C., Fulmer T., Beck
T., Hebert L., Dyer C.B., Paveza G. and Evans D. (2009)
Elder self-neglect and abuse and mortality risk in a
community-dwelling population, Journal of American
Medical Association, 302(5), 517-526.
Dong X.Q, Simon M.A, Beck T.T., Farran C., McCann J.J.,
Mendes de Leon C.F, Laumann E. and Evans D.A. (2010)
Elder abuse and mortality: the role of psychological and
social wellbeing, Gerontology , 57, 549-558.
Donovan K. and Regehr, C. (2010) Elder abuse: Clinical,
ethical and legal considerations in social work practice,
Clinical Social Work Journal, 38(2), 174-182.
Duggan J. and Murphy B. (2009) Community health
service provision in Ireland. Peer Review Social Inclusion.
Accessed on line: www.peer-review-social-inclusion.
eu/.../ireland.../download.
Eisikovits Z., Lowenstein A. and Winterstein T. (2005) The
national survey of elder abuse and neglect in Israel. The
Centre for Research and Study of Ageing, Haifa
University, Haifa.
Ejaz, F.K., Bass, D.M., Anetzberger G.J. and Nagpaul K.
(2001) Evaluating the Ohio elder abuse and domestic
violence in late life screening tool and referral protocol,
Journal of Elder Abuse and Neglect, 13(2), 39-57.
Erlingsson C.I., Saveman B.I. and Berg A.C. (2005)
Perceptions of elder abuse in Sweden: Voices of older
persons, Brief Treatment and Crisis Intervention, 5(2),
213-227.
Feldhaus K.M., Koziol-McLain J., Amsbury H.L., Norton
I.M., Lowenstein S.R. and Abbott J.T. (1997) Accuracy of 3
brief screening questions for detecting partner violence
in the emergency department, Journal of the American
Medical Association, 277(17), 1357-1361.
Fulmer T. (2003) Elder abuse and neglect assessment,
Journal of Gerontological Nursing, 29(1), 8-9.
Fulmer T. (2008) Barriers to neglect and self-neglect
research, Journal of the American Geriatrics Society, 52,
S241–S243.
Fulmer T. and O’Malley T.A. (1987) Inadequate care of the
elderly: A health care perspective on abuse and neglect.
Springer, New York.
Fulmer T. and Wetle T. (1986) Elder abuse screening and
intervention, Nurse Practitioner, 15(5), 33-38.
Fulmer T., Guadagno L., Bitondo-Dyer C. and Connolly
M.T. (2004) Progress in elder abuse screening and
assessment scales, Journal of the American Geriatric
Society, 52(2), 297-304.
Fulmer T., Paveza G., Vende Weerd C., Guadagno L.,
Fairchild S., Norman R., Abraham A. and Bolton-Blatt M.
(2005) Neglect assessment in urban emergency
departments and confirmations by an expert clinical
team, Journal of Gerontology, 60(8), 1002-1006.
Fulmer T., Street S. and Carr K. (1984) Abuse of the
elderly: screening and detection, Journal of Emergency
Nursing, 10(3), 131-140.
24
A Review of Elder Abuse Screening Tools for Use in the Irish Context

References
Gilleard C. (1994) Physical abuse in homes and hospitals.
In Old Age Abuse: A New Perspective (Eastman E. ed).
Chapman and Hall, London.
Goergen T. (2001) Stress, conflict, elder abuse and
neglect in German nursing homes: A pilot study among
professional caregivers, Journal of Elder Abuse and
Neglect, 13, 1-26.
Goldman H.H. (1994) Review of general psychiatry
textbook. Appleton and Lange, Norwalk CT.
Greene R. (2000) Social work with the aged and their
families (2 nd ed). Aldine De Gruyter, New York.
Gutman G. and Spencer C. (2010) Preface. In Aging,
ageism and abuse: Moving from awareness to action.
(Gutman G. and Spencer C. Eds.), Elsevier, Amsterdam.
Halpern L.R., Susarla S.M. and Dodson T.B. (2005) Injury
location and screening questionnaires as markers for
intimate partner violence, Journal of Oral and
Maxillofacial Surgery, 63(9),1255-1261.
Hansberry M.R., Chen E. and Gorbien M.J. (2005).
Dementia and elder abuse, Clinics in Geriatric Medicine,
21, 315–332.
Hawkins J.W., Pearse C.W., Skeith J., Dimitruk B. and
Roche R. (2009) Using technology to expidite screening
and intervention for domestic abuse and neglect, Public
Health Nursing, 26(1), 58-69.
Health Service Executive (2011) HSE Elder Abuse: Service
Developments 2011: Open your eyes. HSE, Dublin.
Heath J.M., Kobylarz F.A., Brown M. and Castaño S.
(2005) Interventions from home-based geriatric
assessments of adult protective service clients suffering
elder mistreatment, Journal of the American Geriatric
Society, 53(9),1538-42.
Hempton C., Dow B., Cortes-Simonet E.N., Ellis K., Koch
S., LoGiudice D., Mastwyk M., Livingston G., Cooper C.
and Ames D. (2010) Contrasting perceptions of health
professionals and older people in Australia: What
constitutes abuse? International Journal of Geriatric
Psychiatry, Accessed on-line: http://onlinelibrary.wiley.
com/doi/10.1002/gps.2549/pdf
Imbody B. and Vandsburger E. (2011) Elder abuse and
neglect: assessment tools, interventions and
recommendations for effective service provision,
Educational Gerontology, 37(7), 634-650.
Jogerst G.J., Daly J.M., Dawson J.D., Peek-Asa C. and
Schmuch G. (2006) Iowa nursing home characteristics
associated with reported abuse, Journal of American
Medical Directors Association, 7(4), 203-7.
Johnson D. (1981) Abuse of the elderly, Nurse
Practitioner, 6, 29-34.
Johnson T.F. (1986) Critical issues in the definition of
elder mistreatment. In Elder abuse: Conflict in the family
(Pillemer K. and Wolf R. eds.). Auburn House, Dover MA,
167-196.
Jones J.S., Veenstra T.R., Seamon J.P. and Krohmer J.
(1997) Elder abuse: A national survey of emergency
physicians, Annals of Emergency Medicine, 30(4), 473-479.
Kennedy R.D. (2005) Elder abuse and neglect: The
experience, knowledge and attitudes of primary care
physicians, Family Medicine, 37(7), 481-485.
Kettles A.M., Moir E., Woods P., Porter S. and Sutherland
E. (2004) Is there a relationship between risk assessment
and observation level? Journal of Psychiatric and Mental
Health Nursing, 11, 156-164.
Killick C. and Taylor B.J. (2009) Professional decision
making on elder abuse: A systematic review, Journal of
Elder Abuse and Neglect, 21, 211-238.
Kimball M.J. (1995) The hidden victim, Nursing News
(New Hampshire), 45(4), 8.
Kingston P. and Penhale B. (1995) Elder abuse and
neglect: Issues in the accident and emergency
department, Accident and Emergency Nursing, 3(3),
122-128.
Koenig H.G., Weslund R.E., Lockwood K., Hughes D.C.,
Blazer D.G. and Hybels C. (1993) Abbreviating the Duke
Social Support Index for use in chronically ill elderly
individuals, Psychosomatics, 34(1), 61-69.
Kosberg, J. (1988) Preventing elder abuse: identification
of high risk factors prior to placement decisions,
Gerontologist, 28(1), 43-50.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 25

References
Kosberg J.I. (1998) Hidden problem of elder abuse: clues
and strategies for health care workers. In Gerontology for
health professionals, a practise guide (Safford F. and Krell
G.I. eds). NASW, Washington, 130-147.
Kreuger P. and Patterson C. (1997) Detecting and
managing elder abuse: Challenges in primary care,
Canadian Medical Association Journal, 157(8), 1095-1100.
Kruger R.M. and Moon C.H. (1999) Can you spot the
signs of elder mistreatment? Postgraduate Medicine,
106(2), 169-73, 177-178, 183.
Lachs M.S. (1998) The mortality of elder abuse, Journal of
the American Medical Association, 280(5), 428-32.
Lachs M.S. (2004) Screening for family violence: What’s
an evidence-based doctor to do? Annals of Internal
Medicine, 140(5), 399-400.
Lachs M.S. and Pillemer K. (2004) Elder abuse, The
Lancet, 364, 1263-1272.
Lachs M.S., Williams C.S., O’Brien S. and Pillemer K.A.
(2002) Adult protective service home use and nursing
home placement, Gerontologist, 42(6), 734-739.
Lachs M.S., Williams C., O’Brien S., Hurst L. and Horwitz
R. (1997) Risk factors for reported elder abuse and
neglect: A nine year observational cohort study,
Gerontologist, 37(4), 469-474.
Lachs M.S., Williams C.S., O’Brien S., Pillemer K.A. and
Charlson M.E. (1998) The mortality of elder abuse,
Journal of the American Medical Association, 280,
428-443.
Lalor T., Doyle G., McKenna A. and Fitzsimons A. (2009)
Learning through life: a 2009 study of older people with
literacy difficulties in Ireland. National Adult Literacy
Agency, Dublin.
Laumann E.O., Leitsch S.A. and Waite L.J. (2008) Elder
mistreatment in the United States: Prevalence estimates
from a nationally representative study, Journal of
Gerontology Series B Psychological Sciences and Social
Sciences, 63(4), S248-S254.
Layte R. (2009) Coping with population change in Ireland:
The implications for healthcare. Economic and Social
Research Institute, Dublin.
Layte R., Barry M., Bennett K., Brick A., Morgenroth E.,
Normand C., O’Reilly J., Thomas S., Tilson L., Wiley M.M.
and Wren M.A. (2009) Projecting the Impact of
Demographic Change on the Demand for and Delivery of
Health Care in Ireland. ESRI, Dublin.
Lifespan of Greater Rochester Inc., Weill Medical School,
Cornell University, New York City Dept. Of Aging (2011)
Under the radar: New York State Elder Abuse Study.
Access on-line: http://nyceac.com/wp-content/
uploads/2011/05/UndertheRadar051211.pdf
Lowenstein A., Eisikovits Z., Band-Winterstein T. and
Enosh G. (2009) Is elder abuse and neglect a social
phenomenon? Data from the first national prevalence
survey in Israel, Journal of Elder Abuse and Neglect, 21(3),
253-77.
MacDonald A.D.J. and Carpenter G.I. (2003) The
recognition of dementia in ‘non-EMI’ nursing home
residents in South East England, International Journal of
Geriatric Psychiatry, 18(2), 105-108.
MacMillan H.L., Nadine Wathen C., Jamieson E., Boyle
M., McNutt L.A., Worster A., Lent B. and Webb M. (2006)
Approaches to screening for intimate partner violence in
health care settings: A randomised trial, Journal of the
American Medical Association, 296(5), 530-536.
Malmedal W., Ingebrigtsen O. and Saveman B.I. (2009)
Inadequate care in Norwegian nursing homes as reported
by nursing staff, Scandinavian Journal of Caring Sciences,
23, 231-242.
Mandiracioglu A., Govsa F., Celikli S. and Yildirim G.O.
(2005) Emergency health care personnel’s knowledge and
experience of elder abuse in Izmir, Archives of
Gerontology and Geriatrics, 43(2), 267-276.
McFarlane J., Parker B., Soeken K. and Bullock L. (1992)
Assessing for abuse during pregnancy, Journal of the
American Medical Association, 267(23), 3176-3178.
McNamee C.C. and Murphy M.B. (2006) Elder abuse in
the United States, National Institute of Justice Journal,
225, 16-20.
McNutt L.A., Waltermaurer E., McCauley J., Campbell J.
and Ford D.E. (2005) Rationale for and development of
the computerised intimate partner violence screen for
primary care, Family Violence Prevention and Health
Practice, 3, 1-12.
26
A Review of Elder Abuse Screening Tools for Use in the Irish Context

References
Meeks-Sjostrom D. (2004) A comparison of three
measures of elder abuse, Journal of Nursing Scholarship,
Third Quarter, 36(3), 247-250.
Mellor J. and Brownell P. (2006) Elder abuse and
mistreatment: Policy, practice and research, British
Journal of Social Work, 37(3), 574-576.
Millard P. and Roberts A. (1991) Old and forgotten,
Nursing Times, 87(22), 24-28.
Miller L.S., Lewis M.S., Williamson G.M., Lance C.E.,
Dooley W.K., Schultz R. and Weiner M.F. (2006) Caregiver
cognitive status and potentially harmful caregiver
behaviour, Ageing and Mental Health, 10(2), 125-133.
Moody L.E., Voss A., Lengacher C.A. (2000) Assessing
abuse among the elderly living in public housing, Journal
of Nursing Measurement, 8(1), 61-70.
Morgenroth E. (2009) The impact of demographic change
on demand for and delivery of health services in Ireland
2006-2021. Economic and Social Research Institute,
Dublin.
Mowlam A., Tennant R., Dixon J. and McCreadie C.
(2007) UK study of abuse and neglect of older people:
Qualitative findings. King’s College London and the
National Centre for Social Research, London.
Nagpaul K. (2001) Application of elder abuse screening
tools and referral protocol: Techniques and clinical
considerations, Journal of Elder Abuse and Neglect, 13(2),
59-78.
Naik A.D., Pickens S., Burnett J., Lai J.M. and Dyer C.B.
(2007) Assessing capacity in the setting of self-neglect:
development of a novel screening tool for decisionmaking
capacity, Journal of Elder Abuse and Neglect,
18(4), 79-91.
Naik A.D., Teal C.R., Pavlik V.N., Dyer C.B. and
McCullough L.B. (2008) Conceptual challenges and
practical approaches to screening capacity for self-care
and protection in vulnerable older adults, Journal of the
American Geriatric Society, 56(52), S266-S270.
Naik A.D., Kunik M.E., Cassidy K.R., Nair J. and Coverdale
J. (2010) Assessing safe and independent living in
vulnerable older adults: Perspectives of professionals who
conduct home assessments, The Journal of the American
Board of Family Medicine, 23(5), 614-621.
National Council on Ageing and Older People (2009)
Review of the recommendations of Protecting our Future:
Report of the Working Group on Elder Abuse. National
Council on Ageing and Older People, Dublin.
Naughton C., Drennan J., Treacy M.P., Lafferty A., Lyons I.,
Phelan A., Quin S. O’Loughlin A. and Delaney L. (2010)
Abuse and neglect of older people in Ireland: Report on the
national study of elder abuse and neglect. National Centre
for the Protection of Older People, Dublin.
Neale A.V., Hwalek M.A., Scott R.O., Sengstock M.C. and
Stahl C. (1991) Validation of the Hwalek-Sengstock elder
abuse screening test, Journal of Applied Gerontology,
10(4), 406-418.
Nelson H.D., Nygren P., McInerney Y. and Klein J. (2004)
Screening women and elderly adults for family and
intimate partner violence: A review of the evidence for
the U.S. preventative services, Annals of Internal
Medicine, 140(5), 387-404.
Newton J.P. (2005) Abuse in the elderly: A perennial
problem, Gerontology, 22, 1-2.
Norbeck J.S. (1984) Modification of life event
questionnaires for use with female respondents, Research
in Nursing and Health, 7(1), 61-71.
O’ Brien J.G. (1996) Screening: A primary care clinician’s
perspective. In Abuse, neglect and exploitation of older
persons: Strategies for assessment and intervention
(Baumhover L.A. and Beall S.C. eds.) Health Professions
Press, Baltimore.
O’Keeffe M., Hills A., Doyle M., McCreadie C., Scholes S.,
Constantine R., Tinker A., Manthorpe J., Biggs S. and
Erens B. (2007) United Kingdom study of abuse and
neglect of older people. King’s College London and the
National Centre for Social Research, London.
Oswald R.A., Jogerst C.J., Daly D.M. and Bentler S.E.
(2004) Iowa family physician’s reporting of elder abuse,
Journal of Elder Abuse and Neglect, 16(2), 75-88.
Pan American Health Organisation (2002) Guía clínica
para atención primaria a las personas adultas mayors.
PAHO, Washington.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 27

References
Paranjape A., Rodríguez M., Gaughan J. and Kaslow N.J.
(2009) Psychometric properties of a new scale to assess
family violence in older African women: The Family
Violence Against Older Women (FVOW) Scale, Violence
Against Women, 15(10), 1213-1226.
Perel-Levin S. (2008) Discussing screening for elder abuse
at primary health care level. World Health Organisation,
Geneva, Switzerland.
Petersen A., (1997) Risk, governance and the new public
health. In Foucault, health and medicine (Petersen A. and
Bunton R. eds). Routledge, London.
Pfeiffer E. (1975) A short portable questionnaire for the
assessment of organic deficit in elderly patients, Journal
of the American Geriatric Society, 23(10), 433-441.
Phelan A. (2009) Elder abuse and neglect: The nurse’s
responsibility in care of the older person, International
Journal of Older People Nursing, 4(2), 115-119.
Phelan A. (2010) Discursive constructions of elder abuse:
Community Nurses Accounts. Unpublished PhD thesis,
University College Dublin.
Phelan A. (2011) Socially constructing older people:
Examining discourses which can shape nurses’
understanding and practice, Journal of Advanced Nursing,
67(4), 893-903.
Pillemer K. (1986) Risk factors in elder abuse: results from
a case control study. In Elder abuse: Conflict in the family
(Pillemer, K. and Wolfe R. eds.), Auburn House, Dover,
MA.
Pillemer K. and Finkelhor H. (1988) The prevalence of
elder abuse: a random sample survey, The Gerontologist,
1, 28-29.
Pillemer K. and Moore D.W. (1989) Abuse of patients in
nursing homes: findings from a survey of staff,
Gerontologist, 29, 314-320.
Pollock S.E. and Duffy M.E. (1990) The health related
hardiness scale and psychometric analysis, Nursing
Research, 39(4), 218-222.
Post L., Page C., Conner T., Prokhorov A., Fang Y. and
Biroscak B.J. (2010) Elder abuse in long term care: Types,
patterns and risk factors, Research on Aging, 32(3),
323-348.
Programme for Action for Children (2004) A review of
national newborn screening programme for inherited
metabolic disorders. HSE, Dublin.
Quinn M.J. and Tomita S.K. (1997) Elder abuse and
neglect: Causes, diagnosis and intervention strategies, (2 nd
ed). Springer Publishing Company, New York.
Rabin R.F., Jennings J.M., Campbell J.C. and Bair-Merritt
M.H. (2009) Intimate partner violence screening tools-a
systematic review, American Journal of Preventative
Violence, 36(5), 439-445.
Ramsey J., Richardson J., Carter Y.H., Davidson L.L. and
Feder G. (2002) Should health professionals screen
women for domestic violence? Systematic review, British
Medical Journal, 325, 314-318.
Rasch G. (1960) Probabilistic models for some intelligence
and attainment tests. (Reprint with foreward and
afterword by B.D. Wright, University of Chicago Press,
Chicago), Danmarks Paedogogiske Institut, Copenhagen.
Rathbone-McCuan E. (1980) Elderly victims of family
violence and neglect, Social Casework, 61, 296-304.
Reichenheim M.E., Paixão C.M. and Moraes C.L. (2009)
Reassessing the construct validity of a Brazilian version of
the instrument Caregiver Abuse Screen (CASE) used to
identify risk of domestic violence against the elderly,
Journal of Epidemiological Community Health, 63,
878-883.
Reeves K.A., Desmarais S.L., Nicholls T.L. and Douglas
K.S. (2007) Intimate partner abuse of older men:
Considerations for assessment of risk, Journal of Elder
Abuse and Neglect, 19(1), 7-27.
Reis M. (2000) The IOA screen: An abuse-alert measure
that dispels myths, Generations, 24(2), 13-16.
Reis M. and Nahmiash D. (1995a), Validation of the
caregiver abuse screen (CASE), Canadian Journal on
Aging, 14 (sup2), 45-60.
Reis M. and Nahmiash D. (1995b), When seniors are
abused: An intervention model, The Gerontologist, 35,
666-671.
Reis M. and Nahmiash D. (1995c) When seniors are
abused: A guide to intervention. Captus Press, Ontario.
28
A Review of Elder Abuse Screening Tools for Use in the Irish Context

References
Reis M. and Nahmiash D. (1998). Validation of the
indicators of abuse (IOA) screen, Gerontologist, 38(4),
471-480.
Rhodes W. (2005) A model to estimate the prevalence of
hard-to-reach populations, Abt Associates, Abstracts, 1
(1), Accessed on line http://www.abtassociates.com/
Page.cfm?PageId=16285.
Ryden M. (1988a) Aggression behaviour in persons with
dementia living in the community, The Alzheimer Disease
and Associated Disorders: International Journal, 2(4),
342-355.
Ryden M. (1988b) Aggressive behaviour in cognitively
impaired nursing home residents. Paper presented at the
Annual Scientific Meeting of the Gerontological Society
of America, San Francisco.
Saveman B.I., Astrom S., Buncht G. and Norberg A. (1999)
Elder abuse in residential settings in Sweden, Journal of
Elder Abuse and Neglect, 10(1/2), 43-60.
Scheier M.F., Carver C.S. and Bridges M.W. (1994)
Distinguishing optimism from neuroticism (and trait
anxiety, self mastery and self esteem). A re-eveluation of
the Life Orientation Test, Journal of Personality and Social
Psychology, 67(6), 1063-1078.
Schofield M., Reynolds R., Michra G., Powers P. and
Dobson A. (1999) Vulnerability to abuse, powerlessness,
and psychological stress among older women. Women’s
Health Australia Study. University of Australia, New South
Wales, Australia.
Schofield M.J., Reynolds R., Mishra G.D., Powers J.R. and
Dobson A.J. (2002) Screening for vulnerability to abuse
among older women: Women’s health Australia study,
Journal of Applied Gerontology, 21(1), 24-39.
Schofield M.J. and Mishra G.D. (2003) Validity of selfreported
screening for elder abuse: Women’s Health
Australia study, Gerontologist, 43(1), 110-120.
Selwood A., Cooper C., and Livingston G. (2007) What is
elder abuse- who decides? International Journal of
Geriatric Psychiatry, 22, 1009-1012.
Sengstock M.C. and Hwalek M. (1987) A review and
analysis of measures for the identifications of elder abuse,
Journal of Gerontological Social Work, 10, 21-36.
Shefet D., Dascal-Weichhendler H., Rubin O., Pessach N.,
Itzik K ., Benita S. and Ziv A. (2007) Domestic violence: a
national simulation-based educational program to
improve physicians’ knowledge, skills and detection rates,
Medical Teacher, 29(5), e133-e138.
Shinan-Atlman S. and Cohen M. (2009) Nursing aides’
attitudes to elder abuse in nursing homes: The effect of
work stressors and burnout, Gerontologist, 49(5), 674-684.
Stampfer M.J., Ridker P.M. and Dzau V.J. (2004) Risk
factor criteria, Circulation, 109, IV-3-IV5.
Shugarman L.R., Fries B.E., Wolf R.S. and Morris J.N.
(2003) Identifying older people at risk of abuse during
routine screening practices, Journal of the American
Geriatric Society, 51(1), 24-31.
Straus M.A. (1979) Measuring intra family conflict and
violence: The Conflict Tactics Scale, Journal of Marriage
and the Family, 41, 75-88.
Tatara T., Kuzmeskus L.B., Duckhorn E., Bivens L.,
Thomas C. and Gertig J. (1998) National elder abuse
incidence study: Final report. National Center on Elder
Abuse, American Public Human Services Association,
Washington D.C.
Tomita S. (1982) Detection and treatment of elderly
abuse and neglect, Physical and Occupational Therapy in
Geriatrics, 2, 37-51.
Trochim W. (1989) An introduction to concept mapping
for planning and evaluation, Evaluation and Programme
Planning, 12, 1-16.
Twomey M., Quinn M.J. and Dakin E. (2005) From behind
closed doors: shedding light on elder abuseand domestic
violence in later life, Journal for the Centre for Families,
Children and the Courts, 6, 73-80.
United States Preventive Services Task Force (1996)
Guide to Clinical Preventive Services, (2 nd ed), International
Medical Publishing, Alexandria, VA.
United States Preventative Service Task Force (2004)
Screening for family and intimate partner violence:
Recommendation statement, Annals of Internal Medicine,
140(5), 382-386.
A Review of Elder Abuse Screening Tools for Use in the Irish Context 29

References
Waalen J., Goodwin M.M., Spitz A.M., Peterson R. and
Saltzman L.E (2000) Screening for intimate partner
violence by health care providers: Barriers and
intervention, American Journal of Preventative Medicine,
19(4), 230-237.
Wang J.J. (2005) Psychological abuse behaviour exhibited
by caregivers in the care of the elderly and correlated
factors in long term care facilities, Journal of Nursing
Research, 13(4), 271-280.
Wang J.J., Lin J.N. and Less F.P. (2006) Psychological
abusive behaviour by those caring for the elderly in a
domestic setting, Geriatric Nursing, 27(5), 284-291.
Wang J.J., Tseng H.F. and Chen K.M. (2007) Development
and testing of screening indicators for psychological
abuse of older people, Archives of Psychiatric Nursing,
21(1), 40-47.
Wang J.J., Lin M.F, Tseng H.F. and Chang W.Y. (2009)
Caregiver factors contributing to psychological elder
abuse behavious in long-term-care facilities: a structural
equation model approach, International Psychogeriatrics,
21(2), 314-320.
Ware J., Kosinski M. and Keller S.D. (1994) SF-36 Physical
and mental health summary scales: A user’s manual. The
Health Institute, New England Medical Centre, Boston.
Wetzels P. and Greve W. (1996) Older people as victims of
family violence. Results of a German victimization survey.
Zeitschrift fur Gerontologie und Geriatrie, 29(3), 191-200.
Wiglesworth A., Mosqueda L., Mulnard R., Liao S., Gibbs
L. and Fitzgerald W. (2010) Screening for abuse and
neglect of people with dementia, Journal of the American
Geriatric Society, 58, 493-500.
Wilson J.M.G. and Junger G. (1968) Principles and
practice of screening for disease. WHO, Geneva.
World Health Organisation (2002) The Toronto
Declaration on the global prevention of elder abuse.
Accessed on line: http://www.who.int/ageing/projects/
elder_abuse/alc_toronto_declaration_en.pdf
World Health Organisation (2006) Elder abuse and
alcohol fact sheet. World Health Organisation, Geneva.
World Health Organisation (2008) A global response to
elder abuse and neglect: Building primary health care
capacity to deal with the problem worldwide- Main report.
WHO, Geneva.
World Health Organisation (2011) European report on
preventing elder mistreatment. WHO, Copenhagen.
Wu C. (1995) The burden of caregivers with impaired
persons. Unpublished MSc, University of Wisconsin, USA.
Yaffe M.J. (2010) Personal communication. 5/12/10.
Yaffe M.J., Weiss D., Wolfson C. and Lithwick M. (2007)
Detection and prevalence of abuse in older males:
Perspectives from family practice, Journal of Elder Abuse
and Neglect, 19(1), 47-60.
Yaffe M.J., Wolfson C., Litwick M. and Weiss D. (2008)
Development and validation of a tool to improve
physician identification of elder abuse: The Elder Abuse
Suspicion Index (EASI) ©, Journal of Elder Abuse and
Neglect, 20(3), 276-300.
Yaffe M.J., Wolfson C. and Lithwick M. (2009) Professional
show different enquiry strategies for elder abuse
detection: Implications for training and interprofessional
care, Journal of Interprofessional Care, 23(6), 646-654.
Yaffe M., Weiss D. and Lithwick M. (2011) Selfadministration
of the Elder Abuse Suspicion Index (EASI):
A feasibility study, Journal of Elder Abuse and Neglect,
Published on-line 29/12/11.
Yan E. and Kwok T. (2011) Abuse of older Chinese with
dementia by family caregivers: an inquiry into the role of
caregiver burden, International Journal of Geriatric
Psychiatry, 26(5) 527-35.
Yesavage J.A., Brink T.L., Rose T.L., Lum O., Huang V.,
Adey M. and Leirer V.O. (1983) Development and
validation of a geriatric depression screening scale: A
preliminary report, Journal of Psychiatric Research, 17(1)
37-49.
Zink T., Jeffrey C., Jacobson Jnr. S.R. and Pabst S. (2004)
Hidden victims: The healthcare needs and experiences of
older women in abusive relationships, Journal of Women’s
Health, 13(8), 898-908.
30
A Review of Elder Abuse Screening Tools for Use in the Irish Context

Notes

Notes