Interventions for preventing elder abuse: What's the evidence?
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Health Evidence hosted a 90 minute webinar examining the effectiveness of interventions for preventing elder abuse. Philip Baker, Australia Regional Director APACPH, School of Public Health and Social Work Queensland University of Technology led the session and presented findings from their review: Baker PRA, Francis DP, Hairi NN, Othman S, Choo WY. (2016). Interventions for preventing abuse in the elderly. Cochrane Database of Systematic Reviews, 2016, CD010321 http://www.healthevidence.org/view-article.aspx?a=interventions-preventing-abuse-elderly-29428 Many older adults experience some form of abuse (psychological, physical, and sexual) that often goes unreported. Elder abuse is associated with morbidity and premature mortality. This review examines the effectiveness of interventions for preventing elder abuse in the home, institutions and community settings. Findings of the review suggest there is uncertainty in the effectiveness of educational interventions to improve knowledge of caregivers about elder abuse and uncertainty on its effect of reducing abuse. This webinar will examine the effectiveness and components of interventions that prevent elder abuse.
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Interventions for preventing elder abuse: What's the evidence?
- 1. Welcome! Interventions for preventing elder abuse: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
- 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
- 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http://www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence /videos 3
- 4. What’s the evidence? • Baker PRA, Francis DP, Hairi NN, Othman S, Choo WY. (2016). Interventions for preventing abuse in the elderly. Cochrane Database of Systematic Reviews, 2016, CD010321 http://www.healthevidence.org/view- article.aspx?a=interventions-preventing-abuse-elderly- 29428
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- 7. Poll Question #1 How many people are watching today’s session with you? A. Just me B. 2-3 C. 4-5 D. 6-10 E. >10
- 8. The Health Evidence™ Team Maureen Dobbins Scientific Director Heather Husson Manager Susannah Watson Project Coordinator Students: Emily Belita (PhD candidate) Jennifer Yost Assistant Professor Olivia Marquez Research Coordinator Emily Sully Research Assistant Liz Kamler Research Assistant Zhi (Vivian) Chen Research Assistant Research Assistants: Lina Sherazy Claire Howarth Rawan Farran
- 10. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
- 11. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
- 12. Stages in the process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
- 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
- 14. Searchable Questions Think “PICOS” 1. Population (situation) 2. Intervention (exposure) 3. Comparison (other group) 4. Outcomes 5. Setting
- 15. How often do you use Systematic Reviews to inform a program/services? A.Always B.Often C.Sometimes D.Never E.I don’t know what a systematic review is Poll Question #3
- 16. Dr Philip Baker Professor of Epidemiology Australia Regional Director APACPH, School of Public Health and Social Work Queensland University of Technology
- 17. http://goo.gl/8ovq1H Baker PRA, Francis DP, Hairi NN, Othman S, Choo WY. Interventions for preventing abuse in the elderly. Cochrane Database of Systematic Reviews 2016,
- 18. What we set out to do • Identify specific programs or strategies to prevent or reduce elder abuse (aged 60 and over) • Look at studies describing the effects of the programs or strategies • Summarise the evidence
- 19. Searchable Question “PICOS” 1. Population Older adults, > 60 years old 2. Intervention Primary, secondary and tertiary intervention programs aimed at reducing or preventing elder abuse 3. Comparison No intervention. 4. Outcomes Primary Outcomes: Occurrence or recurrence of reported elderly abuse. 5. Setting within their home, an institution, or community Secondary Outcomes: Changes in effects of interventions due to types of abuse, types of participants, setting, or cognitive status of the elderly
- 20. What is elder abuse? • Physical, psychological, sexual abuse, neglect and/or financial exploitation. Single, or repeated act, or inaction. • Occurs within a relationship where there is an expectation of trust • Often from someone who they know well or have relationship • Service providers
- 21. Importance of this review • Canada: 4 to 10% (PHA 2012), 1 in 5 say they know someone • Australia and South Korea 6% • Global health issue 2.7 to 27.5% (Cooper et. al 2008) • Prevalence as high as 44.6% • Significant public health issue which has great economic costs • Populations aging
- 22. Causes / risk factors of elder abuse • Result of complex interactions among factors at the individual, relationship, community and societal levels • Factors interact • Increased dependence on caregivers • Abuser’s own problems
- 23. What studies did we include? Any strategies that avoid potential elder abuse or reduce recurrent elder abuse’ to lower rates of elder abuse in communities and in institutions. • Education, Reduce factors influencing elder abuse • Specific policies, Legislation & detection • Programs targeted to victims of elder abuse & perpetrators
- 24. How did we do it? • Searched 19 databases on 12 platforms including multidisciplinary - March 2016 • Randomised controlled trials, other comparative designs (e.g. ITS) • Duration 12 weeks or longer • Minimum 2 authors independently extract and assess with Cochrane Risk of Bias tool • Application of GRADE to describe quality of evidence
- 25. What studies did we find? • Nearly 30,000 articles screened • 231 assessed full text • 7 studies included, 1 ongoing • 1,924 Older persons and 740 other people such as caregivers and family member • USA (4), UK (2) and Taiwan (1) • None of: legislation on elder abuse, rehabilitation programs, specific policies for older persons
- 26. Characteristics of the studies • 5 randomised controlled trials, 2 nonrandomised CBA • Interventions with: Carers (in a contractual, duty of care relationship) Family members providing care and Those abused
- 27. Risk of Bias Summary of included studies
- 28. Included studies by intervention approach • Educational Interventions targeted at health professionals and/or carers (3 studies) Hsieh 2009, Richardson 2002, Teresi 2013 • Programs to reduce factors influencing elder abuse (1 study) Cooper 2015 • Programmes to increase detection (1 study) Bartels 2005 • Programmes targeted to victims (2 studies) Davis 2001, Brownell 2006
- 29. Primary outcome: Educational Interventions for health professionals and/or carers Hsieh 2009: Aimed at decreasing the caregiver’s inappropriate verbal or emotional behaviours, improve ability to cope with stress, promote knowledge, and providing geriatric care • 112 caregivers, 8 months program 97% females • Low intensity, lecture topic 30 minutes, 40 minutes sharing • High risk of bias
- 30. Primary outcome: Educational Interventions for health professionals and/or carers Hsieh 2009: continued Reported a between-group effect of a net decrease in abusive behaviours. • Mean difference in the post-test measures for intervention and control was -1.22 (95% CI -13.5 to 1.10) • Increases in knowledge from the training
- 31. Educational Interventions targeted at health professionals and/or carers Richardson 2002: Health professionals, RCT, attending an educational course (n=44) vs printed materials (n=42), UK • 1 day workshops, over 10 months • 77% and 82% female • Nurses, care assistants & social workers, • Knowledge, attitudes, burnout especially with patients with demented patients
- 32. Primary outcome: Educational Interventions targeted at health professionals and/or carers Richardson 2002: continued • The adjusted mean difference was only 0.2, and the adjusted % relative to control group was 3.2%. • Attitudes high to begin with….
- 33. Primary outcomes: Educational Interventions targeted at health professionals Teresi 2013: Cluster RCT, educational intervention, nursing homes USA, 1405 residents, 47 nursing homes • Healthcare professionals, units within the same facility, Prevent Resident to resident elder mistreatment (R-REM) • 3 modules – recognise and manage R-REM • 4 w intervention, 6 & 12 month follow-up • Skill of recognising abuse
- 34. Primary outcomes: Educational Interventions targeted at health professionals • Teresi 2013: continued • 6 months nursing self reported events mean incidents in 2-week period: 0.82 incidents; Change relative to control 304% • 12 months: 0.42 incidents, relative to control 420% • Improved recognition and report – does it mean less abuse?
- 35. Primary Outcome: Programs to increase detection rate for prevention of elder abuse Bartels 2005: Increase detection for prevention, USA, controlled before /after, medium intensity • aimed to improve assessment and service planning practices of clinicians who undertake assessments of abuse and neglect. • Claims of improvement by the study investigator were not supported with statistical analysis (13 agencies, 44 clinicians, 100 elderly persons; low quality evidence). • Re-analysis showed no difference
- 36. Primary Outcome: Programs targeted to victims of elder abuse Davis 2001: prevent re- occurence, including whole of community component & individual level intervention • A nested RCT program for community residents who experienced elder abuse Public education only vs control no difference • Made much worse (Home Visit, HR=2.05) • low quality evidence
- 37. Primary Outcome: Programs targeted to victims of elder abuse Brownell 2006: Prevent re-occurrence of abuse, Social support groups, RCT, USA • Structured education in group setting, older women with family problems • Small study, assigned 9 victims to a psycho-social support group with structured curriculum for 2-hour weekly sessions for 8 weeks. • Too small(very-low quality evidence)
- 38. Primary Outcome: Programs to reduce factors influencing elder abuse through promoting mental health of caregivers Cooper 2015: Pragmatic RCT, carer related factors, family members with dementia, START trial 8 to 14 weeks duration, medium intensity. • Abusive behavior - Underpowered • Learning coping strategies – less anxiety and depression of family care givers, HADS scale (-1.80 points, 95% CI -3.29 to - 0.31; 1 study; 260 caregivers; moderate quality evidence).
- 39. New study in progress • Loh 2015 A cluster randomised trial on improving nurses’ detection and management of elder abuse and neglect (I-NEED): study protocol. Journal of Advanced Nursing 2015; 71 (11):2661-72 • ISRCTN47326902 DOI 0.1186/ISRCTN47326902
- 40. Overall considerations: Programs to reduce influencing factors • Targeting risk factors doesn’t necessarily prevent or reduce elder abuse • 1 RCT found no difference (Cooper 2015)
- 41. Overall considerations: Programs to increase detection • Not enough quality evidence • A new integrated system of clinical assessment and decision support didn’t measure abuse • Staff more likely to screen for safety, neglect
- 42. Overall considerations: Program targeting to victims • Unable to determine which types of victims programs are most effective and under what circumstances • Potentially negative harmful effects with home visiting • Uncertain
- 43. General Implications • Very little evidence for guidance. • Lack of research for models of practice. • Increasing care givers knowledge and attitudes not necessarily less abuse. • Education of health providers may increase ability to detect abuse. • Education of coping skills is likely to reduce anxiety and depression of carers.
- 44. Implications for practice and policy • Doing more of a program, or more combination of strategies not an evidence informed approach. • Attempts to increase knowledge about abuse and attitudes of care givers does not necessarily result in improved attitudes or less abuse • Detection training - Less abuse? • Reduce anxiety and depression in caregivers.
- 45. Implications for research • Are programs to increase detection effective? • Determine effective programs targeting victims of elder abuse • Use appropriate study designs • Low and middle income countries • Avoid waste • Support Front-line agencies in comparative evaluation.
- 46. Conclusions • Challenge for policy development • Moderate quality evidence teaching coping skills to family carers of those with dementia • Health professionals training increases knowledge, may increase detection. • Poor quality and wasteful research needs to be avoided • New research underway
- 47. Communication strategies Health Evidence Summary
- 48. • Podcasts
- 49. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
- 50. Poll Question #4 The information presented today was helpful A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree
- 51. What can I do now? Visit the website; a repository of over 4,800 quality-rated systematic reviews related to the effectiveness of public health interventions. Health Evidence™ is FREE to use. Register to receive monthly tailored registry updates AND monthly newsletter to keep you up to date on upcoming events and public health news. Tell your colleagues about Health Evidence™: helping you use best evidence to inform public health practice, program planning, and policy decisions! Follow us @Health Evidence on Twitter and receive daily public health review- related Tweets, receive information about our monthly webinars, as well as announcements and events relevant to public health. Encourage your organization to use Health Evidence™ to search for and apply quality-rated review level evidence to inform program planning and policy decisions. Contact us to suggest topics or provide feedback. info@healthevidence.org
- 52. Poll Question #5 What are your next steps? A. Access the full text systematic review B. Access the quality assessment for the review on www.healthevidence.org C. Consider using the evidence D. Tell a colleague about the evidence
- 53. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx
Editor's Notes
- Poll question #4
- here’s a look at the team many involved in the work to keep HE current and maintained
- Health Evidence launched in 2005 comprehensive registry of reviews evaluating the effectiveness of public health and health promotion interventions provide over 90,000 visitors per year access to over 4,600 quality-rated systematic reviews links to full text, plain language summaries, and podcasts (where available) One of main goals of Health Evidence, in addition to making evidence re: effectiveness of PH interventions more accessible, is to make it easier for professionals to use evidence in decision making
- Model for Evidence-Informed decision making in PH consists of 5 components visible in this diagram Traditionally public health practitioners and decision makers do consider evidence about community health issues and local context, existing resources, and community and political climate in making decisions about programs and policies however, it has become apparent that a considering evidence about research may be more challenging As such the Health Evidence webinar series is designed to identify research evidence relevant to public health decisions
- The EIPH wheel illustrates the steps involved in evidence-informed practice The wheel is a guide for practitioners and decision makers to determine how to address a particular issue by systematically incorporating research evidence in the decision making process There are 7 steps in the EIPH process that starts with: Clearly defining the problem; Searching the research literature; Appraising the evidence you find; Synthesizing or summarizing the research on your issue; Adapting and interpreting the findings to your local context; Implementing the evidence or appropriate intervention; and Evaluating your implementation efforts. We will hear today about how (presenter) has worked through the first 4 steps, in order to help with the decision makers with the remainder of the 7 steps
- Poll question #4
- This review has been published in the Cochrane Library. I would also like to acknowledge my authors Daniel, Noran, Sajar and Claire. The work was supported through grants from the University of Malaya and QUT.
- Identify specific programs or strategies to prevent or reduce elder abuse (aged 60 and over) Look at studies describing the effects of the programs or strategies Summarise the evidence
- Elder abuse is defined as Physical, psychological, sexual abuse, neglect and/or financial exploitation - is common but often underreported. Single, or repeated act, or lack of appropriate action. Occurs within a relationship where there is an expectation of trust, but abuse occurs, The abuse can often come from someone who they know well or have relationship with such as a spouse, partner, family member, or friend. It can also be someone with whom the is contractional relationships such as service providers in institutions and healthcare settings.
- - is common but often underreported. Very information available about elder abuse. Canada: 4 to 10% (PHA 2012), 1 in 5 say they know someone Australia and South Korea 6% Global health issue 2.7 to 27.5% (Cooper et. al 2008) Prevalence as high as 44.6% in some countries Significant public health issue which has great economic costs, and that these include direct costs to health, social, legal, police and other services. Populations aging
- Elder abuse is result of complete interactions among various factor at the individual, relationship, community and societal levels which can be conceptualised using an ecological model. Factors from each level can interact, putting the elderly at risk of abuse. Older people who experience dementia, disabilities and chronic health problems result in an increased dependence on caregivers, and it is this dependence which puts them at greater risk of maltreatment. Low social support, experience of lonelliness and lack of social netweorks puts older people at risk Often abusers have their own problems such as suffering metal illness, high levels of hostility, depend upon the older person for accommodation and financial support. They can be frustrated by the older person’s problems. They may also take the opportunity to ‘pay back’ the abuse which they received as a child.
- In this review we looked very broadly for interventions which could prevent the occurance and re-oourance of elder abuse Any strategies that avoid potential elder abuse or reduce recurrent elder abuse’ to lower rates of elder abuse in communities and in institutions. These included education programs for carers. Programs to reduce factors influencing elder abuse such as anger and stress management. Specific elder abuse related policies such as those to improve housing, banking etc. legislation that are law orientated such as manditory reporting, Programs that hel increase the detection of abuse so that re-occurance can be prevented, programs to help the abused such as protective services and theose which seek to rehabiliate the abusers. Legislation on elder abuse Programmes to increase detection rate for prevention of elder abuse Programs targeted to victims of elder abuse Rehabilitation programmes for perpetrators of elder abuse
- We undertook a comprehensive, transparent and repeatable search strategy. Searched 19 databases on 12 platforms including multidisciplinary - March 2016 Randomised controlled trials, other comparative designs (e.g. ITS) Duration 12 weeks or longer Minimum 2 authors independently extract and assess with Cochrane Risk of Bias tool Application of GRADE to describe quality of evidence
- Most of the studies had some serious problems in the methodology which threatened the trustworthiness of the findings. Amongst these were more difficult to achieve such as blinding the participants and personnel as to which group they had been assigned to. Most of the studies achieved good followup providing complete data, and complete reporting of the findings. In some of the studies the groups weren’t entirely comparable at the start.
- Of the 7 interventions, three of these were targeted at health professionals, teaching skills. One recent study on training coping skills to care givers, One study sought to improve detetion amongst residents in care facilities, and 2 studies targeted those persons identified as victims with strategies such as social support.
- This 8-month study included 112 caregivers and provided a program to nearly all female the improve the caregivers inappropriate verbal or emotional behaviours, improve their abilitity to cope with stress, promote knowk,eledge and better care. On this aspect, there were two studies where the risk of bias associated with outcome assessment (detection bias) was at high risk, given the lack of blinding for both those providing the intervention and for the participants (a combined assessment). There is a lack of trustworthiness in the finding
- Heisch Reported a statistically significant between-group effect of a net decrease in abusive behaviours, as measured through the Caregiver Psychological Elder Abuse Behavior Scale. Certainly there is evidence of that those who participated in the training increased their knowledge about elder abuse. What the effect of the intervention upon abusive behaviour is uncertain.
- This study by Richardson did not report a primary outcome of detecting abuse: It involved 1 day workshopd of 10 month period compared to giving information The outcomes were based upon knowledge and management questionnaire based on vignettes of realistic or actual scenarios, given pre- and post- intervention (KAMA -knowledge and management).
- Post-intervention results: participating in the educational course improved, while those who received the material declined, with an adjusted mean difference of 6.6 (95% confidence interval (CI 95% 1.97 to 11.23) in favour of the intervention. How ever the differences are negligible when adjusted for baseline differences between the two group also reported on attitudes of staff towards demented patients, and while there was no difference brought about by the intervention, it was noted that pre-intervention scores were high, so no improvement would have been expected.
- A newer study Sample size A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes were assessed. Certified Nursing Assistants were trained in recognising abuse and identifying the risk factors, management of the resident to resident abuse and implementing ‘best-practices’. It was a 4 week intervention and the follow-up occurred at 6 & 12 months.
- This study found that the detection of resident to resident abuse was increased at 6 months and also 12 months relative to the control group. to be of unclear risk of selection bias due to inadequate information. Likely to improve detection and management of elder abuse of allocation concealment. Staff (n = 325) in the 24 control units only received training on the reporting form used to collectoutcome data regarding the 1405 residents, 685 control and 720 intervention).
- Bartels 2005: was a controlled before / after study in the seeking to increase detection for prevention, USA. medium intensity It aimed to improve assessment and service planning practices of clinicians who undertake assessments of abuse and neglect. Claims of improvement by the study investigator were not supported with statistical analysis (13 agencies, 44 clinicians, 100 elderly persons; low quality evidence). Re-analysis showed no difference
- Davis 2001 sought to prevent re-occurrence of abuse, including whole of community component & individual level intervention It was a nested RCT program for community residents who experienced elder abuse by family members included community awareness, police and social worker visits, and active monitoring of the premise. Public education only vs control no difference. But when combined with the home visits, the abuse appeared to become significant worse, essentially doubling. The levels of abuse were reported for those in the combined program groups (403 victims; low quality evidence)
- Brownell 2006 also sough to Prevent re-occurrence of abuse using Social support groups, a RCT design in the USA. It can best be described as a preliminary study with 16 victims . It involved Structured education provided in a group setting, to older women with family problems 9 of the victims to a psycho-social support group with structured curriculum for 2-hour weekly sessions for 8 weeks. Unfortunately the study was too small to detect a difference (very-low quality evidence). It seems the authors were unconvinced by the approach as there was never a larger study.
- Cooper 2015: is a Pragmatic RCT, carer related factors, family members with dementia, START trial 8 to 14 weeks duration, medium intensity. They measured abusive behavior using the Modified conflicts tactics scale between treatment groups, the study appreared lilkely too small to determine the difference. Learning coping strategies reduced anxiety and depression of family care givers, HADS scale (-1.80 points, 95% CI -3.29 to -0.31; 1 study; 260 caregivers; moderate quality evidence). Unclear if teaching coping skills reduces risk of abusive behaviour as the study was to small. But clearly it is helpful to reduce anxiety and depression of family members carers.
- We also found a cluster RCT in progress in Malaysia which is seeking to improve nurse’s detection and management of abuse and neglect.
- To summarise our finmdings. Overall there is no strong evidence that programs specifically targeting risk factors actually reduce abuse
- We found that there isn’t enough evidence to draw a firm conclusion about whether programs aiming specifically to increase detection actually lead to less abuse. The evidence does show that the training programs are likely to lead to increased screening for safety of older people and also for neglect.
- Very little evidence available to guide public health in the provision of services. Significant absence of research to inform models of practice. Attempts to increase knowledge about abuse and attitudes of care givers does not necessarily result in improved attitudes or less abuse. Education of health providers may increase ability to detect abuse. Education of coping skills is likely to reduce anxiety and depression of carers.
- Doing more of a program, or more combination of strategies not an evidence informed approach Caution in considering programs based on intensity of the intervention. Attempts to increase knowledge about abuse and attitudes of care givers does not necessarily result in improved attitudes or less abuse Specialty training of carers may aid in the detection of abuse perpetrated by other residents. ? Less abuse Consider programs to reduce anxiety and depression in caregivers. Caution using ‘evidence
- Research needed to determine if and to what extent programs to increase detection for elder abuse are effective. Determine effective programs targeting victims of elder abuse Use study designs that identify a causal relationship between the intervention and the outcomes of abuse More studies required from low and middle income countries Avoid waste Front-line agencies should be supported in undertaking comparative evaluation of their services.
- Poor quality and wasteful research needs to be avoided as such research fails to answer the important question of effectiveness, may mislead, creates confusion and uncertainty for those in practice and policy development
- Podcast about this review has been recorded in 6 languages.
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