Interventions
and Response

A number of strategies have been identified to aid in the prevention of and response to elder mistreatment. They range from interpersonal and community-based supports to restorative and criminal justice remedies. Multidisciplinary teams represent another model of intervention developed to address complex cases of abuse. Professional provider education and public awareness, as well, are established and growing efforts to bolster primary prevention. These models are addressed in greater detail below.

Studies have recommended implementation of harm reduction interventions that align with the older adult’s preferred case resolution. Goal attainment scaling has been proposed as an approach tailored to meet the older adult’s individual needs. Using this model, individuals define and determine their own desired outcomes or goals.¹ Another model suggests a severity framework to guide individualized outcome measures. This construct shifts the focus from binary remedies to nuanced interventions that consider the complexity, variability, types, and spectrum of mistreatment. This person-centric approach is tailored to the victim’s circumstances, needs, presenting harm, risk of recurrence, and contextual considerations.²

Other models have contemplated comprehensive approaches to intervention that go beyond victim-directed responses to holistically embrace the victim’s relationship with the offender, the context of abuse, and the home environment.³

Leading researchers in the field agree that high quality research is a requisite to evaluate and affirm best practice strategies to address elder mistreatment.⁴

Low social support is one of the most common risk factors for abuse across types.⁵ Conversely, the presence of a social network may act as a protective influence to help prevent abuse. Available social resources may also mitigate adverse outcomes such as poor health and diminished mental health in the aftermath of mistreatment.⁶

The degree and quality of social interactions have been found to impact an older adult’s perceived social support and susceptibility to abuse. Negative exchanges may lower the level of apparent support or contribute to an environment more conducive to perpetrator misconduct.⁷

Social reserves may be drawn from informal family, friend, and faith networks. Formal supports include institutional response systems such as law enforcement, Adult Protective Services, and the Long-term Care Ombudsman, addressed below. They also embrace formal health services such as homecare and community-based programs.⁸

Several community-based response models have been advanced to prevent and respond to elder mistreatment. Among them, Age-friendly Health Systems (AFHS) suggests a construct for screening older adults for abuse across health care settings. AFHS uses the 4M framework, namely, What Matters, Medication, Mentation, and Mobility in primary care, emergency departments, and long-term care facilities to detect and respond to suspected abuse.⁹

Adult Protective Services (APS) is the most widely used intervention to address elder mistreatment and neglect. This social services agency is charged with investigating allegations of abuse and neglect and facilitating appropriate responses. Interventions may include assessment and service coordination. Referrals may be made to law enforcement and result in criminal prosecution. APS may make recommendations for protective elder abuse restraining orders or guardianships. Caseworkers may also suggest and help implement restorative resolutions.

APS arose out of Title XX of the Social Security Act of 1974, which provided federal funding to states to develop APS programs. In response, each state developed its own APS organization and infrastructure.¹⁰ Current APS systems are separately funded and administered by state and local governments.¹¹

Programs differ among states and between counties as to client eligibility and available resources. A California study evaluating APS investigations across county jurisdictions reported significant variability in findings.¹² To better ensure consistent APS policies and practices nationwide, a working group of experts developed the Voluntary Consensus Guidelines for State APS Systems to provide a framework for state APS rules and laws. The guidelines address domains of program administration, response times, reports, investigations, interventions, training, and program evaluation.¹³ ¹⁴ The National Adult Maltreatment Reporting System (NAMRS) collects quantitative and qualitative data on APS practices and policies and the outcomes of investigations, as reported to APS agencies.

All states require statutorily specified professionals and/or agencies or facilities to report incidents of suspected elder abuse to reporting agencies, including APS. Mandatory reporters may include healthcare professionals, social service providers, caregivers, clergy, financial institutions, among others. The list of mandated reporters as defined by state statute.

Generally, individuals who have experienced abuse must consent to APS services and interventions. Older people with decisional capacity may decline APS assistance. Under certain circumstances, APS may render involuntary protective assistance to individuals who lack capacity or when the exigencies of the situation require intervention. A screening tool has been developed to assess the decisional capacity of abused and neglected older adults.¹⁶

Studies have been conducted to evaluate older adults’ utilization of APS services,¹⁷ examine barriers to victim self-reports,¹⁸ and measure older adults’ satisfaction with APS services and investigations.¹⁹ Researchers have explored the effectiveness of APS outcomes²⁰ ²¹ and means to measure individualized case resolutions.²²

Some issues facing APS workers are compassion fatigue and stress, largely attributed to large caseloads of complex cases.²³ Misconceptions about APS can also negatively impact their work and often has negative consequences for how their clients engage with them and their willingness to accept support from APS. In particular, many older adult clients may fear that the involvement of APS means that they will lose their autonomy.²⁴ Some potential solutions to these challenges are promoting self-care strategies, integrating compassion fatigue resiliency programs, reframing the public’s perception of APS, and complementary programs that work alongside APS.²⁵

Mandated reporters are a crucial part of reporting and responding to elder abuse because they often work closely with older adults who may be exposed to abuse. A recent study examining obstacles to communication between APS and reporters of elder abuse found that feedback may have a significant role in supporting victims of elder abuse. Mandated reporters are essential abuse prevention and intervention partners and improvements need to be made in the communication between APS and reporters.²⁶

The RISE program (Repair harm, Inspire change, Support connection, Empower choice) was implemented in Maine as a component of a larger community-based elder abuse and self-neglect intervention that complements APS. A teaming approach provides opportunities for members of the older adult’s social network to strengthen relationships that, in turn, provide a resilient social network for the older adult experiencing mistreatment. The presence of social support can provide important opportunities for monitoring the mistreatment and holding alleged harmers accountable for their actions.²⁷

Like APS community-based responses, long-term care ombudsmen investigate allegations of abuse in facilities. Ombudsmen serve as advocates who act at the behest of residents to help resolve complaints, protect their rights, and improve systemic problems in long-term care.²⁸

The Long-term Care Ombudsman Program was authorized in 1978 under the Older Americans Act to establish a consumer advocacy program intended to maintain or improve the quality of life for long-term care residents. Administered at the state level, programs employ both paid and volunteer ombudsmen to investigate complaints.²⁹

Data regarding program activities, including facility visits, complaints, information and assistance provided, and community education are reported in the National Ombudsman Reporting System (NORS).³⁰

Cases of elder abuse are often complex and multifactorial, invoking several different and disparate domains of practice. A single case may intersect social service, health care, law enforcement, and civil legal disciplines. Multidisciplinary teams (MDT) provide regular, coordinated elder mistreatment case review across practice areas. Integrated case review is associated with greater interagency collaboration, intended to enhance the efficient delivery of remedial assistance to older victims of abuse.³¹

Team characteristics, program structures, resources, constituent members, and processes differ by team.³² MDT’s typically have a geriatric health, social service, mental health, law enforcement, victim advocate, and prosecutorial presence.³³ More recently, some MDTs have added forensic accountants to their teams.³⁴ ³⁵ One type of MDT, the elder abuse forensic center (FC), applies forensic science to address complicated cases of abuse.³⁶ ³⁷ FC’s often support the efforts of frontline workers and include conducting home visits to assess older adult’s medical and mental health capacities.³⁸

Two elder mistreatment MDTs based out of the emergency department are the Vulnerable Elder Protection Team (VEPT) at Weill Cornell Medicine/NewYork-Presbyterian Hospital and the Vulnerable Elder Services, Protection, and Advocacy (VESPA) team at the University of Colorado and Denver Health.³⁹ Using trauma-informed and trust building strategies to screen and respond to elder mistreatment, these interdisciplinary response teams are a promising model to improve detection and intervention where older adult patients with socio-medical issues are commonly present.⁴⁰

MDTs continue to replicate across urban and rural areas across the country.⁴¹ MDTs have demonstrated promise as an effective intervention.⁴² As teams grow, researchers have suggested that the field develop a coordinated, uniform data collection strategy to advance best practices.⁴³

Community awareness campaigns continue to be an important approach to enhance understanding of aging and elder abuse. World Elder Abuse Awareness Day (WEAAD), celebrated across the United States and internationally since 2006, continues to be an annual platform for global awareness, recognition, and engagement.⁴⁴

The Reframing Aging and Reframing Elder Abuse initiatives have developed evidence-based communication strategies to increase public awareness and promulgate systemic solutions to prevent ageism and address elder abuse.⁴⁵ In collaboration with the Frameworks Institute, the NCEA created a public communications strategy to increase recognition of aging and elder abuse, recasting public perceptions of older people and mistreatment.⁴⁶

Educational programs have also been identified as an intervention. Older people can receive instruction in understanding the risk factors associated with mistreatment and the availability of helping agencies and resources. For example, the Keep Control campaign in Dublin, Ireland is a strengths-based intervention which empowers older adults to protect themselves from financial abuse.

Middle school students to undergraduates have been found to benefit from classroom education on aging and ageism.⁴⁹ ⁵⁰ Intergenerational programs have also been identified to increase awareness and reduce ageism and discrimination.⁵¹ Studies have reported on the efficacy of intergenerational service learning,⁵² pen pal projects,⁵³ and art activities.⁵⁴

Professional provider instruction and training in the signs and symptoms of elder mistreatment is an essential intervention. Healthcare providers are often best positioned to detect mistreatment, report abuse, and identify helping resources. In addition to medical and mental health clinicians, educating other mandatory reporters, as designated by state statute, is a key component to prevention and early identification of abuse.

Many research endeavors related to educational approaches to elder abuse prevention focus on healthcare professionals and the general public, but few focus on community gatekeepers. There is a need for evidence-based programs that educate gatekeepers on preventing elder abuse from occurring in the first place.⁵⁵ Researchers recommend that certain areas of study such as social work⁵⁶ and nursing⁵⁷ incorporate education on elder abuse throughout their curricula.

Diminished financial management abilities and reduced cognitive function have been identified among the risk factors that predispose older adults to financial exploitation. Evidence-based approaches such as the Success After Financial Exploitation (SAFE) program, developed by the Lifespan Fraud and Scams Prevention program in Rochester, New York, educate and coach older adults on finances and money management. A recent study found that most SAFE participants were very satisfied or satisfied (91%) with the services they received. Participants also reported significantly less stress at the six-month follow-up.⁵⁸ They also provide information on fraud and scams to professionals who work with older people.⁵⁹ In addition to providing education, elder financial programs may help older adults respond to consequential financial hardships in the wake of exploitation.

As noted above, cases of elder abuse are often complex and multilayered. Traditional interventions, such as criminal justice and social service remedies, may not be the preferred resolution for older adults at the center of conflict. More recently, as individualized goals and outcomes have risen to the fore, restorative justice approaches have gained increased currency.

Researchers have found that restorative processes have the potential to prevent social isolation, a predictor of abuse, and serve as an alternative remedy for abuse.⁶⁰ Specifically, researchers have drawn attention to restorative processes to educate offenders on harmful behaviors, mitigate social isolation, heal relationship rifts, and support overwhelmed caregivers.⁶¹

Studies have explored the use of harm reduction approaches to inform work with older people who have experienced abuse in later life and across the lifespan. This holistic, conceptual framework recognizes the collective neurological, biological, psychological, and socio-cultural impacts of trauma and the weight that burden places on individuals, families, and communities. A trauma-informed approach incorporates the six principles of safety, trust, peer support and self-help, collaboration, empowerment, voice, and choice. With these principles in mind, trauma-informed services integrate individualized care and tailored services to empower elders, improve the community response, and reduce the risk of revictimization.⁶²

Person-centric interventions that focus on older adults have been identified as particularly important in interventions addressing elder sexual abuse.⁶³ One approach applies a holistic life course lens, assessing an older adult’s life history of abuse when developing a treatment plan.⁶⁴ An intervention study targeting older adults who experienced elder abuse, who were also experiencing depression, found that 20% endorsed suicidal ideation. A 10-week treatment called PROTECT (Providing Options to Elderly Clients Together) was successful in reducing suicidal ideation over time as well as significantly decreasing depressive symptoms in non-suicidal patients.⁶⁵ Recent research has highlighted the importance of involving older adults in developing policies that could affect their rights.⁶⁶

Another client-centered, restorative practice that has emerged is the service advocate model. This approach developed as an extension of forensic center services. Working within the forensic center, a service advocate provides case management, crisis intervention, and supportive services to forensic center clients. The advocate promotes client wellbeing and self-efficacy, while balancing their preferences and protective interests. The service advocate may also offer resources and services to the offender to promote safety and wellbeing within the caregiver/client dyad.⁶⁷

Elder mediation is a community-based, voluntary intervention that has been utilized to help older adults and their family members resolve conflict.⁶⁸ It is a specialized form of dispute resolution that addresses conflicts arising within the context of aging and elder issues. Typically, a neutral, impartial mediator assists parties to collaboratively arrive at mutual agreement using an interests-based, solutions-oriented approach.

The focus is generally client-centered, with an emphasis on preserving elder rights, preferences, and needs. Education, care planning, and resource dissemination may be part of the recommended resolution. Studies have found that mediation may be an effective strategy to prevent or end financial abuse.⁶⁹

Elder shelters, such as the prototype Weinberg Center for Elder Justice in New York, provide a safe haven and wraparound resources to older adults who have been abused. Beyond providing a home, medical care, and provisions, shelters can be a hub for a coordinated, interdisciplinary community response to abuse.⁷⁰ Advocates help residents access their legal rights and available remedies in the aftermath of trauma.

KINDER (Knowledge and Interpersonal Skills to Develop Enhanced Relationships), is an 8-week psychoeducational intervention to prevent psychological mistreatment among family caregivers to persons living with dementia by building healthy caregiving relationships. A pilot study of the intervention demonstrated a statistically significant decrease in psychological mistreatment and relationship strain, increased quality of care, and increased caregiver resourcefulness.⁷¹

COACH (Comprehensive Older Adult and Caregiver Help), a strengths-based, individualized caregiver support intervention, successfully reduced elder mistreatment of persons living with chronic illness. Mistreatment dropped from 22.5% at baseline to 0% following the completion of the intervention, compared with a control group, who did not report a significant change.⁷²

Since the passage of the Elder Justice Act in 2010, the elder justice movement has gained traction, but federal recognition and funding have only begun to address the prevailing and mounting need to prevent elder mistreatment and address consequential harms. Several articles discuss the present and future of elder justice.⁷³ ⁷⁴ ⁷⁵ ⁷⁶