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“Elder Abuse Screening Tools for Use in Primary Care:Reaching for Solid Ground”Presenter:Hollie K. Caldwell, PhD(c), MSN, RNAssociate Dean for the School of Nursing,Platt CollegeNote: A copy of today’s presentation slides will be available along with a recording of thewebinar on NCCD’s website within two weeks from today’s presentation.


Elder Abuse Screening Tools forUse in Primary Care: Reachingfor Solid GroundHollie K. Caldwell, PhD(c), MSN, RNCollege of NursingMedical University of South Carolinahollie.caldwell@plattcolorado.edu


Introduction Determinants of vulnerability Individuals age 65 and older are a vulnerable population Tong>hereong> is a need to screen for abuse physical, psychological/emotional, sexual, and financial abuseand neglect


Introduction:Prevalence of Elder Abuse Variations make it difficult to establish Acierno et al. (2010) determined an 11.4% prevalencerate (n=5,777) of abuse among community-dwelling,cognitively intact elders. A single incident of abuse can initiate a downward trendresulting in loss of autonomy, serious health issues, andeven death


Understanding EA Five forms Physical Psychological/Emotional Financial/Material Sexual Neglect Excludes self-neglect Eldercide


Screening Definition of screening “The presumptive identification of unrecognized disease or defectby the application of tests, examinations, or other procedures,which can be applied rapidly to distinguish between apparently wellpersons who probably have a disease (or its precursor) and thosewho probably do not” (Wilson & Jungner, 1968, p. 11). Criteria for screening programs & screening tests Definition of screening for violence by US Preventive ServicesTask Force (USPSTF, 2004) “as assessment of current harm or risk of harm from family andintimate partner violence in asymptomatic persons in a health caresetting”


Gold Standard? Reference standard Best single test (or a combination of tests) that is considered thecurrent preferred method of diagnosing a particular disease All other methods of diagnosing a disease, including any new test,need to be compared against this ′gold′ standard. Different for different diseases USPSTF Diagnostic Accuracy Studies Criteria: Study uses a credible reference standard, performed regardless oftest results. Reference standard interpreted independently of screening test. Gold standard is EA is difficult to determine(Parikh et al, 2008)


Screening – Sensitivity & Specificity Sensitivity Probability that the test says a person has the disease Specificity SpIN: a highly Specific test if Positive, rules IN disease. Probability that the test says a person does not have thedisease when in fact they are disease free SnNOUT: a highly Sensitive test if Negative, rules OUT disease What is ideal? A test should have high sensitivity and high specificity. Sometimes tong>hereong> are compromises in terms of sensitivity andspecificity Even with both high sensitivity and high specificity, it ispossible to get false positives and false negatives(NCSSM, 1999; Parikh et al, 2008)


Screening – Positive & NegativePredictive Values Positive Predictive Value (PPV) percentage of patients with a positive test who actually have thedisease Negative Predictive Value (NPV) percentage of patients with a positive test who actually have thedisease The higher the PPV or NPV, the better the test is performing PPV & NPV are directly related to the prevalence of thedisease in the population PPV will increase with increasing prevalence; and NPV decreaseswith increase in prevalence In diseases with low prevalence (EA), number of false-positiveresults will be far higher than the number of true-positive results


Screening Recommendations• American Medical Association (AMA, 2007)• ong>Nationalong> Gerontological Nurses Association (NGNA, 2006)• The Joint Commission (TJC)• Mandatory reporting laws• USPSTF– Insufficient evidence to recommend for or against routine screening(Nelson et al., 2004; Nelson et al, 2012).– Cites the need for evidence regarding the accuracy of EA screeninginstruments used in primary care– Barriers to screening


Literature Review• Integrative review method described by Whittemore andKnafl (2005)• Evidence synthesis methodology performed by Nelson,Nygren, and McInerney (2004) for the USPSTF• Aim– Explore the state of the science related to EA screening toolsdeveloped from 2004 to 2011 for use in primary care


Literature Review Three key questions used by Nelson et al.(2004)1. How well do the EA screening tools developed since 2004 identifycurrent harm or risk for harm from EA (sensitivity & specificity)?2. Does screening for EA reduce harm and premature death and disability?3. What is the quality of the studies conducted from 2004 to 2011 tovalidate the EA screening tool when compared to USPSTF criteria?


Literature Review Three additional descriptive questions4. In EA screening tools developed since 2004, who is the EAscreening tool designed to screen - the elder (care recipient), thecaregiver, or both?5. What type of EA is identified in EA screening tools developedsince 2004?6. Were the potential adverse effects & ethical issues of EAscreening addressed?


Methods• May – August 2011• Search of:– PubMed, Ovid/MEDLINE, CINAHL, PsycINFO, Academic SearchPremier, Health Source: Nursing/Academic Edition, andPsychology and Behavioral Sciences Collection to identifypublished works written in English between 2004 and 2011• Terms:– "elder abuse, "diagnosis," "screening, "mass screening,"“questionnaire,” “interview,” “primary care,” and "primaryhealth care.– Inclusion criteria– Exclusion criteria– Determination of Quality of Evidence


Determination of Quality of Evidence USPSTF CRITERIA FOR ASSESSING INTERNAL VALIDITY (USPSTF,2009) Good: Fair: Evaluate relevant available screening test; uses a credible referencestandard; interprets reference standard independently of screeningtest; reliability of test assessed; has few or handles indeterminateresults in a reasonable manner; includes larger number (more than100) broad-spectrum patients with and without disease. Evaluates relevant available screening test; uses reasonable althoughnot best standard; interprets reference standard independent ofscreening test; moderate sample size (50 to 100 subjects) and a“medium” spectrum of patients Poor: Has important limitation such as: uses inappropriate referencestandard; screening test improperly administered; biasedascertainment of reference standard; very small sample size of verynarrow selected spectrum of patients.


Determination of Quality of Evidence USPSTF CRITERIA FOR ASSESSING EXTERNAL VALIDITY(USPSTF, 2009) Good: Fair: The study differs minimally from the US primary carepopulation/situation/providers and only in ways that are unlikelyto affect the outcome; it is highly probable (>90%) that theclinical experience with the intervention observed in the study willbe attained in the US primary care setting. The study differs from the US primary carepopulation/situation/providers in a few ways that have thepotential to affect the outcome in a clinically important way; it isonly moderately probable (50%-89%) that the clinical experiencewith the intervention in the study will be attained in the USprimary care setting. Poor: The study differs from the US primary care population/ situation/providers in many way that have a high likelihood of affecting theclinical outcomes; the probability is low (


What was found? 211 articles 10 studies met inclusion criteria International scope United States (3), Canada (1), the United Kingdom (2),Australia (1), Taiwan (1); Israel (1), & the Federation ofBosnia and Herzegovina (1) In EA screening tools developed since 2004, who is the EAscreening tool designed to screen - the elder (carerecipient), the caregiver, or both? Caregivers screen (2) Caregivers & elders (2) Elders only (6)


What was found? What is the quality of the studies conducted from 2004 to2011 to validate the EA screening tool when compared toUSPSTF criteria? Descriptive (4) Descriptive cross-sectional (1) descriptive correlational (4) Predictive (1) Part of other longitudinal studies (2) Randomized sampling method (1)


What was found? Self-report measures in the forms of questionnaires andinterviews (n= 10)face-to-face interviews conducted by a researcher or expertself-administration of the questionnaire by caregiver and/or elderface-to-face interviews with a healthcare providertelephone interview or mailed questionnaireface-to-face interview combined with direct observation by tong>hereong>searcher


What was found? Settings: ranged from the home to primary care clinics inpatient internalmedicine and orthopedic units Unclear (2) Sample: Community dwelling caregivers & elders (9) Community & institutional care facilities in Taiwan (1) Sample Size: ranged from 86 to 10,421


What was found? Language: English (8) Hebrew (1) Not stated (1) Gender Men & Women (9) Women only (1) Elder Ages 65 & over (3) 50 & over (1) Age ranges (3) Mean ages (3) Cognitive Capacity Cognitively intact (6) Dementia (4)


What was found? Scales Nominal & ordinal Multiple-and single-item assessments of concepts Likert scales (5) Dichotomous (5) Items ranged from 6 to 32 Period of self-report ranged from 3 previous months to 12previous months Administration time from 2 minutes to 2 hours


What was found?What type of EA is identified in EA screeningtools developed since 2004?• Psychological & Physical(MCTS)(2)• Abuse specific (3)• Financial/material (OAFEM)• Psychological (EPAS; OAPAM)• New Tools (4)• OAFEM• OAPAM• EPAS• EASI• Use of Previously DevelopedInstruments• MCTS (5)• EAI (2)• E-IOA (1)• H-S/EAST (2)


What was found? How well do the EA screening toolsdeveloped since 2004 identify currentharm or risk for harm from EA(sensitivity & specificity) (Nelson etal., 2004)? Sensitivity & Specificity Positive predictive values (PPV) & negative predictive values(NPV)


What was found? Ongoing issue in EA screening instrumentdevelopment is lack of “gold standard” observer-rating (1) expert documentation review (1) an in-depth expert interview (1) or a combination of these or other reference standards (3) APS identification of abused & nonabused elders (3) No reference standard (1)


What was found? Establishment of reference standard credibility Inter-rater reliability (2) a priori determination of expert consensus guidelines (1) concurrent validity (1) Limitations Modified Data Set-A (Cooper et al.,2008) Physician inter-rater reliability (Racic et al, 2006) Failure to conduct screening results & reference standards independently(3)


What was found? Were the potential adverse effects & ethicalissues of EA screening addressed? Determination of cognitive capacity During informed consent (4) Surrogate consent (2) After enrolled (3) Not stated (4) Mandatory reporting as limitation (2)


What was found? Does screening for EA reduce harm andpremature death and disability (Nelsonet al., 2004)? Similar to the findings of Nelson et al. in 2004, NONE of thestudies reviewed provided evidence to answer this question. Acceptability addressed by Cooper et al. (2008)


Author Sensitivity Specificity PPV NPV Comparison FalsepositiveFalsenegativeCooperet al.(2009)MCTSCohenet al.(2006)E-IOAWiglesworth etal.(2010)CTS2Yaffe etal.(2008)EASIRacic etal.(2006)EAST87% 70% 18% 99% 2 geriatricpsychiatrists92% 98% NR NR LESSA &APSidentification75.4% 70.6% NR NR Expertpanelreview47% 75% NR NR Socialworkereval.Notreported(NR)NR2.1% 7.1%NR NR NR NR NR 2% 3%NRNRNRNR


Study 1: Cooper et al, 2008 Descriptive correlational design 86 male & female caregivers of care recipients with dementia inUK; mean age 64 Instrument: Modified Conflict Tactics Scale (MCTS) 5 items psychological abuse; 5 items physical abuse; Likert scale 0=4 Period: previous 3 months Score of 2 or greater = significant abuse Researchers conducted interviews; setting not stated Comparison: Minimum Data Set Abuse screen (MDS-A); 1-hourinterview Results: Distinguished abuse in 27.9% of caregivers; 83.7%caregivers reported the MCTS scale was acceptable; MCTS abusescore correlated with dysfunctional coping strategy score.


Study 1: Cooper et al, 2008 Quality Rating: Internal Validity:Poor: MDSA reasonable although not best standard; narrowselected sample of patients with dementia (mean MMSE 9.3). External Validity: Poor: Low probability (


Study 2: Cooper et al, 2009 Descriptive design 220 family caregiver (CG) of care recipients (CR) with dementia;CG age mean=61.7; CR age mean=86.1 in UK Instrument: Modified Conflict Tactics Scale (MCTS) 5 items psychological abuse; 5 items physical abuse; Likert scale 0=4 Period: previous 3 months Score of 2 or greater = significant abuse Pillimer criteria for frequency of abuse in previous 12 months Self-administered in home with interview assistance available Comparison: MCTS & Pillemer criteria to expert opinion of geriatricpsychiatrists Results: Sensitivity 87%; Specificity 70%; ppv=18%; npv=99% Threshold for EA much higher in geriatric psychiatrists than researchers


Study 2: Cooper et al, 2009 Quality Rating Internal Validity: Fair: Expert opinion (reference standard) interpretation made withknowledge of MCTS & Pillemer results instead of independently ofscreening tests; third expert used to resolve dispute External Validity: Fair: Moderately probable (50%-89%) clinical experience withweighted scoring & unknown administration time of MCTS would beattained in US primary care.


Study 3: Cohen et al, 2006 Descriptive correlational design 108 caregivers & care recipients age 65 and older during inpatient stayin two hospitals Jerusalem, Israel Instrument: Expanded Indicators of Abuse (E-IOA) 15 factors; 50 items; 1-4 scale; four factors: caregivers & care recipientpersonal & interpersonal dimensions; abuse reference time period unknown Semi-structured interviews by trained & experienced geriatric socialworkers Added a physiological measure (albumin level) Comparison: List of evident signs & symptoms of abuse (LESSA)obtained through interviews & assessments by RNs & SWs Results: E-IOA to LESSA -> Sensitivity 92%; Specificity 98%; 7.1%false negative; 2.1% false positive; E-IOA was not able to identifyknown cases of financial abuse & neglect


Study 3: Cohen et al, 2006 Quality Rating: Internal Validity: Good: LESSA reasonable although not best standard due tolack of establishment of inte-rrater reliability for RNs & SWs;interpreted LESSA independent of E-IOA using discriminatefunctional analysis (DFA). External Validity: Poor: Prolonged administration time, experience level ofgeriatric social workers used to conduct interviews, & semistructuredformat of instrument negatively impact theprobability (


Study 4: Wiglesworth et al, 2010 Descriptive designConvenience sample of 129 English-speaking, communitydwellingcaregivers and care recipients diagnosed withdementia/Alzheimer’s age 50 and older in US Instrument: Modified version of Conflict Tactics Scale(CTS2) 7-item psychological aggression subscale; 12-item physicalassault subscale Administered in home by expert researchers Comparison: Expert panel (3 geriatricians), dementiaresearcher, gerontologist with EA research expertise Results: Any physical abuse items & four psychological abuseitems resulted in Sensitivity 75.4%; Specificity 70.6%;positive response to any one of 6 items (3 items for psych &3 items from physical) resulted in false positive of 18.6%


Study 4: Wiglesworth et al, 2010 Quality Rating: Internal Validity: Fair: Reference standard (expert review) was not interpretedindependently of screening test since all research data wasprovided to LEAD panel and discussed with researcherspresent although a priori guidelines set threshold forincidences per year for each physical & psychological abusethat would indicate abuse External Validity: Fair: Moderately probable (50%-89%) that the clinicalexperience with the intervention in the study will be attainedin the US primary care setting due to higher education andincome of sample between sample and population andunknown administration time of CTS2.


Study 5: Conrad et al, 2010 Descriptive design 227 men & women age 75 to 90 who were verified by APSas having at least one type of EA in US Instrument: Older Adult Financial ExploitationMeasure (OAFEM) 79-, 54- & 30-item version (30-item evaluated) Dichotomous Yes/No Raw score of 12 out of 60 indicative of financial abuse Face-to-face interviews conducted by 22 APS personnel Comparison: None available. Results: Cronbach’s alpha = 0.93 (excellent internalconsistency); needs further sensitivity & specificity testingafter more firm cut scores are determined


Study 5: Conrad et al, 2010 Quality Rating: Internal Validity: Good: Reference standard (APS confirmation of abuse) usedindependently of OAFEM screening test; internal reliability(consistency) of test assessed and good; included largernumber (more than 100) of patients for instrument fieldtesting. External Validity: Fair: Limited geographic sample, unknown administrationtime of 30-item instrument & administration by experts ratherthan clinicians has potential to affect the outcome in aclinically important way; it is only moderately probable (50%-89%) that the clinical experience with the intervention in thestudy will be attained in the US primary care setting.


Study 6: Conrad et a; 2011 Descriptive correlational design 226 men & women age 75 to 90 who were verified by APS ashaving at least one type of EA in US Instrument: Older Adult Psychological Abuse Measure(OAPAM) 31- & 18-item version (18-item evaluated0 Yes/No/suspected/unknown Raw sore of 12 or more out of 62 indicating more severe psychologicalabuse Face-to-face interviews conducted by 22 APS personnel in homes Comparison: Illinois Dept. of Aging (IDOA) questionnaire & APSstaff observations Results: Cronbach’s alpha = 0.87 (good internal consistency);needs further sensitivity & specificity testing after more firm cutscores are determined


Study 6: Conrad et a; 2011 Quality Rating Internal Validity: Good: Reference standard (IDOA & APS confirmation of abuse) usedindependently of OAPAM screening test; internal reliability of testassessed and good; included larger number (more than 100) of patientsfor instrument field testing. External Validity: Fair: Limited geographic sample, unknown administration time of 18-item instrument & administration by experts rather than clinicians haspotential to affect the outcome in a clinically important way; it is onlymoderately probable (50%-89%) that the clinical experience with theintervention in the study will be attained in the US primary care setting.


Study 7: Racic et al, 2006 Descriptive design 185 men and women age 65 and older with mentalimpairments presenting to four family practice clinics inBosnia, Herzegovina Instrument: Hwalek-Sengstock Elder AbuseScreening Test (EAST) 15-items; "No" response to items 1, 6, 12, & 14; a responseof “someone else” to item 4; & “yes” response to all otheritems is scored in the “abused” direction" (Neale et al, 1991) Self-administered (RN assist available) as part of largergeriatric assessment Comparison: Clinical re-evaluation completed by MD & MDhome visit Results: False positives = 2%; false negatives = 3%


Study 7: Racic et al, 2006 Quality Rating: Internal Validity: Fair: EAST is relevant available screening test but known to haveissues with low internal consistency (Cronbach alpha = 0.29)and high false negative rates & this was not discussed (Neale,Hwalek, Scott, Sengstock & Stahl, 1991); physician evaluationas reference standard not completed independently of EASTscreening results. External Validity: Fair: Lack of information related to administration time,determination of cognitive capacity & difference in prevalence ofmental health impairments is US population compared toBosnian elders has potential to affect the outcome in a clinicallyimportant way; it is only moderately probable (50%-89%) thatthe clinical experience with the intervention in the study will beattained in the US primary care


Study 8: Schofield et al, 2004 Multiple time series, descriptive correlational 10, 421 community-dwelling women age 73-78 in Australia as part ofnational longitudinal study with oversampling of rural residents Instrument: Vulnerability to Abuse Screening Scale (VASS) 12-items; four factors; 10-items from H-S/EAST (dichotomous) and 2items from Conflict Tactics Scale (Likert scale). Self report of abuse in last12 months. Time 1: mailed survey in 1996; Time 2: most received mailed surveywith some being telephone surveyed Comparison: None Results: Cronbach’s alpha by factor - Dependence 0.74 (acceptable);Dejection 0.44; Vulnerability 0.45; Coercion 0.31 (all


Study 8: Schofield et al, 2004 Quality Rating: Internal Validity: Fair: Relevant available screening test with demonstratedmoderate internal consistency; very large sample fromrandomized national sample of females; but lacks use ofreference standard. External Validity: Fair: Longitudinal nature of sample differs from the USprimary care population having the potential to affect theoutcome in a clinically important way; moderately probable(50%-89%) that the clinical experience with the interventionin the study will be attained in the US primary care setting


Study 9: Wang et al, 2007 Descriptive design 195 elders age 60 or older who were partially dependent on acaregiver & able to verbally communicate from institutional caresetting & private setting in Taiwan Instrument: Elders’ Psychological Abuse Scale (EPAS) 32-items; detects actual & at risk for psychological abuse; Dichotomous; total score was the sum of all items answered "yes." Scoreequal to or > than 10 demonstrating larger possibility of psychologicalabuse; 10 = cut score Face-to-face interviews including reports from elder’s caregiver &direct observation by researchers Comparison: Short Portable Mental State Questionnaire (SPMQ) Results: 26 of 32 items had kappa values Inter-rate agreement) >0.6;remaining 6 items >.4 indicating moderate to substantial strength ofagreement. Concurrent validity between EPAS and SPMSQ = -.32(p


Study 9: Wang et al, 2007 Quality Rating: Internal Validity: Poor: EPAS is relevant available screening test; moderatesample size, but EPAS improperly administered in that CGs &interviewer provided some answers on behalf of elder.External Validity: Poor: Taiwanese study population differs from the US primarycare population in ways that have a high likelihood to affectclinical outcomes; the probability is low (


Study 10: Yaffe et al, 2008) Descriptive design 858 elders age 65 and older presenting to two universitybasedfamily practice clinics & one social service center inMontreal, Canada Instrument: Elder Abuse Suspicion Index (EASI) 6-items; dichotomous answer choices (5 for elder and 1 twopartquestion for healthcare provider). Suspicion of EA if onequestion of 5 questions directed at elder is answered "yes."Reference time period 12 months. Structured interview byhealthcare provider Comparison: Social Worker Evaluation (SWE) 1.5 to 3-hour interview conducted by trained APS personnel l3weeks after EASI screening Results: Sensitivity 47%; Specificity 75%; 97.2% MDs feltit would be impact practice


Study 10: Yaffe et al, 2008 Quality Rating Internal Validity: Good: EASI is relevant available screening test; use of SWEwas credible reference standard; SWE interpretedindependently of EASI score through blinding APS workers;included larger number (more than 100) broad-spectrumpatients with and without disease that was representative ofCanadian population. External Validity: Good: Rapid administration time & positive reception byphysicians with successful administered by clinicians inCanadian primary care setting makes it highly probable(>90%) that the clinical experience with the EASI will beattained in the US primary care setting.


Discussion Studies reflect lower level evidence to USPSTF USPSTF design code III: Opinions of respected authorities,based on clinical experience; descriptive studies or casereports; reports of expert committees Cross sectional data using descriptive research methods (n=8) USPSTF design code II-3 (2): Multiple time series with orwithout the intervention; dramatic results from uncontrolledexperiments Level of evidence has not improved Global recognition of EA as problem demonstrated


Discussion Four novel EA instruments created: EASI (Yaffe et al., 2008); OAPAM (Conrad, 2010); OAFEM (Conrad et al., 2011); VASS (Schofield and Mishra, 2004) Increased recognition of importance of screening forfinancial/material abuse Primary care & inpatient settings Increasing number of types of screens


Discussion Increase in instrument language availability Need more Spanish Inconsistency in sample size ratings Inclusion of participants with dementia Determination of sensitivity & specificity and ppv & npv testing Issues in external validity Issues in studies with fair to poor ratings Feasibility issues


Limitations Studies could have been missed Quality ratings not confirmed with another investigator More broad than Nelson et al. (2004)


Areas for Future Research No studies investigated the possible adverse effects of EAscreening Future qualitative research could examine the livedexperience of elders who screen positive Feasibility studies to examine the time requirement,impact on clinic processes, implementation fidelity, andcosts of EA screening


Areas for Future Research Impact of the instrument delivery method on the selfreportof abuse by elders Use of technology to deliver EA screening questionnaires Validate EA screening instruments with various ethnic andcultural groups. Validate instruments in other languages especially Spanish


Conclusions More EA screening instruments administered in healthcareenvironments 9 of 10 studies reviewed were & less complicated EAscreening instruments Increased number of studies with participants withdementia Researchers are trying to meet the challenge


Conclusions Significant growth seen in nature & number of studiesexamining EA screening instruments for caregivers,caregivers and elders (care recipients), & elders Knowledge gained in new EA instrument development &ability of EA screening instruments to identify currentharm or risk of harm using sensitivity and specificity andpositive and negative predictive values.


Relevance to APS practice Finding or developing EA screening tools is challenging Be aware of the USPSTF criteria when evaluating inaddition to Wilson & Jungner (1968) classic screeningrecommendations Watch for that Gold Standard & more serious errors We are making progress! Never underestimate the importance of what you do inprotecting American elders


Reaching Solid Ground…. "People seldom see the halting and painful stepsat which the most insignificant success isachieved."- Anne Sullivan 1866-1936 (instructor of/companionto Helen Keller)Thank you!Questions??


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Save the Date: Wednesday, October 30, 2013Presenter:Topic:Dr. Mark YaffeSeniors’ Self-Administration of the Elder AbuseSuspicion Index (EASI): A Feasibility StudyThank you!www.napsa-now.orgwww.preventelderabuse.orgwww.nccdglobal.org

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