Elder abuse, a universal human rights problem, is associated with many negative consequences. In most jurisdictions, however, there are no comprehensive hospital-based interventions for elder abuse that address the totality of needs of abused older adults: psychological, physical, legal, and social. As the first step towards the development of such an intervention, we undertook a systematic scoping review.
Our primary objective was to systematically extract and synthesize actionable and applicable recommendations for components of a multidisciplinary intersectoral hospital-based elder abuse intervention. A secondary objective was to summarize the characteristics of the responses reviewed, including methods of development and validation.
The grey and scholarly literatures were systematically searched, with two independent reviewers conducting the title, abstract and full text screening. Documents were considered eligible for inclusion if they: 1) addressed a response (e.g., an intervention) to elder abuse, 2) contained recommendations for responding to abused older adults with potential relevance to a multidisciplinary and intersectoral hospital-based elder abuse intervention; and 3) were available in English.
The extracted recommendations for care were collated, coded, categorized into themes, and further reviewed for relevancy to a comprehensive hospital-based response. Characteristics of the responses were summarized using descriptive statistics.
649 recommendations were extracted from 68 distinct elder abuse responses, 149 of which were deemed relevant and were categorized into 5 themes: Initial contact; Capacity and consent; Interview with older adult, caregiver, collateral contacts, and/or suspected abuser; Assessment: physical/forensic, mental, psychosocial, and environmental/functional; and care plan. Only 6 responses had been evaluated, suggesting a significant gap between development and implementation of recommendations.
Citation: Du Mont J, Macdonald S, Kosa D, Elliot S, Spencer C, Yaffe M (2015) Development of a Comprehensive Hospital-Based Elder Abuse Intervention: An Initial Systematic Scoping Review. PLoS ONE 10(5): e0125105. https://doi.org/10.1371/journal.pone.0125105
Academic Editor: Antony Bayer, Cardiff University, UNITED KINGDOM
Received: November 11, 2014; Accepted: March 20, 2015; Published: May 4, 2015
Copyright: © 2015 Du Mont et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: Janice Du Mont was supported in part by the Atkinson Foundation. Funding for this review was obtained from the Canadian Institutes of Health Research (Funding Reference Number: SCI-131864, http://www.cihr-irsc.gc.ca/e/193.html). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Elder abuse, a universal human rights problem , is often defined as the mistreatment of older adults through “actions/behaviours or lack of actions/behaviours that cause harm or risk of harm within a trust relationship” (p.2). According to the United States Department of Justice , examples of abuse of older adults can include isolation and neglect by an adult child or caregiver; physical or sexual assault by an intimate partner, adult child or caregiver; financial or material exploitation by a stranger, family member or professional; abuse or neglect by a partner with advancing dementia; and/or systemic neglect by a long-term care provider resulting in inadequate services. Although many forms of abuse appear unlawful and involvement of criminal justice systems may be appropriate, perpetrators are rarely prosecuted and future offenses are thereby not deterred [4,5].
A growing research literature on elder abuse suggests that the problem is widespread. Cooper, Selwood, and Livingston  systematically reviewed studies measuring its prevalence and found globally that in general populations rates ranged between 3.2% to 27.5%. When assessing for specific types of abuse 4.2% of older adults reported psychological abuse, 0.5% to 4.3% physical abuse, 1.1 to 10.8% verbal abuse, 1.3 to 5.0% financial abuse, and 0.2 to 6.7 neglect. Older adults who are cognitively impaired, socially isolated, and very elderly (e.g., over age 75 or 80) or who have a lower educational status and a lower income are at an increased risk (for different types) of elder abuse [7–9]. The problem of elder abuse will continue to grow in magnitude as the population ages; globally, the number of people aged 80 years and older will almost quadruple to 395 million between 2000 and 2050 .
Elder abuse is associated with many negative health outcomes. Studies have shown that it is a notable source of emotional distress, depression, anxiety, social isolation, as well as loss of financial resources for self-care  and can result in immediate physical injuries, sexually transmitted infections, chronic health problems, and death directly and indirectly related to the abuse [12,13]. Moreover, abused older adults are more likely than those not abused to report higher levels of lung, bone, joint and digestive problems, chronic pain, and psychological issues such as depression, anxiety, and post-traumatic stress disorder [14,15]. Among community dwelling older adults, elder abuse is also associated with increased rates of emergency department use , admission to nursing facilities , and hospitalization [17,18].
The prevalence and adverse outcomes of elder abuse call for further clarity surrounding the role that health professionals might play in responding to the issue. Although elder abuse is increasingly seen as being within the scope of medical practice, a review of the scientific literature revealed that the time and resources needed to address such a complex issue are increasingly constrained across all health systems . Few elder abuse interventions are housed in hospitals and physicians frequently do not assess for or identify elder abuse because for the most part it has not been a component of their training . Internationally, there is growing recognition that to adequately and appropriately address such a multifaceted issue, health providers will need to work collaboratively with the social welfare sector (e.g., to provide housing, financial, and legal supports) . The problem lies in that in most jurisdictions there is currently no comprehensive hospital-based intervention for elder abuse that addresses the totality of needs of abused older adults: psychological, physical, legal, and social.
Forensic nurse examiner hospital-based violence programs, often in collaboration with community agencies and law enforcement services, have played a key role in providing comprehensive health, psychosocial, and medico-legal care to victims of sexual assault that present in the emergency department so as to minimize harm experienced and reduce the likelihood of future victimizations . Generally, mandates of forensic nurse-examiner hospital-based violence programs do not include elder abuse. Of 754 forensic nurse examiner programs in the United States listed with the International Association of Forensic Nurses, only 58 have reported having staff who can provide medical/legal forensic examination for elder abuse and neglect . In Ontario, Canada, where there are 35 such programs, no comprehensive response to the various types of elder abuse currently exists, although over 80% of program leaders surveyed expressed interest in expanding their mandates to work collaboratively with other services in the community (e.g., Public Trustee and Guardian) to address this issue .
To fill the gap in service provision to abused older adults and build on the success, infrastructure, and expertise of forensic nurse examiner programs, we undertook a systematic scoping review of the scholarly and grey literatures as the first steps towards the development of a multidisciplinary and intersectoral hospital-based elder abuse intervention. This methodology was utilized to capture the breadth of the available recommendations [25,26] relevant to addressing the complexity of elder abuse within a comprehensive hospital-based response. Our primary objective was to systematically extract and synthesize actionable and applicable recommendations for components of a hospital-based elder abuse intervention. A secondary objective of this systematic scoping review was to summarize the characteristics of the responses reviewed, including their methods of development and validation.
This review was conducted in accordance with PRISMA guidelines (see S1 Appendix).
Data sources and search strategy
We employed a systematic search strategy and data extraction methodology to ensure scientific rigour. With the assistance of an experienced medical librarian, the scholarly literature was searched using the electronic databases Medline, Embase, and PsychInfo from January 1, 1995 to October 11, 2013. Search terms included elder abuse, elder neglect, elder mistreatment, elder maltreatment, intervention, response, guideline, protocol, consensus, and recommendation (see S2 Appendix. Hospital-based Elder Abuse Intervention Systematic Scoping Review Search Strategy). The grey literature search was concluded December 6, 2013 and included a targeted examination of a total of 252 guideline databases (e.g., National Guideline Clearinghouse) and websites focused on elder abuse (e.g., National Center on Elder Abuse), interpersonal violence (e.g., Women Against Violence Europe), and aging and care for older persons (add e.g., Aging in America). Where the website search function allowed for Boolean operators to combine or exclude keywords (e.g., AND, OR, NOT, or AND NOT), the search statement was run as: ("Elder abuse" OR "elder maltreatment" OR "elder mistreatment" OR "older persons abuse") AND (protocols OR guidelines OR practices OR "consensus statement") AND (intervention OR response). Where Boolean operators could not be accommodated, key words were run individually. A search of Google was run using the same search statement to find any relevant documents that may have been missed in the targeted search. The first 100 search results (approximately 10 pages) were reviewed for any relevance/inclusion. During full text review of all eligible documents, other potentially relevant documents cited were retrieved and reviewed where possible.
Document inclusion/exclusion criteria
Documents were considered eligible for inclusion if they: 1) addressed a response to elder abuse; 2) contained recommendations for responding to abused older adults with potential relevance to a multidisciplinary and intersectoral hospital-based elder abuse intervention; and 3) were available in English. Documents were excluded if the focus was solely on elder self-neglect, were not free-of-cost, were web pages only, were curricula, and/or were screening tools.
Two independent reviewers conducted the title, abstract, and full text screening (JDM, MW). Documents were retained at each stage of screening if the inclusion criteria were met (see Fig 1.). Disagreements were resolved through discussion and consensus.
A data extraction form was created by the research team to record the characteristics of the included documents/responses: name, year of publication, country of publication, intended sector, stakeholder involvement, method of development, and method of validation (see S1 Dataset). Recommendations, defined as strong declarative statements  that were actionable and applicable by a multidisciplinary intersectoral team of professionals in a comprehensive hospital-based elder abuse intervention, as determined by the research team, were collected in a separate excel table. Four authors (JDM, SM, DK, SE) independently piloted the data extraction form, modifications and clarifications to the form were made where necessary, to achieve consensus in data extraction, which was then performed in dependently by two reviewers (DK, SE). Data extraction disagreements were resolved by discussion and consensus, and a third author (JDM) was consulted where an agreement could not be reached. Kappa statistics were generated to evaluate consistency in extraction of the data. For various characteristics of the approaches examined, the kappa values ranged from 0.676 to 1.00 (moderate to perfect agreement).
Data synthesis and analysis
Characteristics of the responses were summarized using descriptive statistics. The extracted recommendations for care were collated, coded, and categorized into themes over several consensus meetings (JDM, SM, SK, SE). Recommendations within themes were then further reviewed for relevancy to hospital-based forensic nurse examiner models of care (JDM, DK, SE), under the direction of the Provincial Coordinator of Ontario’s 35 Sexual Assault/Domestic Violence Treatment Centres (SM), who has over 20 years’ experience as a forensic nurse examiner providing care to victims of violence. Duplicate or similar recommendations and those that provided additional detail to a broader more general recommendation were removed. Only those recommendations pertaining to the ‘what’ should be included in the hospital-based response were reported in this systematic review (e.g., “Determine the level and urgency of safety concerns” , whereas those recommendations pertaining more to the ‘how’ to provide care (e.g., “When asking questions, talk to the older person alone, don’t rely on the explanation of others, use non-threatening words and questions”)  were retained for future use in the development of curricula and training tools.
Two thousand five hundred twenty-four scholarly citations were retrieved, along with 168 grey literature documents, 141 from the website and guideline database searches, and 27 from Google search. After removing duplicate citations, screening titles and abstracts of the scholarly literature, and adding additional documents based on citations seen during full text review, 581 full text documents were reviewed, 70 of which were eligible for inclusion in this review, based on our inclusion and exclusion criteria. During full text review, two documents each were combined where they represented aspects of the same response, for a final 68 distinct elder abuse responses reviewed. Documents that were part of a larger ‘parent’ document or drew heavily from a larger ‘parent’ document were excluded. Where a more recent version of a document by the same authors was available, the updated version was reviewed (Fig 1.).
Characteristics of the included responses to elder abuse
Of the 68 responses reviewed, 28 were categorized as guidelines, 18 as frameworks, seven as protocols (including a subchapter of protocol), six as manuals (including subchapter of a manual), four as tools, three as interventions, and two as tool kits. Responses were categorized as self-identified where possible. Where the response did not self-identify, two authors (JDM, SK) categorized them based on their mission statement or other relevant content. Three of the included responses were primarily focused on the abuse of vulnerable adults, but also included abuse of the elderly [29–31]. Most of the responses were published in the United States (53%), followed by Canada (32%), Australia (6%), the United Kingdom (3%), Portugal (3%), New Zealand (1%), and Hong Kong (1%). Approximately half (49%) were targeted to more than one sector: 79% the health sector, 59% the community/social service sector, 31% the legal sector, 28% the law enforcement sector, 10% the financial sector, and 10% other sectors (e.g., faith-based institutions/spiritual leaders) (see Table 1).
More than four-fifths (81%) of responses identified in our review were developed with input from two or more professional groups or sectors. Knowledge users, those working in the sectors targeted, were involved in the development of most (85%) of the responses examined; these professionals were most commonly health care providers (59%), legal experts (19%), and law enforcement personnel (18%). Researchers/academics were involved in the development of 56% of the responses, followed by policy makers (38%), and public representatives (12%) (see Table 2).
Fewer than three-quarters (72%) of the responses examined described methods of development used; 23% listed more than one method. The most common method cited was use of pre-existing guidelines/protocols (62%). Consensus methods (e.g., consensus meetings, advisory groups) were used to inform 16%, and non-systematic literature reviews 13%, of responses (see Table 2).
Approximately, one third (35%) of responses reported having been validated in some capacity. Most commonly this included having been reviewed by external stakeholders and revised based on feedback before finalization (15%). Several responses had been pilot tested (10%) and/or evaluated (9%). For example, it was noted in Procedural Guidelines for Handling Elder Abuse Cases that
and in A Model Intervention for Elder Abuse and Dementia that
[T]he [Hong Kong Christian Service] … conducted a pilot run to test out the feasibility of the first draft of the Guidelines. … Drawing on the experience obtained from the pilot run, [it] made some amendments of the content of the draft Guidelines. Lastly, the Guidelines were further refined by the [Social Welfare Department] based on the views of members of the [Working Group on Elder Abuse]. 
Some (13%) responses had been endorsed by external organizations such as Elder Abuse, Neglect, and Family Violence: A Guide for Health care Professionals, endorsed by the Wisconsin Medical Society  (see Table 3).
[E]valuation involved assessment of the training program through participant completion of evaluation forms before training was initiated and after each session was completed. … critical review of agency protocols and analysis of client outcomes. … anecdotal reports [from staff] regarding cross-referrals and consultations following the training.” (pp. 495, 496)
Recommendations relevant to a comprehensive hospital-based elder abuse intervention
Of the 1649 recommendations for potential implementation by a multidisciplinary intersectoral team of professionals in a comprehensive hospital-based elder abuse intervention extracted and collated, 149 were retained following the final relevancy review, and were coded and categorized into five themes: Initial contact (e.g., “Determine the level and urgency of safety concerns” ; n = 7); Capacity and consent (e.g., “[Determine the] client's perspective on the questions raised about their capacity” ; n = 8); Interview with older adult, suspected abuser, caregiver and/or other relevant contacts (e.g., “Assess longstanding relationship problems [dynamics] between victim and perpetrator” ; n = 69); Assessment: physical/forensic, mental, psychosocial, and environmental/functional (e.g., “Identify and document details of the neglect [as reported] (frequency, what needs aren't being met, etc.)” ; n = 41); and Care plan (e.g., “All [relevant] professionals should attend [multidisciplinary care committee meetings] wherever possible to assist the formulation of a welfare plan for the abused elder” ; n = 24) (see Table 4).
The prevalence, negative sequelae, lack of available services, and increasing aging population globally indicate a strong need for effective comprehensive health service interventions to address elder abuse. Our systematic scoping review of the grey and scholarly literatures identified 68 elder abuse guidelines, protocols, and related materials with recommendations relevant to a multidisciplinary intersectoral hospital-based intervention. The recommendations possibly pertinent to forensic nurse examiner models of care focused on initial contact with the older adult, assessing the older adult’s mental capacity and obtaining informed consent, interviewing the older adult, suspected abuser, caregiver, and/or other relevant contacts, providing physical/forensic, psychological, environmental/functional assessments, and formulating and delivering a care plan. These recommendations, upon further evaluation and with proper training and organizational supports, could be implemented within existing forensic nurse examiner programs .
Although elder abuse is a problem that has been documented worldwide , our review revealed that more than 4-in-5 responses relevant to hospital-based care were developed in the United States or Canada and, therefore, may not be entirely applicable, to other jurisdictions. This may be because the multiple databases searched tend to retrieve results from North America and Europe . Additionally, the limitation of our review to inclusion of English language documents only may have restricted our ability to capture the full range of relevant international responses. The health sector and the community/social service sector were most often the target audience of responses. Only a handful of documents were aimed at those working in the financial sector, which may be problematic given that some population-based studies have shown that financial/material abuse is one of the most common types of elder abuse experienced [39–42].
In this review, representatives from the public were identified as underrepresented in the development of responses to elder abuse—involved in the construction of just 12% of the reviewed responses. This is similar to findings from another review article , and contrary to recommendations for developing guidelines [44,45]. As the responses examined are designed explicitly to address the needs of older adults where abuse is suspected and or has occurred, it is critical to ensure that their first hand perspectives and experiences are considered in shaping services. This group of stakeholders should be better engaged in the development of future interventions.
A substantive proportion of the elder abuse responses reviewed did not report their methods of development, making it impossible to comment on their rigor. The overwhelming majority drew on recommendations from pre-existing materials that themselves were not evidence-based. This is consistent with a systematic review by Shaneyfelt et al.  who found that only 33.6% of the guidelines they reviewed adhered to the established methodological standards for the identification and summary of evidence. Only one response in our sample of 68 was developed using a systematic review of the literature. Eleven responses were based on findings from consensus methods, although none used a formal Delphi consensus survey, which allows for the integration of the opinions of many different experts, and has been used successfully in other areas of elder abuse research [47–49].
We found that in almost two thirds of elder abuse responses reviewed there was no report of validation. The most common form of validation documented, in 15% of cases, was external stakeholder review. Only 6 responses of 68 had been evaluated, suggesting a significant gap between development and implementation of recommendations. This fact may be a disservice to older adults, as thorough evaluation of interventions is critical to developing evidence informed responses to elder abuse that prevent harm. It has been previously demonstrated that rigorously developed and evaluated clinical guidelines do improve clinical practice when implemented .
This review has strengths and limitations. The broad search strategy used in this review is congruent with the complex and multifaceted nature of addressing the elder abuse problem and as such captured documents developed by a variety of important stakeholders. The resulting diverse sample of responses allows for the integration of perspectives from multiple disciplines and sectors in the development of a comprehensive hospital-based elder abuse intervention. That said, although every attempt was made to capture all relevant guidelines, protocols, and related materials, some may have been missed. For example, post search and analysis, we found an elder abuse guideline for occupational therapists, although upon examination, it contributed no additional relevant recommendations to a hospital-based response . The inclusion of a range of document types made a formal quality assessment of the included responses unfeasible as there is no currently available validated tool for that purpose , although we did describe the methods used to develop and validate the responses. Given the paucity of high quality studies assessing elder abuse interventions, as cited in a previous systematic review , we were unable to systematically evaluate the strength of the evidence for individual recommendations. To address this lack of evidence to support the recommendations, a next step in the development of any hospital-based response to address elder abuse must be a further evaluation of the extracted recommendations.
The next phase of this research is a Delphi consensus survey to determine the final components of care in the intervention under development, in which the nurse examiner will work with other healthcare providers and collaborators from the community/social service, finance, law enforcement, and legal sectors to address the complex functional, medical, legal, and social, needs of abused older adults. A group of 33 experts in hospital-based violence programs have been assembled to review and rank the recommendations extracted in this review for their importance to a comprehensive hospital-based response. This type of program of research, which addresses a high priority area in the field of aging and a significant gap in health research, will lead to an intervention that could improve the quality of life of abused older women and men and prevent further victimization.
S2 Appendix. Hospital-based Elder Abuse Intervention Systematic Scoping Review Search Strategy.
We would like to thank Meghan White for research assistance in early stages of this project and Mona Franzke for assistance in the development of the search strategy. Janice Du Mont was supported in part by the Atkinson Foundation. Funding for this review was obtained from the Canadian Institutes of Health Research (Funding Reference Number: SCI-131864)
Conceived and designed the experiments: JDM SM CS MY. Performed the experiments: JDM SM DK SE. Analyzed the data: JDM DK. Wrote the paper: JDM, DK. Reviewed and revised drafts of manuscript: SM SE CS MY.
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