EASI TOOL

EASI: Elder Abuse Suspicion Index*

Developed and presented by Lucy Barylak M.S.W.

2013

*Mark J. Yaffe, MD, Université McGill, Montréal, Canada mark.yaffe@mcgill.ca

Maxine Lithwick, MSW, CSSS Cavendish, Montréal, Canada maxine.lithwick.cvd@ssss.gouv.qc.ca

Christina Wolfson, PhD, Université McGill, Montréal, Canada christina.wolfson@mcgill.ca

Training Objectives

Older Adults at Risk

Facts about Elder Abuse

Caregivers and Elder Abuse

Part 2

Intervention Guidelines

(American Medical Association, 1992)

References

Why Develop a Screening Tool?

Barriers to Identification

Training Objectives

There are several reasons that elder abuse is under-identified by health care providers:

• Lack of education or training about the problem, its scope and signs, identification skills, and reporting procedures
• Lack of awareness of abuse
• Feeling uneasy asking patients about abuse
• Time restraints
• Skepticism and disbelief in the possibility of making a change once elder abuse is identified and reported
• The signs of abuse might overlap with symptoms and outcomes of various diseases or side effects of medications (for example, bruising from anticoagulants).
• Older adults are frequently hesitant to disclose abuse to health care providers, they may be ashamed, fearful or feel hopeless about the situation.

(Lachs et al., 1995; Lachs Bomba, 2006; Fulmer, 2008; Krueger & Patterson, 1997)

Rates of abuse identification by healthcare providers is usually low (Fulmer et al., 2000).

• Some experts believe that elder abuse is under-reported by 80%
• Research shows that social workers are more willing to get involved in cases of elder abuse than physicians-physicians were more likely to feel hesitant and powerless (WHO-CIG, 2006).
• Studies in the U.S. reported that more than 60% of physicians surveyed said that they had never asked their patients about abuse (Kennedy, 2005).
• More than half of the physicians surveyed had never identified a case of abuse, or had not identified one in the last 12 months (McCreadie et al., 2000).
• An encounter with a health professional may be the only chance an isolated older adult has to get help (Cohen, 2008).

Part 1

• Case Studies
• Recognizing the signs and symptoms of elder abuse
• Why develop a screening tool?
• Barriers to the identification of elder abuse
• The EASI tool-background
• The EASI tool-guidelines
• The EASI tool-limitations
• Future directions and recommendations

• Defining elder abuse
• Prevalence and incidence of elder abuse
• Risk factors for older adults
• Facts about elder abuse
• Caregivers and elder abuse
• Broad categories of abuse
• Different forms of abuse
• Consequences of abuse

• To raise awareness of the prevalence, types and signs of elder abuse.
• To develop the capacities of health and social service professionals to identify and address elder abuse.
• To develop the capacities of health and social service professionals to identify and address caregiver risk factors that could lead to elder abuse.
• To present the EASI tool and the guidelines for it’s use.
• To provide recommendations and future directions for research and practice.
• To provide resources relevant to health and social service professionals working with older adults, caregivers and victims and\or perpetrators of elder abuse.

Recognizing Abuse

Certain signs can help detect situations of abuse. For example:

• Delays between injuries or illness and seeking medical attention
• Implausible or vague explanations for injuries or ill-health, from either patient or caregiver
• Differing case histories from patient and caregiver
• Frequent visits to emergency departments because a chronic condition has worsened, despite a care plan and resources to deal with this in the home
• Functionally-impaired older patients who arrive without their main caregiver
• Laboratory findings that are inconsistent with the history provided.

(WHO, 2004)

Defining Elder Abuse

The EASI Tool-Guidelines

The EASI Tool-Background

“Elder abuse is a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person”

(World Health Organization, 2002, p.3)

• Bruises, injuries, depression, poor hygiene (These may have medical causes but should be investigated further)
• Changes in behavior such as appearing afraid, difficulty making eye contact
• Increase in the number of banking transactions, disappearance of objects of value
• Social isolation
• Family member, friend or caregiver speaking for the individual, not letting them respond.

(For a more detailed list of signs and symptoms of abuse and neglect see the National Elder Abuse Incidence Study, 1998).

The EASI tool was developed to improve the detection of elder abuse.

• Designed for use by physicians of cognitively intact older adults in an office setting.
• Designed to be used in face-to-face encounters with older adults

For example, in clinics, medical offices, emergency rooms.

• The tool consists of 6 items, 5 of them direct yes or no questions asked of the patient; the 6th item asks the physician if any behaviors indicative of abuse have been noticed.

(Yaffe et al., 2008; WHO-CIG, 2006)

The EASI tool questions were developed with the assistance of doctors, nurses, and social workers with known expertise in elder abuse policy and practice.

Different attitudes towards the EASI questions were present based on profession:

• Social workers approach was based on the need to advocate for clients.
• Nurses were most concerned with practicality, directness and wanting to respect doctors’ time constraints.
• Physicians’ were more holistic in their concerns but also focused on practicality and time management.

The EASI tool has been tested in 8 countries for it’s validity in different cultural and geographic contexts.

When compared to other screening tools, EASI has fewer questions and takes less time to administer.

(Yaffe et al., 2008; WHO-CIG, 2006)

Prevalence and Incidence

• Cognitive impairment

-Research indicates that people with dementia are at greater risk of elder abuse than those without (Cooney et al., 2006).

• Physical conditions and dependence on others for care

-Difficulty with activities of daily living, requires assistance from others

• Inability to express wishes

-Due to cognitive decline, communication difficulties, language barriers etc.

• Isolation

-Social or geographic isolation

• Lack of choice

-Due to government policies, available beds etc.

• Economic vulnerability

-Limited financial resources, reduced options to move to a different long term care home etc.

• Being cared for by a caregiver who is overwhelmed, stressed, depressed or unwilling to care.

(University of Toronto, 2008)

• It is challenging to estimate the prevalence and incidence of elder abuse because of factors such as: under-reporting, confusion about what constitutes elder abuse, and lack of awareness. (National Seniors Council, 2007).
• According to the National Incidence Study on Elder Abuse, approximately 450,000 elderly experienced abuse in 1996 in the United States. If self-neglect is included, the number is 551,000. (1998).
• It is estimated that between 4-10% of older adults in Canada experience some type of abuse (National Seniors Council, 2007).
• In 2004, the APS (Adult Protective Services) confirmed 44,694 cases of abuse, neglect or exploitation involving older adults in Texas communities.

The EASI Tool

What next?

The next steps will depend on whether or not you are suspicious that elder abuse is present.

Treatment and intervention protocols will vary depending on the country in which you live, and the particular organization in which you work.

The steps to follow will be different depending on the patient’s capacity to consent and make decisions.

Facts about Elder Abuse

EASI Questions

Q.1-Q.5 asked of patient; Q.6 answered by doctor

Within the last 12 months:

1) Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

2) Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides or medical care, or from being with people you wanted to be with?

3) Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

4) Has anyone tried to force you to sign papers or to use your money against your will?

5) Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

6) Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?

Elder abuse occurs regularly in community and long term care settings:

• In a study of 2,000 nursing home residents, 44% said they had been abused and 95% said they had been neglected, or seen another resident neglected (Broyles, 2000).

• In one study, over 50% of nursing home staff admitted to mistreating older patients within the last year (Ben Natan, 2010).

Facts about Elder Abuse

Perpetrators of elder abuse are commonly family members, and/or caregivers:

• In the U.S. 90% of elder abuse was perpetrated by a family member (National Elder Abuse Incidence Study, 1998).
• Three international studies found overall rates of abuse of people with dementia by their caregivers ranging from 34% to 62% (Cooney, Howard Cooper et al., 2009; Yan & Kwok, 2010).
• In a U.S. study, 20% of caregivers expressed fears that they would become violent with the people they cared for (Pillemer & Suitor, 1992).

Facts about Elder Abuse

The EASI TOOL-Limitations

The EASI Tool-Strengths

According to Statistics Canada (2010):

• In the last decade in Canada, 50% of all family homicides against older adults were committed by grown children.
• 36% of family perpetrators against older adults aged 65-69 were grown children, followed by spouses at 30%
• By age 85-89, grown children were 49% of all family perpetrators, spouses 21%

• The sensitivity and specificity of the EASI tool to determine the presence of abuse was low when compared to an evaluation interview done by a social worker (Cohen, 2011).
• Due to it’s low sensitivity, it has been asked if the EASI tool is any better than a physician’s independent judgment about the presence of elder abuse.
• The EASI tool asks about only one risk factor (dependency, Q.1) among many other and more prominent risk factors.
• The EASI tool is designed to only be applicable to cognitively intact older adults, and is suggested for use by physicians in office based settings.
• There is no “gold standard” for the diagnosis or validation of mistreatment
• The EASI tool is intended to be asked verbatim, however there is no way to ensure physicians use exact wording.

(Yaffe et al., 2008)

Treatment Guidelines

(American Medical Association, 1992)

• The EASI questions were derived from multidisciplinary focus groups in which there was very high consensus about which questions to include and how to ask them.
• The questions are easy to understand and are asked directly to potential victims.
• The tool has been tested and adapted for use in different cultural contexts.

-For example, focus groups in Brazil identified culturally specific risk factors for elder abuse, such as having a family member involved in drug dealing.

• The tool is a simple way to familiarize health professionals with elder abuse.
• The tool is written in doctor friendly language and increases their involvement in the detection of elder abuse.
• A post study survey about the use of EASI found that doctors appreciated the tool's suitability for office use, and it's easy and quick administration.

Caregivers and Elder Abuse

Screening (for example use of the EASI tool)

(Yaffe et al., 2008)

Abuse or neglect suspected

Abuse or neglect NOT suspected

• Caregivers who do not want to care but have no other options, or who are experiencing financial burden may be at a greater risk for mistreating a care receiver.

• It has been found that family members who abuse drugs or alcohol, have a mental illness, and who feel burdened by their caregiving responsibilities abuse at higher rates than those who do not (Schiamberge & Gans, 1999).

• Caregiver anxiety, depressive symptoms, social contacts, perceived burden, emotional status, and role limitations due to emotional problems have been associated with the mistreatment of older adults with dementia. (Wigglesworth et al., 2010).

Report to Adult Protective Services

Is there an immediate danger?

Undertake full, private assessment with patient

NO

Caregivers and Elder Abuse

YES

Obstacles

The EASI Tool-Future Directions

Ben Natan, M. & Lowenstein, A. (2010). Study of factors that affect abuse of older people in nursing homes. Nursing Management, 17(8), 20-24.

Bitondo, D.C., Pavlik, V.N., Murphy K.P., & Hyman, D.J. (2000). The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatrics Society, 48, 205-208.

Broyles, K. (2000). The silenced voice speaks out: A study of abuse and neglect of nursing home residents. A report from the Atlanta Long Term Care Ombudsman Program and Atlanta Legal Aid Society to the National Citizens Coalition for Nursing Home Reform. Atlanta, GA: Authors.

Cohen, M. (2011). Screening tools for the identification of elder abuse. Journal of Clinical Outcomes Management, 18(9), 261-270.

Comijs, H.C., Penninx, B.W.J.H., Knipscheer, K.P.M., & van Tilburg, W. (1999). Psychological distress in victims of elder mistreatment: The effects of social support and coping. Journal of Gerontology, 54B(4), 240-245.

Cooney, C., Howard, R., & Lawlor, B. (2006). Abuse of vulnerable people with dementia by their carers: Can we identify those most at risk? International Journal of Geriatric Psychiatry, 21, 564-571.

Cooper, C., Selwood, A., Blanchard, M., Walker, Z., Blizard, G., & Livingston, G. (2009). Abuse of people with dementia by family carers: Representative cross sectional survey. British Medical Journal, 339(7694), 1-5.

Dong, X., Simon, M., Mendes de Leon, C., Fulmer, T., Beck, T., Hebert, L., et al. (2009). Elder self-neglect and abuse and mortality risk in a community-dwelling population. Journal of the American Medical Association, 302(5), 517-526.

Dong, X., Simon M.A., Beck, T., Farran, C., McCann, J., Mendes de Leon, C., et al. (2011). Elder abuse and mortality: The role of psychological and social wellbeing. Gerontology, 57(6), 549-558.

Fulmer, T. (2008). Screening for mistreatment of older adults. American Journal of Nursing, 108, 52-59.

National Elder Abuse Incidence Study. (1998). Washington, DC: National Center on Elder Abuse at American Public Human Services Association.

National Research Council. (2003). Elder mistreatment: Abuse, neglect, and exploitation in an aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect. In Richard J. Bonnie and Robert B. Wallace, Eds. Committee on National Statistics and Committee on Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.

National Seniors Council (2007). Report of the National Seniors Council on Elder Abuse. Retrieved from: http://www.seniorscouncil.gc.ca/eng/research_publications/elder_abuse/2007/hs4_38/hs4_38.pdf

NO

YES

More about abuse

Assessment: Health and performance status, safety, social and financial resources, frequency and severity, cognitive status, emotional status

Create safety plan: hospital admission, court protective order, safe home placement

Discuss safety issues, schedule for full assessment

• As the demands facing caregivers increase, so too does their risk for providing compromised care. (Dooley et al. 2007).

• One study showed that the influences of anxiety, depression, and resentment on quality of care are largely determined by the degree to which caregivers also experience anger

• Caregivers should be periodically assessed for anger, depression and resentment.

• Interventions, such as respite services, anger management training, cognitive reframing for resentment and increasing pleasant events should be provided.

(MacNeil, 2010)

Broad Categories of Elder Abuse

• Doctors may opt to use the tool repetitively as it is quick to administer-this may help gradually desensitize patients that are fearful to disclose abuse.
• Exploration of the feasibility of self-administration of the EASI Tool (for example, in waiting rooms)

(Yaffe et al., 2008)

Screening tools on their own are not enough. Some obstacles that need to be overcome in order to better detect, and intervene in, elder abuse:

• Lack of awareness of the problem
• Insufficient knowledge about how to identify or follow up a potential case of abuse
• Ethical issues
• Time constraints
• Victim’s reluctance to report

(Cohen, 2011; WHO-CIG, 2006)

Reason to believe abuse or neglect

occurred. Plan intervention.

No abuse or neglect found

Collective Abuse

(e.g., Ageism*)

Institutional Abuse

(e.g., Within long term care home settings)

Individual Abuse

(e.g., When a family member, friend, neighbor or caregiver abuses an elderly person in their own home)

*Ageism: Prejudice against a person or group because of one’s age. This can include use of negative stereotypes, reduced access to certain resources etc.

(Payne, 2005)

Payne, B. K. (2005). Crime & elder abuse: An integrated perspective, 2nd edition. Springfield, IL: Chas. C. Thomas Publisher, Ltd.

Pillemer, K. & Suitor, J. (1992). Violence and violent feelings: What causes them among family caregivers? The Journal of Gerontology, 47(4), 5165-5172.

Schiamberg, L. & Gans, D. (1999). An ecological framework for contextual risk factors in elder abuse by adult children. Journal of Elder Abuse & Neglect, 11(1), 79-103.

Sinha, M. & Milligan, S. (2010). Section 4: Family violence against seniors (p.88-96), in Family violence in Canada: A statistical profile. Ottawa: Statistics Canada.

The National Committee on the Prevention of Elder Abuse. Retrieved from http://preventelderabuse.org/elderabuse/

Titterington, V. B. (2010). Elder abuse report. Sam Houston State University: Crime Victims’ Institute & Criminal Justice Center.

University of Toronto (2008). University of Toronto (2008). National Snapshot: Preventing abuse and neglect of older adults in institutions. Retrieved from: http://aging.utoronto.ca/sites/aging.utoronto.ca/files/NationalSnapshot_Full%20Final_2008_1.pdf

Wigglesworth, A., Mosqueda, L., Mulnard, R., et al. (2010). Screening for Abuse and Neglect of People with Dementia. Journal of the American Geriatrics Society, 58(3), 493-500.

World Health Organization. (2002). The Toronto Declaration of the global prevention of elder abuse. Geneva: WHO, INPEA.

World Health Organization (2002). Facts: Abuse of the elderly. Retrieved from: http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/en/elderabusefacts.pdf​

WHO-CIG. (2006). A Global Response to Elder Abuse and Neglect. Building Primary Health Care Capacity to Deal with the Problem World-Wide. Geneva: World Health Organization.

Yaffe, M.J., Wolfson, C., Withwick, M., et al. (2008). Development and validation of a tool to improve physician identification of elder abuse: The Elder Abuse Suspicion Index (EASI). Journal of Elder Abuse and Neglect, 20, 276- 300.

Yan, E., & Kwok, T. (2010). Abuse of older Chinese with dementia by family caregivers: An inquiry into the role of caregiver burden. International Journal of Geriatric Psychiatry, doi:10.1002-gps.2561.

Recommendations

Different forms of abuse

• Education for older adults and caregivers
• Peer and professional counselling for victims and perpetrators of elder abuse
• Training for service providers (how to recognize, prevent and prosecute instances of elder abuse)
• Multi-agency collaborations and the strengthening of a continuum of care.

(Titterington, 2010)

• Physical abuse is physical force that results in bodily injury, pain, or impairment. It includes assault, battery, and inappropriate restraint.

• Sexual abuse is non-consensual sexual contact of any kind with an older person.

• Domestic violence is an escalating pattern of violence by an intimate partner where the violence is used to exercise power and control.

Different forms of abuse

• Psychological abuse is the willful infliction of mental or emotional anguish by threat, humiliation, or other verbal or nonverbal conduct.

• Financial abuse is the illegal or improper use of an older person's funds, property, or resources.

• Neglect is the failure of a caregiver to fulfill his or her care giving responsibilities.

• Self-neglect is failure to provide for one's own essential needs.

(National Elder Abuse Incidence Study, 1998)

Consequences of Abuse

Consequences for victims

• The personal losses associated with abuse can be devastating and include the loss of independence, homes, life savings, health, dignity, and security.

• Elder abuse impacts the quality of life of its victims; they tend to withdraw, feel anxious, insecure, and confused, and can become depressed and neglected.

• Victims of abuse have been shown to have shorter life expectancies than non-abused older people.

• In certain cases the abuse goes so far that its victims resort to suicide.

• Abusers experience consequences such as feelings of guilt and fear, financial loss and possible jail time.

(Dong et al., 2009, 2011; Comijs et al., 1999; Bitondo et al., 2000).

Coordinate approach with Adult Protective Services (or as mandated in your country)

Patient is unwilling to accept voluntary services or lacks capacity to consent

Patient is willing to accept voluntary services

Patient with capacity to decide

Patient without capacity to decide

• Educate patient about the incidence of elder abuse and neglect, and the tendency towards increasing frequency and severity over time
• Implement safety plan (safe home, court protective order, hospital admission)
• Assist to alleviate causes of mistreatment (refer caregiver to rehabilitation or support services, provide education, homemaker services)
• Refer patient and or family members to appropriate services (social work, counselling, legal assistance)

• Educate patient about incidence of elder abuse and neglect, and the tendency towards increasing frequency and severity over time
• Provide written information on emergency numbers and appropriate referrals
• Develop and review safety plan
• Develop a follow-up plan

Discuss with appropriate

authorities the following options:

• Financial management assistance
• Conservatorship or Guardianship
• Special court proceedings (orders of protection)