Effects of changing criteria on improving interRAI assessment for elder abuse: analysis of a national dataset from Aotearoa New Zealand

Discussion

EA has been a worldwide major public health threat for decades, yet it remains a form of victimisation receiving limited attention, resources and research. EA has far-reaching and long-lasting impacts on older adults, their families and communities. By 2030, one in six people worldwide will be aged 60 or older, and approximately 16% will experience at least one form of maltreatment.25 A recent review aiming to describe the status of EA prevention research on a global scale identified 72 articles published in the last 6 years. Several gaps were identified by the authors in the EA literature including the need for sensitive and valid tools to identify EA.4 These reports serve to support a call for health professionals to serve a very critical role in recognising, detecting and managing EA and it is recommended that guidelines for the detection and treatment of abuse and neglect be prepared and implemented.26 Despite these critically important recommendations, the last decade saw only 18 controlled trials focusing on identifying and preventing EA. Only one of these clinical trials attempted to implement a screening tool for EA.27

In this study, we were able to validate our previous pilot study and to establish that changing the interRAI criteria can increase older adults at risk of EA identification rates. We found similarities between the UDA group and the A-CAP group compared with the general sample. The A-CAP and UDA groups tended to include people who were younger, had higher rates of depression and were less likely to be assessed as living independently than the general sample. The A-CAP group was more likely to live alone but interestingly the UDA group was less likely to live alone. It is unclear whether this reflects the UDA identifying those people who were at higher risk of abuse but living in different settings to those in the A-CAP group or if there is some confounding with other factors, as this result weakened when confounders were included in the statistical model.

Some studies indicate higher rates of EA in ethnic and racial minority populations. A systematic review with 25 included studies focused on 5 racial categories in the USA and racial minorities in Canada. The review identified a lack of current research on EA in racial minority older women and race minority subgroups.28 Yet EA is increasingly identified as a serious problem in Native American communities, Australian Aborigines,29 Chinese minorities30 and Canadian Inuits and immigrant communities.31 In New Zealand, an EA intervention with tribal communities was founded in 2007 to try and address EA in the Māori communities. It is based on a family conference intervention developed by the Māori people of New Zealand, who determined that Western European ways of working with welfare issues were undermining such family values as the definition and meaning of family, the importance of spirituality, the use of ritual and the value of non-interference. The Family Care Conference provides the opportunity for family members to come together to discuss and develop a plan for the well-being of their elders.32 In this study, we have found that older Māori people are at a higher risk of potentially being abused as captured by the UDA and A-CAP while Asian New Zealanders are more likely to be captured at a higher risk of potentially being abused by the UDA inclusion but not by the A-CAP. This finding is concerning as it reflects the relative insensitivity of the interRAI identification of abuse to cultural and ethnic differences. On the other hand, we are encouraged that the use of both A-CAP and the UDA while tapping into similar aspects of the abuse variables are still capturing different people potentially casting a net more sensitive to ethnic differences.

EA has been recognised as a serious problem for decades.33 Yet rigorous studies are rare. Unfortunately, EA research has largely lacked the resources required to conduct the range of well-designed studies needed to obtain a clear picture of the problem and how to address it. One of the important recent attempts to overcome some of the major flaws of past studies is the use of a large, over 23 000 participants, representative dataset from the Canadian Longitudinal Study on Aging, to examine annual EA prevalence, as well as risk and protective factors. They found an annual rate of EA of 10% and reinforced findings from previous work that being physically, cognitively and or emotionally vulnerable increases the risk for EA.34 In many ways, the findings of this study come to a similar inference.

There are limitations to this study that need to be acknowledged. This is a retrospective analysis of a cross-sectional dataset. There is no external validation of EA possible with the methodology herein applied. Thus, the objective capture of EA is not completed by an external source. Future studies will need to design a validation procedure to capture cases of EA and not those ‘…at high risk of abuse…’. This is in line with a recent attempt to map assessment tools for EA and determine their psychometric properties. However, this study showed psychometric limitation since the internal structure of the 17 scales examined was not evaluated by validity evidences.35 The interRAI-HC recognises that it is ‘…difficult to assess the extent of financial abuse in the absence of detailed information on financial resources… and that not all economic trade-offs are due to abuse…’.36 Finally, the interRAI-HC assessment was not designed to capture EA and indeed lacks sensitivity.

In an ideal world, we would have validated external measures of who was a victim of EA and who was not that we could compare these rules to. But there is no such absolute measure, if it did that is the analysis we would have done. There is no external standard that can be applied. The A-CAP appears to be highly insensitive, flagging a very small percentage of what we would expect based on the literature around EA. The UDA is an attempt to capture more potential cases in the absences of any ‘gold-standard’ measure. Without this external measure, we are left comparing the characteristics of the people identified to see if there is face validity to this approach and we would argue that there is strong face validity based on the characteristics of who the UDA captures. Given the percentage is still well under what we expect the real rate to be then changing thresholds will not help as we have used the most sensitive threshold possible by including any UDA, we are still well under what we expect the true EA rate to be.

We are also undertaking work to see if we can compare other health measures that may give insight into who is captured by this approach, however, this falls outside the scope of this paper and is an ongoing area of research.

In conclusion, most variables and indicators of EA analysed in this study show a similar pattern for UDA and the A-CAP. We suggest that increasing the capture rate of older adults at risk of EA by the interRAI through incorporation of the UDA cohort into the ‘…at a higher risk of potentially being abused…’ is an important step in improving suspicion of EA in a large number of vulnerable older adults. We call for further studies testing this strategy in countries using the interRAI.