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Background: There are widespread concerns about abuse of care home residents. We report, in the largest care home survey, prevalence of staff anonymously-reported, perpetrated/witnessed abusive behaviours towards care home residents over 3 months. We also report positive care behaviours., Methods: 1544 staff in 92 English care home units completed the revised Modified Conflict Tactics Scale and Maslach Burnout Inventory., Outcomes: Most staff reported positive care behaviours, but specific person-centred activities were sometimes infrequent. Many care home staff were never or almost never aware of a resident being taken out of the home for their enjoyment (34%, n = 520); or an activity planned around a resident's interests (15%, n = 234). 763 (51%; 95% Confidence Interval (CI) 47% to 54%) of care home staff reported carrying out or observing potentially abusive or neglectful behaviours at least sometimes in the preceding 3 months; some abuse was reported as happening "at least sometimes" in 91/92 care homes. Neglect was most frequently reported: making a resident wait for care (n = 399, 26%), avoiding a resident with challenging behaviour (n = 391, 25%), giving residents insufficient time for food (n = 297, 19%), and taking insufficient care when moving residents (n = 169, 11%). 1.1% of staff reported physical and 5% verbal abuse. More staff reported abusive/neglectful behaviour in homes with higher staff burnout-depersonalisation scores (adjusted odds ratio 1.191, CI 1.052-1.349)., Interpretation: Staff anonymous reports of abusive behaviour and neglect could be used to monitor care quality, as cases currently reported are probably tip of the iceberg, and be an outcome in intervention studies.

Background: Family carers of people with dementia frequently report acting abusively toward them and carer psychological morbidity predicts this. We investigated whether START (STrAtegies for RelaTives), a psychological intervention which reduces depression and anxiety in family carers also reduces abusive behavior in carers of people living in their own homes. We also explored the longitudinal course of carer abusive behavior over two year., Methods: We included self-identified family carers who gave support at least weekly to people with dementia referred in the previous year to three UK mental health services and a neurological dementia service. We randomly assigned these carers to START, an eight-session, manual-based coping intervention, or treatment as usual (TAU). Carer abusive behavior (Modified Conflict Tactic Scale (MCTS) score ≥2 representing significant abuse) was assessed at baseline, 4, 8, 12, and 24 months., Results: We recruited 260 carers, 173 to START and 87 to TAU. There was no evidence that abusive behavior levels differed between randomization groups or changed over time. A quarter of carers still reported significant abuse after two years, but those not acting abusively at baseline did not become abusive., Conclusion: There was no evidence that START, which reduced carer anxiety and depression, reduced carer abusive behavior. For ethical reasons, we frequently intervened to manage concerning abuse reported in both groups, which may have disguised an intervention effect. Future dementia research should include elder abuse as an outcome, and consider carefully how to manage detected abuse.

Elder abuse may be defined as a violation of a vulnerable older person's human and civil rights. Psychiatric illness is an important cause of vulnerability to abuse, especially when it is comorbid with other risk factors, such as physical frailty, sensory impairment, social isolation, and physical dependency. Health care providers are likely to encounter elder abuse regularly, and therefore have an important role in its detection and management, and in the treatment of subsequent psychiatric illness. This article reviews the relationships between psychiatric illnesses and elder abuse and neglect, examines the psychiatric consequences, and discusses how these may be treated., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Elder abuse in care homes is probably common but inherently difficult to detect. We developed the first questionnaire to ask care home workers to report abuse anonymously., Method: We held qualitative focus groups with 36 care workers from four London care homes, asking about abuse they had witnessed or perpetrated., Results: The participants reported that situations with potentially abusive consequences were a common occurrence, but deliberate abuse was rare. Residents waited too long for personal care, or were denied care they needed to ensure they had enough to eat, were moved safely, or were not emotionally neglected. Some care workers acted in potentially abusive ways because they did not know of a better strategy or understand the resident's illness; care workers made threats to coerce residents to accept care, or restrained them; a resident at high risk of falls was required to walk as care workers thought otherwise he would forget the skill. Most care workers said that they would be willing to report abuse anonymously. Care workers were sent the newly developed Care Home Conflict Scale to comment on but not to complete and to report whether it was acceptable and relevant to them. Several completed it and reported abusive behavior., Conclusion: Lack of resources, especially care worker time and knowledge about managing challenging behavior and dementia were judged to underlie much of the abuse described. We describe the first instrument designed to measure abuse by care home workers anonymously; field-testing is the logical next step.

Aim: This study aimed to compare perceptions about elder abuse among health professionals and students in the same health disciplines., Methods: The Caregiving Scenario Questionnaire (CSQ) was disseminated to Australian health professionals from two metropolitan health services and to university health care students., Results: One hundred and twenty health professionals and 127 students returned surveys. Significantly more students than health professionals identified locking someone in the house alone all day and restraining someone in a chair as abusive., Conclusion: There is a need for further definition clarification and education about detection and management of elder abuse for health students and professionals in Australia. Student education should include consideration of the real-life situations likely to be encountered in practice. Education for both students and health professionals should include strategies for carers to manage difficult situations such as the one described in the CSQ., (© 2013 The Authors. Australasian Journal on Ageing © 2013 ACOTA.)

Background: Elder abuse is often unreported, undetected, and underestimated by professionals. For the first time, we report the effectiveness of an educational elder abuse intervention over three months and its impact on professionals' practice., Methods: Forty trainee psychiatrists in two London National Health Service trusts completed the KAMA (Knowledge and Management of Elder Abuse) and CSQ (Caregiver Scenario Questionnaire) measuring knowledge about managing and detecting elder abuse, before and immediately after a brief group education session. We asked how often they considered, asked about, detected, and managed elder abuse and their confidence in doing so, at baseline and three months post-intervention., Results: Compared with baseline, participants scored higher on the KAMA (paired t = 3.4, p = 0.002), and identified more definitely abusive (t = 3.0, p = 0.003) and possibly abusive (t = 2.1, p = 0.043) items immediately post-intervention. At three-month follow up, 24 (60%) participants reported higher confidence in managing abuse (Wilcoxon signed ranks test z = 3.7, p < 0.001) and considered it more frequently (z = 2.8, p = 0.006), but did not ask older people and their carers about abuse more frequently (z = 1.2, p = 0.24). Two (5%, 95% confidence interval 2%-17%) participants detected abuse in the three months before the intervention, compared with 2 (8%, 2%-26%) in the same period afterward., Conclusions: This brief educational intervention increased trainee psychiatrists' knowledge and vigilance for abuse immediately and after three months. They remained reluctant to ask about abuse for reasons including fear of causing offence or harming the therapeutic relationship and being unsure how to ask people with dementia. We postulate that changing doctors' behavior may require a more complex intervention, focusing on communication skills.

Background: A third of family carers of people with dementia report abusive behaviour towards the person for whom they are caring. This is the first longitudinal study to investigate such behaviour., Aims: To test our hypotheses that carers' reports of abusive behaviour would increase over time, and that change in abuse scores would be predicted by change in anxiety and depression scores., Method: In total, 131 (71.6%) of the family/friend dementia carers consecutively recruited from new referrals to Essex and London community mental health teams who were interviewed at baseline, completed the revised Modified Conflict Tactics Scale to measure abuse 1 year later., Results: Sixty-three (48.1%) of the carers reported any abusive behaviour at baseline compared with 81 (61.8%) a year later (chi(2) = 6.9, P = 0.009). An increase in abuse scores was predicted by an increase in anxiety and depressive symptoms (respectively beta = 0.32, t = 3.9, P<0.001 and beta = 0.24, t = 2.9, P = 0.005), and by less domiciliary care at baseline (beta = -0.18, t = -2.2, P = 0.031)., Conclusions: Most abusive behaviour reported by carers at baseline persisted or worsened in the following year, despite contact with specialist services. We suggest that trials of psychological interventions shown to reduce anxiety and depression in the carers of people with dementia are needed to determine whether they also reduce elder abuse, and can be delivered cost-effectively within the National Health Service (NHS).

Background: No previous studies have considered elder abuse in Eastern Europe. We aimed to determine the proportion of home care workers and older people receiving care in a Romanian home care service who correctly identified elder abuse in a vignette, and who had detected elder abuse at work., Methods: In 2009, care workers and clients of a non-government home care organization serving four areas in Romania completed the Caregiver Scenario Questionnaire to measure ability to identify abuse. We asked the professionals whether they had detected a case of abuse., Results: 35 (100%) professionals and 79 (65.8%) older people took part. Four (11.4%) professionals had encountered a case of elder abuse, two (5.7%) in the last year. No staff and only one older person correctly identified all four abusive strategies in a vignette. Staff with more professional caregiving experience recognized fewer abusive strategies (r = -0.46, p = 0.007)., Conclusion: Rates of identification were worryingly low among all professionals, and this was more marked if they had worked longer, suggesting their experiences may have reduced their ability to detect it. Mandatory abuse training for care professionals, and strategies to support reporters of suspected abuse, could help improve the management of elder abuse in all countries.

The authors systematically reviewed the 32 articles fitting predetermined criteria that investigated health and social care professionals' knowledge, detection, and reporting of elder abuse. These included 21 surveys (of 5,325 professionals), nine analyses of elder abuse reports to statutory bodies, and two intervention studies. Compatible results were pooled in a meta-analysis. Professionals consistently underestimated the prevalence of elder abuse. Only a quarter of U.S. physicians were aware of American Medical Association elder abuse guidelines. The authors found that 33.7% (95% confidence interval: 27.5-40.1) of health care professionals had detected a case of older adult abuse in the last year. This was slightly higher when only studies judged to be most representative, which all surveyed physicians, were included (39.9% [23.4-57.7]). About half of the detected abuse cases were reported. Professionals who recalled receiving any training on abuse were no more likely to detect abuse than those who stated they had not had training, although they were more likely to report the abuse if they detected it. Interventions that taught professionals about the management of abuse by face-to-face training were effective in increasing knowledge, whereas giving written information was not. No intervention studies have investigated whether detection and reporting of abuse can also be increased through education. Current evidence would support the development and testing of interventions to increase professionals' detection and reporting of abuse. These would encourage them to ask older people about abuse, and address professionals' concerns about the impact of reporting on therapeutic relationships, victims; and legal consequences for the reporter.

Background: A third of family carers of people with dementia describe acting abusively in research studies, but far fewer cases of abuse are currently detected in clinical situations. This discrepancy may be explained by inadequate detection by health professionals, or disagreement regarding what constitutes elder abuse. This study was undertaken to determine the sensitivity and specificity of the revised Modified Conflict Tactics Scale (MCTS) for detecting clinically significant abuse., Methods: We interviewed 220 family carers of people consecutively referred to psychiatric services with dementia in Essex and London (U.K.), using the MCTS to measure abuse. We defined abuse cases using (1) the MCTS conventional scoring system; (2) the Pillemer criteria; and (3) clinical judgment of an expert panel., Results: Our panel judged that 15 (6.8%) of carers reported potentially clinical concerning abusive behavior; but 47 (21%) were cases according to the Pillemer criteria and 74 (34%) using the MCTS conventional scoring system. We developed a weighted MCTS scoring system, with high sensitivity and specificity for detecting clinically concerning abuse., Conclusions: The MCTS could be used routinely in clinical practice with carers of people with dementia to detect clinically concerning cases of abuse, many of which are currently being missed.

Objectives: To determine the proportion of fourth-year medical students who correctly recognise abusive and not abusive care of older people and whether recognition is related to sociodemographic factors and education., Design: A cross-sectional self-report questionnaire study, using the Caregiving Scenario Questionnaire; measuring recognition of elder abuse according to the Department of Health's definition., Participants: Fourth-year medical students at University College London and the University of Birmingham, UK., Results: Two hundred and two of 207 students (97.6%) responded. Twenty-nine of 201 (14.4%) identified accepting someone was not clean; 113/200 (56.5%) locking someone in alone; and 160/200 (80.0%) trapping someone in an armchair as abusive. All medical students correctly identified four out of five not abusive responses. Twelve (6.0%) incorrectly identified camouflaging the door to prevent wandering as abusive. Logistic regression analysis found the independent predictors of recognising that locking in alone was abusive were working as a professional carer (OR = 3.33, 95% CI = 1.25-8.89, p < 0.05) and reporting being taught to look for elder abuse (OR = 0.46, 95% CI = 0.24-0.89, p < 0.05). Similarly, the independent predictors of recognising that restraint in an armchair was abusive were attending university A versus university B (OR = 2.38, 95% CI = 1.09-5.26, p < 0.05); being of White British versus Asian ethnicity (OR = 4.00, 95% CI = 1.75-9.09, p < 0.01)., Conclusions: Medical students are good at recognising not abusive care, but not as successful at recognising elder abuse. Working as a professional carer was associated with better recognition of abuse, while personal contact with a person with dementia and recalling formal education about abuse were not.

Background: A third of family members caring for people with dementia report acting abusively towards them, but there are currently no evidence-based interventions to reduce or prevent such behavior. Family carers who act abusively have not previously been consulted about what may help to reduce abuse., Method: We prospectively recruited a consecutive sample of 220 family carers of people with dementia referred to secondary psychiatric services. We asked carers who reported any abusive behavior in the previous three months to select from a list of services and potential interventions those that they thought might help to reduce or prevent this abusive behavior. Carers were also asked to suggest other interventions that might help prevent abuse., Results: 113/115 carers who reported any abusive behavior answered questions about possible interventions. The three most frequently endorsed interventions were: medication to help the care recipient's memory (n = 54; 48.2%); written advice on understanding memory problems and what to do (n = 48; 42.9%) and more information from professionals caring for the person with dementia (n = 45; 40.2%). When asked which interventions were most important, medication to help memory (n = 21; 18.6%), home care (n = 17; 15.0%), residential respite and sitting services (both n = 12; 10.6%) were most frequently endorsed., Conclusion: To prevent abuse, family carers prioritized medication for memory, good communication from professionals, written advice on memory problems, home care, residential respite and sitting services. As no interventions to reduce abuse by family carers have yet been formally evaluated, a good starting point may be the expressed wishes of family carers.

Objective: To determine the prevalence of abusive behaviours by family carers of people with dementia., Design: Representative cross sectional survey, Setting: Community mental health teams in Essex and London., Participants: 220 family carers of people newly referred to secondary psychiatric services with dementia who were living at home., Main Outcome Measure: Psychological and physical abuse (revised modified conflict tactics scale)., Results: 115 (52%, 95% confidence interval 46% to 59%) carers reported some abusive behaviour and 74 (34%, 27% to 40%) reported important levels of abuse. Verbal abuse was most commonly reported. Only three (1.4%) carers reported occasional physical abuse., Conclusions: Abusive behaviour by family carers towards people with dementia is common, with a third reporting important levels of abuse and half some abusive behaviour. We found few cases of physical or frequent abuse, although those with the most abusive behaviour may have been reluctant to report it.

Background: Several studies have investigated abusive behaviour by carers towards people with dementia, most using unvalidated scales; only two reported correlates of abuse after controlling for mediators and confounders, and these controlled for different factors., Objective: To investigate the acceptability and validity of the Modified Conflict Tactics Scale (MCTS) and abuse correlates., Methods: Eighty-six people with Alzheimer's disease and their family carers, originally recruited for a representative community study were interviewed. We asked carers about acceptability of the MCTS and investigated its validity by comparing scores to the Minimum Data Set (MDS) abuse screen (an objective measure) and testing hypotheses that MCTS score would correlate with the COPE dysfunctional coping scale but not carer education., Results: Twenty-four (27.9%) were identified as abuse cases by interview. No care recipients (CRs) screened positive for abuse using the MDS screen. Seventy-two (83.7%) participants thought that the scale was acceptable, ten (11.6%) that it was neither acceptable nor unacceptable, and three (3.5%) that it was unacceptable. As hypothesised, MCTS scores correlated with dysfunctional coping scale score but not carer education., Conclusions: This is the most comprehensive study so far in this field. The MCTS was acceptable and had convergent and discriminant validity for measuring carer abuse. The MDS failed to identify cases of abuse. Carer male gender and burden, and greater CR irritability, cognitive impairment but less functional impairment predicted carer abusive behaviour. Our findings appear to refute UK government elder abuse reduction policy which assumes that few incidents of abuse arise from carer stress.

Objective: to perform a systematic review of studies measuring the prevalence of elder abuse or neglect, either reported by older people themselves, or family and professional caregivers or investigated using objective measures., Methods: we conducted a comprehensive literature search of multiple databases up to October 2006, supplemented by a search of the references of all relevant articles. Validity of studies was graded by two authors independently using a standardised checklist., Results: forty-nine studies met our inclusion criteria, of which only seven used measures for which reliability and validity had been assessed. In the general population studies, 6% of older people reported significant abuse in the last month and 5.6% of couples reported physical violence in their relationship in the last year. In studies using valid instruments involving vulnerable elders, nearly a quarter reported significant levels of psychological abuse. Five per cent of family caregivers reported physical abuse towards care recipients with dementia in a year, and a third reported any significant abuse. Sixteen per cent of care home staff admitted significant psychological abuse. Rates of abuse recorded using objective measures (5%) or reported to home management or adult protective services (APS) (1-2%) were low., Conclusion: one in four vulnerable elders are at risk of abuse and only a small proportion of this is currently detected. Elders and family and professional caregivers are willing to report abuse and should be asked about it routinely. Valid, reliable measures and consensus on what constitutes an adequate standard for validity of abuse measures are needed.

Objectives: To test the hypothesis that family and professional caregivers have different views about what constitutes elder abuse., Design: A vignette was given to family and professional carers. They were asked to rate 13 management strategies for behavioural difficulties in a person with dementia on a Likert scale ranging from good idea to abusive. Some of the strategies were abusive according to the Department of Health's 'No Secrets' definition., Setting and Participants: Family carers were recruited as part of a study of Alzheimer's disease. We recruited professionals working in several clinical disciplines and settings from a mental health service for older people., Results: Seventy-four family and 38 professional carers completed questionnaires. The only abusive strategy that significantly more professionals than family carers identified correctly was preventing someone moving by putting a table over their lap (33(86.8%) vs 35(47.3%), p < 0.0005). In contrast, significantly more family carers identified that the neglect item of accepting someone was not clean was abusive (21(28.4%) vs 3(7.9%), p = 0.009)., Conclusions: Professionals and carers reported significantly different views from each other and guidelines about what constituted elder abuse. This may be because abuse remains unacknowledged if people feel there are no better management options, and reporting leads only to punitive action for the carer perhaps coupled with institutionalisation for the person with dementia. Successful guidelines require societal agreement about what constitutes abuse and that prevention leads to better outcomes., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

Objective: The objective of this study was to determine crossnationally the prevalence of indicators of elder abuse and their relationship to putative risk factors, particularly depression, dementia, and lack of service provision., Method: Nearly 4,000 people aged 65+ receiving health or social community services in 11 European countries were interviewed using the minimum dataset homecare (MDS-HC) interview, which includes an abuse screen used previously in elder abuse studies and questions about demographic, physical, psychiatric, cognitive, and service factors., Results: One hundred seventy-nine (4.6%) people assessed had at least one indicator of abuse. The proportion screening positive increased with severity of cognitive impairment, presence of depression, delusions, pressure ulcers, actively resisting care, less informal care, expressed conflict with family or friends, or living in Italy or Germany, but not with having a known psychiatric diagnosis., Conclusion: Severity of cognitive impairment, depression, and delusions predicted screening positive for abuse in older adults, but having a known psychiatric diagnosis did not, indicating that screening for psychiatric morbidity might be rational strategies to combat elder abuse. People in Italy and Germany were most likely to screen positive for indicators of abuse, and the authors suggest that this might relate to higher levels of dependency in the participants looked after at home in these countries as a result of cultural and service provision differences.

Objective: to develop and validate an instrument which measures applied knowledge and practice regarding identification and management of potentially abusive situations in staff who work with older vulnerable inpatients. One of the anticipated uses will be to measure any change produced by attending an educational intervention designed to improve management of abuse. A vignette-based instrument was chosen to measure applied knowledge and practice over other methods of assessments which were felt not to be practical or provide too much cueing for the volunteering staff., Method: a parallel form vignette-based instrument was developed so that not only baseline knowledge but also change in knowledge could be measured. Abusive scenarios were adapted from researchers' clinical practice and from the literature. Advice from senior nurses about the suitability of the vignettes for ward and community based staff was obtained and the instrument was piloted. Staff working with older people and employed by health or social services working in inner London completed the questionnaire., Results: 79 (92%) of the eligible staff took part in this study. All completed the instrument. Version A of the Knowledge and Management instrument was answered by 39 staff, whilst 40 answered version B. The proportion of qualified and unqualified staff as well as the proportion employed by health or social services was similar for each parallel version of the instrument. The measure of internal consistency Cronbach's alpha was 0.89 for version A and 0.79 for version B. Parallel form reliability coefficient was calculated as 0.82, indicating that the two versions of the Knowledge and Management instrument perform similarly. Measures for concurrent validity according to years of experience and professional education also proved significant. Inter-rater reliability was calculated at 0.98 (P=0.01). Test-retest reliability at 0.69 (P=0.01) indicated that the instrument is stable yet sensitive to change., Conclusion: this instrument is a valid assessment tool that can be used to identify gaps in applied knowledge and management in potentially abusive situations in older people and allow knowledge in this field to be built on.

Background: Abuse of older adults may occur to a disproportionate extent in institutions. Lack of familiarity with protocols when managing abuse once it occurs is one of the reasons why it persists. Educational interventions are one of the ways to improve knowledge and management in this area., Objective: To compare the effectiveness of attending an educational course (Group 1) to printed educational material (Group 2) in improving management of abuse of older people. To determine if positive attitude and low burnout scores are related to improvement., Design: Randomized controlled trial., Setting: North London, UK., Subjects: Nurses, care assistants and social workers working with older people., Methods: Staff answered questionnaires pre- and post-intervention., Results: The study was completed by 64 (81%) of staff. Baseline scores on knowledge and management abusive scenarios were low. Those randomized to Group 1 improved after intervention and Group 2 deteriorated (Group 1=3.7 [standard deviation=8.1], ANOVA F=23.0; P=0.0001 and Group 2=-2.9 [standard deviation=10.0]). There was a ceiling effect with those who knew more learning less. The significant independent variables in regression analysis to predict learning were being randomized to Group 1 (P=0.003; odds ratio=6.8; 95% confidence interval=1.9-24.5) and low baseline knowledge and management score, (P=0.015, odds ratio=4.8, confidence interval=1.4-16.9). Most staff had a positive attitude towards people with dementia; positive attitude score correlated with baseline knowledge, but did not predict learning., Conclusion: Identifying, documenting and reporting abuse of older people is not carried out consistently. Whilst an educational course goes some way in improving this, it needs to be targeted to take into account the baseline knowledge.

If you suspected that an elderly patient had been abused, would you know what action to take? If you witnessed abuse by a colleague, how would you react? A study investigating nurses' reactions to such scenarios revealed that many were unsure how to proceed and worried about the repercussions. This paper looks at reasons why abuse may not be reported.