NIJ - National Institute of Justice

01/15/2025 | Press release | Distributed by Public on 01/15/2025 08:36

Studies of Mistreatment of Older Adults Offer Solutions to an Urgent and Growing Societal Problem

Mistreatment of older persons - acts of physical, psychological, financial, and sexual harm or neglect - affects an estimated one in every 10 individuals age 60 or older each year - more than 7 million Americans.[1] Many older adults are reluctant to report mistreatment to authorities, and some lack the capacity to do so due to cognitive decline. As a result, the reported incidence of abuse understates the true extent of the problem.[2]

Cases of mistreatment of older adults have risen over the past two decades and are expected to increase as the population of individuals over 60 grows.[3] The COVID-19 pandemic highlighted the vulnerabilities of older adults, including around mistreatment. COVID disproportionately affected older adults, both directly through illness and mortality and indirectly through COVID-related financial fraud, limits on social interaction, and daily inconveniences.[4] Research also suggests that mistreatment of older adults increased during the pandemic.[5]

Although much is known about different forms of abuse of older individuals - physical, verbal, emotional, sexual, and financial - much remains to be done to understand effective prevention strategies and tools.

An essential first step toward prevention solutions is adequate, evidence-driven research. Science has lagged well behind need, with a notable absence of research on programmatic solutions and rigorous evaluations to gauge their effectiveness.[6]

The pandemic also obstructed the search for solutions. COVID-19 impeded data collection for studies on abuse of older adults and many other subject areas even as the disease disproportionately affected older individuals. Eighty percent of global COVID-related deaths between 2020 and 2021 occurred among people age 60 and older, according to data published by the World Health Organization.[7]

However, preliminary findings from two recent research initiatives supported by the National Institute of Justice (NIJ) reveal opportunities for new program frameworks to prevent abuse of older adults. The two programs, COACH and EMPOWER, deliver interventions to help older adults still living in the community - in their homes - rather than in a senior facility or other institutionalized setting. Both studies used randomized controlled trials, a rigorous method of measuring the impact of a treatment by comparing the outcomes for a group that receives treatment against an equivalent group that does not (the control group). The study randomly assigns people to each group.

Despite pandemic disruptions in the studies, the researchers found that both EMPOWER and COACH delivered significant specific benefits for participants.

The power of both programs is the complementary nature of their approaches to prevention, said EMPOWER project consultant Shelly L. Jackson of the Elder Justice Initiative at the U.S. Department of Justice.[8] EMPOWER targeted older adults who live alone, while COACH participants were caregivers of older adults who received resources and support that indirectly benefited older adults. Consistent with a public health approach, Jackson added, each program addressed underlying risk factors believed to contribute to forms of abuse of older people.

COACH and EMPOWER impart prevention education that clients could use to avoid - or at least mitigate the effects of - abusive treatment, and the researchers suggest how these solutions could be refined and more widely applied.

This article summarizes the two programs and discusses their limitations and implications for broader use in larger, more diverse populations.

EMPOWER - Building Late-Life Resilience

Researchers from the Urban Institute and practitioners from the Phoenix-based Area Agency on Aging, Region One, implemented the NIJ-funded demonstration project EMPOWER from 2017 to 2021.[9] The organizations co-developed and piloted an abuse prevention demonstration in Maricopa County, Arizona. The Urban team then preliminarily evaluated the pilot's effectiveness through a randomized controlled trial.

The EMPOWER program's theoretical framework recognizes that many types of mistreatment of older adults are beyond the individual victim's control. EMPOWER focused on the controllable factors that help older adults with safe and healthy aging. EMPOWER sought to strengthen participants' knowledge of community resources and social supports, motivation to adapt to age-related changes, and life skills that facilitate self-empowerment.

The collaborating entities designed EMPOWER as a 12-week home intervention featuring one-hour weekly visits by experienced facilitators, initially intended to be delivered in person. The intervention consisted of a series of one-on-one assessments, client-centered prevention education, and needs-responsive life-skills training delivered through cognitive reframing conversations. Participants were age 60 and older and lived alone.

The EMPOWER study assessed the short-term outcomes associated with late-life resilience by comparing adults who were randomly assigned to receive EMPOWER with those in the control group. The primary data sources were surveys and interviews with treatment and control participants as well as information from program facilitators.

COVID compelled the program to be delivered over the telephone or by videoconferencing when in-person engagement was not possible. The pandemic also led to a compressed study time frame, allowing data measurement at only two points: pre-test and post-test approximately four months later. The study could not assess longer-term outcomes following program completion.

The project team recruited eligible participants from the Area Agency's list of people waiting for services to support independent living. Participants' ages ranged from 60 to 96, with an average age of 73. More than 90% reported annual incomes of $20,000 or less.

Two fundamental research questions guided the EMPOWER study:

  • How well was the EMPOWER program implemented in terms of providers' fidelity to the intervention model?
  • Did participants assigned to EMPOWER show short-term gains in late-life resilience outcomes?

Implementation Evaluation Findings

Seventy-nine percent of EMPOWER participants (74 out of 94) completed the program. Facilitators conducted an average of 10 in-home, telephone, or videoconferencing sessions per participant over an 11-week period.

Post-test surveys found that most participants who completed the program reported they were satisfied with it. A large majority of participants who completed the program strongly agreed that the EMPOWER facilitator:

  • Treated them with respect (96%).
  • Fostered a safe and trusting environment (96%).
  • Made them feel comfortable sharing thoughts and questions (88%).
  • Understood their problems and concerns (85%).

Nearly all other subjects agreed with those statements, but not strongly.

Most participants who completed the program also agreed or strongly agreed the program content had the following positive results:

  • Made them more aware of personal strengths (93%).
  • Improved their ability to solve problems in their lives (84%).
  • Improved their ability to accomplish goals (85%).
  • Made them aware of social relationships they should be cautious about (80%).

EMPOWER staff had similar positive feelings about the program and perceived that the clients' greatest program benefits came from discussions of home safety, physical health, and financial well-being.

Outcome Evaluation Findings

The researchers examined whether the program improved late-life resilience outcomes - strengths and protective factors necessary to respond to and overcome adversity as well as support safe and healthy aging - that may protect against abuse. They found that following program participation, study participants assigned to the EMPOWER treatment group scored significantly higher than those assigned to the control group for outcomes related to knowledge and attitudes about home safety, physical health, financial well-being, and social support.

The researchers noted that changes in behaviors, connections, and experiences - as opposed to knowledge or attitudes - showed no statistically significant treatment effects. Given the study's short time frame, the researchers observed that resilience impacts related to participants' knowledge and attitudes might have been the most realistic result they could expect.

COACH - Comprehensive Older Adult and Caregiver Help

For the COACH study, researchers from the University of Southern California collaborated with practitioners from the Los Angeles Medical Center, a Kaiser Permanente facility near downtown Los Angeles. The medical center serves more than 235,000 people age 65 and older each year.[10]

The research team systematically reviewed prior research, which revealed a need to vastly expand research on mistreatment of older adults.

Project Goal: To Pilot and Evaluate an Intervention on Mistreatment of Older Adults

The COACH program was designed based on the observation that many of the risk factors experienced by victims of child maltreatment and intimate partner violence are similar to those associated with the mistreatment of older adults. These shared risk factors suggest that similar prevention interventions that work for those at risk of child maltreatment and intimate partner violence could hold promise for older adults. Such interventions include educating caregivers, providing education about risk, and comprehensively assessing needs, care planning, and support.

Like EMPOWER, the COACH program was a pilot project that used a randomized controlled trial research design and an evidence-informed prevention program developed over a 24-month planning phase. Prevention included both primary prevention (defined as keeping participants who were not experiencing mistreatment at the start of the study free from mistreatment) and secondary or tertiary prevention (defined as reducing the occurrence or severity of mistreatment in those who were experiencing mistreatment at the start of the study).

Intervention

The original COACH program intervention offered three to 12 in-home visits by a professional care coach. The home visits were designed to provide education, skill building, and links to additional support consistent with elements of healthy caregiving. The tools and strategies came from an eight-component toolkit shown to support caregivers of older people.

COACH recruited participants from Kaiser Permanente patients treated at the medical center. Researchers identified pairs of caregivers and care recipients. The recipients were age 65 or older, with care provided primarily by a family member or friend who either lived with the recipient or provided in-home care multiple times a week. The program called for caregivers to complete three surveys: a baseline pre-test, a follow-up at the end of the intervention, and a second follow-up three months later.

The program began in February 2020, but within a month it needed to be revamped following the onset of COVID-19. The researchers reported that data collection was done by paper-and-pencil assessments or phone interviews, and the COACH interventions were done by phone.

Clinicians initially referred 636 caregivers of older adults to the Kaiser Permanente research division. Of those, Kaiser Permanente referred 110 caregivers who met initial screening criteria to the study team; 92 met all inclusion criteria. Eighty individuals from that group took part in a baseline survey, with 40 each in the treatment and control groups. In the end, a total of 55 caregivers completed a three-month follow-up survey: 27 in the treatment group and 28 in the control group.

Results and Findings

At the end of the intervention and at the three-month follow-up, the evaluations measured whether caregivers in the treatment or control groups experienced:

  • Lower self-reported elder mistreatment of the care recipients.
  • Higher self-rated quality of life of the care recipient in four domains: physical, social, psychological, and environmental.
  • Lower caregiver burden.

Three months following the COACH intervention a significant difference in mistreatment emerged between the treatment and control groups. Mistreatment among the treatment group three months after completing the program was 0.0% compared to 22.5% mistreatment of that group at the start of the study (baseline). In contrast, the control group was measured at 23.1% mistreatment after three months. At the program's start, 15.4% of the control group reported mistreatment.

Caregiver social quality of life significantly increased in the treatment group from baseline to post-test (i.e., program completion) and again from post-test to three-month follow-up. Although the social quality of life was significantly higher for the treatment group than for the control group at post-test, the difference between treatment and control was no longer significant at the three-month follow-up.

With respect to the caregiver burden factor, the researchers found no significant difference between the COACH treatment and control groups.

Limitations

The COVID-19 pandemic required the in-home, face-to-face COACH interventions - which were painstakingly developed from research evidence on other forms of family violence - to be replaced by phone contacts. The pandemic also greatly reduced study sample size, which limited the study's ability to detect changes.

In the EMPOWER project, the pandemic forced the program to be delivered by telephone and videoconference, not in-person as intended. The pandemic also prevented recruitment from April to December 2020, resulting in a sample size less than half of the initial target.

The researchers also noted limited generalizability of the EMPOWER study findings due to the predominantly white and female sample. In addition, they noted that the outcomes examined were limited because the post-test was conducted immediately after program completion, so long-term impacts could not be assessed.

The generalizability of both studies is limited because each pilot was confined to one geographic location and researchers had to examine outcomes much sooner than originally planned.

Expected Application

EMPOWER is one of the first programs developed to empower older adults themselves to prevent elder abuse. The Urban team, in its report, noted that the pilot study used the strongest evaluation method possible, a randomized controlled trial, to test the treatment's impact on a study population who had experienced significant trauma in their lives, despite the intervention being designed as a primary prevention program. The research team reported that the intervention resulted in "several statistically significant treatment effects on the late-life resilience outcomes that EMPOWER aims to achieve for older adults."[11] The researchers said the pilot study results suggested that the program should be replicated in diverse communities with larger sample groups. NIJ recently funded the Urban Institute, in partnership with NORC at the University of Chicago, to conduct a multisite randomized controlled study of the EMPOWER program in communities that have been historically underserved, marginalized, adversely affected by inequality, or disproportionately impacted by crime, violence, and victimization.[12]

The COACH study researchers reported that the strong design and encouraging findings provide a good base for further research on caregiver support to prevent mistreatment of older adults. Particularly encouraging, their report said, "was the complete absence of [mistreatment of care recipients] in the intervention group."[13]

Conclusion

The EMPOWER and COACH pilot studies show potential to fill a void in existing research on systematic solutions to mistreatment of older individuals. Though significantly limited by the COVID-19 pandemic, these studies suggest broader application of similar interventions across more diverse populations may be beneficial. Their most significant contribution, perhaps, is the creation of viable intervention and evaluation frameworks to guide future research and treatment that address an urgent and worsening societal need.

About This Article

This article was published as part of NIJ Journal issue number 286.

This article discusses the following NIJ awards: