When it comes to elder abuse, the data is discouraging. Each year, about 10 percent of Americans aged 60 and over are thought to experience some form of mistreatment, including caregiver neglect and emotional, physical, sexual or financial abuse. Estimates jump to as high as 50 percent for people living with dementia. From lower quality of life to higher rates of hospitalization to shorter lifespans, the consequences are costly. Over the last several decades, researchers have made progress identifying the prevalence of abuse, the risk factors associated with it, and its impacts on individuals, families, communities, and society. Yet, successful strategies for preventing elder abuse have remained elusive.
A new USC-led pilot study may change that.
Pairing caregivers with one-on-one coaches in a short-term, intensive program significantly reduced abuse that had been occurring and prevented new abuse from happening, according to research published in October in the Journal of the American Geriatrics Society.
At an initial assessment before the start of the intervention, the rate of caregiver-reported elder mistreatment in the treatment group was 22.5%, versus 15.4% in the control group. When the same caregivers were asked about mistreatment that occurred in the 3 months after the end of the intervention period, the rate in the control group had inched up to 23.1%. In the treatment group, however, it had dropped to zero.
“The outcome of the randomized control trial is impressive,” said Kathleen Wilber, the Mary Pickford Foundation Professor of Gerontology at the USC Leonard Davis School of Gerontology and senior author of the study. “We were very excited with these findings and believe they may be the first results to show that an intervention has succeeded in preventing elder abuse.”
Wilber and lead author Zachary Gassoumis, an assistant professor of family medicine and gerontology at the Keck School of Medicine of USC, were part of a team of collaborators at the Keck School of Medicine of USC and the USC Leonard Davis School of Gerontology. Additional co-authors came from Kaiser Permanente Southern California, WISE & Healthy Aging in Santa Monica, and Case Western Reserve University in Cleveland, Ohio.
Aiming High
The team knew they were setting themselves an ambitious goal. “There have been a lot of studies” on how to reduce elder mistreatment, Wilber said. But until now, “no interventions have been shown to be effective at preventing abuse.”
First, Wilber and her team studied interventions shown to work with other forms of family violence, such as child abuse and intimate partner violence. These interventions included supportive home visiting programs, social support, modeled behavior and attitude reframing. The research team held listening sessions with physicians, nurses and social workers at Kaiser Permanente’s Los Angeles Medical Center in Hollywood, seeking input on what should be included in the assessment and the intervention program.
The intervention, called the Comprehensive Older Adult and Caregiver Help program, or COACH, launched in late February 2020, with a plan to ultimately enroll several hundred Kaiser patients and their caregivers, randomly assigning them to the control or intervention group, Wilber said. “We launched it, and we were all happy for a minute. Then COVID hit.”
Out went any possibility of in-home visits. With many subjects lacking access to video conferencing, the research team switched to weekly telephone consultations with the intervention group caregivers.
“We thought, ‘Well, this is problematic,’” Wilber recalled. But to everyone’s surprise, the study still worked.
As the researchers had hoped, caregivers proved willing to self-report abusive behavior. When Kaiser staff and physicians were referring people to the study, “they were very explicit that we were looking at elder mistreatment,” Wilber said. That did not deter many people from enrolling, and once enrolled, from admitting to abusive behaviors.
“I think some portion [of the caregivers] really want to figure out, ‘How do I do this better?’” Wilber said. Perhaps too, some report because they don’t recognize that yelling at their relative constituted abuse, she said.
A System of Support
Both caregivers in the treatment group and those in the control group were given a toolkit of information, containing caregiver tools and coping strategies. In addition, those in the treatment group received weekly contact from their assigned care coach – people with masters’ degrees who received training in topics and approaches including motivational interviewing and active listening. Two of the four coaches were bilingual Spanish speakers, and all the intervention materials were available in English and Spanish.
The coaches met with their assigned caregivers at least three times, and up to 12 times, to listen to their concerns and guide them through a behavioral and educational intervention drawn from the provided materials but tailored specifically for each caregiver.
“Being person-centered is really key,” Wilber said.
One common issue that many caregivers struggled with was a lack of understanding of their loved one’s health issue. So, coaches worked with the subjects to help them understand the illnesses they were dealing with, which included dementia, cancer, and many others. For instance, Wilber said, “‘It’s not Mom being difficult, it’s that Mom has an illness, and that’s why she’s asked you what’s for lunch over and over.’”
A well-known risk for elder abuse is caregiver isolation. “One of the things we came away with from the study is that social support is key,” Wilber said. “All the other things that you want to do to help caregivers manage self-care – take a walk, watch a good movie, whatever it is – you can’t do that unless you have enough social support.”
Care coaches helped study subjects identify people in their lives who could help them – say, by coming in to watch a bedridden relative – so the caregiver could get a much-needed break. Then, together, the coaches and caregivers came up with strategies to contact and engage that help network – creating a “CareMap.”
“You’re empowering the caregiver to be able to both ask for and sustain some of these things that they need,” Gassoumis said. “Whether it’s asking a neighbor if they can walk the dog or asking a doctor for more information, the CareMap is one way to formalize the process of identifying sources of support.”
Attempts to limit elder mistreatment often focus narrowly on the caregiver-care recipient pair, Wilber said. But if the caregiver doesn’t know what help is available, or doesn’t know how to access it, improvement can be difficult or even impossible].
Going forward, the research team hopes to replicate the study on a larger scale, with different samples.
“Social isolation and lack of social support are major risk factors for abuse,” Wilber said. “We hope that the COACH Program will help caregivers obtain needed social support during the intervention period and also provide effective tools for caregivers to activate and engage their support system going forward.”
