Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Secondary Prevention of Elder Abuse

Prepared by Christopher Patterson, MD, FRCPC, Professor and Head, Division of Geriatric Medicine, McMaster University, Hamilton, Ontario



Objective
To make recommendations about secondary prevention of elder abuse in Canada. Elder abuse is defined as "any act of commission or omission that results in harm to an elderly person".

Burden of Suffering
Elder abuse may be simply defined as "any act of commission or omission that results in harm to an elderly person". The Department of National Health and Welfare has categorized abuse and neglect as follows: physical abuse (e.g., assault), psychosocial abuse (e.g., verbal assault), financial abuse (misuse of money or property), and neglect (can lead to any of the three types of abuse).

Studies of elder abuse have reported prevalence rates from 1% to 4%. However, estimates as high as 10% have been claimed. Of a random sample of staff from a New Hampshire nursing home, 36% reported witnessing physical abuse in the preceding year, while psychological abuse had been witnessed by 81%. Risk factors for abuse in the victim include dependency, lack of close family ties, a culture of family violence, lack of financial resources, lack of community support and factors such as low pay and poor working conditions in institutions.

Options
Detection measures included questionnaires and direct questions such as "Has anyone at home ever hurt you?". Interventions included mandatory reporting, a team approach utilizing principles of problem recognition, provision of information, assessment of decision-making skills and facilitating choices.

Outcomes
No specific outcomes were discussed.

Evidence
MEDLINE was searched for 1980 to March 1993 using the major MeSH heading "elder abuse" with subheading "epidemiology"; a separate search was conducted using the MeSH heading "elder abuse" with publication type "clinical trials". Other data sources included standard reference works and their bibliographies and consultations with experts.

Values
The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs
There is little agreement about the definition and categories of elder abuse. A review of elder abuse identification measures reported that assessment protocols were conceptually and operationally suboptimal and had not undergone empirical testing. Few items measured types of abuse other than physical and the effects of disease were not distinguished from those of potential abuse.

No rigorous studies have evaluated the effectiveness of interventions for elder abuse. Results from case series have been disappointing.

Recommendations
Recommendation grade [A, B, C, D, E]  and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

Validation
This report was externally peer reviewed. This report was externally peer-reviewed. The American Medical Association recommends screening in daily practice. The 1989 U.S. Preventive Services Task Force did not recommend routine screening.

Sponsors
The Canadian Task Force on Preventive Health Care developed this guideline with funding from Health Canada under the Government of Canada’s Family Violence Initiative.

Source Document
Patterson C. Secondary prevention of elder abuse. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 922-9.