Interventions for preventing abuse in the elderly
Abstract
Background
Maltreatment of older people (elder abuse) includes psychological, physical, sexual abuse, neglect and financial exploitation. Evidence suggests that 10% of older adults experience some form of abuse, and only a fraction of cases are actually reported or referred to social services agencies. Elder abuse is associated with significant morbidity and premature mortality. Numerous interventions have been implemented to address the issue of elder maltreatment. It is, however, unclear which interventions best serve to prevent or reduce elder abuse.
Objectives
The objective of this review was to assess the effectiveness of primary, secondary and tertiary intervention programmes used to reduce or prevent abuse of the elderly in their own home, in organisational or institutional and community settings. The secondary objective was to investigate whether intervention effects are modified by types of abuse, types of participants, setting of intervention, or the cognitive status of older people.
Search methods
We searched 19 databases (AgeLine, CINAHL, Psycinfo, MEDLINE, Embase, Proquest Central, Social Services Abstracts, ASSIA, Sociological Abstracts, ProQuest Dissertations & Theses Global, Web of Science, LILACS, EPPI, InfoBase, CENTRAL, HMIC, Opengrey and Zetoc) on 12 platforms, including multidisciplinary disciplines covering medical, health, social sciences, social services, legal, finance and education. We also browsed related organisational websites, contacted authors of relevant articles and checked reference lists. Searches of databases were conducted between 30 August 2015 and 16 March 2016 and were not restricted by language.
Selection criteria
We included randomised controlled trials (RCTs), cluster‐randomised trials, and quasi‐RCTs, before‐and‐after studies, and interrupted time series. Only studies with at least 12 weeks of follow‐up investigating the effect of interventions in preventing or reducing abuse of elderly people and those who interact with the elderly were included.
Data collection and analysis
Two review authors independently extracted data and assessed the studies' risk of bias. Studies were categorised as: 1) education on elder abuse, 2) programmes to reduce factors influencing elder abuse, 3) specific policies for elder abuse, 4) legislation on elder abuse, 5) programmes to increase detection rate on elder abuse, 6) programmes targeted to victims of elder abuse, and 7) rehabilitation programmes for perpetrators of elder abuse. All studies were assessed for study methodology, intervention type, setting, targeted audience, intervention components and intervention intensity.
Main results
The search and selection process produced seven eligible studies which included a total of 1924 elderly participants and 740 other people. Four of the above seven categories of interventions were evaluated by included studies that varied in study design. Eligible studies of rehabilitation programmes, specific policies for elder abuse and legislation on elder abuse were not found. All included studies contained a control group, with five of the seven studies describing the method of allocation as randomised. We used the Cochrane 'Risk of bias' tool and EPOC assessment criteria to assess risk of bias. The results suggest that risk of bias across the included body of research was high, with at least 40% of the included studies judged as being at high risk of bias. Only one study was judged as having no domains at high risk of bias, with two studies having two of 11 domains at high risk. One study was judged as being at high risk of bias across eight of 11 domains.
All included studies were set in high‐income countries, as determined by the World Bank economic classification (USA four, Taiwan one, UK two). None of the studies provided specific information or analysis on equity considerations, including by socio‐economic disadvantage, although one study was described as being set in a housing project. One study performed some form of cost‐effectiveness analysis on the implementation of their intervention programmes, although there were few details on the components and analysis of the costing.
We are uncertain whether these interventions reduce the occurrence or recurrence of elder abuse due to variation in settings, measures and effects reported in the included studies, some of which were very small and at a high risk of bias (low‐ and very low‐quality evidence).Two studies measured the occurrence of elder abuse. A high risk of bias study found a difference in the post‐test scores (P value 0.048 and 0.18). In a low risk of bias study there was no difference found (adjusted odds ratio (OR) =0.48, 95% 0.18 to 1.27) (n = 214). For interventions measuring abuse recurrence, one small study (n = 16) reported no difference in post‐test means, whilst another found higher levels of abuse reported for the intervention arms (Cox regression, combined intervention hazard ratio (HR) = 1.78, alpha level = 0.01).
It is uncertain whether targeted educational interventions improve the relevant knowledge of health professionals and caregivers (very low‐quality evidence), although they may improve detection of resident‐to‐resident abuse. The concept of measuring improvement in detection or reporting as opposed to measuring the occurrence or recurrence of abuse is complicated. An intervention of public education and support services aimed at victims may also improve rates of reporting, however it is unclear whether this was due to an increase in abuse recurrence or better reporting of abuse.The effectiveness of service planning interventions at improving the assessment and documentation of related domains is uncertain. Unintended outcomes were not reported in the studies.
Authors' conclusions
There is inadequate trustworthy evidence to assess the effects of elder abuse interventions on occurrence or recurrence of abuse, although there is some evidence to suggest it may change the combined measure of anxiety and depression of caregivers. There is a need for high‐quality trials, including from low‐ or middle‐income countries, with adequate statistical power and appropriate study characteristics to determine whether specific intervention programmes, and which components of these programmes, are effective in preventing or reducing abuse episodes among the elderly. It is uncertain whether the use of educational interventions improves knowledge and attitude of caregivers, and whether such programmes also reduce occurrence of abuse, thus future research is warranted. In addition, all future research should include a component of cost‐effectiveness analysis, implementation assessment and equity considerations of the specific interventions under review.
PICOs
Plain language summary
Interventions for preventing abuse of older people
Review question
Our aim was to identify if specific programs or strategies are useful to prevent or reduce abuse in older people (60 years and over). We looked to include studies that described the effect of these programs or strategies whether aimed at the elderly themselves or people (such as caregivers or nursing home staff) with whom they interact.
Background
Elder abuse – physical, psychological, sexual abuse, neglect and/or financial exploitation ‐ is common but often underreported. Elder abuse can be a single, or repeated act, or may be a lack of appropriate action. Elder abuse occurs within a relationship where there is an expectation of trust, but regrettably harm or distress is caused to the older person. The abuse can often come from someone who they know well or have relationship with such as a spouse, partner, family member, or friend. It can also be caused by service providers in institutions and healthcare settings. It is most likely to occur when staff have inadequate training and supervision, or lack sufficient resources to undertake their responsibilities. This is a global problem that affects millions of older people resulting in great economic costs to both the individuals and the healthcare system. Abuse can lead to poorer health, injuries and even premature death.
Search date
All databases were searched up to August 2015. Additional searches of the main databases were conducted between 30 August 2015 and 16 March 2016.
Study characteristics
We found seven studies from our search of 19 databases. All together, the studies included 1924 elderly participants and 740 people (such as carers or nursing home staff) with whom they interact. These studies described methods of preventing or reducing elder abuse with elderly people. The studies included programs and strategies that took place in many different settings (home, community, institutions) although only in high‐income countries. The programs and strategies identified included methods to increase detection in clinical practice and community settings, victim support, increasing awareness of elder abuse and delivering training programs aimed at building skills in care providers. Most studies described changes in knowledge and attitudes, with very few measuring the occurrence or reoccurrence of abuse. The study durations ranged from six to 24 months.
Key results
The included studies suggest it is uncertain whether targeted educational interventions improve the knowledge of health and allied professionals and caregivers about elder abuse. It is unclear whether any improved knowledge actually leads to changes in the way they behave thereafter, and whether this leads to the elderly being abused less. Similarily, supporting and educating elderly victims of abuse appears to lead to more reporting of abuse, however it is unclear if the higher reporting meant more abuse occurred or a greater willingness to report the abuse as it occurred.
None of the studies reported any unintended outcomes of these approaches.
Quality of the evidence
Most of the evidence was low or very low quality (we cannot assume the findings of these studies are true) and limits our understanding of what strategies or programs work best to decrease or prevent elder abuse. Many of the studies were unclear in the design, too small in size or not similar enough in their findings to have full confidence in the findings.
Authors' conclusions
Summary of findings
| Educational interventions compared with control for preventing elderly abuse | ||||
| Patient or population: Carers of elderly persons Settings: Workforce training Intervention: Educational interventions Comparison: Control – no specific training | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Occurrence of abuse – caregivers: Caregiver’s abusive behaviours (Caregiver Psychological Elder Abuse Behaviour Scale) (duration not specified, assumed 10 months) | Abusive behaviour typically lower in the trained caregiver group (e.g. adjusted mean difference ‐3.46, adjusted % change 11.4%) | 112 caregivers (1 study) | ⊕ΟΟΟ Very Low1 | One study included this primary outcome |
| Occurrence of abuse by elderly persons: Detecting resident‐to‐resident abuse ( 6 & 12 months) | Intervention group reported more incidents at 6 & 12 months for the intervention than the control (adjusted mean difference to the control of 420%)#1 | 325 caregiver nurses, 1405 residents (1 study) | ⊕⊕ΟΟ Low2 | One study included this primary outcome |
| Knowledge and attitude to elder abuse (6 to 12 months) | Knowledge generally improved after intervention (e.g. KAMA scores adjusted mean change 25.8%, KGNS 5%) | 523 caregivers (3 studies) | ⊕ΟΟΟ3 Very Low | Substantial heterogeneity between trials regarding type of interventions and measured outcomes. |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded three levels for non‐randomised study, serious risk of bias and imprecision 2 Downgraded two levels for serious risk of bias and possible contamination 3 Downgraded three levels for substantial heterogeneity and risk of bias in the 3 studies, and the inclusion of one non‐RCTstudy of 112 caregivers as 'very low', #1 Refers to 12‐month result | ||||
| Programs to reduce factors influencing elderly abuse | ||||
| Patient or population: Carers of elderly persons Settings: Caregivers of family members suffering from dementia Intervention: Reducing factors influencing elderly abuse through promoting the mental health of caregivers | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Occurrence of abuse – caregivers: Caregiver’s abusive behaviours (Modified conflict tactics scale) (8 months) | No statistical difference in abusive behaviour between the groups(adjusted OR 0.48, 95% CI 0.18 to 1.27) | 260 caregivers (1 study) | ⊕⊕ΟΟ Low1 | One low risk of bias study which appeared inadequately powered included this primary outcome |
| Anxiety and depression: total scores on hospital anxiety and depression scale (HADS) (8 months) | Mean total HADS score lower for the intervention group of caregivers than the control (‐1.80 points (95% CI ‐3.29 to ‐0.31, P = 0.02) | 260 caregivers (1 study) | ⊕⊕⊕Ο Moderate2 | One low risk of bias study included this secondary outcome |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded two level for very serious imprecision 2 Downgraded one level based on only one study reporting as a secondary outcome | ||||
| Programs for increasing detection for preventing elderly abuse | ||||
| Patient or population: Carers of elderly persons with a responsibility for detecting abuse Settings: Community mental organisations and home care organisations Intervention: Programs for increasing detection for preventing elderly abuse through the provision of a toolkit | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Occurrence of elder abuse | Outcome was not reported for this comparison | |||
| Clinician assessment practices (1 year) | The study authors claimed that there was a significant increase in the proportion of clinicians in conducting clinical assessments in neglect and abuse domain, however they failed to provide statistical analyses to support this conclusion | 13 agencies, 44 clinicians, 100 elderly persons (1 study) | ⊕ΟΟΟ Very low1 | One high risk of bias study included this secondary outcome |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded three levels based on only one non‐randomised study with very serious risks of bias and a lack of transparency in the analysis of this secondary outcome (indirectness) | ||||
| Programs targeted to victims for preventing elderly abuse | ||||
| Patient or population: Victims of abuse Settings: Community settings Intervention: Programs targeted to victims for preventing elderly abuse including the provisions of psycho‐education support and materials | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Recurrence of abuse: Physical abuse – Hartford study physical abuse subscale (8 weeks post intervention) | Unable to determine | 16 (1 study)3 | ⊕ΟΟΟ Very low1 | One very small study at high risk of bias included this primary outcome |
| Recurrence of abuse – elderly persons: Modified version of the Conflict Tactic Scale (6 & 12 months) | Higher reports of victimisation | 403 (1 study) | ⊕⊕ΟΟ Low2 | It is unclear whether this increase reflects an increase in the rate of abuse recurrence (more abuse) or better reporting of abuse. |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded three levels for very serious risk of bias, very sparse data from one study.and a resulting in lack of clarity 2 Downgraded two levels for very serious risk of bias. 3 This number includes one participant unaccounted for in the analysis. The data analysis presented by the authors includes 15 individuals. | ||||
Background
Description of the condition
Maltreatment of older people (or commonly termed as elder abuse) is a global problem, affecting millions of older people worldwide. It was recently reported that elder abuse was responsible for 2500 deaths a year in Europe (WHO 2011). These figures will inevitably elevate with populations ageing and living longer. According to the World Health Organization (WHO), elder abuse is defined as "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person" (WHO 2002a). This definition encompasses harms towards the elderly by people they know or with whom they have a relationship, such as a spouse, partner or family member, a friend or neighbour, or those they rely on for services (Action on Elder Abuse 1995a). The research literature in this area tends to refer to elder abuse as physical abuse, psychological or emotional abuse, financial abuse (or financial exploitation), sexual abuse, and neglect (Cooper 2008; Lachs 2004).
Routine data on elder abuse remain scarce and have a short history with first references to "granny bashing" appearing in the literature in 1975 (Baker 1975; Burston 1975). The exact scale of the problem has been difficult to determine, given the varying definitions and social norms across the world (Kosberg 2003). Available community‐based studies contain evidence that abuse, neglect and financial exploitation of elders are much more a universal phenomenon than societies admit. A review of the prevalence of elder abuse found the overall elder abuse rate ranged between 3.2% and 27.5%, with significantly higher rates among vulnerable older people (Cooper 2008). Data suggest that 2.7% of elderly people reported physical maltreatment, 19.4% reported mental abuse, 0.7% reported sexual abuse and 3.8% reported financial abuse in the previous year (Soares 2010). The prevalence of maltreatment is reported to be much higher among vulnerable dependent elderly requiring care, particularly those in nursing and residential homes. In a survey in the United States, 24.3% of elderly relatives reported at least one incident of physical abuse by staff in nursing homes in the previous 12 months (Schiamberg 2012). In rural China, more than one‐third of elderly people reported elder abuse, with psychological mistreatment and caregiver neglect being the most common types of abuse (Wu 2012). Elderly people with dementia are also reported to be at a higher risk of being abused by family carers (Cooper 2009).
Emerging evidence shows that elder maltreatment has great economic costs, including the direct costs to health, social, legal, police and other services. The direct cost arising from maltreatment is attributed to increased healthcare costs to treat and rehabilitate the maltreated elderly. It was estimated that the direct healthcare costs of injuries due to elder maltreatment has contributed more than USD 5.3 billion to the annual healthcare expenditure in the United States (Mouton 2004). Maltreated elderly were found to have longer hospital stays and higher rates of utilisation of emergency services compared to their non‐maltreated counterparts (Dong 2012; Dong 2013). In Australia, costs due to hospital admissions for elder maltreatment were estimated to be between AUD 9.9 million and AUD 30.7 million for 2007/2008 (Jackson 2009). Other costs include provision of protection and care by the legal and social system, such as adult social services agencies, which spent at least USD 500 million in 2004 alone (Dyer 2007; NCEA 2006). In addition, financial abuse could seriously affect older people who survive on limited resources. Indirect costs as a consequence of elder maltreatment include loss of productivity of caregivers, inability to continue with activities of daily life, diminished quality of life and lost investment in social capital (Butchart 2008). Given these enormous social and economic costs, there is a dire need for evidence‐based and immediate actions on elder abuse.
Elder abuse is a result of complex interactions among factors at the individual, relationship, community and societal levels, which can be conceptualised using an ecological perspective (Gordon 2001; Wolf 2003). Factors from each level can interact, putting the elderly at risk of abuse. For example, older people with dementia (Dyer 2000; Hansberry 2005), disabilities (Ansello 2010; Laumann 2008) and chronic health problems (Lowenstein 2009) that result in increased dependence on caregivers are particularly at risk of elder maltreatment. Furthermore, low social support, loneliness, social isolation and lack of social networks among the elderly further perpetuate maltreatment (Acierno 2010; Dong 2007; Dong 2009). Perpetrators’ mental illness, high levels of hostility, substance abuse, psychological distress and their dependence on the victim for accommodation and financial support appear to be strong risk factors that predispose elderly to maltreatment (Jackson 2011; Schiamberg 2000). Women were generally significantly more likely to have experienced maltreatment than men, but this may differ according to the type of abuse (Biggs 2009). Intergenerational transmission of violent behaviour is a plausible risk factor, given the association found between history of childhood violence with child abuse and other forms of aggressive behaviour (Biggs 2009; Jackson 2011; Lowenstein 2009; Yan 2003). Distinctive characteristics were found to be associated with greater maltreatment in institutions and healthcare settings (or institutional abuse) and include inadequate staff training and supervision, inadequate staff to carry out daily activities, and prejudiced attitudes towards elderly (Jogerst 2008a; Phillips 2011).
Community factors that exacerbate elder maltreatment include high crime rates, social disorganisation, lack of social resources and networks, and poverty (Luo 2011). Further, societal‐level factors that have been connected with elder abuse include culture, ethnicity and policies. These are evident in the different views on what constitutes elder abuse as well as the societal response to the problems that exist between different ethnic and cultural groups and can influence the reporting of the problem to health and protection services (Dakin 2009; Moon 1993; Wolf 1999). In addition, customary practices in some societies might be judged to be abusive in some countries but not in others (Kosberg 2003; Podnieks 2010).
Description of the intervention
This review encompasses any strategy or intervention that could be utilised to prevent or reduce elder abuse. Our definition encompasses interventions that have been developed to address the multifaceted nature of elder abuse, targeted at different levels reflecting the socio‐ecological approach, that is, at individual, familial, community and societal levels. Browne and Herbert (1997) identified three fundamental types of interventions that could operate at different levels. Based on their classification, we define primary prevention as interventions related to preventing the abuse from occurring, secondary intervention as actions aimed to prevent further abuse, and tertiary intervention as actions to manage the consequences after abuse has occurred (Browne 1997).
We included primary prevention activities that could be individually‐focused activities, community‐based interventions or changes in policies. Individually‐focused activities could involve interventions targeting the elderly directly, their family members, or both. For example, health educational and skills‐based programmes have been specifically developed for the elderly and their families to provide them with the skills to communicate effectively, manage stress, resolve conflicts, and promote healthier relationships (Hsieh 2009). Other approaches are those which encourage positive attitudes towards older people by increasing meaningful interaction between elderly and younger persons via an intergenerational programme. Other programmes target schools, university students or youths from community settings, such as church groups and employment programmes (Fujiwara 2006; Hermoso 2006; Sanders 2008), and may vary in the type of activities conducted. Within this, activities could range from simply exchanging letters or e‐mails to long‐term or direct engagement with the elderly through participation in joint community projects, group activities, or help with activities of daily living (e.g. gardening, house cleaning or tutoring).
Community‐based interventions such as awareness campaigns and health education conducted across society using mass media such as television, radio, printed materials and Internet web sites will be included in this review. Such campaigns are generally designed and implemented to raise awareness of elder maltreatment, encourage respectful and dignified treatment of older people, and provide education about available support services that, in turn, may prevent elderly abuse (HSE 2009).
It cannot be assumed that an intervention programme being implemented will bring only beneficial effects. Some interventions might endanger elders due to inappropriate risk assessment, breach of confidentiality, invasion of privacy and failure in safety plan (Dugan 2003). For example, several studies suggest that interventions such as psychologically‐based programmes (e.g. anger, stress and coping management) (Cooper 2015), behavioural therapy (Drossel 2011), provision of respite care or temporary relief care (Jeon 2005), and social support groups (Brownell 2006) for family members or caregivers may reduce risk factors of elder abuse, such as caregivers’ stress and dependency of elderly. However, several evaluations have reported an increase in maltreatment following interventions such as the restraints reduction programme (mechanical devices or barriers that restrict the movement of a person in a chair, wheelchair, or bed), home‐visiting programme, and advocate volunteers (Davis 2001; Filinson 1993). Therefore, we also considered the negative consequences associated with the elder abuse prevention strategies in this review.
How the intervention might work
This review aims to give a broader perspective on the interventions to prevent or reduce elder abuse. Elder abuse interventions occur in a range of settings, including healthcare and social or legal settings, and they may be primary, secondary and tertiary in nature.
A logic model was developed to capture the broad range of approaches that may be used to prevent or reduce elder abuse (Figure 1). It also articulates a range of possible short‐ and long‐term outcomes that may be used to measure the effectiveness of interventions and capture the levels where the intervention may be operating. Short‐term outcomes include participant‐, victim‐ or perpetrator‐related outcomes, such as increased knowledge, attitudes and skills, identification of abuse and elderly independent living. Long‐term outcomes could include lower rates of elder abuse reporting or a reduction in the recurrence of elder abuse.
Footnotes (Figure 1):
1Programmes to reduce factors influencing elder abuse (e.g. respite care, social support, psychological programme, restraint reduction, intergenerational programme)
2Legislation (e.g. advocacy‐based programme, law‐orientated programme, legal institution, elderly act, mandatory reporting, adult protection statutes)
3Specific policies for elderly (e.g. improve housing, transport, aged friendly cities, banking, pension, welfare aid)
4Programmes to increase detection rate for prevention (e.g. home visit, home‐based geriatric assessment, helpline, training for healthcare workers and social worker, guideline/ protocol, screening)
5Programmes targeted to victims (e.g. adult protective services, emergency shelter, temporary residential services)
6Rehabilitation programmes (e.g. legal assistance, psychiatric intervention, support, counselling)
7Other professionals (e.g. legislators, policy makers, politicians, journalists)
8 Increase identification (e.g. increase detection rate, increase reporting)
Within the range of interventions, specific ‘elderly friendly’ policies may be implemented with the intention to strengthen and improve elderly welfare, economic and social standing, which decrease their dependency. These policies may consist of financial independency, welfare assistance, employment opportunities and poverty reduction, involving the financial or banking industries, health sectors, government planners and religious organisations. To achieve this, financial incentives and compensation are provided, which include direct payments to families through cash grants or vouchers to purchase services. Tax incentives for caregiving include deductions and credits. In UK and New Zealand, various banks released the statement of intent on age‐friendly banking practices for vulnerable customers (BBA 2010; NZBA 2007). Further, the health sector is encouraged to engage with outside sectors, particularly city councils, urban planners and politicians designing the urban environments in highly innovative age‐friendly cities that suit the ageing populations (Heathcote 2011). Some countries have specific employment policies to protect older people. In England, the Independent Safeguarding Authority ensures that employers report a dismissed employee or volunteer for causing serious harm to a vulnerable adult and the employee is then barred from further such employment. Employers need to undertake the Criminal Records Bureau (CRB) checks for health‐ and social care‐related employment (UK Home Office 2012). In addition, initiatives to reduce poverty and social exclusion have been organised, such as the Coming Home Program in United States creating affordable assisted living facilities for lower‐income older and frail persons eligible for Medicaid services in rural areas since 1992 (Jenkens 2005; NCBDC 2012).
Secondary intervention involves close monitoring of vulnerable older adults, early detection of elder abuse through screening or intervening through mandatory reporting, with the assumption that this will avoid recurrence. Monitoring of vulnerable older adults is possible through screening, home‐visiting, and home‐based geriatric assessment. Helplines (or hotlines) aim to provide victims with the opportunity to report abuse and seek further support, as well as obtain information or referrals to local and national support services. By increasing screening activities, training and education programmes are targeted at health and social care professionals who come into routine contact with older people and are in an ideal position to detect those at risk of, or already experiencing, maltreatment. However, professionals were found to have little insight or guidance for deciding and making judgements regarding abuse of older people, particularly when faced with complex family and contextual factors and ethical dilemmas (Killick 2009). Training programmes are provided with the intention of increasing professional awareness of the various types of elder abuse and their signs and symptoms, and to improve their ability to identify and manage suspected cases effectively (Shefet 2007). They are incorporated in formal curriculum (Wagenaar 2009) or delivered through training courses, workshops (Day 2010), online (Smith 2010) or via printed learning materials (McGarry 2007; Richardson 2002). Although numerous evaluations of training and education programmes have been conducted, they varied substantially in quality, with their effectiveness for the victims showing mixed results. There is currently no such review of the effectiveness of educational interventions in preventing or reducing elder abuse (Day 2010; Richardson 2002).
Legal provisions, including mandatory reporting and adult protection statutes, have been established with the intention of increasing reporting and ending elder abuse (American Bar Association 2006). Disclosure of abusive situations to a legal authority by the affected elderly are impeded due to physical or psychological impairments, poor communication skills, fear of institutionalisation and retaliation, fear of shame or embarrassment, or dependency on the perpetrator (Desmarais 2007). Many states in United States now require mandatory reporting by any persons or specific professionals, such as physicians, psychologists, nurses, law enforcement officials and clergy, to increase reporting (Koenig 2005). Also, laws that govern the licensing and certification of institutions and prohibit healthcare fraud have been introduced to assure the quality of care of nursing home residents and their protection from mistreatment (Gittler 2008). Some laws, especially mandatory reporting, have been implemented with the assumption that they will reduce abuse. However, it has been a contentious issue with many questions raised about its effects; indeed its actual efficacy has yet to be determined (Bonnie 2003; Fulmer 2008a).
When abuse is recognised, it seems logical that referrals need to be made early and adequate follow‐up arranged. Tertiary efforts tend to focus on dealing with the immediate consequences of elder abuse, providing support to victims and punishing the offenders rather than preventing abuse in the short and longer term. Thus, temporary placement, adult protective services, emergency shelters, counselling and assistance via support groups targeted at protecting and monitoring victims are widely developed in several countries (Doe 2009; Koenig 2005; Kurrle 2008; Penhale 2008; Podnieks 2008). For example, South Korea has established a centralised system that includes 24‐hour emergency hotline for reporting elder abuse, five‐day respite programs for caregivers, 15‐day temporary residential services for elders and establishment of elder abuse prevention centres (Doe 2009). Multidisciplinary response teams are created in addition to existing adult protective services to respond more efficiently to cases of elder maltreatment. These include forensic centres; vulnerable adult or financial abuse specialist teams; and elder maltreatment prosecution units, or a prevention team that raises awareness of elder maltreatment in the community (Dyer 2005; Schneider 2010; Twomey 2010). For substantiated maltreatment cases, although criminal and civil actions will be undertaken against alleged perpetrators, rehabilitation programmes such as counselling, psychiatric intervention and legal assistance are also available to the perpetrator in some countries (Lithwick 2000).
Why it is important to do this review
Successful responses to elder abuse involve a public health approach that accounts for the magnitude of the problem, its risk factors and the evidence base of what works that subsequently can be implemented on a wider scale at individual or population levels (Lachs 2004). One major barrier to successful responses to any type of violence, including elderly abuse, is that prevention programmes have been developed in isolation (WHO 2002b). Greater emphasis needs to be placed on undertaking evidence‐informed approaches to addressing elder maltreatment. While interventions have been initiated in health, social and legal settings to prevent or reduce elder abuse, little systematic research has been devoted to combining all current evidence available worldwide. There are some initial efforts to gather such evidence (Ploeg 2009), but less so in developing countries. In their review, Ploeg and colleagues found that there were no significant differences in case resolution and rates of recurrence of abuse among the elder abuse interventions evaluated (Ploeg 2009). However, their findings may be limited in the extent to which they can be generalised due to the exclusion of unpublished research reports, non‐English language studies, recent studies from developing countries and lack of formal qualitative assessment of included studies. This current review intends to address this gap, reduce the fragmentation in research and improve the evidence base of the actions needed to prevent maltreatment.
Objectives
The primary objective of the review was to assess the effectiveness of primary, secondary and tertiary intervention programmes utilised to reduce or prevent, or both, elderly abuse in organisational, institutional and/or community settings (i.e. their own or someone else's home). We sought to identify and report on adverse consequences or effects of the intervention/s in the review.
The secondary objective was to investigate whether the intervention’s effects are modified by types of abuse, types of participants, setting of intervention, or cognitive status of the elderly.
Methods
Criteria for considering studies for this review
Types of studies
We included all randomised controlled studies (RCTs) comparing the use of strategies for the prevention and reduction of recurrent elder abuse with a minimum follow‐up of 12 weeks in community‐dwelling and institutionally cared for elderly persons. Given that elder abuse interventions may involve an entire community or city, quasi‐experimental designs such as cluster‐randomised controlled trials which use a comparison control population were included. Although the inclusion of non‐RCTs increases the susceptibility for bias, we included non‐RCTs such as interrupted time (ITS) studies, controlled before‐and‐after studies (CBAs), and those with comparator groups because a wide variety of approaches and designs have been used in elder abuse interventions and we anticipated that a limited number of RCTs would be available.
We included studies that compared the use of an intervention to prevent elder abuse in one group versus the use of no prevention in the other. Within this, the intervention component of included studies could be a one‐off intervention or an intervention extending over a specified length of time. We only included studies that measured elder abuse occurrence (using standardised subjective or objective tools) pre‐ and post‐intervention.
Types of participants
The target population was elderly people living in the community as well as those being cared for in an institution. We included studies of elderly persons (60 years and older) living in communities (their own or someone else's home) or institutions (such as residential care, health facilities or shelters, prisons or detention centres). This is based on the UN agreed cutoff for the older population (United Nations 2012). Studies that focus on interventions to prevent other crimes against older people by those without a relationship or care responsibility for them (e.g. street mugging or robbery) were excluded.
Types of interventions
We defined elder abuse prevention intervention (EAPI) as 'any strategies that avoid potential elder abuse or reduce recurrent elder abuse' to lower rates of elder abuse in communities and in institutions. The resources could be provided by government planners, community‐based groups, institutions and legislators. As EAPIs could be applied in a number of settings, we used the logic model (Figure 1) to classify the type of intervention and the level (community or individual) in which it is utilised.
The following are examples of EAPIs that we thought might be utilised in order to avoid potential elder abuse or reduce recurrent elder abuse in communities and institutions, consistent with the logic model included in this review. In addition, these included studies improving the quality of care and living situations that provide barriers to situations of potential abuse; and programmes that bring about improvement to long‐term care that reduce recurrence of elder abuse. The following interventions were eligible within the defined scope of the review.
Education
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Training and professional development to service providers on elder abuse.
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Education to the public and elderly, caregivers and other professionals to increase awareness, improve attitudes and build skills for prevention.
Programmes to reduce factors influencing elder abuse
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Interventions that reduce risk factors, e.g. psychological programmes (anger and stress management), behavioural therapy, provision of respite care and social support groups for caregivers.
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Restraint reduction programmes and institutional policies to limit the unnecessary use of physical restraints.
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Intergenerational programmes to create positive attitudes towards the elderly.
Specific policies on elder abuse
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Elder abuse‐related policies such as those that seek to improve housing, transport, aged‐friendly cities, banking, pension management and financial aid that lead to improvements in independent living and welfare.
Legislation on elder abuse
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Legislation resulting in advocacy‐based programmes, law‐orientated programmes and legal provisions such as mandatory reporting, adult protection statutes, and specific laws to protect whistle‐blowers, specifically on elder abuse.
Programmes to increase detection rate for prevention of elder abuse
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Programmes that attempt to increase the detection rate, such as home visits, home‐based geriatric assessment, helplines, training for healthcare and social workers and guidelines and protocols for screening.
Programs targeted to victims of elder abuse
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Programmes for victims, such as adult protective services, emergency shelters, temporary residential services as crisis management and relocation for improvements in long‐term care.
Rehabilitation programmes for perpetrators of elder abuse
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Programmes of rehabilitation for perpetrators, such as legal assistance, psychiatric intervention, support and counselling that may involve conflict resolution skills.
In this review, education‐based interventions were grouped together prior to combining the data. Other modes of interventions were studied as individual programmes due to the differences in the approaches used, motives, content and targeted groups.
Types of outcome measures
The following are the primary and secondary outcomes pre‐defined in this review.
Primary outcomes
A primary outcome is any measure of rates of elder abuse in either communities or institutions. They could be further classified as the following, due to the intervention effort (as specified in Figure 1):
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incidence of elder abuse (new instances of abuse occurring);
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recurrence of elder abuse (a second or subsequent episode of abuse occurring).
The definition of incidence of abuse included physical, sexual, emotional, financial abuse, and neglect. Abuse could be assessed using self‐report measures (e.g. Conflict Tactics Scale, Elder Abuse Assessment Instrument, Elder Abuse Suspicion Index, Indicators of Abuse screen, Elders Psychological Abuse Scale, or as defined by the authors), medical records, number of protection orders sought, calls to police or police records filed. Incidence may be reported as a frequency count, a rate, or a proportion, but must be for a defined population within a specific period of time (Porta 2014).
Secondary outcomes
Secondary outcomes included those that may be related to elder abuse behaviour or that explain how interventions work to improve quality of care and living situations, as well as elderly long‐term care and those that reduce the potential for elder abuse.
Participant‐related outcomes such as:
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increase in awareness regarding elder abuse;
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improvement in attitude towards elder abuse;
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improvement in skills towards handling elder abuse;
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increase in detection;
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increase in elderly independent living.
Victim or perpetrator‐related outcomes which include:
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improvement in crisis management and relocation of the victims;
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improvement in conflict resolution and management of the perpetrators.
We reported any adverse outcomes from interventions; where any such events occurred, these were recorded and discussed in the narrative summary.
Search methods for identification of studies
Electronic searches
We searched relevant multiple databases and websites (as recommended by Armstrong 2011) using a sensitive search strategy developed by review author PB in liaison with the Public Health Group's Information Specialist and Queensland University of Technology's librarians, and then tailored the MEDLINE strategy for each database during 2015 and then again in early 2016. We handsearched all studies identified in the reference lists of review articles and contacted experts in the field for other potentially eligible studies. We imposed no language in our search. All publications dated from 1975 to present were searched.
The search strategies used to search each database and the dates of search are delineated in Appendix 1.
We searched the following databases.
Health
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MEDLINE
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Embase
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CINAHL
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PsycINFO
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LILACS
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Proquest central
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Web of Science
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EPPI centre databases – e.g. BiblioMap, DoPHER, TRoPHI
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the Cochrane Library including Central Register of Controlled Trials (CENTRAL) and CRD
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InfoBase
Legal & Social sciences
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Sociological abstracts
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Social Science abstracts
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Social Services abstracts
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ASSIA
Grey literature, unpublished research
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Health Management Information Consortium (HMIC)
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OpenGrey
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Proquest Dissertations and Thesis
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Web of Science
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ZETOC
In addition, we searched the WHO International Clinical Trials Registry Platform (WHO ICTRP) and Clinicaltrials.org to identify studies in progress.
Searching other resources
In addition to databases, we searched other resources for published and unpublished studies.
We searched the reference lists of all papers and relevant systematic reviews that were identified as meeting the inclusion criteria for the review.
We conducted a Google Scholar search for relevant material and search key websites (International Labour Organisation, WHO and International Network of Agencies for Health Technology Assessment, National Guideline Clearinghouse, Joseph Rowntree Foundation, AgeConcern) and relevant global social/health government departments such as Department of Health in the UK, Australia, etc. The full list of the key organisation websites are presented in Appendix 2..
We contacted subject experts through the International Network for the Prevention of Elder Abuse, The European Reference framework Online for the Prevention of Elder Abuse and Neglect and the National Center on Elder Abuse in the United States.
Data collection and analysis
Selection of studies
We imported article records identified through database searching, websites and other approaches from each database into the bibliographic software package Endnote X7, where duplicates were removed and potentially relevant articles selected. We undertook an initial screening of titles and abstracts to remove those which were obviously outside the scope of the review; a task divided between the review authors (WYC, NH, PB) and a research assistant. We were intentionally over‐inclusive at this stage and, if in doubt, we included the paper for further consideration. The full text for the papers potentially meeting the inclusion criteria (based on the title and abstract only) were then obtained, and then multiple publications and reports on the same study were linked together. There was no blinding with respect to authors’ names, journal or date of publication during this process. Three review authors (WYC, NH, PB) initially independently screened all the full‐text papers which were obtained and, utilising the logic model (Figure 1), assessed whether basic components of the definition of an intervention for preventing abuse and permissible study designs had been fully met. Where there was a persisting difference of opinion, review authors SO and DF reviewed the paper in question in order to reach a consensus between the review authors. We maintained a record of the outcome of the study assessment process for all reviewed material. After the initial selection for full‐text review, DF and PB performed a re‐screening of a random 10% of all excluded titles to ensure no suitable titles had been omitted.Subsequently, DF then independently reviewed all potentially included studies, the results were compared and disagreements were identified, discussed and a consensus of included studies reached. We recorded the selection process in detail to complete a study flow diagram (Figure 2).
Study flow diagram.
Data extraction and management
We developed a data extraction form based upon the 'Data Extraction and assessment form' of the Cochrane Public Health Group (CPHG 2011)
Two review authors (WYC and NH), independently completed a data extraction form for each study, tailored to the requirements of this review. WYC, DF and PB piloted the data extraction form to assess its ability to capture study data and inform assessment of risk of bias. We resolved any problems identified through discussion and we revised the form, as required. Where studies reported more than one endpoint per outcome, we extracted the primary endpoint identified by the authors. Where the study did not identify a primary endpoint, we ranked the measures by effect size and extracted the median measure (Curran 2007). For any relevant study reported in languages that could not be translated by the review team, WYC completed the data extraction form in conjunction with a translator. We did not find any studies that required further translation.
A checklist was used to ensure inclusion of data relevant for health equity based on PROGRESS‐Plus criteria so disadvantaged could be considered in terms of place of residence, race or ethnicity, occupation, gender, religion, socio‐economic position, social capital, age, disability and sexual orientation (Ueffing 2011).
In addition, multiple reports and publications of the same study were assembled and then compared for completeness and possible contradictions. We used the logic model (Figure 1) by marking the specific components present in the primary paper and companion publications to assist in the categorisation of studies and interpretation of results, where heterogeneity was present. We managed numerical data that were extracted from the included studies for analysis using a Microsoft Excel spreadsheet.
WYC and NH with the support of PB and DF cross‐checked the completed data extraction forms for consistency, and where any discrepancy arose, we achieved consensus through discussion as a complete review team. WYC undertook responsibilities for filing and storing all copies of studies undergoing data extraction and completed data extraction sheets (including printed versions of electronic forms) in a filing cabinet for auditing and checking purposes. Data collated was transferred from our data extraction sheets to RevMan 5.1 (RevMan 2011); NH independently checked the accuracy of this procedure. Where necessary, we contacted study authors to seek provision of data that appeared to be missing from the study reports or to resolve any uncertainty about reported information. We recorded any study that underwent the data extraction process. Studies that did not meet the eligible criteria where examined further and then listed in the Characteristics of excluded studies table with the reason for exclusion noted. All relevant information for the included studies was entered in the Characteristics of included studies table.
Using the location of the intervention, we planned to categorise studies as occurring in low‐, middle‐ and high‐income countries, as determined by the World Bank classification. However, we did not find any studies from low‐ or middle‐ income countries in this review.
All papers and reports of included studies were reviewed to identify whether any description of costs or resources were made by the authors. Information extracted included descriptors of cost to deliver the intervention over the time specified. Where possible, we intended to separate the cost of the intervention from the cost of the evaluation and research components. Where the results were presented at a population level, we planned to calculate the cost per person. This approach included identifying and including in‐kind support. We also sought to extract general statements (e.g. "low‐cost intervention") made by the authors, where no expression of monetary value was made. Two of the studies included in this review conducted some forms of costing analysis of their intervention, however details of the costing components were not reported in their studies.
Assessment of risk of bias in included studies
Two review authors (WYC and NH) independently assessed the risk of bias in each study using the Cochrane ‘Risk of bias’ tool. This primarily included the assessment of sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessors; incomplete outcome data; selective outcome reporting; and other sources of bias when evaluating RCTs (Higgins 2008).
In addition, we used the Effective Practice and Organisation of Care (EPOC) ‘Risk of bias’ tool to assess the risk of bias of non‐randomised studies. For the analysis of non‐RCTs, we assessed studies for the five general domains of bias: selection, performance, attrition, detection, and reporting, as well as for an additional category to capture any other concerns pertaining to the study's risk of bias. Eleven questions appropriate for the included study designs were identified from the EPOC tool (EPOC 2015) as shown in the Risk of bias in included studies table. Each question was assessed with answers of 'Yes' indicating low risk of bias, 'No' indicating high risk of bias, and 'Unclear' indicating either lack of information or uncertainty.
All eligible studies were judged as at ‘low’, ‘high’ or ‘unclear’ risk of bias, given an overall consideration of the designs and the potential impact of the identified risks noted in the table for each study that contributed results for that outcome according to the EPOC descriptors. We considered overall the study designs and the potential impact of the identified risks. Where a singular minor methodological issue occurred which was deemed unlikely to change interpretation of the findings, we determined that an overall downgrading of the study to high risk was unwarranted (Baker 2015). Disagreement between review authors in the 'Risk of bias' of assessment, where required, were resolved in a discussion with a third author (SO). A standard and consistent approach to Interpretation was developed by the full review team as the method and interpretation was discussed and reviewed by the team prior to application. A second independent assessment for consistency of interpretation was undertaken by the two remaining review authors (PB and DF) who reviewed all decisions made for each study.
The 'Risk of bias' assessment for each included study is documented in the Risk of bias in included studies table. Two figures were generated: a graph that illustrates the proportion of studies for each assessment criterion and a summary figure that shows the methodological rigour of each study.
Measures of treatment effect
All dichotomous and continuous data were reported separately as found in the primary research. For studies with continuous outcomes, mean and standard deviation (SD) were used. For continuous outcomes, mean differences (MD) were used to analyse changes in outcome between the intervention and control groups where possible. Had the studies reported outcomes using disparate scales, we planned to use standardised mean differences (SMDs), if meta‐analysed. The effect sizes for dichotomous outcomes were expressed as relative risks (RR) with 95% confidence intervals, where feasible were calculated. Alternatively the odds ratio (OR) was reported if provided in the study.
To allow for comparison between studies, and given the important differences between intervention (I) and control (C) groups at baseline, we calculated an adjusted estimate of effect. This calculation is based on the differences between the intervention and control group at baseline, similar to Baker 2015. Therefore, for dichotomous outcomes we calculated the following.
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Adjusted risk difference = (Ipost ‐ Ipre) ‐ (Cpost ‐ Cpre).
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Adjusted relative risk = (Ipost / Cpost)/(Ipre/Cpre).
Confidence intervals (95%) were calculated using the Wald test.
For continuous outcomes we used the data extracted from the included studies to calculate the following.
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Post mean differences (PMD) = Imeanpost ‐ Cmeanpost
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Adjusted mean difference = [(Imeanpost ‐ Cmeanpost) ‐ (Imeanpre ‐ Cmeanpre)]
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Adjusted percentage change relative to the control group = [((Imeanpost ‐ Cmeanpost) ‐ (Imeanpre ‐ Cmeanpre))/Cmeanpost] x 100.
The 95% confidence intervals could not be calculated using this approach.
In this current review it was not appropriate to conduct a meta‐analysis.
Unit of analysis issues
We planned to include cluster‐randomised trials in the analyses as well as individually‐randomised trials. We would have adjusted their sample sizes using the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008) and used an estimate of the intra cluster correlation co‐efficient (ICC) from the trial or from a study of a similar population. If ICCs from other sources were used, we planned to conduct sensitivity analyses to investigate the effect of variation in the ICC and reported the results. We consider it reasonable to combine the results from both cluster‐randomised and individually‐randomised trials if there is little heterogeneity between the study designs. A sensitivity analysis would therefore be performed to investigate the effects of the randomisation unit.
In trials with multiple intervention or control groups, we planned to use weighted, pooled means and standard deviations to generate SMDs in order to avoid statistical problems with non‐independence of data that would result from including multiple intervention groups as separate trials. Studies comparing different intervention groups or different intensities of the same intervention, with control group, would be excluded from the meta‐analysis, but reported in narrative.
All outcome results are described in the narrative.
Dealing with missing data
Where data were missing, were unclear, or were not fully reported, we attempted to contact the authors of these potentially included studies for clarification and further information. Attempted contact of authors was primarily via email by searching for most recent email address through a Google search. Although stated in our protocol, we chose not to attempt contact via postal address. If we were unable to trace the authors or information was unavailable from the authors within two months of contacting them, we record the information as missing in the data extraction form. Unobtainable methodological data are documented in our ‘Risk of bias’ tables and unobtainable statistical data were assessed and managed following the guidance provided in Higgins 2008.
Assessment of heterogeneity
We found content and methodological diversity between all included studies. The logic model was used in categorising the type of intervention strategies used, the participants and outcome measures assessed. Due to heterogeneity in the study designs employed, the populations in which the interventions were conducted, and the interventions themselves, no meta‐analysis was conducted in this present review.
Assessment of intensity
We categorised the intensity of the elder abuse prevention intervention to assess whether intensity could account for differences that existed in the outcomes between studies. Similar to Baker 2015, the intensity of the intervention was categorised based on the six characteristics and attributes that we hypothesised would be important in understanding differences in the effectiveness of the elder abuse prevention interventions. Specifically, these characteristics included: 1) development of community partnerships and coalition; 2) levels of intervention; 3) reach of the strategies; 4) magnitude of the intervention, the extent of continuous provision of the intervention through the intervention period; 5) description of cost; and 6) statement of intensity.
Two review authors (NH and WYC) independently assessed each characteristic as 'more intensive', 'less intensive', or 'unclear' (Baker 2015). We categorised the overall assessment of intensity for each study as 'high', 'medium', 'low', or 'unclear'. Discrepancies were resolved by discussion.
Assessment of reporting biases
We considered plotting trial effect against standard error (SE) using funnel plots (Sterne 2011). Given that asymmetry could be caused by a relationship between effect size and sample size, or by publication bias (Egger 1998). However, as no meta‐analysis was produced, we did not examine any observed effect for clinical heterogeneity or carried out additional sensitivity tests.
Data synthesis
The assessment of the effect of different types of interventions was guided by the logic model presented in Figure 1. The protocol stated that meta‐analysis would only be undertaken if the studies were considered to be clinically homogenous. The diversity of interventions and outcomes however, and the limitations in the quantity and quality of studies meant that it was not appropriate a to conduct any meta‐analyses in this review.
Narrative synthesis was therefore conducted with studies categorised using the interventions presented in the logic model. An additional synthesis by the primary and secondary study outcomes already identified in this paper was also conducted. In synthesising the data, the results of any intervention versus no intervention (i.e. control group), immediately post‐intervention, and at any intervals within the 12 months follow‐up, were used, and where possible reported on the original scale. All data were recorded using an Excel spreadsheet.
Subgroup analysis and investigation of heterogeneity
There were insufficient studies identified to allow all subgroup analyses to be performed as planned in the protocol for this review. Where sufficient data were available, we planned to carry out the following subgroup analyses based on the following; 1) type of abuse; 2) type of intervention (e.g. primary, secondary or tertiary prevention); 3) cognitive status of elderly (cognitively intact versus impaired); 4) type of setting (e.g. community dwelling versus institutions such as residential care, health facilities or shelters); 5) geographical regions (those from low‐ middle‐ or high‐income countries); 6) socio‐demographic characteristics of the target population (e.g. victims, perpetrators, socio‐economic status, gender or others); 7) effect of low follow‐up in the studies. Given the absence of trustworthy data or appropriate subgroups reported in these studies, no further subgroup analysis could be undertaken.
Sensitivity analysis
We had intended to carry out a sensitivity analysis for studies with low risk of bias which were combined, however as no meta‐analysis was conducted in this review, this was not performed.
'Summary of findings' tables
We intended to prepare 'Summary of findings' tables for the primary outcomes related to elder abuse using GRADE profiler (Schünemann 2011), however due to the limited studies which could not be combined, we prepared modified tables. We summarised the quality of evidence by applying the principles of the GRADE framework and following the recommendations and worksheets of EPOC for creating 'Summary of findings' tables (EPOC 2011).
We used four levels of quality (high, moderate, low and very low) to describe the body of evidence. We assessed the quality of evidence for each outcome across studies. We assessed the study design, risk of bias, imprecision, inconsistency, indirectness and magnitude of effect based on GRADE criteria. The primary determinant for upgrading or downgrading the evidence was whether the issues identified were likely to affect the outcome. The ratings of the quality of evidence were modified downward based on study limitations, imprecision, inconsistency of results, indirectness of evidence and likelihood of publication bias. The ratings were modified upward when the study had a large magnitude of effect, existing dose‐response gradient, or when consideration of all plausible residual confounders and biases would reduce a demonstrated effect, or suggest a spurious effect when results showed no effect.
We had intended one 'Summary of findings' table to contain a summary statement of the effect of the intervention upon population levels of primary outcomes using three scenarios of elder abuse levels and intervention approaches that are indicative of low‐, middle‐ and high‐income countries, however there were insufficient data from low‐ and middle‐income countries to determine this. We also intended to explore if an equity gradient was apparent, such as the staircase effect (Tugwell 2006) and to examine the data to identify whether there could be an increasing gap and decreasing effectiveness by advantaged and disadvantaged populations across relevant components of the intervention. However, the current body of evidence was insufficient to undertake these analyses.
As a meta‐analysis was not appropriate for this current review, alternative 'Summary of findings' tables using narrative analysis of the included studies were prepared.
Results
Description of studies
See Characteristics of included studies; Characteristics of excluded studies; Ongoing studies
Results of the search
As shown in Figure 2, the electronic searches between 30 August 2015 and 16 March 2016 of the databases yielded 33,488 hits. Web searches and from other sources yielded 3681 additional records. Following the removal of duplicates, 29,761 records remained. After initial screening based on the title, 230 citations were considered potentially eligible and were assessed in full text. Following the review of full‐text, seven studies (nine reports) were identified as meeting the inclusion criteria (Bartels 2005; Brownell 2006; Davis 2001; Hsieh 2009; Cooper 2015; Richardson 2002; Teresi 2013) and one ongoing study (Loh 2015), The results of the searches are shown in Appendix 1 and Appendix 2.
Included studies
Characteristics of included studies. All seven included studies were set in high‐income countries according to the World Bank economic classification (USA four, Taiwan one, and UK two).The included studies were grouped into four of the seven categories defined prior to the commencement of the review and as presented in the logic model. Of the seven included studies, three investigated the effectiveness of educational interventions targeting healthcare professionals (Richardson 2002; Teresi 2013), and caregivers (Hsieh 2009). One randomised study evaluated the effectiveness of a programme aiming to reduce factors influencing elder abuse by promoting the mental health of family carers (Cooper 2015). One study evaluated an intervention designed to increase the detection of abuse (Bartels 2005). Two studies targeted victims of abuse; one by providing a psycho‐social support and a structured educational programme in a group setting (Brownell 2006), and the other, a 'blended' multi‐strategy consisting of a broad community public education strategy followed by active individual social support services and monitoring by police of households (Davis 2001) There were no eligible studies which investigated the effectiveness of rehabilitation programmes for perpetrators of elder abuse, legislation, or specific policies on elder abuse. Summary details of all included studies are found in Table 1.
| Study | Intervention category | Study design | Sample size | Population of Interest | Country | Number of items at low risk of bias |
| Educational Interventions targeted at health professionals and/or carers | ||||||
| Educational Interventions | Controlled before‐and‐after study | 112 (recruited) | Caregivers | Taiwan | 6/11 | |
| Educational Interventions | Randomised controlled trial | 86 | Health personnel | United Kingdom | 8/11 | |
| Educational Interventions | Cluster‐randomised controlled trial | 1405 | Nursing home residents | United States | 6/11 | |
| Progammes to reduce factors influencing elder abuse | ||||||
| Programmes to reduce factors influencing elder abuse | Randomised controlled trial | 260 | Carers (family members) | United Kingdom | 10/11 | |
| Programmes to increase detection | ||||||
| Programmes to increase detection | Controlled before‐and‐after study | 44 clinicians; 100 elderly people | Clinicians and elderly consumer | United States | 2/11 | |
| Programmes targeted to victims | ||||||
| Multi‐component intervention of community‐wide education and then individual level intervention by police and social workers | Randomised controlled trial | 403 | Victims of elder abuse | United States | 3/11 | |
| Psycho‐educational support group structured with educational content | Randomised controlled trial | 16 | Abused elder women | United States | 2/11 | |
Three different study designs were employed in the seven included studies. Five studies were described as randomised with a control or comparison. Four were randomised controlled trials (Brownell 2006; Davis 2001; Cooper 2015 and Richardson 2002) and one was a cluster‐randomised trial (Teresi 2013). Randomised trials were used in studies examining the effectiveness of educational interventions (n = 2), programmes to reduce risk factors (n = 1) and interventions targeted at victims (n = 2). Two of the included studies, one investigating educational interventions (Hsieh 2009), and the other programmes to increase detection (Bartels 2005), used controlled before‐and‐after study designs without randomisation comparing outcomes before and after the implementation of the intervention.
A subjective assessment of intensity was conducted based on the consideration of six criteria as described in the methods section. Two studies were judged to be of high intensity, two of medium intensity and three of low intensity (Table 2). Categorisation of high intensity was typically assigned to an intervention which acted on more than one level within the target population and multiple components as understood by the logic model (Figure 1). For example, Davis 2001 utilised two stages; the first stage targeted the broader public through education, and the second involved participants (victims) who received a visit, and was thus deemed 'high intensity'. Bartels 2005, also a high‐intensity intervention, demonstrated a prolonged duration of delivery (24 months) with a comprehensive program that incorporated 22 assessments and treatment‐planning domains, and involved an extensive number of agencies, and broad participation of clinicians. Cooper 2015, at eight to 14 weeks duration, was of shorter duration than Bartels 2005, however provided a comprehensive approach during the period of intervention. Both Bartels 2005 and Cooper 2015 were deemed 'medium intensity', having intensity scores of six and five, respectively.
| Study | Community Partnerships | Level of Intervention | Reach of Strategies | Magnitude of Intervention | Cost Per Person | Intensity | Overall | Assessment |
| 2 | 2 | 0 | 2 | 0 | 0 | 6 | medium | |
| 0 | 1 | 0 | 1 | 0 | 0 | 2 | low | |
| 0 | 1 | 0 | 1 | 0 | 0 | 2 | low | |
| 2 | 2 | 1 | 2 | 0 | 0 | 7 | high | |
| 0 | 3 | 1 | 1 | 0 | 0 | 5 | medium | |
| 2 | 3 | 1 | 2 | 0 | 0 | 8 | high | |
| 0 | 1 | 0 | 1 | 0 | 0 | 2 | low |
Overall assessment of intensity: high (8‐10), medium (5‐7), low (1‐4).
The overall assessment used a subjective informed determination rather than a pre‐defined algorithm. The informed assessment approach was selected as the six categories presented here are not distinct, and the sufficiency of detail varies between the studies.
Excluded studies
Of the 230 papers examined in full text, we found 221 that did not meet our inclusion criteria and that we summarily excluded.The Characteristics of excluded studies table lists the studies that were excluded and the determined reasons. In several cases the studies were excluded for more than one reason. The predominant reasons for studies being excluded at this stage of the selection process were ineligible study design (151), no outcomes measures or no outcomes related to elder abuse (45), not about elder abuse (12), no evaluation described (9), no intervention (2), and not an eligible population (2). Three studies were excluded as while they appeared to use an interrupted time series (ITS) design, they did not have at least three data points before and after the intervention that is necessary to be defined as an ITS study.
Risk of bias in included studies
All included studies were assessed for their risk of bias. We assessed the risk of bias using the Cochrane 'Risk of bias' tool to which we added minor amendments according to EPOC recommendations as outlined in the methods section.The individual assessment and the reasons for the assessment are detailed in the Risk of bias in included studies tables. Graphical presentation of the results of the individual studies and of the overall body of evidence are found in Figure 3 and Figure 4. Assessment using the 'Risk of bias' tool suggests the trustworthiness of the studies across the included body of research was poor. Only one study (Cooper 2015) was judged as having no domains at high risk of bias, with two studies having two (Richardson 2002; Teresi 2013). Across nine of the 11 domains for which studies were judged, at least 40% of studies were judged as being at high risk of bias.
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
General agreement between authors assessing the risks of bias in the studies was high with consensus reached quickly through discussion when queries arose.
Allocation
Selection bias was expected to be relatively low as five of the seven studies were described by the authors as 'randomised'. However, only three ( Cooper 2015; Richardson 2002; Teresi 2013) of the five randomised studies described an adequate method of sequence generation. Allocation concealment was even more problematic, in that only two of the seven studies (29%) were judged as low risk for selection bias (Cooper 2015; Richardson 2002). This was also made more problematic for one study for which the baseline characteristics were not comparable for the intervention and control (Bartels 2005). If those selected for treatment were reversed, there is no assurance the outcome would be the same and thus the findings and conclusions could not be deemed trustworthy. For example, in Bartels 2005 the intervention group had large, medium and small amounts of caseloads, whereas the control had only small and large caseloads. Further, there were also differences in the average number of clinicians and average elderly persons between the intervention and comparison groups.
Blinding
Blinding effects both measurement bias and performance bias. In these studies, blinding of the participants was generally inadequate to minimise these biases. Two (Cooper 2015; Teresi 2013) of the seven studies blinded both participant and the personnel performing the intervention. We judged four studies at high risk of bias (Bartels 2005; Davis 2001; Hsieh 2009; Richardson 2002) given the lack of blinding for both those providing the intervention and for the participants (a combined assessment). Although Richardson 2002 did not blind interventionists, the participants' outcome assessment was blinded as the tutor and persons undertaking the rating were blinded as to who was participating in the study. On this aspect, there were two studies where the risk of bias associated with outcome assessment (detection bias) was at high risk (Hsieh 2009 and Bartels 2005), and two were the outcome assessment was unclear (Brownell 2006; Davis 2001). The knowledge of the allocated intervention within the context of outcome assessment resulted in a high risk of bias in three studies (Bartels 2005; Hsieh 2009; Teresi 2013). In the case of Teresi 2013, this was related to an inability to blind the certified nursing group.
Incomplete outcome data
The data were generally complete for the included studies and this was one of the two domains with better scores. Only one study (Davis 2001) was judged at high risk of bias. Davis 2001 experienced dropout rates in the control group ranging from 35.1% to 39.7%, and in the home‐visiting intervention group ranging from 25.8% to 29.7%. The remaining six studies were all judged at low risk of bias for this domain.
Selective reporting
Selective reporting of outcome bias was relatively low. Only one study was judged at high risk of selective reporting (Brownell 2006), with six studies being seen as being at low risk of bias for this domain. The outcomes generally aligned with the intent of the study, although an absence of trial registration and publication of protocols made this more difficult to assess. In the one study assessed as high risk of bias, Brownell 2006, one of the secondary measures (self‐esteem) was not reported.
Other potential sources of bias
As discussed in the Methods section, the inclusion of non‐randomised studies in this review prompted the assessment of additional 'Risk of bias' domains. Of concern, overall, 40% the studies were judged as being at high risk of bias when considering similarity between groups at baseline, prevention of knowledge of allocation concealment during the study, protection against contamination, and other biases. Most studies failed to describe efforts aimed at preventing contamination where it may have been possible to occur (e.g.Bartels 2005; Brownell 2006) resulting in an assessment of “unclear" risk of bias for more than half of the studies. High risk of bias from continuation was apparent in Davis 2001 where a cross‐over of participants occurred during the study. More complicated, Teresi 2013 involved randomisation of units within the same facility, and thus there was potential for the control groups to also receive the intervention.
Effects of interventions
See: Summary of findings for the main comparison ; Summary of findings 2 ; Summary of findings 3 ; Summary of findings 4
As reported previously, the nature of the studies included in this review, as well as the outcomes and data reported meant that it would be inappropriate to conduct any formal statistical pooling of studies of the primary outcome measures of occurrence or recurrence of abuse. The synthesis presented here is therefore predominantly narrative with findings organised by elder abuse preventive initiative (EAPI) as defined in the methods and presented in the logic model (Figure 1). Within these categories, findings from randomised and non‐randomised studies have been presented separated. To help the reader appreciate the evidence around individual outcomes, we also synthesised findings around the primary and secondary outcomes.
For each of the EAPI's for which there were included studies, a 'Summary of findings' table was developed (summary of findings Table for the main comparison; summary of findings Table 2; summary of findings Table 3; summary of findings Table 4). In addition, details of the design, sample size, population included, country of study, and 'Risk of bias' domains judged to be at low risk of bias of the individual studies have been summarised in a separate table (Table 1).
Educational Interventions for health practitioners and/or carers
Three studies investigating the effects of educational interventions were included in this review. Of these, two were randomised studies (Richardson 2002; Teresi 2013), and one was a controlled before and after study (Hsieh 2009). Two of the interventions included in this category were aimed at health practitioners (nurses, trainee psychiatrists, care assistants etc), while one was aimed at caregivers (Hsieh 2009). Findings are summarised in the summary of findings Table for the main comparison, however we were unable to perform any meta‐analysis given the differences in interventions, populations and outcomes used in the included studies, and therefore the results of the studies are presented below individually. Each of the studies did however measure knowledge and found that through their interventions they were able to improve knowledge relevant to elder abuse.
Randomised studies
In Richardson 2002, a study having two items judged as being at high risk of bias, the investigators aimed to determine the effectiveness of attending an educational course compared to printed educational material in improving the management of abuse of older people by nurses, care assistants and social workers. Participants were randomised to receive either an educational course (n = 44) or reading material (comparison) (n = 42). Outcomes were measured using a knowledge and management questionnaire based on vignettes of realistic or actual scenarios, given pre‐ and post‐intervention (KAMA ‐knowledge and management). The authors reported a significant difference between groups at baseline with those receiving the educational course having significantly higher mean KAMA scores (P = 0.0001). Post‐intervention results indicated that those participating in the educational course improved (3.7), while those who received the material declined (‐2.9), with an adjusted mean difference of 6.6 (95% confidence interval (CI) 1.97 to 11.23) in favour of the intervention. It was difficult to determine whether this difference was due to the intervention or to the difference in baseline scores. Analysis using ANOVA indicated that the only other significant variables ‐ other then being randomised to the educational course ‐ were low baseline scores. Further, there was no reporting of a difference between the two groups at post‐intervention with mean KAMA scores at this time point. The review authors calculated an adjusted mean difference of 6.6 and an adjusted % change relative to control group of 25.8%.
The intervention group had a higher positive attitude at both baseline and at post‐intervention. The adjusted mean difference was 0.2, and the adjusted % relative to control group was 3.2%.
For burn‐out, there was no significant difference between intervention and control at follow‐up (MD1.50, 95% CI ‐6.75 to 3.75). Adjusted mean difference was 0.1, and the adjusted % change relative to control group 0.6%.
Teresi 2013 was a prospective cluster‐randomised study which sought to evaluate the impact of a training program plus an implementation protocol to increase the knowledge, recognition and reporting of resident‐to‐resident elder mistreatment (R‐REM) in nursing homes. Nursing home units of five large facilities were randomised with nursing staff from 23 nursing homes receiving three modules of training around recognising, and managing R‐REM, as well as implementing a best‐practice protocol and improving reporting of R‐REM. Importantly, the study was deemed to be of unclear risk of selection bias due to inadequate information of allocation concealment. Staff (n = 325) in the 24 control units only received training on the reporting form used to collect outcome data regarding the 1405 residents, 685 control and 720 intervention).
At six months the adjusted mean difference for the staff‐reported number of incidents in the previous two weeks was 0.82, and the adjusted % change relative to control group was 304%. However at 12 months, the adjusted mean difference was 0.42, and the adjusted % change relative to control group 420%.
Staff knowledge (related to R‐REM) and frequency of recognition and reported R‐REM was measured only for the intervention group thus forming a process description (not an outcome assessment). Follow‐up measurements at six and 12 months suggested a significant increase in knowledge of elder‐to‐elder abuse (P < 0.001), significantly increased recognition of R‐REM occurring (P < 0.001), and significantly increased longitudinal reporting (documentation) as compared with the control group (P = 0.0058). Detection bias was high as the assessors had knowledge of the intervention. This was maintained with the experimental group reporting seven times as many incidents at six months and 12 times as many incidents at 12 months with 23 cases detected in the control and 239 in the intervention (Poisson model P = 0.0058).The process evaluation also found that management skills increased for the intervention group.
Non‐randomised study
Hsieh 2009 was a controlled before‐and‐after study in which 50 caregivers from two nursing homes in southern Taiwan attended eight group sessions of 1 to 1.5 hours length over an eight‐week period. Caregivers from two other nursing homes served as the control group (n = 50) (112 randomised). The outcomes measured included the Caregiver Psychological Elder Abuse Behavior (CPEAB) Scale for which a high score indicated a higher tendency towards abusive behaviour. The adjusted mean difference was ‐3.46 and adjusted % change relative to the control group was 11.4%. Statistically significant differences between the post‐test scores of the two groups relative to CPEAB were found (F = 4.02, P = 0.048 and 0.018, respectively). For the Knowledge of Gerontology Scale (KGNS), the adjusted mean difference was 1.32, and the adjusted % change relative to control group 5%. For the Work Stressors Inventory (WSI), the adjusted mean difference was 3.2, and adjusted % change relative to control group of 6% (overall comparison, P = 0.666) . The results suggested a significant difference in the alleviation of caregiver psychological abusive behaviour and improvement in knowledge of elder care, however the trustworthiness of this finding is low as both selection and detection bias were high. There was no difference reported in carer stress.
In summary, across the three studies, it is uncertain that these programs improve knowledge (based on a ' very low' GRADE rating), and if it did, whether it would translate into a reduction of elder abuse. Such programs may be able to improve the ability to detect resident‐to‐resident abuse (based on a 'low' GRADE rating).
Programme to reduce factors influencing elder abuse
Only one study investigated a programme to reduce factors influencing elder abuse (Cooper 2015). This low risk of bias study targeted carers of family members suffering from dementia and reported an outcome related to potentially abusive carer behaviour towards those in their care. summary of findings Table 2
Randomised study
The START trial (Cooper 2015), a low risk of bias study, randomised primary carers of family members suffering from dementia (but not living in 24‐hour care) to receive eight sessions of a manual‐based coping strategy delivered over an eight‐ to 14‐week period (n = 173) or usual care (n = 87) . The purpose of this well‐conducted study was to evaluate the effectiveness of an intervention designed to promote the mental health of carers of family members with dementia. A modified conflict scale of potentially abusive carer behaviours towards the recipient of their care was utilised for the primary outcome. There was no significant difference between reporting of less abusive behaviour in carers in the intervention group compared to those in the control group at eight months (adjusted OR 0.48, 95% CI 0.18 to 1.27) and at 24 months (adjusted OR 0.59, 95% CI 0.27 to 1.28). Secondary outcomes of anxiety and depression and quality of life of both the carer and the recipient of care were measured at three time points over an eight‐week period. The measures of anxiety, depression and quality of life favoured the intervention. For anxiety, the mean total scores on the hospital anxiety and depression scale (HADS) were statistically lower in the intervention group than in the usual care group over the eight‐month evaluation period with an adjusted difference in means of ‐1.80 points (95% confidence interval ‐3.29 to ‐0.31; P = 0.02) and absolute difference in means of ‐2.0 points. Health status (carers) was statistically higher (adjusted treatment effect scores 4.55 (0.92 to 8.17) (n = 219)). Carers in the intervention group were less likely to have case‐level depression (OR 0.24, 95% CI 0.07 to 0.76), and there was not a statistically significant reduction in case‐level anxiety (OR 0.30, 95% CI 0.08 to 1.05). Treatment effect reported was adjusted for baseline score and centre: ‐0.88 (‐1.68 to ‐0.09) (n = 229). Carers' quality of life was higher in the intervention group (difference in means 4.09, 95% CI 0.34 to 7.83), but not for the recipient of care (difference in means 0.59, ‐0.72 to 1.89). We graded the outcome of occurrence of abuse as 'low quality' as the findings are based on one study which had serious imprecision as it was underpowered for the outcome measures. However, for the combined surrogate outcome of 'anxiety and depression', we graded the evidence as 'moderate quality', indicating that this intervention approach probably reduces anxiety and depression of caregivers. It is unclear whether this translates into less abuse as occurrence is not reported.
Programme to increase detection rate for prevention of elder abuse
One non‐randomised controlled trial at high risk of bias reported on an intervention that included a component to improve the documentation of abuse and neglect which the study reported on as an outcome. summary of findings Table 3.
Non‐randomised study
Bartels 2005 reported on a controlled before‐and‐after study evaluating the effectiveness of an assessment and service planning intervention for improving the clinical practices of non‐physician community mental health providers caring for older persons. The intervention was an integrated system of clinical assessment, decision support, and outcomes measurement process designed to improve assessment practices and service planning for older adults with mental illness. Thirteen community mental health organisations and home healthcare organisations were assigned to intervention or comparison groups. Clinicians in the intervention group received a review of the assessment and service planning methodology. The clinicians from both groups were asked to enrol eligible older adult persons. Only secondary outcomes are reported.
There were no differences in clinician‐reported baseline assessment practices for neglect and abuse between the intervention and comparison groups. The analyses compared pre–post change scores between the intervention group and the comparison group and reported an odds ratio of 6.50 (however neither the P value or confidence interval was provided to substantiate the claim that it is 'significant' (n = 44 clinicians)). Re‐analysis by the review authors found an adjusted risk difference (RD) of 37.2 (95% CI ‐3.5 to 77.9) and adjusted RR of 3.24 (95% CI 0.75 to 13.9). Chart reviews at 12 months suggested the intervention was associated with an increase in assessment and documentation of domains relating to abuse including safety, and neglect and abuse.
The study authors stated that there was a significant increase at follow‐up in the proportion of charts which documented neglect and abuse in the intervention group (baseline 19.7%; follow‐up 91.8%) compared to the comparison group (baseline 0%, follow‐up 2.6%) ('odds ratio could not be calculated'). Re‐analysis of the chart audits by the review authors found an adjusted RD of 69.5 (95% CI 62.9 to 71.1) showing evidence of increased documentation. The adjusted RR could not be calculated from the data provided.
The GRADE of the evidence is 'very low quality' as it represents one study which is at seriously high risk of bias over eight of the 11 items assessed, and lacked transparency in the analysis to support claims made by the authors.
Programmes targeted to victims of elder abuse
Two randomised studies investigated the effectiveness of programs targeted at the victims of elder abuse. The nature of the interventions, however, were very different (one primarily educational and one involving a psycho‐social support group) it was inappropriate to conduct a meta‐analysis. The findings have however been summarised in summary of findings Table 4.
Randomised studies
Davis 2001 reported on a nested randomised control trial within the communities of 403 residents who had previously reported an incident of elder abuse. In the first instance, the communities were randomised to receive or not receive a whole community public education program comprising of presentations by police, posters displayed, and leaflets delivered to all elderly persons. At the individual level, abused participants were then randomised to receive or not receive a multi‐component intervention consisting of police and social worker visits with support, following up domestic violence complaints and household monitoring by police. Reccurence of elder abuse was measured over an 18‐month period. While the home visit intervention produced no difference in victims knowledge of elder abuse issues, their use of social services or their psychological well‐being, the outcome for the intervention group was worse than the controls as they were more likely to report new instances of abuse to police and research personnel. The Hazard ratio (HR) from a cox multiple regression analysis was reported: public education ( HR =1.26, home visit HR=2.05 (alpha level 0.05) and both public education and home visit HR = 1.78 (alpha level = 0.01), (n = 403). As no baseline data are provided for knowledge and the use of services at baseline, no meaningful comparison of the effects of the intervention are available for reporting.
Brownell 2006 was a very small randomised controlled trial in which victims (all mistreated at baseline) were randomised to participate in an elder mistreatment psycho‐social support group which included a structured curriculum of learning on domestic violence and abuse and neglect amongst other topics delivered in two‐hour sessions for eight consecutive weeks (n = 9), or no intervention (n = 6). As with the previous study, this small study reported the primary outcomes of recurrence of victim abuse. For physical abuse, post‐test: 0% of controls and 13% of intervention participants reported abuse (P = 0.41). The adjusted RR could not be calculated although the adjusted RD was 34 (95% CI ‐23.5 to 91.5). For non‐physical abuse, 75% of controls and 83% of intervention participants reported non‐physical abuse during the study with a comparison between intervention and control groups finding no significant difference (P = 0.71), with an adjusted RR 0.91 (95% CI 0.58 to 1.45) and an adjusted RD ‐9 ( 95% CI ‐56.8 to 38.8).
There was no statistically significant difference between the groups for depression as indicated by the adjusted RR (adjusted RR .42, (95% CI 0.05 to 3.7), an adjusted RD (adjusted RD ‐19 (95% CI ‐60 to 22.0)). Guilt was also not statistically different ((adjusted RR 1.33 (95% CI 0.30 to 5.89); and adjusted RD 3 (95% CI ‐11.5 to 17.5)).
There was Insuffcient reporting of Self‐Esteem (Rosenberg scale), and the findings for Sense of Control and Social Support, anxiety and somatisation were not reported.
No firm conclusions can be drawn from this study due to its small size and high risk of bias on eight of the 11 categories assessed.
Rehabilitation programmes for perpetrators of elder abuse
There we no eligible studies of programmes for perpetrators.
Primary outcomes
The details of the primary outcomes measured by the included studies are provided in Table 3 and Table 4, and described earlier in Effects of interventions. Two of the included studies used measures or proxy measures for outcomes relating to the occurrence of elder abuse (Cooper 2015; Hsieh 2009), and two studies measured the recurrence of abuse (Brownell 2006; Davis 2001). The tools and methods used to measure these outcomes varied between studies as did the interventions which the studies evaluated.
| Study/outcome | |||||||
| Intervention approach | Educational intervention health professionals | Educational intervention for health professionals | Educational intervention for carers | Programmes targeted to victims, support group and education | Programmes targeted to victims, multi‐component, community education and individual intervention by police and social workers | Programs to reduce factors influencing elderly abuse (family members) | Programs for increasing detection for preventing elderly abuse |
| Intervention level | S | S | S | T | T | P | T |
| Primary outcomes | |||||||
| Abuse occurrence | ￭ | ￭ | |||||
| Abuse recurrence | ￭ | ￭ | ￭ | ||||
| Secondary outcomes ‐ Participant‐related outcomes | |||||||
| Improve detection | ￭ | ￭ | ￭ | ||||
| Improve management skills | ￭ | ||||||
| Improve knowledge | ￭ | ￭ | ￭ | ||||
| Improve attitudes | ￭ | ||||||
| Burn‐out | ￭ | ||||||
| Stress | ￭ | ||||||
| Sucide | ￭ | ||||||
| Self‐esteem | ￭ | ￭ | |||||
| Depression | ￭ | ￭ | |||||
| Anxiety | ￭ | ￭ | |||||
| Guilt | ￭ | ||||||
| Quality of Life | ￭ | ||||||
| Service satisfaction | ￭ | ||||||
| Service delivery | ￭ | ||||||
| Secondary outcomes ‐ Victim or perpetrator‐related outcomes* | |||||||
| Crisis management | |||||||
| Management of perpetrators | |||||||
Level of intervention: P: Primary S: Secondary T:Tertiary
*None identified in the included studies.
| Author | Type of intervention | Study design | Type of abuse measured | Measurement for outcome | Authors' FIndings |
| Programme to reduce factors influencing elder abuse | Pragmatic randomised parallel group superiority trial | Occurrence of abuse | Modified conflict tactics scale | Family member carers in the intervention group report lower abusive behaviour (MCTS ‐ modified conflict tactics scale with at least 1 item scoring > 2) towards the recipient of care compared with those in the treatment as usual group which were not statistically significant 24 months. 8 months: treatment effect: OR 0.47, 95% CI 0.18 to 1.23, P > 0.05 (n = 214) Adjusted OR 0.48, 95% CI 0.18 to 1.27 (n = 206) 24 months: Treament effect: Adjusted for baseline OR 0.59, 95% CI 0.27 to 1.28 (n = 213) | |
| Educational interventions (for health professionals and/or carers) | Controlled before‐and‐after trial | Occurrence of abuse | Caregiver Psychological Elder Abuse Behavior Scale (CPEAB) | Caregivers’ abusive behaviours: (n = 50, each group analysed) Decreased significantly after the intervention. The intervention group’s change from baseline (Mean 31.22, 95% CI 29.53 to 32.91, SD 6.10) to post‐test (Mean 29.16, 95% CI 27.49 to 30.83, SD 6.02) (P = 0.01). (n = 100 analysed) No significant differences between the pre‐ (Mean 28.98, 95% CI 27.36 to 30.6, SD 5.84) and post‐tests (Mean 30.38, 95% CI 28.76 to 32, SD 5.84) in the control group (P < 0.179). Adjusted mean difference ‐3.46, Adjusted % change relative to the control group 11.4% (confidence intervals can not be calculated) Statistically significant differences between the post‐test scores of the two groups relative to CPEAB (F = 4.02, P = 0.05 and 0.02, respectively). | |
| Programmes for victims (Psyco‐educational support groups) | Randomised controlled trial | Recurrence of abuse: "Non‐physical abuse"; "physical abuse" | Hartford Study Physical Abuse Subscale, Hartford Study Non‐physical Abuse Subscale | Findings based on Intervention of 9 persons, control 6. Only women only included. Physical abuse reported: Pre‐test: 43% of controls and 22% of intervention participants Post‐test: 0% of controls and 13% of intervention participants (n = 15, post‐intervention & control comparison, P = 0.41). Adjusted RR can not be calculated. Adjusted RD 34, 95% CI ‐23.5 to 91.5 Non‐physical abuse reported: Pre‐test: 83% of controls and 100% of intervention participants. Post‐test: 75% of controls and 83% of intervention participants reported non‐physical abuse at post‐test. Intervention & control comparison, P = 0.71, n = 15. Adjusted RR 0.91, 95 CI 0.58 to 1.45. Adjusted RD ‐9, 95% CI ‐56.8 to 38.8 (Neither OR or RR were provided by the authors, but calculated by review authors) | |
| Programme for victims (including a whole of community component of public education) | Nested randomised controlled trial | Recurrence of abuse | Modified version of Conflict Tactic Scale | Elderly who received public education did not differ from those in the control group. However, elderly in the home visit group fared worse than those in the control group, while those who received both treatment reported more repeated victimisation. All persons reported abuse at baseline. Total abuse: At 6 months, total abuse reported repeated victimisation* No intervention: mean 5.87, 95% CI 3.39 to 8.35 SD 12.63 Public education: mean 3.18, 95% CI 1.79 to 4.57, SD 7.11, Home visit: mean 4.61, 95% CI 2.47 to 6.75, SD 10.92 Both (PE+HV): mean 12.63, 95% CI 8.13 to 17.13, SD 25.96. At 12 months, total abuse reported victimisation*. No intervention: mean 5.36, 95% CI 3.66 to 7.06 ,SD 8.67 Public education: mean 4.07, 95% CI 2.32 to 5.82, SD 8.94 Home visit: mean 3.66, 95% CI 2.17 to 5.15, SD 7.62 Both (PE+HV): mean 8.58, 95% CI 4.01 to 13.15, SD 23.32 Hazard ratio (HR) from Cox multiple regression: Public education HR 1.26, Home visit HR = 2.05 (alpha level 0.05), Both (PE+HV) HR = 1.78 (alpha level = 0.01), n = 403 *The study does not specify the exact numbers of participants in each group. The review authors have made the 95%CI calculations based upon an estimate of 100 persons in each group. The 95% CI are indicative only. |
Study arranged according to type of intervention, followed by study design
OR: odds ratio, RD: risk difference, RR: relative risk, SD: standard deviation
Of the studies measuring the occurrence of elder abuse, only Hsieh 2009, a non‐randomised study at high risk of bias, examining an educational intervention in caregivers in nursing homes in Taiwan, reported a between‐group effect of a net decrease in abusive behaviours, as measured through the Caregiver Psychological Elder Abuse Behavior Scale (between‐group F =4.02, P = 0048). Using the data provided, the mean difference in the post‐test measures for intervention and control was ‐1.22 (95% CI ‐13.5 to 1.10). In a randomised trial, at low risk of bias, the post‐mean difference of an intervention intended to promote the mental health of family carers showed no significant difference in the reporting of less abusive behaviour in carers in the intervention group (Cooper 2015).
Two studies investigated interventions which targeted victims of abuse. A trial of an intervention which included a home visit by a police officer and a social worker to victims of elder abuse reported an increase in the occurrence or reporting of abuse in the intervention group over a 12‐month follow‐up (Davis 2001). A small randomised study (n = 14) evaluating the effectiveness of a psycho‐social support group with relevant curriculum, found no difference on re‐occurence of abuse between the two groups (Brownell 2006).
Secondary outcomes ‐ participant‐related outcomes
Secondary outcomes reported in the included studies are detailed in Table 5, and described earlier in the Effects of interventions section.
| Author | Type of intervention | Study design | Types of secondary outcomes measured | Measurement for outcome | Authors' FIndings |
| Programme to reduce factors influencing elder abuse | Pragmatic randomised parallel group superiority trial | Carer‐related risk factors | Hospital anxiety and depression scale health status questionnaire (family member carers), depression, quality of life‐Alzheimer's disease | Anxiety: Mean total scores on the hospital anxiety and depression scale were statistically lower in the intervention group than in the usual care group over the eight‐month evaluation period: adjusted difference in means ‐1.80 points (95% CI ‐3.29 to ‐0.31, P = 0.02) and absolute difference in means ‐2.0 points. Health status (carers): Statistically higher, adjusted treatment effect 4.55 (95% CI 0.92 to 8.17) (n = 219) Depression: Carers in the intervention group were less likely to have case‐level depression (OR 0.24, 95% CI 0.07 to 0.76) and there was not a statistically significant reduction in case level anxiety (0.30, 95% CI 0.08 to 1.05). Treatment effect reported adjusted for baseline score and centre: ‐0.88 (‐1.68 to ‐0.09) (n = 229) Quality of life: Carers' quality of life was higher in the intervention group (difference in means 4.09, 95% CI 0.34 to 7.83) but not for the recipient of care (difference in means 0.59, 95% CI ‐0.72 to 1.89). | |
| Educational interventions (for health professionals and/or carers) | Controlled before‐and‐after, not randomised | Caregivier related | Knowledge of Gerontology Nursing Scale (KGNS) Work Stressors Inventory (WSI), | KGNS: Statistically significant differences were found between the post‐test scores of the two groups for KGNS (P = 0.018), improved significantly for the intervention group. Post‐test Intervention (n = 50, each group) Intervention group: Mean scores increased, pre‐test mean 28.74, 26.89 to 30.59, SD 6.67 and post‐intervention mean 32.96, 95% CI 31.07 to 34.85, SD 6.82. Control group: No significant differences between the pre‐ and post‐tests on KGNS measures (pre‐test = mean 26.06, 95% CI 23.97 to 28.15, SD 7.55; post‐test = mean 28.96, 95% CI 27.17 to 30.75, SD 6.47; P = 0.065) Adjusted mean difference 1.32 Adjusted % change relative to control group 5% Stress (WSI): no effect on caregivers' perceived level of stress between intervention and control groups. Intervention group: pre‐test mean 64.14, 95% CI 47.53 to 61.63, SD 20.52; post‐test mean 59.42, 95% CI 53.31 to 65.53, SD 22.04. Control group: pre‐test mean 59.50, 95% CI 52.37 to 66.63, SD 25.72; post‐test = mean 54.58, 95% CI SD 25.44; P = 0.330). Adjusted mean difference 3.2, adjusted % change relative to control group 6% Overall comparison, P = 0.660. | |
| Educational interventions (for health professionals and/or carers) | RCT pre‐ and post‐ measurements | Caregiver related | Knowledge and Management of Elder Abuse (KAMA) Caregiver Scenario Questionnaire (CSQ) Attitude of Health Care Personnel towards Maslach Burnout Inventory (MBI) | KAMA: There was a significant difference between intervention groups in final KAMA score with those randomised to Intervention ("Group 1" educational course intervention) improving after intervention and Control ("Group 2" educational material ) deteriorating Intervention mean = 3.7; 95% CI 0.85 to 6.55, SD 8.1, Control mean = –2.9; 95% CI ‐6.31 to 0.51, SD 10.0 ANOVA F=23.0; P<0.0001). Adjusted mean difference 6.6, Adjusted % change relative to control group 25.8% Attitude: At baseline Intervention had a significantly more positive attitude than Control 2 (pre‐intervention mean attitude score 13.5; SD 5.4 and 5.6; SD 4.2, respectively; P < 0.0001; mean difference 7.9; 95% CI = 5.1 to 10.7) and post‐intervention score was higher than the control Intervention: mean score 14.3, 95% CI 12.36 to 16.24, SD 5.5 Control mean 6.2, 95% CI 4.39 to 8.01, SD 5.3 P < 0.0001 Mean difference 8.2, 95% CI 5.0 to 11.2 Adjusted mean difference 0.2, adjusted % change relative to control group 3.2% Burn‐out:There were no significant differences in burn‐out scores between Intervention and Control before or after intervention. Intervention: Baselline 16.0, 95% CI 12.69 to 19.31, SD 9.4, Follow‐up 15.2; 95% CI 12.45 to 17.95, SD 7.8. Control Baseline 17.6, 95% CI 13.54 to 21.66, SD 11.9, Follow‐up 16.7; 95% CI 12.71 to 20.69, SD 11.7 Adjusted mean difference 0.1, adjusted % change relative to control group 0.6% | |
| Educational interventions (for health professionals) | Cluster‐RCT | Resident‐to‐resident elder mistreatment focus with caregiver | 10 items knowledge test. Resident‐to‐Resident Elder Mistreatment Behavior | Dectection incidents in the past 2‐weeks: Intervention: (n = 720) Baseline: (n = 353), mean 0.51, 95% CI 0.22 to 0.8, SD 2.79 At 6 months:(n = 580, mean 1.08, 95% CI 0.48 to 1.68, SD 7.34 12 months: (n = 239), mean 0.51, 95% CI, 0 to 1.02, SD 4.01 Control: (n = 784) Baseline: (n = 354) mean 0.52, 95% CI 0.17 to 0.87, SD 3.4 At 6 months: (n = 79) mean 0.27, 95% CI 0.00 to 0.59, SD 1.46 12 months: (n = 23) mean 0.10, 95% CI 0.00 to 0.26, SD 0.39 At 6 months: Adjusted mean difference 0.82 Adjusted % change relative to control group 304% At 12 months: Adjusted mean difference 0.42 Adjusted % change relative to control group 420% The intervention group reported more incidents at 6 and 12 months than did the control group. The sum of incidents reported during the staff interview at baseline for the previous two week period was 354 for the control group and 353 for the experimental group. After training, the six‐month numbers for the control and experimental groups were 79 and 580 and at 12 months 23 and 239, respectively.(Poisson model P = 0.0058) Knowledge scores, reported only for intervention group: Nursing staff’s gain in knowledge was significantly higher for both Module 1 (Pre‐test mean 7.43, 95% CI 7.3 to 7.56 SD 1.16 n = 319; post‐test Mean 8.13, 95% CI 7.99 to 8.27, SD 1.29; P < 0.001) Module 2 (Pre‐test mean 7.40, 95% CI 7.22 to 7.58 SD 1.54; n = 271; post‐test mean 8.38, 95% CI 8.2 to 8.56, SD 1.52; P < 0.001) in intervention group without comparison to the control group. Process evaluation: showed management skills increased for the intervention group: Baseline 7.43 SE 1.54, follow‐up 8.38, SE1.52. | |
| Programme to increase detection of elder abuse | Controlled before‐and‐after trial, not randomised | Assessment practices | Interview and audit of clinician practices of abuse identification | There were no differences in clinician‐reported baseline assessment practices for neglect and abuse between the intervention and comparison group. However, baseline comparisons of medical records found greater documentation for neglect and abuse within intervention agencies Neglect and abuse Clinican interview. clinicians reporting assessment of neglect and abuse Intervention (n = 26) Baseline: 11.5% Year 1 follow‐up : 65.4% Control (n = 18) Baseline: 22.2% Year 1 follow‐up 38.9% Reported OR = 6.50 Authors state that at 1‐year follow‐up, there was a significant increase in the proportion of clinicians in the intervention group (baseline 11.5%, follow‐up 65.4%) who reported routinely conducting clinical assessments in neglect and abuse domain. In contrast, there was little change in reported clinical practices by clinicians in the comparison sites (baseline 22.2%, follow‐up 38.9%). The analyses compared pre–post change scores between the intervention group and the comparison group and have reported OR of 6.50, however neither the P value or confidence interval is provided to substantiate the claim that it is 'significant'. (n = 44) Re‐analysis by review authors: adjusted RD 37.2, 95% CI ‐3.5 to 77.9; adjusted RR 3.24, 95% CI 0.75 to 13.9 (not statistically different) Chart audit: The authors states that there was a significant increase in the proportion of charts which documented neglect and abuse in the intervention group (baseline 19.7%; follow‐up 91.8%) compared to the comparison group (baseline 0%, follow‐up 2.6%) at follow‐up. Chart audit: Intervention (n = 61 charts audited) Baseline 19.7 % 1‐year follow‐up: 91.8% Control (n = 39) Baseline 0.0% Follow‐up 2.6% 'Odds ratio could not be calculated' Re‐analysis by review authors: adjusted RD 69.5, 95% CI 62.9 to 71.1; adjusted RR could not be calculated. | |
| Programme for victims (psycho‐educational support groups) | Randomised controlled trial | Victims: sense of control, social support, alcohol abuse, depression, drug use, family relationship problems, guilt, suicide, anxiety and somatisation | CESB‐D 10 Hartford Study; Guilt Subscale; Rosenberg Self‐Esteem Scale; Health Locus of Control Scale; Medical Outcomes Study Social Support Survey; BSI‐18 | Recruitment of 16 women, 15 completers. 9 intervention, 6 control There were no significant changes in outcome measures for either control or intervention group participants after the intervention ended; depression, guilt, and self‐esteem (n = 15). Depression: 14% of controls and 56% of intervention participants suffered from depression at pre‐test. 33% of controls and 56% of intervention participants suffered from depression at post‐test. (Post, intervention & control comparison P = 0.49). Guilt: 28% of the control participants scored above threshold and 33% of the intervention participants scored above threshold at pre‐test. 14% of the control participants scored above threshold and 22% of the intervention participants scored above threshold at post‐test.(post, intervention & control comparison P = 0.75). Calculated adjusted RR 1.33 (favouring control) 95% CI 0.30 to 5.89. Adjusted RD 3, 95 CI ‐11.5 to 17.5. Self‐Esteem (Rosenberg scale): Authors stated "Participants scored an average of 32, which is above the midpoint." Average score for either groups not reported. Findings on Sense of Control and Social Support, anxiety and somatisation not reported. | |
| Programme for victims (including a whole of community component of public education) | Nested randomised controlled trial | Victims: i) knowledge of services ii) satisfaction with police iii) assessment of service delivery iv) self‐esteem v) well‐being of victims | i) six‐item Use of Services Scale ii) self‐developed questions iii) self‐developed questions iv) Rosenberg Self‐esteem v) Bradburn Affect‐Balance Scale | No baseline data are provided for comparison, The study authors stated there was no significant difference between intervention and control group in relation to knowledge about elder abuse or awareness and use of services at 6th or 12th months. There is no significant difference between experimental and control group in their psychological states. Without baseline comparison, no further reporting is warranted.See Davis 2001 for further detail. |
CI: confidence interval, OR: odds ratio, RD: risk difference, RR: relative risk, SD: standard deviation
Increased awareness regarding elder abuse
No studies included outcomes relating to increasing the awareness of elder abuses.
Improvement in knowledge and attitude towards elder abuse
Several studies included outcomes that related to the knowledge and attitude of carers towards elder abuse. Educational interventions, appeared to be broadly effective at increasing knowledge regarding elder abuse with Hsieh 2009, Richardson 2002, and Teresi 2013 all reporting an increase in knowledge in health professionals included in their studies. Richardson 2002 also reported on attitudes of staff towards demented patients, and while there was no difference brought about by the intervention, it was noted that pre‐intervention scores were high, so no improvement would have been expected.
Improvement in skills towards handling elder abuse
While some studies included measurement of reporting or detection behaviours, skills were not measured in any of the trials included, with the exception of Teresi 2013, which demonstrated a gain in knowledge of management of resident‐to‐resident elder mistreatment after an educational module in the intervention group, but this was not compared to the control.
Increased detection
The concept of measuring improvement in detection or reporting as opposed to the occurrence or recurrence of abuse is complicated. Nonetheless, Bartels 2005 and Teresi 2013 included outcomes related to the detection or reporting of elder abuse. The educational intervention evaluated by Teresi 2013 was effective at improving recognition and longitudinal reporting of resident‐to‐resident abuse.
In a study designed to improve detection through the improvement of mental health screening and service planning practices by clinicians for older adults, Bartels 2005 found that an assessment and service planning intervention was associated with an increase in assessment and documentation of domains relating to abuse including safety, and neglect and abuse.
Increase in elderly independent living
No studies measured elderly independent living
Secondary outcomes ‐ victim‐ or perpetrator‐related outcomes
Improvement in crisis management and relocation of victims
No studies measured improvement in crisis management or relocation of victims.
Improvement in conflict resolution and management of perpetrators
No studies measured improvement in conflict resolution and management of perpetrators.
More intense studies
Four of the studies included in the review were classed as being medium to highly intensive based upon the subjective assessment in the methods section (Bartels 2005; Cooper 2015; Davis 2001; Teresi 2013). Of these studies, Bartels 2005 did however show some effect, but because of high risk of bias of the included studies, incompleteness of reporting, inconsistency of the effectiveness, and the heterogeneity observed in the intervention approaches, no firm conclusion can be drawn.
Discussion
Summary of main results
Seven studies met the criteria for inclusion in this review; five of which were described as 'randomised trials'. These seven studies investigated the efficacy of interventions aimed at decreasing the occurrence or recurrence of elder abuse by acting on mechanisms believed to be capable of moderating long‐term outcomes. Five of the studies sought to modify the behaviour of carers, family members, other service providers, or victims of abuse through the provision of a variety of programmes. There is some evidence to suggest that the interventions were able to improve knowledge and attitudes relevant to elder abuse; however their ability to change the occurrence or recurrence of elder abuse is uncertain. Similarly, a study a with low risk of bias (Cooper 2015) aimed at promoting the mental health of carers was successful at improving certain mental health measures, however it found no difference in the 'harder' outcome of reporting behaviours of elder abuse.
Other interventions identified in this review sought to intervene on victims or perpetrators with the intention to prevent the recurrence of abuse. While there was some evidence that these interventions may have some effect on more distal outcomes (e.g. attitudes and coping), there is no evidence to show an effect on the occurrence of elder abuse.
Educational Interventions
Educational interventions provided the largest body of evidence in this review. Most educational interventions focused primarily on healthcare professionals. There is some limited evidence to suggest that educational interventions improve knowledge and attitudes towards elder abuse among healthcare professionals. There is no evidence to suggest if educational interventions prevent elder abuse or reduce recurrent elder abuse or other related outcomes. There is, however, emerging evidence (Teresi 2013) that education interventions for healthcare professionals might improve detection and management of elder abuse.
There is very little detailed information available about the educational intervention programme that could be a useful guide for future curriculum development. There are significant variations in the methods of delivery, frequency and intensity of the educational programmes used in the included studies. Didactic, face‐to‐face sessions were the most common method of information dissemination which were conducted as a one‐off session except for Teresi 2013 and Hsieh 2009. Only one study compared the effectiveness of the methods of information delivery (Richardson 2002). The findings from that study suggests that dissemination of printed information is less effective compared to face‐to‐face didactic sessions. An observation that we made in this review was of the lack of underlying theoretical basis to inform these programmes. Outcome measures were different across studies, particularly in relation to the tools used and duration of the measurement. WIth such variations, it is difficult to draw any useful comparisons. Most studies did not provide enough information on the development and process of these intervention programs to be replicable in other populations or settings.
Programme to reduce factors influencing elder abuse
There is no strong evidence to suggest that programmes specifically targeting risk factors on elder abuse actually prevent or reduce elderly abuse. The only randomised controlled trial included in this review that examined this type of programme found no significant difference in the reporting of abusive behaviour among carers in the intervention group compared to those in the control group (Cooper 2015).
Programme to increase detection rate for prevention of elder abuse
We did not have enough evidence to draw a firm conclusion about the effectiveness of programmes specifically aiming to increase detection through interventions such as home visits, home‐based geriatric assessment and helplines. Neither is there information about whether they are useful to reduce occurrence or recurrence of abuse. In one study (Bartels 2005), which compared clinicians who performed usual care with clinicians in the intervention group using a new integrated system of clinical assessment, and decision support for elderly with mental illness. The clinicians in the intervention group were more likely to screen for elder safety, neglect and abuse during the 12‐month period than the clinicians in the control (usual care) group.
Programmes targeted to victims
Findings from this review suggest that there is insufficient trustworthy evidence to identify which type of victims' programmes are most effective and under what circumstances. There is an indication that there may be negative, harmful effects associated with these programmes where abuse was reported higher among the elderly who received home visits than those in the control group (Davis 2001). The study authors hypothesised that it was possible that the abusers of the elderly became angered by attempts to intervene. There is also the possibility that the elderly who received the intervention were more likely to report new instances of abuse to police and research personnel during or after the intervention.
On the other hand, Brownell 2006 did not find any significant change in outcomes among older women who were victims of mistreatment receiving psycho‐social support. The insignificant outcomes may be largely attributed to participants already receiving services from other aging services providers prior to the study, or due to the ineffectiveness of the programmes or due to programme implementation factors (not reported in the studies).
Rehabilitation programmes for perpetrators
There is an absence of evidence to support any particular intervention related to elder abuse that targets perpetrators.
Overall completeness and applicability of evidence
The logic model, published in the protocol for this review, nominated seven avenues through which interventions may act (education, reducing influential risk factors, legislation, policies for the elderly, programmes to increase detection, programmes targeted to victims, rehabilitation programs). Three of the seven studies included in this review were of educational interventions directed at health professionals or carers, with another aiming to reduce risk factors of carers, one to increase detection, two of programs targeting victims (one primarily around education and one utilising a psycho‐social support group and providing educational material), and one was a programme targeting perpetrators. Many of these studies were of high risk of bias or were very small and thus lacked trustworthiness. There are therefore considerable gaps in the available evidence and in our understanding of effective mechanisms to reduce the incidence of elder abuse.
Analysing and applying the body of evidence is complicated by the variety and reliability of measures employed in the trials. Measuring outcomes of elder abuse is complicated by the complex causes and manifestations of elder abuse, as well as the distal and long‐term nature of many of the interventions conflicting with the pragmatic realities of trials. Further, depending on the context, instances of elder abuse may be rare therefore requiring a large sample size to discern any meaningful difference. Investigators may therefore adopt proxy or intermediate measures that reflect the cascade of actions that the intervention being evaluated is intended to produce. For example, an intervention may be designed to increase knowledge, then behaviour change, improve assessment and reporting, and eventually prevent instances of elder abuse, or improving detection. If hard outcomes are unable to be used then there is a need for validated, relevant and meaningful proxy outcomes. The absence of these inevitably leads to questions about how much confidence can be placed in the link between proxy measures and abuse.
There is also significant need for further development and evaluation of interventions, as well as the need to explore efficacy in different settings. All studies were conducted in high‐income countries, in three western countries and one Asian country. Hsieh 2009 investigated an educational intervention on nursing home caregivers in Taiwan. The literature therefore provides little guidance as to the likely effectiveness of interventions in different settings, particularly in middle‐ and lower‐income countries where there are often different expectations and practices in caring for the elderly, and therefore likely different pathways to abuse. The limited number of settings explored in the included data, therefore further limits the applicability of the study findings.
Quality of the evidence
Two of the studies were non‐randomised (Bartels 2005; Hsieh 2009), which was particularly problematic in that other aspects of study design were often not strongly conducted. Several studies had very small sample sizes and there were further issues in relation to the validation of measurements and outcomes employed. Many of the studies were at high risk of bias or unclear risk of bias for most domains, so we down‐graded the quality of the evidence to low or very low.
Potential biases in the review process
There were several potential biases that we encountered during identification of relevant studies in the review process. Firstly, the multidisciplinary nature of this topic and the heterogeneity of the interventions prompted us to adopt a broad search strategy approach. The topic crosses multiple disciplines such as health, medicine, social sciences, law, and policies. During the search process, we found there is a lack of standard and clear terminology used within this topic due to the range of disciplines, countries and the type of abuse covered in this review. An extensive list of terms and synonyms were utilised to capture the concept of "abuse" itself, ranging from abuse, maltreatment, mistreatment, assault, neglect and so on. A similar issue was identified for the concept of 'elder' and various interventions where many terms and synonyms were used in addition to employing truncation and adjacency operators during the search process to minimise any potential risk of missing any relevant studies. However, a broad search approach drew a large number of irrelevant literature as evidence in Figure 2. In addition, few bibliographic databases allowed limited terms to be searched, hence presenting the risk that relevant studies could be missed in this review. The databases searches tended to duplicate each other.
This review has a strict inclusion criteria, primarily including interrupted time series (ITS), controlled before‐and‐after (CBA) and randomised controlled trial (RCT) study designs that have at least 12 weeks of follow‐up period. During the screening process, we found a number of relevant elder abuse interventions, but these were mainly descriptive, observational studies and case studies. In cases where the study designs fitted the inclusion criteria, there were studies which had measurement time points limited to pre‐ and one post measurement, or no comparison groups. Three excluded studies originally appeared as ITS design ( Cooper 2012; Nusbaum 2007; Reay 2002), but a closer examination revealed that there was inadequate pre‐intervention measurements of outcomes. We argue that the strict inclusion criteria is necessary given that it is absolutely vital to identify methodologically rigorous studies that can provide evidence of sustainable outcomes.
Agreements and disagreements with other studies or reviews
This review concurs with findings from four recent reviews conducted ( Alt 2011; Daly 2011; Ploeg 2009; WHO 2011) that there is insufficient evidence on elder abuse interventions to demonstrate prevention or reduction of elder abuse. Among these interventions, in particular, no low risk of bias studies on provision adult protective services, emergency shelters, legislation support, public information or educational campaigns or intergenerational programmes, restraint‐reduction programmes and helplines that could be included in this review. Although we identified a number of interventions implemented in various countries, three major issues identified were: 1) interventions are embedded within a larger study, not specifically address to elder abuse, 2) the scarcity of a comprehensive evaluation on the effectiveness of these programme (e.g. lack of multiple time point measurements or long‐term follow‐up), and 3) intervention not measuring abuse‐related outcomes and its cost effectiveness. This research, as shown in the Characteristics of excluded studies, concurs with reviews such as Alt 2011 that a large proportion of the literature on elder abuse describes programs for elder abuse which are often brief, without a comparison, and in many cases, only report post‐intervention descriptions of satisfaction with a program. Although these publications are useful to describe the processes and acceptability of the interventions, they fail to meet the criteria to establish a causal relationship (Schünemann 2011a) for abuse prevention that policy makers and health professionals can use. These findings are frustrating as much earlier, the Wilson 2003 review identified few evaluations of interventions to end or reduce elder abuse, with the majority of the literature at high risk of bias.
Footnotes (Figure 1):
1Programmes to reduce factors influencing elder abuse (e.g. respite care, social support, psychological programme, restraint reduction, intergenerational programme)
2Legislation (e.g. advocacy‐based programme, law‐orientated programme, legal institution, elderly act, mandatory reporting, adult protection statutes)
3Specific policies for elderly (e.g. improve housing, transport, aged friendly cities, banking, pension, welfare aid)
4Programmes to increase detection rate for prevention (e.g. home visit, home‐based geriatric assessment, helpline, training for healthcare workers and social worker, guideline/ protocol, screening)
5Programmes targeted to victims (e.g. adult protective services, emergency shelter, temporary residential services)
6Rehabilitation programmes (e.g. legal assistance, psychiatric intervention, support, counselling)
7Other professionals (e.g. legislators, policy makers, politicians, journalists)
8 Increase identification (e.g. increase detection rate, increase reporting)
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
| Educational interventions compared with control for preventing elderly abuse | ||||
| Patient or population: Carers of elderly persons Settings: Workforce training Intervention: Educational interventions Comparison: Control – no specific training | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Occurrence of abuse – caregivers: Caregiver’s abusive behaviours (Caregiver Psychological Elder Abuse Behaviour Scale) (duration not specified, assumed 10 months) | Abusive behaviour typically lower in the trained caregiver group (e.g. adjusted mean difference ‐3.46, adjusted % change 11.4%) | 112 caregivers (1 study) | ⊕ΟΟΟ Very Low1 | One study included this primary outcome |
| Occurrence of abuse by elderly persons: Detecting resident‐to‐resident abuse ( 6 & 12 months) | Intervention group reported more incidents at 6 & 12 months for the intervention than the control (adjusted mean difference to the control of 420%)#1 | 325 caregiver nurses, 1405 residents (1 study) | ⊕⊕ΟΟ Low2 | One study included this primary outcome |
| Knowledge and attitude to elder abuse (6 to 12 months) | Knowledge generally improved after intervention (e.g. KAMA scores adjusted mean change 25.8%, KGNS 5%) | 523 caregivers (3 studies) | ⊕ΟΟΟ3 Very Low | Substantial heterogeneity between trials regarding type of interventions and measured outcomes. |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded three levels for non‐randomised study, serious risk of bias and imprecision 2 Downgraded two levels for serious risk of bias and possible contamination 3 Downgraded three levels for substantial heterogeneity and risk of bias in the 3 studies, and the inclusion of one non‐RCTstudy of 112 caregivers as 'very low', #1 Refers to 12‐month result | ||||
| Programs to reduce factors influencing elderly abuse | ||||
| Patient or population: Carers of elderly persons Settings: Caregivers of family members suffering from dementia Intervention: Reducing factors influencing elderly abuse through promoting the mental health of caregivers | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Occurrence of abuse – caregivers: Caregiver’s abusive behaviours (Modified conflict tactics scale) (8 months) | No statistical difference in abusive behaviour between the groups(adjusted OR 0.48, 95% CI 0.18 to 1.27) | 260 caregivers (1 study) | ⊕⊕ΟΟ Low1 | One low risk of bias study which appeared inadequately powered included this primary outcome |
| Anxiety and depression: total scores on hospital anxiety and depression scale (HADS) (8 months) | Mean total HADS score lower for the intervention group of caregivers than the control (‐1.80 points (95% CI ‐3.29 to ‐0.31, P = 0.02) | 260 caregivers (1 study) | ⊕⊕⊕Ο Moderate2 | One low risk of bias study included this secondary outcome |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded two level for very serious imprecision 2 Downgraded one level based on only one study reporting as a secondary outcome | ||||
| Programs for increasing detection for preventing elderly abuse | ||||
| Patient or population: Carers of elderly persons with a responsibility for detecting abuse Settings: Community mental organisations and home care organisations Intervention: Programs for increasing detection for preventing elderly abuse through the provision of a toolkit | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Occurrence of elder abuse | Outcome was not reported for this comparison | |||
| Clinician assessment practices (1 year) | The study authors claimed that there was a significant increase in the proportion of clinicians in conducting clinical assessments in neglect and abuse domain, however they failed to provide statistical analyses to support this conclusion | 13 agencies, 44 clinicians, 100 elderly persons (1 study) | ⊕ΟΟΟ Very low1 | One high risk of bias study included this secondary outcome |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded three levels based on only one non‐randomised study with very serious risks of bias and a lack of transparency in the analysis of this secondary outcome (indirectness) | ||||
| Programs targeted to victims for preventing elderly abuse | ||||
| Patient or population: Victims of abuse Settings: Community settings Intervention: Programs targeted to victims for preventing elderly abuse including the provisions of psycho‐education support and materials | ||||
| Outcomes (duration of follow‐up) | Summary of effects | No of Participants | Quality of the evidence | Comments |
| Recurrence of abuse: Physical abuse – Hartford study physical abuse subscale (8 weeks post intervention) | Unable to determine | 16 (1 study)3 | ⊕ΟΟΟ Very low1 | One very small study at high risk of bias included this primary outcome |
| Recurrence of abuse – elderly persons: Modified version of the Conflict Tactic Scale (6 & 12 months) | Higher reports of victimisation | 403 (1 study) | ⊕⊕ΟΟ Low2 | It is unclear whether this increase reflects an increase in the rate of abuse recurrence (more abuse) or better reporting of abuse. |
| GRADE Working Group grades of evidence | ||||
| 1 Downgraded three levels for very serious risk of bias, very sparse data from one study.and a resulting in lack of clarity 2 Downgraded two levels for very serious risk of bias. 3 This number includes one participant unaccounted for in the analysis. The data analysis presented by the authors includes 15 individuals. | ||||
| Study | Intervention category | Study design | Sample size | Population of Interest | Country | Number of items at low risk of bias |
| Educational Interventions targeted at health professionals and/or carers | ||||||
| Educational Interventions | Controlled before‐and‐after study | 112 (recruited) | Caregivers | Taiwan | 6/11 | |
| Educational Interventions | Randomised controlled trial | 86 | Health personnel | United Kingdom | 8/11 | |
| Educational Interventions | Cluster‐randomised controlled trial | 1405 | Nursing home residents | United States | 6/11 | |
| Progammes to reduce factors influencing elder abuse | ||||||
| Programmes to reduce factors influencing elder abuse | Randomised controlled trial | 260 | Carers (family members) | United Kingdom | 10/11 | |
| Programmes to increase detection | ||||||
| Programmes to increase detection | Controlled before‐and‐after study | 44 clinicians; 100 elderly people | Clinicians and elderly consumer | United States | 2/11 | |
| Programmes targeted to victims | ||||||
| Multi‐component intervention of community‐wide education and then individual level intervention by police and social workers | Randomised controlled trial | 403 | Victims of elder abuse | United States | 3/11 | |
| Psycho‐educational support group structured with educational content | Randomised controlled trial | 16 | Abused elder women | United States | 2/11 | |
| Study | Community Partnerships | Level of Intervention | Reach of Strategies | Magnitude of Intervention | Cost Per Person | Intensity | Overall | Assessment |
| 2 | 2 | 0 | 2 | 0 | 0 | 6 | medium | |
| 0 | 1 | 0 | 1 | 0 | 0 | 2 | low | |
| 0 | 1 | 0 | 1 | 0 | 0 | 2 | low | |
| 2 | 2 | 1 | 2 | 0 | 0 | 7 | high | |
| 0 | 3 | 1 | 1 | 0 | 0 | 5 | medium | |
| 2 | 3 | 1 | 2 | 0 | 0 | 8 | high | |
| 0 | 1 | 0 | 1 | 0 | 0 | 2 | low | |
| Overall assessment of intensity: high (8‐10), medium (5‐7), low (1‐4). The overall assessment used a subjective informed determination rather than a pre‐defined algorithm. The informed assessment approach was selected as the six categories presented here are not distinct, and the sufficiency of detail varies between the studies. | ||||||||
| Study/outcome | |||||||
| Intervention approach | Educational intervention health professionals | Educational intervention for health professionals | Educational intervention for carers | Programmes targeted to victims, support group and education | Programmes targeted to victims, multi‐component, community education and individual intervention by police and social workers | Programs to reduce factors influencing elderly abuse (family members) | Programs for increasing detection for preventing elderly abuse |
| Intervention level | S | S | S | T | T | P | T |
| Primary outcomes | |||||||
| Abuse occurrence | ￭ | ￭ | |||||
| Abuse recurrence | ￭ | ￭ | ￭ | ||||
| Secondary outcomes ‐ Participant‐related outcomes | |||||||
| Improve detection | ￭ | ￭ | ￭ | ||||
| Improve management skills | ￭ | ||||||
| Improve knowledge | ￭ | ￭ | ￭ | ||||
| Improve attitudes | ￭ | ||||||
| Burn‐out | ￭ | ||||||
| Stress | ￭ | ||||||
| Sucide | ￭ | ||||||
| Self‐esteem | ￭ | ￭ | |||||
| Depression | ￭ | ￭ | |||||
| Anxiety | ￭ | ￭ | |||||
| Guilt | ￭ | ||||||
| Quality of Life | ￭ | ||||||
| Service satisfaction | ￭ | ||||||
| Service delivery | ￭ | ||||||
| Secondary outcomes ‐ Victim or perpetrator‐related outcomes* | |||||||
| Crisis management | |||||||
| Management of perpetrators | |||||||
| Level of intervention: P: Primary S: Secondary T:Tertiary *None identified in the included studies. | |||||||
| Author | Type of intervention | Study design | Type of abuse measured | Measurement for outcome | Authors' FIndings |
| Programme to reduce factors influencing elder abuse | Pragmatic randomised parallel group superiority trial | Occurrence of abuse | Modified conflict tactics scale | Family member carers in the intervention group report lower abusive behaviour (MCTS ‐ modified conflict tactics scale with at least 1 item scoring > 2) towards the recipient of care compared with those in the treatment as usual group which were not statistically significant 24 months. 8 months: treatment effect: OR 0.47, 95% CI 0.18 to 1.23, P > 0.05 (n = 214) Adjusted OR 0.48, 95% CI 0.18 to 1.27 (n = 206) 24 months: Treament effect: Adjusted for baseline OR 0.59, 95% CI 0.27 to 1.28 (n = 213) | |
| Educational interventions (for health professionals and/or carers) | Controlled before‐and‐after trial | Occurrence of abuse | Caregiver Psychological Elder Abuse Behavior Scale (CPEAB) | Caregivers’ abusive behaviours: (n = 50, each group analysed) Decreased significantly after the intervention. The intervention group’s change from baseline (Mean 31.22, 95% CI 29.53 to 32.91, SD 6.10) to post‐test (Mean 29.16, 95% CI 27.49 to 30.83, SD 6.02) (P = 0.01). (n = 100 analysed) No significant differences between the pre‐ (Mean 28.98, 95% CI 27.36 to 30.6, SD 5.84) and post‐tests (Mean 30.38, 95% CI 28.76 to 32, SD 5.84) in the control group (P < 0.179). Adjusted mean difference ‐3.46, Adjusted % change relative to the control group 11.4% (confidence intervals can not be calculated) Statistically significant differences between the post‐test scores of the two groups relative to CPEAB (F = 4.02, P = 0.05 and 0.02, respectively). | |
| Programmes for victims (Psyco‐educational support groups) | Randomised controlled trial | Recurrence of abuse: "Non‐physical abuse"; "physical abuse" | Hartford Study Physical Abuse Subscale, Hartford Study Non‐physical Abuse Subscale | Findings based on Intervention of 9 persons, control 6. Only women only included. Physical abuse reported: Pre‐test: 43% of controls and 22% of intervention participants Post‐test: 0% of controls and 13% of intervention participants (n = 15, post‐intervention & control comparison, P = 0.41). Adjusted RR can not be calculated. Adjusted RD 34, 95% CI ‐23.5 to 91.5 Non‐physical abuse reported: Pre‐test: 83% of controls and 100% of intervention participants. Post‐test: 75% of controls and 83% of intervention participants reported non‐physical abuse at post‐test. Intervention & control comparison, P = 0.71, n = 15. Adjusted RR 0.91, 95 CI 0.58 to 1.45. Adjusted RD ‐9, 95% CI ‐56.8 to 38.8 (Neither OR or RR were provided by the authors, but calculated by review authors) | |
| Programme for victims (including a whole of community component of public education) | Nested randomised controlled trial | Recurrence of abuse | Modified version of Conflict Tactic Scale | Elderly who received public education did not differ from those in the control group. However, elderly in the home visit group fared worse than those in the control group, while those who received both treatment reported more repeated victimisation. All persons reported abuse at baseline. Total abuse: At 6 months, total abuse reported repeated victimisation* No intervention: mean 5.87, 95% CI 3.39 to 8.35 SD 12.63 Public education: mean 3.18, 95% CI 1.79 to 4.57, SD 7.11, Home visit: mean 4.61, 95% CI 2.47 to 6.75, SD 10.92 Both (PE+HV): mean 12.63, 95% CI 8.13 to 17.13, SD 25.96. At 12 months, total abuse reported victimisation*. No intervention: mean 5.36, 95% CI 3.66 to 7.06 ,SD 8.67 Public education: mean 4.07, 95% CI 2.32 to 5.82, SD 8.94 Home visit: mean 3.66, 95% CI 2.17 to 5.15, SD 7.62 Both (PE+HV): mean 8.58, 95% CI 4.01 to 13.15, SD 23.32 Hazard ratio (HR) from Cox multiple regression: Public education HR 1.26, Home visit HR = 2.05 (alpha level 0.05), Both (PE+HV) HR = 1.78 (alpha level = 0.01), n = 403 *The study does not specify the exact numbers of participants in each group. The review authors have made the 95%CI calculations based upon an estimate of 100 persons in each group. The 95% CI are indicative only. | |
| Study arranged according to type of intervention, followed by study design OR: odds ratio, RD: risk difference, RR: relative risk, SD: standard deviation | |||||
| Author | Type of intervention | Study design | Types of secondary outcomes measured | Measurement for outcome | Authors' FIndings |
| Programme to reduce factors influencing elder abuse | Pragmatic randomised parallel group superiority trial | Carer‐related risk factors | Hospital anxiety and depression scale health status questionnaire (family member carers), depression, quality of life‐Alzheimer's disease | Anxiety: Mean total scores on the hospital anxiety and depression scale were statistically lower in the intervention group than in the usual care group over the eight‐month evaluation period: adjusted difference in means ‐1.80 points (95% CI ‐3.29 to ‐0.31, P = 0.02) and absolute difference in means ‐2.0 points. Health status (carers): Statistically higher, adjusted treatment effect 4.55 (95% CI 0.92 to 8.17) (n = 219) Depression: Carers in the intervention group were less likely to have case‐level depression (OR 0.24, 95% CI 0.07 to 0.76) and there was not a statistically significant reduction in case level anxiety (0.30, 95% CI 0.08 to 1.05). Treatment effect reported adjusted for baseline score and centre: ‐0.88 (‐1.68 to ‐0.09) (n = 229) Quality of life: Carers' quality of life was higher in the intervention group (difference in means 4.09, 95% CI 0.34 to 7.83) but not for the recipient of care (difference in means 0.59, 95% CI ‐0.72 to 1.89). | |
| Educational interventions (for health professionals and/or carers) | Controlled before‐and‐after, not randomised | Caregivier related | Knowledge of Gerontology Nursing Scale (KGNS) Work Stressors Inventory (WSI), | KGNS: Statistically significant differences were found between the post‐test scores of the two groups for KGNS (P = 0.018), improved significantly for the intervention group. Post‐test Intervention (n = 50, each group) Intervention group: Mean scores increased, pre‐test mean 28.74, 26.89 to 30.59, SD 6.67 and post‐intervention mean 32.96, 95% CI 31.07 to 34.85, SD 6.82. Control group: No significant differences between the pre‐ and post‐tests on KGNS measures (pre‐test = mean 26.06, 95% CI 23.97 to 28.15, SD 7.55; post‐test = mean 28.96, 95% CI 27.17 to 30.75, SD 6.47; P = 0.065) Adjusted mean difference 1.32 Adjusted % change relative to control group 5% Stress (WSI): no effect on caregivers' perceived level of stress between intervention and control groups. Intervention group: pre‐test mean 64.14, 95% CI 47.53 to 61.63, SD 20.52; post‐test mean 59.42, 95% CI 53.31 to 65.53, SD 22.04. Control group: pre‐test mean 59.50, 95% CI 52.37 to 66.63, SD 25.72; post‐test = mean 54.58, 95% CI SD 25.44; P = 0.330). Adjusted mean difference 3.2, adjusted % change relative to control group 6% Overall comparison, P = 0.660. | |
| Educational interventions (for health professionals and/or carers) | RCT pre‐ and post‐ measurements | Caregiver related | Knowledge and Management of Elder Abuse (KAMA) Caregiver Scenario Questionnaire (CSQ) Attitude of Health Care Personnel towards Maslach Burnout Inventory (MBI) | KAMA: There was a significant difference between intervention groups in final KAMA score with those randomised to Intervention ("Group 1" educational course intervention) improving after intervention and Control ("Group 2" educational material ) deteriorating Intervention mean = 3.7; 95% CI 0.85 to 6.55, SD 8.1, Control mean = –2.9; 95% CI ‐6.31 to 0.51, SD 10.0 ANOVA F=23.0; P<0.0001). Adjusted mean difference 6.6, Adjusted % change relative to control group 25.8% Attitude: At baseline Intervention had a significantly more positive attitude than Control 2 (pre‐intervention mean attitude score 13.5; SD 5.4 and 5.6; SD 4.2, respectively; P < 0.0001; mean difference 7.9; 95% CI = 5.1 to 10.7) and post‐intervention score was higher than the control Intervention: mean score 14.3, 95% CI 12.36 to 16.24, SD 5.5 Control mean 6.2, 95% CI 4.39 to 8.01, SD 5.3 P < 0.0001 Mean difference 8.2, 95% CI 5.0 to 11.2 Adjusted mean difference 0.2, adjusted % change relative to control group 3.2% Burn‐out:There were no significant differences in burn‐out scores between Intervention and Control before or after intervention. Intervention: Baselline 16.0, 95% CI 12.69 to 19.31, SD 9.4, Follow‐up 15.2; 95% CI 12.45 to 17.95, SD 7.8. Control Baseline 17.6, 95% CI 13.54 to 21.66, SD 11.9, Follow‐up 16.7; 95% CI 12.71 to 20.69, SD 11.7 Adjusted mean difference 0.1, adjusted % change relative to control group 0.6% | |
| Educational interventions (for health professionals) | Cluster‐RCT | Resident‐to‐resident elder mistreatment focus with caregiver | 10 items knowledge test. Resident‐to‐Resident Elder Mistreatment Behavior | Dectection incidents in the past 2‐weeks: Intervention: (n = 720) Baseline: (n = 353), mean 0.51, 95% CI 0.22 to 0.8, SD 2.79 At 6 months:(n = 580, mean 1.08, 95% CI 0.48 to 1.68, SD 7.34 12 months: (n = 239), mean 0.51, 95% CI, 0 to 1.02, SD 4.01 Control: (n = 784) Baseline: (n = 354) mean 0.52, 95% CI 0.17 to 0.87, SD 3.4 At 6 months: (n = 79) mean 0.27, 95% CI 0.00 to 0.59, SD 1.46 12 months: (n = 23) mean 0.10, 95% CI 0.00 to 0.26, SD 0.39 At 6 months: Adjusted mean difference 0.82 Adjusted % change relative to control group 304% At 12 months: Adjusted mean difference 0.42 Adjusted % change relative to control group 420% The intervention group reported more incidents at 6 and 12 months than did the control group. The sum of incidents reported during the staff interview at baseline for the previous two week period was 354 for the control group and 353 for the experimental group. After training, the six‐month numbers for the control and experimental groups were 79 and 580 and at 12 months 23 and 239, respectively.(Poisson model P = 0.0058) Knowledge scores, reported only for intervention group: Nursing staff’s gain in knowledge was significantly higher for both Module 1 (Pre‐test mean 7.43, 95% CI 7.3 to 7.56 SD 1.16 n = 319; post‐test Mean 8.13, 95% CI 7.99 to 8.27, SD 1.29; P < 0.001) Module 2 (Pre‐test mean 7.40, 95% CI 7.22 to 7.58 SD 1.54; n = 271; post‐test mean 8.38, 95% CI 8.2 to 8.56, SD 1.52; P < 0.001) in intervention group without comparison to the control group. Process evaluation: showed management skills increased for the intervention group: Baseline 7.43 SE 1.54, follow‐up 8.38, SE1.52. | |
| Programme to increase detection of elder abuse | Controlled before‐and‐after trial, not randomised | Assessment practices | Interview and audit of clinician practices of abuse identification | There were no differences in clinician‐reported baseline assessment practices for neglect and abuse between the intervention and comparison group. However, baseline comparisons of medical records found greater documentation for neglect and abuse within intervention agencies Neglect and abuse Clinican interview. clinicians reporting assessment of neglect and abuse Intervention (n = 26) Baseline: 11.5% Year 1 follow‐up : 65.4% Control (n = 18) Baseline: 22.2% Year 1 follow‐up 38.9% Reported OR = 6.50 Authors state that at 1‐year follow‐up, there was a significant increase in the proportion of clinicians in the intervention group (baseline 11.5%, follow‐up 65.4%) who reported routinely conducting clinical assessments in neglect and abuse domain. In contrast, there was little change in reported clinical practices by clinicians in the comparison sites (baseline 22.2%, follow‐up 38.9%). The analyses compared pre–post change scores between the intervention group and the comparison group and have reported OR of 6.50, however neither the P value or confidence interval is provided to substantiate the claim that it is 'significant'. (n = 44) Re‐analysis by review authors: adjusted RD 37.2, 95% CI ‐3.5 to 77.9; adjusted RR 3.24, 95% CI 0.75 to 13.9 (not statistically different) Chart audit: The authors states that there was a significant increase in the proportion of charts which documented neglect and abuse in the intervention group (baseline 19.7%; follow‐up 91.8%) compared to the comparison group (baseline 0%, follow‐up 2.6%) at follow‐up. Chart audit: Intervention (n = 61 charts audited) Baseline 19.7 % 1‐year follow‐up: 91.8% Control (n = 39) Baseline 0.0% Follow‐up 2.6% 'Odds ratio could not be calculated' Re‐analysis by review authors: adjusted RD 69.5, 95% CI 62.9 to 71.1; adjusted RR could not be calculated. | |
| Programme for victims (psycho‐educational support groups) | Randomised controlled trial | Victims: sense of control, social support, alcohol abuse, depression, drug use, family relationship problems, guilt, suicide, anxiety and somatisation | CESB‐D 10 Hartford Study; Guilt Subscale; Rosenberg Self‐Esteem Scale; Health Locus of Control Scale; Medical Outcomes Study Social Support Survey; BSI‐18 | Recruitment of 16 women, 15 completers. 9 intervention, 6 control There were no significant changes in outcome measures for either control or intervention group participants after the intervention ended; depression, guilt, and self‐esteem (n = 15). Depression: 14% of controls and 56% of intervention participants suffered from depression at pre‐test. 33% of controls and 56% of intervention participants suffered from depression at post‐test. (Post, intervention & control comparison P = 0.49). Guilt: 28% of the control participants scored above threshold and 33% of the intervention participants scored above threshold at pre‐test. 14% of the control participants scored above threshold and 22% of the intervention participants scored above threshold at post‐test.(post, intervention & control comparison P = 0.75). Calculated adjusted RR 1.33 (favouring control) 95% CI 0.30 to 5.89. Adjusted RD 3, 95 CI ‐11.5 to 17.5. Self‐Esteem (Rosenberg scale): Authors stated "Participants scored an average of 32, which is above the midpoint." Average score for either groups not reported. Findings on Sense of Control and Social Support, anxiety and somatisation not reported. | |
| Programme for victims (including a whole of community component of public education) | Nested randomised controlled trial | Victims: i) knowledge of services ii) satisfaction with police iii) assessment of service delivery iv) self‐esteem v) well‐being of victims | i) six‐item Use of Services Scale ii) self‐developed questions iii) self‐developed questions iv) Rosenberg Self‐esteem v) Bradburn Affect‐Balance Scale | No baseline data are provided for comparison, The study authors stated there was no significant difference between intervention and control group in relation to knowledge about elder abuse or awareness and use of services at 6th or 12th months. There is no significant difference between experimental and control group in their psychological states. Without baseline comparison, no further reporting is warranted.See Davis 2001 for further detail. | |
| CI: confidence interval, OR: odds ratio, RD: risk difference, RR: relative risk, SD: standard deviation | |||||
