By Laura Mosqueda and Theresa Sivers Teixeira
Mr. P is a 78-year-old man with early-stage Alzheimer’s disease. His son was observed in the pharmacy yelling at him as his Dad kept repeating the same question. The pharmacist called Adult Protective Services (APS), and they discovered that Mr. P lives with his son, daughter-in-law and two small grand-children in a two-bedroom apartment. During the interview, it became clear that the family needed the combined incomes to stay in the apartment. The son and daughter-in-law explained that they are overwhelmed with caregiving needs and admitted that sometimes they yell or “get a little physical” with him.
“It’s So Complicated!”
Though elder abuse (mistreatment) can take many forms, it is defined by the Centers for Disease Control and Prevention as “an intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.”
Mistreatment can play out as physical, sexual, emotional or psychological abuse, as well as financial abuse and neglect. Often, older adults are the victims of more than one form of mistreatment, and many cases are not clear-cut, either in determining whether abuse has occurred or in deciding what steps to take once possible abuse is discovered. Many cases involve complicated medical, social, emotional and financial issues that intersect and interact, making it difficult to shape an appropriate response.
The Abuse Intervention Model (AIM)
The AIM model, which can help in situations like Mr. P’s, is a useful tool for identifying multidimensional, modifiable risk factors for elder mistreatment. AIM is a practical framework that allows for targeted and practical individualized intervention to successfully prevent, stop and mitigate elder mistreatment. Mistreatment is multidimensional, made up of complex relationships between risk factors in three broad domains (see Figure 1, above). These domains include the older adult (potential or known victim of mistreatment), the “trusted other” (potential or known perpetrator of mistreatment) and the context in which the mistreatment occurs. One goal of the AIM model is to identify modifiable risk and protective factors in individual cases, thus enabling a practical plan to be developed and implemented.
How Older Adults Are at Risk for Abuse
Many physical or emotional conditions or financial circumstances older adults face increase their susceptibility to mistreatment. Dependence upon another for care or being perceived as difficult to care for are examples of personal characteristics associated with mistreatment.
Functional issues like impaired physical abilities or diminished cognitive abilities can make activities of daily living more difficult for older adults. Physical and-or cognitive limitations can also lead to dependency upon a trusted other for management of finances, transportation, meal preparation, shopping and medication management.
Illnesses such as Alzheimer’s disease may cause impairment in executive function, which makes a person an easier tar-get for exploitation. A diminishing ability for self-control can contribute to challenging behaviors, making caregiving more difficult. An elder’s emotional distress and mental illness can lead to emotional dependence—a situation that caregivers and others may resent or exploit.
Caregiving and the “Trusted Other”
Trusted others include family members, neighbors, friends and paid caregivers. Dependence upon the older adult, especially financial dependence, may compel the trusted other to remain in an unwanted relationship. Emotional dependence can lead to conflicted relationships and foster resentment in a caregiver. Mood, substance or personality disorders can compromise caregiver reliability. If a caregiver feels overwhelmed, he or she may be hostile or abusive. Physical impairment and limited mobility also can reduce the caregiver’s ability to provide appropriate care.
The context in which the older adult and trusted other interact can moderate or intensify the risk for elder mistreatment. Social isolation that separates either the older adult or caregiver from supports and resources can exacerbate the risk. Often, the relationship of the vulnerable older adult and the trusted other predates the caregiving phase. The quality of the relationship prior to the caregiving relation-ship can alter the risk for mistreatment. A good relationship can be a protective factor, while a poor quality relationship can increase the risk for mistreatment.
Culture also can influence the perception of elder mistreatment. In some cultures, illnesses, such as Alzheimer’s disease, are considered shameful or embarrassing and may lead to an older adult’s isolation.
Managing Mistreatment Risk
Some risk factors for elder mistreatment are modifiable and some are not. The AIM model can give professionals like medical providers, social workers, APS and law enforcement a framework to assess and identify risk factors for elder mistreatment from the perspectives of the vulnerable adult, the trusted other and the context in which they interact. Once the model is applied to an in- case (such as Mr. P’s), professionals can identify risk factors that can be mitigated and protective factors that can be bolstered.
It seems that Mr. P has experienced emotional mistreatment, and possibly physical mistreatment. His risk factors include cognitive impairment, accompanied by behavior change, dependence on his son for housing and dependence on the family for assistance with daily living activities. Knowing the course of the disease, we can predict that Mr. P’s cognition will become further diminished with time, which correspondingly increases his dependence and elevates his risk for mistreatment.
The trusted others (Mr. P’s son and daughter-in-law) are financially dependent on Mr. P’s income and admit to feeling overwhelmed and stressed by care-giving. The family lives in a cramped apartment with two very young children whose needs are many and may compete with Mr. P’s caregiving needs. Though we don’t know the relationship history of Mr. P and his son, we do know their relationship is currently strained. Additionally, there is evidence that Mr. P’s son has the propensity to be verbally and physically aggressive with his father.
AIM in Action
Though Mr. P’s cognition cannot be substantially improved or reversed over the course of his disease, the AIM model could be used to analyze and improve the situation, as follows:
• Mr. P’s son and daughter-in-law attended their local no-cost Alzheimer’s Association Savvy Caregiver course. This helped them to understand that Mr. P’s repetitive and bothersome be-haviors were not purposeful, but rather a part of his illness. The family learned strategies to lessen frustration and reduce conflict.
• A social work referral was made through their area agency on aging. The social worker helped the family receive In-Home Supportive Services (a government-subsidized benefit) several days a week to help with some of the caregiving responsibilities.
• The family doctor referred the son and daughter-in-law to several sessions of low-cost counseling in which they learned stress-reduction techniques to use when feeling particularly upset.
• Mr. P’s geriatrician discovered that Mr. P was feeling nauseated and light-headed much of the time, which was exacerbating his agitated behavior. By dis-continuing one medication and reducing another medication’s dosage, he became calmer and more content.
This combination of interventions had a significant impact on decreasing the stress of the family’s situation, and the abusive behavior was drastically reduced.
The Abuse Intervention/Prevention Model (AIM) identifies risk factors for abuse by focusing on the dyadic relationship between care recipients with dementia and their caregivers. Register for the Aging in America Conference and attend The Abuse Intervention/Prevention Model: A Practical Framework for Practitioners, a workshop led by Laura Mosqueda which will explore how practitioners can use AIM as a pragmatic tool to identify risk factors for abuse and provider referrals to resources to prevent elder abuse among patients with dementia.
Laura Mosqueda, M.D., is a professor of family medicine and geriatrics, Chair of the Department of Family Medicine and an associate dean of primary care at the USC Keck School of Medicine in Los Angeles. Mosqueda also directs the National Center on Elder Abuse in Alhambra, Calif. She is a member of ASA’s Generations Editorial Advisory Board. Theresa Sivers Teixeira, P.A.-C., is an instructor of Clinical Family Medicine at the USC Keck School of Medicine. For more information on elder mistreatment, contact your National Center on Elder Abuse.
Editor’s Note: This article appears in the November/December, 2017, issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.