The Three D s: Assessment of and Interviewing Strategies with Older Victims of Abuse. Sheri Gibson, Ph.D. Rocky Mountain PACE

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1 The Three D s: Assessment of and Interviewing Strategies with Older Victims of Abuse Sheri Gibson, Ph.D. Rocky Mountain PACE

2 Mr. and Mrs. Stanley Married couple living together in an apartment with a 24-hour home aide. Mrs. Stanley is 90 years old with vision impairment, hip fractures from multiple falls, and diabetes. Mr. Stanley is 85 years old with a diagnosis of dementia and history of stroke.

3 Setting the Stage The home aide was providing full time care without additional assistance. Mrs. Stanley suffers another fall resulting in surgery to repair the damage and subsequent rehabilitation in a SNF. The Stanley s niece managed the couple s finances without permission.

4 Three Types of Abuse in this case Polyvictimization Neglect: A failure to fulfill caretaking obligation, either intentional or unintentional, resulting in a wide range of problems that can lead to death. Financial Exploitation: The unauthorized or improper use of funds, property, or assets. Psychological or Emotional Abuse: Subjecting a person to a behavior that results in fear, mental anguish, or emotional pain.

5 The Interviews APS Caseworker Attends a home visit to interview the home aide. Evaluates the safety of the home environment; overall cleanliness, lighting, rough carpet edges, and blocked room entrances. Home aide acknowledges burden caring for Mr. Stanley given level of cognitive impairment. Mr. Stanley s PCP confirmed that his impairment would require more support; 2 aides are assigned to work 12 hr shifts.

6 Interviewing Mrs. Stanley Occurs in the SNF. APS caseworker conducts a thorough interview to determine the cause for the multiple falls before discharging Mrs. Stanley back into the community. Mrs. Stanley reports symptoms of depression and attributed this to being threatened and called derogatory names by her niece.

7 Mrs. Stanley Reports the niece gave her no choice but to manage the couple s finances and threatened her by stating that if she didn t relinquish control, the niece would inform the bank that Mrs. Stanley had dementia. Mrs. Stanley acknowledges concerns about her memory and states that she is confused at times about details regarding the couple s finances.

8 Normal Aging Cognitive and mental disorders are not part of normal aging Physiological changes affect all systems including metabolism Metabolism affects how the person handles medications, environmental stressors, etc. Very common medications can create problems as well as polypharmacy

9 Three Common Causes for Mental Health Symptoms Dementia chronic cognitive problems, variety of causes Delirium acute confusion caused by physiological problem Depression mood disturbance, symptoms may be different in older adults

disease Vascular disease Dementia due to medical condition

10 Dementia Progressive, deteriorating disease NOT normal aging Broad cognitive impact Different types Alzheimer s disease Vascular disease Dementia due to medical condition Head injury; brain tumor Substance-induced dementia Alcoholism

11 Dementia Found in 14% of adults age 71 years+ (Plassman et al., 2007) 24% of persons ages and 27% of persons over age 90 are diagnosable with dementia (Plassman et al., 2007) Many types Pick s, Creutzfeld-Jacob, Vascular, FTD, Parkinson s, Alzheimer s, Loewy body disease, Alzheimer s Dementias

12 Alzheimer s Disease In 2009, ~5.3 million people had a diagnosis of Alzheimer s disease one of the many forms of dementia Every 72 seconds, another 1 (Alzheimer s Association, 2009)

13 Risk factors for dementia Advancing age Gender & education Genetics Cardiovascular disease and associated lifestyle factors, e.g. diet, exercise, obesity Brain injuries and infections

14 Association between Dementia and Victimization Higher prevalence of elder abuse among people with dementia (Cooper et al., 2008) Research findings: nearly 50% of persons with dementia experience some form of abuse (Cooper et al., 2009) 47% of persons with dementia had been mistreated by their caregivers (Wiglesworth et al., 2010)

15 Types of Abuse most reported by U.S. caregivers of persons with dementia (Wiglesworth et al., 2010; Vanderweerd & Paveza, 2005; Paveza et al., 1992) Types of Abuse 16% 14% 10% 60% Verbal Physical Neglect other

16 Common Dementia Symptoms Memory Loss Confusion Disorientation (advanced) Language problems Inability to recognize familiar objects Changes in personality or behavior Disturbance in executive functioning

17 Real Challenges Victims experience difficulty talking about their experience of abuse. Particularly for people with dementia who may have difficulty communicating their experiences and feelings People with dementia may worry that they will not be believed if they speak out Attitudes from others that they are confused and not a reliable witness People with dementia are easy targets Dementia can lead to behavioral reactions to abuse such as withdrawal from communication or being in the presence of others.

18 The Interview: Assessing for Dementia Dementia Depending on the stage of dementia, the person will likely be able to understand and give a basic explanation of why you are there In early to middle stages Vague speech when asked why you are there, person might say there must be a problem Repeated phrases Lose track during conversation; use story-telling May not be troubled by mistakes or will lack awareness of incorrect answers May make excuses for why he or she cannot perform a task or answer a question May present as excessively friendly or hostile

19 Communication Strategies TALK tactics Take it slow Ask simple questions Limit reality checks Keep eye contact

20 Communication Strategies Approach from the front Introduce yourself Speak slowly Use simple, familiar language Ask one question/give one direction at a time Be mindful of body language Minimize distractions

21 Communication Strategies Establish a timeline/routine with contextual clues Construct each subsequent question building on what the person has already told you Use the person s exact words and phrases Listen patiently and redirect as needed Use memory cues: What were you doing before this happened?

22 Delirium Is a physiological consequence of: Medical conditions, substance intake, withdrawal from medication, toxicity from medication Rapid onset hours to days Symptoms can include confusion, hallucinations, agitation Will seem bewildered, Where am I?

23 Delirium cont. Common medical causes: Acute illness, e.g., urinary tract infection Central nervous system disorders, e.g., stroke Cardiovascular disorders Dehydration Metabolic disturbances Persons with pre-existing cognitive impairment are at high risk Can be reversible, but is a serious risk factor for illness and mortality rates; increases the risk of long-term care placement

24 Meds that can cause confusion Antacids Reglan Benadryl Beta-blockers Blood Pressure Meds Anti-depressants Muscle relaxants

25 Delirium in the Older Victim Environmental conditions Psychosocial factors Sensory deprivation Sleep deprivation Malnourishment

26 Assessment through interviewing ALWAYS tell the person who you are and why you are there Delirium Person will not be able to make sense of your presence Person will not be able to repeat what you told them Person will appear bewildered, Where am I, what are you doing here? Person will be difficult to console His/her conversation will likely contain suspiciousness; seem panicky, emotional or pressured Person will be difficult to connect with during the interview Person will tend to misinterpret what he or she sees and hears (e.g., thread on the couch is a snake)

27 Conversational Clues to Status Delirium Where are we right now? What day/time/date is it? Can they engage in meaningful dialogue? Do they appear aware of their surroundings and able to focus?

28 Depression Is classified within a broad range of mood disorders disruption in mood is most salient characteristic Fewer older adults than younger adults suffer from diagnosable depression

29 Depression Less likely to report depressed mood More likely to report: Lack of purpose Worthlessness Sleep disturbance Attribute symptoms to physical aches and pains or aging process Greater suicide risk

30 Depression cont. Prevalence studies show higher rates of depression among older adults in hospital and nursing home settings (Blazer, 2003) Is associated with medical illnesses, medication side effects, psychoactive substances, psychosocial stressors Unresolved or complicated grief Physical illness Institutionalization Can lead to greater cognitive impairment when untreated

31 Older Victims of Violence Have additional health care problems than non-abused older adults (Bitondo Dyer et al., 2000; Burt & Katz, 1985; Mouton & Espino, 1999; Fisher & Regan, 2006; Coker et al., 2002; Stein & Barrett-Connor, 2000; Mouton et al.., 2004): Increased bone or joint problems Digestive problems Depression or anxiety Chronic pain High blood pressure Heart problems

32 Depression Assessment Depression Person should be able to repeat what you have said without any difficulty Speech will sound flat, person will appear uninterested, detached Listen for indicators of hopelessness, helplessness Typical responses include I don t know or I don t care Resignation

33 Conversational Clues to Status Depression: Over the past month have you felt down, depressed, or hopeless? Over the past month have you felt little interest or pleasure in doing thing? Questions will identify possible depression

34 Interviewing Strategies

35 Victim s Account Victim may be discounted if: Statements are not consistent He/she appears confused He/she has a medical condition such as dementia or other cognitive limitation

36 Group Discussion What interviewing strategies did you observe? What functional limitations did you notice that may require accommodations? What characteristics did you observe in Ms. Prim? Cognition Speech Mood/Affect Eye contact Rapport Her story

37 Helpful Interview Strategies Determine the best time of day to conduct the interview (sun downing) Establish the victim s daily routine without asking about the crime Construct each subsequent question building on what the victim has already told you Use the victim s exact words or phrases

38 Strategies cont. To enhance communication: Ask victim how he or she would prefer to communicate with you Ask how he or she prefers to be addressed (First or last name, Dr., Reverend?) Read written materials to the individual Use an interpreter as needed Use visual aids, charts, or diagrams Ask short questions Limit environmental distractions

39 Strategies cont. Ask the older victim if she/he can draw or show the object or what happened Ask open ended questions first, then use process of elimination questions Ask more specific questions rather than broad questions

40 Strategies cont. Listen patiently and redirect as needed if the older victim digresses Use memory cues such as What were you doing before this happened? Do not discount the alleged abuse because the victim has made statements that seem untrue or may be the result of delusions

41 Mobility issues Conduct interview in the best location for the older adult Consider future needs for transportation and accessibility at police station and court Assist with arranging for assistive devices Collaborate with health care providers

42 Multicultural Considerations Latino culture Machismo (e.g., male dominance), respect, love are important cultural values that guide relationships African American and other minority groups Fear of institutionalism or incarceration; mistrust in law enforcement, particularly person with previous history of negative interactions with state officials LGBT community Family traditions/values

43 Self-Reflections Importance of Self-care Prior experiences Similarities / Differences in child vs. older adult forensic interviewing Beliefs about autonomy and protection shaped by society and personal experiences Myths or beliefs about aging Infantilizing language

44 Take Home Points Mental health symptoms may be indicative of possible dementia, delirium, and/or depression when working with older adults. The 3D s are not a part of normal aging and should be assessed and treated appropriately. Modifying your interview approach can lead to improved communication and interventions.

45 Thank you Resources: Alzheimer s Association National Center on Elder Abuse (NCEA) National Committee to Prevent Elder Abuse (NCPEA) Center of Excellence on Elder Abuse and Neglect National Council on Aging

How to Approach Someone Having a Mental Health Challenge

How to Approach Someone Having a Mental Health Challenge Susan Allen-Samuel, M.S. NAMI NH Copyright NAMI NH, 2013. Do not use printed or web version of this document for other than personal use without