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      Elder Abuse in the time of COVID-19 – Increased Risks for Older Adults and Their Caregivers

      editorial

      , MD, MS 1 , 2 , * , , PhD 1 , 3 , , MD, MS 1 , 2

      The American Journal of Geriatric Psychiatry

      Elsevier

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          Abstract

          Since the first case of the novel coronavirus SARS-CoV-2 causing the COVID-19 illness was diagnosed in the US on January 20, 2020, 1 a steady stream of new policy measures have been enacted to protect the public from this growing pandemic. At the forefront of these efforts have been measures to limit interpersonal contact to prevent transmission of the virus. Social distancing, school closures and the shuttering of non-essential businesses have already led to significant personal, social and economic hardship. While it has been well publicized that older adults are at highest risk of serious illness and death from COVID-19, 2 they may also be at high risk for negative consequences from the measures being enacted to protect them from the viral threat. Healthcare providers should be aware that their older patients are now particularly vulnerable to social isolation, financial hardship, difficulties accessing needed care and supplies, and anxiety about avoiding COVID-19; the family caregivers these patients often rely on are also vulnerable to increased stress from financial hardships and competing demands on their time. Unfortunately, all of these factors are known to be associated with increased risk of elder abuse for older adults. In this article, we outline how the current pandemic may impact older adults, their caregivers, and the caregiving context to increase elder abuse risk and present interventions for healthcare providers to consider that may help to reduce this risk. An estimated one in ten older adults (age ≥60 years) experience elder abuse annually in the US. This includes physical, sexual or psychological abuse, as well as financial exploitation (such as diversion of money without permission or scams) or neglect by caregivers. 3 Even in the best of times, elder abuse cases are rarely detected, with only 1 in 24 cases identified and reported to the appropriate authorities. 4 Elder abuse often results from a combination of factors related to the older adult themselves, caregivers and others in the adult's social circle, and the context in which they all live and co-exist. 5 The public policy measures being enacted for COVID-19, and their downstream mental health consequences, are likely having impacts on each of these areas in ways that increase the likelihood of older adults experiencing abuse. COVID-19 impacts on older adults For older adults themselves, social isolation is a known risk factor for experiencing elder abuse. 6 The social distancing measures enacted to combat SARS-CoV-2 transmission, and recommendations by the Centers for Disease Control and Prevention for adults over the age of 65 to not leave their homes, 7 are undoubtedly creating new degrees of social isolation even amongst those previously well-connected. These limits on in-person contact can greatly limit ability for caregivers to provide care in person, and in general limit opportunities for ongoing elder abuse to be detected by others. In addition, with unprecedented drops in the stock market, older adults may see any investments or retirement savings plummet, leading to financial instability, which is known to make them more vulnerable to financial scams and other types of abuse. 8 Older adults, who often have chronic health conditions, may now find it more difficult to access healthcare and supplies needed to manage their conditions and stay healthy. All of these issues - isolation, financial stress, and concerns about health - can in turn lead to increased depression and anxiety, which is also known to make older adults more susceptible to suffering abuse. 9 , 10 While many older adults previously turned to their healthcare providers for treatment of these mental health symptoms, cancellations of face-to-face visits and unfamiliarity with technologies needed to conduct remote healthcare visits may be preventing older adults from receiving the care they need. COVID-19 impacts on caregivers Caregivers of older adults, who ordinarily deal with stress and systemic lack of support in the US, are now facing even more burdens which are known to increase caregivers’ risk of being abusive to or neglectful of their older care recipients. Caregivers of older adults are frequently family and friends of working age who, in 2013, collectively sacrificed $67 billion in lost wages as a result of unpaid caregiving for their loved ones. 11 With over 20 million people filing for unemployment in the US from mid-March to mid-April 2020, 12 and this number expected to grow, many caregivers are undoubtedly facing new financial strains. Low financial means and financial co-dependency with the care recipient are likely on the rise and are known risk factors for caregiver abuse of older adults. In addition, many caregivers are experiencing increased demands on their time, including increased time caring for children home from closed schools, for other family members who have fallen ill, or increased time working outside the home for those in key service sector jobs. These increased financial stressors, time demands, and worries about their care recipient's health may be contributing to the large increase in adults’ anxiety about loved ones observed in a recent study. 13 In response to increased anxiety, caregivers already struggling with unhealthy use of alcohol or other drugs may increase their use, and caregivers who are in remission from a substance use disorder (SUD) may experience relapse. Decreased availability of in-person treatment or support programs, and limited ability to use other healthier coping strategies like exercise, may exacerbate these issues. Unfortunately, SUD is also known to add to caregivers’ risk of using abusive behavior. COVID-19 impacts on the caregiving context Contextual factors in which caregiver-care recipient dyads function are also rapidly changing. In addition to competing demands on caregivers’ time, many may simply be afraid to spend time in physical contact with an older adult due to concern for contagion. This can inadvertently lead to neglect of older adults. With more limited ability to have in-person contact, many caregivers are trying to use virtual technologies to stay connected with their care recipient. While some older adults may be comfortable with these technologies, many are not, and those with limited financial means may not have the necessary smart phone, computer or high-speed internet to use them. Furthermore, while certain care tasks might be readily replaced by virtual interaction (e.g., medication reminders), many more require in-person contact and may not be carried out during this time, leading to neglect of care that can have significant personal and health consequences. In addition to increased risks for new abusive situations arising, this pandemic may be worsening the severity or lethality of existing abusive relationships. For example, with increases in social distancing, not only was there a rush to buy food and other household products, but there was a substantial increase in the purchase of firearms and ammunition. 14 If mood disorders and substance use increase, both on the part of older adults and their caregivers, having easy access to lethal means at home may significantly increase the ability of violence to become deadly. With social distancing requiring a higher bar for in-person evaluations not only from healthcare and crisis professionals, but also from police and Adult Protective Services, these violent situations in the home may be less likely to be identified and intervened upon. Confronting increased elder abuse risk during the COVID-19 pandemic So, what can we as healthcare providers do? In the face of the many challenges presented by the current COVID-19 crisis, there are also many opportunities. First, as healthcare providers doing telephonic or video visits with our older adult patients, we have a unique chance to observe our patients in their home environment. This is a rare window into how they are living, caring for themselves and being cared for by others. We can systematically observe for signs of unsafe situations, and directly inquire about older adults’ safety and well-being. For example, we can ask about food insecurity and whether guns in the home are stored safely (locked and unloaded with ammunition stored separately). 15 Second, these visits present opportunities for us to provide support for caregivers, many of whom may not typically attend clinic visits. Caregivers may live with patients, and often help patients connect to phone or video remote visits, especially for the most vulnerable older adult patients (e.g., those with dementia). Caregivers who live apart from patients may find it easier to call into remote visits than they did participating in in-person clinic visits. Caregivers may be more comfortable disclosing sensitive information related to their ability to provide care when speaking from a home environment. Healthcare providers can assess caregiver stress, ability to maintain previous levels of caregiving, and ability to access necessary resources and supplies. Providers can then provide brief counseling, problem-solving strategies, and appropriate referrals. Digital technologies and remote visits also present challenges. For older adults without the financial means or tech savvy, video tele-visits may be unfeasible. Proactive assessment and cataloging of patients’ access to the necessary devices and internet or data services to identify those with limitations can allow for alternative strategies with these patients, such as simple telephone visits, or—if having an urgent medical concern— considering the risks and benefits of in-person evaluation, either in clinic or via in-home assessment. An additional challenge related to detecting elder abuse is the inability to know reliably when you are evaluating a patient via a virtual-visit if the patient is really alone. While caregiver presence can have benefits as previously discussed, it may also hinder disclosure of abuse or neglect if present. One potential strategy to approaching patients where elder abuse is a concern may be to make an unscheduled call to the older adult, so the caregiver cannot plan ahead to be present. On our side is an unprecedented and rapid mobilization of resources available in our healthcare systems and communities to support older adults and caregivers in need. For example, the Veterans Health Administration (VA) has information regarding coping with stress and related resources for those individuals concerned about their mental health and well-being during the COVID-19 pandemic. 16 The VA is also providing free peer support services via twice weekly phone meetings for any Veteran wanting to talk and receive support from certified Peer Specialists during this pandemic. Outside the VA, Kaiser Permanente has launched an innovative “Food for Life” program to contact more than 450,000 members in California to identify those struggling to pay for food and provide application support to help them apply for food benefits. 17 Local Area Agencies on Aging (AAA) are another resource for all health systems, providing a range of services to meet the social needs of older adults, including home-delivered meals, personal care services, health promotion and chronic disease management, transportation, and social engagement. Recent research has shown that older patients benefit when their health systems partner with AAAs, 18 and the new challenges presented by the COVID-19 pandemic present an important opportunity to forge these new partnerships. 19 If we suspect emerging mental health or substance use needs for either the older adult or caregiver, and referrals to local resources are scarce, several national agencies (e.g. the US Substance Abuse and Mental Health Services Administration) have dedicated COVID-19 webpages that list resources for patients as well as providers. 20 Some of these resources include links to virtual recovery groups (e.g., Alcoholics Anonymous) for those patients interested in receiving support from peers. Familiarizing ourselves with these websites and resources will be important for our patients in the coming weeks and months. In our communities we are seeing an outpouring of support from individuals and organizations reaching out to their older neighbors in caring ways. Encouraging our older patients to forge new bonds being made possible during this pandemic will be more important than ever. We can facilitate older patients connect to neighboring families who can help check on their wellbeing, to volunteers who can pick up needed groceries, 21 and to local organizations that will donate supplies to community older adults, which can help fill in gaps, decrease isolation, and reduce unmet needs. This pandemic also presents an opportunity for research expanding our understanding of elder abuse. Perhaps most understudied, and the area where new revelations could have the biggest impact, are caregiver-related risk factors. With many people experiencing caregiving stress and concern about whether loved ones’ needs will be met, caregivers may be more open to participating in research to share their experiences, even uncomfortable ones. Surveys of caregivers of older adults being conducted now in the context of COVID could include questions related to risks of using abusive or neglectful behavior. Other geriatrics and caregiving researchers should be mindful about the potential increased risk of elder abuse during this time, and could consider incorporating assessments related to this area in their studies. Being aware of the challenges older adults and their caregivers are facing is critical to helping them survive and thrive during this crisis. Attending to mental health needs, addressing increased risks, and connecting older adults to financial and caregiving resources may all help our patients and their loved ones be safer and avoid abusive and violent situations. We must not let out-of-sight mean out-of-mind – our older patients need us now, more than ever. Disclosures Lena K. Makaroun, Rachel L. Bachrach and Ann-Marie Rosland were involved in the conceptualization, drafting and critical revision of the manuscript. The views expressed in this article do not necessarily represent those of the US Department of Veterans Affairs or the US government. Lena K. Makaroun, Rachel L. Bachrach and Ann-Marie Rosland report no conflicts with any product mentioned or concept discussed in this article.

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          Most cited references 9

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          First Case of 2019 Novel Coronavirus in the United States

          Summary An outbreak of novel coronavirus (2019-nCoV) that began in Wuhan, China, has spread rapidly, with cases now confirmed in multiple countries. We report the first case of 2019-nCoV infection confirmed in the United States and describe the identification, diagnosis, clinical course, and management of the case, including the patient’s initial mild symptoms at presentation with progression to pneumonia on day 9 of illness. This case highlights the importance of close coordination between clinicians and public health authorities at the local, state, and federal levels, as well as the need for rapid dissemination of clinical information related to the care of patients with this emerging infection.
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            Gun storage practices and risk of youth suicide and unintentional firearm injuries.

            Household firearms are associated with an elevated risk of firearm death to occupants in the home. Many organizations and health authorities advocate locking firearms and ammunition to prevent access to guns by children and adolescents. The association of these firearm storage practices with the reduction of firearm injury risk is unclear. To measure the association of specific household firearm storage practices (locking guns, locking ammunition, keeping guns unloaded) and the risk of unintentional and self-inflicted firearm injuries. Case-control study of firearms in events identified by medical examiner and coroner offices from 37 counties in Washington, Oregon, and Missouri, and 5 trauma centers in Seattle, Spokane, and Tacoma, Wash, and Kansas City, Mo. CASES AND CONTROLS: Case firearms were identified by involvement in an incident in which a child or adolescent younger than 20 years gained access to a firearm and shot himself/herself intentionally or unintentionally or shot another individual unintentionally. Firearm assaults and homicides were excluded. We used records from hospitals and medical examiners to ascertain these incidents. Using random-digit dial telephone sampling, control firearms were identified by identification of eligible households with at least 1 firearm and children living or visiting in the home. Controls were frequency matched by age group and county. The key exposures of interest in this study were: (1) whether the subject firearm was stored in a locked location or with an extrinsic lock; (2) whether the firearm was stored unloaded; (3) whether the firearm was stored both unloaded in a locked location; (4) whether the ammunition for the firearm was stored separately; and (5) whether the ammunition was stored in a locked location. Data regarding the storage status of case and control guns were collected by interview with respondents from the households of case and control firearms. We interviewed 106 respondents with case firearms and 480 with control firearms. Of the shootings associated with the case firearms, 81 were suicide attempts (95% fatal) and 25 were unintentional injuries (52% fatal). After adjustment for potentially confounding variables, guns from case households were less likely to be stored unloaded than control guns (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.16-0.56). Similarly, case guns were less likely to be stored locked (OR, 0.27; 95% CI, 0.17-0.45), stored separately from ammunition (OR, 0.45; 95% CI, 0.34-0.93), or to have ammunition that was locked (OR, 0.39; 95% CI, 0.23-0.66) than were control guns. These findings were consistent for both handguns and long guns and were also similar for both suicide attempts and unintentional injuries. The 4 practices of keeping a gun locked, unloaded, storing ammunition locked, and in a separate location are each associated with a protective effect and suggest a feasible strategy to reduce these types of injuries in homes with children and teenagers where guns are stored.
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              The high prevalence of depression and dementia in elder abuse or neglect.

              The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people. To describe the characteristics of abused or neglected patients and to compare the prevalence of depression and dementia in neglected patients with that of patients referred for other reasons. A case control study. Baylor College of Medicine Geriatrics Clinic at the Harris County Hospital District (Houston, Texas). Forty-seven older persons referred for neglect and 97 referred for other reasons. Comprehensive geriatric assessment. Standard geriatric assessment tools. There was a statistically significant higher prevalence of depression (62% vs 12%) and dementia (51% vs 30%) in victims of self-neglect compared to patients referred for other reasons. This is the first primary data study that highlights a high prevalence of depression as well as dementia in mistreated older people. Geriatric clinicians should rule out elder neglect or abuse in their depressed or demented patients.
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                Author and article information

                Contributors
                Journal
                Am J Geriatr Psychiatry
                Am J Geriatr Psychiatry
                The American Journal of Geriatric Psychiatry
                Elsevier
                1064-7481
                1545-7214
                19 May 2020
                19 May 2020
                Affiliations
                [1 ]Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
                [2 ]Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
                [3 ]Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
                Author notes
                [* ] Corresponding author: Lena K. Makaroun, MD, MS, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240, Phone: 412-360-2253 lkm35@ 123456pitt.edu
                Article
                S1064-7481(20)30346-8
                10.1016/j.jagp.2020.05.017
                7234937
                792b89ef-4cd4-40a9-9fd7-a236e6629ca5

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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