Person Centered Care of Elder Abuse
By Julia Margaret Martinez, PhD
Augest 29, 2022
I have heard countless stories of elder abuse over the last 15 years. Initially, as a multidisciplinary team (MDT) facilitator, and later as a student observing MDTs for my doctoral research. Most cases entailed tension inherent when an adult is susceptible to the ongoing risk of harm—from unknown predators, from family or friends taking advantage, or even from their own decisions—and the challenge of balancing protection with autonomy. Although nearly a quarter of MDT members consider client preferences as their top personal priority, protection is the top priority of most MDTs and participating agencies. MDTs may integrate the older adult’s stated preferences into case review recommendations, but protection trumps their preferences, and it is extremely rare that a team will invite the individuals whose lives they are discussing to participate.[i]
Seeking to understand individualized perspectives is characteristic of a person-centered approach.
Person-centered (also referred to as client-centered,) is a term that is often used to describe services with an emphasis on autonomy and choice. In health care, there is consensus that person-centered care is when “individuals’ values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires.”[ii]
Person-centeredness is important in elder abuse cases for several reasons. Promoting choice in older adults improves health, emotional state, and overall wellbeing.[iii] Empowering decision making among survivors of elder abuse may offset the impacts of abuse, which includes psychological distress, increased hospitalization, and early mortality.[iv] Choice, inclusion, and empowerment are principles of trauma-informed care, and are crucial when working with marginalized populations.[v] In addition, in long-term care settings, person-centered care reduces staff burnout and stress and improves job satisfaction.[vi] And, crucially, person-centeredness is important because protection of adults at the cost of honoring preferences can be damaging, even deadly.[ix][x]
Elder abuse MDTs facilitate dynamic relationships among a range of service providers making decisions and collaborating to support a coordinated plan of action for older victims. The preferences and values of impacted elders are recognized as critical to successful client-defined and centered outcomes. Yet, adapting truly person-centered care to elder abuse interventions is rife with challenges. Older adults were not consulted in the design of elder justice response systems, and their preferences and priorities might be outside the available interventions. Although the right to refuse help is an expression of self-determination, it does not equate to person-centeredness. Truly person-centered care holds the person’s choice as priority, rather than organizational procedure, and adapts when those choices change.[ii][viii]
There are many drivers behind an older adult’s decisions that may not be readily revealed; understanding these may be precedent for person-centered care in elder abuse interventions. For example, willingness to engage in public services can be impacted by past traumatization, rapport with the provider offering help, limited experience making complex decisions with high-stakes consequences, or, importantly, the belief that the current situation is better than any alternatives.[vii] However, even those with the time and communication skills to come to this understanding may be limited by agency rules delineating what can and cannot be done to help older adults. True person-centeredness may necessitate creating more flexible systems, that can bend to individual needs.[viii]
There are a handful of service providers, whom I have had the privilege to speak with and learn from, offering person-centered care in a manner that seeks to assist older adults whose answers do not lie in the predominant service offerings. These trailblazers have described the humility of letting go of preconceived notions to understand the point of view of their clients, and the emotional flex of working with clients who remain, at their preference, in risky situations. It is important that older adults feel truly heard and understood, and that their strengths are recognized by those advocating on their behalf. Suspending assumptions about an older adult’s situation to develop a relationship of trust and mutual respect is an essential foundation. Motivational interviewing is one effective technique being utilized to help older victims examine their situation and options.
It is probable that service providers and investigators of elder abuse across the United States are using person-centered approaches without identifying them as such. Surveying what person-centered practices exist, those that are lacking, and understanding how they conceptualize person centeredness and support their service providers, would aid systematic diffusion of this approach in MDTs and communities across the country.
[i] Wilber K, Mosqueda L, Gassoumis Z, Galdamez G, Louis A, Rowan J, et al. Final report. Developing a better understanding of a unique MDT model: the Elder Abuse Forensic Center. ACL. 2021. No.90EJIG0006-01-00
[ii] American Geriatrics Society Expert Panel on Person-Centered Care (2016). Person-Centered Care: A Definition and Essential Elements. Journal of the American Geriatrics Society, 64(1), 15–18. https://doi.org/10.1111/jgs.13866
[iii] Mallers, M. H., Claver, M., & Lares, L. A. (2014). Perceived control in the lives of older adults: the influence of Langer and Rodin's work on gerontological theory, policy, and practice. The Gerontologist, 54(1), 67–74. https://doi.org/10.1093/geront/gnt051
[iv] Pillemer, K., Burnes, D., Riffin, C., & Lachs, M. S. (2016). Elder abuse: Global situation, risk factors, and prevention strategies. Gerontologist, 56, S205. doi:10.1093/geront/gnw004
[v] Ernst, J. S., & Maschi, T. (2018). Trauma-informed care and elder abuse: a synergistic alliance. Journal of elder abuse & neglect, 30(5), 354–367. https://doi.org/10.1080/08946566.2018.1510353
[vi] Kogan, A. C., Wilber, K., & Mosqueda, L. (2015b). Person-Centered Care for Older Adults with Chronic Conditions and Functional Impairment: A Systematic Literature Review. Journal of the American Geriatric Association, 64, e1-e7. DOI: 10.1111/jgs.13873
[vii] Lachs, M. S., Williams, C. S., O’Brien, S., & Pillemer, K. A. (2002). Adult Protective Service Use and Nursing Home Placement. The Gerontologist, 42(6), 734-739.
[viii] Blenkner, M., Bloom, M., & Nielses, M. (1972). A research and demonstration project of protective services: 289. Nursing Research (New York), 21(3), 280. doi:10.1097/00006199-197205000-00067
[ix] Bergeron L. R. (2006). Self-determination and elder abuse do we know enough? Journal of gerontological social work, 46(3-4), 81–102. https://doi.org/10.1300/J083v46n03_05
[x] Berwick D. M. (2009). What 'patient-centered' should mean: confessions of an extremist. Health affairs (Project Hope), 28(4), w555–w565. https://doi.org/10.1377/hlthaff.28.4.w555