The Three D’s:
Assessment of and
Interviewing Strategies with
Older Victims of Abuse
Sheri Gibson, Ph.D.
Rocky Mountain PACE
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.
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.
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.
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.
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.
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.
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
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
Dementia
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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
Dementia
• Found in 14% of adults
age 71 years+ (Plassman et al.,
2007)
• 24% of persons ages 8089 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
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)
Risk factors for dementia
• Advancing age
• Gender & education
• Genetics
• Cardiovascular
disease and
associated lifestyle
factors, e.g. diet,
exercise, obesity
• Brain injuries and
infections
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)
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%
Verbal
Physical
14%
Neglect
60%
10%
other
Common Dementia Symptoms
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Memory Loss
Confusion
Disorientation (advanced)
Language problems
Inability to recognize familiar objects
Changes in personality or behavior
Disturbance in executive functioning
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.
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
Communication Strategies
• TALK tactics
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Take it slow
Ask simple questions
Limit reality checks
Keep eye contact
Communication Strategies
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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
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?”
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?”
Delirium cont.
• Common medical causes:
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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
Meds that can cause confusion
Antacids
Reglan
Benadryl
Beta-blockers
Blood Pressure Meds
Anti-depressants
Muscle relaxants
Delirium in the Older Victim
• Environmental conditions
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Psychosocial factors
Sensory deprivation
Sleep deprivation
Malnourishment
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)
Conversational Clues to Status
• Delirium
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“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?
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
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
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
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):
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Increased bone or joint problems
Digestive problems
Depression or anxiety
Chronic pain
High blood pressure
Heart problems
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
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
Interviewing Strategies
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
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?
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Cognition
Speech
Mood/Affect
Eye contact
Rapport
Her story
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
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
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
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
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
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
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
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.
Thank you
• Resources:
• Alzheimer’s Association
• www.alz.org
• National Center on Elder Abuse (NCEA)
• www.ncea.aoa.gov
• National Committee to Prevent Elder Abuse (NCPEA)
• www.preventelderabuse.org
• Center of Excellence on Elder Abuse and Neglect
• www.centeronelderabuse.org
• National Council on Aging
• www.ncoa.org