Full text of DOI:10.1093/geront/40.4.492

Practice Concepts
Eleanor S. McConnell, RN, PhD, Editor
Copyright 2000 by
The Gerontological Society of America
This article describes a 2-year collaborative project in Cleveland, OH, that improved the
reporting and management of potential and suspected elder abuse situations involving persons
with dementia. Educational curricula for cross-training, screening tools, and referral protocols
were developed and tested for staff and volunteers in adult protective services and dementia
care. A handbook for caregivers of persons with dementia was produced that enables
caregivers to self-identify elder abuse risk and seek appropriate interventions to prevent abuse.
Project organization, implementation, and evaluation are discussed along with strategies for
replication in other communities.
The Gerontologist
Vol. 40, No. 4, 492–497
Key Words: Curricula, Screening tools, Referral protocols
A Model Intervention for Elder
Abuse and Dementia
Georgia J. Anetzberger, PhD,1 Barbara R. Palmisano, MA,2 Margaret Sanders, MA,2
David Bass, PhD,3 Carol Dayton, MSW,4 Sharen Eckert, MS,5
and Maria R. Schimer, MPH, JD2
Several recent studies suggest that persons with
dementia are at increased risk of elder abuse. The re-
search focusing on the caregivers of family members
with dementia indicates more abuse in these families
than in the general population (Wolf, 1998). Paveza
and his associates (1992) used the severe violence
subscale of the Conflict Tactic Scales (Straus, Gelles,
& Steinmetz, 1980) to identify the frequency of vio-
lent behaviors between caregivers and care recipi-
ents in a 184-person sample taken from an Alz-
heimer’s disease registry. In the year after diagnosis,
15.8% of care recipients were violent toward their
caregivers, 4.4% of caregivers were violent toward
their care recipients, and 3.8% were mutually vio-
lent. Coyne, Reichman, & Bergib (1993) surveyed
callers to a dementia care hotline to explore the fre-
quency of physical abuse that had occurred since
they had become a caregiver. Among 342 respondent
caregivers, 33% had been abused by the care recipi-
ent and 12% had abused the care recipient at least
once. In 9% of the families there was mutual abuse
between caregiver and care recipient. Pillemer and
Suitor (1992) interviewed 236 family members pro-
viding care to persons who had received a diagnosis
of dementia within the previous 6 months. They
found that 20% of the caregivers feared they would
become violent, 6% had been violent, and 25% indi-
cated that the care recipient was violent. Other research
also suggests a link between elder abuse and dementia
in caregiving relationships (Anetzberger, 1987; Cooney
& Mortimer, 1995; Lau & Kosberg, 1979; Steinmetz,
1988).
Studies on self-neglect show its association with
dementia. In a national investigation of self-neglecting
elders who had been reported to adult protective ser-
vices, Duke (1991) found a high ratio of mental im-
pairment. Among Vinton’s (1992) sample of 227 com-
petent but self-neglecting elders, 22% had Alzheimer’s
disease or related dementia. Dementia also was present
in one third of the 1,500 cases of self-neglect studied by
Longres (1994). Finally, in the recently released Na-
tional Elder Abuse Incidence Study (National Center
This project was funded in part by a grant from The Cleveland Founda-
tion. The assistance of the following project Work Group members and
support staff is gratefully acknowledged: Jean Booth, Jennifer Constantino,
Casey Durkin, Joan Lavelle, Catherine McCarthy, Kamla Nagpaul, Rita
Rothstein, Joan Scharf, Susan Stewart, and Carolyn Sugiuchi.
1Address correspondence to Georgia J. Anetzberger, PhD, Associate
Director for Community Services, The Benjamin Rose Institute, 2373 Euclid
Heights Blvd., Cleveland Heights, OH 44106. E-mail: georgia@
benrose.org
2Office of Geriatric Medicine/Gerontology, Northeastern Ohio Univer-
sities College of Medicine, Rootstown.
3Margaret Blenkner Research Center, The Benjamin Rose Institute,
Cleveland, Ohio.
4Adult Protective Services, Cuyahoga County Department of Senior
and Adult Services, Cleveland, Ohio.
5Cleveland Area Chapter, Alzheimer’s Association, Ohio.
492
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on Elder Abuse, 1998), three quarters of substantiated
self-neglecting elders had some degree of confusion.
Despite the recognized association between elder
abuse and dementia, until now no intervention has
been developed that addresses these interfacing prob-
lems. In this article we describe a multiagency, multi-
faceted project in greater Cleveland, OH, that im-
proved the detection and management of elder abuse
situations involving persons with dementia.
dated reporters from contacting authorities about elder
abuse experienced by their clients (Faulkner, 1982;
Gilbert, 1986).
Project Purpose and Structure
The goals of A Model Intervention for Elder Abuse
and Dementia were to increase case identification,
improve care planning and intervention, and pro-
mote prevention of abuse in persons with dementia
who are suspected of being or who are at risk of elder
abuse. Supported for 2 years with funding from The
Cleveland Foundation and in-kind agency contribu-
tions, the project involved five organizations. In addi-
tion to the Alzheimer’s Association, Cleveland Area
Chapter, and the Cuyahoga County Department of
Senior and Adult Services, Adult Protective Services,
project partners were The Benjamin Rose Institute,
Northeastern Ohio Universities College of Medicine,
and Western Reserve Consortium for the Prevention
and Treatment of Elder Abuse. The major roles and
responsibilities of each organization in the project
are delineated in Table 1.
Barriers to Referral and Collaboration
Cross-referral and reporting between Adult Protec-
tive Services (APS) and the Alzheimer’s Association
were rare in greater Cleveland, as in other parts of the
country. During the past decade there were less than
a half-dozen reports of elder abuse by Alzheimer’s
Association staff and volunteers and a comparable
few referrals for dementia care by APS at the Cuya-
hoga County Department of Senior and Adult Ser-
vices. The scarcity of cross-referrals was even more
striking given the large number of older persons in
the county (i.e., more than 300,000 individuals aged
60 and older) and the high volume of referrals han-
dled by each agency annually, about 2,300 and
1,800, respectively.
Project members developed several products to
accomplish the project goals:
Barriers to cross-referral and service collaboration
among agencies specializing in elder abuse and those
specializing in dementia care have been recognized
both locally (Balaswamy, 1992) and nationally (Fla-
herty & Raia, 1994; Haley & Coleton, 1992). Barriers
include limited training about the other problem area
and the interface between the two problems in home
and community settings and failure of agencies to es-
tablish appropriate protocols for collaborative service
delivery. Barriers also exist because of insufficient
knowledge and trust regarding how other agencies
contend with the sensitive issues of elder abuse and
dementia. Finally, concern about differing agency phi-
losophies along with fear of eroding client rapport and
confidentiality further contribute to underreporting.
In particular, professional codes of ethics that empha-
size client confidentiality often inhibit even legally man-
• An educational curriculum on issues of elder
abuse, a parallel curriculum on dementia, and an
integrative curriculum on effective intervention in
situations of elder abuse and dementia.
• A cross-training program for Alzheimer’s Associa-
tion and APS staff and volunteers based on the ed-
ucational curricula.
• A screening tool for use by Alzheimer’s Associa-
tion staff and volunteers to identify abusive and
potentially abusive situations and tools useful in
identifying cognitive impairment for APS staff.
• Protocols for referral and intervention among the
three service-providing partners.
• A handbook for caregivers to self-assess risk of el-
der abuse and to identify community resources for
assistance.
Table 1. Responsibilities of Partnering Organizations
Partner
Major Responsibilities
The Benjamin Rose Institute
Project administration and direction
Evaluative research
Services to potential elder abuse situations
Project coordination
Curricula development and implementation
Northeastern Ohio Universities College of Medicine
Alzheimer’s Association, Cleveland Area Chapter
Caregiver handbook design
Advisory and Work Group participation
Services to persons needing dementia care
Recipient of cross-training
Cuyahoga County Department of Senior and Adult Services,
Adult Protective Services
Advisory and Work Group participation
Investigation of and services to reported elder abuse situations
Recipient of cross-training
Western Reserve Consortium for the Prevention and Treatment
of Elder Abuse
Caregiver abuse screening tool development
Project dissemination among the Consortium’s 100-plus
individual and organization members
Vol. 40, No. 4, 2000
493

Three groups were formed to implement the project.
The Advisory Group was led by the project’s principal
investigator (the first author of this article) and com-
prised executive staff from the partnering organiza-
tions. Meeting quarterly, the Advisory Group pro-
vided direction for project activities and reviewed
and approved all products. The Work Group was led
by the project’s director (the second author of this ar-
ticle) and included key clinical staff from the service
partners along with the evaluation assistant. Meeting on
an average of bimonthly, it produced key elements of
the educational curricula, referral and intervention pro-
tocols, and handbook for caregivers. Lastly, the Evalu-
ation Group consisted of Benjamin Rose Institute re-
search staff and students. It functioned to design and
implement the project evaluation as well as to help
develop and test the caregiver abuse screening tool in
the handbook for caregivers.
fluid system with flexibility for the referral process to
begin at any agency and proceed in a logical manner
to the appropriate agency(ies). The client may enter
the system at any point and go back and forth be-
tween agencies or receive concurrent services from
more than one agency. A lead agency is established
to direct and coordinate services.
Open communication among agency intake de-
partments, case managers, and supervisors was de-
veloped so that staff have opportunities to seek coun-
sel when making difficult decisions about clients. On
an informal basis, staff are encouraged to use the ex-
pertise of the partner agencies through case consulta-
tion. Once a client is formally referred to another
agency, the referring agency receives feedback on
the status of the case. This feedback is important to
assure the referring agency that the client is being
served. The referring agency also is notified if the
case is not accepted for service or upon discharge
from services. This procedure helps to prevent clients
from falling through service gaps.
Collaborative Process
Building relationships and trust among the partner
agencies was an ongoing process that involved all
levels of staff. Agency executives established core
values for the project that assured a common purpose
and reflected ethical values of service delivery. Staff
and volunteers actively participated in the interactive
sessions of the cross-training program and through
representation in the Work Group.
The Work Group was an important component of
the project. Membership of the group remained sta-
ble, and the group members established close work-
ing relationships and remarkable openness with each
other. Meetings were conducted in a problem-solv-
ing forum, revolving around case discussions. The
Work Group used the cases to explore ways to share
resources, break down service barriers, and improve
care management. Points of tension or “unsolvable”
dilemmas emerged from these discussions. After the
meetings, group members discussed the dilemmas
with their administrators and colleagues.
The Advisory and Work Groups both faced chal-
lenges in resolving issues that emerged during the
project. Initial meetings were spent dispelling mis-
conceptions about partner agency roles and discuss-
ing agency responsibilities and limitations. Group
members clarified legal, financial, and staffing con-
straints of their respective agencies. They examined
issues of client confidentiality and violation of trust in
terms of cooperative case management. Boundaries
were set for disclosure of client information. The
group members established clear lines of responsibil-
ity and authority to avoid confusion and duplication of
effort when multiple agencies were involved in a case.
The challenges brought up during the case discus-
sions led to the development of a new model for case
referral: the Referral and Services Model for Preven-
tion and Intervention of Abuse in Clients Affected by
Dementia (Figure 1). The model, developed by the
third author of this article, graphically demonstrates
collaboration among the Alzheimer’s Association,
The Benjamin Rose Institute, and APS. The model is a
Educational Curriculum and Cross
Training Program
A 156-page Model Intervention curriculum was
developed through literature review and synthesis as
well as Advisory and Work Group contribution. It
was pilot tested among volunteer staff from APS and
the Alzheimer’s Association. As a result of testing, we
revised the curriculum for APS staff to recognize their
knowledge regarding elder abuse and to empower
them through demonstration of their ability to solve
problems in difficult case situations.
The curriculum was organized into three modules:
• Module 1 emphasizes manifestations of various
types of dementia, identification of early dementia
symptoms, assessment of client capacity and com-
petency, and referral and management of persons
with dementia. The module is a full-day training
program for staff from APS.
• Module 2 provides background information on el-
der abuse, theories of causation, ways to screen
for possible abuse or neglect, elder abuse law and
the APS system, and referral protocols. This mod-
ule was designed as a full-day training program for
Alzheimer’s Association staff and volunteers.
• Module 3 is an integrative module that brings to-
gether staff and volunteers from the Alzheimer’s
Association and APS for a half-day training pro-
gram. The module focuses on communication
techniques, agency philosophies and roles, and le-
gal and ethical dilemmas in cases of elder abuse
and dementia.
The Model Intervention curriculum is available for
use by other agencies. It includes faculty guides, work-
books for participants, and references. The faculty
guide is complete with teaching instructions, op-
tional interactive exercises, and case discussions. The
content of the curriculum is tailored to specific agen-
494
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Figure 1. Referral and service model for prevention and intervention of abuse in clients affected by dementia. APS ϭ Adult Protective
Services; BRI ϭ Benjamin Rose Institute; AA ϭ Alzheimer’s Association.
cies in Cuyahoga County, OH, and is based on Ohio
law. However, it can be easily adapted to other com-
munities, states, and service provider networks. Mod-
ifications of the curriculum have been used for train-
ing Area Agency on Aging staff along with police and
other “first responders” who come in contact with
older persons. The curriculum modules were devel-
oped to be given in a series but also may be pre-
sented as single training programs.
The training was mandatory for all staff at APS and
all staff and volunteers at the Alzheimer’s Associa-
tion. The 2.5-day training program was repeated
three times so that only one third of agency staff was
involved at a given time. The sessions were team
taught by various Advisory and Work Group mem-
bers. All APS and Alzheimer’s Association staff and
volunteers attended the training.
haviors of the care recipient that have been found to
be highly stressful to the caregiver. The second in-
strument provides a list of physical and emotional in-
dicators of strain to assist caregivers in identifying
their reactions to stress. Finally, a list of caregiver be-
haviors that are indicative of elder abuse is included.
The tone of the handbook is nonpunative, emphasiz-
ing that harm can occur without intent. Readers are
made aware that they can prevent abuse by recogniz-
ing their sources of stress, identifying the effects of
their response to stress, and seeking assistance. Com-
munity resources and educational references are pro-
vided throughout the text. The handbook was pilot
tested among participants of Alzheimer’s Association
support groups before its broad dissemination by the
project partners.
The handbook was originally written in English.
However, because greater Cleveland has a large His-
panic population—mainly Puerto Rican—a Spanish
version was produced by bilingual staff of The Ben-
jamin Rose Institute using funds provided by the local
Area Agency on Aging. The Spanish version was pilot
tested across multiple Hispanic cultures and reading
levels before distribution primarily through local His-
panic senior centers.
Handbook for Caregivers
The Work Group developed a 10-page handbook
as a resource to help caregivers experiencing strain to
identify the risk of harm to themselves or to the persons
for whom they are caring. The handbook includes
three brief self-assessment instruments adapted for
the project from research conducted at the Margaret
Blenkner Research Center of The Benjamin Rose In-
stitute, sometimes in collaboration with the Preven-
tion/Education Committee of the Western Reserve
Consortium for the Prevention and Treatment of Elder
Abuse. The first instrument identifies disruptive be-
Evaluation
We evaluated several dimensions of the project to
determine changes in knowledge, attitudes, and be-
haviors of partner agency staff and volunteers. The
Vol. 40, No. 4, 2000
495

evaluation involved assessment of the training pro-
gram through participant completion of evaluation
forms before training was initiated and after each ses-
sion was completed. In addition, project evaluation
included critical review of agency protocols and
analysis of client outcomes. Finally, staff were asked
for anecdotal reports regarding cross-referrals and
consultations following the training.
Results of the educational training showed significant
increases in understanding in 4 areas evaluated for APS
workers (Table 2). After the training APS staff serving cli-
ents with dementia were more willing to collaborate
with the Alzheimer’s Association. Alzheimer’s Associa-
tion staff and volunteers had significant increases in
perceived understanding in all 13 areas evaluated
(Table 2). After the training, all Alzheimer’s Associa-
tion staff and volunteers showed a substantial will-
ingness to collaborate with APS. Ratings for staff and
volunteers of the Alzheimer’s Association were sig-
nificantly similar in magnitude and not significantly
different.
ited to monthly calls from the case manager. He was
very resistant to accepting other services or another
agency’s assistance. An irate Mr. A contacted the
Alzheimer’s Association after he received a letter
from APS, because a report had been made that his
wife was being left alone and locked in a bedroom.
The APS worker attempted to make a visit but was re-
fused entry into the home. The case manager from
the Alzheimer’s Association called the APS social
worker to discuss the situation. They agreed to make
a joint visit to the home to minimize the trauma of
the investigation. They diffused a tense situation by
combining the trust established between Mr. A and
the case manager and the interviewing skills of the
APS social worker. The allegations of neglect were
unsubstantiated. Mr. A was convinced to place his
wife in a local day care program to increase her so-
cialization and provide him with some respite.
Prior to the project, Alzheimer’s Association and
APS staff could not have effectively cooperated to ad-
dress the situation of Mr. A and Mrs. A for two rea-
sons: (a) the rapport and trust for communication did
not exist and (b) there was insufficient understanding
of the potential role each agency could assume in
handling elder abuse situations known to both.
Cross-training and referral protocol development es-
tablished a climate of enhanced communication and
collaboration between the Alzheimer’s Association
and APS to resolve difficult client situations like that
of Mr. A and Mrs. A.
A poignant example of the success of the project is
the case of Mr. A and Mrs. A. Mr. A had been the pri-
mary caregiver for his wife for 10 years. Mrs. A had
advanced Alzheimer’s disease resulting in emotional
instability, difficulty swallowing, and limited ability
to communicate. Mr. A had been involved in the
Alzheimer’s Association family assistance program
for at least a year; however, his participation was lim-
Table 2. Evaluation Results of Cross-Training
Outcomes and Discussion
A Model Intervention for Elder Abuse and Demen-
tia represents the first initiative ever undertaken that
addresses elder abuse and dementia as interfacing
problems requiring referral and management by com-
munity agencies from diverse service systems and phi-
losophies. The success of the project is evident in three
ways. First, although the curriculum and handbook for
caregivers were developed for greater Cleveland, their
basic content is state-of-the-art, easily adaptable, and
proven with other groups and in other communities.
Second, project goals were achieved. Cross-training
and collaboration on project Advisory and Work
Groups improved communication and relations across
partnering agencies. This improvement is illustrated in
the pre- and posttraining test results, increased re-
ports and referrals among service-providing partners,
and greater consultation around difficult case situa-
tions. There had been less than a half-dozen referrals
or reports between APS and the Alzheimer’s Associa-
tion in the 10-year period prior to project onset.
Within 1 year following the cross-training, the Alz-
heimer’s Association had made 27 elder abuse re-
ports to APS, 17 of which were accepted for formal
investigation, including 15 substantiated as abuse, ne-
glect, or exploitation and in need of protective inter-
vention. In addition, the intake supervisor at APS re-
ported that staff at the Alzheimer’s Association called
her on several occasions to informally discuss other
client situations. All situations identified as elder
APS Results
Areas where perceived understanding significantly increased
• Prevalence of dementia and stages of Alzheimer’s disease
• Services offered by the Alzheimer’s Association
• Time at which to refer suspected dementia to the Alzheimer’s
Association
• Assessment of the decision-making ability of persons with
dementia
Areas where likelihood of future interaction with Alzheimer’s
Association staff increased
• Referral of clients with dementia to the Alzheimer’s
Association
• Consultation on how to best assist clients with dementia
Alzheimer’s Association Results
Areas where perceived understanding significantly increased
• Prevalence of elder abuse among families dealing with
dementia
• Barriers to reporting elder abuse
• Types, causes, and risk factors of elder abuse
• Links to caregiving stress
• Guidelines for referring to APS and use of elder abuse laws
• Legal issues related to reporting elder abuse
• APS investigation methods for reported elder abuse and the
service process that prevents elder abuse
• Confidentiality of reporting suspected elder abuse to APS
Areas where likelihood of future interaction with APS staff
increased
• Referral of a family if there is suspected abuse
• Reports of cases of suspected abuse
• Suggestion that a family call APS about suspected abuse
• Consultation with someone from APS about a family
Note: APS ϭ Adult Protective Services.
496
The Gerontologist

References
abuse by Alzheimer’s Association staff were either re-
ported to APS or discussed with the APS intake super-
visor. Although the Alzheimer’s Association has not
received formal referrals from APS, they have been
called on as a collateral resource. The Benjamin Rose
Institute has had 18 community service referrals of
potential abusive situations from the Alzheimer’s As-
sociation since the training. Seventeen of these were
accepted for service. In all but one instance, interven-
tion was effective in preventing elder abuse from oc-
curring. Finally, the handbook for caregivers was so
well received in the community that the initial supply
of 1,500 copies was quickly depleted. Grants from
the John P. Murphy Foundation and Wolfpert Fund
were sought and obtained to print additional copies
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• A belief in the value in interagency collaboration,
manifested in the release of staff time and commit-
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• The capacity to build and sustain trust, evident in
the ability to risk and to set aside past suspicions
and misperceptions.
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• The willingness to identify and solve problems,
which requires honest and open communication.
• The ability to “let go” and change directions when
initial efforts fail and alternative strategies need to
be undertaken to achieve ultimate goals.
Received October 14, 1999
Accepted March 6, 2000
Decision Editor: Vernon L. Greene, PhD
Vol. 40, No. 4, 2000
497