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498

CHAPTER 18

Elder Abuse

PATRICIA BROWNELL and GINA R. ROSICH

LDER ABUSE IS

a complex and significant social and public health problem.

There are neither easy explanations nor firmly established methods for ex-

amining, assessing, or ameliorating it. Despite over 30 years of research,

policy implementation, practice, and public awareness efforts, there is still little

consensus among researchers and policy-makers about definitions and measures

(Chalk, 2000). However, professionals from a wide variety of disciplines continue

to make progress in understanding the many forms of elder abuse that occur and

evaluating the effectiveness of practice, program, and policy interventions in-

tended to prevent and ameliorate this troubling social phenomenon.

This chapter examines the scope of the problem of domestic elder abuse and

presents an overview of theoretical perspectives on elder abuse and mistreat-

ment. Evidence-based interventions found in the professional literature and prac-

tice guidelines with vignettes are intended to assist professionals with ways to

help victims of elder abuse. Finally, recommendations are made for policy initia-

tives and future research.

TRENDS AND INCIDENCE

In spite of over 30 years of public debate about elder abuse, there is no definitive

answer to the question of how many cases of elder abuse occur in a given year. Re-

search prevalence estimates have ranged from 3% to 10%, and the latest incidence

study estimated that 820,000 to 1,860,000 older adults are abused each year

(Tatara, Kuzmeskus, Duckhorn, & Bivens, 1998). These data are disputed by other

experts in the field as representing undercounts (Thomas, 2000). There are many

reasons for a discrepancy in estimates: methodology, samples used, and how the

definition of elder abuse was operationalized. The earliest researchers in the field

experienced conflict regarding these questions, and to this day, there is still some

disagreement (Choi & Mayer, 2000; National Center on Elder Abuse [NCEA], 2006;

Quinn & Tomita, 1997; Wolf, 1996). Variations in definitions used by policy mak-

ers, researchers, and practitioners compound the difficulty of achieving accurate

estimates of incidence and prevalence, as well as identifying emerging trends.

Elder Abuse 499

Elder abuse can take many forms, but generally speaking, it can be broken

down into six major categories:

1. Physical abuse, which involves the use of physical violence that induces pain

or impairment and may or may not result in bodily injury (hitting, slapping,

striking with objects).

2. Sexual abuse, which includes nonconsensual sexual contact of any kind with

an elderly person.

3. Emotional or psychological abuse, which inflicts pain, distress, or anguish

through threats, intimidation, insults, humiliation, harassment, and other

forms of verbal aggression.

4. Financial and material exploitation, which involves the illegal or improper use

of an elder’s funds, property, or assets.

5. Neglect, which includes the deliberate or unintended failure on the part of a

caregiver to provide a dependent elderly person with necessities such as

food, medication, bathing, and social contact.

6. Self-neglect, which is failure on the part of the elderly person living indepen-

dently to provide for himself or herself, threatening the health and safety of

the individual (Choi & Mayer, 2000; NCEA, 2006).

These categories are generally accepted by researchers, having been adopted

early by pioneers in the field such as Pillemer and Finkelhor (1988), who con-

ducted the first large-scale prevalence study of elder abuse and neglect, and who

continue to be cited in the literature.

The disagreements that arise in comparison studies of Adult Protective Ser-

vices (APS) laws and in prevalence and incidence studies of elder abuse gener-

ally fall into practical and theoretical realms. Practically speaking, abuse

definitions and mandatory reporting laws vary across the country by state and

between researchers, among reporters, and in the understanding of the general

public. Some do not use the term “abuse,” and others distinguish between self-

neglect and neglect by others. Adult Protective Services agencies also do not use

the same terms when documenting reports and do not always collect the same

type of data (Choi & Mayer, 2000; Goodrich, 1997; Hudson & Carlson, 1998;

Jogerst et al., 2003; Wolf, 1996). Theoretically, some researchers are interested in

broader categories, such as violation of rights (e.g., forced institutionalization or

removal of personal property) and abandonment. Questions arise as to whether

self-neglect should be included as a form of elder abuse as it is conceptually dif-

ferent from abuse and neglect by others, even though interventions may be sim-

ilar for both situations. Still others distinguish between cases of accidental and

intentional neglect or abuse when considering both criminal prosecution and in-

terventions to help the elder person and the abuser (Choi & Mayer, 2000; Hudson

& Carlson, 1998; Wolf, 1996).

These differences have made it difficult to compare research findings, develop

assessment instruments, count the incidence and prevalence of elder abuse, and

develop causal theories. Despite this, some impressive research has been con-

ducted. As stated earlier, Pillemer and Finkelhor (1988) conducted the first large-

scale random sample survey of elder abuse and neglect. They interviewed 2,020

elderly persons residing in a metropolitan community in Boston regarding their

experiences of physical abuse, psychological abuse, and neglect. Financial abuse

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and self-neglect were not included. Their results indicated a prevalence rate of

overall maltreatment of 32 per 1,000 elderly persons (age 65 and up). Physical

abuse was reported most often, and spouses were found to be the most likely

abusers (58%), followed by adult children (24%). They found no difference in

number of incidents by sex, although women seemed to suffer more serious

abuses than men. They also found the frail elderly to be the population at greatest

risk for maltreatment.

In a study by Pavlik, Hyman, Festa, and Dyer (2001), case reports received dur-

ing 1 year in a centralized computer database maintained by the Texas Depart-

ment of Protective Regulatory Services—APS Division were reviewed. Texas is

the largest state to have a centralized reporting system, and it has the largest pro-

tective service data repository in the country. Cases of physical abuse, emotional

abuse, sexual abuse, neglect, medical neglect, and exploitation for clients age 65

years and older were tracked, with neglect differentiated by self-neglect and neg-

lect by others. The study found that 80% of allegations reported were for neglect

and that the risk of being reported to APS nearly doubled with each 10-year in-

crease in age. They also noted that older women were 40% to 300% more likely

than older men to be reported for abuse or neglect. They suspect that women are

at higher risk than men for abuse by others; in terms of self-neglect, however, the

ratio of men to women was close to 11.

Choi and Mayer (2000) conducted a study using data from intake and assess-

ment files and case managers’ progress and termination notes from 370 cases

from the Erie County, New York Protective Services for Older Adults unit be-

tween 1992 and 1997. Their article includes a rich literature review on elder

abuse. The study itself identified self-neglect (including self-endangering behav-

iors, poor financial management, and environmental hazards not involving oth-

ers) as the largest problem facing their sample (51.9%). The remaining 48.1% of

the sample were neglected, abused, and/or financially exploited by others; 37.6%

(18.1% of the entire sample) were in the financial exploitation-only group, and of

this group, most were victimized by perpetrators unrelated to them, such as

neighbors, tenants, guardians, and others who initially came forward as “helping

hands” but were overcome by greed. In addition, 10.7% experienced abuse only,

and 2.2% experienced abuse and neglect; 15.7% experienced neglect and finan-

cial exploitation.

Choi and Mayer (2000) found that those who had acute or chronic illnesses

were 62% more likely to have been abused, neglected, or exploited by others, and

those who had alcohol or substance abuse problems were 70% more likely to have

been self-neglecting. Neglect, psychological abuse, and financial exploitation

were more commonly reported and substantiated than physical abuse. However,

neglect was the highest reported problem (including self-neglect). Multiple forms

of abuse and neglect are also found to occur simultaneously. Elders were less

likely to be abused, neglected, or exploited by others if they lived alone and had

social supports, but more likely to suffer self-neglect if they had difficulties with

activities of daily living and substance abuse problems. Those with acute or

chronic illnesses were 62% more likely than those without illnesses to be abused,

neglected, or exploited by others. Elders living with others (mostly family mem-

bers) faced the greatest likelihood of being physically and psychologically abused

and neglected.

Both prevalence and incidence data on elder abuse to date are considered by

many experts to be vastly underreported because of a lack of self-reporting by

Elder Abuse 501

victims and perpetrators, the relative invisibility of the elder population, the lack

of awareness of the problem on the part of the general public, and the lack of ade-

quate assessment tools for professionals (Quinn & Tomita, 1997). This has led to

the popularization of the “iceberg theory,” which posits that substantiated inci-

dents of elder abuse represent only the tip of the iceberg, with the largest number

of cases identified by professionals but not reported to authorities, and a smaller

percentage of cases both unidentified and unreported (Cyphers, 1999).

The most recent research study on incidence of elder abuse was the first na-

tional survey of state APS programs by the National Center on Elder Abuse

(Tatara et al., 1998), which found that approximately 450,000 elderly people in do-

mestic settings in the United States were the victims of some sort of abuse or neg-

lect. This number increased to 551,000 when the category of self-neglect was

added. Tatara et al. also reported the following findings:

• Female elders are abused at a higher rate than males, after accounting for

their larger proportion in the aging population.

• Our oldest elders (80 years and over) are abused and neglected at 2 to 3

times their proportion of the elderly population.

• In almost 90% of the elder abuse and neglect incidents with a known perpe-

trator, the perpetrator is a family member, and two-thirds of the perpetra-

tors are adult children or spouses.

• Victims of self-neglect are usually depressed, confused, or extremely frail

(p. 12).

The findings of this national study were controversial. When results showed

lower than expected numbers of incidence, advocates and agencies worried that

funding for elder abuse research and services would not be prioritized (Thomas,

2000). However, with population trends showing an increase in the proportion of

people age 65 and up with the aging of the baby boomer generation, and research

showing that older people who are mistreated are 3 times more likely to die dur-

ing a 3-year period than those who do not experience abuse, those concerned

about elder abuse should caution against dismissing or minimizing it (Lachs &

Pillemer, 2004).

Although APS statutes are state- and county-based and differ from one jurisdic-

tion to another, the Older Americans Act (OAA) Amendments Title VII presents a

national definition that frames elder abuse, neglect, and mistreatment in a human

rights context (OAA, 42 U.S.C. section 3001 et seq., 2000). Here, abuse is defined as

“the willful infliction of injury, unreasonable confinement, intimidation, or cruel

punishment with resulting physical harm, pain, or mental anguish or deprivation

by a person, including a caregiver, of goods and services that are necessary to avoid

physical harm, mental anguish, or mental illness” (42 U.S.C. section 3001 et seq.,

2000). This definition is intended to guide state and area agencies on aging in de-

veloping programs and services for preventing and protecting adults age 60 and

above from experiencing family mistreatment.

The OAA defines elder abuse in broad terms, but agencies and services funded

by the OAA do not have the enforcement powers of APS agencies, which are man-

dated by state law and regulation to provide involuntary services if deemed nec-

essary to protect abused, neglected, and self-neglecting adults, including older

adults, from harm, assuming they lack the mental or physical capacity to protect

themselves from harm.

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ETIOLOGY AND PROGNOSIS

Multiple theories have emerged to explain the phenomenon of elder abuse and

shed light on possible preventive and intervention measures. Theoretical per-

spectives cited in the literature range from individual characteristics of the vic-

tim and abuser to structural theories that reflect societal and cultural factors

(Anetzberger, 2005). Vulnerability and psychopathology theories suggest that

elder abuse and mistreatment can occur as a result of individual characteristics

such as victim high care needs (Steinmetz, 1990) or abuser psychopathology

(Brownell, Berman, Salamone, & Welty, 2002). Situational theory (Grunig & Dis-

brow, 1977), vulnerability theory (Penhale & Kingston, 1997), role theory (Soeda

& Araki, 1999), and ecology theory (Schiamberg & Gans, 1999) all suggest that in-

teractional effects among individual circumstances and environmental contexts

can lead to elder abuse and neglect. Social learning theory (Wolf, 2000), symbolic

interactionism (Steinmetz, 1990), and functionalism (Powell, 2001) provide

frameworks for understanding the impact of cultural values and norms on abuse

of older adults by family members and significant others. Feminist theory

(Nerenberg, 2002) explains the abuse of older women in terms of structural in-

equities in societies that disadvantage women and girls.

EVIDENCE-BASED INTERVENTIONS

Interventions can include preventive strategies as well as interventions intended

to minimize or stop abuse or neglect of a vulnerable older adult. All interventions

must start with good assessments, which include identification of risk factors and

diagnosis and prognosis. The goal of screening and assessment of elder abuse is to

identify the target (victim) of abuse or neglect, reduce or eliminate the continua-

tion of mistreatment, and protect the victim. Health care workers are often the

first to observe the physical manifestations of elder abuse and neglect but may

misidentify the causes or choose to ignore them. Self-reporting of abuse or neg-

lect is uncommon and unreliable; the stigma of abuse may make older adult vic-

tims and family members uncomfortable about disclosing it (U.S. Department of

Health and Human Services, 2006).

SSESSMENT

Research on assessing older adult victimization is far behind that of interpersonal

violence in adolescents and young adults. Some researchers (Acierno, Resnick,

Kilpatrick, & Stark-Riemer, 2003) have questioned whether valid methods for as-

sessing elder victimization should be based on those used with youth and re-

searched whether telephone screening could be used to assess psychopathology.

However, the reliability and validity of telephone interviews (versus in-person in-

terviews) has also been raised. In one study of elder abuse and neglect by family

and caregivers and criminal violence (assault), researchers found no significant

differences in observed rates of victimization (recent and distant past) for either

form of assessment or in assessing psychopathology. In testing the feasibility of

interview types, no difference was found in hearing problems, fatigue during the

interview, or elevated distress from the interview questions. Telephone inter-

views were found to be significantly shorter, and elderly participants expressed a

great deal more comfort with telephone interviews; however, these were informal

Elder Abuse 503

assessments. In-person interviewers can provide more empathy and support.

Conversely, telephone interviews may capture people afraid to allow someone

into their home to conduct the interviews.

The use of explicit, behaviorally specific closed-ended event questions, contex-

tually orienting preface statements, and simultaneous assessment of both assault

by strangers and abuse by family members and caregivers are applicable to as-

sessing victimization with older adults. These types of questions were able to de-

tect various types of interpersonal violence as well as outline violence-related

assault and perpetrator characteristics.

Fulmer, Guadagno, Bitondo, and Connolly (2004) provide a comprehensive

overview of different types of assessment screening instruments. They included

an overview of theoretical models for the occurrence of elder mistreatment (EM)

and problems with underreporting and inconsistencies across fields and loca-

tions. They divided screening and assessment instruments and protocols into

four types: checklists and guidelines, qualitative assessments, quantitative as-

sessments, and combined qualitative and quantitative. They demonstrated how

different screenings might be used in different settings (e.g., short forms in hos-

pitals, longer forms by APS workers) and discussed some of the difficulties in

distinguishing EM from normal signs of aging.

One study that evaluated a screening procedure for assessing elder mistreat-

ment, emphasizing elder neglect, also examined how expert neglect assessment

teams assess and diagnose cases of suspected elder neglect (Fulmer et al., 2003).

Key themes identified in the study that must be understood by expert team mem-

bers to determine if neglect should be suspected or confirmed include the under-

lying health status of the elder and caregiver dyad, the socioeconomic and life

circumstances of the dyad, the credibility of data collected by others, and conse-

quences of the assessment outcome.

Reis and Nahmiash (1998) sought to validate the Indicators of Abuse (IOA) as

a screening tool for elder abuse and neglect. The tool was based on studies guided

by theories of abuse that included “nonnormal” abusers, dependency, caregiver

burden or stress, transgenerational violence, and social isolation. The researchers

wanted to know which items from their 48-item checklist discriminated abuse

and nonabuse cases. They also asked which of the indicators do not discriminate

abuse and nonabuse and sought to develop a theoretical model of the problems

that are abuse indicators.

The study successfully isolated a subset of 29 key items from the original

checklist of 48 that discriminated the “abuse likely” and “abuse not likely” cases.

Primary predictors were marital and family conflict, mental and behavioral

health problems of the caregiver, and past abuse of the elderly person receiving

care. Other indicators specifically about the caregiver included poor relation-

ships with others, failure or difficulty understanding the care receiver’s medical

condition, reluctance to provide care, alcohol or drug addiction problems, unreal-

istic expectations on the part of the caregiver, inexperience in caring for an el-

derly person, financial dependence on the elderly person, and if the caregiver

was a blamer. Lack of social support and poor current caregiver-receiver relation-

ships were also indicators. Variables that did not signal cases of abuse, but that

might still be problems experienced by the elderly person receiving care, in-

cluded requiring help with activities of daily living, financial difficulties other

than dependency, physical or cognitive impairment, the desire of the caregiver to

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institutionalize, and caregiver stress. The study partially supported theories of

dependency, transgenerational violence, and social isolation as causes of abuse.

Ultimately, the IOA was validated as a screening tool and identified as having po-

tential as a teaching tool.

DIAGNOSIS

Diagnosis in the context of elder abuse and mistreatment is complicated by the ne-

cessity to identify the presence of abuse, neglect, or financial exploitation in a

family situation, in addition to identifying physical, psychological, substance

abuse, and other factors reflecting personal characteristics of the victim and

abuser. Diagnosis of elder abuse and neglect depends on good assessment (Quinn

& Tomita, 1997). Elder abuse may be difficult to detect if the signs are ambiguous

and the victim is unwilling or unable to disclose the abuse.

Medical and social assessment tools have been developed, as discussed earlier,

yet symptoms of abuse may be misattributed to chronic disease or cognitive im-

pairment (Merck Manual of Geriatrics, 2000). Recognizing high-risk situations is

critical for health practitioners as well as other helping professionals to ensure

the safety and protection of a vulnerable older adult. Older adults may agree to

share their home with family members who have substance abuse problems or se-

rious mental disorders, and family members may have been discharged from a

psychiatric or other institution to the home of an older adult without having been

screened for risk of harm (Brownell et al., 2002). Physicians and social workers

should pay particular attention to those situations in which an older person is

discharged with high care needs to a family situation that may be unable to sup-

port that level of care (Merck Manual of Geriatrics, 2000).

Abused elderly people are at high risk of death through maltreatment or even

homicide (Brownell & Berman, 2004). In one New York City study, female homi-

cide victims 75 or older were more likely to be strangled, bludgeoned, or burned

to death by adult children, grandchildren, or siblings than women under 75. One

longitudinal study found a threefold higher mortality rate for abused patients

over a 3-year period after the abuse than for nonabused patients during the same

period of time (Merck Manual of Geriatrics, 2000). Prognosis is poorer for older

patients whose caregivers have chronic medical and functional problems than for

those with adequate care-giving supports.

SERVICE INTERVENTIONS

Although possible risk factors for occurrence of elder abuse have been identified

in the literature, most interventions have not been subjected to systematic evalu-

ation (National Research Council, 2003). Intervention research in elder abuse is in

its earliest stages, and intervention models have been developed to address differ-

ent types of elder abuse and neglect without rigorous testing for outcomes. The

next stage in elder abuse research is to begin more rigorous investigation into the

models’ effectiveness in preventing or ameliorating the occurrence or effects of

mistreatment on older people who may be traumatized or cognitively impaired. It

is essential to educate university-based institutional review boards on elder

abuse so that research can move forward (National Research Council, 2003).

Elder Abuse 505

Elder abuse and mistreatment is a complex social phenomenon, and interven-

tions must be designed to address very specific factors related to individual situ-

ations. For example, different interventions are needed for frail, care-dependent

older adults with impaired cognitive capacity and for mistreated older adults who

are cognitively intact, live independently in the community, and sometimes serve

as caregivers for their abusers (Brownell & Heiser, in press). Financial abuse may

require different strategies from psychological or physical, including sexual,

abuse. For elder abuse victims who choose not to separate from their abusive fam-

ily members, a family preservation program is recommended (Bergeron, 2002).

This model, adapted from child abuse practice models, was evaluated by a reex-

amination of data from a 1996 exploratory study in New Hampshire. Following

are examples of programs targeting specific forms of elder abuse that have been

described as representing best practice models in the literature.

INTERDISCIPLINARY TEAM INTERVENTIONS

NTERDISCIPLINARY

EAM

ODEL

An interdisciplinary team (IT) model was developed in Wisconsin to address

cases of elder abuse on county APS caseloads that have one or more of the follow-

ing characteristics: chronic intractable case, case with ethical issues, case needing

specialized expertise, caseworkers denied access, abuser or victim refuses ser-

vices, and case with victim and family members facing serious environmental

problems representing health and safety problems. A manual was developed for

use by county APS offices, based on assessed need for IT services (Abramson,

2005).

ASE

ANAGEMENT

ROGRAMS

An intervention program for elder abuse victims using case managers was devel-

oped in Hamilton, Ontario, to help victims set long- and short-term goals, sup-

porting victims in decisions as to whether or not to take action against their

abusers, explaining harm-reduction options, and involving others in care plans.

Outcomes for the program, which was targeted to mentally competent older

adults living in the community, included a success rate of eliminating abuse in

35% of cases serviced and improving situations in another 31% of cases (Vlade-

scu, Eveleigh, Ploeg, & Patterson, 1999).

FINANCIAL ABUSE

IDUCIARY

BUSE

PECIALIST

EAM

ROGRAM

Malks, Schmidt, and Austin (2002) presented a case study of a rapid response

team in Santa Clara, California, that was created in the wake of a rise in caseloads

from financial abuse. In their literature review, the authors reiterated the wide-

spread problem of inaccuracy in counting the exact number of cases of elder abuse

(in this case, specifically involving financial exploitation) because cases often are

not recognized or reported. The authors found financial abuse a particularly un-

derreported crime, and stated that family members and in-home caregivers ac-

counted for 60% to 90% of perpetrators. They cited the 1996 national study, which