Introduction

The Nature and Scope of Elder Abuse

By Rosalie S. Wolf, Guest Editor

A decade or so earlier, Congress had passed the 1962 Public Welfare Amendments to the Social Security Act. The amendments authorized payments to the states to establish protective services for "persons with physical and/or mental limitations, who were unable to manage their own affairs . . . or who were neglected or exploited" (U.S. Deptartment of Health, Education and Welfare, 1966). Twelve years later, with the adoption of the Title XX amendment to the 1974 Social Security Act, adult protective services (aps) became a state-mandated program covering all adults 18 years and older. Because the aps system for reporting and investigating cases was already in operation by the time elder abuse became a public issue, legislators could support action on elder abuse without having to call for additional state expenditures. Within a few years, most states had passed elder-abuse laws or had amended existing adult protective services legislation to address the issue.

In the United States, the construction of elder abuse as a social problem was profoundly affected by the alignment of elder abuse with adult protective services and pre-existing stereotypes about aging. The images of impaired, vulnerable victims that this association conveyed seemed to fit into the predominant model of how child abuse occurs. Many envisioned a dependent elderly parent being cared for by a well-intentioned but overburdened and guilt-ridden daughter. The analogy extended further. Because there was no model statute and no database on elder abuse, child-abuse law with its mandatory reporting of suspected cases became the prototype for legislation in more than three-quarters of the states.

Before long, however, the inadequacies of this paradigm became apparent--along with its potential for infantalizing older adults and violating their civil rights. New findings on the prevalence of spouse abuse in the elderly population suggested that the domestic violence model might be a better fit. Working with this conceptualization, policy makers have expanded intervention and treatment possibilities to include the methods and instruments of the public health and criminal justice systems.

Over the years, federal policy has reflected the various constituencies that have laid claim to the issue of elder abuse. Public welfare laws, some provisions of the Older Americans Act, and multiple crime bills have been national legislative responses to victims and their families. At the state level, laws addressing elder abuse and adult protective services are continually being amended to incorporate these new conceptualizations. The multifaceted nature of elder-abuse cases, which involve physical, psychological, social, legal, ethical, and environmental matters, requires that action take place on the psychological, social, and legal levels and that it involve multiple systems. For practitioners, the cases are demanding and often frustrating; for older adults, solutions are diffcult and, frequently, unacceptable. A brief overview of the nature, scope, and consequences of elder abuse is given below.

Definitions of Elder Abuse

In its common usage, elder abuse is an all-inclusive term representing all types of mistreatment or abusive behavior toward older adults. This mistreatment can be an act of commission (abuse) or omission (neglect), intentional or unintentional, and of one or more types: physical, psychological (or emotional), or financial abuse and neglect that result in unnecessary suffering, injury, pain, loss or violation of human rights, and decreased quality of life (Hudson, 1991). Whether a behavior is labeled as abusive, neglectful, or exploitative may depend on its frequency, duration, intensity, severity, consequences, and cultural context.

Abusive acts include striking, burning, threatening, humiliating, isolating, abandoning, or starving older adults, or taking their property without consent. If an act of violence, such as a slap, occurs once, by most standards it is probably not considered to be elder abuse. If it happens fairly often or results in hospitalization of the victim, the action is deemed abuse; likewise, threatening with a gun, sexual assault, or other markedly violent acts need only occur once. Regardless of how various state statutes define abuse and neglect, the older person's perception of the action and the cultural context in which the action occurs are salient factors in identification and intervention (Moon and Williams, 1993; Hudson and Carlson, 1999).

Prevalence and Incidence

Elder abuse occurs in domestic and institutional settings.

Elder abuse in domestic settings. The five community surveys described below, all conducted in the past decade, show that 4 percent to 6 percent of older adults report experiencing incidences of domestic elder abuse, neglect, and financial exploitation. Using a methodology previously validated in two U.S. family violence surveys, a research team surveyed over 2,000 noninstitutionalized elders living in the metropolitan area surrounding Boston, Massachusetts (Pillemer and Finkelhor, 1988). They found that after reaching 65 years of age, 2.0 percent had experienced physical abuse; 1.1 percent, verbal aggression; and 0.4 percent, neglect. The overall prevalence rate was 3.2 percent, and the researchers did not inquire about financial exploitation. Of the incidences of abuse reported, spouse abuse (58 percent) was more prevalent than abuse by adult children (24 percent). The proportion of victims was almost equally divided between males and females, and economic status and age were not related to risk of abuse.

A similar survey of Canadian elders, which contained an additional question about financial exploitation, showed that 4.0 percent of older adults surveyed had been abused, of which the predominant type--2.5 percent of all respondents--was financial exploitation (Podnieks, 1992). In a third study, 5.4 percent of elders in one semi-industrialized Finnish town reported having been the victims of abuse, neglect, or exploitation since they had reached retirement age (Kivelä et al., 1992). A fourth study, based on a poll of British residents, indicated that 5.0 percent of adults ages 65 and over had been verbally abused by a close family member or relative in the recent past; 2.0 percent, physically abused; and 2.0 percent, financially abused (Ogg and Bennett, 1992). In yet another study, 1,797 persons ages 65­84 who were living in Amsterdam and who were not institutionalized and not demented were interviewed about elder mistreatment, using definitions from the Boston study. The one-year prevalence of elder mistreatment was found to be 5.6 percent, that of chronic verbal aggression, 3.2 percent; physical aggression, 1.2 percent; financial mistreatment, 1.4 percent; and neglect, 0.2 percent (Comijs et al., 1998). Since all five surveys are based on self-reporting and, except for the Boston project, excluded those who could not respond to a survey question, the percentages are considered to be underrepresentative of the problem.

In the United States, the number of reported cases of domestic elder abuse nationwide, calculated by combining state reports and adjusting for differences in definitions and eligibility criteria, has increased steadily from 117,000 in 1986 to 296,000 in 1996 (Tatara, 1995; Tatara, Kuzmeskas, and Duckhorn, 1997). It is not clear whether the increase is due to the rising number of elders or to increased public awareness and professional education efforts. Even these numbers are assumed to be an undercount, since it is believed that many cases are not reported.

To obtain more valid incidence data, a national study was mandated by Congress in 1996 (National Center on Elder Abuse, 1998). The research made use of the "sentinel" approach that had been employed previously in three federally sponsored child-abuse surveys. The assumption underlying the sentinel approach is that reported cases present only the proverbial tip of the iceberg and that many more cases in the community are never reported. Through a random sampling process, twenty counties were selected to serve as the sample sites. In each county, information on cases was obtained from the local adult protective services agency and a specifically trained group of individuals (the "sentinels") drawn from agencies that ordinarily serve older people, such as hospitals and clinics, law enforcement agencies, senior citizen programs, and banking institutions.

The study estimated that 449,924 persons ages 60 and older living in domestic settings were abused, neglected, or exploited in the United States in 1996. Of this total, 70,942 cases were reported and substantiated by adult protective services agencies; the remaining 378,982 were not reported but were identified by the sentinels. That is to say, for every case reported to adult protective services, it is assumed that five cases were not reported. But even this ratio of reported to unreported cases may be too small, since many mistreated elders are believed to be homebound and isolated, and thus are unlikely to be seen at banks, senior centers, hospitals, health programs, and police stations.

Elder abuse in institutional settings. No prevalence or incidence data on elder abuse in institutional settings are available even though a vast literature exists on quality-of-care issues. However, abuses have been well documented in reports of governmental inquiries, ethnographic studies, personal histories, and ombudsman projects. A survey of nursing home personnel in one U.S. state disclosed that 36 percent of the nursing and aide staff reported having seen at least one incident of physical abuse by other staff members in the preceding year, and 10 percent admitted having committed at least one act of physical abuse themselves. At least one incident of psychological abuse against a resident had been observed by 81 percent of the sample in the preceding year, and 40 percent admitted to having committed such an act (Pillemer and Moore, 1990). The findings suggest that mistreatment of older residents may be even more extensive than is generally believed.

Theoretical Explanations

Researchers have offered various theoretical explanations of why elder abuse occurs: an overburdened caregiver (situational model), a dependent elder or perpetrator (exchange theory), a mentally/emotionally disturbed perpetrator (psychopathology), and a childhood of abuse and neglect (social learning theory). Others have criticized the emphasis on individual traits. They propose that structural forces such as the imbalance of power within relationships (feminist theory) or the marginalization of elders within society (political economic theory) have created conditions that lead to conflict and violence.

Notwithstanding the popular image of abuse arising from dependent victims and stressed caregivers, evidence is accumulating that neither caregiver stress levels nor victim levels of dependence may be core factors leading to elder abuse. Although not denying the effects of stress on caregivers, researchers have tended to incorporate these into a wider context examining the quality of relationships (Cooney and Mortimer, 1995; Nolan, 1993; Reis and Nahmiash, 1998). Some of the studies on the relationships between caregiver stress, Alzheimer's disease, and elder abuse suggest that the long-term or preabuse nature of the relationship between the caregiver and the care recipient may be the important factor in predicting instances of mistreatment (Cooney and Mortimer, 1995; Hamel et al., 1990; Nolan, 1997). Today, the conclusion is that stress may be a contributing factor in cases of abuse but does not explain the phenomenon. The dependency of the abuser on the victim; the mental state of the abuser, which may include emotional, psychiatric, and substance abuse problems; and lack of external social supports for the victim continue to emerge as risk factors in studies of elder abuse (Phillips, 1986; Wolf and Pillemer, 1989; Reis and Nahmiash, 1998; Grafstrom, Nordberg, and Winblad, 1994).

As a way of accommodating the complexity and multiplicity of factors and theories associated with elder abuse, researchers such as Schiamberg and Gans (1999) and Carp (1999) are turning to an "ecological" model, first applied to child abuse (Garbarino and Crouter, 1978; Garbarino and Kostelny, 1992) and, more recently, to intimate partner violence (Chalk and King, 1998). In one iteration of this model, violence results from individual, interpersonal, and societal factors. The advantage of this model is that it allows elder abuse to be linked to broader social issues.

Consequences of Abuse

Even after twenty years of research, studies of the effects of abuse on the victim's psychological and physical status are rare. Research studies that could disentangle the effects of the aging process, disease, and abuse would be not only difficult, but costly. There is some evidence that samples of abused elders contain higher proportions of people with depression or psychological distress than are found among their nonabused cohorts (Bristowe and Collins, 1989; Phillips, 1983; Pillemer and Prescott, 1989; Comijs et al., 1999). However, these studies were cross-sectional in design, so there is no way of knowing whether these conditions preceded or resulted from the mistreatment. Clinicians suggest that other effects of elder abuse include feelings of learned helplessness, alienation, guilt, shame, fear, anxiety, denial, and posttraumatic stress syndrome (Solomon, 1983; Booth, Bruno, and Marin, 1996; Goldstein, 1996), but the validity and extent of these conditions have not been investigated.

Only one study has examined the effects of mistreatment on victims' physical status (mortality); it produced some disturbing results. Data from an annual health survey of 2,812 elders in one U.S. city were compared against reports of elder abuse and neglect made to the local adult abuse agency over a nine-year period (Lachs et al., 1998). The mortality rates of the nonabused and the abused were tracked; by the thirteenth year following the initiation of the study, 40 percent of the nonreported (nonabused, nonneglected) group were still alive--while only 9 percent of the physically abused or neglected elders were still living. After adjusting the figures to account for all possible factors that might affect mortality (e.g., age, gender, income, functional status, cognitive status, diagnosis, social supports) and finding no other significant factors predictive of mortality, the researchers speculate that mistreatment causes extreme interpersonal stress that may confer an additional death risk. The possibility also exists that the intervention of public agencies itself may have a deleterious effect on the victim's health. These startling findings underscore the need for more research, not only on the psychosocial and physical consequences of mistreatment, but also on the effectiveness of current intervention strategies.

In This Issue

Part one of this issue of Generations presents various perspectives on the nature of elder mistreatment--as a social-psychological construct or medical syndrome, as an act perpetrated by others or by oneself, as an event occurring in domestic settings or in institutions.

In the first article, Myrna Reis describes the development of a twenty-nine-item screening tool that successfully differentiates between cases likely and unlikely to be characterized by abuse. As one of only a few available validated instruments, it is an important milestone in assessment methodology. Based on her clinical experience with forensic investigations, Holly Ramsey-Klawsnik, the succeeding author, has developed a typology of elder-abuse offenders to help guide practitioners in recognizing and responding to incidents of elder abuse.

The role of the geriatric medicine team in self-neglect cases of the elderly is the topic of an article by Carmel Bitondo Dyer and Angela M. Goins, who contend that self-neglect should be included as a form of elder mistreatment.

And in the last article in this section, Diane Menio and Beth Hudson Keller provide brief background information about nursing home abuse, and then describe the multifaceted abuse prevention training program that their agency designed and implemented.

The second section of the issue demonstrates the wide array of programs and disciplines that are involved in elder abuse intervention: adult protective services; domestic violence prevention programs; and the law enforcement, criminal justice, legal, and judicial systems.

Joanne Marlatt Otto traces the history of adult protective services in the U.S., starting with the founding of the National Association of State Adult Protective Services Administrators in the 1960s. Next, in contrast to the caregiver stress theory that has been identified with adult protective services intervention, Bonnie Brandl's article discusses the domestic violence paradigm--and current strategies for aiding victims and empowering them. In the article that follows, Georgia J. Anetzberger finds positive qualities in both the caregiver stress and empowerment models. She integrates both into a framework that expresses the complexity and dynamic quality of the elder abuse phenomenon.

A series of graphic case vignettes sets the stage for Candace Heisler's argument that the criminal justice system should play a role in stopping elder abuse and neglect, protecting the victim, and holding the offender accountable. Lori Stiegel's article on the role of the courts surveys the civil and criminal legal remedies that can be called upon to help victims of elder abuse, and existing collaborations between social and legal services to ensure successful prosecution of offenders.

"When does persuasion become undue influence?" Mary Joy Quinn asks in the final piece of this section. She describes the pattern of actions leading to exploitative relationships, the guidelines for identifying whether undue influence has occurred, and procedures for working with victims.

Part three of the issue focuses on the challenges facing the practitioner and the policymaker in a field still being defined.

Lilla Pennant writes about a very troubling case of financial exploitation that entrapped a family who sought the best care for their elderly, infirm mother. Pennant then outlines a set of intervention and prevention strategies that practitioners might employ to remedy a similar situation.

In the next article, Ailee Moon reviews the literature on elder abuse among ethnic minority populations in the United States, and discusses how acculturation level and socioeconomic factors, rather than ethnicity, may offer more powerful insights into understanding the perceptions and risk of elder abuse among these groups. In her discussion of ethical decision-making in cases of elder mistreatment, Tanya Johnson reflects on the rules of conduct embodied in our political process, and offers "communicative ethics" as a means of reconciling both the individual and collective interests and achieving ethically resolved decisions.

The ever-expanding definition of elder abuse is the subject of the final article, written by Lisa Nerenberg, who notes that without consensus about the scope and boundaries of the field, researchers have been hampered in building a knowledge base for effective service delivery.

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