By Georgia J. Anetzberger
Dr. Rosalie S. Wolf served as co–guest editor for the Summer 2000 issue of Generations—the first issue of the journal to focus solely on elder abuse—and wrote the issue’s introductory article, “The Nature and Scope of Elder Abuse: Changes in Perspective and Response over the Past 25 Years” (Wolf, 2000). Wolf was well–suited to assess how far research on this complex and disturbing problem had progressed over twenty–five years: she was a pioneer researcher in the field, with studies extending as far back as the early 1980s. She also helped to mentor many elder abuse investigators, showcasing their work in the peer–reviewed journal she launched, the Journal of Elder Abuse & Neglect, begun in 1989 as the official publication of the National Committee for the Prevention of Elder Abuse.
Wolf’s Generations article explored the four primary areas of elder abuse inquiry leading up to the millennium: definitions, prevalence and incidence, theoretical explanations, and consequences Clearly, the field had come a long way since the late 1970s, when the major thrust of investigation was on establishing the existence of elder abuse and delineating its various forms. Today, our understanding of elder abuse is changing because there has been more research, propelled in part by a related National Research Council agenda, increased federal funding for investigations, and a growing number of scholars interested in the problem. This article examines selected important studies since 2000, and suggests how their findings are affecting our understanding of elder abuse.
The Search for a Definition of Elder Abuse
In 2000, Wolf presented elder abuse as a fairly straightforward concept. She emphasized that in common usage it is a term with broad meaning, including many forms and examples, but always describing harm or loss to an older victim. Wolf limited the term’s complexities to how frequency, severity, and/or cultural context can affect perception and response to the problem. There was no mention of the controversies that have plagued attempts to define elder abuse since the mid–1980s.
Concern about the absence of a generally accepted definition of elder abuse was articulated at the first Research Conference on Elder Abuse and Neglect at the University of New Hampshire in 1986, and reinforced at the National Research Council’s Panel to Review Risk and Prevalence in 2003. In 2011, defining elder abuse was the lead priority at the Research–to–Practice Consensus Workshop in New York.
There are three primary reasons why generally accepted definitions of elder abuse remain elusive. First, in the early years of recognizing elder abuse, there was no federal government or national leadership (ideally coupled with funding or other incentive for compliance) to compel states or researchers to use common definitions. No uniform term was established and one probably cannot be established now—at least not for states and their elder abuse or adult protective services laws; too many years have passed, and systems are in place.
Second, there has been a tendency to continually expand the concept of elder abuse. Payne (2005), for example, offers three broad types: collective, institutional, and individual. Each type has several forms and sub–forms. Together, they capture virtually any possible harm inflicted on an older person by society, care setting, or person. The media, members of Congress, and even researchers sometimes label fraud, abuse, and homicide by strangers as elder abuse. Ultimately, elder abuse has become a convenient catch–all term for the various “wrongs” against older people.
Studies Explore Definitions of Elder Abused
Few studies during the past decade explored definitions of elder abuse. Collectively, those that did suggested the following findings:
Finally, the many controversies that surround defining elder abuse have not been resolved, and currently there exists no national consensus body with authority to accomplish this. Even the definition proposed by the National Research Council (2003) never received traction, in part because popular key elements were missing, such as able–bodied victims and self–neglect or self–abuse (domestic violence in later life, a variation of elder abuse, can happen to able–bodied older persons, but the Council’s definition only applies to vulnerable older persons and only addresses elder abuse where there is a perpetrator other than the older person victim, and therefore excludes self–abuse and self–neglect).
A Suggested Taxonomy of Elder Abuse
To derive a “generally accepted definition of elder abuse,” one can revisit the taxonomy proposed by Margaret Hudson (1991)—the single source cited in Wolf’s 2000 article discussing elder abuse definitions. Updating the taxonomy to reflect current understanding of the problem offers a way to move toward this goal, at least with respect to empirical research. As updated, the taxonomy acknowledges that elder abuse is a broad term (see Figure 1 below). It is only when the lowest levels are reached that operational definitions can be developed with comparative potential.
The taxonomy suggests that elder abuse can be perpetrated by the victim, a trusted other, a stranger, or an acquaintance. Elder abuse can occur in domestic or institutional settings, where it takes similar forms: abuse or neglect (either of which can be intentionally or unintentionally motivated). Lastly, notwithstanding the motivation, the locus of harm can be physical, psychological, social, financial, or sexual in nature.
Within the revised taxonomy, it is best to approach operational definitions of elder abuse by selecting from each definition level (e.g., intentional abuse by a trusted other in a domestic setting where the locus of harm is physical in nature). The result is sufficiently specific for comparative purposes. It also is consistent with our knowledge to date that suggests etiology and other characteristics may differ among elder abuse variations, each of which should be separately investigated.
The Prevalence and Incidence of Elder Abuse
The scope of elder abuse has been a subject of interest and speculation since the problem was recognized more than a half century ago. In her 2000 article for Generations, Wolf described five community surveys conducted in the previous decade in the Americas and Europe in which 4 to 6 percent of older adult respondents reported experiencing elder abuse. In addition, she cited a study where four–fifths of nursing home personnel witnessed psychological or physical abuse against a resident, and two–fifths committed such an act in the prior year.
Fast–forwarding to 2012, we see an explosion of research on elder abuse prevalence and incidence. This reflects priorities set forth by the National Research Council (and federal funding sources) as well as the desire of advocates for data to move public policy agendas. Recent research shows elder abuse to be a problem that may be twice as large as previously thought, and one seemingly without geographic or setting boundaries. Reviewing the literature on elder abuse prevalence and incidence research since 2000 reveals more than fifty studies. Half examine the problem in the United States; the remainder spread across the global landscape and consider more than a dozen countries, mostly in Europe and the Western Pacific. Eighty percent of the investigations explore elder abuse in community or domestic settings; 20 percent focus on the problem in residential care settings, typically in nursing homes.
The studies are fairly evenly divided between those that survey older adults (or their proxies, particularly in the case of institutional abuse) within a nation, or some smaller political jurisdiction, and those that use clinical samples of older adults, generally in healthcare or social service contexts. Very few studies use professional surveys or available official data to suggest problem scope. The studies also vary considerably on operational definitions employed, sample representation, and response rates, and whether or not validity and reliability have been demonstrated.
A closer look at recent studies
Several studies are described in the following paragraphs. They were selected on the basis of varied problem contexts, scope of inquiry, and potential to advance the field. Collectively, they reflect the breadth of recent research on elder abuse prevalence and incidence.
There are now two large–scale, population–based, nationally representative studies that estimate the prevalence of elder abuse in the United States. The first study surveyed 3,005 community–dwelling persons, ages 57 to 85, about experience with three elder abuse forms in the past year (Laumann, Leitsch, and Waite, 2008). Nine percent of respondents reported verbal mistreatment; 3.5 percent, financial mistreatment; and 0.2 percent, physical mistreatment. Data analysis also revealed more verbal mistreatment for women and those with physical disabilities and more financial mistreatment for African Americans and those without a spouse or intimate partner.
In the National Elder Mistreatment Study, 5,777 community–dwelling adults ages 60 and older and 813 proxies were interviewed about five elder abuse forms (Acierno et al., 2010). The results revealed past–year prevalence of emotional mistreatment (4.6 percent); physical mistreatment (1.6 percent) and sexual mistreatment (0.6 percent); current potential neglect (5.1 percent); current financial exploitation by family (5.2 percent); and lifetime financial exploitation by a stranger (6.5 percent). Excluding financial exploitation, roughly one in ten respondents reported at least one form of past–year mistreatment, and 1.2 percent reported two or more forms. Data analysis further indicated that spouses or intimate partners were more likely than adult children to perpetrate most forms of elder abuse.
A large–scale, population–based (but state–specific) study also revealed how infrequently elder abuse situations come to the attention of authorities. Lachs and Berman (2011) examined self–reported and documented case data on the incidence of elder abuse among elderly New York residents. The sample consisted of 4,156 community–dwelling adults older than age 60, or their proxies, and 292 agencies, such as Adult Protective Services, Area Agencies on Aging, and law enforcement. Study results revealed a self–reported, past–year elder abuse rate of 7.6 percent, led by financial abuse at 4.2 percent. These rates were, respectively, nearly twentyfour and forty–four times greater than the number of cases referred to various agencies that can help older victims.
Researchers in the United Kingdom and Spain recently did comparable elder abuse–prevalence investigations. The United Kingdom study involved interviews with 2,111 adults, ages 66 and older, living in a private residence about past–year elder abuse across four forms (O’Keeffe et al., 2007). A family member, friend, or care worker was reported to have victimized 2.6 percent of respondents during that period. However, overall elder abuse prevalence increased to 4 percent when neighbors and acquaintances were included. Neglect was the most common form. Perpetrators were near equally as likely to be a spouse or intimate partner (51 percent) as another family member (49 percent), but much less likely to be a care worker (13 percent) or friend (5 percent).
In Spain, in a study of five elder abuse forms, 2,401 interviews were conducted with adults older than age 64, and 788 interviews were conducted with those providing care to dependent older people (Marmolejo, 2008). The past–year rate of elder abuse by a family member was 0.8 percent for the larger sample and 1.5 percent for the smaller one, with the rate of abuse rising as the level of dependency increased. Women were the more likely victims of psychological, financial, and sexual abuse; men were the more likely victims of neglect; and women and men were equally as likely to be victims of physical abuse. Half of all perpetrators were spouses or intimate partners, and one–third were sons and daughters.
Two recent studies suggest the scope of elder abuse in residential care. In a rare look at abuse across settings, Page and colleagues (2009) interviewed 718 family members or others responsible for those ages 60 and older receiving long–term care in a nursing home, an assisted living facility, or paid homecare. Nearly 30 percent reported at least one instance of elder abuse in the past year—neglect was the most common form and sexual abuse the least. Nursing homes had the highest rates for all abuse forms. Adjusting for demographics and health conditions, the odds of neglect did not significantly differ between assisted living and nursing homes; however, the odds for caretaking abuse increased five–fold. Similarly, the odds of neglect tripled and the odds of caretaking abuse more than doubled when moving from paid home care to nursing homes.
Finally, Schiamberg and colleagues (2012) interviewed 452 family members who had a relative, age 65 or older, residing in a nursing home. Nearly one–fourth of study respondents reported at least one instance of physical abuse by facility staff during the relative’s stay. Two–thirds of that abuse consisted of forced restraint, more than one–fourth represented physical mistreatment, and the remainder was sexual abuse.
Theoretical Explanations for Abuse
Wolf concluded her discussion of theoretical explanations for elder abuse with the following three observations:
- Accumulated evidence suggested that the popular notions of caregiver stress and victim dependency were not core factors resulting in elder abuse. Stress and dependency may contribute to abuse, but they failed to explain it.
- A select set of salient risk factors for elder abuse had emerged from research. Particularly noteworthy were an abuser’s dependency on the victim, an abuser’s mental or emotional problems (including substance abuse), and lack of social support for victims.
- The social–ecological model, which considers the complex interplay between individual, relationship, community, and societal factors, was gaining credibility as a way to accommodate the multiple factors and theories explaining elder abuse. The model also linked the problem to broader social issues, such as the marginalization of older people in society.
The decade following Wolf’s observations has witnessed less activity around elder abuse theory than in earlier decades. Although exceptions exist (e.g., the National Research Council, 2003), there have been few new explanatory frameworks, and much recently published research fails to include specific theoretical context. This is not to say that theory is seen as unimportant to elder abuse (e.g., Biggs and Goergen, 2010). Instead, it is often acknowledged as critical to understanding ways for explaining this phenomenon.
Unfortunately, certain traditions continue to dominate the field and inhibit theory development and testing. For example, it has been difficult to give up on past explanations, even when there is no research to support them. As a result, they continue to be referenced in the literature. Caregiver stress is the most obvious illustration of this tendency. Moreover, the field of elder abuse tends to borrow theory from other fields rather than constructing its own, which is unfortunate given its unique dimensions and dynamics. The borrowing tradition is currently evident in the field’s use of theory from domestic violence and criminal justice (e.g., Straka and Montminy, 2006; Payne and Gainey, 2006).
Today the most frequently cited theoretical explanations for elder abuse appear to be those that were just emerging before the millennium (e.g., integrated theory, ecology theory) and those that emphasize an imbalance of power or oppression (e.g., Bender and Wainwright, 2004; Walsh et al., 2011). Increasingly, it is suggested that the field differentiate theories by elder abuse form (e.g., Lauder, 2001; Rabiner, O’Keeffe, and Brown, 2004) or setting (e.g., Sandvide et al., 2006).
Risk factors for abuse
Since the turn of the century, dozens of studies have considered risk factors for elder abuse. Risk factors are characteristics of the victim, perpetrator, or situation that are closely linked to the occurrence of elder abuse. Recent studies suggest the following conclusions.
Risk factors differ somewhat depending upon the form of elder abuse. In findings from the National Elder Mistreatment Study (Acierno et al., 2009), victims with physical disabilities were associated with the risk of financial exploitation; victims who were low income, had poor health, and low social support predicted neglect; and perpetrators who were unemployed, substance abusers, and had mental health problems elevated the risk for physical, emotional, and sexual abuse of elders.
Salient risk factors identified before the millennium continue to receive support from subsequent research. Among the factors receiving the most support in recent investigations are a lack of social support for the victim; social isolation of the victim, perpetrator, or both; perpetrator substance abuse or other pathology; poor behavior (e.g., aggression, socially inappropriate actions) on the part of the victim as perceived by the caregiving perpetrator; and poor or declining health or functional capacity for the victim.
Few new or additional risk factors are gaining momentum. One exception seems to be lower income or education, which has been linked to neglect in the United States (Acierno et al., 2009), in Turkey (Keskinoglu et al., 2007), and in China (Dong, Simon, and Gorbien, 2007).
Consequences of Elder Abuse
In 2000, Wolf lamented the scarcity of research describing the effects of elder abuse, excusing this deficit because of the difficulties and costs associated with such studies. Nearly all investigations until then were cross–sectional, and provided no clarity on whether conditions such as depression and psychological distress existed prior to the abuse or had resulted from it. One study was highlighted, a case comparison suggesting higher mortality for abused elders than non–abused elders.
In the past decade, research on the consequences of elder abuse has improved in methodology, but has narrowed in focus. Case comparisons are common, and quantitative analysis is routine. Most inquiries concentrate on mortality or economic loss. Little attention has been given to possible emotional, behavioral, social, or other physical effects of abuse— except as forensic markers, which are of collective interest to the two primary federal funding sources for elder abuse research, the National Institute of Justice and the National Institute on Aging.
Mortality as a consequence of abuse
Research by Dong and colleagues (2009, 2011) reflects the emphasis on mortality as a consequence of elder abuse. Using a subset of participants in the Chicago Health and Aging Project, they found that self–neglecting elders were at five times greater risk of premature death than non–self–neglecting elders. In addition, black older adults had a higher mortality rate than did their white counterparts. Although the rate was less, the same pattern existed between mistreated elders and non–mistreated elders. Baker and colleagues (2009) also found that older women exposed to physical and verbal abuse in the past year had greater mortality risk than those who were not exposed. Abuse victims also experienced poorer health and functioning.
Economic costs of financial abuse
The MetLife Mature Market Institute (2009, 2011), in collaboration with the National Committee for the Prevention of Elder Abuse and the Center for Gerontology at Virginia Tech, used mixed methods to examine the economic costs of financial abuse. The results provided a national estimate of annual losses to victims calculated at $2.6 billion in 2008, increasing 12 percent to $2.9 billion three years later. Likewise, in examining 158 cases of incapacitated victims of abuse or neglect, many of whom were elderly, the U.S. Government Accountability Office (2010) found that guardians stole or improperly obtained approximately $5.4 million in assets from their wards.
Beyond mortality and economic loss, recent research suggests that institutionalization may be an outcome of elder abuse. Rovi and colleagues (2009) looked at hospitalizations in the United States with diagnostic codes indicating elder mistreatment. Comparing the codes to hospitalizations of older adults without such codes, the researchers found that abused elders were three to four times more likely to be discharged to a nursing home or other facility than discharged to homecare or self–care.
Among the greatest fears of old age are economic loss, institutionalization, and premature death. Yet these seem to be common effects of elder abuse. Almost as troubling, the road to these dreaded destinations is likely to be littered with other potential abuse consequences, ranging from pain to mental anguish.
Knowledge of Abuse Expanding, but More Study Needed
The report from the first Research Conference on Elder Abuse and Neglect included attendees’ commentary, with one person lamenting that “all we know at this stage is what we don’t know” (University of New Hampshire, 1986). This is no longer true: we know a little—but with absolute certainty! Clearly, there is a great deal more to discover, but real progress is being made in most areas identified in the report’s recommendations under the sections “Defining Elder Abuse and Neglect” and “Improving Research Design.” There is every reason to be optimistic that our understanding of elder abuse will continue toexpand sufficiently to warrant another update on its nature and scope, should a third issue of Generations focus on this problem twelve to fifteen years hence.
Georgia J. Anetzberger, Ph.D., A.C.S.W., is president of the National Committee for the Prevention of Elder Abuse, the immediate past editor of the Journal of Elder Abuse & Neglect, and a lecturer in healthcare administration at Cleveland State University in Cleveland, Ohio. She can be contacted at firstname.lastname@example.org.
Acknowledgment from the Author
Shortly after I completed this article, Toshio Tatara, Ph.D., passed away in his homeland of Japan on April 23, 2012. Like Rosalie Wolf, Tatara was a pioneer in the field of elder abuse, with more than twenty–five years of contributions across research, policy, and practice in the United States and globally. He was a kind and generous human being, and a dear friend.
During the 1990s, Tatara assumed a leadership role among those who encouraged scholarly inquiry into the meaning of elder abuse in racial and ethnic minority populations. While director of the National Center on Elder Abuse (1988-1998), he served as principal investigator for the first national elder abuse incidence study conducted in the United States. His influence, which spans the landscape of international research and social action, is illustrated in groundbreaking investigations of elder abuse in Japan (which helped inspire the enactment of the first national elder abuse law anywhere) and in activities on behalf of many organizations, including the National Committee for the Prevention of Elder Abuse, the Gerontological Society of America, and the International Network for the Prevention of Elder Abuse. However, nowhere is Tatara’s legacy perhaps greater than in his efforts to shape the next generation of researchers and practitioners who work in the area of elder abuse: mentoring students was his great passion.
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Editor’s Note: This article is taken from the Fall 2012 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “Elder Abuse and the Elder Justice Movement in America” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.