III. ELDER ABUSE

The phenomenon known as elder abuse first appeared in the British scientific literature in 1975 (Burston) to describe the physical abuse of an elderly dependent person by a caregiving family member. In the years that followed, the definition expanded to include acts of commission (physical, psychological, and financial abuse) and omission (neglect) that result in harm to a person sixty-five years (in some states, sixty years) or older by a relative or a person with whom the elder has a trusting relationship. Self-neglect and self-abuse typically are included under broad conceptualizations of elder abuse. They refer to neglectful or abusive behaviors of older persons directed at themselves that threaten their own health or safety.

Beginning in the mid-1980s the meaning attached to elder abuse expanded further to reflect a criminalization of the phenomenon. Accordingly, there evolved interest in such areas as sexual assault in later life, battered older women, and fraud and scams (e.g., Ramsey-Klawsnik; Harris; Tueth). Likewise, since the 1990s there has been a resurgence of attention given to elder abuse in institutions, particularly nursing facilities. Exposure of fires and inadequate care in these settings during the 1970s fueled the enactment of federal legislation to protect residents. Investigations of resident conditions led to the identification of additional institutional elder abuse forms, like violation of rights, thefts, and examples of covert abuse (e.g., Meddaugh; Payne and Kovic; Harris and Benson). Finally, international perspectives on elder abuse resulted in the United Nations (2002) World Assembly on Aging's delineation of still more abuse forms. Included among them are variations emanating out of social conditions in individual countries, like systemic abuse as well as political violence and armed conflict.

Throughout this thirty-year period of problem recognition and definition expansion, there has been concern about the lack of universally accepted definitions and forms of elder abuse evident in either research or state laws. The most notable attempts to standardize both are found in research conducted by Margaret Hudson and her associates (Hudson, 1991; Hudson and Carlson, 1999; Hudson et al.,2000). Using a national panel of elder abuse experts, Hudson developed a five-level elder abuse taxonomy with eleven related definitions. Subsequent work compared the experts' perceptions to public perceptions across cultures, the results suggesting differences between cultural groups in defining and responding to elder abuse. Other studies have yielded similar findings (Tatara, 1997, 1999). For example, Georgia Anetzberger, Jill Korbin, and Susan Tomita (1996) focused on four ethnic groups in Ohio and Washington and discovered that the worst thing family members could do to an elderly person was psychological neglect, according to European-American and Puerto Rican subjects, and psychological abuse, according to Japanese-American and African-American subjects. Only African Americans listed financial abuse or exploitation among the worst things. Moreover, response to elder abuse varied by ethnic group. European-Americans and African Americans typically would contact an agency serving elders, Japanese Americans would talk to family or friends, and Puerto Ricans would contact the proper authorities.

Policy Development

In the United States interest in elder abuse was sparked by testimony on battering of parents before a U.S. House of Representatives subcommittee investigating family violence in 1978. The growing numbers of elderly persons in society, the rising political power of the older population, and the existing state bureaucracies for delivering protective services lent legitimacy to making elder abuse a public issue. Despite the efforts of a few representatives to pass national legislation throughout the 1980s, no action was taken by the Congress. Nevertheless, federal agencies did incorporate elder abuse into their agendas, but not at the funding level of the U.S. Children's Bureau program for child abuse.

Without a national focus, a knowledge base, or model statutes, the states developed their own laws, definitions, and reporting procedures. Some used existing adult protective legislation; others, domestic violence acts. Still others passed specific elder abuse laws. By the late 1980s, each of the fifty states had a system in place for receiving reports and investigating, assessing, and monitoring cases. Four-fifths of the states adopted the child-abuse approach, making it mandatory for health and social-service professionals and others who work with older persons to report suspected cases of abuse and neglect, subject to a fine or imprisonment or both. In the other states, reporting is voluntary.

Despite the widespread enactment of mandatory reporting laws, most elder abuse is not reported to authorities charged with investigating the problem. It is estimated that only one in eight (or fewer) abuse situations are reported (Pillemer and Finkelhor; U.S. House Select Committee on Aging). Still, elder abuse reporting has increased over time. From 1986 to 1996 the number of reports nationwide grew 150 percent (i.e., 117,000 to 293,000). During this period reports of neglect and self-neglect increased; those of sexual abuse remained constant; and reports of physical, financial, and psychological abuse decreased (Tatara and Kuzmeskus).

Since the 1980s all states have made revisions to their protective or elder abuse laws, often to clarify definitions, increase penalties for perpetrators, or criminalize certain abuse types. Much recent policy activity seems centered at the federal level. This includes convening the first National Policy Summit on Elder Abuse in 2001. More than eighty individuals and agencies from across the country identified priority recommendations to address elder abuse at multiple levels of responsibility. Some of these recommendations are evident in the first comprehensive legislation to address elder abuse—the Elder Justice Act, introduced in the U.S. Senate in 2002. Among its many provisions, the Act seeks to create Offices of Elder Justice in the Departments of Health and Human Services and Justice, develop forensic capacity in abuse detection, establish safe havens and other programs for elderly victims, and increase efforts to address abuse in long-term care.

Theoretical Considerations

Early attempts to understand the nature of elder abuse were influenced by the child-abuse model. Victims were viewed as very dependent older women mistreated by well-meaning but overburdened adult daughters. Later findings suggested that spouse abuse might be a more useful framework for study, since the individuals involved were legally independent adults. To some health researchers, however, using the family violence paradigm, with its emphasis on harm, intentionality, and responsibility, was counterproductive, particularly in cases that involved elders with unmet needs (Phillips, 1986; Fulmer and O'Malley). They recommended that elder abuse be considered from the perspective of family caregiving. None of these interpretations are sufficient in and of themselves. Neither the child abuse nor the spouse abuse model takes into consideration the impact of the aging process, while the family caregiving theory cannot explain abusive situations in which the victim has no unmet physical needs. It has been suggested that the concept of elder abuse may be too complex to be encompassed in one unifying theoretical model (Stein).

Risk Factors and Characteristics

Although early studies were useful in documenting the existence of the problem and promoting state elder abuse policies, they were generally based on data collected from agency files, used small, unrepresentative samples, and lumped together the various types of abuse. Karl Pillemer (1986) sought to overcome some of these methodological weaknesses by interviewing victims directly, adding a nonabused comparison group, and limiting the investigation to physical abuse. His results showed that the abusers were much more likely than the comparison group of caregivers to have mental, emotional, and/or alcohol problems and to be dependent on the victims. Conversely, the abused elders were less functionally dependent than the control group in carrying out their activities of daily living. The families in which abuse occurred also tended to have fewer outside contacts and were less satisfied with them than were their nonabuse counterparts. Similar results have been reported by other researchers (Phillips, 1988; Bristowe and Collins; Anetzberger; Lachs et al., 1997).

A comparison of 328 cases by abuse type revealed three distinct profiles (Wolf et al.). Perpetrators of physical/psychological abuse were more likely than perpetrators of neglect to have a history of mental illness and alcohol abuse, and to be dependent on the victim for financial resources. The victims were apt to be in poor emotional health but relatively independent in the activities of daily living. In contrast, those cases involving neglect appeared to be very much related to the dependency needs of the victim. Neither psychological problems nor financial dependency was a significant factor in the lives of these perpetrators; instead, the victims were a source of stress. Financial abuse represented still another profile. The victims were generally widowed and had few social supports. The perpetrators had financial problems and histories of substance abuse. Rather than interpersonal pathology or victim dependency, the salient factor in explaining these cases was the desire for money.

Few studies have examined the consequences of elder abuse. Those that have suggest that the effects of abuse infliction may have physical, behavioral, psychological, or social dimensions. In particular, victims of elder abuse seem to experience higher levels of depression than non-victims (Pillemer and Prescott; Harris). Furthermore, they are three times as likely to die sooner (Lachs et al., 1998).

Prevalence and Incidence

Although knowledge about the extent of elder abuse is sorely needed to guide policy and planning activities, no national prevalence study has been conducted in the United States. Among localized studies, the best known used a methodology that had been validated in two national family violence surveys. Karl Pillemer and David Finkelhor (1988) surveyed 2,020 noninstitutionalized elders living in the metropolitan Boston area and found that 3.2 percent had experienced physical abuse, verbal aggression, and/or neglect in the period since they reached sixty-five years. Spouse abuse was more prevalent (58%) than abuse by adult children (24%), the proportion of victims was roughly equally divided between males and females, and economic status and age were not related to the risk of abuse. Using comparable methodologies, but typically including financial abuse among forms to be investigated, national prevalence studies in Canada, Great Britain, Finland, and the Netherlands found that between 4 and 6 percent of older people surveyed were elder abuse victims (Podnieks; Ogg and Bennett; Kivelä et al.; Comijs et al.).

In 1998 the National Center on Elder Abuse completed the first national incidence study on elder abuse in the United States. Using a representative sample of twenty counties in fifteen states, two data sources were examined to identify the number of unduplicated new cases of elder abuse in a single year. The data sources were reports to Adult Protective Services and reports from sentinels, namely, specially trained community agency personnel having frequent contact with older people. The results for 1996 suggested a national incidence rate of 551,011, with self-neglect and neglect comprising over two-thirds of all elder abuse reported.

Treatment and Ethical Issues

A number of potential conflicts face practitioners who are handling elder abuse cases. While tangible proof may be obtainable in situations involving physical and financial abuse, psychological abuse and neglect are far more difficult to verify. Symptoms of sexual abuse may elude the investigator who is not aware that old people can be so victimized. Cultural biases and lack of full knowledge about the circumstances involved in a case may lead a worker to conclude, falsely, that abuse has occurred. The instability of the mental and physical status of the victim and/or the perpetrator and the dynamics of their relationship may add to case uncertainty. The issue of competency can be particularly troublesome. There may be resistance on the part of the victim to undergo medical assessment, or of the perpetrator to allow it, or even of the medical profession to make a decision.

An individual who under the law is mandated to report a case of suspected abuse may hesitate because the details of the situation have not been fully documented. Whether the problem is civil or criminal may be unclear. Certainly, the unwillingness of the victim to press charges has been a major hindrance to intervention efforts. Even though the law may require an investigation, the older person may not wish to cooperate or to accept the services that are offered. This negative response brings the worker face to face with a dilemma: the interest of the state, professionals, and society in protecting vulnerable persons versus the individual's right to self-determination; in terms of ethical principles, the tension between autonomy and beneficence.

Conclusion

Advances in understanding the nature of elder abuse will necessitate examining the problem from many perspectives. Not only must distinctions be made among the various types of elder abuse, but more attention must be paid to differences based on gender, race, culture, relationships, and circumstances. The growing interest in the problem among social scientists and medical personnel all over the world is important. The results of their efforts should be very constructive in building the theoretical and empirical base for successful treatment and prevention programs.

rosalie s. wolf (1995)

revised by georgia j. anetzberger

SEE ALSO: Aging and the Aged: Old Age; Dementia; Harm; Long-Term Care; and other Abuse, Interpersonal subentries

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