Elder Abuse and Neglect: History and Concepts
Good afternoon and thank you for the opportunity to address you on this important topic. I am going to quickly cover definitions, history, theories, risk factors, consequences, assessment instruments, prevalence, and interventions, if we have enough time.
Elder abuse has been used as an all-inclusive term that is often used to represent physical abuse. So that already indicates that there are differences in the way elder abuse is interpreted. It may involve relationships between spouses, adult children, other relatives, maybe friends, and anyone else in whom the older person has placed trust. Other behavior that is considered abusive may depend on its duration, its frequency, its intensity, its intentionality, and the consequences.
Although elder abuse first appeared on the national scene in the late 1970s, the formal efforts to help vulnerable elders began at least two decades before that time. Public welfare officials were faced with an increas-
NOTE: This is an edited transcript of the text of a presentation to the Panel on Elder Abuse and Neglect, May 24, 2001.
ing number of older persons who were unable to manage on their own and began to develop a new approach to providing services, which they called “protective services units.” It was an approach that would provide not only social services, but also legal assistance, particularly guardianship.
As a result of this interest in the 1950s, Congress passed legislation, as part of the Social Security Act, providing funds to the states on a three-to-one matching basis for setting up these protective service units. Some states took advantage of these federal dollars. In addition, Congress provided funds for six demonstration projects (they might represent the very first research on adult protective services).
One of those demonstration projects supported a team at the Benjamin Rose Institute in Cleveland under Margaret Blenkner and her associates. She matched a group of elders receiving protective services with a group from the community who were receiving traditional services and found that, during the grant period, those who received protective services had a higher mortality rate and higher nursing home placement rate than those who received traditional services.
But the advocates for the system went right ahead with their work in the Congress and in 1974, despite some of the findings of that study and five other studies that showed these protective services units to be very costly and of questionable effect (U.S. Department of Health, Education, and Welfare, 1966), Congress amended the Social Security Act to mandate protective service units in all states for adults over the age of 18. The target populations were people with mental and physical impairments who were unable to manage on their own and who had been or were being exploited or neglected. There was a lot of criticism of these programs, partly because they were so costly and partly because they seemed to infringe on the rights of the elders.
Interest temporarily waned on adult protective services, but at about the same time (middle to late 1970s), renewed interest in elder abuse became apparent, in part due to congressional hearings (U.S. House of Representatives, 1978, 1979). At one of those hearings, a witness spoke about “granny battering.” The topic began to interest some of the members of Congress, particularly the late Claude Pepper of Florida. He and his Special Subcommittee on Aging sponsored other investigations and hearings, and there were, I think, two research projects submitted to the Administration on Aging for a discretionary grant that were of questionable methodology, but they did, at least, confirm that cases existed.
This congressional interest in elder abuse served to revive interest in adult protective services. When members of Congress looked around to see what was happening to these abused and neglected adults, they saw the adult protective service units and concluded that it wasn’t necessary to
establish a new system. Instead, they decided to continue trying to raise awareness of the problem.
In 1981, Congress proposed legislation to establish a national center on elder abuse, but the bill never reached the floor of Congress. Finally, in 1989, Claude Pepper introduced that proposal as an amendment to the Older Americans Act. The national center was funded the following year and began the federal government’s specific commitment to this area, albeit with very small amounts of money. But at least elder abuse had been recognized in federal legislation.
Initially the conceptualization of this issue was not of adults needing protection and safety. It became an aging issue, whereas initially the response involved public welfare and the social services and legal services. By gaining the interest of the aging network, a larger constituency of interested people became involved.
It is interesting that the emphasis was on elder abuse and abused elders in the context of caregiving. The portrait of the problem was that of an impaired victim, usually an elderly parent being cared for by an adult caregiver, who wasn’t able to manage the caregiving because of stresses in life, job, family, and so forth.
This picture of elder abuse seemed to resonate with Congress. The media really helped to promote this issue. Together the media and Congress provided the real push for interest in this problem.
In the 1980s, Surgeon General Louis Sullivan held a workshop on family violence, declaring it to be a public health and criminal justice issue that included the problems of elder abuse and neglect. Elder abuse was included under the umbrella of family violence. That had a very positive effect, because it brought in the medical community, and the criminal justice community and broadened the range of constituency groups interested in the topic
This was a real positive step forward. Sometimes the social service people are concerned about the so-called criminalization of the issue, but in terms of the breadth and depth of interest, it was a very positive step.
A number of theories have been promoted or proposed to explain elder abuse (Phillips, 1986). I’m not going to review them in depth, but I want to focus specifically on the “situational theory” because it represented a particularly popular theory in relation to the image of the overburdened caregiver. It is true that some caregivers are overburdened, and it is true that some of them do abuse or neglect the person for whom they are caring. When you look at some of the cases and some of the studies, you see perpetrators who are caregivers and who show a history of emotional
problems, so psychopathology seems to be another way of explaining what takes place.
Several additional theories have been used to explain elder abuse:
the exchange theory, which describes how some of the dependencies that exist between a victim and a perpetrator relate to tactics and responses developed in family life, which continue into adulthood;
social learning theory, which brings in the whole issue of how abuse was learned and that spouse abuse among the elderly does exist; and
political economic theory, which focuses on the challenges faced by elders in a society that leaves people in poverty and takes away their importance in community life. Political economic theory addresses the marginalization of elders in society.
People in the field have come to realize that you can’t really explain such a complicated construct as elder abuse with one theory, and that perhaps what is needed is something that looks at factors across several domains. Heist has examined this issue in relation to child abuse, but it has subsequently been presented in a broader context by the Committee on Interventions of Family Violence (National Research Council and Institute of Medicine, 1998) as an ecological model that incorporates and links individual-level psychopathology and interpersonal relationships in the context of the overall sociocultural environment. That could be exchange dependency in the caregiver, for example, in the context of the elder community. For instance, are there services to take care of caregivers with alcohol problems? And it highlights some of the societal issues, such as the loss of the importance of older persons in transmitting values and traditions and certain cultural issues.
In the absence of an overarching theoretical framework, research has thus far focused on the characteristics of situations and victims and perpetrators that constitute risk factors for abuse. I will mention victim dependency, abuser dependence/deviance, social isolation, and living arrangements as examples.
There is no question that there are some people who are impaired and neglected, but is impairment necessary? There is a model of family violence in which victims are generally seen as people unable to leave the situation. When you think of a younger victim of what I will refer to as intimate partner violence, this represents the classic “battered woman syndrome.” When you look at those younger victims, you know that they find it very difficult to leave a situation. There is a concerted effort on the part of the
perpetrator to isolate the victim. In child abuse, the child goes to school, but the family itself is isolated. This may be even more so for older persons who may be isolated because of physical impairments or loss of friends and family. Living arrangements are a major focus for examination. Generally, abuse or neglect takes place in the context of people living together, yet there is an obligation on the part of adult children, for example, to not neglect their elders. Theoretical frameworks are in need of great attention.
Moving into risk assessment instruments, since elder abuse first emerged as a problem, the focus has been on developing some instrument that determine whether a person is at risk. There are a number of groups working on this. Hwalek and Sengstock (1986) did some of the earliest work with funding from the Administration on Aging. They asked many people from various agencies what items in fact should be considered and came up with a list in the hundreds, if not thousands; they then conducted a multivariate analysis and came down to 15 and later to 10 statements from self-reports on elder abuse. Another study tested those original 15 statements by using the Australian longitudinal study on health, in which they had a sample of 12,000 women age 65 and older (Kurrle, 1993). They added two additional intimate family violence questions, coming up with a brief screening tool of six questions, which were reliable as a test for elder abuse. The idea is that a physician or any other screener could use these questions in the interview and could at least identify an at-risk elder.
A team from Montreal (Reis and Nahmiash, 1998) developed a completely different screening effort. They had nurses and social workers conduct a comprehensive interview of clients who had been seen by a social service agency and screened to determine who was abused. Their original research across demographics came out with three categories of risk factors relating to: (1) the abusive caregiver, (2) interpersonal characteristics (personal alcohol or substance abuse, characteristics of depression, personality disorder, mental outlook, behavioral problems), and (3) reluctance to discuss abusive behavior. The last is quite important, but it has not been followed up. The second category, interpersonal characteristics, includes poor relationships with the caregiver, marital or family conflict, lack of empathy for the elder, and financial dependence.
There has been very little work done on the consequences of elder abuse, in terms of both the effect on physical health and on mental health. We know from the family violence area that abuse has a substantial effect
on the health of women, and that they make up a good proportion of emergency room admissions. But research on the effects of elder abuse has been inhibited because of the complexity of untangling the synergistic effects of aging, and disease in old age from the impact of abuse or neglect.
There is only one study on the consequences of abuse on physical health. Lachs and colleagues (1998) used an existing National Institute on Aging cohort study that looked at the status of the abused elders over a period of 13 years, examining statistics of physical health, mental health, social situations, even religious habits, and so forth. They merged that dataset with one from the adult protective services unit serving New Haven, Connecticut. That unit, which is in a mandatory reporting state, has been collecting data since 1978. There were 7 cases of abuse that had been investigated for corroboration, 57 cases of neglect, and 2,608 cases not reported but investigated by researchers. They looked at the rate of mortality and found there was no difference in the first few years, but by the 13th year there was a decided difference in outcomes: 40 percent of the nonreported elders were still alive, 13 percent of the “self-neglect” category were still alive, and 9 percent of the “reported abused” category were still alive.
What was interesting is how closely this followed the Blenkner results, from 30 years earlier. Both showed a higher rate of institutionalization and a higher rate of nursing home placement. It suggests to me that the intervention itself may be a factor. This would be an important area for research.
Let me go back to depression. Depression is the only aspect of psychological abuse that has been explored by researchers at all, and those studies are very small and the methodology is subject to question. But indeed, if you look at groups of elders who have been abused, neglected, and exploited, you find more depression in this group. Commentators have suggested that other causes of emotional distress are also provoked by the acts of elder abuse or exploitation—depression, fear, guilt, shame, stress, learned helplessness, and post-traumatic stress syndrome (see, for example, Goldstein, 1996).
PREVALENCE AND INCIDENCE
Five studies have been done on prevalence in five different countries, using three or four or five different methodologies, some better than others.
The first was the Pillemer and Finkelhor (1988) study of the metropolitan Boston area. A representative sample of elders was interviewed over the telephone, or if the older person was unable to respond on the telephone, they conducted face-to-face interviews. They found that 3.2 percent of that sample was abused or neglected. However, they did not include financial
exploitation, which is a real shortcoming of that study. Another shortcoming was the very strict definition in terms of physical abuse and neglect. They used scales that had been used in the national family violence surveys to describe physical abuse, which may have been too limiting.
The Conflict Tactics Scale was also used on a national sample of Canadian elders (Podnieks, 1992). In that sample, Podnieks added financial exploitation and found several different results: 5 percent of the sample was financially abused, which was the largest category, followed by physical abuse and neglect. Podnieks concluded that 4 percent of the population had been abused, neglected, or financially exploited.
Researchers in the United Kingdom wanted to do a similar study but they couldn’t get it through their human subjects review panel, so they added a few questions from the Boston study to another annual survey in the United Kingdom (Ogg and Bennett, 1992). They concluded that overall, 5 percent of the elders 65 and over had been abused or neglected or exploited (about 2 percent had been physically abused).
The next study was done in a small town in Finland (Kivela et al., 1992). It was a geriatric mental health study by geriatricians in a health center. They used a completely different methodology, with the subjects saying whether they were abused or neglected. They defined abuse simply as the infliction of unnecessary pain or injury. The researchers asked the subjects if they knew anybody who had been abused, if they had ever been abused, and then asked the same questions about the issues of exploitation, sexual abuse, and neglect. They found that 5.7 percent of that representative sample had been abused.
The latest study was reported in 1998 in Amsterdam (Comijs et al., 1998). The researchers added some questions about elder abuse and neglect from the Boston study to a health study being done in a representative sample of persons 69 and older. They came out with 5.6 percent prevalence.
An incidence study funded by the Administration for Children and Families and the Administration on Aging (National Center on Elder Abuse, 1998) attempted to answer some of these questions. Its methodology was questioned, but it was based on the iceberg theory and the assumption that what is reported to adult protective services is only part of what exists in the community.
Because of the shortage of time, I won’t go into it in too great detail. The study showed that there were 70,942 new cases in 1996. But when these cases are added to the cases that came in from the sentinels (people, working in hospitals, senior centers, police departments, and banks), the total amounted to over 379,000 cases. Although the methodology has been questioned, there is much to examine in this study.
One criticism of the methodology stems from the fact that many older,
vulnerable people do not have any contact with people outside their home or institution. The National Center on Elder Abuse has tried to find out how to reach these isolated elders. Currently some demonstration projects are trying to do that.
About 470,790 reports came to adult protective services units in the year 1999, with all states reporting (including Guam and the District of Columbia) except Mississippi. Of that number, 332,000 were investigated. That means the others did not meet minimal criteria for conducting an investigation. It is interesting that some states investigate every report, while some states do so in a triage arrangement. If it doesn’t seem to be abuse, they pass it along or refer that case to whatever agency is appropriate. Of those that were investigated, 45 percent were validated.
Q & A SESSION
Richard Bonnie: In the beginning of your talk, you referred to different images of the problem, as you put it, which appealed to different constituencies. One was the adult in need of protection, then “elder” abuse and neglect and exploitation, which obviously borrowed from the child abuse tradition, and then the family violence orientation. You made the observation that, overall, you thought that this had a positive impact, at least from the standpoint of building constituencies. But I detected some reservations among some people, as to whether this interweaving of strands has been a good thing or not. Could you comment on that?
Rosalie Wolf: I think it comes mostly from the social service field. I’m not sure whether that is true today. It was true a few years ago, I believe.
Bonnie: One thing I am wondering about, in terms of the agenda for this panel, is that elder abuse is a very complicated construct. There are these three different strands that you have mentioned, and each one focuses on a different thing. For example, in the context of adult protective services, the “perpetrator,” the third party, is not the centerpiece. It is the vulnerability of the individual. From the other two perspectives, at least, a third-party focus emerges.
I think this explains at least in part some of the confusion about definitions. For a sound research base to develop, isn’t greater cohesion needed about the concept of elder abuse itself?
Wolf: I think that the whole criminal justice perspective has brought in an emphasis on the perpetrator—you’re right, let me say, that the emphasis previously was totally on the victim. If you look at the laws of the states, I’m not sure the perpetrator is mentioned at all. Yet, as we know, it could be a mutual problem, but the perpetrator certainly bears the guilt in these situations.
I think when you bring in the criminal justice system, this was definitely
a result of what had happened earlier with family violence. I think that as focus has been brought on the perpetrator, prosecution is now an intervention, where it never was before. In the social service field, they felt that prosecution was not anything that should be done, partly because older people don’t want to prosecute, they don’t want to bring charges against their children or their grandchildren. So it was more in keeping with the wishes of the victim, and prosecution was not a possibility. Then there were difficulties with perpetrators; it is hard to find them sometimes.
Constantine Lyketsos: Given that the dementia problem increases with age, if you look at reports of sentinel events or reports of events in much higher age groups in which dementia is more prevalent, do you see an increase of reports of abuse from communities as people get much older? Do you have any data on that?
Wolf: There are data in terms of reporting through adult protective services, which show that the highest number of reports of abuse within the age categories is among the 85 and over category. However, the prevalence study showed no difference in age. Since the author of that study is here, later on he can explain more about that.
Karl Pillemer: I think one of the reasons for some of the confusion is that there are two strands or traditions of research that have been used. One is the Murray Strauss school of family violence research, which is equally applicable to child abuse or wife abuse when you take a survey approach. The other has come out of the gerontological family caregiving tradition, which has looked at caregivers as samples—and hasn’t used the general population. That typically doesn’t include elderly spouse abuse, for example, which might occur among healthy elders.
That is where these lines become a lot less clear. So I think that is one reason for some of the confusion.
Wolf: I won’t try to answer the first part, because it raises the whole issue of why do we segregate a whole service system, how do we approach the needs of elders. It is a separate service system. Why do we have the Administration on Aging, for instance?
Most states use the criterion of people age 18 and over who are vulnerable. So the vulnerability risk factor shows up very strongly in adult protective services. Some of the states don’t use that criterion and instead serve all adults who are 60 or over; in those states, one doesn’t see such a strong showing of vulnerability as a risk factor.
For instance, I think the statistics show that in states in which adult protective services serve younger and older persons with disabilities, about 40 percent of the reports that come in for people age 18 and over are collected from caregivers. In contrast, the state that I come from, Massachusetts, doesn’t include vulnerability as a criterion. It has physical abuse and neglect without any necessary indicators. Illinois, which doesn’t have
vulnerability as a criterion, either, shows a much higher rate of financial abuse. The bottom line is that there are all sorts of issues that have to be taken into account.
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