Elder Abuse, Premature Mortality, and Intervention Strategies

Introduction and Statement of the Problem

Elder abuse is a growing phenomenon across a wide range of societies and populations today. Research on this social problem has tended to focus on estimates of its prevalence and on characterizations of its perpetrators and victims; however, there remains a paucity of research offering explanations for the emergence of the phenomenon itself (Litwin & Zoabi, 2004). Estimates of elder abuse in the Western world vary widely, making it difficult to confirm the true extent of the problem. In many cases, the phenomenon is underreported largely because physical and psychological symptoms of abuse may be denied by victims or misinterpreted by service personnel as simply being the normal consequences of the aging process (Litwin & Zoabi, 2004). In addition, elder abuse is more difficult to detect than other forms of abuse because elders tend to be reluctant to disclose such behaviors, especially when they involve close family members, out of fear of future retribution or institutionalization if they are removed from the abusive environment.

Moreover, the lack of satisfactory treatment alternatives for abused older people serves as a disincentive to reporting (Litwin & Zoabi, 2004). This point is underscored by Bergeron (2000), who reports that "Elder abuse has been documented to be a social problem of national and international concern" (p. 40). The Select Committee on Aging of the U.S. House of Representatives reported that "some 5% of the Nation's elderly may be the victims of abuse from moderate to severe... or more than 1.5 million elderly may be victims of such abuse each year" (Select Committee, 1990, p. xi). A consistent theme that emerges from the research is just how underreported the problem may be. While all states have laws and services in place to detect domestic elder abuse, only about one in five actual cases is reported and substantiated; therefore, how cases are identified and resolved varies significantly across the nation because laws and regulations differ greatly (Jogerst, 2004).

According to Gellert (1997), there are three settings in which elder abuse generally takes place: (a) domestically; (b) institutionally, in nursing homes, hospitals, and long-term care facilities; and (c) through self-neglect and self-abuse. Gellert notes that, "Elder abuse tends to occur in a situation in which an elderly person's needs are exceeding, or will soon exceed, the ability of a caregiver to address them adequately. The caregiver experiences increasing frustration and stress as his or her ability to give care diminishes. Elder abuse tends to increase in frequency and severity over time" (Gellert, p. 190). In his book Handbook of Domestic Violence Intervention Strategies: Policies, Programs, and Legal Remedies, Roberts (2002) reports that:

Elder abuse as a form of institutional abuse involves a care-dependent victim and an abusive formal caregiver (e.g., nurse's aide, nurse, home health aide). Institutional abuse can occur in a nursing home, hospital, or the victim's home, with the abuser part of a formal care system. Depending on the severity of the neglect or mistreatment of a care-dependent older adult by a formal caregiver, the abuse or neglect may constitute a criminal offense. Most state laws mandate reporting of any suspected or actual abuse or neglect by a formal caregiver against a care-dependent older adult to the state department of health. Perpetrators may be subject to criminal investigation, prosecution, fines, and loss of license to practice. (p. 488)

While institutional elder abuse has received considerable attention, elder abuse by family members has also been identified as a growing problem in American society. Since the first congressional investigation of elder abuse in 1978 (Olinger, 1991), every state has implemented some form of elder abuse reporting law designating an agency to accept reports of suspected elder abuse, investigate allegations, and provide intervention for the elderly victim (Bergeron & Gray, 2003). The American Medical Association (AMA) also issued its first guidelines on elder abuse in 1992, urging physicians and other healthcare providers to be more alert to signs of mistreatment or neglect of older patients (Aguilera, 1998). According to Aguilera, "The 42-page guidelines, part of a new AMA campaign against family violence, come amid growing national concern about a long-hidden problem in which as many as 2 million elderly Americans are believed to be victims of abuse or neglect" (p. 112).

According to the National Elder Abuse Incidence Study (National Center on Elder Abuse, 1998), "the best national estimate is that a total of 449,924 elderly people, aged 60 and over, experienced abuse and/or neglect in domestic settings in 1996" (p. 4), and of that number approximately 16% were reported to elder protection agencies. Experts in the field say that elder abuse is grossly underreported for several reasons: the isolation of elderly people, lack of uniform reporting laws, and the general resistance of people — including professionals — to report suspected cases (Tatara, 1993). The majority of perpetrators of domestic elder abuse are family members (Bergeron & Gray).

According to Baker (2007), the mistreatment of the elderly — even unto death — represents a widespread and increasingly serious problem in the United States. "Elders who are mistreated face negative consequences, including higher mortality risk when compared to nonmistreated peers," Baker advises, adding that "Factors such as childhood physical abuse or neglect, depression, and dependence on others for activity of daily living assistance make elders vulnerable to mistreatment. Geriatric syndromes, such as frailty, may also contribute to elder mistreatment vulnerability, whereas chronic stress may be a mediator in early mortality" (p. 313). Finally, as Ebersole and Hess (1998) emphasize, "In a society becoming increasingly more violent, it is reasonable to assume that abuse of elders and other vulnerable persons will continue to increase" (p. 562).

Complex problems require complex solutions, and such is the case with elder abuse. According to Thursz, Nusberg, and Prather (1995), "The causes of elder abuse are complex, arising from any one of the following: the abuser's personality, the older person's behavior, family dynamics, or environmental pressures" (p. 42). Within this broad range of contributing factors is a constellation of social, cultural, and gender issues that make developing effective interventions problematic, and the problem is only going to worsen in the years to come. As Gellert (1997) advises, "A number of factors contribute to elder abuse, including psychological, social, medical, and economic influences. These influences affect an elderly person's interpersonal and family relationships" (p. 191). Therefore, the purpose of this study was to critically review the relevant peer-reviewed and scholarly literature concerning elder abuse in general and its contribution to premature death among this population in particular, in order to identify opportunities for improving the delivery of support services and to describe best practices as they exist today.

Since the beginning of the 20th century, average life expectancy in the United States has increased from 47 years to over 75 years (Gardner & Hudson, 1996). According to Johnson (1999), "In 1900, over half of all deaths involved persons 14 years of age or younger. Today only 2% of all deaths occur within this age group. As a corollary, an increase in the relative size of the older population (persons 65 years of age or over) is clearly evident. Elderly persons comprised 4% of the total population in 1900, 12.6% in 1990, and will be as much as 23% by the year 2050" (p. 126). Although the number of elderly in the United States is increasing, the study of elder abuse is of fairly recent origin. During the last three decades of the 20th century, following the "discovery" of child abuse and domestic violence, scholars and professionals began taking an active interest in the subject of elder abuse. This increased academic attention, combined with clear signals from state and federal governments that they were willing to intervene in family matters and a growing aging population at risk for violence in the home, explains why elder abuse has gained public and scholarly attention in recent years.

In this regard, Nadien (1995) notes that, "Violence against the elderly, often referred to as elder abuse, emerged as a serious concern only in the late 1970s and early 1980s. At that time, the first set of published research and governmental findings revealed that maltreatment, while only 4% among the well elderly, reached 10% among the frail or impaired elderly. Today elder maltreatment is thought to be six times greater than these figures suggest" (p. 177).

Despite this growing attention, some observers suggest that elder mistreatment research is lagging 20 years behind (Kurst-Swanger & Petcosky, 2003). According to Ebersole and Hess (1998), "States on average spend $22 per child for youth protective services but only $2.90 per elder for protective services, though 40% of reported abuse involves elders" (p. 562). The results of an 11-year longitudinal study of community elders showed that almost 10% of them were referred for adult protective services at some point in time (Lachs et al., 1996). Moreover, recent increases in the incidence of elder abuse have introduced difficult questions concerning the advantages of separating family members when abuse or neglect has been reported, especially when the abused person depends on the relationship for important benefits (Chalk & King, 1998). Finally, as Proctor (2004) emphasizes, "Nearly half a million cases of elder abuse are reported each year. Yet, we know very little about it. The little that is known comes from small studies or anecdotal information. Thus, research on the correlates and causes of elder abuse are badly needed" (p. 131).

Although this study examined the issues surrounding elder abuse across various cultural settings, there was a specific focus on the United States.

Because there are going to be more elderly people in the United States in the years to come, it is reasonable to posit that the incidence of elder abuse will also continue to increase. According to Adler and Denmark (1995), "The need to identify and remedy elder abuse takes on urgency in the light of a burgeoning of the aged population, who currently make up almost 13% of the U.S. population and who are projected to account for over 20% of the population by the year 2020, with 21% of all males and 24% of all females expected to be 65 years or older" (p. 177). Elders who are emotionally, physically, or sexually abused are at increased risk for the entire constellation of comorbidities that can accompany such abuse, including death.

Review of Related Literature: Background and Definitions

Furthermore, besides being the fastest-growing age segment, the elderly population is living much longer. As Adler and Denmark point out, "Among U.S. residents who reached age 65 during the 1980s, males can expect to live until age 80, and females to age 84. Thus, it is important to find ways of detecting and checking the maltreatment of impaired old-agers" (p. 177). Much has been written about improving the quality of life for senior citizens, but the bottom-line outcome for the purposes of this investigation is the relationship of such abuse to premature death. As one authority notes, "The ultimate measure of the quality of life is mortality" (Kosberg, 2005, p. 9).

There are some profound constraints involved in investigating instances of abuse among the elderly, because it requires a long-term casework approach. In this regard, Bergeron (2000) emphasizes that, "The building of trust with older clients, particularly abused older clients, is paramount in creating a working relationship. Elderly people traditionally are skeptical of the helping profession. They are slow to disclose, and they fear being removed from their homes and placed in nursing homes" (p. 40). In fact, at least one study has shown that elder victims of abuse would choose to remain in their own homes and continue to suffer from abuse rather than be uprooted to a nursing home setting (Bergeron). As Kohl (2003) reports, "Despite the stringent federal regulation of long-term care facilities, nursing home abuse remains rampant throughout the United States" (p. 2083).

This study used a five-chapter format to achieve the above-stated research purpose. The first chapter introduced the topics under consideration, the purpose of the study, and its importance, scope, and rationale. The second chapter presents a critical review of the relevant peer-reviewed and scholarly literature concerning elder abuse, including its incidence, causes, and current intervention approaches. Chapter three describes the research methodology used to develop the research findings, and chapter four provides a recapitulation and summary of key findings from the research. Finally, chapter five provides a summary of the research, salient conclusions, and recommendations for policymakers and those providing caregiving services for the elderly, as well as directions for future research.

Although no specific legal definition is provided for elder abuse by Black's Law Dictionary (1990), Gellert (1997) provides a useful working definition: "Elder abuse is any action that, either by commission or omission, harms an elderly person. Elder abuse and neglect are complex problems that have evaded clear definition" (p. 183). Likewise, Adler and Denmark (1995) note that, "Violence against the elderly assumes different forms. Although all forms entail suffering for the victim, the source of that pain may derive either from something inflicted or something withheld" (p. 178). Researchers concerned with elder abuse differ significantly on precisely what constitutes it. According to Gellert, "While child and spouse abuse have been clearly recognized for a number of years, elder abuse has received substantial attention only quite recently. Abuse of the elderly involves physical injury by caregivers, psychological abuse, financial exploitation, violation of human rights, and neglect. The varying aspects have not been shaped into a single definition" (p. 183). It remains nebulous, for instance, whether the definition of physical abuse should include the failure to provide medical care to an elderly person, lack of supervision, or only direct physical injuries. Similarly, disagreement exists over whether elder abuse occurs when the victim is fifty-five years and older or sixty-five and older (Gellert).

It is possible to identify several aspects of elder abuse. Physical or sexual abuse involves direct physical assault, including intentionally striking an elderly person, rough handling, sexual assault, and threats with a weapon. Force-feeding and improper use of restraints or medications also constitute physical abuse. Psychological elder abuse includes verbal assault, social isolation, or threats that create fear, anguish, and anxiety. It occurs when an elderly person is humiliated or intimidated, and may also include denying older persons participation in decisions that affect their lives (Gellert). In their study of elder abuse patterns, Oktay and Tompkins (2004) report that, "Verbal abuse (sometimes called psychological abuse) is usually the most frequent type of mistreatment, followed by physical abuse and neglect; sexual abuse is usually the least prevalent type of abuse" (p. 177).

Victimization of the elderly can take place in other ways as well. For example, the elderly are frequently easy marks for entrapment in financial schemes in which they are coerced or manipulated to give others their money, rewrite their wills, give up control over their finances, assign durable power of attorney, or sign away ownership of their homes and property (Gellert). According to Gellert, "Financial elder abuse involves fraud, theft, or unauthorized use of an elderly person's money or property for the gain of an advisor or caretaker. Neglect is failure to meet the needs of an elderly person and withholding or failing to provide that person with the essentials of life, such as food, shelter, clothing, the means for personal hygiene, medical care, and social stimulation. Neglect often overlaps with other kinds of elder abuse" (p. 183). The financial exploitation of elders has resulted in many trust officers paying careful attention to signs of abuse by caregivers (Lunt, 1995).

Physical abuse involves inflicted pain that can occur when frail or ill elderly persons are pushed, shoved, grabbed, hit, or assaulted with a weapon (Pillemer & Finkelhor, 1988). Such inflicted injuries or concomitant pain may also result from psychological abuse, as occurs in verbal aggression (e.g., insults, blame, ridicule), threats where no weapon is involved, or some form of coercion, abandonment, or confinement (Adler & Denmark). In addition, inflicted pain may derive from legal or material abuse — the misuse or misappropriation of an elder's real property or other resources (Adler & Denmark).

The growing body of research into elder abuse has provided some useful starting points for further investigation. Early attention given to elder abuse was largely focused on elderly residents of nursing homes in which there were incidents of abuse by employees; since the majority of care provided for elderly Americans occurs in the home, however, it is not surprising that the majority of elder abuse also happens in these settings. Some of the underlying causes of elder abuse include the vulnerability of older individuals, the high level of violence in society generally, stress, substance abuse, and poverty among both victims and abusers (Gellert).

Elder abuse has been generally regarded as a public health issue, and like the allocation of educational resources for domestic violence, much of the literature specifically on teaching about elder abuse is found in nursing and medicine (Wilke & Vinton, 2003). According to these authors, "The medicalization of elder abuse results from elders being viewed as a group whose impairments are exacerbated by abuse or neglect and therefore requires health care services. Because elder abuse is now covered by both civil law and criminal law, proposals have been suggested for its inclusion in legal education" (p. 225). As the baby boomers continue to reach retirement age and experience the physical ravages that accompany the aging process, an increasing number of adult children are going to be tasked with caregiving responsibilities. These caregivers will likely not enjoy the same level of preparedness as healthcare professionals, and the problems associated with the increased levels of stress that are natural concomitants of this caregiving are well documented.

Recent innovations in medical technology have provided the ability for people to live longer lives, but this does not necessarily equate to healthier and fulfilled lives. Although some people in the United States may not realize it, many frail or sick elderly people continue to live in their homes and are cared for by various family members — mostly women, frequently the elder's spouse (Bergeron & Gray, 2003). Despite these findings, Kosberg points out that, "Although males are popularly depicted as abusers (of children and females), there is reason to believe that males are at least as likely as females to be victims of abuse — including elder abuse" (p. 9).

Domestic caregivers of the elderly, of whatever gender, are frequently beset by a wide range of financial, emotional, and physical stresses associated with their caregiving responsibilities. Common feelings reported by such caregivers are isolation and loneliness; in many cases, a dearth of community resources contributes to the sense of hopelessness and fatigue they experience (Bergeron & Gray). According to Jensen (2001), "Elder abuse is found to be associated with the stresses of caring for elders. These include psychological exhaustion, subsuming individual needs to the needs of the elderly family member, devaluing the caregiving, and financial strains involved in caregiving. The less others are available to assist, the greater the dependency of the elder on a single caregiver, and the greater the degree of dependence, the more likely it is that abuse will take place" (p. 54). As Thursz and his colleagues (1995) point out, "Under the burden of care, the caregiver lashes out. In other cases, the caregiver may be settling old scores, after the 'fall of the tyrant,' taking revenge on a once-powerful parent for real or imagined slights and hurts sustained in childhood" (p. 42).

Some of the traits typically found in elderly abusers include: (a) low self-esteem, (b) poor coping mechanisms and communication skills, (c) drug or alcohol abuse, and (d) mental illness (Thursz et al.). Those who abuse the elderly may feel trapped and resent loss of career, friends, and leisure time; disappointment at inadequate recognition or rewards for caregiving; and outrage at the injustice of an unshared caregiving burden within the family (Thursz et al.). According to Gellert, "Elderly people with severe mental and/or physical disabilities are more likely to be abused than those without disabilities. The amount and complexity of care required for a disabled elderly person promotes stress in the caretaker and contributes to abuse. Some experts believe that violent behavior is learned by younger generations from parents and transmitted in a cycle of violence" (p. 191).

Causes of Elder Abuse

The traits found most irritating and provocative in the dependent elderly have been identified as including selfishness, self-pity, masochism, sadism, complaining, feigned illnesses, indulging in amateur dramatics, and begging for overdoses or to be smothered or killed (Thursz et al.). The various family dynamics that have been shown to contribute to elder abuse include poor family integration, cycles of violence inherited by each generation, sibling feuds, and social isolation removing the family from the controlling influence of neighborhood disapproval (Thursz et al.). Environmental factors contributing to elder abuse may include unemployment, inadequate housing, migration, and man-made and natural disasters (Thursz et al.). Consequently, elder homicide, as an extension of these types of elder abuse, can reasonably be posited to be influenced by these factors (Bergeron & Gray).

Women's relationships with children and elders share some significant commonalities, including the following: the social demand, in more traditional social systems, for women to care exclusively for both the very young and the elderly; the frequent stigmatizing of women caregivers who seek outside help such as child care or nursing home care; and the economic strain that such caregiving often causes, compounded by women's disadvantaged position in the workforce (Jensen).

Emotional stress has been identified as a major trigger in elder abuse, but it is unlikely that stress alone will result in a homicidal event. In this regard, Coney and colleagues report that stress, when combined with a lack of social and economic support and extreme isolation, can lead to a state in which options are seen as limited. Isolation and feelings of entrapment were also reported in elder abusers, and these problems are compounded by the dependency of the elder on the caregiver (Jensen).

The effects of isolation and limitations of social options can be intensified by a lack of economic resources to obtain necessary assistance. In both child abuse studies (Milner and Crouch, 1993; Gelles, 1993) and elder abuse studies (Boudreau, 1993; Gelles, 1993; Hooyman and Ryan, 1987), limited economic resources interacted with subjective experiences of stress to make abuse more likely. If these familial homicides are viewed as a lethal extension of abuse, a picture emerges of women as more likely to kill when they are expected to be the sole caregivers and to sacrifice their own needs, when they are experiencing stress from caregiving demands, when they are isolated, and when they receive little financial assistance. Low levels of gender equality increase the likelihood that women will experience these conditions (Jensen).

The homicidal event will likely be a final effort to escape from a seemingly inescapable situation. Like the intimate partner homicide counterpart, the female familial homicide offender will kill the perceived object of her oppression. As Unnithan and colleagues (1994) discuss, in lethal violence the choice of homicide occurs when the source of one's stress and anger becomes externalized. At this point aggression will be turned toward that perceived source, making the killing of children and family members most likely when no other alternatives for alleviating stress are seen. There is also a sense that abuse — and, by extension, killing — of the powerless is fed by a woman's own powerlessness and represents a desperate attempt to gain power for herself (Jensen).

Finally, Johnson (1999) reports that, "No form of elder abuse receives more public and professional involvement than self-neglect (including self-abuse)" (p. 197). This is evident in at least three ways: the higher reporting of self-neglect over other abuse forms; the breadth of agencies encountering self-neglect situations; and the importance placed on handling self-neglect cases in protective practice (Johnson, p. 197).

One of the natural outcomes of long-term self-neglect is premature death, but this problem remains understudied; nevertheless, it is well established that psychological well-being plays a significant role in the preservation of physical health and functional capacity (Grant, 1996). According to Lachs (2007), "Although self-neglect in community-dwelling elders is suspected to have psychiatric antecedents, depression has not been formally investigated as a predictor of this syndrome" (p. 37).

When older people are removed from comfortable surroundings they have been familiar with for years and placed in alternative living arrangements, many will experience depression. To the extent that such depression continues unresolved is likely the extent to which self-neglect and its adverse outcomes will occur. To explore this relationship, Lachs and colleagues (2007) sought to determine the contribution of depressive symptoms to a multivariate model predicting self-neglect in community elders. Using the New Haven Established Population for Epidemiologic Studies in the Elderly (EPESE) cohort, which included 2,812 community residents older than 65 years in 1982, linked to adult protective service records, the researchers completed data analysis on 2,161 subjects over a nine-year follow-up.

The incidence of clinically significant depressive symptomatology at baseline (score >16 on the Center for Epidemiologic Studies for Depression Scale) was found to be 15.4% (Lachs et al.). During 1982 to 1991, the researchers identified 92 corroborated cases of self-neglect among the 2,161 subjects, resulting in a weighted crude incidence of 0.007 self-neglect cases per person year. Study subjects with depression scores above the threshold were 2.6 times more likely than those with lower scores to experience self-neglect; after adjusting for age, gender, race, and income, depression continued to be a significant predictor of self-neglect, with an incidence rate ratio of 2.4 (95% confidence interval, 1.3–4.5, p<.007) (Lachs et al., 2007).

A final model for self-neglect was developed using a stepwise selection procedure; depression contributed significantly to this model (incidence rate ratio, 2.04; 95% confidence interval, 1.12–3.69, p<.05), as did male gender, age, income less than $5,000 per year, living alone, cognitive impairment, history of hip fracture, and history of stroke (Lachs et al., 2007). These authors conclude that, "Whether aggressive identification and treatment of depression in isolated older adults would decrease the subsequent onset of self-neglect is an area worthy of future study" (Lachs et al., p. 37). These findings are congruent with other studies of self-abuse and self-neglect. According to Byers and Zeller (1995), "Self-neglect may be the most common form of neglect among older adult protective services clients. Some data suggest that nearly one-half of all elder-abuse cases and possibly two thirds of all neglect cases involve self-neglect" (p. 331).

The causes of self-abuse among elders depend on who is doing the defining and, in many cases, a highly subjective assessment of older people's cognitive abilities and capacity to care for themselves. Furthermore, it is important to note that elder abuse can be either intentional or unintentional. As Gellert notes, "If unintentional, it usually results from ignorance or inexperience in a caregiver or a lack of desire to provide care. Some organizations recognize self-neglect and self-abuse among the elderly, which is neglectful or abusive behavior by an older person that threatens his or her own health and safety. It usually results from physical and/or mental impairment in an elderly person, particularly when he or she is socially isolated" (p. 184).