Mapping the Elder Mistreatment Iceberg: U.S. Hospitalizations With Elder Abuse and Neglect Diagnoses

Purpose: This study describes U.S. hospitalizations with diagnostic codes indicating elder mistreatment (EM). Method: Using the 2003 Nationwide Inpatient Sample (NIS) of the Healthcare Costs and Utilization Project (HCUP), inpatient stays coded with diagnoses of adult abuse and/or neglect are compared with stays of other hospitalized adults age 60 and older. Results: Few hospitalizations (< 0.02%) were coded with EM diagnoses in 2003. Compared to other hospitalizations of older adults, patients with EM codes were twice as likely to be women (OR = 2.12, 95% CI = 1.63–2.75), significantly more likely to be emergency department admissions (78.0% vs. 56.8%, p < .0001), and, on average, more likely to have longer stays (7.0 vs. 5.6 days, p = 0.01). Patients with EM codes were also three to four times more likely to be discharged to a facility such as a nursing home rather than “routinely” discharged (i.e., to home or self-care) (OR = 3.66, 95% CI = 2.92–4.59). Elder mistreatment–coded hospitalizations compared to all other hospitalizations had on average lower total charges ($21,479 vs. $25,127, p < .001), with neglect cases having the highest charges in 2003 ($29,389). Implications: Knowledge about EM is often likened to the “tip of the iceberg.” Our study contributes to “mapping the EM iceberg”; however, findings based on diagnostic codes are limited and should not be used to minimize the problem of EM. With the so-called graying of America, training is needed in recognizing EM along with research to improve our nation's response to the mistreatment of our elderly population.     

Physical Abuse of Older Adults in Nursing Homes: A Random Sample Survey of Adults With an Elderly Family Member in a Nursing Home

Few empirical studies have focused on elder abuse in nursing home settings. The present study investigated the prevalence and risk factors of staff physical abuse among elderly individuals receiving nursing home care in Michigan. A random sample of 452 adults with elderly relatives, older than 65 years, and in nursing home care completed a telephone survey regarding elder abuse and neglect experienced by this elder family member in the care setting. Some 24.3% of respondents reported at least one incident of physical abuse by nursing home staff. A logistic regression model was used to estimate the importance of various risk factors in nursing home abuse. Limitations in activities of daily living (ADLs), older adult behavioral difficulties, and previous victimization by nonstaff perpetrators were associated with a greater likelihood of physical abuse. Interventions that address these risk factors may be effective in reducing older adult physical abuse in nursing homes. Attention to the contextual or ecological character of nursing home abuse is essential, particularly in light of the findings of this study.     

Elder Abuse in Nursing Homes: An Ecological Perspective

Population trends suggest that the next 20 years will witness a dramatic increase in the adult population aged 65 and older. Projected increases in the elderly population are expected to significantly increase the stress on family and professional caretakers. Stress, in the context of caregiving relationships, is a risk factor associated with increased prevalence of elder abuse in familial and institutional settings. As increasing numbers of older adults are moved from family caregiving to nursing home care settings, it becomes important to identify the pattern of elder abuse risk factors in nursing home facilities. An ecological model is proposed for better understanding the risk factors associated with elder abuse in nursing homes and the complex interaction of individual/person characteristics and contextual factors in institutional elder abuse. An ecological perspective to institutional elder abuse provides a framework for guiding and informing future research on the risk factors of nursing home abuse and, in turn, for the development of effective interventions and relevant social policies.     

What Is “Elder Abuse”? Voices From the Margin: The Views of Underrepresented Canadian Older Adults

We know relatively little about the definitions and perceptions of elder abuse held by marginalized groups of older adults in Canada. The current study used focus group methodology to explore perceptions of elder abuse among marginalized groups such as Aboriginal persons, immigrants, refugees, and lesbians. We found both similarities and differences in perceptions of elder abuse across groups. Groups identified traditional forms of elder abuse (i.e., physical, sexual, psychological/emotional, financial abuse, and neglect) as well as less frequently identified types of abuse such as disrespect and government or systemic abuse. Groups also discussed issues related to immigrant sponsorship arrangements and abuse in nursing homes.     

Frailty in self-neglecting older adults: A secondary analysis

ABSTRACT

Self-neglect (SN) and frailty in older adults is associated with increased disability and mortality. Despite these commonalities, there have been no studies objectively assessing frailty in older adults who SN. This secondary analysis classified frailty in N = 37 older adults with Adult Protective Services validated SN using the Fried Frailty Phenotype (FFP) of weight loss, weakness, exhaustion, activity level, and walking speed. Overall, 3% were classified as robust, 62% as prefrail, and 35% as frail. Most (72%) were overweight/obese, with clinically significant decreases in activity level (60%) and walking speed (97%). Compared to the original FFP population, older adults who SN exhibit important differences in frailty phenotypes, and finding that the largest percentage of older adults who SN were prefrail may indicate a critical opportunity for intervening in this population to reduce future functional decline and mortality.     

Elder Abuse and Barriers to Help Seeking in Chennai,India: A Qualitative Study

This qualitative study attempts to understand why older persons abused by their family members in India do not seek help. In-depth interviews over three visits were conducted with six adults aged 65 years and above who had been physically abused by their sons/daughters-in-law. The interviews were transcribed and themes identified using a thematic analysis method. The barriers preventing a person from seeking help were service-related (accessibility, lack of trust); religious (Karma); family (deleterious effects on family, family members’ responses to help seeking); and individual (socioeconomic dependency, self-blame). The unique findings that surfaced were fear of losing one's identity by losing one's family, attributing abuse to past sins, and concern over not attaining salvation if one's sons did not perform funeral rites. The authors propose a checklist to explore and assess the barriers to seeking help. Recommendations for geroprofessionals in overcoming barriers include implementing outreach programs and changing the misconceptions regarding Karma.     

Screening for Elder Abuse in Hospitalized Older Adults With Dementia

When older adults with dementia are hospitalized for psychiatric treatment, which elder abuse screen to use is questionable. This article reviews screens to identify desirable characteristics. For clinician completion, the Elder Assessment Instrument and the Brief Abuse Screens for the Elderly are recommended. For the older adult, the brief Hwalek-Sengstock Elder Abuse Screening Test is suitable. The Modified Conflict Tactics Scale, which can be used by both the older adult and the nonprofessional caregiver, has many of the recommended characteristics. Research is necessary in the application of these screens within hospitals to detect elder abuse within this specialized population.     

Exploring gender and elder abuse from the perspective of professionals

We conducted an online survey of professionals working in two Canadian provinces to learn about their knowledge of elder abuse from a gender-based perspective. A total of 169 professionals (90% women) completed a survey in either French or English. Five topic areas emerged from the analysis: the influence of gender on the risk of abuse; types of abuse detected; knowledge gaps; capacity to respond to gender-based abuse; and awareness of resources. To gain further insight into these results, we conducted three focus groups with a total of 24 professionals. Professionals held relatively little recognition of, or knowledge about, gender related to elder abuse. Our results indicate the need to develop educational and awareness raising opportunities for professionals who work with abused older adults in both French and English to identify and respond to the unique needs of older women and men.     

The National Elder Mistreatment Study: Race and Ethnicity Findings

The prevalence of elder mistreatment with respect to race and ethnicity was examined in an unweighted sample of 5,777 participants (5,776 participants in weighted sample). Random Digit Dialing methodology was used to select a representative sample of community-dwelling older adults, and the survey was available in English and Spanish. Mistreatment types included emotional, physical, and sexual abuse. Race- and ethnicity-based differences were largely absent, and the only observed increase was for physical mistreatment among non-White older adults; however, this association was not sustained in multivariate analyses controlling for income, health status, and social support. Findings are in contrast to prior reports of increased risk of mistreatment in minority populations and point to correlated and modifiable factors of social support and poor health as targets for preventive intervention.     

Public Opinion on Mandatory Reporting of Abuse and/or Neglect of Older Adults in Manitoba,Canada

This article discusses the results of a survey administered as part of a study titled, “Legislation and Service Provision Regarding Abuse and/or Neglect of Older Adults in Manitoba.” Public views of mandatory reporting and knowledge of legislation were investigated in the case where an older adult is living at risk of abuse and/or neglect in Manitoba, Canada. The survey data demonstrate that older respondents stated that mandatory reporting was not always preferable, except when an older adult was clearly diagnosed as incompetent and, even with no evidence, thought to be at risk. With less awareness of the topic in general, and with less contact with older adults, younger adults had much stronger views in support of mandatory reporting in all cases. Little knowledge and awareness of legislation existed in all age groups, although older adults knew more about such abuse and/or neglect than younger adults. Given the projected increase of older adults in Canada in the next 20 years, it is critical that the prevention of abuse and/or neglect and protection of older adults be addressed.     

Cultural and Ethical Issues in Korea's Recent Elder Abuse Reporting System

The primary purpose of this article is to examine the relevance of cultural values, such as familism and individualism, that influence public policy implementation processes for protecting older adults in Korea and the United States. The secondary purpose is to identify ethical dilemmas and policy implications for effectively implementing the recently developed public law designed to protect vulnerable older adults in Korea. This article discusses both similarities and differences found in the two countries' elder abuse reporting systems and the service delivery systems for protecting older adults at risk of abuse and neglect.     

The prevalence and nature of abuse and neglect in children under four: a national survey

This paper reports the results from a Danish national survey of child abuse and neglect. Data were obtained by a written questionnaire sent to all home health visitors. All newborn Danish children receive visits by a home health visitor several times during their first year of life. For children in need of special care for social reasons the visits may continue until school age (at 6 or 7 years). The questionnaire included four checklists of signs of abuse and neglect. The home health visitors were asked to record what they had actually observed visiting the children in their homes. Eighty‐three per cent (covering about 80% of all newborns) answered the questionnaire. The objective was to establish a scientific based framework that could be used to guide preventive efforts. Ten per cent of all children under 1 year of age may be characterized as children in need of special care for social reasons, the most frequent single reason being reliance on social assistance, alcohol abuse or violence against the mother. A minimum of 4% of infants are subjected to broadly defined abuse or neglect from one or more of the four categories: physical abuse, physical neglect, emotional abuse and emotional neglect, physical and emotional neglect being the most frequent and physical maltreatment the most rare. Copyright © 1999 John Wiley & Sons, Ltd.     

The Vulnerability for Elder Abuse Among a Sample of Custodial Grandfathers: An Exploratory Study

ABSTRACT

Older adults have been known to make sacrifices in their caregiving roles. Gerontology literature on custodial grandparents has primarily focused on grandmothers and the challenges they face when they assume primary care for grandchildren. Little is known about the risks that older men face when they become custodial grandparents. This article highlights types and warning signs of abuse, exploitation and neglect. Exploratory study was undertaken with a racially diverse group of custodial grandfathers to fill a gap in the literature about the vulnerability for elder abuse, exploitation and neglect as expressed by older Black, Latino and White custodial grandfathers. To provide a more inclusive understanding of elder abuse, areas of vulnerability were identified for consideration by practitioners, educators and researchers. The implications of this research point to the need to rethink elder abuse assessment, prevention and intervention strategies with older men.     

Family Members' Reports of Abuse in Michigan Nursing Homes

The objective of this article is to describe abuse and neglect of adults age 65 and older in Michigan nursing homes, as reported by members of their families. Using list-assisted random-digit dialing, data on abuse and neglect for a 12-month period were collected from individuals who had a relative age 65 or older in a Michigan nursing home. Of the nursing home residents represented in this analysis, the majority were female, Caucasian, and widowed. Neglect and caretaking mistreatment were the most frequent types of abuse reported. Comparison of these data with data from the National Ombudsman Reporting System suggests that family members constitute a sensitive source of data on abuse in nursing homes.     

The Impact of Relationship Dynamics on the Detection and Reporting of Elder Abuse Occurring in Domestic Settings

There is a keen desire to increase the detection and reporting of elder abuse. The purpose of this study was to describe the circumstances under which abuse is detected and reported and to identify the relationship dynamics that might be impacting detection and reporting decisions. Interviews were conducted with 71 Adult Protective Services (APS) caseworkers, 55 of their elderly clients, and 32 third-party adults. Detection and reporting are distinct but related acts. The temporal relationship between detection and reporting generally differed depending on the nature and quality of the relationship between (a) the victim and offender and (b) the victim and reporter. Efforts to increase reporting may benefit from taking into consideration these relationship dynamics. A range of individuals detected and reported elder abuse, including victims, under a range of circumstances, reinforcing the value of public efforts to increase awareness of elder abuse.     

The victim–offender overlap in late adulthood

This study contributes to the general knowledge of the victim–offender overlap by determining whether the phenomenon exists among older adults and whether known correlates of crime and victimization explain the relationship. Cross-sectional survey data from telephone interviews conducted with individuals 60 years and older (N = 2,000) residing in Arizona and Florida are used to estimate confirmatory factor models for both victimization and criminal offending. The results from a series of multivariate regression models show that victimization is associated with criminal offending. While factors such as low self-control, depression, and spending time in commercial drinking establishments partially attenuate the victimization–crime link, the statistically significant relationship persists in a multivariate context. Further testing indicates that the observed findings are robust across measurement and modeling strategies. Coupled with prior research, the results support the argument that the victim–offender overlap exists (and is difficult to explain) over the life course.     

Prevention of Elder Mistreatment in Nursing Homes: Competencies for Direct-Care Staff

Existing training on elder mistreatment in nursing homes focuses on detection and reporting of abuse, with little training specifically targeted toward prevention of mistreatment before it occurs. We used qualitative interviews with nursing home staff, policy makers, and related professionals to identify training needs. Based on participant accounts, we drafted a number of competencies essential for caregiver training to prevent mistreatment in nursing homes. Competencies include those dealing with definitions and policies, risks for mistreatment, communication and respect in relationships with residents, and development of a cooperative work environment. Competencies are discussed along with illustrative examples, and implications for practice and policy are addressed.     

Mistreatment and Self-Reported Emotional Symptoms: Results From the National Elder Mistreatment Study

Many community-residing older adults in the United States report past year mistreatment; however, little is known about mental health correlates of abuse. This study investigated whether a recent history of emotional, physical, or sexual abuse is associated with self-reported emotional symptoms (e.g., anxiety, depression) among a representative sample of older adults. Results demonstrated that each abuse type increased likelihood of reporting emotional symptoms; when other known correlates were controlled, only emotional abuse remained a significant predictor. Additional study of mistreatment-related correlates of depression and anxiety is needed, with a focus on the often overlooked category of emotional mistreatment.     

Challenges to Aging in Place: Understanding Home Maintenance Difficulties

Age-related declines in capabilities may compromise older adults’ ability to maintain their homes, threatening successful aging in place. Structured interviews were conducted with 44 independently living older adults (mean age = 76.1, standard deviation = 4.7) to discuss difficult home maintenance tasks and how they managed those tasks. Solutions to managing difficulties were categorized as person-related or environment-related. The majority (85%) of responses were person-related solutions. An understanding of the specific challenges that older adults face in maintaining their homes can guide redesign efforts and interventions to effectively support older adults’ desire to age in place.     

Professional Decision Making on Elder Abuse: Systematic Narrative Review

Social work and health care professionals internationally are recognizing the need to understand and respond to the abuse of older people. Policy and guidance have identified processes but definitions of key concepts remain problematic, and the literature suggests that practitioners and agencies have little insight or guidance for decision making. Nine bibliographic databases were searched for studies on professional decision making regarding abuse of older people. Relevant studies retrieved were appraised for quality using explicit criteria. The findings of the 19 articles meeting the inclusion criteria were synthesised using a structured narrative approach. Common themes identified were abuse factors, situational factors, and broader contextual factors. Abuse factors relating to risk levels and client vulnerability were central; age, gender, and health status were considered as key indicators of vulnerability. The opinion of adult protection workers about the potential effectiveness of their intervention was a factor in deciding about responding to alleged or suspected abuse. Professionals struggled with complex ethical dilemmas created by elder abuse, particularly when the victim did not want an investigation. Making objective judgements was difficult when faced with complex family and contextual factors. A structured approach to narrative synthesis of a diverse range of studies retrieved through an explicit search and inclusion process provided a useful summary of key issues for practice and identified gaps in the research literature.