Elder abuse: What research says about prevalence, assessment and prevention

 
Elder abuse
Image by Mabel Amber from Pixabay
By

July 16, 2020

Abuse of people age 60 and older is widespread, research shows. According to a 2017 study in The Lancet Global Health, “elder abuse seems to affect 1 in 6 older adults worldwide, which is roughly 141 million people.”

Elder abuse takes many forms. A 2015 review article in The New England Journal of Medicine explains that research on elder abuse generally addresses these five categories:  “physical abuse, or acts carried out with the intention to cause physical pain or injury; psychological or verbal abuse, defined as acts carried out with the aim of causing emotional pain or injury; sexual abuse, defined as nonconsensual sexual contact of any kind; financial exploitation, involving the misappropriation of an older person’s money or property; and neglect, or the failure of a designated caregiver to meet the needs of a dependent older person.”

Take for example a 2014 study in the Journal of General Internal Medicine, in which researchers studied nearly 4,000 older residents of New York state. They found that financial abuse afflicted nearly 5% of them during their lifetime, with Black people at higher risk.  “If a new disease entity were discovered that afflicted nearly one in 20 adults over their older lifetimes and differentially struck our most vulnerable subpopulations, a public health crisis would likely be declared,” the authors write. “Our data suggest that financial exploitation of older adults is such a phenomenon.”

But as prevalent as elder abuse is, it also goes widely unreported.

A 2018 article in Clinics in Geriatric Medicine, citing research from a 2011 report from the New York City Department for Aging, suggests that about only 1 in 24 cases of elder abuse is identified and reported to social service or legal authorities. The recognition, identification and regulation of elder abuse is complicated by the self-determination granted adults; in other words, while children are mostly seen as a vulnerable population requiring protection, there’s less oversight with vulnerable older adults.

In the past few years federal legislation designed to protect older Americans has passed or been proposed. The Elder Abuse Prevention and Prosecution Act of 2017, signed into law in October of that year, increased data collection, information sharing, training for federal prosecutors and investigators and penalties for criminal acts for elder abuse. It also established coordinator positions at the Federal Trade Commission and the Department of Justice.

In recent months, the U.S. Senate’s Special Senate Committee on Aging has called attention to increased risk of elder abuse during the COVID-19 pandemic. In May, Sens. Susan Collins, R-Maine; Bob Menendez, D-NJ; and Chuck Grassley, R-Iowa, introduced the “Promoting Alzheimer’s Awareness to Prevent Elder Abuse Act.” That bill builds on the Elder Abuse Prevention and Prosecution Act of 2017 and is paired with companion legislation in the House. When introducing the bill, Sen. Collins said, “During the COVID-19 pandemic, there may be increased risk for elder abuse, including elder financial exploitation. Our bipartisan bill would help to ensure that the frontline professionals who are leading the charge against elder abuse have the training needed to respond to cases where the victim or a witness has Alzheimer’s disease or other forms of dementia.”

Health care providers who work with elderly patients also warn that the pandemic has exacerbated some of the risk factors for elder abuse, for both victims and perpetrators. The COVID-19 stay-at-home orders/recommendations that are meant to keep older people physically safe from the virus may create conditions for abuse. Older adults are now more likely to be isolated and out of sight, for example, making potential abuse harder to detect. Perpetrators, including family members, who experience increased personal or financial stress caused by the pandemic may be more likely to commit abuse.

In addition, there has been increasing ageism rhetoric in the United States during the COVID-19 pandemic, devaluing the lives of older adults, note the authors of a recent letter to the editor in the Journal of the American Geriatrics Society. To combat ageism in our culture, they suggest “increasing representation of older people with decision-making power in public and private sectors.”

To help journalists cover stories of elder abuse, we’ve gathered and summarized several relevant studies, including a recent article on abuse in the context of the COVID-19 pandemic. We also have compiled information on current and pending legislation on the topic, an introduction to a specific type of elder abuse called guardianship abuse, and additional resources for in-depth reporting.

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A note on the limitations of data in many studies of elder abuse:  Data is often self-reported, depending on the victim to divulge the abuse. Shame of abuse and/or the vulnerable position of older people who may rely on abusers for daily living needs often make older adults less likely to report abuse, leading to underreporting. And most studies exclude participants with dementia or cognitive impairment, even though older people with those issues experience abuse. According to Professor Pamela Teaster, director of the Center for Gerontology at Virginia Tech, these exclusions occur because self-reporting by people with dementia may be unreliable and because of protections for people with dementia regarding research. In an e-mail to Journalist’s Resource she explained, “We have to be very careful because, depending on the degree of the dementia, they may be unable to consent to participate in research.” 

 

Elder Abuse
Mark S. Lachs and Karl A. Pillemer. The New England Journal of Medicine, November 2015

The authors of this highly cited paper estimate that across the U.S., approximately 10% of older adults not living in care facilities are victims of abuse. “Thus, a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse,” they write.

People with dementia are at especially high risk, and women are at higher risk than men, the authors note. Those at the younger end of the age group, the so-called “young old,” also have increased risks, as they more often live with the most likely abusers: a partner or adult children.

To help physicians identify elder abuse, the authors create a detailed breakdown of types of elder abuse (physical, verbal/psychological, sexual, financial, neglect) along with ways that abuse manifests itself during physical exams (for example, bone fractures may be a manifestation of physical abuse).

Assessment strategies for physicians include interviewing potential victims separately and alone and recognizing that mental illness resistant to treatment may have its source in emotional abuse. The authors also note that signs of neglect and financial abuse may be more subtle than those of physical abuse (e.g., weight loss and failure to keep appointments or fill prescriptions). Other assessments are specific to the abuse manifestations, such as determining if fractures are from abuse or falls/accidents. Physicians are cautioned that interviews with suspected perpetrators are best conducted by specifically trained professionals.

The authors note that successful treatment usually doesn’t involve just a single intervention of removing the victim from an abusive environment. Instead, successful interventions are typically “interprofessional, ongoing, community-based, and resource-intensive.” They write that the role for physicians is not to lead interventions, but rather to identify abuse, know the local organizations and services that provide resources to victims and refer patients to them, while coordinating care. These services can include Adult Protective Services, police and district attorneys, home health care organizations and appropriate nonprofits, and more.

 

Elder Abuse in the Time of COVID-19—Increased Risks for Older Adults and Their Caregivers
Lena K. Makaroun, Rachel L. Bacrach and Ann-Marie Rosland.  The American Journal of Geriatric Psychiatry, May 2020

The stay-at-home orders and recommendations intended to protect people, especially older people, from COVID-19 have created additional risks for elder abuse, note the authors of this perspective article. “Even in the best of times, elder abuse cases are rarely detected, with only 1 in 24 cases identified and reported to the appropriate authorities,” the authors write, citing a 2011 report of elder abuse in New York.

In the pandemic environment, older people and their family caregivers may be especially vulnerable to isolation, anxiety, financial stress and difficulty accessing healthcare and supplies, along with increased co-dependency brought on by the changing living conditions. These stressors increase risk factors for elder abuse.

Health care providers and outside caregivers are now less likely to have in-person contact with their patients, relying instead on technology-based communication; however, many older adults are not adept at technology, may not have the necessary hardware devices, and may not be able to speak privately if living with an abuser. And some elder care must be provided in person. The reduction or loss of this care could lead to neglect.

Existing abusive relationships may become more severe or lethal as mood disorders and substance abuse increase among caregivers. Additionally, during the pandemic, “there was a substantial increase in the purchase of firearms and ammunition.”

The pandemic does offer opportunities for positive change, the authors note. Providers who can contact elder patients via technology can now observe patients in their homes and can provide support for caregivers whom they may not typically see during in-person visits. Institutions and organizations are mobilizing programs and support for elders during the pandemic, including the Veterans Health Administration and local agencies on aging. The authors report that “the new challenges presented by the COVID-19 pandemic present an important opportunity to forge these new partnerships.”

The pandemic also presents opportunities for new research. The authors write, “Perhaps most understudied, and the area where new revelations could have the biggest impact, are caregiver-related risk factors. With many people experiencing caregiving stress and concern about whether loved ones’ needs will be met, caregivers may be more open to participating in research to share their experiences, even uncomfortable ones.”

 

Elder abuse prevalence in community settings: a systematic review and meta-analysis
Yongjie Yon, et al. The Lancet Global Health, February 2017

This meta-analysis of 52 international studies in 28 countries describes how prevention of elder abuse requires a better understanding of the breadth of the problem. The authors report that “elder abuse seems to affect 1 in 6 older adults worldwide, which is roughly 141 million people.” Psychological abuse was reported most often, at a 11.6% pooled prevalence estimate (pooled prevalence is a statistical technique for pooling results of many epidemiological studies), followed by financial abuse, neglect, physical abuse and sexual abuse.

The authors note that reported rates vary widely. “For example, national estimates of past-year abuse prevalence rate ranged between 2.6% in the UK and 4% in Canada to 18.4% in Israel and 29.3% in Spain,” they write. That’s due in part to a lack of consensus on how to define and measure different types of elder abuse, they note, making elder abuse a “neglected global health priority.”

The authors report that if the proportion of elder abuse cases remain constant through the aging global population, they expect elder abuse victims to number 330 million by 2050.

 

The National Elder Mistreatment Study: An 8-year longitudinal study of outcomes
Ron Acierno, et al. Journal of Elder Abuse & Neglect, 2017

This study is the 8-year follow-up to a 2011 study published in the American Journal of Public Health, “Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study.” The original study analyzed interviews (in English and Spanish) with over 5,500 respondents across the continental U.S., finding that 1 in 10 self-reported some type of elder abuse or neglect. The follow-up study attempted to contact all 752 original participants who reported mistreatment since age 60, of which they reached 183. They also interviewed 591 randomly selected non-mistreated participants from the original study.

The authors of the 2017 paper found that lack of social support increased the likelihood of all forms of abuse, while the presence of social support mitigated negative effects of abuse, particularly anxiety and poor health. Few instances of abuse were reported to authorities.

The authors describe how the 2017 follow-up study “represents the first longitudinal epidemiological study of elder mistreatment to date,” and focuses on how abuse affected victims’ health over time.

In the 2017 study, the authors look at the factors that exacerbated or mitigated the long-term effects of elder abuse. Variables of gender, income, and employment status were not as relevant as levels of social support. Further, beyond the effects on elder mistreatment, the researchers report that “low social support consistently predicted negative outcomes” in mental and physical health, even more consistently than did abuse.

“This is encouraging insofar as these findings speak directly to an actionable intervention to prevent both elder mistreatment and its negative effects,” they write.

They recommend that when family and friends can’t provide sufficient levels of social support, policies should further social support programs “in the form of education, volunteerism, or socialization” with examples including online and in-person classes, and social activities and meal programs through senior centers.

Limitations of both studies were that data was self-reported, respondents were all “community-residing” elders (not living in elder care facilities) who were “cognitively intact,” and the stigma of abuse and mental illness may have led to under-reporting. In the follow-up study a significant proportion of the original respondents were “not available for follow-up, either due to death, relocation, or inability to participate.”

 

Prevalence of elder abuse in institutional settings: systematic review and meta-analysis
Yongjie Yon, et al. The European Journal of Public Health, June 2018

This systematic review and meta-analysis, described by the authors as the “first rigorous quantitative synthesis of prevalence estimates for elder abuse in the institutions” estimates a high global prevalence of elder abuse for those living in elder care facilities during the 12 month period preceding this study.

Based on nine international studies that focused on staff-to-resident abuse in six countries, the authors report more than half of the staff interviewed for these studies admitted to elder abuse, with psychological abuse being most common, followed by physical abuse.

Among self-reporting victims, more than a third had experienced psychological abuse. Next-most common was physical abuse, followed by financial abuse, neglect and sexual abuse. While abuse in elder care facilities also occurs resident-to-resident and visitor-to-resident, the selected papers did not include these categories of data.

The main risk factors in an institutional setting are reported as “being female, presence of a cognitive impairment and disability, and being older than 74 years old,” with a “strong association between increasing dependency and elder abuse occurring” regardless of whether older adults live in an elder care facility or elsewhere.

Staff who self-reported committing abuse described stress from staff shortages and time pressure. The authors also cite staffing data from prior research in which staff who committed abuse described emotional exhaustion. In addition, higher ratios of patients to registered nurses correlated to higher levels of abuse, while “increased presence of qualified nurses” correlated with lower risk.

 

Comparing older adult and child protection policy in the United States of America
Peiyi Lu and Mack Shelley. Ageing & Society, September 2019

This study compares child and adult protection policies in the U.S., noting that by 2050 the U.S. is “expected to have 88.5 million older adults and 79.9 million children.” The authors describe an estimated prevalence of abuse as more than five times higher among older adults than children (10% vs 1.71%); however, they note that the data for elder abuse is not always available or comparable to the detailed data on child abuse.

Overall, U.S. adult protection policies were developed later and more slowly than those for children. The authors include comparisons across multiple factors including response services, post-response services, prevention services and allocation of resources and funding. “Compared to child protection policy, older adult protection policy lacked federal legislative and administrative direction, well-developed diagnosis and evaluation tools, a national data system, sufficient federal funds and a comprehensive response mechanism,” they write.

The autonomy of adults complicates some elements of adult protection. While children are viewed as a vulnerable population requiring protection, “older adults have lived independently for most of their lives and still expect to be independent in most periods of their late life. When abuse happens, especially for the self-neglect and financial exploitation cases, it is difficult to determine whether it is intentional.”

As one example, federal protection policies mandate reporting for both child and adult abuse. Child protection policies are more strictly implemented than those for adults.

“There is a trade-off,” the authors write, “between protecting older adults’ rights to be free from violence and exploitation, and maintaining their individual autonomy.” They cite other researchers who believe that a mandatory system not only interferes with the autonomy of older adults but presents ethical conflicts for physicians.

 

Financial Exploitation of Older Adults: A Population-Based Prevalence Study
Janey C. Peterson, et al. Journal of General Internal Medicine, July 2014

The authors conducted over 4,000 interviews in 2008–2009 with older adults in New York state not living in elder care facilities to identify those who had experienced financial exploitation, defined as: “improper use of funds, property or resources, coerced property transfers, denial of access to assets, fraud, false pretense, embezzlement, conspiracy, or falsifying records.” They found that almost 1 in 20 adults were victims of financial exploitation in their older years.

Older adults who self-reported financial abuse were more likely to already be economically, medically or otherwise demographically vulnerable. Poverty was an indicator for financial exploitation, possibly because individuals in poverty may be sharing homes with others. Family members are most often (57.9 % of the time) the ones financially exploiting victims, with adult children being the primary perpetrators. In addition, living with non-spousal family members put older adults at greater risk. Other perpetrators, in order of occurrence, were friends and neighbors, and home care aides.

Being Black was associated with greater relative risk of being a victim of financial abuse. People who have trouble with the tasks of daily living (e.g. managing finances, shopping, cooking and cleaning, or taking medications) were also at higher risk, as people providing assistance have access to their finances. Other factors associated with financial exploitation were “non-use of social services, need for [assisted daily living] assistance, poor self-rated health, no spouse/partner and lower age.”

The authors conclude, “In addition to robbing older adults of resources, dignity, and quality of life, victims of [financial abuse] likely cost our society dearly in the form of increased entitlement encumbrances, health care, and other costs.”

As with other studies of elder abuse, the limitations are that data was self-reported, did not include participants with dementia, and that elder people are often less likely to report abuse, leading to underreporting.

 

Risk Factors for Elder abuse and Neglect: A Review of the Literature
Jennifer E. Story. Aggression and Violent Behavior, Jan-Feb 2020

To help health care providers identify older adults at risk for abuse, this literature review provides a summary of risk factors that increase the likelihood of becoming either an abuse victim or perpetrator. Many risk factor categories are similar for perpetrators and victims. For example, “dependency” is a risk for a perpetrator, particularly if they are financially dependent on the victim, possibly leading to anger and abuse. For victims, dependency creates a vulnerability because it increases isolation and makes it harder to seek help.

The paper includes a detailed chart with the categories of factors that can increase the likelihood of becoming either a victim or a perpetrator of elder abuse: physical and mental health problems; substance abuse; dependency; problems with stress, coping and attitudes; problems with relationships, and previous experience with or witness to abuse.

 

Screening for elder mistreatment in emergency departments: current progress and recommendations for next steps
Tony Rosen, Timothy F. Platts-Mills & Terry Fulmer. Journal of Elder Abuse & Neglect, June 2020

This paper advocates for universal screening for elder abuse in emergency departments. The authors describe the “dismally low rate at which emergency providers are currently recognizing or reporting abuse” even though, compared with other older adults, victims of elder abuse seek emergency care more frequently and primary care less frequently. They note that “annual rates of ED usage by elder abuse victims are 3 times greater than non-victims.”

Current screening tools, the authors argue, are either likely to miss incidents of elder abuse or are too long and complex for the busy, chaotic emergency department environment. Patients are often screened in the emergency department for safety issues such as domestic abuse with a single vague question: “Do you feel safe at home?”

Instead, the authors propose a two-step screening process: a brief universal screen followed by a comprehensive screen for those positively identified. The initial screen would be designed to more specifically detect elder abuse, with questions such as: “Has anyone close to you harmed you?” or “Has anyone close to you failed to give you the care that you need?” Another option for the initial screen would be to design the electronic health record system to identify at-risk patients. The second-step comprehensive screening would involve a brief cognitive assessment, questions for the patient and a physical exam.

To improve emergency department detection and intervention for elder abuse they also recommend stronger ties between emergency departments and Adult Protection Services, development of multi-disciplinary response teams modeled after similar teams for child protection, and involving emergency medical service providers in initial screenings.

 

A note on guardianship abuse

There’s a relative dearth of peer-reviewed research on a specific type of abuse called guardianship abuse. This occurs when a court-appointed guardian, who is typically granted control over an elder person’s financial and medical decisions, takes advantage of their position in an abusive way. As described in Rachel Aviv’s 2017 New Yorker article “How the Elderly Lose Their Rights,” abusive guardians overtly exploit the system to steal from those they’ve been entrusted to protect. Some guardians forge relationships with hospital personnel to help them identify potential vulnerable clients and then convince courts of the need for guardianship, even when family members object. These abusive guardians have convinced physicians to prescribe sedating medications and oftentimes isolate their clients from family or friends.

The scope of the problem and devising remedies has been hindered by lack of data. Testifying before the United States Senate Special Committee on Aging in April, 2018, Dr. Pamela Teaster, professor and director of the Center for Gerontology at Virginia Tech, said that “despite estimates that some 1.5 million adults are under guardianship, in 2018, not one single state in the country can identify its people under guardianship.”

No central national database exists to identify guardians and track potential abuse. Oversight of guardians varies by state. For example, only some states require background checks and few have safeguards to protect against abuse of the system.

In 2018 the U.S. Senate’s Special Senate Committee on Aging published a report on guardianship abuse, Ensuring Trust: Strengthening State Efforts to Overhaul the Guardianship Process and Protect Older Americans. While special committees have no legislative authority, they can study issues and make legislative recommendations. Committee Chairman Sen. Susan Collins and Ranking Member Sen. Bob Casey subsequently sponsored the “Guardianship Accountability Act of 2019,” which, in its most recent action, was sent to the Committee on the Judiciary in February 2019. The bill addresses many of the 2018 report’s recommendations, including the establishment of a National Online Resource Center on Guardianship.

Guardianship may not always be the best way to assist an older adult who needs assistance. As described in the 2018 Senate Ensuring Trust report, “a full guardianship order may remove more rights than necessary and may not be the best means of providing support and protection to an individual.” One relatively new alternative to guardianship is  called “supported decision-making. This concept, which first gained traction in the disability rights community, is now proposed as an option to guardianship for some older adults, including those with dementia, and is supported by the American Bar Association. Under supported decision-making the individual relies on support from family, friends, and/or service organizations to help make their own decisions, without having to relinquish legal autonomy. These arrangements can range from informal understandings to written agreements, which are recognized as legally enforceable in nine states.

In a recent issue of Generations, Erica F. Wood, who is the assistant director of the American Bar Association Commission on Law and Aging, provides information for those working with older populations on how to avoid guardianship or how to ensure a proper guardianship. She provides a practical information on how to manage a legal process that will potentially result in the appointment of a guardian.

She suggests obtaining legal representation, and describes possible actions to take before a hearing, including checking applicable laws, assessing for less-restrictive measures than guardianship, and collecting evidence. If the court does appoint a guardian the author describes which aspects of the guardianship to investigate (e.g. who’s the guardian; how will assets be protected), and how to monitor the guardian (e.g. reviewing reports and accounts) and to legally protect the adult under guardianship, by reporting abuse or exploitation or seeking a restoration of rights.

Wood also identifies six common scenarios that can lead to legal guardianship, including a medical crisis, a family feud, discharge from hospital to an elder facility, abuse, eviction and an unpaid care bill.

 

Additional Resources

Frequently Asked Questions by Guardians about the COVID-19 Pandemic

This COVID-19 resource document for professional and family guardians was jointly created by the American Bar Association, the National Center for State Courts and the National Guardianship Association (a professional association). It includes information on accessing and communicating with older adults living in facilities during the pandemic and protecting the legal, medical and financial rights of older adults under guardianship.

 

Restoration of Rights in Adult Guardianship: Research & Recommendations
American Bar Association Commission on Law and Aging with the Virginia Tech Center for Gerontology, 2017

This report describes that an “unknown number” of adults remain under guardianship longer than necessary or could have benefitted from less-restrictive support from the outset. The report focuses on guardianship for all ages, and includes legal research on restoration of rights by state, as well as court file research to extract data on guardianship.

 

Guardianship and Supported Decision Making

Among the resources on this American Bar Association page are yearly (2013–2019) summaries of state laws and policies regarding guardianship.

 

National Center for State Courts: Center for Elders

The National Center for State Courts is an independent, nonprofit “court improvement” organization that provides research, information services, education, and consulting to professionals involved in the workings of state courts. Its Center for Elders includes information on issues likely to concern state courts regarding aging, elder abuse and guardianship.

 

Government Resources

National Center on Elder Abuse

The National Center on Elder Abuse is a program of the U.S. Administration on Aging, which includes research, statistics and data, risk factors, and the multiple definitions of “How Is Elder Abuse Defined for Research Purposes,” among other resources. They’ve recently added a page on COVID-19 with resources for identifying and reporting abuse during the pandemic.

The Center also published a 2018 guide,  “Understanding and Working with Adult Protective Services.”

 

National Center on Law & Elder Rights

As part of the U.S. Department of Health & Human Services, NCLER has tools and resources for legal assistance regarding elder rights, particularly for those with the “greatest economic and social needs.”

 

The U.S. Department of Justice Elder Justice Initiative

This site has extensive resources regarding all types categories of elder abuse, focused on the justice system, with information for victim specialists, law enforcement and prosecutors, as well as specific rural and Tribal resources.

 

Centers for Disease Control and Prevention

The CDC published the report Elder Abuse Surveillance in 2016, which provides “uniform definitions and recommended core data elements for possible use in standardizing the collection of [elder abuse] data locally and nationally.”

 

United State Government Accountability Office
Elder Abuse, Report to Congressional Requesters, 2016

Focusing on the issue of guardianship for older adults, the report is based on research with federal agencies, relevant state court officials, and nongovernmental organizations with expertise in guardianship-related issues.

 

Academic Centers that Focus on Elder Abuse

Center of Excellence on Elder Abuse & Neglect, University of California, Irvine, School of Medicine

This center’s website has extensive information across multiple disciplines, including links to national resources and tools for promising practices, along with their own research publications.

 

Center for Gerontology at Virginia Tech

The center’s Resource page includes resources for preventing abuse, as well as specific information on intimate partner violence and violence against rural older women.

 

USC Center on Elder Mistreatment

The University of Southern California’s Center on Elder Mistreatment is a multi-disciplinary academic research center specializing on issues of elder mistreatment and includes publications on their research topics. One of their key projects is on the use of multi-disciplinary teams for elder abuse interventions.

 

For more help with reporting stories related to COVID-19, please visit our archive of resources for covering the coronavirus pandemic. 

 

 

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