ceusource

Uncovering Substance Abuse and Elder Abuse

(6 hours)

(This text is provided by the Center for Substance Abuse Prevention, a division of SAMHSA, an Agency of the U.S. Department of Health & Human Services)
 

PART I: Introduction to Elder Abuse

Acknowledging the Problem

In 1985, the U.S. Surgeon General declared family violence a national epidemic.1 Family violence, which includes elder abuse, refers to violence perpetrated by parents, spouses, or other members sharing a household. Unlike violence perpetrated by strangers, family violence by its nature occurs in the context of ongoing relationships that are expected to be protective, supportive, and nurturing.2 Frequently, it is this clash between what society expects of families and how individuals actually behave that keeps elder abuse and neglect in the shadows.

We now know that much of elder abuse is perpetrated by family members, such as adult children or spouses, rather than by strangers. Recognizing the reality of elder abuse and other forms of family violence and treating it openly are the first steps to finding solutions.

Older people living in the United States have survived wars, once deadly childhood diseases, catastrophic economic declines, and a host of other events and conditions that seem inconceivable in light of modern advances. Even the youngest seniors have adapted to individual, institutional, and technological changes of immense proportions.

Yet, after years of contributing to society, many older people face a major challenge: elder abuse.

The abuse may surface as:

  • Physical bruises from a family member or caregiver
  • Shame or guilt resulting from emotional abuse
  • Neglect following an illness
  • Numerous other ways that endanger the safety and well being of older people.

The National Center on Elder Abuse

The National Center on Elder Abuse (NCEA), funded by the U.S. Administration on Aging (AoA), has comprehensive information on elder abuse, neglect, and exploitation. NCEA also hosts the Clearinghouse on Abuse and Neglect (CANE), an annotated bibliography of research, reports, and other materials. NCEA's Web site contains more in-depth information on topics in this course including other training materials, publications, directories, list serves and organizations, research reports and other resources for professionals and members of the public.

Scope of Problem

There is no definitive number quantifying how many people are affected by elder abuse, largely because of the lack of research, varying definitions of elder abuse, and underreporting. Estimates range from more than 550,000 to 2 million older people who may be victims of physical, psychological, or other forms of elder abuse and neglect every year. 3,4 These estimates do not include abuse that occurs in long-term care settings, such as nursing homes.

Because elder abuse remains a largely hidden problem, the actual number of people affected is most certainly even higher. According to the 1998 National Elder Abuse Incidence Study on abuse and neglect within domestic settings, for every one reported incident of abuse or neglect, approximately five go unreported.5

The study's design limitations show only a partial picture of the problem of elder abuse and neglect. However, even this incomplete picture demonstrates cause for concern.

Reported cases of elder abuse are increasing at an alarming rate. The National Elder Abuse Incident Study found that:

  • The number of elder abuse cases reported to Adult Protective Services (APS) agencies increased 150 percent between 1986 and 1996.
  • People 80 years or older suffered abuse and neglect in numbers much greater that their representation in the general population.6

A 2000 nationwide survey of State APS programs found that the total number of elder abuse or adult abuse reports to APS programs was 472,813 in the most recent year in which data was available. Substantiated allegations of maltreatment from 40 States which were organized by categories of abuse showed that:

  • 41.9 percent of the cases involved self-neglect
  • 20.1 percent involved physical abuse
  • 13.2 percent involved caregiver neglect or abandonment.7

Men and women from diverse socioeconomic backgrounds can be victims of elder abuse. Contrary to popular belief, most older adults live outside institutional settings. As a result, most elder abuse occurs within family settings (although older adults living in residential settings are particularly at risk for abuse and neglect).

Recognizing the Cost to Society

Elder abuse comes at tremendous health, social, and economic costs. Experts have pointed out that because many older people have fewer support systems and reserves, physical, psychological, and economic, the impact of abuse and neglect is increased. Even a single incident can cause a downward spiral in an otherwise productive, self-sufficient individual, leading to loss of independence, serious complicating illness, and even death.8

Older adults who are abused and neglected are three times more likely to die than those who are not abused. Older adults who suffer from self-neglect are nearly two times more likely to die than those who do not.9

The extent and cost of elder abuse can only escalate, given the demographics of an aging population with fewer children available as family caregivers and an ever-growing need for quality caregiving.
                                                                                                                                          The U.S. Census Bureau predicts that by 2030, the population over age 65 will more than double. Older people will make up more than 20 percent of the population.10

Uncovering the Hidden Problem

Researchers note that the state of medical knowledge and forensic science regarding elder abuse and neglect is about three decades behind the state of scientific knowledge on child abuse and about one decade behind that of domestic violence.11  To detect abuse and neglect in older people, health care and other professionals need to understand the aging process, including age-related changes and those markers indicating abuse or neglect. Unfortunately, many professionals who come into contact with older people are unlikely to recognize the signs of elder abuse.

Modern medical advancements and other improvements have made it possible for the majority of our nation's older people to remain healthy, both physically and mentally, longer than any preceding generation. By uncovering the extent of the problem and finding ways to reduce the risk of abuse for older people, everyone will be able to look toward the later years as a time for caring and support -- not as a period of neglect and abuse.

Understanding Risk Factors for Abuse

Effective responses are needed to address the causes of elder abuse, regardless of the setting and circumstance. To find effective methods of treatment and prevention, health and mental health practitioners need to understand which factors put older people at risk. Decreasing risk factors and, conversely, increasing protective factors to make older people less vulnerable are important steps in addressing the hidden problem of elder abuse.

Substance abuse is a major risk factor associated with elder abuse and neglect.

Recognizing the context of the relationships in which elder abuse occurs also is important. Elder abuse experts have found that the characteristics within the caregiver are better predictors of elder abuse than are victim characteristics. Emphasis must be put on changing the dynamics of the relationship to ensure behaviors of the perpetrator are addressed. To guard against "blaming the victim," it is important to hold abusers accountable and to address situational factors conducive to abuse.

Aging-associated vulnerabilities, such as decreased physical or mental faculties or reduced social contacts, may increase the risk of elder abuse, neglect, or self-neglect. As with other forms of violence, one of the most common factors putting older people at risk is the victim's or perpetrator's abuse of alcohol or other substances. The National Committee for the Prevention of Elder Abuse identifies substance abuse as the most frequently cited risk factor associated with elder abuse and neglect. Substance use may impact the problem in several ways:

  • An older person who abuses substances may self-neglect, endangering her/his health and well-being.
  • An older person may have physical or cognitive impairments resulting from substance abuse that make him or her dependent on others and vulnerable to exploitation.
  • Family members who abuse substances may try to gain access to an older relative's home or other resources.
  • Substances may be used to control the victim through over- or undermedication.
  • Caregivers may try to cope with the demands of providing care by using drugs or alcohol.
  • If the caregiver is a spouse, substance abuse can increase the likelihood of intimate partner violence. Problem drinking in men increases the chance of partner abuse eightfold.12

A major problem in addressing an older person's substance abuse is that the signs of alcohol abuse mirror symptoms of other diseases and chronic conditions associated with aging. Alcohol use also may mask signs of trauma (e.g., confusion may be caused by victimization, dementia, or substance abuse). Family members and many health and mental health care professionals often have difficulty identifying substance abuse among older adults, which hinders assistance.

Not all seniors who use alcohol are at risk for elder abuse. Likewise, substance abuse does not always play a part in elder abuse situations. Elder abuse is a complex problem involving a range of factors.

Cultural Factors in Elder Abuse

A myriad of attitudes and behaviors within society, the family, and individual cultures contribute to the prevailing attitudes toward older people. These beliefs and behaviors also influence how elder abuse is detected, treated, and prevented.

Cultural values, beliefs, and traditions result in different responses to family roles, responsibilities, and decisions. Culture can affect how the abuse is perpetrated as well as how it is perceived. Cultural frameworks also may influence the willingness of a particular family or community to seek help from outsiders or contact authorities.

Public awareness of the extent of elder abuse can help shape solutions reflecting sensitivity to the role of the individual, the family, the culture, and public institutions. Increased attention to the issue also can dispel misconceptions about the aging process and inspire a person to confront the difficult issues relating to individual ability and the right to self-determination.

Summary

  • Elder abuse is a major problem that often goes unreported and undetected.
  • Substance abuse is a major risk factor for elder abuse.
  • Individual, family, and community factors contribute to the problem.

PART II: Basics of Elder Abuse

The Problem of Elder Abuse and Neglect

Elder abuse, neglect, and exploitation often go unrecognized and unreported for many reasons. It is natural to question why older adults are the victims of such injustice, especially when a family member perpetrates the abuse. The reasons are complex and multifaceted. Family dynamics often play a role. Some older adults may rely on their children or other family members for their physical care. In other cases, family members may depend on the older adult for housing or financial support. These interdependencies frame the context for exploitation and abuse, which can be either unintentional or intentional:

  • Intentional abuse is a conscious and deliberate attempt to inflict physical, emotional, or financial harm, often due to a need for control
  • Unintentional abuse is an inadvertent action resulting in physical, emotional, or financial harm, usually due to ignorance, inexperience, lack of desire, or inability to provide proper care13

Elder abuse shares many characteristics with other family violence issues, such as child abuse and domestic violence, including:14

  • Victims who are vulnerable
  • Similar perpetrator characteristics
  • Effects of the abuse on the victim
  • Difficulties associated with interventions to stop the abuse
  • A growing perception of the abuse as a recognized social problem

However, elder abuse also creates its own set of problems and challenges for professionals, family members, and others concerned with the well-being of vulnerable adults.

Age-Related Vulnerabilities

The living situations of many older adults can make them vulnerable to abuse and create barriers for intervention. An abusive family member may be one of the few people who come into contact with an older victim, creating fewer opportunities for outsiders to witness the abuse and intervene. Older adults living in an institutional setting may have severe mental and physical infirmities or be isolated or estranged from family members. This can make it difficult to detect physical or emotional abuse, medication misuse, or neglect.

Medical knowledge regarding elder abuse and neglect is years behind that of child abuse and domestic violence. Many health practitioners can have difficulty distinguishing between changes related to aging and signs of abuse or neglect. Are the bruises on an older patient the result of an accident or an act of abuse? Practitioners need training in identifying suspicious-looking bruises and other signs.

Older people are subject to psychological and physical challenges inherent in aging as well as "ageist" attitudes that discount the value or ability of older adults to contribute to society.

In addition to barriers to treatment and intervention for elder abuse, barriers exist to prosecution of abusers. The death of an older person, despite signs of abuse, may not be as closely scrutinized as the death of a younger person, particularly if medical or psychological conditions related to aging are observed.15

The presence of all these age-related conditions and factors increases an older person's risk of elder abuse or neglect.

Defining Abuse and Neglect

Researchers have identified "unclear and inconsistent definitions" of elder abuse as a barrier toward increasing understanding of the problem. For example, there is some debate as to whether all forms of abuse and neglect should be considered under the same rubric. State laws vary as to whether "self-neglect" is included in the definition of elder abuse. Some researchers define the withholding of personal care as physical abuse; others define it as neglect. Abuse also can be defined in terms of actions, such as hitting, or in terms of the injuries that result, such as cuts or burns.16

Elder abuse generally has two characteristics:17

  1. An injury or deprivation has occurred to the older adult.
  2. Someone else bears responsibility for causing the injury or deprivation or failing to prevent it.

The 1998 National Elder Abuse Incidence Study includes the following types of abuse in its definition:

Physical Abuse

Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include, but is not limited to, such acts of violence as:

  • Striking (with or without an object)
  • Hitting, beating, pushing, shaking, slapping, kicking, and burning
  • Unwarranted administration of drugs and physical restraints or force-feeding
  • Physical punishment

Sexual Abuse

Sexual abuse is nonconsensual sexual contact of any kind with an elderly person. It includes, but is not limited to:

  • Unwanted touching
  • All types of sexual assault or battery such as rape, sodomy, and coerced nudity
  • Sexually explicit photographing

Emotional/Psychological Abuse

Emotional or psychological abuse involves inflicting anguish, emotional pain, or distress. Emotional or psychological abuse includes, but is not limited to:

  • Verbal assaults, insults, and threats
  • Intimidation, humiliation, and harassment
  • Physically or socially isolating an elderly person from family, friends, or regular activities
  • Giving an older person the "silent treatment"

Neglect and Abandonment

Neglect is the refusal or failure to fulfill any part of a person's obligations or duties to an elder. Neglect of an older adult may be shown by someone who has fiduciary responsibilities to care for an elder, such as a family member or guardian, or by an in-home service provider hired to provide necessary care. Neglect can be active -- a willful failure to provide care, or it can be passive -- an unintentional failure to provide care due to inadequate knowledge or illness on the part of the caregiver. Neglect typically means:

  • The refusal or failure to provide an elderly person with such life necessities as food, water, clothing, and shelter
  • The refusal or failure to provide personal hygiene, medicine, comfort, personal safety, and other essentials included as a responsibility or an agreement

Abandonment is the desertion of an elderly person by an individual who has assumed responsibility for providing care or a person with physical custody of an elder.

Financial Exploitation

Financial exploitation is the illegal or improper use of an elder's funds, property, or assets. Examples include, but are not limited to:

  • Cashing checks without authorization or permission
  • Forging an older person's signature
  • Misusing or stealing an older person's money or possessions
  • Coercing or deceiving an older person into signing a document (e.g., contracts or a will)
  • The improper use of conservatorship, guardianship, or power of attorney

Self-Neglect

Self-neglect is characterized as behaviors of an elderly person that threaten his/her own health or safety. The definition of self-neglect excludes a situation in which a mentally competent older person (who understands the consequences of his or her decisions) makes a conscious and voluntary decision to engage in acts that threaten his or her health or safety. Self-neglect generally manifests itself as:

  • An older person's refusal or failure to provide himself or herself with adequate food, water, clothing, shelter, and safety
  • Refusal or failure to maintain personal hygiene
  • Misuse of medications or mixing medications with alcohol.

NOTE: Most experts agree that self-neglect cases constitute a large percentage of elder abuse. Yet, research, practice, and policies on self-neglect are still evolving. As a result, this course will not focus on the complex aspects of elder abuse.

Other forms of elder abuse not included in the National Elder Abuse Incidence Study, but relevant to this course, include:18

Medication Abuse

Medication abuse can include:

  • Misuse of an older adult's medication and prescriptions, such as withholding medication or overmedicating
  • Theft or illegal use of an older person's medications
  • Mixing alcohol and medications

Violation of Rights

Violation of rights refers to denial of an elderly person's fundamental rights, such as:

  • Withholding information
  • Denying privacy (personal or financial)
  • Denying visitors
  • Censoring mail

If doubt exists about the capability of an older adult to make informed decisions about his or her life, he or she should be referred to an appropriate medical professional.

Who Are the Victims?

Elder abuse cuts across all ethnic backgrounds, religions, and social status, affecting older men as well as women. Although older people who are infirmed or impaired are at a higher risk, healthy older people also may be in an abusive situation or relationship. However, because this problem is largely underreported, researchers are only able to deduce patterns and profiles from the reported cases.

Unlike random acts of violence, elder abuse implies the presence of a personal relationship, usually with someone in a position of trust, such as a caregiver, lawyer, or family member who has caused injury or failed to protect the older person from harm. In these relationships of trust, the victim and perpetrator have strong emotional ties. Victims, often loyal to or economically dependent on the abuser, frequently find themselves in paradoxical situations, such as:19

  • Wanting to escape the abuse, but wanting to belong to a family
  • Wanting to continue family relationships, even though this may create opportunities for repeat victimization
  • Wanting the attention and affection that often goes hand in hand with the abuse

Characteristics of Victims

Current studies show:

  • Most elder abuse victims are female; however, this gender gap is narrowing.20
  • Those most likely to be victimized are people over 75, a rapidly growing subset of the adult population; 40 percent of reported elder abuse cases involve victims over 80.21
  • The frailest individuals with the most chronic conditions are more likely to be targeted for abuse and neglect.22
  • Recent physical decline or psychological impairment increases dependence on others for many daily needs, thus increasing the risk of abuse or neglect.23
  • Older adults who are physically or socially isolated due to a recent divorce or separation, or move to live with a family member are at higher risk for abuse and neglect. Isolation can sometimes be imposed by abusers through tactics such as screening phone calls, mail, and visitors.

Within residential long-term care settings, older adults who are abused may:

  • Be dependent on staff because of physical and cognitive limitations
  • Exhibit behavioral difficulties, such as physical aggression, due to neurological changes, memory losses due to disease, or other factors24

Who Are the Abusers?

The National Elder Abuse Incidence Study, which examined elder abuse outside institutional settings, found that in 90 percent of the reported cases in which the abuser was known, the abuser was a family member.25,26 Looking more closely, the elder abuse perpetrators were:

  • Adult child of aging parent -- 47 percent
  • Spouse -- 19 percent
  • Grandchild -- 9 percent
  • Family relative -- 9 percent
  • Sibling -- 6 percent
  • Friend, neighbor, or in-home or out-of-home service provider -- 10 percent

In institutions, a staff member, another resident, intruder, visitor, or family member may be the abuser.

Characteristics of Abusers

Understanding the characteristics of the abusers as well as the victims of abuse can help predict future episodes. Further research has assisted in developing the following profile:

  • In two-thirds of these cases, the abuser was under 60.27
  • Abusers are equally split between men and women, although men perpetrate a higher percentage of physical, emotional, and financial abuse, and females are slightly higher perpetrators of neglect.28
  • The overwhelming majority of perpetrators of abuse in reported cases were Caucasian.29 Further research has determined that behavior interpreted as abuse, and the tendency to report these incidences to the police, vary widely across cultures.30
  • Although no specific data exist on actual numbers, many abusers have a history of psychiatric illness and/or past or present problems with substance abuse.
  • Family members who are perpetrators of abuse, particularly financial exploitation, may have substance abuse, gambling or financial problems, or a sense of entitlement about an older person's assets.31
  • A caregiver's dependence on an older adult for financial or emotional support may contribute to elder abuse.32

Elder abuse researcher Holly Ramsey-Klawsnik has suggested five types of offenders:33

  1. Overwhelmed offenders enter a caregiving position expecting to provide adequate care, but the amount of care exceeds their capacities.
  2. Impaired offenders have problems that render them unqualified to provide adequate care, such as advanced age and frailty, physical and mental illnesses, and developmental disabilities.
  3. Narcissistic offenders are motivated by personal gain, not the desire to help others, and may neglect or financially exploit older adults.
  4. Domineering or bullying offenders believe their actions are justified and the victim "deserved" the abuse.
  5. Sadistic offenders derive feelings of power and importance by humiliating, terrifying, and harming others.

Where Does Elder Abuse Occur?

A common misperception about elder abuse is that the abuse occurs primarily in institutions, such as nursing homes and other long-term care facilities. Although nursing homes are not immune to elder abuse, only 4 to 5 percent of all adults over 65 live in institutions due to their care needs.

Home

Family members and friends provide nearly three-quarters of the care to impaired older adults living in the community.34 More than 22.4 million people provide unpaid help to spouses, parents, or other relatives and friends who have at least one limitation on their activities of daily living (ADLs). The economic savings of this care in terms of health and long-term care expenses have been estimated at $257 billion a year.35

Caregivers may help with ADL activities, such as bathing, dressing, getting in and out of bed and chairs, and using the toilet. Family caregivers also may provide additional help with housework, grocery shopping, preparing meals, arranging for assistance from agencies or outside service providers, and managing finances and medications.

Some older adults are cared for in their home by nonfamily members paid by the individual receiving the care, family members, private insurance, or State or Federal entitlement programs. Local organizations or agencies also may provide helpers.

Thus, the overwhelming majority of elder abuse episodes occur in the older adult's private home or the family member's home where the older adult lives. This has serious implications for health and mental health professionals who may be visiting older adults at home and providing care in the presence of the family member perpetrating the abuse.

Long-Term Care Settings

Although most elder abuse occurs in the community setting, researchers and policymakers have raised concerns about elder abuse in residential long-term care facilities. According to a Congressional report investigating physical, sexual, and verbal abuse in nursing homes in the United States, almost one of every three U.S. nursing homes was cited for an abuse violation during a 2-year period.36 The same report found that the percentage of nursing homes with abuse violations is increasing.

Only 4 to 5 percent of all adults over 65 live in nursing homes.

Elder abuse in nursing homes presents its own challenges. Family members often place their older parents or a spouse in an institution because they do not have the skills and abilities to care for their loved ones. In doing so, they try to choose a safe place, an institution well suited to provide comprehensive care. Even though the nursing home industry is well regulated to address abuse, incidences can and do occur.

Older adults living in nursing homes are vulnerable to abuse because they often depend on others as a result of chronic diseases or physical or cognitive limitations.

  • In research conducted in nursing homes, one-third of nurses and nurses' aides reported witnessing physical abuse of an older resident by facility staff within the past year.37
  • Psychological abuse (yelling at or insulting residents) by staff was observed by 80 percent of staff.38,39

Within institutional settings, one form of mistreatment of special concern is the failure to carry out a plan of treatment or care. This may involve physical or chemical restraints or using medications or isolation as punishment, for staff convenience, or as a substitute for treatment and in conflict with a physician's order.40

In general, however, elder abuse may look the same and have similar consequences, whether it occurs in a private home or a residential facility.

Why Does Elder Abuse Occur?

No one explanation exists for elder abuse. A combination of factors may contribute to the problem. In addition to characteristics of the caregiver (such as addiction to alcohol or personal problems) and the victim (such as physical or cognitive impairments), other factors can affect the degree and duration. Within the family setting, these include:

Family Dynamics

A history of violence in a family or strained family relationships, family stresses, financial pressures, and isolation may trigger abuse. Domestic violence may continue into later years.

Cultural and Societal Issues

Cultural Values

Society's preoccupation with youth can send the message that older people are not valued and elder abuse is tolerated.

Beliefs

The belief that behaviors within the home, including abuse, are "family matters" fosters an environment that tolerates elder abuse. Other belief systems may diminish the rights of some family members, especially women.

Communication Barriers

Family structure, cultural and generational values, and language barriers may affect the willingness of older people and other family members to communicate with people considered "outsiders." Health care practitioners must approach elder abuse prevention, intervention, and treatment with cultural competence. Communication must convey the universal message that abuse is illegal and the rights of individuals will be protected.

Situational Factors

Within the residential long-term care setting, researchers agree situational factors contributing to elder abuse include:

  • Staff shortages and stressful working conditions, including mandatory overtime
  • Staff burnout
  • Poor staff training on handling challenging behaviors among residents, such as aggression41

Theories of Elder Abuse

Practitioners have noted that the complex nature of elder abuse -- encompassing many forms and across various domains -- makes it difficult to construct one theory to conclusively explain the causes of elder abuse.

Furthermore, the number of constituencies -- including the medical community, judicial systems, and social service agencies -- bring widely varying perspectives regarding interventions for the victim and the perpetrator. Although expanding the group of stakeholders can only help address the problem, finding a common theoretical framework for discussion becomes more difficult.

The lack of clarity reflects an overarching uncertainty about how elder abuse fits within other theoretical frameworks related to violence. Parallels have been drawn between elder abuse and child abuse and between elder abuse and domestic violence. Many elder abuse cases fit the paradigm of family violence -- that is, acts of abuse or misuse of power that may result in harm to a family member.42 However, not all cases involve spouses or family members. Practitioners stress the need to understand the entire range of elder abuse and the underlying causes -- including self-neglect, abuse and neglect within the family, and abuse that occurs in institutional settings.                                                    

Theories about elder abuse have described many different kinds of contributing factors. These include factors in the individual, factors involving individuals in an abusive relationship, and factors in the environment and society. Some theories have withstood scrutiny better than others. Some have not been supported by current research. For example, early theories focusing on caregiver stress erroneously assumed that all victims of elder abuse were older and frail. This model has tended to overlook older victims of domestic violence who are in good physical and mental health.43 Rosalie S. Wolf, a pioneer in the field of elder abuse and former President of the National Committee for the Prevention of Elder Abuse, documented the following theories relating to elder abuse that have been proposed over the years:44

Researchers have looked at psychological factors to explain a correlation with elder abuse, such as the relationship of violent behavior and aggressive personality traits, and the proportion of abusers with mental illness and/or substance abuse problems.

This theory states an individual adult's behavior relates to the social environment of childhood and views violence as a learned behavior. For example, a child observing an adult using violence to cope with conflict may revert to the same pattern as an adult.

This early theory of elder abuse focused on the role of stress and the burden of care giving in leading to elder mistreatment and neglect. According to this theory, reducing the level of caregiving stress is one way to reduce the likelihood of elder abuse. However, experts note that the theory fails to consider key aspects of the interpersonal relationship at play.

This theory notes the importance of an individual's expectation of his or her role when interacting with an older person. The level of stress related to dependency tasks, therefore, is subjective. According to this theory, behaviors in an older person consistent with individual expectations and roles result in less conflict than in situations in which a discrepancy exists in expectations.

This theory is based on the premise of reciprocity: when individuals contribute equally, a fair exchange results. If one person becomes disabled, it upsets this balance. Power is an important aspect of this theory, suggesting abuse can occur as a response to perceived powerlessness.

This theory is based on domestic violence models and highlights the role of violence among men as a way to demonstrate power.

This theory looks at individual characteristics of abusers and their victims as well as behavior in the social context (family, work, school, and peer relationships).

This model refers to society's marginalization of older people as a cause of elder abuse.

Elder abuse theory still is evolving. Current theory focuses on the dynamics of the relationship between the perpetrator and the older adult victim and the behaviors of the perpetrator (including substance abuse) as well as risk factors affecting the victim. "There seems to be no scarcity of theories" relating to elder abuse, Dr. Wolf noted. "The critical issue with regard to elder mistreatment is the lack of rigorous scientific studies to test the theories."45

Consequences of Abuse and Neglect

Abuse, neglect, and exploitation have consequences beyond bruises and other physical manifestations. The consequences also extend to unnecessary suffering, pain, injury, loss and/or violation of human rights, and decreased quality of life.46

The aging process and chronic diseases only magnify the problem. Older people generally do not have the same physical, psychological, and economic reserves as younger people, which means even minor incidents of mistreatment can have devastating effects leading to loss of independence, illness, or even death.47

Consequences for Victims

Physical Consequences for Victims

Elder abuse may be manifested physically through bruises, fractures, malnutrition, dehydration, burns, sexually transmitted diseases, or other injuries. Older adults also may demonstrate adverse side effects due to the misuse of medications. Elder abuse also may result in lack of personal hygiene from neglect.

Emotional/Psychological Consequences for Victims

Abused older adults are more likely to experience depression than those who are not abused. Older victims also may respond to abuse with "learned helplessness" and alienation associated with a loss of coping mechanisms and self-esteem. Other psychological consequences include posttraumatic stress syndrome and feelings of guilt, shame, or fear. Victims also may deny they are being mistreated, minimize the abuse, or excuse the abuser.

Social Consequences for Victims

Virtually all forms of abuse can have social consequences, including increased isolation, visits to the emergency room, and hospital admissions. However, financial abuse and neglect also can lead to the loss of assets, the inability to maintain a home, and other limitations on quality of life and independence.

Death as a Consequence of Abuse

The first longitudinal study to examine mortality rates among older adults that included a subset of those referred to protective services for elder mistreatment concluded "reported elder mistreatment confers additional death risk." In this 1998 study, older adults seen by Adult Protective Services for mistreatment had lower survival rates (9 percent) after a 13-year follow-up period than older adults seen for self-neglect problems (17 percent) or those having no contact with Adult Protective Services (40 percent).48

Consequences for Abusers

Psychological Consequences for Abusers

Caregiver depression has been linked to the presence of abuse when a family member (but not a spouse) has Alzheimer's disease. Some psychological problems among caregivers, such as emotional distress, mental illness, or substance abuse, often may precede the violence.49

Increased Dependency

Researchers have studied the phenomenon of the adult offspring's abuse of the parent, followed by the parent's rejection, and then acceptance of the "child" back into the household in an unhealthy "web of interdependency."50 One study focused on adult children who abused their parents and suffered from emotional distress, mental illness, or alcoholism. The cycle of behavior began with excessive drinking by the adult child, followed by abusive behavior toward the parent. The abuse caused the victim to force the adult child from the household, but later, the parent accepted him or her back into the home.51

Homicide-Suicide

A large number of homicide-suicides involve older married couples, typically with the man killing his wife and then taking his own life. At least half the perpetrators are depressed or have other undiagnosed psychiatric problems. In about 30 percent of these cases, there is a history of marital problems or domestic violence in the relationship. A common characteristic of these situations is the husband's perception of an unacceptable threat to the relationship -- such as a move to a nursing home, a real or perceived decline in health, or an increase in interdependency in the relationship.52

Need for Data and Research

A lack of agreement exists regarding theories explaining the causes of elder abuse. This, with other research gaps, has resulted in practitioners emphasizing the role of risk and protective factors related to elder abuse. As the knowledge base expands on the reasons for elder abuse, policies and practices can be adapted for better intervention and prevention of this hidden problem.

Summary

  • Elder mistreatment includes physical, sexual, and emotional abuse as well as financial exploitation, neglect or abandonment, self-neglect, medication misuse, and violation of rights.
  • Elder abuse implies the presence of a relationship between the victim and the abuser.
  • Family members perpetrate most elder abuse. The typical perpetrator is an adult child or spouse in a family setting.
  • The consequences of elder abuse are devastating for the victim, the abuser, and society.

PART III: Substance Use and Other Risk Factors

Risk Factors for Abuse and Neglect

Risk factors are elements within the individual, family, community, or environment that increase the probability of an event or behavior. Understanding risk factors for elder abuse is critical to eliminating ongoing violence and preventing it in the future.

In the 1970's, elder abuse began to emerge from the shadows. Much of the literature focused on caregiver stress as a predominant risk factor. Caring for an older adult who is frail and declining in physical or cognitive abilities is demanding work that challenges the caregiver's skills and abilities.

However, current research shows a higher degree of caregiver stress does not necessarily lead to elder abuse. In fact, many caregivers under undue stress provide top-quality care to older adults.

Experts today emphasize the interpersonal dynamics between the abuser and the abused, particularly prior to the abuse. Recent studies also distinguish between caring for an individual with cognitive decline and one with other types of disabilities.53

Caregiving is not the primary cause of elder abuse, but rather, a context for interaction in which abuse can occur. The characteristics of perpetrators, their problems, pathologies, perceptions, and characteristics of care recipients may trigger abuse.54

A major report published by the National Research Council on the prevalence of elder abuse and neglect identified the following risk factors for elder abuse based on current research:

  • Living arrangements, such as cohabitation of family member and older adult or an older adult who is living alone.
  • Social isolation of abuser and victim.
  • Presence of Alzheimer's disease or related dementia.
  • Presence of mental illness or increased levels of hostility in the abuser.
  • Alcohol abuse on the part of the perpetrator.
  • Dependency of perpetrator on the victim.55

Research also shows that a history of marital violence, also known as intimate partner violence, may continue into later years.56 The American Psychological Association notes that the best predictor of future violence is often previous violence. Men who abuse their elderly partners may be continuing a pattern of abuse that has been going on throughout the life cycle.57

Sociodemographic Factors

Sociodemographic factors also can contribute to elder abuse -- not only in leading to the abuse, but in making it more difficult to diagnose. Such factors include:58

  • Stress in the family, such as separation, divorce, and financial strain
  • Decreased importance of traditional respect for older adults, including minimizing an older person's problems, needs, and basic rights
  • Increased life expectancy
  • Advances in medical technology and medications that allow people to live longer but with chronic illness

The National Center on Elder Abuse notes that older individuals may be more susceptible to financial exploitation and fraud simply because many older adults have assets in the form of savings, stocks, insurance, policies, and property.59

Health and mental health professionals and others have a responsibility to familiarize themselves with all the risk factors contributing to elder abuse, neglect, and exploitation. For this course, particular attention is focused on substance use as a risk factor.

Substance Use as a Risk Factor

Like other forms of violence, elder abuse is more likely to occur with alcohol or other substance abuse. Since the 1970s, researchers have noted the prevalence of alcohol abuse by elder abuse perpetrators.60 The National Committee for the Prevention of Elder Abuse (NCPEA) has found that alcohol abuse is the most frequently cited risk factor associated with elder abuse and neglect. The NCPEA cites a literature review conducted in Canada of 157 publications that identified substance abuse as a risk factor. Other researchers have pointed out the limitations of research findings and the need for more indepth exploration of specific forms of elder abuse, types of perpetrators, and substance abuse.61

The link between substance abuse and violence has been more closely examined in the field of domestic violence, in which drug and alcohol abuse have been shown to play a role in violence before, during, or after an incident. More than half of men who commit acts of violence against their partners also have alcohol abuse problems.62 Many studies have documented the use of alcohol among sexually abused women.63 One study of women with alcohol problems found that 40 to 74 percent reported some type of sexual abuse, such as incest or rape.64

Types of Substance Abuse-Related Elder Abuse

Substance abuse has long been associated with family violence. This can take several forms. The perpetrator of elder abuse may have the substance abuse problem, or the older adult may have the substance abuse problem. In some cases, both parties misuse alcohol, illicit drugs, or medications. In all cases, substance abuse is part of the psychodynamic in the relationship. Elder abuse associated with substance abuse can entail physical, emotional, or financial abuse, neglect, or medication misuse.

Physical Abuse

Physical abuse is more likely when the victim or perpetrator is intoxicated. The injuries often are more serious as well.65

Emotional Abuse

Emotional abuse is likely to take the form of humiliation, degradation, and threats.

Financial Abuse

Someone with an addiction will need to ensure a steady supply of drugs or alcohol and will go to any means to get it. Theft and fraud are common. Older adults with alcohol problems often have cognitive impairment, making them easy targets for financial abuse.

Medication Misuse

Medication abuse and misuses usually takes one of the following forms:66

  • Withholding necessary and/or prescribed medication
  • Overmedicating
  • Giving nonprescribed or over-the-counter medication to chemically restrain an older person

Substance Use by Elder Abuse Victims

Conventional culture views "Grandpa" taking a shot of whiskey while watching the news, or "Grandma" enjoying a glass of sherry over a bridge game as harmless indulgences. For older adults, however, such practices require a few warning labels. Health specialists have identified specific concerns that may make alcohol use dangerous to the health and well-being of an older adult.

Alcohol Misuse

An older adult's decision to use alcohol has to take into account the effects of aging, the presence of medical conditions and prescription drugs, and other factors. Too few older adults understand the connection among alcohol, drugs, and the aging process. About one in five older adults misuses alcohol and prescription drugs.67

Sometimes One Drink Is Too Many

According to research, the use and misuse of alcohol may vary among aging groups and settings. Studies indicate older men are much more likely than older women to have alcohol-related problems. However, women are more likely than men to start drinking heavily later in life.68

Older people in long-term residential care settings may have preexisting alcohol-related problems. Some nursing home communities may show particularly high rates of problem drinking if they are being used for short-term alcoholism treatment stays. Alcohol abuse may increase in retirement communities where drinking at social gatherings is the norm.

Health personnel may not easily identify a substance problem in older adults. Studies consistently find older adults are less likely to receive a primary diagnosis of alcoholism than younger adults.69 Family and friends may notice the effects of alcohol before a doctor does.

Diagnosis may be a problem in the institutional setting as well. According to a review of studies of drug use in nursing homes, "Alcoholism is consistently underdiagnosed and underreported by health care providers, especially in elderly female patients."70

Family members also may ignore substance abuse problems in an older adult or confuse signs of alcohol abuse with age-related symptoms.

Misuse of Medications

The daily regimen of the average older adult requires careful tracking of various vitamins, prescription drugs, and other supplements beneficial to long life and health. Health practitioners are increasingly concerned about health effects from these and other medications taken improperly.

Statistics support the potential for harm. Half of all hospitalizations for adverse drug reactions are older adults over 65 years old.71

Experts have identified several concerns regarding medication abuse in institutional settings.

  1. Institutionalized older adults take more medications than any other group.72
  2. While acknowledging that survey methods vary widely among studies, a 1995 review of studies on drug use in nursing homes noted psychoactive drugs were prescribed for 34 percent to 90 percent of nursing home residents.73
  3. One study of adverse drug events among residents in a Veteran's Affairs nursing home implicated four commonly prescribed medications in 72 percent of the cases.74

Half of all hospitalizations for adverse drug reactions are older adults over 65 years old.

In some cases, medications can be underused, particularly in treating depression and pain. Some physicians fail to diagnose depression in older adults, and those diagnosed may not be taking medication properly.

  • As many as 70 percent of older patients using antidepressant medications fail to take from 25 to 50 percent of their medications.75
  • One study of 60 nursing homes found only 10 percent of residents with a diagnosis of depression were treated with an antidepressant.76

Substance Use by Perpetrators of Elder Abuse

A perpetrator of elder abuse also may misuse or abuse alcohol or other drugs. At any age, drug and alcohol abuse can play a role in violence before, during, or after an incident. In the 1970s, surveys of professionals and paraprofessionals in contact with older people listed alcoholism among the major perceived correlates of elder abuse. A later comparison study from 1989, which sampled abused and nonabused elders from one site, found one-third of the abusive caregivers, but none of the nonabusing caregivers, had a drinking problem.77 

Studies have reported:

  • Problem drinking in a partner can increase the chances of intimate partner abuse eight times and can double the risk of femicide or attempted femicide by a partner.78
  • In reported cases of elder abuse by adult children reported in Wisconsin, 44 percent of the sons and 14 percent of the daughters had alcohol or drug problems. 79
  • Abusers were twice as likely as nonabusers to have drank alcoholic beverages during the last 2 years. Nearly two-thirds of abusers who used alcohol drank daily.80
  • The perpetrator was a substance abuser in 13 percent of reported cases reviewed in a study by the Illinois Department on Aging. In cases in which the abuser was chemically dependent, physical abuse occurred 33 percent of the time, and emotional abuse occurred 63 percent of the time.81

The Link Between Elder Abuse and Substance Abuse

Elder abuse and substance abuse share certain characteristics:

  • For some people, abusing drugs, alcohol, or other people becomes a way to cope with the difficulties of life or control negative feelings.
  • Family members are likely to experience feelings of shame and denial regarding elder abuse and/or chemical dependence.
  • Older adults in a relationship with a person who has a substance abuse problem may become "codependent" and take responsibility for the other person's abusive behavior or minimize its negative effects.

The association between substance abuse and family violence, however, is complex and involves the interplay of many other variables, including personality; nature of the relationship; type of substance abuse problem; degree of family conflict; environmental factors, such as poverty and social isolation; and social and cultural factors.82

The National Committee for the Prevention of Elder Abuse has noted numerous patterns that demonstrate the link between substance and elder abuse. Researchers and practitioners have observed trends when substance abuse is present in victims and perpetrators of elder abuse.

When the Victim Uses Alcohol or Other Drugs

Among older adults who abuse drugs or alcohol, researchers have observed:

  • The likelihood of self-neglect
  • The tendency to have poor relationships with family, making it difficult for the older person to obtain adequate care
  • The vulnerability to financial exploitation and other abuses resulting from dependence on caregivers who may have easy access to an older person's resources
  • The use of drugs or alcohol to cope with anxious or fearful situations or feelings
  • The practice among abusive caregivers to encourage older people to abuse alcohol or other drugs, including illegal drugs, to make them more compliant or easier to care for or exploit financially, or to create barriers to reporting or detecting elder abuse

When the Perpetrator Uses Alcohol or Other Drugs

Perpetrators of elder abuse who abuse drugs or alcohol are likely to:83

  • Perceive that older family members, acquaintances, or strangers are easy targets for financial exploitation
  • Move into an older person's home to use as a base of operation for drug use or trafficking
  • Be violent while under the influence
  • Use drugs as a coping mechanism, particularly among those who depend on the older adult financially or emotionally

Substance Abuse as a Barrier

Whether the substance abuser is the perpetrator or the victim, many barriers make it difficult for older people to seek help for the substance abuse problem and elder abuse.

Older people may consciously or unconsciously deny they:

  1. Have a substance abuse problem
  2. Are experiencing substance abuse-related elder abuse or neglect

If the family caregiver is using drugs or alcohol, the older person may deny it because of fear of retribution or abandonment.

Older adults may fail to seek help for fear it could trigger a loss of autonomy or independence. Ignorance about individual rights to self-determination may cause older adults to keep problems of abuse hidden. Older adults addicted to drugs may fear losing the lifestyle that allows them to abuse drugs.

Diagnosis Difficulties

Practitioners may fail to recognize signs of substance and/or elder abuse. Alcohol problems and diseases and complications of aging, adverse drug reactions, trauma, and elder abuse can all have similar symptoms, including:

  • Clouding of the senses
  • Disorientation
  • Recent memory loss
  • Slowed thought process
  • Muscle incoordination
  • Tremors
  • Inflammation of joints
  • Gastritis
  • Hypertension
  • Depression
  • Congestive heart disease
  • Heart arrhythmias
  • Anorexia
  • Altered response to stress
  • Malnutrition
  • Excess excretion of potassium
  • Edema

Future Trends

As the baby boomer generation gets older, experts have hypothesized that the rate of substance abuse may increase. This is due in part to the large numbers of people and to the higher rates and greater cultural acceptance of substance use among baby boomers than previous generations. The projections for the future are not encouraging. One study estimated the number of problem substance users age 50 or older will likely double during the next two decades -- from 2.5 million in 1999 to 5.0 million in 2020.84                                                                                                                                                                       If these predictions are accurate, the need for substance abuse treatment will likely increase. People in all age groups need to acknowledge the possibility that -- because of the link between substance abuse and elder abuse -- the level of elder abuse could increase as well.

Summary

  • Substance abuse is a major risk factor for elder abuse.
  • Older adults are particularly susceptible to alcohol and drug misuse or abuse and substance abuse-related violence.
  • Many barriers prevent intervention in substance abuse-related elder abuse.
  • Elder abuse and substance abuse are likely to increase because of demographic changes.

PART IV: Screening and Assessment

What Is Screening and Assessment?

The goal of screening for elder abuse is to identify who is experiencing abuse, reduce or eliminate the risk of continuing abuse, and protect the individual. Screening can actually prevent the initiation or escalation of elder abuse. Yet, recognizing mistreatment is often difficult because elder abuse is hard to diagnose. Assessment is a broad-based concept that includes diagnosis and screening.

Because of the link between substance abuse and elder abuse, cross-training can help elder abuse workers learn how to identify the problem and their role in substance abuse interventions and help substance abuse providers learn the dynamics of elder abuse. Screening for alcohol use in the context of elder abuse, and screening for elder abuse in the context of alcohol or substance abuse, creates a proactive process conducive to prevention and treatment.

Health and medical providers often are the first to observe abuse and neglect. Yet, physicians may miss or choose not to report elder abuse for many reasons.85 Self-reporting is unreliable. The stigma of abuse may make older adults, family members, and providers uncomfortable when addressing the signs and symptoms.

Although more research is needed to completely understand the risk factors and causes, routine screening is a vital first line of defense.

Who Can Screen For Elder Abuse?

Screening can be initiated or conducted by any of the following:

Health and medical professionals often are the first to recognize abuse, neglect, and exploitation. Many older adults see their doctors as trusted individuals who are willing and able to help. The American Medical Association has recognized health providers' critical role and has recommended routine screening for abuse as part of daily practice.86 Health professionals are well positioned to:

  • Conduct screening for abuse and neglect
  • Identify signs and symptoms of abuse and neglect
  • Intervene and treat problems that result from abuse and neglect

Social service workers often are called to assess the situation and screen for abuse and neglect. State Adult Protective Services agencies are responsible for screening, intervening, and treating suspected elder abuse cases in the home.

Family members, relatives, and in-home caregivers also are in a good position to identify abuse or neglect. As people age, they can become more isolated from professional or social situations, interacting less with others outside the family. A family member or relative may visit and observe the abuse by another family member or in-home caregiver, or the caregiver may observe the abuse by a family member. Although not professionally trained to conduct an assessment, individuals in these situations often take responsibility for getting help. In dangerous situations, they may have to call the police to intervene.

Other people who may be able to assess abuse include neighbors, home care nurses, family dentists, doctors, or emergency room staff. Given the various ways abuse is suspected, observed, and/or recognized, screening can occur by any of these individuals.

What Are the Indicators of Elder Abuse?

Indicators are signs or clues that abuse may have occurred. In most States, suspicion of elder abuse is sufficient cause to generate a report to Adult Protective Services. The challenge for health and social service providers is that other conditions may cause the same signs and symptoms. For example, an accidental fall can cause an injury, and some medications can cause inappropriate or unusual behavior. No single sign or clue can be conclusive of abuse. Only a pattern of physical, behavioral, and environmental indicators points to a need to question.87

Indicators of abuse may vary based on the type of abuse or the behaviors exhibited as a result of abuse.

Signs of Physical Abuse

Signs of physical abuse include:

  • Sprains, dislocations, fractures, or broken bones
  • Burns from cigarettes, appliances, or hot water
  • Abrasions on arms, legs, or torso that resemble rope or strap marks
  • Internal injuries characterized by pain, difficulty with normal functioning of organs, and bleeding from body orifices
  • History of similar injuries and/or numerous suspicious hospitalizations
  • Injuries in various stages of healing (indicating they occurred over time)

The following types of bruises are rarely accidental:88

  • Bilateral bruising to the arms (indicating the person has been shaken, grabbed, or restrained)
  • Bilateral bruising of the inner thighs (indicating sexual abuse)
  • "Wrap-around" bruises on an older person's arms, legs, or torso (indicating physical restraint)
  • Multicolored bruises (indicating they were acquired over time)
  • Untreated previous injuries
  • Signs of traumatic hair and tooth loss

Signs of Sexual Abuse

Signs of specifically sexual physical abuse include:89

  • Genital or anal pain, irritation, or bleeding
  • Bruises on external genitalia or inner thighs
  • Difficulty walking or sitting
  • Torn, stained, or bloody underclothing
  • Sexually transmitted diseases

Signs of Psychological Abuse

Indications of psychological or emotional abuse include:90

  • Significant weight loss or gain not attributed to other causes
  • Stress-related conditions, including elevated blood pressure
  • Problems sleeping
  • Depression or confusion

Signs of Financial Abuse

Financial abuse may be evidenced by:91

  • Unpaid bills, eviction notices, or notices to discontinue utilities
  • Withdrawals from bank accounts or transfers between accounts the older adult cannot explain
  • Bank statements and canceled checks no longer delivered to the older person's home
  • New "best friends"
  • Legal documents, such as powers of attorney, the older person did not understand when signing
  • Unusual activity in the older person's bank accounts, including large, unexplained withdrawals, frequent transfers, or ATM withdrawals
  • A caregiver's excessive interest in the amount of money spent on the older adult
  • Missing belongings or property
  • Suspicious signatures on checks or other documents
  • Absence of documentation about financial arrangements
  • Implausible explanations by the older adult or caregiver about the his/her finances
  • Ignorance or lack of understanding regarding financial arrangements made on his or her behalf

Signs of Neglect

The following warning signs may indicate neglect:92

  • Poor personal hygiene including soiled clothing, dirty nails and skin, matted or lice-infested hair, odors, and the presence of feces or urine
  • Unclothed or improperly clothed
  • Bedsores
  • Skin rashes
  • Dehydration, evidenced by low urinary output, dry/fragile skin, dry/sore mouth, apathy, lack of energy, and mental confusion
  • Untreated medical or mental conditions, including infections, soiled bandages, and unattended fractures
  • Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces, or commodes
  • Exacerbation of chronic diseases despite a care plan
  • Worsening dementia

Signs of Medication Misuse

Signs of medication abuse/misuse include:93

  • Drowsiness
  • Incoherence
  • Abnormal laboratory or clinical findings

Signs of Violation of Personal Rights

Indications that a person's rights may have been violated include:94

  • Forcible eviction or placement in a nursing home
  • Loss of decisionmaking power, power of attorney, or guardianship
  • Loss of privacy

Environmental Indicators

Other signs that an older person may not be receiving proper care include:95

  • Absence of necessities, including food, water, and heat
  • Inadequate living environment evidenced by lack of utilities, sufficient space, and ventilation
  • Animal or insect infestations
  • Signs of medication mismanagement, including empty or unmarked bottles or outdated prescriptions
  • Unsafe housing as a result of disrepair, faulty wiring, inadequate sanitation, substandard cleanliness, or architectural barriers

Behavioral Signs in the Suspected Victim of Abuse

The following behaviors in the older adult and the unusual manner in which the older adult and family member/caregiver interact can indicate abuse: 96, 97

  • Delays between onset of problem and seeking care
  • Repeated cancellations of appointments
  • "Doctor shopping" -- seeing many doctors or frequenting many facilities, making it difficult for health and social service professionals to observe a pattern of symptoms
  • Frequent emergency room visits
  • Vague complaints and unexplained injuries
  • Different explanations for cause of injury provided by family member or caregiver
  • Reluctance of family member or caregiver to leave older adult alone in exam room, or domination of interviews
  • Fear of family member or caregiver
  • Signs of emotional distress -- crying, acting withdrawn
  • Repeated noncompliance with treatment

Indicators of Nursing Home Abuse and Neglect

Elder abuse in nursing home settings may have different root causes (understaffing, inadequate staff training, weak management infrastructure, or poor health care delivery systems). However, the impact on its residents and their families is similar. The following are some of the signs indicating abuse in residential long-term care facilities:98

Signs of Physical Abuse

  • Open wounds, cuts, and welts
  • Dehydration
  • Malnutrition
  • Weight loss
  • Burns

Signs of Emotional Abuse

  • Sudden change in behavior
  • Emotionally upset
  • Extremely withdrawn or noncommunicative
  • Confusion or dementia

Signs of Nursing Home Negligence

  • Poor personal hygiene
  • Withholding medication or overmedicating
  • Lack of assistance with eating and drinking
  • Unsanitary conditions
  • Soiled bed, with fecal or urine odor

Remember, as with all indicators of abuse or neglect, no single sign or clue can be conclusive of abuse. It is a pattern of physical, behavioral, and environmental indicators that point to a need to question what is going on.99

How to Assess Abuse

Health and mental health professionals working with older adults are in an ideal position to screen for elder abuse, intimate partner violence, substance use, and depression. Professionals can use the following screening tools with victims and /or perpetrators.

  • Screening Victims for Elder Abuse
  • Screening Caregivers for Elder Abuse
  • Screening for Intimate Partner Violence
  • Screening for Alcohol Abuse
  • Screening for Depression

Screening Victims for Elder Abuse

The American Medical Association (AMA) recommends that every clinical setting have a protocol, such as a narrative, checklist, or some other standardized form, that enables all service providers to rapidly assess elder mistreatment. The AMA recommends providers first obtain basic demographic information about the patient's family and socioeconomic status. In addition, providers should ask general questions about the overall well-being of the older person and direct questions relating to common indicators for each type of mistreatment.

Available instruments include:

1) Screening For Elder Abuse:

            Screening for Elder Abuse and Neglect (This is not a diagnostic tool, but is a place to start the conversation with older adults).

Has anyone at home ever hurt you? Does anyone currently hurt you?

Has anyone ever touched you without your consent? Does anyone currently touch you without your consent?

Has anyone ever made you do things you did not want to do? Does anyone currently make you do things you do not want to do?

Has anyone taken anything that was yours without asking? Does anyone currently take anything that is yours without asking?

Has anyone ever scolded you or threatened you? Does someone currently scold you or threaten you?

Have you ever signed any documents that you did not understand? Have you recently signed any documents that you did not understand?

Are you afraid of anyone at home?

Are you alone a lot?

Has anyone ever failed to help you take care of yourself when you needed help? Does someone currently fail to help you take care of yourself when you need help?

Source: Adapted from Ansell, P. & Breckman, R. (1988). Elder mistreatment guidelines for health care professionals: Detection, assessment, and intervention. New York: Mount  Sinai/Victim Services Agency

2) Detection: Indications of Elder Mistreatment:

Detection: Indicators of Elder Mistreatment

Professional Observations

  • Patient appears fearful of family member
  • Patient appears reluctant to respond when questioned
  • Patient and family member provide conflicting accounts of incident
  • Family member is indifferent or angry towards patient and refuses to provide necessary assistance
  • Family member appears overly concerned with costs of medical care and services
  • Family member seeks to prevent the patient from interacting privately or speaking openly with health care provider
  • Family member appears concerned about a particular patient problem but not the patient's overall health

History

  • Pattern of physician and/or hospital hopping
  • Unexpected delay in seeking treatment
  • Series of missed medical appointments
  • Previous unexplained injuries
  • Explanation of past injuries inconsistent with medical findings
  • Previous reports of similar injuries

Risk Factors

  • Family Member Psychopathology: Presence of mental illness, mental retardation, dementia, or drug or alcohol abuse
  • Transgenerational Violence: Family history of violence
  • Dependency: Patient or family member dependent on the other for housing , finances, emotional support, or caregiving
  • Isolation:Patient does not have the opportunities to relate with people or pursue activities and interests in a manner he or she chooses
  • Stress: Recent occurrence of stressful life events such as loss of a job, moving, or death of a significant other
  • Living Arrangements: Patient and family member live together

Source: Breckman, R. S., & Adelman, R. D. (1998). Strategies for helping victims of elder mistreatment. Newbury Park, CA: SAGE Publications.

 3) Indicators of Abuse Screen - has been tested for reliability and validity and can help sensitize professionals to high-risk signals for abuse.

4) Brief Abuse Screen for the Elderly (BASE)

5) Hwalek-Senstock Elder Abuse Screening Test (HSEAST):

Hwalek-Senstock Elder Abuse Screening Test (HSEAST)

Violation of Personal Rights or Direct Abuse

  1. Does someone else make decisions about your life -- like how you should live or where you should live?
  2. Does someone in your family make you stay in bed or tell you you're sick when you know you're not?
  3. Has anyone forced you to do things you didn't want to do?
  4. Has anyone taken things that belong to you without your OK?
  5. Has anyone close to you tried to hurt or harm you recently?

Characteristics of Vulnerability

  1. Do you have anyone who spends time with you, taking you shopping or to the doctor?
  2. Are you sad or lonely often?
  3. Can you take your own medication and get around by yourself?

Potentially Abusive Situations

  1. Are you helping to support someone?
  2. Do you feel uncomfortable with anyone in your family?
  3. Do you feel that nobody wants you around?
  4. Does anyone in your family drink a lot?
  5. Do you trust most of the people in your family?
  6. Does anyone tell you that you give them too much trouble?
  7. Do you have enough privacy at home?

A response of "no" to items 6, 8, 13, and 15 and a response of "yes" to all others score in the abused direction.

Source: Nelson H.D., Nygren P., McInerney Y., Klein J. Screening Women and Elderly Adults for Family and Intimate Partner Violence: A Review of the Evidence for the U.S. Preventive Services Task Force. March 2004. Originally in Ann Intern Med 2004; 140(5)387-96. Agency for Healthcare Research and Quality, Rockville, MD.

6) The Caregiver Abuse Screen (Reis-Nahmiash CASE) - assesses abuse and the potential risk for abuse. It is intended for use with all caregivers and is useful when the care recipient is unavailable or unable to answer questions.

Screening Caregivers for Elder Abuse

In addition to screening older adults, health and mental health providers may screen caregivers who may be at risk for becoming abusive or who may be abusing an older adult. The following screening tools are available for caregivers:

1)    Interview With Caregiver -- provides suggested screening questions

Interview with Caregiver:

Thank you for waiting while I interviewed your mother. Now it's your turn. I need your help -- I am doing an (psychosocial) assessment of your mother's current functioning and situation in order to determine what services are appropriate at this time. I would like to spend some time with you and have you tell me your perception how things are here.

"Tell me what you want me to know about your mother."

"What is her medical condition? What medicine does she take?"

"What kind of care does she require?"

"How involved are you with your mother's everyday activities and care?"

"What do you expect her to do for herself?"

"What does she expect you to do for her?

Do you do those things? Are you able to do them? Have you had any difficulties? What kind?"

"Please describe how you spend a typical day."

"How do you cope with having to care for your mother all the time?"

"Do you have supports or respite care? Who and what? Are there other siblings who help?"

"What responsibilities do you have outside the home? Do you work? What are your hours? What do you do?

"Would you mind telling me what your income is?" (If this question seems touchy to the caregiver, say, "I just wondered if your family can afford the pills she needs to take." At the same time you are assessing the caregiver's degree of dependence on the elderly client's income/pensions/assets.)

"Is your mother's Social Security check directly deposited in the bank?"

"Who owns this house? Do you pay rent? Whose name is on the deed?"

"If you help your mother pay her bills, how do you do it? Is your name on her account? Do you have power of attorney? Does it have a durable clause? When did you get it?"

Save More Delicate Questions for Last

"You know those bruises on your mother's arms (head, nose, etc.). How do you suppose she got them?" (Document response verbatim. If possible, follow up with request that caregiver demonstrate how injury may have happened.)

"Your mother is suffering from malnourishment and/or dehydration," or, "Your mother seems rather undernourished and thin; how do you think she got this way?"

"Is there any reason you waited this long to seek medical care for your mother?"

"Caring for someone as impaired as your mother is, is a difficult task. Have you ever felt so frustrated with her that you pushed her a little harder than you expected? How about hitting or slapping her? What were the circumstances?" (Record verbatim.)

"Have you ever had to tie your mother to a bed or chair, or lock her in a room when you go out at night?"

"Have there been times when you've yelled at her or threatened her verbally?"

Signs of High-Risk Situation

  • Alcohol use, drug abuse, and/or mental illness in caregiver's residence.
  • Caregiver is alienated, socially isolated, has poor self-image.
  • Caregiver is young, immature, and behavior indicates own dependency needs have not been met.
  • Caregiver is forced by circumstances to care for patient who is unwanted.
  • Caregiver is unemployed, without sufficient funds, dependent on client for housing and money.
  • Caregiver's and/or client's poor health or chronic illness may exacerbate poor relationship.
  • Caregiver exhibits abnormal behavior, for example, overly hostile or frustrated, secretive, shows little concern, demonstrates poor self-control, "blames" client, exhibits exaggerated defensiveness and denial, lacks physical contact, lacks facial or eye contact with client, shows over concern regarding correcting client's bad behavior, visits patient with alcohol on breath.

Source: Breckman, R. S., & Adelman, R. D. (1998). Strategies for helping victims of elder mistreatment. Newbury Park, CA: SAGE Publications.

2)    Caregiver Self-Assessment Questionnaire -- available in English and Spanish. This questionnaire was developed by the American Medical Association in recognition that caregiving can lead to health risks, such as chronic stress, family conflicts, and failure to meet one's own personal and emotional needs. The questionnaire encourages caregivers to assess their own well-being to identify the need for a physical check-up, respite care, or support group.

3)    The Caregiver Questionnaire -- features questions to help caregivers determine whether they should consider professional help.

Screening for Intimate Partner Violence

Routine screening for violence also helps victims discuss the issue.

Intimate partner violence can occur at any age. Health and mental health practitioners working with older adults, particularly women, should routinely screen for intimate partner violence. Routine screening for violence also helps victims discuss the issue. Abused women have stated that an important aspect of a doctor's visit is the ability to talk about the abuse.

Many screening tools can help identify domestic violence. The following resources concern older adults:

1)    Domestic Abuse in Later Life

Domestic Abuse in Later Life: Tips on Working With Victims

Ask About Abuse

Lead into questions about abuse with a statement such as, "Because many of the people I work with are hurt by family members, I ask questions about relationships and abuse."

The questions may include:

  • How are things going with your spouse (or adult child)?
  • Are you getting out with your friends?
  • Are you afraid of your spouse (or other family member)?
  • Have you ever been hit, kicked, or hurt in any way by a family member? Does anyone threaten you or force you to do things you do not want to do?
  • Have you ever been forced to do sexual acts you did not wish to do? Is this going on now?

IF YES, ask for more information and ask questions such as, "How are you staying safe?"

IF NO, state that if a family member ever does hurt you or you know someone who is being hurt, there are people who can help. Feel free to contact me for information if you ever need it.

Red Flags (Things to listen to and watch for)

From a potential victim:

  • Has repeated "accidental" injuries
  • Appears isolated
  • Says or hints at being afraid
  • Considers or attempts suicide
  • Has history of alcohol or drug abuse (including prescription drugs)
  • Presents as a "difficult" patient or client
  • Has vague, chronic complaints
  • Is unable to follow through on treatment plans or medical care. May miss appointments.
  • Exhibits severe depression

From a potential abuser:

  • Is verbally abusive to staff in public, or is charming and friendly to service providers
  • Says things like "he's difficult," "she's stubborn," "he's so stupid," or "she's clumsy"
  • Attempts to convince others that the family member is incompetent or crazy
  • Is "overly attentive" to the family member
  • Controls the family member's activities
  • Refuses to allow interview or exam to take place without being present
  • Talks about the family member as if he or she is not a person

Interventions: At least do no harm

DO everything possible to give a victim a sense of hope by:

  • Believing the account of the abuse
  • Saying that abuse can happen to anyone and the victim is not to blame
  • Planning for safety or finding someone who can
  • Offering options and giving information about resources or finding someone who can
  • Allowing the victim to make decisions about next steps (returning power to the victim)
  • Keeping information shared by the victim confidential
  • Documenting the abuse with photographs, body maps, and victim statements

DO NOT do anything that further isolates, blames or discourages victims, such as:

  • Telling the victim what to do (e.g., "you should leave immediately")
  • Judging a victim who returns to an abusive relationship
  • Threatening to or ending services if a victim does not do what you want
  • Breaking confidentiality by sharing information with the abuser or other family members
  • Blaming the victim for the abuse (e.g., "if only you had tried harder or done this, the abuse might not have happened")
  • Reporting abuse to the authorities without permission from the victim (unless mandated by law). If you are a mandated reporter, tell the victim what you are doing and why. Help the victim with safety planning or find someone who can.
  • Documenting opinions (e.g., "he's drunk and obnoxious" or "she's hysterical and overreacting"). These statements are opinions and may not be accurate. However, they can be used against a victim in court.

DO NOT collude with the abuser and give him/her more power and control by:

  • Accepting excuses from the abuser and supporting the violence (e.g.," I can understand how much pressure you are under. These things happen.")
  • Blaming alcohol/drug use, stress, anger, or mental illness for the abuse. Abusers must be held accountable for their actions before they will change their behavior.
  • Minimizing the potential danger to the victim or yourself if you offer help. Arrange for appropriate security for the victim and your staff when working with a potentially lethal batterer (e.g., has made homicidal/suicidal threats or plans, owns weapons)
  • Work Collaboratively
  • To learn more about potential interventions, contact local domestic abuse and/or sexual assault, victim/witness, or adult protective services/elder abuse agencies.
  • With the victim's permission, refer to appropriate agencies for assistance.
  • Use experts in a variety of fields as case consultants on difficult cases. Bring challenging cases to a multi-disciplinary team for review. Ensure client confidentiality.

Source: National Clearinghouse on Abuse in Later Life, Wisconsin Aging and Disabilities Program. (2003). Domestic abuse in later life: Tips on working with victims. Retrieved June 24, 2004, from http://www.ncall.us/docs/Tips_Older_Victims.pdf

       2)  Danger Assessment

Danger Assessment

Several risk factors have been associated with homicides (murders) of both batterers and battered women in research conducted after the murders have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of severe battering and for you to see how many of the risk factors apply to your situation.

Using the calendar as a guide, please mark the approximate dates during the past year when you were beaten by your husband or partner. Write on that date how bad the incident was according to the following scale (if any of the descriptions for the higher number apply, use the higher number):

  • Slapping, pushing; no injuries and/or lasting pain
  • Punching, kicking; bruises, cuts, and/or continuing pain
  • Beating up; severe contusions, burns, broken bones
  • Threat to use weapon; head injury, internal injury, permanent injury
  • Use of weapon; wounds from weapon

Mark YES or NO for each of the following. ("He" refers to your husband, partner, ex-husband, ex-partner, or whoever is currently physically hurting you.)

Has the physical violence increased in frequency over the past year?

___ Yes  ___ No

Has the physical violence increased in severity over the past year and/or has a weapon or threat from a weapon ever been used?

___ Yes  ___ No

Does he ever try to choke you?

___ Yes  ___ No

Is there a gun in the house?

___ Yes  ___ No

Has he ever forced you to have sex when you did not wish to do so?

___ Yes  ___ No

Does he use drugs? By drugs, I mean "uppers" or amphetamines, speed, angel dust, cocaine, crack, street drugs, or mixtures.

___ Yes  ___ No

Does he threaten to kill you and/or do you believe he is capable of killing you?

___ Yes  ___ No

Is he drunk every day or almost every day? (In terms of quantity of alcohol.)

___ Yes  ___ No

Does he control most or all of your daily activities? For instance: Does he tell you who you can be friends with, how much money you can take with you shopping, or when you can take the car? (If he tries, but you do not let him, check here: ______.)

___ Yes  ___ No

Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him, check here: _____.)

___ Yes  ___ No

Is he violently and constantly jealous of you? (For instance, does he say, "If I can't have you, no one can.")

___ Yes  ___ No

Have you ever threatened or tried to commit suicide?

___ Yes  ___ No

Has he ever threatened or tried to commit suicide?

___ Yes  ___ No

Is he violent toward your children?

___ Yes  ___ No

Is he violent outside if the home?

___ Yes  ___ No

Total "Yes" Answers ________

Source: Campbell, J. C. (1995). Prediction of homicide of and by battered women. In J. C. Campbell (Ed.), Assessing dangerousness: Violence by sexual offenders, batterers, and child abusers. Thousand Oaks, CA: SAGE Publications.

Screening for Alcohol Abuse

Alcohol misuse and abuse can result in accidents, falls, and exacerbation of chronic medical problems. Signs of elder abuse and alcohol abuse can be similar. It is important to recognize signs of an alcohol problem and then conduct screening. Signs of an alcohol problem in older adults include:100

  • Daily use of alcohol
  • Memory loss
  • Continuation of drinking after warning to stop
  • Physical signs of chronic alcohol use, such as glazed look, flushed skin, intoxication
  • Anemia
  • Liver chemistry abnormalities
  • Frequent falls or fractures
  • New seizure activity

The following alcohol screening tools may be used by professionals working with older adults:

1)       MAST-G: Alcohol Screening for Older Adults                                                               

2)       The CAGE Questionnaire:

The CAGE Questionnaire

  1. Have you ever felt you should Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt bad or Guilty about your drinking?
  4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

Scoring: Responses on the CAGE are scored 0 for "no" and 1 for "yes" with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.

Source: Ewing, J. A. (1984). Detecting alcoholism: The CAGE Questionnaire. Journal of the American Medical Association, 252, 1905-1907.

In addition to formal screening by providers, inhome helpers, Meals-on-Wheels volunteers, caretakers, and others can informally interject screening questions into their conversations with older adults.101

Rather than asking how much or how many drinks an older adult has had, a family member or caregiver in the home can gauge the amount more accurately by observing or asking about the glass used to serve the drink. Family members and others also can informally assess whether an older person is taking prescription and over-the-counter drugs properly.

Screening for Depression

Signs of elder abuse often are difficult to separate from signs of general depression. Elder abuse, substance abuse, and depression may go hand in hand, indicating the need for screening in all three areas. Depression is a difficult diagnosis to make among all ages, but particularly with people over 65. Older adults may not know how to describe how they feel, or they may fear being labeled as weak. Families often minimize the signs of depression -- explaining the symptoms as a bad mood or a "normal part of getting old." In reality, depression can result from a range of causes, including:

  • Genetics
  • Biological changes in the brain
  • Illness
  • Adverse drug reactions
  • Stressful life events, such as the loss of a spouse, the sale of one's home, or retirement

Depression can be treated effectively with appropriate diagnosis and follow-up care. Symptoms of depression include:102

Physical Signs of Depression
  • Aches, pains, or other physical complaints
  • Marked changes in appetite
  • Change in sleep patterns
  • Fatigue
Emotional Signs of Depression
  • Pervasive sadness
  • Apathy
  • Decreased pleasure
  • Crying for no apparent reason
  • Indifference to others
Changes in Thoughts and Feelings
  • Feelings of hopelessness and helplessness
  • Feelings of worthlessness
  • Impaired concentration
  • Problems with memory
  • Indecisiveness
  • Recurrent thoughts of death and suicide

Persistent sadness and serious depression are not inherent to aging and can be treated.

Changes in Behavior
  • Loss of interest in activities previously enjoyed
  • Neglect of personal appearance
  • Withdrawal from people
  • Increased use of alcohol
  • Increased agitation
  • Talking about "the end"

If you suspect depression in an older adult, the following can be effective tools:

Barriers to Identifying Elder Abuse

It can be challenging to identify elder abuse because of the complexity and dynamics of the relationships that often are involved. The following are some of the many barriers that exist on the part of the health care provider and victim:

Provider Barriers

  • Lack of Knowledge and Training About Signs of Elder Abuse and How To Report It -- Due to the hidden nature of elder mistreatment, many medical providers lack up-to-date training on the available screening tools and protocols for diagnosis, intervention, treatment, and reporting.
  • Disbelief and Discomfort -- Health practitioners may have long-standing relationships with the victim and perpetrator. When this is the case, disbelief may overshadow the warning signs, or the discomfort in confronting the patient may be overwhelming.
  • Reluctance To Report Abuse -- Health providers may be reluctant to report abuse due to fear of the unknown, feelings of helplessness to protect the patient, or belief that reporting against a patient's wishes may destroy the doctor-patient relationship or increase the violence.
  • Ageism -- Some may believe the functional or cognitive decline due to aging is inevitable, or simply have an unfavorable attitude toward older adults.103
  • Signs of Abuse Mimic Signs of Aging or Chronic Disease -- Dehydration, confusion, or impaired mobility can be symptoms of a chronic medical condition or signs of aging. However, these same signs can indicate physical or emotional abuse or neglect. Without proper screening for elder abuse, alcohol and medication misuse, or depression, it is impossible to determine the root cause of these symptoms.

Collecting information from an older adult may require patience, tact, belief, discretion, and the ability to create trust.104 This is a challenge for health and mental health professionals who often have large caseloads, limited time, and inadequate resources.

Victim Barriers

  • Cognitive Challenges -- Older adults may seem confused, which can disguise the signs of abuse. The confusion can be the result of abuse or cognitive decline due to aging, medication side effects, or chronic disease.
  • Fear -- Victims of abuse often are reluctant to report the abuse for fear of retaliation, punishment, abandonment, or institutionalization by the abuser. This fear may cause the victim to minimize or negate the effects of the abuse.
  • Stigma -- Elder mistreatment, much like other forms of family violence, often results in feelings of shame, guilt, and denial. Some feel at fault, making it less likely for them to divulge the abuse to a health provider or mental health professional. When substance abuse is a factor in the abuse, strong denial of both problems creates challenges.
  • Cultural Factors -- Cultural beliefs, attitudes, values, and traditions can strongly influence how elder abuse is perceived and manifested and how an individual or family responds to it. Culture determines how families make decisions, how problems are defined, and how and when they seek help.105 Thus, what one family might define as abuse, another might see as a traditional family role. This complicates the problem of identifying abuse and assessing appropriate intervention.
  • Dependence -- Despite the abuse, the victim may depend on the abuser for physical care, food, and financial assistance. Particularly when a family member perpetrates the abuse, the older adult often displays loyalty to the abuser, jeopardizing his or her health and well-being.106 In situations in which the abuser depends on the older adult (e.g., an adult child with mental health or substance abuse problems) neither the victim nor the abuser is likely to report the abuse.
  • Substance Abuse and Codependence -- The substance abuser is likely to mistrust or resist any offer of assistance or outside services. A codependent family member may rationalize or minimize the problems caused by substance abuse or resulting violence, or even take responsibility for it.
  • Autonomy and Self-Determination -- In elder abuse cases, a conflict often exists between protecting a client's health and safety and preserving the client's right to autonomy and self-determination. Adults have the right to make decisions about their lives without unwanted interference.107 This can be a delicate issue with older adults with cognitive decline or those with potential indicators of abuse.
  • Isolation -- Physical and social isolation are a common problem for older adults. This isolation may increase with escalating violence, making it difficult to identify the abuse.

Summary

  • No one symptom conclusively identifies elder abuse. Rather, there is often a pattern of physical, behavioral, and environmental indicators.
  • The goal of screening for elder abuse is to identify those at risk to prevent, reduce, or stop it, and to provide victims with alternatives to protect themselves.
  • Elder abuse often is associated with substance abuse or mental health issues. Screening should include questions on substance abuse and mental health, particularly depression.
  • Identifying abuse is difficult due to numerous provider and victim barriers.

PART V: Intervention and Treatment

Intervention and Treatment Goals

The goals of intervention are to provide safety and support to victims and to work with abusers and hold them accountable. Depending on the type of abuse, the setting, and the victim's physical and mental health, the response to elder abuse will vary.

The complexity of elder abuse, particularly when alcohol or other substances is present, may require different service delivery systems and agencies. Collaboration among agencies is essential to avoid what researchers call "clashing paradigms."108 Clashing paradigms result when professionals in one field may define the goals and outcomes of a particular situation differently. Without collaboration, possible tensions between professionals focused mainly on helping the victims and others responsible for punishing the perpetrators can arise.109

Cross-training on substance abuse, domestic violence, and elder abuse will help professionals work with individuals, families, and communities to find the most appropriate strategies to stop and prevent abuse.

Collaboration among agencies is essential to avoid what researchers call "clashing paradigms."

Further complicating the situation is the fact that older adults sometimes refuse to admit abuse. Often, the older adult would rather endure continuing abuse than be separated from the family or move into an institutional setting. A survey of older victims of reported domestic abuse in New York City, for example, reported the tendency among elderly victims to be less likely to accept services if services were not made available for their abusive family members.110 These various manifestations of complex interpersonal dynamics of elder abuse demonstrate the importance of treating and addressing problems with the perpetrator as well as the victim.

Self-neglect is one of the most common forms of elder abuse and may be accompanied by mental illness or substance abuse. Yet determining an individual's cognitive ability and ability to function independently, the presence of mental health problems, and identifying possible treatment or intervention span complex health, legal, and policy areas. In fact, society has yet to fully grapple with the extent of this problem, find possible solutions, and allocate adequate resources to address the needs of self-neglecting older adults.

Intervention Basics

Primary intervention approaches include measures to protect, empower, or advocate on behalf of older adults:

  • Protection approaches are modeled after child abuse interventions and include mandatory reporting requirements.
  • Empowerment measures are those based on the domestic violence interventions.
  • Advocacy approaches originated from the aging advocacy network and stress the rights of older adults.

Intervention services may include:

  • Emergency responses, such as hotlines, and shelters.
  • Support services, such as personal care and home-delivered meals.
  • Rehabilitation services, such as counseling and substance abuse treatments.
  • Prevention, such as training in caregiving and education.

Variables to consider in determining interventions include:111

  • Urgency of the situation
  • Involvement of people other than the victim and perpetrator
  • Capabilities of the involved parties
  • Forms of abuse
  • Cooperation of involved parties

Community Responses

In light of the challenges inherent in addressing all aspects of elder abuse, elder abuse groups and adult protective service workers have found they need to coordinate their services and outreach efforts. Many communities are forming special task forces focusing on elder abuse (as well as other family violence issues). Other communities have established elder abuse networks for education, advocacy, and programming. One of the most promising approaches in the treatment and prevention of elder abuse in communities is the creation of multidisciplinary teams to review cases that involve diverse systems.112

Adult Protective Services

Most States provided few services to older adults prior to passage of the Title XX amendment to the Social Security Act in 1974. This act enabled States to create services to protect adults. Without strong Federal direction, in the 1980s, States adopted their own statutes for the creation of Adult Protective Services (APS). By 1991, 42 States had mandatory elder abuse reporting laws, and 34 provided protective services to impaired adults as well as the elderly. As of 2000, only five States did not mandate reporting.113

The APS model is based on social casework and systems approaches, aiming to provide elder abuse victims with a coordinated system of social and health services.114

The primary activities of APS agencies covered by most State statutes include:115

  • Receiving reports
  • Conducting investigations
  • Evaluating risk to clients
  • Assessing clients' capacity to agree to services
  • Developing and implementing case plans
  • Counseling clients
  • Arranging various services and benefits
  • Monitoring ongoing service delivery

An individual who suspects elder abuse should contact the local APS agency. The U.S. Administration on Aging outlines the APS process as following:116

  • The APS agency screens for potential seriousness following a report of suspected abuse. All information is confidential.
  • If the agency finds a possible violation of the State elder abuse laws, it assigns a caseworker to investigate and provide crisis intervention if warranted.
  • If elder abuse is not substantiated, most APS agencies will work with community agencies to obtain social and health services that the older person needs.

The older person has the right to refuse services offered by APS.

The APS agency provides services only if the older person agrees or has been declared incapacitated or incompetent by the court and a surrogate decisionmaker has been appointed.

The guiding principles used to shape most APS practices include:117

  • Emphasizing the client's right to self-determination
  • Using the least restrictive alternatives
  • Maintaining the family unit whenever possible
  • Promoting use of community-based services rather than institutions
  • Avoiding placement of blame
  • Presuming inadequate or inappropriate services are worse than none

States have varying definitions of abuse, neglect, or exploitation.

Although all States have employed a combination of approaches to classifying mistreatment, no two have the same set of laws. All States define abuse (and delineate categories such as physical, sexual, and emotional/psychological) and address neglect.

APS caseloads and training differ among States. States have varying definitions of abuse, neglect, or exploitation.118 In 28 States, the definition of neglect includes self-neglect, while in 5 States, self-neglect is a separate category of maltreatment.119

Besides varying definitions, the age groups protected by various State abuse legislation differ. For example, many States protect adults over age 18 who lack the mental, physical, or emotional ability to make and carry out decisions. Other States limit protection to vulnerable adults over age 60 or 65.

Reporting Elder Abuse

Regardless of variations in coverage and definition, most States have mandatory reporting procedures that require certain professionals to report suspected cases of elder abuse.

Mandatory reporting involves two categories:

  • Those requiring all citizens to report
  • Those requiring only certain categories of individuals to report

Health care professionals, long-term care facility personnel, and mental health professionals are almost uniformly required to report abuse. Some States have exempted certain professionals, such as clergy, physicians, lawyers, and therapists who work personally with the victims or perpetrators.

States differ in the type of abuse that triggers the reporting requirement. For example, in Missouri, the likelihood of suffering physical harm and the need for protective services force the reporting. Some States enable professionals to use their own judgment. Illinois specifies additional conditions on reporting. The person filing the report must believe the adult is unable to seek assistance for himself or herself, and the abuse/neglect or financial exploitation must have occurred with the previous 12 months. To date, 44 States have some form of mandatory reporting.

All States grant mandatory and voluntary reporters good faith immunity from civil and criminal liability. To be protected, a person must believe his or her report is based on the truth or what is reasonably true. Civil immunity, in most cases, protects the reporter from being sued for defamation or malicious prosecution. In States requiring mandatory reporting of elder abuse, failure to report is a misdemeanor of varying degrees.120

The National Center on Elder Abuse provides a list of State elder abuse toll-free hotlines to help vulnerable adults who may be in abuse situations.

Nursing Home Abuse

Amendments to the Older American Act require States to establish long-term care (LTC) ombudsmen programs to investigate and resolve nursing home complaints. State ombudsman programs allow residents of LTC facilities, their families, and friends to voice concerns and correct conditions affecting the quality of their care. The program also promotes policies and practices to improve the quality of life in adult care facilities. Suspected cases of elder abuse that involve an older person living in an institutional setting should be reported to the local LTC ombudsman.

Responsibilities of LTC ombudsmen include:

  • Identify, investigate, and resolve complaints made by or on behalf of residents.
  • Provide information to residents about LTC services.
  • Represent the residents' interests before Governmental agencies and seek administrative, legal, and other remedies to protect residents.
  • Analyze, comment on, and recommend changes in laws and regulations pertaining to the health, safety, welfare, and rights of residents.
  • Educate and inform consumers and the general public and facilitate public comment on laws, regulations, policies, and actions.
  • Promote the development of citizen organizations to participate in the program.
  • Provide technical support for the development of resident and family councils to protect the well-being and rights of residents.
  • Advocate for changes to improve residents' quality of life and care.

Residents have the following rights:121

  • Treatment that is courteous and respectful
  • Freedom from chemical and physical restraints
  • Control of their own finances
  • Ability to voice grievances without fear of retaliation
  • Freedom to communicate privately with any person of their choice
  • Freedom to send and receive personal mail
  • Confidentiality of personal and medical records
  • Nondiscriminatory acceptance for State and Federal assistance
  • Full disclosure before admission of their rights, services available, and all charges
  • Advanced notice of transfer or discharge

Intervention Options

The victim, abuser, or family may need various health and social services to address the underlying causes of elder abuse, stop it, and reduce the chance it will occur again. Other services treat the emotional, physical, and financial effects. Legal responses may involve prosecution and other measures. The Federal Government funds some services, while State or local entities fund others.

All services must be culturally sensitive so victims, family members, and communities will report and openly discuss elder abuse. Professionals may not be able to achieve an understanding of all the cultures they encounter. However, they can be sensitive to the cultural norms defining family roles, responsibilities, and problem solving as well as the values, past experiences, and beliefs about social service agencies or law enforcement.122

Culturally sensitive interventions may include ethnic-specific education, the use of mediators and professional translators, asking questions, and assisting with advocacy and challenging commonly held myths.123

The following services or interventions will be addressed:

  • Substance Abuse Treatment Services
  • Health and Mental Health Services
    • Counseling Services
    • Empowering Victims
    • Support Groups for Women
    • Support for Men
  • Case Management Services
  • Support Services
  • Caregiver Services
  • Crime Victim Services
  • Law Enforcement and the Courts

Substance Abuse Treatment Services

Many victims and perpetrators require intervention and treatment for substance abuse. Treatment needs among older adults may involve addressing legal or illegal substance use. However, most substance abuse problems involve alcohol and/or its combination with prescription drugs.

Most professionals who treat addictions use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to help diagnose anxiety disorders, affective disorders, psychotic disorders, and substance abuse disorders. DSM-IV defines substance abuse as "a maladaptive pattern of substance use characterized by hazardous or compulsive use or the presence of role impairment or recurrent legal problems, but without evidence of tolerance or withdrawal." Most people meeting the criteria for substance abuse eventually will meet the criteria for alcohol dependence if they continue their behavior.124

A knowledgeable, positive, determined, hopeful orientation toward alcoholism and its treatment is indispensable in persuading abused and nonabused older people to overcome denial and shame and seek help. Whether the substance abuse rests with the victim or the elder abuser, a tool for understanding the motivation to address the problem is FRAMES.

Clinically, addressing alcohol abuse in older adults is challenging, especially if it is long-standing behavior. One approach is motivational interviewing, which helps people recognize their problems and increase their motivation to change. It is useful in resolving ambivalence. It is a supportive, respectful approach -- persuasive without being coercive.

Motivational interviewing differs from other more confrontational approaches in the following ways:125

  • Deemphasizes labels such as "alcoholic" or "addict"
  • Emphasizes personal choice and responsibility for change
  • Focuses on eliciting the client's own concerns
  • Understands the clinician's role can affect the client's resistance
  • Uses reflection to meet resistance

Treatment programs for alcohol abuse can benefit older adults, even those with long-standing problems. Studies show older adults comply with treatment and recover as well as or better than younger patients.126

Even a brief intervention by a physician or other clinician -- one or more counseling sessions -- can reduce drinking to moderate levels among 10 to 30 percent of nondependent problem drinkers. This intervention may include:127

  • Motivation-for-change strategies
  • Patient education
  • Assessment and direct feedback
  • Contracting and goal setting
  • Behavioral modification techniques
  • Self-help manuals

Substance abuse treatment, for the perpetrator or the victim, also encompasses:

  • inpatient/outpatient detoxification treatment
  • inpatient rehabilitation
  • residential rehabilitation
  • outpatient services

The Medicare Web site includes an interactive database that allows older adults to access information about Medicare coverage for outpatient substance abuse treatment and other conditions on a State-by-State basis.

In cases involving substance abuse, professionals must be aware that addressing addiction issues in perpetrators will not necessarily make the violence disappear. Domestic violence experts have found that violence does not always stop or even diminish when the batterer becomes abstinent, and when it does diminish, an increase in other abusive and controlling behavior often replaces it. Professionals must treat both the substance abuse problem and the problem with violence.

Health and Mental Health Services

Health and mental health professionals play important roles in identifying abuse. They can evaluate the plausibility of the explanation victims or abusers give for injuries, screen for other problems, and treat injuries or health problems resulting from abuse.

Assessments of abusers also are necessary to determine if they pose a danger to others and need treatment.

It is important to assess receptivity to intervention before developing a plan. One study suggests receptivity to intervention can be assessed along a continuum of three stages -- from reluctance to recognition to acceptance.128

Stage 1 -- Reluctance

  • Victim has not acknowledged abuse.
  • Victim has tremendous denial, self-blame, and ambivalence.
  • Victim is extremely isolated.

Stage 2 -- Recognition

  • Victim recognizes seriousness and complexity of abuse.
  • Victim has decreased denial and self-blame, but is still ambivalent.
  • Victim recognizes need for help from outside individual.

Stage 3 -- Acceptance

  • Victim seeks a change in the situation and a reshaping of self-identity.
  • Victim has diminished self-blame.
  • Victim wants to develop a support system.

Crucial to successful intervention is assessing how receptive the older adult victim is to accepting help. Establishing rapport with the older adult and knowing how much information to give at the time are key. Mental health professionals or family physicians can provide counseling for older adult victims to help them overcome feelings of denial, isolation, guilt, and self-blame. They can provide information or referral to emergency assistance, housing alternatives, financial services, or Adult Protective Services. Suspected victims also may need information concerning access to the police, courts, the criminal justice system, and advocacy services.129

Private therapists, health maintenance organizations, or mental health clinics may provide individual, couple, family, or group counseling. In abuse cases, counseling typically focuses on:

  • Educating victims about resources and options
  • Breaking through denial and shame
  • Safety planning (planning what to do if abuse occurs)
  • Building support networks
  • Addressing codependency for substance abuse problems
  • Addressing traumatic or posttraumatic stress

In some cases, counseling may involve psychiatric treatment and medical assessment or institutionalization. Abusers who may depend on their victims for money or housing can benefit from vocational counseling or job placement programs. Educational groups teach abusers alternatives to violence.

Counseling Services

The American Psychological Association (APA) has compiled general principles for working with older adults. These principles can help psychologists and others find appropriate interventions for elder abuse and other problems. These principles include:130

  • Ascertaining the older adult's understanding of why he or she is meeting with the psychologist, his or her possible expectation for treatment, and motivation for treatment
  • Addressing the stigma commonly applied by older adults to issues concerning mental health and services
  • Educating older adults about the rationale, structure, and goals of psychological interventions, if necessary
  • Being attuned to sensory deficits and environmental factors, such as lighting, the facility's accessibility, and other possible interferences
  • Coordinating with other service providers regarding concurrent physical or social problems and ascertaining whether psychological symptoms are caused or exacerbated by underlying medical problems or medications
  • Addressing biases in the counselor regarding stereotypes about older people, including their suitability for psychological treatment

The APA also cautions that although older people share similar generational experiences, considerable diversity exists among them and differences in race, gender, sexual orientation, and socioeconomic background need to be taken into account.

Research and practices in the field of domestic violence treatment and prevention provide a wealth of information that can be applied to instances of intimate partner violence of older women. Interventions for older women are frequently based on the domestic violence approach because many cases of elder abuse fit the definition of domestic violence.

Empowering Victims

In any abusive situation, abusers take power and control from the victim by isolating them from supportive people. Mental health professionals can unwittingly perpetuate this imbalance by controlling access to information or developing goals and expectations for the client.131 Using an empowerment model, the mental health professional can offer information, options, and support.

The empowerment model features:

Empathic listening
Making time to properly document
Providing information about domestic abuse in later life
Offering options and choices
Working with domestic abuse and elder abuse specialists
Encouraging planning for safety and support
Referring to local resources

"Empowerment groups," although not common, are successful interventions in elder abuse. Led by a nurse, domestic violence advocate, or social worker in a community organization and typically consisting of female victims, empowerment groups generally meet once a week for 12 weeks. The goals of the group include:132

  • Maximizing the ability to take control of one's life
  • Making informed decisions
  • Helping oneself
Support Groups for Women

Support groups are effective in reaching older women because they validate each woman's subjective view of her reality. The groups play a crucial part in letting women know someone listens to and believes them, their lives matter, and they are not alone.133

Unfortunately, very few support groups for battered women are tailored for older adults. Some reasons may include:134

  • Ageism -- the older adult not considered as important as the younger
  • Financial limitations of programs
  • Focus on those with the greatest need -- young women with children
  • Reluctance of elder abuse victims to join self-help groups, attributed in part to generational values frowning on disclosure of private family matters in public as well as separation and divorce

Support groups are effective in reaching older women because they validate each woman's subjective view of her reality.

The first support groups for older victims originated more than 10 years ago. Aging services sponsor them; domestic violence agencies sponsor the newer groups. Most groups use open discussion of topics or a set curriculum and/or exercises. Outside speakers are mainly financial, legal, or social security experts.135 Most elder abuse programs do not address substance abuse or have concurrent groups for addiction issues. A National Domestic Abuse in Later Life Resource Directory, created by the National Clearinghouse on Abuse in Later Life, lists support groups, coalitions, and other information. Support group topics most often discussed include education about domestic violence and elder abuse, methods to deal with abuse, and how to build self-esteem.

To overcome high resistance among older adult victims, programs need to keep their intake procedure simple. Also, meeting sites must provide anonymity, accessibility, and parking. Some good choices are hospitals, shelters, and senior centers.136

The benefits to older abused women are numerous. Support groups break their isolation, enable them to make new friends, and allow them to laugh and feel joy -- something many have not experienced in many years.137

Support for Men

Research into elder abuse strategies for men (as well as minority groups) is limited -- which by no means implies a lack of need for services. For example, according to the National Elder Abuse Incidence Study, although abandonment accounted for only 3.6 percent of all victims of abuse, 62.2 percent of the victims were men.138

Many older men face challenges to their physical and mental well-being that make them vulnerable to elder abuse and neglect. Older men may avoid confronting physical or mental health problems, such as warning signs of prostate or colorectal cancer, sexual dysfunction, or depression. Military veterans and former prisoners of war from World War II, Korea, and Vietnam may have experienced post-traumatic stress syndrome. Older men may be ill equipped to handle life changes from retirement (voluntary or forced), death of a spouse, and other losses.139

Older men in either heterosexual or gay relationships face the possibility of domestic abuse. Older men are much more likely than older women to have alcohol-related problems. Most adults with long-standing drinking problems are men.140

Professionals working with older adults must be aware of socialization and cultural issues that make it difficult for older adults to discuss problems with members of the opposite sex. Older men who reside in long-term care facilities, whose staff is largely female, and experience abuse may find it particularly difficult to seek assistance.

Case Management Services

Case management provides services to seniors with multiple needs. Case managers may work for private or public agencies to provide some of the following services:

  • Assessing the older person's mental health
  • Developing "care plans"
  • Arranging needed services
  • Responding to problems or emergencies

Case managers may:141

  • Take responsibility for assessment and referral, and connect clients to needed services.
  • Focus on rehabilitation, emphasize client-centered needs assessment, and develop goals to help plan discharge.
  • Highlight the case manager's relationship to allow the professional to work directly with the client to set specific short- and long-term goals.
  • Work on empowering the client.

Support Services

Older adults and their families may also need the following help:

  • Support groups for caregivers and victims
  • Respite programs for caregivers
  • Home-delivered meal programs
  • Adult day health centers
  • Friendly visitors programs
  • Telephone reassurance programs

In some cases, elder abuse requires professional help addressing the need for alternative living arrangements for the abuser or the abused. These living arrangements may include a nursing home, a group home, separate apartments, or arrangements with family members or friends.

Caregiver Services

The Older Americans Act Amendments of 2000 established the National Family Caregiver Support Program, which calls on States to partner with local area agencies on aging, faith-based and community service providers, and Tribes to serve family caregivers' needs. The program provides:

  • Information about available services
  • Assistance in gaining access to support services
  • Individual counseling, organization of support groups, and caregiver training to assist them in making decisions and solving problems relating to their roles
  • Respite care to provide breaks from their caregiving responsibilities
  • Health promotion, such as stress reduction techniques
  • Assessments to help develop comprehensive plans for meeting needs and addressing problems
  • Support services, such as home-delivered meals, escort services, home modification services, and day programs
Holding Abusers Accountable

Abusive caregivers need to be told their behavior is abusive and unacceptable. Frequently, caregivers need training on assisting with daily living or health care. Care managers can refer the caregiver to support groups and other services for respite care.

Abusers in domestic violence situations need to understand their behavior will have consequences -- sometimes criminal. When criminal behavior has occurred, law enforcement should be called to investigate. Too often, police do not arrest an older abusive husband because they do not want to take an "old man" to jail. Adult children often are not perceived as abusers.142

Crime Victim Services

The Directory of Crime Victim Services is a Web-enabled, online resource sponsored by the U.S. Department of Justice, Office for Victims of Crime (OVC). The directory is designed to help service providers and individuals locate victim services in the United States and other countries. Victims, family members, and professionals can locate mental health services, law enforcement, shelters, and religious organizations and identify types of services organized by types of victimization.143

Law Enforcement and the Courts

The Federal Older Americans Act provides definitions of elder abuse and authorizes the use of Federal funds for the National Center on Elder Abuse. It also authorizes certain elder abuse awareness, training, and coordination activities in States and local communities, but does not fund Adult Protective Services or shelters for abused older persons.144

An increasing number of States are passing laws or taking other measures that provide explicit criminal penalties for various forms of elder abuse. Even if no specific statute or provision authorizes criminal prosecution, a jurisdiction's basic criminal laws (e.g., battery, assault, fraud, rape, and theft) can be used to prosecute someone who abuses an older person.

Although definitions vary, all States have some legal protection for victims of elder abuse within the context of domestic violence.145 Older adults who are victims of intimate partner abuse may seek civil protection orders -- legally binding orders designed to prevent partner abuse. Under these orders, the abusive partner or family member cannot contact the victim at any place he or she designates (e.g., home or work). Covered activities include contact by phone, fax, e-mail, and beeper, or through an intermediary. An individual who violates such an order may face civil contempt, misdemeanor, or felony charges. Each State has its own laws regarding civil protective orders (restraining orders or "no contact orders") and ex parte orders (applying without a lawyer present on his or her behalf).

Local domestic violence or victim assistance centers can provide information regarding specific State laws. A victim is eligible for special treatment under the law, including removal of the abuser from his or her home (ex parte and protective orders).

Each State may differ slightly in defining who is covered under specific domestic violence victim laws. But generally, the definitions include:

  • Current or ex-spouse
  • Cohabitant (who have lived in the same dwelling as a sexual partner for at least 90 days in the past 365 days)
  • Child (in 75 percent of States)
  • Person related to the abuser by blood, marriage, or adoption
  • Parent or stepparent who has lived with the abuser for 90 days within the past year
  • "Vulnerable adult" (who lacks the physical or mental capacity to ensure his or her well-being or care for daily needs)
  • Individual with a child in common with the abuser, such as a girlfriend

In most States, an abused person can file for a civil protection order with the courts or the local sheriff without having to hire an attorney. (Local domestic violence shelters or hotlines have more State-specific information).

The Older Americans Act requires each State to appoint a legal assistance developer responsible for developing and coordinating the State's legal services and elder rights programs.

Older adults or their families may seek legal advice on numerous elder abuse-related topics, such as:

  • Lawsuits to recover assets or property
  • Restraining orders
  • Guardianships (conservatorships)
  • Prosecution of offenders

Financial Crimes Against the Elderly, published by the U.S. Department of Justice, Office of Community Oriented Policing Services (COPS), provides a comprehensive overview of financial elder abuse and guidelines for customizing a law enforcement approach to address the problem locally.146

Summary

  • Victims and perpetrators can benefit from a range of intervention services, such as substance abuse treatment and mental health counseling in addition to addressing the abusive behaviors.
  • The goals of intervention are to provide safety and support to victims and work with abusers and to hold them accountable.
  • Federal and State programs investigate and address abuse in the community and residential long-term care settings.

PART VI: Preventing Elder Abuse

Bringing Elder Abuse Out in the Open

A beloved mother with a fatal disease enduring verbal abuse from an in-home care worker, an aging bachelor who lost the family's centennial farm to a scam artist, a cherished aunt whose engagement ring "disappeared" in a nursing home, a widowed mother facing domestic violence in a new marriage, a frail father in agony because of neglect -- most people can easily cite examples of elder abuse within their families or circle of friends.

The pervasive nature of elder abuse -- which involves acts as disparate as unintentional neglect, intentional cruelty, financial or psychological exploitation, and other wide-ranging behaviors -- requires a broad response involving many players and sectors. In other words, ending elder abuse is everyone's responsibility.

Fortunately, resources and programs exist, geared to potential abusers and victims in various settings, to combat the hidden problem of elder abuse. Prevention is a constantly evolving discipline that incorporates new research findings and practices to reach a range of audiences -- from the entire population to those individuals at particular risk.

Community-Wide Prevention

The severity of elder abuse cannot be overstated. However, experts caution against focusing exclusively on legal remedies against perpetrators. Prevention models that emphasize empowering victims and focusing on safety and risk reduction are just as important.

In addition to the community-wide response, professionals, family members, adult children, older adults, and others must assume a proactive role in preventing elder abuse individually. Many steps can help older adults avoid potentially abusive situations. Some involve reducing the risk of abuse and enhancing protective factors -- those assets within an individual that increase their resiliency. Some involve becoming more educated about the problem and the responsibility for intervening to stop or prevent it.

Prevention activities may include:

  • Professional Training -- designing workshops, conferences, training manuals, videos, and other materials for Adult Protective Services personnel, social workers, and other professionals
  • Coordination Among Social Service Systems and Providers -- creating elder abuse hotlines, forming coalitions and task forces, and participating in other multisector and multidisciplinary activities
  • Technical Assistance -- developing policy manuals and protocols to outline procedures for prevention screening, reporting, intervention, and treatment of elder abuse
  • Public Education -- developing elder abuse prevention education campaigns for the public, including public service announcements, posters, flyers, and videos147

Reducing Risk Factors and Enhancing Protective Factors

Health and mental health professionals can play an important role in preventing elder abuse. As a start, they can inform older adults about what they can do to avoid risk. The National Center on Elder Abuse offers the following suggestions:148

  • Take care of your health.
  • Seek professional help for drug, alcohol, and depression and urge family members to do the same.
  • Attend support groups for spouses and learn about domestic violence services.
  • Plan for your future; be aware of power of attorney or Living Will choices.
  • Stay active and connected.
  • Know your rights.

Decreasing Social Isolation

One of the greatest risk factors for abuse is social isolation.

Older adults with larger social networks and activities are at lower risk of abuse and neglect.

Many local, State, and Federal programs can help older adults remain active contributors to society. The U.S. Administration on Aging can direct families to resources on the following issues and other concerns:

One way for older adults to stay connected is through volunteering. Some activities involve helping other seniors, thereby reducing their risk of abuse. The National Senior Service Corps is a national network placing older volunteers in assignments in their communities. Programs include:

  • Foster Grandparent Program, which links senior volunteers to children who need their help.
  • The Senior Companion Program, which places its volunteers with adults needing extra assistance to live in the community, such as frail older persons.
  • The Retired and Senior Volunteer Program is one of the largest volunteer efforts in the Nation, engaging older adults in neighborhood watch programs, tutoring, renovating homes, teaching English to immigrants, assisting victims of natural disasters, and performing other activities.
  • Special Volunteer Program -- Homeland Security helps volunteers engage in activities to make their communities safer, stronger, and better prepared to respond to any kind of disaster.

Local senior citizens or community centers, religious centers, and other organizations may provide recreational and other activities to help older adults stay healthy and active.

Increasing Money Management Skills

Older people who cannot manage their finances are at risk for elder abuse. Daily money management (DMM) programs can help protect seniors from family members, acquaintances, and predators who seek to exploit them. DMM programs help older adults pay bills, prepare checks for signature, make bank deposits, and dispense cash. Public agencies as well as private, nonprofit, and for-profit organizations may offer programs and enlist the services of accountants, home care workers, bookkeepers, social workers, volunteers, private fiduciaries, nurses, and others.

DMM programs are preventive because the programs can eliminate opportunities for abuse by helping older adults arrange automatic deposits and remove their names from telemarketing lists. The National Center on Elder Abuse has created a manual on Daily Money Management programs.

Preventing Elder Abuse by Family Caregivers

Most family caregivers provide quality care for older adults. It is common for family members with limited health care training or interest to find themselves responsible for a parent or other relative. Often, family caregivers accept the responsibility, creating fulfilling roles for themselves, their parents, and their children. Caregiving is generally a long-term commitment -- the average duration of caregiving is more than 4 years.149 However, family members need resources and guidance to learn how to be good caregivers.

Professionals and other concerned adults can help family caregivers enhance their coping skills and reduce stress factors that may lead to the risk of abuse. Helping caregivers enhance their coping skills to reduce stress is important for the well-being of the caregiver and the older adult. One study found that caregivers experiencing the highest levels of stress were 63 percent more likely than noncaregivers to die within the next 4 years.150 A review of the research on caregivers of family members with dementia published by the American Psychological Association discovered caregivers had higher stress hormones, lower resistance to some viruses, and poorer health than those not providing care to older adults.151

Caregiver Survival Tips

Family caregivers can enhance their protective factors to reduce the risk that they will become abusive. The Administration on Aging's National Family Caregiver Support Program has created the following caregiver survival tips:

  • Plan ahead.
  • Learn about available resources.
  • Take 1 day at a time.
  • Develop contingency plans.
  • Accept help.
  • Make YOUR health a priority.
  • Get enough rest and eat properly.
  • Make time for leisure.
  • Be good to yourself!
  • Share your feelings with others.

A study by the National Alliance for Caregiving and the American Association of Retired Persons identified numerous coping mechanisms found to reduce caregiver stress levels. Caregivers frequently used one or more of the following:152

  • Prayer -- 73 percent
  • Talking with friends or relatives -- 61 percent
  • Reading about caregiving -- 44 percent
  • Exercise -- 41 percent
  • Seeking information on the Internet -- 33 percent

Less commonly used techniques included seeking help from a professional or spiritual counselor (27 percent) or taking medication (12 percent).

Professionals, family members, and others can help caregivers avoid faulty coping mechanisms, such as avoidance, smoking, drinking, or overeating.153

Preventing Elder Abuse by In-home Helpers

In-home helpers provide essential help to thousands of older and vulnerable adults. People employed as in-home helpers perform many tasks, some of which may save the lives of their patients. Valued in-home helpers can become integrated into the daily lives of extended families as well as the older adults they care for. For those without the option of family care, in-home helpers play a vital role in assisting with daily living and helping an older person maintain a positive and healthy outlook.

In many communities, however, the demand for in-home helpers exceeds the supply, and older adults cannot find qualified helpers. Most in-home helpers have limited training and receive low wages. These conditions make it difficult to retain workers and meet clients' needs.

To reduce the risk of abuse, the National Center on Elder Abuse recommends training for in-home helpers in the following basic areas:154

  • Introduction to Elder Abuse and Neglect, including reporting laws and procedures
  • Advice on Managing Difficult Behaviors, building on research showing the need for managing such behavior
  • Review of Professional Practices, including guidelines to clarify expectations and help agencies and workers defend themselves against unfair allegations

Experts have disagreed on the relative advantages and disadvantages of hiring methods, such as whether the older adult (or his or her family) or an agency hires the caregiver. In either case, experts have emphasized the need to hire workers without criminal backgrounds, particularly in light of the intimate nature of the work and the lack of supervision.

Federal law bars long-term care (LTC) facilities from employing workers with criminal convictions of abuse, and Medicare requires home health agencies to conduct criminal checks on home health aides.155,156 However, laws do not cover all situations in all States. State laws vary in the types of workers covered and background checks required for potential employment. Some States bar persons with certain convictions.

The U.S. Department of Justice has developed Guidelines for the Screening of Persons Working With Children, the Elderly, and Individuals with Disabilities in Need of Support to help States protect the elderly and people with disabilities from abuse.157 The guidelines include triggers to help determine the type and necessary extent of screening, based on contact between worker and client, the amount of worker supervision, and the characteristics of the consumer.

Elder care advocates also stress the need for uniform standards of training and supervision as a first step toward accountability. They also recognize the importance of expanding the pool of qualified, trustworthy workers by improving the work environment.

Preventing Elder Abuse in Long-Term Care Settings

The National Center on Elder Abuse commissioned a review of research related to preventing abuse in nursing homes and other long-term care (LTC) settings. Among the strategies identified:158

  • Assure coordination among law enforcement, regulatory, adult protection, and nursing home advocacy groups.
  • Support education and training in interpersonal caregiver skills, managing difficult resident care situations, problem solving, cultural issues affecting staff/resident relationships, conflict resolution, stress reduction techniques, information about dementia, and reporting abuse.
  • Improve work conditions for health care staff.
  • Assure compliance with Federal requirements concerning hiring of nurse aides.
  • Promote environments conducive to good care.
  • Assure strict enforcement of mandatory reporting and educate the public.
  • Improve support for nurse aides.
  • Support and strengthen resident councils.
  • Screen prospective employees for criminal backgrounds, history of substance abuse and domestic violence, ability to manage anger and stress, reactions to abusive residents, and feelings related to caring for the elderly.

What Can Individuals and Families Do?

The National Committee for the Prevention of Elder Abuse recommends concerned citizens prevent elder abuse by:159

  • Reporting cases
  • Reaching out to vulnerable neighbors, friends, or family members and providing companionship, assistance with daily activities, and information
  • Helping raise awareness about the problem
  • Volunteering at agencies
  • Advocating needed services and policies
  • Conveying the message that nobody deserves to be abused

Family members can prevent abuse by:

  • Screening or helping family members screen caregivers
  • Acquiring specific training in assistance needed by an older family member
  • Helping with tasks that need no training, such as grocery shopping, laundry, or chores
  • Getting help and support from local Area Agencies on Aging services
  • Recognizing their contributions and the contributions of other family members and friends

Family members and friends can help prevent elder abuse within LTC settings by:160

  • Visiting the facility frequently and at various times to assess the care
  • Talking to nurses, aides, director of nurses, social worker, doctor, and/or administrator about concerns
  • Contacting the LTC Ombudsman
  • Reporting suspected abuse

What Can Professionals Do?

Professionals who can actively prevent elder abuse include justice officials, law enforcement officers, social service workers, spiritual leaders, representatives of religious institutions, and community and nonprofit organizations. Many professional associations acknowledge this responsibility and provide resources addressing elder abuse and prevention.

The Role of Professionals and Concerned Citizens

Professionals and concerned citizens play a critical role in stopping elder abuse and neglect. Learn more about the roles that members of the following groups play and the resources available to them.

The National Committee for the Prevention of Elder Abuse provides a brief description of the role of professionals and concerned citizens:

Adult protective service workers are the "front line" workers in elder abuse prevention. APS programs are designated as the primary agencies in most states to receive and investigate reports.

Professionals in the field of aging often are the first to discover abuse. For that reason, they provide a critical link between victims and protective service. They can provide encouragement and support to victims as they seek help and they can play an important role in educating other professionals about the special needs of the elderly.

Health and medical professionals play a key role in the identification and treatment of abuse. The trust and respect that patients often have for their health care providers places these professionals in a key position to help.

Law enforcement personnel ensure victims' safety and hold perpetrators accountable for their actions.

Researchers provide insight in the etiology, incidence, and risk factors associated with abuse--information that is critical in designing effective interventions and services.

The media plays a fundamental role in educating the public and shaping its perceptions about abuse. It can enlist the public's help in identifying abuse, educate policy makers about the need for improved services and public policy, direct victims to needed services, and warn abusers about the consequences of their actions.

Concerned citizens can play a vital role in preventing abuse by reporting cases, helping to raise awareness about the problem, volunteering at agencies, and advocating for needed services and policy.

Source: National Center on Elder Abuse. Adapted from the National Committee for the Prevention of Elder Abuse (2003, March). Printed with permission.

What Can Communities Do?

Communities can increase awareness of elder abuse, including conducting public education teams, forming coalitions, and advocating for older people.

Multidisciplinary Teams

Many communities are developing Multidisciplinary Teams (MDTs) to identify abuse in the community and prevent future abuse. The advantage of this model is that it is attuned to specific concerns and sometimes divergent professional viewpoints involved in elder abuse.

MDTs bring together experts from the fields of aging, Adult Protective Services (APS), substance abuse, domestic violence, geriatric medicine, mental health, law enforcement, and many others to explore common areas, integrate new knowledge, develop comprehensive care plans, and promote coordination among agencies.161 They vary in what they do, how often they meet, and other specifics. For example, leadership roles may reside with APS, the local Area Agency on Aging, county attorney's office, a nonprofit group, State Attorney's office, university, or a service provider.162

MDTs can benefit professionals, clients, and communities by:163

  • Resolving difficult cases
  • Enhancing service coordination by clarifying agencies' policies, procedures, and roles
  • Identifying services gaps and breakdowns in coordination or communication
  • Enhancing professional skills and knowledge
  • Providing cross-training in substance abuse, sexual abuse, and elder abuse

A new trend among MDTs is the emergence of specialized teams in areas such as financial abuse and suspicious fatalities. Financial abuse specialist teams (FASTs) focus on home equity loan scams, the misuse of powers of attorney and trusts, confidence crimes, identity theft, investment scams, telemarketing fraud, "sweetheart scams," and homicides for profit. Team members include financial and law enforcement experts in fraud or financial crime. Because financial crime can occur with other crimes, FASTs include persons with expertise in other abuse areas.

Elder Fatality Review Teams include representatives from coroners' or medical examiners' offices; geropsychologists and other mental health professionals; local, State, or Federal law enforcement personnel and prosecutors; and other representatives. Teams work together to improve the community's ability to distinguish accidental from nonaccidental deaths. They may identify problems in the service delivery network, create policies and practices to help evaluate injuries and causes of death, and aid in prosecution of elder abuse.

For many years, hospitals have had MDTs in place to help physicians, social workers, administrators, and other medical personnel plan patient care and create protocols for handling elder abuse. New MDTs build on this model by creating community-based medical teams to help agencies that address elder abuse.

Teams work together to improve the community's ability to distinguish accidental from nonaccidental deaths.

MDTs generally conduct the following prevention activities:

  • Creating training materials for bank employees, clergy, gatekeepers, the public, law enforcement, medical students and practitioners, and mandated reporters
  • Sponsoring training events such as conferences, workshops, and "train-the-trainer programs" on fraud prevention, medical issues, APS and its role in receiving reports, fiduciary abuse, real estate fraud, and legal issues related to guardianships
  • Producing brochures, videos, Web sites, reports, public service announcements, and other materials
  • Developing interagency agreements, legislation, protocols, and referral guidelines for APS workers

Prevention Strategies

In addition to creating MDTs, communities may incorporate an integrated services approach into policies and practices. The study of elder abuse in Miami-Dade County, Florida, for example, resulted in the following recommendations directly related to collaboration:164

  • Evaluate policies and practices of elder abuse hotlines to improve responsiveness, ensure cultural competency, and evaluate effectiveness.
  • Establish a common database and exchange information among agencies.
  • Establish a community-wide system for training on elder abuse for hotline counselors; district staff; police, fire, and rescue officials; prosecutors; court personnel; health and social service workers; staff of nursing homes; and assisted living personnel in the domestic violence field. Training will include identification of risk factors (including substance abuse) and discussion of available resources and services.

The Federal Government and private sectors have funded many prevention programs addressing elder abuse that can help professionals and communities tailor prevention to their own needs.

The Administration on Aging has identified Promising Practices in the Field of Caregiving and has identified 28 National Innovations Programs and 11 Projects of National Significance.

Rosalie Wolf has developed prevention strategies that can provide a basis to help communities put an end to elder abuse.165 The strategies recognize that -- as with other forms of violence -- addressing the causes of poverty, health care inequities, and other socioeconomic factors can reduce the likelihood of elder abuse. In addition, communities can increase prevention efforts through:

  • Public awareness and professional training
  • Coalition building
  • Mental health services and family counseling
  • Alcohol and substance abuse programs
  • Assertiveness training and promotion of elder rights
  • Caregiver training and services
  • Financial management programs
  • Conflict resolution and mediation
  • Positive and productive aging

Research and awareness of elder abuse continue to evolve and develop. An important aspect of prevention involves pursuing new information, strategies, programs, collaborative efforts, and other activities to benefit society and its aging population.

Summary

  • Effective prevention requires a multifaceted, multidisciplinary approach targeting a range of audiences.
  • Older adults can take numerous steps to protect themselves against abuse, including increasing social contacts, taking care of their health, and planning for their future.
  • Programs at the Federal, State, and local levels can help families and older adults address caregiving needs and prevent abuse.
  • Multidisciplinary teams bring together experts from diverse fields to explore common areas and develop and coordinate prevention plans in the community.

YOU HAVE COMPLETED READING THE TEXT. NEXT, TAKE THE QUIZ

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28) Dunlop, B. D., Rothman, M. B., Condon, K. M., Hebert, K. S., & Martinez, I. L. (2000). Elder abuse: Risk factors and use of case data to improve policy and practice. Journal of Elder Abuse and Neglect, 12(3/4), 95-122.

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39) Hawes, C. (2003). Elder abuse in long-term care settings: What is known and what information is needed? In R. J. Bonnie & R. B. Wallace (Eds.), Elder mistreatment: Abuse, neglect, and exploitation in an aging America (pp. 446-500). Washington, DC: National Academies Press.

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77) Anetzberger, G. J., Korbin, J. E., & Austin, C. (1994). Alcoholism and elder abuse. Journal of Interpersonal Violence, 9(2), 184-193. Citing: Godkin, M. A., Wolf, R. S., & Pillemer, K. A. (1989). A case-comparison analysis of elder abuse and neglect. In R. A. Kalish & D. K. Reynolds (Eds.), Death and ethnicity: A psychocultural study (pp. 207-225). Amityville, NY: Baywood.

78) Sharps, P. W., Campbell, J., Campbell, D., Gary, F., & Webster, D. (2001). The role of alcohol use in intimate partner femicide. American Journal on Addictions, 10(2), 122-135.

79) Greenberg, J. R., McKibben, M., & Raymond, J. A. (1990). Dependent adult children and elder abuse. Journal of Elder Abuse and Neglect, 2(1/2), 73-85.

80) Anetzberger, G. J., Korbin, J. E., & Austin, C. (1994). Alcoholism and elder abuse. Journal of Interpersonal Violence, 9(2), 184-193.

81) Hwalek, M. A., Neale, A. V., Goodrich, C. S., & Quinn, K. (1996). The association of elder abuse and substance abuse in the Illinois elder abuse system. Gerontologist, 36(5), 694-700.

82) Emery, R. E. & Laumann-Billings, L. (1998). An overview of the nature, causes, and consequences of abusive family relationships: Toward differentiating maltreatment and violence [Electronic version]. American Psychologist, 53(2), 121-135.

83) National Committee for the Prevention of Elder Abuse. (2003, March). Elder abuse and substance abuse.

84) Gfroerer, J.C., Penne, M.A., Pemberton, M.R., & Folsom, Jr., R.E. (2002). The aging baby boom cohort and future prevalence of substance abuse. In S.P. Korper & C.L. Council (Eds.), Substance use by older adults: Estimates of future impact on the treatment system (DHHS Pub. No. SMA-03-3763, Analytic Series A-21). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Retrieved August 30, 2004 from http://oas.samhsa.gov/aging/chap5.htm

85) Swagerty, Jr., D. L., Takahashi, P. Y., & Evans, J. M. (1999, May 15). Elder mistreatment [Electronic version]. American Family Physician, 59(10), 2804-2808. Retrieved March 7, 2000, from http://www.aafp.org/afp/990515ap/2804.html

86) American Medical Association. (n.d.). Diagnostic and treatment guidelines on elder abuse and neglect. Retrieved May 17, 2004, from http://www.ama-assn.org/ama1/pub/upload/mm/386/elderabuse.pdf

87) National Committee for the Prevention of Elder Abuse. (2003, March). What is elder abuse? Retrieved February 25, 2004, from http://www.preventelderabuse.org/elderabuse/elderabuse.html

88) National Committee for the Prevention of Elder Abuse. (2003, March). Physical abuse. Retrieved February 25, from http://www.preventelderabuse.org/elderabuse/physical.html

89) National Committee for the Prevention of Elder Abuse. (2003, March). Sexual abuse. Retrieved October 20, 2003, from http://www.preventelderabuse.org/elderabuse/s_abuse.html

90) National Committee for the Prevention of Elder Abuse. (2003, March). Psychological abuse. Retrieved February 25, 2004, from http://www.preventelderabuse.org/elderabuse/psychological.html

91) National Committee for the Prevention of Elder Abuse. (2003, March). Financial abuse.

92) National Committee for the Prevention of Elder Abuse. (2003, March). Neglect and self-neglect. Retrieved February 25, 2004, from http://www.preventelderabuse.org/elderabuse/neglect.html

93) British Columbia Institute Against Family Violence. (1993, March). Ask the question: A resource manual on elder abuse for health care personnel, by D. S. Pay.

94) British Columbia Institute Against Family Violence. (1993, March). Ask the question: A resource manual on elder abuse for health care personnel, by D. S. Pay.

95) National Committee for the Prevention of Elder Abuse. (2003, March). Neglect and self-neglect. Retrieved February 25, 2004, from http://www.preventelderabuse.org/elderabuse/neglect.html

96) Ahmad, M., & Lachs, M. S. (2002, October). Elder abuse and neglect: What physicians can and should do. Cleveland Clinic Journal of Medicine, 69(10), 801-808.

97) Fisher, J. W., & Dyer, C. B. (2003). The hidden health menace of elder abuse. Postgraduate Medicine, 113(4), 21-26.

98) A Perfect Cause. (n.d.). Warning signs of poor care. Retrieved June 24, 2004, from http://aperfectcause.org/122602-apc-warningsignsofpoorcare.htm

99) National Committee for the Prevention of Elder Abuse. (2003, March). Neglect and self-neglect. Retrieved February 25, 2004, from http://www.preventelderabuse.org/elderabuse/neglect.html                                                          

100)              Institute on Aging. (2002, October). Ask our experts: Signs of alcoholism in the elderly. Retrieved February 18, 2004, from http://www.gioa.org/osubs/holiday.htm

101)              U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (1998). Treatment Improvement Protocol Series No. 26: Substance abuse among older adults (DHHS Publication No. [SMA] 98-3179). Rockville, MD: Author.

102)              Institute on Aging. (2002, October). Ask our experts: Symptoms of depression. Retrieved February 18, 2004, from http://www.gioa.org/osubs/holiday.htm

103)              Levine, J. M. (2003, October). Elder neglect and abuse: A primer for primary care physicians. Geriatrics, 58(10), 37-44.

104)              British Columbia Institute Against Family Violence. (1993, March). Ask the question: A resource manual on elder abuse for health care personnel, by D. S. Pay.

105)              National Committee for the Prevention of Elder Abuse. (2003, March). The role of culture in elder abuse. Retrieved May 10, 2004, from http://www.preventelderabuse org/issues/autonomy.html

106)              Cammer Paris, B. E. (1996, March 2). Violence against elderly people. Mount Sinai Journal of Medicine, 63(2), 97-100.

107)              National Committee for the Prevention of Elder Abuse. (2003, March). Autonomy and self-determination. Retrieved February 26, 2004, from http://www.preventelderabuse.org/issues/autonomy.html

108)              An interview with Charmaine Spencer and Jeff Smith. (n.d.) Retrieved June 16, 2004, from http://www.preventelderabuse.org/nexus/spencersmith.html

109)              National Research Council, Panel To Review Risk and Prevalence of Elder Abuse and Neglect. (2003). Introduction. In R. J. Bonnie & R. B. Wallace (Eds.), Elder mistreatment: Abuse, neglect, and exploitation in an aging America (pp. 9-33). Washington, DC: National Academies Press.

110)              Brownell, P., Berman, J., & Salamone, A. (1999). Mental health and criminal justice issues among perpetrators of elder abuse. Journal of Elder Abuse and Neglect, 11(4), 81-94.

111)              Anetzberger, G. J. (2000, Summer). Caregiving: Primary cause of elder abuse? Generations, 24(11), 46-51.

112)              Brandl, B., & Raymond, J. (1997). Unrecognized elder abuse victims. Journal of Case Management, 6(2), 62-68.

113)              Otto, J. M. (2000). The role of adult protective services in addressing abuse. Generations, 24(2), 33-38.

114)              Otto, J. M. (2000). The role of adult protective services in addressing abuse. Generations, 24(2), 33-38.

115)              Otto, J. M. (2000). The role of adult protective services in addressing abuse. Generations, 24(2), 33-38.

116)              U.S. Department of Health and Human Services, Administration on Aging. (2004, March). Elder abuse prevention [Fact sheet]. Retrieved January 9, 2004, from http://www.aoa.gov/press/fact/alpha/fact_elder_abuse.asp

117)              Otto, J. M. (2000). The role of adult protective services in addressing abuse. Generations, 24(2), 33-38.

118)              Roby, J. L., & Sullivan, R. (2000). Adult protection service laws: A comparison of state statutes from definition to case closure. Journal of Elder Abuse and Neglect, 12(3/4), 17-51.

119)              Roby, J. L., & Sullivan, R. (2000). Adult protection service laws: A comparison of state statutes from definition to case closure. Journal of Elder Abuse and Neglect, 12(3/4), 17-51.

120)              Roby, J. L., & Sullivan, R. (2000). Adult protection service laws: A comparison of state statutes from definition to case closure. Journal of Elder Abuse and Neglect, 12(3/4), 17-51.

121)              U.S. Department of Health and Human Services, Administration on Aging. (2004, April 6). Elder rights and resources. Retrieved May 10, 2004, from http://www.aoa.gov./eldfam/Elder_Rights/LTC/LTC.asp

122)              National Committee for the Prevention of Elder Abuse. (2003, March). The role of culture in elder abuse. Retrieved May 10, 2004, from http://www.preventelderabuse org/issues/autonomy.html

123)              DuPage County, Illinois, Human Services -- Senior Services. (2004, January 22). Elder abuse and neglect: Current research and practice [PowerPoint presentation]. Author.

124)              Ball, S. A., & Kosten, T.A. (1998). Diagnostic classification systems. In A.W. Graham, T. K. Schultz, & B. B. Wilford (Eds.), Principles of addiction medicine (2nd ed.). Chevy Chase, MD: American Society of Addiction Medicine.

125)              Barry, K.L., Oslin, D., & Blow, F.C. (2001). Prevention and management of alcohol problems in older adults. New York: Springer Publishing.

126)              Ibid

127)              Ibid

128)              Breckman, R. S., & Adelman, R. D. (1998). Strategies for helping victims of elder mistreatment. Newbury Park, CA: SAGE Publications.

129)              Breckman, R. S., & Adelman, R. D. (1998). Strategies for helping victims of elder mistreatment. Newbury Park, CA: SAGE Publications.

130)              Abeles, N. Cooley, S., Deitch, I. M., Harper, M. S., Hinrichsen, G., Lopez, M. A., & Molinari, V. A. (1998). What practitioners should know about working with older adults. Washington, DC: American Psychological Association. Retrieved June 24, 2004, from http://www.apa.org/pi/aging/practitioners/homepage.html

131)              Brandl, B., & Raymond, J. (1997). Unrecognized elder abuse victims. Journal of Case Management, 6(2), 62-68.

132)              Wolf, R. S. (2001). Support groups for older victims of domestic violence. Journal of Women and Aging, 13(4), 71-83.

133)              Vinton, L. (1999). Working with abused older women from a feminist perspective. In J. D. Garner (Ed.), Fundamentals of feminist gerontology (pp. 85-100). Binghamton, NY: Haworth Press, Inc.

134)              Wolf, R. S. (2001). Support groups for older victims of domestic violence. Journal of Women and Aging, 13(4), 71-83.

135)              Wolf, R. S. (2001). Support groups for older victims of domestic violence. Journal of Women and Aging, 13(4), 71-83.

136)              Wolf, R. S. (2001). Support groups for older victims of domestic violence. Journal of Women and Aging, 13(4), 71-83.

137)              Brandl, B., Hebert, M., Rozwadowski, J., & Spangler, D. (2003). Feeling safe, feeling strong: Support groups for older abused women. Violence Against Women, 9(12), 1490-1503.

138)              National Center on Elder Abuse at the American Public Human Services Association in collaboration with Westat. (1998, September). National Elder Abuse Incidence Study: Final report. Retrieved May 17, 2004, from http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/AbuseReport_Full.pdf

139)              Kosberg, J. I., & Mangum, W. P. (2002). The invisibility of older men in gerontology. Gerontology and Geriatrics Education, 22(4), 27-42.

140)              Ibid

141)              Vladescu, D., Eveleigh, K., Ploeg, J., & Patterson, C. (1999). An evaluation of a client-centered case management program for elder abuse. Journal of Elder Abuse and Neglect, 11(4), 5-22.

142)              Brandl, B., & Raymond, J. (1997). Unrecognized elder abuse victims. Journal of Case Management, 6(2), 62-68.

143)              Johnson, K. D. (2003). Financial crimes against the elderly (Problem-Oriented Guides for Police, Problem-Specific Guides Series No. 20). Washington, DC: U.S. Department of Justice, Office of Community Oriented Policing Services.

144)              National Center on Elder Abuse. (2003, May 20). Elder abuse law background information. Retrieved March 11, 2004, from http://www.elderabusecenter.org/default.cfm?p=backgrounder.cfm

145)              National Council of Juvenile and Family Court Judges (2002). Model code on domestic and family violence. Reno, Nevada: Conrad Hilton Foundation.

146)              Johnson, K. D. (2003). Financial crimes against the elderly (Problem-Oriented Guides for Police, Problem-Specific Guides Series No. 20). Washington, DC: U.S. Department of Justice, Office of Community Oriented Policing Services

147)              U.S. Department of Health and Human Services, Administration on Aging. (2004, March). Elder abuse prevention [Fact sheet]. Retrieved January 9, 2004, from http://www.aoa.gov/press/fact/alpha/fact_elder_abuse.asp

148)              National Center on Elder Abuse. (2003, May 20). Frequently asked questions. Retrieved February 24, 2004, from http://www.elderabusecenter.org/default.cfm?p=faqs.cfm

149)              National Alliance for Caregiving and AARP. (2004, April). Caregiving in the U.S. Retrieved June 24, 2004, from http://research.aarp.org/il/us_caregiving.pdf

150)              Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality. Journal of the American Medical Association, 282(23), 2215-2219.

151)              American Psychological Association. (2003, November 9). Caregivers of family members with dementia experience more health problems than noncaregivers, according to first time review of the research [Press release]. Retrieved February 25, 2004, from http://www.apa.org/releases/caregiving.html

152)              National Alliance for Caregiving and AARP. (2004, April). Caregiving in the U.S. Retrieved June 24, 2004, from http://research.aarp.org/il/us_caregiving.pdf

153)              Nerenberg, L. (2002, March). Preventing elder abuse by family caregivers. Washington, DC: National Center on Elder Abuse.

154)              National Center on Elder Abuse. (2002, March). Developing training programs on elder abuse prevention for in-home helpers: Issues and guidelines. Washington, DC: Author.

155)              Hawes, C. (2003). Elder abuse in long-term care settings: What is known and what information is needed? In R. J. Bonnie & R. B. Wallace (Eds.), Elder mistreatment: Abuse, neglect, and exploitation in an aging America (pp. 446-500). Washington, DC: National Academies Press.

156)              U.S. Department of Justice, Office of Justice Programs. (1998, March). Guidelines for the screening of persons working with children, the elderly, and individuals with disabilities in need of support.

157)              U.S. Department of Justice, Office of Justice Programs. (1998, March). Guidelines for the screening of persons working with children, the elderly, and individuals with disabilities in need of support.

158)              National Center on Elder Abuse. (2003, October 22). Nursing home abuse. Retrieved October 20, 2003, from http://www.elderabusecenter.org/default.cfm?p=nursinghomeabuse.cfm

159)              National Committee for the Prevention of Elder Abuse. (n.d.). Concerned citizens. Retrieved May 7, 2004, from http://www.preventelderabuse.org/professionals/concerned.html

160)              What you can do: Quick remedies for nursing home abuse and neglect. (n.d.). Retrieved March 22, 2004, from http://www.nursinghomealert.com/stoppingabuse/whatyoucando.html

161)              Nerenberg, L. (2000). Developing a service response to elder abuse. Generations, 24(2), 86-92.

162)              Teaster, P. B., & Nerenberg, L. (n.d.). A national look at elder abuse multidisciplinary teams. Retrieved June 24, 2004, from www.elderabusecenter.org/pdf/publication/mdt.pdf

163)              Teaster, P. B., & Nerenberg, L. (n.d.). A national look at elder abuse multidisciplinary teams. Retrieved June 24, 2004, from www.elderabusecenter.org/pdf/publication/mdt.pdf

164)              Dunlop, B. D., Rothman, M. B., Condon, K. M., Hebert, K. S., & Martinez, I. L. (2000). Elder abuse: Risk factors and use of case data to improve policy and practice. Journal of Elder Abuse and Neglect, 12(3/4), 95-122.

165)              Wolf: Elder Abuse Primary Prevention Strategies (from conference presentation handout materials).