Elder Abuse - A Public Health Perspective

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Elder Abuse
A Public Health
Perspective
Randal W. Summers
Allan M. Hoffman
Editors
NATIONAL INSTITUTES dp HEALTH

NIH LIBRARY
AUG 1 0 2007
BLDG 10, 10 CENTER DR
BETHESDA, MD. 20892*1150
American Public Health Association

Washington, DC
American Public Health Association
8001 Street, NW
Washington, DC 20001-3710
www.apha.org
© 2006 by the American Public Health Association
Library of Congress Cataloging-in-Publication Data

Elder abuse : a public health perspective / Randal W. Summers, Allan M. Hoffman, editors,
p. cm.
ISBN-13: 978-0-87553-050-5
ISBN-10: 0-87553-050-8
1. Older people—Abuse of—United States. 2. Abused elderly—United States. 3. Older
people—Health and hygene—United States. 4. Medical policy—United States. I. Summers, Randal
W., 1946- II. Hoffman, Allan M. (Allan Michael) III. American Public Health Association.
HV6626.3.E436 2006
362.6—dc22 2006048365
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ISBN-13: 978-0-875530-50-5
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1500 07/06
This book is dedicated to our families, with love.
To Randal's family:
Tully, Vivian, Quinn, Aja, Joan, Jamie, Kim, Dawn, Alycia, Anita, and Norman
To Allan's family:
Andrew, Emily, Elijah, Tim, and Annie
We would also like to express our sincere gratitude to all the contributing authors.
Table of Contents
Foreword
John C. Rother, AARP.vii
Acknowledgments.ix
1. Introduction
Randal Summers and Allan Hoffman . 1
2. Elder Abuse: Definition and Scope of the Problem
Tina Fryling, Randal Summers, and Allan Hoffman .5
3. Care Pathway Model and Guidelines for Health Care Professionals
Tom Miller . 19
4. Caregiver Stress and Nurse/Health Therapist Identification of Abuse
in the Home
Denise Bender .35
5. Understanding Elder Abuse in Minority Populations
Paulina Ruf.51
6. Intemational/Cultural Perspectives on Elder Abuse
Mary Newman .65
7. The Moral and Ethical Implications of Elder Abuse
Dawn Oetjen and Reid Oetjen .77
8. Hidden Within the Golden Years:
Intimate Partner Violence and Abuse Against Older Women
Bonnie Fisher, Therese Zink, and Saundra Regan.97
9. Verbal Abuse and Communication Neglect in the Elderly
Helen Sorenson .117
10. Sexual Violence Against Elderly Women
Joanne Ardovini .'. 131
11. Helping Victims: Social Services, Health Care Interventions in Elder
Abuse
James Anderson and Nancie J. Mangels .139
12. Conclusion
Randal Summers and Allan Hoffman . 167
Index. 169
About the Editors and Contributors. 175
Elder Abuse: A Public Health Perspective vii
Foreword
Protection from elder abuse is a key concern for AARP members and the
public at large. The risk of physical and emotional harm, in the community
and in residential care settings, grows as the number of people living into
advanced old age increases. This detailed volume addresses a key issue fac¬
ing older people and, indeed, our entire society.
Widely used estimates of elder abuse prevalence and incidence show that
the problem is huge and growing. The National Elder Abuse Incidence Study
estimated that abuse, neglect, and self-neglect of adults age 60 and over in
domestic settings totaled approximately 551,000, and that about 84 percent of
elder abuse incidents go unreported. The 2004 Survey of State Adult Protective
Services (APS) found that in 2003, APS agencies received over 565,000 reports
of suspected elder and vulnerable adult abuse. This study found almost a 20
percent increase in reports of abuse and neglect and a 15.6 increase in substan¬
tiated cases in the four years since the last APS survey was conducted in 2000.
These figures are alarming—and should be a wake up call for us all.
Elder abuse is a public health problem as well as a criminal justice issue.
It is an epidemic that affects the community as a whole. This volume helps
identify some of the key barriers to understanding and addressing elder mis¬
treatment, including widely varying definitions of elder abuse, a dearth of
reliable data on its frequency, a lack of consensus about causes and effective
preventive measures, a national policy void, and a lack of funds for both
research and implementation of interventions. As a leading elder abuse
researcher recently stated, "Although elder abuse has had its share of horror
stories, exposes, and Congressional hearings, somehow they have failed to
capture the attention required for significant research funding, federal policy,
or comprehensive programming." (Anetzberger, 2005)
The key question is posed by Randal Summers and Allan Hoffman in this
volume's introduction: How can we deal with this problem? Consistent with
the public health ethic of "maximum health for all" and "assuring the condi¬
tions in which people can be healthy," the appropriate and humane starting
point is to improve detection of abuse and provide quality care for victims. The
development of standards of care and standardized models of evaluation and
intervention and the recognition of "at risk" factors and indicators of abuse by
health care professionals is critical to achieving this goal. Further, the volume's
attention to the key role of home care nurses and physical therapists in identi¬
fying, reporting, and perhaps most importantly, preventing abusive situations
through timely intervention and assistance is significant. Older persons living
in the community may be at greater risk of abuse than those living in institu¬
tional settings where initiatives such as ombudsman programs and staff moni¬
toring and training requirements provide a formal framework for safeguarding
residents. Through sharing of information, routine examinations, and interac¬
tions with patients, families, and caregivers, home care nurses and physical
therapists can perform a similar function in community settings.
viii Summers and Hoffman
Another significant theme in the volume is the importance of understand¬

ing cultural factors, particularly as they relate to encouraging the identifica¬
tion of abusive situations involving older minority persons and the likelihood
that older minority victims and their families will seek and/or accept assis¬
tance and services. Recent research indicates that older minority populations
may be over-represented among victims of elder abuse. Given that the pro¬
portion of older minorities is expected to increase significantly in the future,
it is critical to achieve a greater understanding of the impacts of cultural fac¬
tors in order to respond effectively to the needs of an increasingly diverse
older population. I second the call by Summers and Hoffman to foster collab¬
orative efforts, particularly with the criminal and civil justice systems, and to
enhance public awareness of elder abuse.
AARP is also striving to find answers to the question about how we deal
with the problem of elder abuse. We are working to advance the field in a
number of areas including communications and programmatic initiatives,
research, and adoption and implementation of improved federal and state
policies. The general public and too many policy makers are unaware that
elder abuse is a serious problem. AARP recognizes that we must do more to
bring this issue to light. In Maryland, for example, the AARP State Office co¬
sponsored a series of town hall style meetings with the State Attorney General
that focused on preventing elder abuse and neglect. These meetings were
cited by the Attorney General as a strong and positive influence in raising the
awareness of elder abuse to the citizens of Maryland. Our California State
Office worked with the Attorney General in that state to create an awareness
manual entitled "A Citizen's Guide to Preventing and Reporting Elder
Abuse." This manual includes information on the warning signs of abuse and
how to file a report. AARP has also initiated the first national evaluation of
guardianship monitoring practices in over fifteen years. This research
includes a national survey of experts with frontline experience—judges, court
managers, guardians, elder law attorneys, and legal representatives of people
with disabilities; site visits; and the development of best practices.
The challenges we face in preventing and stopping the abuse of our
most vulnerable citizens are formidable. However, the knowledge, empathy,
and commitment to improve the current situation expressed by the authors in
this volume are a ray a hope. On behalf of the AARP, I commend the efforts of
the American Public Health Association to strengthen the ability of the
nation's public health professionals to deal effectively with the problem of
elder abuse. This book serves as a guidebook to help us all face up to this
urgent challenge.
John C. Rother
Director, Policy and Strategy
AARP
Elder Abuse: A Public Health Perspective xx
Acknowledgements
We wish to give special thanks to all the dedicated professionals at APHA who made this pub¬
lication possible:
Nancy Persily and Burton W. Wilcke, Jr., Publications Board; Ellen Meyer, Director of
Publications; Terence Mulligan, Book Production Manager; Tara Kelly, Desktop Publishing
Manager; and Irma Rodenhuis, Graphic Designer.
1
INTRODUCTION
Randal Summers and Allan Hoffman
Toward the end of World War II, our young service men and women
began coming home. This gave rise to an unprecedented population explosion
now referred to as the "baby boom." Here we are, decades later, and this seg¬
ment of the population is now entering the retirement years. On the whole,
life has been "good" for most and there is an expectation that the retirement
years will be a peaceful continuation. The surviving parents of "baby-
boomers" are now in their 70s and 80s. Many of these elders occupy a place
somewhere along a continuum from independence (living in their own home)
to dependence (living with family, or in a senior's retirement home or long
term care facility). One might conclude that this is the natural "cycle of life."
However, there is another side to this "cycle of life"—a side, which reflects all
that is ignoble in our society.
It is comprised of interpersonal behavior (intentional or unintentional)
that causes pain and suffering (physical or emotional) for people in the "sun¬
set" years of their lives. This Public Health enemy is called elder abuse. The
title of this work makes reference to the Public Health perspective. Although
the study of elder abuse tends to focus on the victimization of individuals, it
truly is a study of the health of our communities.
HOW PREVALENT IS ELDER ABUSE?
It is difficult to accurately portray the extent of this problem because so

much of it is "hidden" or unreported. In a study supported by the National
Center on Elder Abuse (1998) it was estimated there were between 820,000
and 1,860,000 abused elderly in our country in 1996. Statistical data on report¬
ed cases of abuse indicated a 150% increase from 1986 to 1996. Today, there are
well over 2 million cases per year suggesting that this is not only a serious
problem but it is one of epidemic proportions. What is even more disconcert¬
ing is the increasing trend predicted with the "graying of America."
WHAT ARE THE UNDERLYING CAUSES?
Because there are many dynamics associated with elder abuse the under¬
lying causes may vary. For example, the causes may differ for domestic abuse
compared to the abuse occurring in nursing homes or other institutions. The
causes may vary in domestic settings depending on the type of abuse, the sex
of victims, the sex of perpetrators and whether the abuser is the elder's spouse
1
Summers and Hoffman
2
or adult child or a non-family caregiver. A number of chapters, in this volume

address 'cause' and Chapter 7 identifies the values and ethical principles that
are violated in elder abuse.
IS ELDER ABUSE UNIQUE TO PARTICULAR GROUPS IN OUR

SOCIETY OR TO THE U.S. AS A COUNTRY?
Although the majority of research studies about elder abuse focus on the
white, non-Hispanic population, there is ample evidence to suggest that elder
abuse knows no racial or ethnic boundaries. Chapter 5 in this volume address¬
es elder abuse in minority populations (Latinos, African Americans, Asian,
Pacific Islanders and Native Americans). The chapter addresses the cultural
implications involved in the definition of elder abuse and the appropriate
interventions.
Elder abuse is not confined to the U.S. Chapter 6 explores elder abuse in
other countries and maintains that although there are many challenges asso¬
ciated with international investigation, many nations are acknowledging that
elder abuse is a significant social problem. The World Health Organization
plays an important role by increasing awareness of elder abuse and recom¬
mending the public health sector's active involvement.
HOW CAN WE DEAL WITH THIS PROBLEM?
Elder abuse poses a serious public health issue today and is expected to
intensify in the future. Like many social problems, it requires a Public Health
approach that draws on scientific knowledge which spans a broad range of
professional disciplines. It is an approach that focuses on the definition of the
problem, the identification of risk factors and the development, implementa¬
tion, and monitoring of prevention and intervention strategies/programs.
The framework of chapters in this volume supports this Public Health
approach. For example, reference is made to the definition and prevalence of
elder abuse and in particular the data associated with specific types of abuse.
Other chapters identify risk factors and point out that we still have much to
learn about the problem (profiling perpetrators, for example).
Chapter 5 explores the cultural dynamics and implications with an
increasingly diverse population. Certain chapters focus on prevention and
intervention. Chapter 3, for example suggests the use of a specific model with
Care Pathway Guidelines for professionals. Chapter 11 highlights Social
Services and Health Care interventions in elder abuse. In addition, various
resources are listed for individuals seeking help and for professionals who
want to know where to find more information.
The purpose of this book is consistent with the fundamental Public Health
goal of "maximum health for all" (Schneider, 2000). Our intent is to provide
greater insight into the many facets of the problem and provide meaningful
support to the professionals who are touched by this tragic epidemic either in
their personal lives or in carrying out their Public Health mission of "assuring
Elder Abuse: A Public Health Perspective 3
the conditions in which people can be healthy" (The Future of Public Health,
1988).
REFERENCES
Institute of Medicine (US), committee for the Study of the Future of Public
Health, The Future of Public Health (Washington, DC: National Academy
Press, 1988)
National Center on Elder Abuse. (1998). The National Elder Abuse Incidence
Study: Final Report. Available at
Schneider, Mary-Jane (2000). Introduction to Public Health, Gathersburg,
Maryland. Aspen.
2
ELDER ABUSE: DEFINITION AND

SCOPE OF THE PROBLEM
Tina Fryling, Randal Summers, and Allan Hoffman
The phrase "elder abuse" is used to describe violence, neglect, and other
crimes aimed at elderly persons. Much research has been directed towards the
concept of elder abuse; however, no universal definition of the phenomenon
exists. Like child abuse, the term "elder abuse" refers to abuse at the hands of
a caregiver of an elderly person, including institutional employees. The abuse
takes many forms, including physical abuse, mental abuse, financial abuse,
and both passive and active neglect. The results of this abuse range from emo¬
tional suffering and inhumane living conditions, along with severe suffering
and pain and even death.
Despite the government's funding of programs to combat elder abuse and
despite increased involvement in this area from the criminal justice system,
elder abuse continues to grow, and no easy solutions exist. Various theories
attempt to explain why elderly persons are abused at alarming rates and pro¬
vide some suggestions as to how social service agencies could attempt to com¬
bat this growing problem.
There is a general reluctance on the part of society to accept the fact that
we are not treating our elderly people as "sweet old grandparents."
Americans have a highly idealized notion of family life and find it difficult to
accept the fact that abuse exists within the family, especially when it is direct¬
ed toward elderly people. It is also quite disturbing to acknowledge that the
large number of elderly people that reside in nursing facilities and other care¬
giving institutions are in danger of being abused. Hence, it is easier to ignore
elder abuse than to accept it and attempt to develop remedies. However, the
tragedy of elder abuse is being recognized more often by our public health,
social service, criminal justice and health care systems as an important prob¬
lem to be studied and solved.
DEFINITION OF ELDER ABUSE
The term "elder abuse" was first coined in the late 1970s during congres¬
sional hearings which focused on the mistreatment of elderly persons. ("Elder
Abuse" 1992) However, depending on the study being undertaken or the
group or agency defining the problem, "elder abuse" may be defined in vary¬
ing ways. For example, although some literature defines elder abuse as being
abuse focused on persons age fifty (50) and older, other studies have defined
5
6 Fryling et al.
the term in respect to persons over sixty (60) or even over sixty five (65). After
abuse of the elderly became a focus of social policy the term "elder abuse"
was sensationalized and sometimes substituted with the terms "granny bash¬
ing/' and, in the medical press, "granny battering."
Elderly persons can be victims of abuse either in their own homes, in the
homes of a family member, friend or other private caregiver, or in a nursing
home or other institutional setting. The term "elder abuse" generally
describes all of the following: physical abuse, psychological abuse, material
abuse, active neglect, and passive neglect of elderly persons. (Wolf and
Pillemer, 1989) More specifically, these categories include sexual abuse, over¬
dosing or withholding an elderly person's necessary medications, and the
general humiliation or harassment of an elderly person. Financial abuse is
another category of abuse which is unfortunately promulgated both by pri¬
vate and institutional caregivers.
Abuse by Guardians and/or Family Members
Many elderly persons reside with a family member, such as their child or
another close relative, and thus may be subjected to abuse by those caregivers.
Other elderly persons have been officially declared incompetent by the court
and have been appointed a "guardian" to maintain their finances and oversee
their care and major life decisions. A guardian may or may not be a relative,
and is unfortunately generally held to a fairly low standard in making choic¬
es about a person's finances and care. For example, the guardian of a sixty-six
year old woman who suffered from schizophrenia was sued for failing to
place the woman in an institution, when the woman was in danger of harm¬
ing herself in a home-care setting. The woman, consistent with previous
behavior, left a burning cigarette in her bed, which caused a house fire and her
subsequent death. The guardian was limited to using the least restrictive
means in caring for the woman, and the woman may not have wanted to be
placed in an institution. Thus, a court determined that the guardian did not
abuse her ward.
The prevalence of abuse by a family member is difficult to study because
the abuse by a family member is often not reported. Abused elderly people
may not report the abuse because they fear reprisals from their caregiver or
love their abusive children too much to turn them in to authorities. In an
investigation, the House Select Committee on Aging found that because of
such fear or because they depended on their abusers, only one out of every six
elderly people who were abused ever brought the abuse to the attention of
authorities. As with other dark figures of crime, we will never know exactly
how many cases of elder abuse are never reported.
Many abused persons are also not in a position to report their abuse
because as part of the abuse they are not taken to doctors appointments or out
of the abuser's home for any reason. Most states have reporting acts that
require a health care provider to report suspected elderly abuse, similar to
reporting statutes for child abuse. However, these statutes can only be of help
if the elderly person is actually permitted by his or her caregiver to actually

obtain medical care or speak in private to a provider.
Elderly people may remain in abusive relationships "by choice, because of
counter balancing factors or because the alternatives (such as institutionaliza¬
tion) appear more negative or frightening." In addition, "pride, embarrassment,
fear, isolation, lack of access to services, and mental confusion are all obstacles
to (elderly persons) acknowledging abuse and seeking professional assistance."
Also, statutes which make elder abuse criminal are often ineffective
because they are rarely utilized by an elderly victim. Elderly people are reluc¬
tant to criminally prosecute a family member, especially when that relative is
his or her child. An elderly person can be institutionalized after reporting that
he/she is being abused. Elderly people do not want to be uprooted from their
homes even if that home is abusive, and most often do not wish to spend the
remainder of their lives in an institution. Additionally, the criminal justice sys¬
tem can cause both physical and emotional strain on a victim, especially when
that victim is elderly, and most victims of elder abuse do not want to deal with
the stress of testifying in court regarding their abuse.
Some elder abuse actually comes in the form of spousal abuse. Certainly
spousal abuse does not take place only among younger couples, and spouses
or intimate partners with a history of abuse do not suddenly stop abusing a
partner in their later years. Additionally, some spousal abuse begins only after
a person is elderly, especially if the elderly victim suffers from some condition
such as Alzheimers or Dementia, which could cause their care-giving spouse
to engage in violence out of frustration. Thus, some theories which purport to
explain domestic violence may also explain some incidents of elder abuse.
Offenders (Perpetrators)
We see some of these theories operationalized when we examine the

characteristics of the offenders or perpetrators of elder abuse. In 1990, the
majority of offenders were male. Elowever, by 1996 both males and females
accounted almost equally for elder abuse incidents. When offenders are
reviewed by type of abuse by gender, the area of neglect is the only area that
has relatively equal representation.
• Neglect: 52.4% female offenders, 47.6% male offenders

• Emotional/psychological abuse: 39.9% female offenders, 60.1 male
offenders
• Financial/material exploitation: 40% female offenders, 60% male
offenders
• Physical abuse: 37.5 female offenders, 62.6% male offenders
• Abandonment: 16.6% female offenders, 83.4% male offenders
When the age of offenders is reviewed we find that most offenders are
in the younger age group although for most types of abuse those under 40
and those older than 80 offend the most.
Fryling et al.
• 65 % of offenders are 59 years and younger

• 10% of offenders are between 60 and 69
• 25% of offenders are age 70 and older
It is often thought that abuse occurs at the hands of institutional or non¬

family care-givers. Contrary to belief, most offenders are the adult children
of the victims:
• Adult Children: 47%

• Spouse: 19%
• Grandchild: 9%
• Other relative: 9%
• Sibling: 6%
• In-home service provider: 3 %
• Out-of home service provider: 1%
Abuse in Nursing Homes and Other Institutions
Employees of nursing homes and other caregiving institutions also engage

in elder abuse. Although ombudsman programs and other statutory reporting
requirements should theoretically reduce the incidence of abuse in nursing
homes, all forms of abuse nevertheless take place in such institutions.
A report from the Special Investigations Division, Committee on
Government Reform of the United States House of Representatives published
on July 31, 2001 focused on the abuse of nursing home residents. That report
indicated that thousands of nursing homes, over thirty percent (30%) of those
in the United States, were cited for abuse. Some of these violations were so
severe that they caused the resident's death. The violations included direct
physical abuse, verbal abuse, and the act of allowing one patient to harm anoth¬
er. There were also many incidents of nursing home personnel ignoring com¬
plaints of sexual or other serious abuse; in fact, such failure to investigate was
the most frequent abuse violation reported. Many nursing homes were also
cited for failing to develop and implement policies that would lessen incidents
of abuse, even though such policies are generally mandatory. (Abuse 2001).
It is possible that the statistics gathered on nursing home abuse might be
slightly more accurate than statistics gathered for other forms of elder abuse.
Nursing homes are inspected and are subject to government regulations, espe¬
cially if residents receive funding from Medicare or Medicaid. There also exists
a formal complaint process in nursing homes and states must investigate those
complaints once they are lodged.
Nursing home violations consist of all forms of physical abuse, including
broken bones, bruises, and lacerations. State inspection reports also demon¬
strate many reported cases of sexual abuse to nursing home residents by other
residents or by staff, from incidents of fondling to rape. Nursing home residents
also complained of verbal abuse, which many times causes a patient to fail to
ask for help or for medical care, a form of forced self-neglect. (Abuse, 2001).
TYPES OF ABUSE
Physical Abuse
Physical abuse involves the use of physical force to harm or impair an eld¬
erly person. Any sort of physical violence or such actions as burning, the inap¬
propriate use of drugs—such as over-medicating a person or even failing to
give a person proper medication, the use of physical restraints, and even force
feeding are considered physical abuse. (National Centeron Elder Abuse 1998).
As with children, it may be difficult to determine whether physical injuries
were a result of abuse or an accident such as a fall.
Physical incidents of elder abuse can also include sexual abuse, which
includes any sexual acts for which the elderly person has not given or is inca¬
pable of giving consent. Coerced nudity and taking sexually explicit photo¬
graphs of an elderly person is also considered physical and mental abuse.
Mental Abuse
Any infliction of anguish, pain, or distress in an elderly person is consid¬

ered mental abuse. Specific examples include "treating an older person like an
infant; isolating an elderly person from his/her family, friends, or regular
activities; giving an older person the 'silent treatment;' and enforced social
isolation." (National Center on Elder Abuse 1998). As discussed previously,
when caregivers verbally abuse or threaten a victim, that victim may then be
less likely to request care or make their needs known, which then leads to a
lack of proper care and medical services for that victim.
Financial Abuse
Elderly persons are often an easy target for financial abuse both in private
homes and in institutional settings because they often give their caregiver
control over their finances. Any illegal or improper use of an elderly person's
hands is considered financial abuse. Incidents of financial abuse include forg¬
ing an elderly person's signature, forcing them to sign any document, such as
a will or contract, that would benefit the person who is forcing the signature,
and stealing and/or misappropriating funds from the elderly person. Many
elderly persons are either coerced into turning over or decide on their own to
turn over their financial freedom to someone else in the form of a power of
attorney or guardianship, and very often the elderly person consequently has
little control over the funds they have turned over. Even elderly persons with¬
out official paperwork requiring them to turn over financial control to a third
party feel obligated to give their caregiver control of their finances in return
for the care they are receiving. Additionally, an elderly person may not know
who to turn to even if he believes those funds are being abused. If the caregiv¬
er that is taking financial advantage of them is also the person providing him
10 Fryling et al.
with transportation and phone services, the elderly person may not have con¬
tact with anyone other than the caregiver in order to lodge a complaint.
In the area of financial abuse of the elderly, a question exists regarding
whether an adult child is "abusive" of the parent if he or she does not finan¬
cially support that parent. In Stone v. Brewster, a domestic relations court adju¬
dicated a claim that was brought to force a person to financially support his
parents. The court stated that a statutory obligation arises only after the court
determines the parent's need for support, the child's ability to furnish such
support, and the extent to which such support should be furnished. Courts do
occasionally find through the interpretation of statutes or by common law
that a person is legally obligated to assume a "duty of care" for his/her elder¬
ly parent. However, because this "duty of care" refers only to financial care,
not to a duty to care for an elderly parent's physical and emotional needs.
Many people may respond to their duty of care by placing their elderly par¬
ent in a nursing home, thus eliminating the possibility of at home abuse, but
subjecting the person to abuse by institutional caregivers. Additionally, as dis¬
cussed below, a person providing resources for a parent or other elderly rela¬
tive may become stressed due to the financial strain that is created and phys¬
ical or mental abuse might occur as a result of that stress.
Neglect
Most elder abuse initially takes the form of physical abuse or neglect;
financial abuse, abuse of basic constitutional rights, and psychological abuse
follow. Neglect is any refusal or failure to fulfill an elderly person's needs.
Many cases of elder abuse involve neglect due to a family member's inability
or non-interest in providing proper care to an elderly person who is living in
their home. Issues in this area again involve the question of what duties a per¬
son actually must perform for an elderly person. Neglect can be inflicted upon
an elderly person by family caregivers or even by in-home service providers
that have been hired to provide certain types of assistance to an elderly per¬
son, whether it be medical care, psychological care, or assistance with gener¬
al daily needs. "Passive neglect" refers to a failure to care for a person or non¬
intended neglect that might take place due to a person's lack of knowledge of
how to care for an elderly person's needs (Krummel, 1996). Active neglect
involves withholding something from a person that they clearly need to sur¬
vive. (Rathbone-McCuan and Voyles, 1982). Often, the line is blurred between
active neglect and outright physical or mental abuse.
Clearly the failure to provide life necessities for an elderly person is a
form of neglect. Food, water, clothing, shelter, medication, and personal safe¬
ty are all life necessities. Many neglect cases revolve around unsanitary living
conditions caused by the caregiver ignoring the person. In Texas, an elderly
woman was found in a great deal of pain, lying in her own urine and excre¬
ment, wtih bedsores on her heel, back, and hip that were so large they had
eaten away her flesh to the bone. She had also sustained second degree burns
on her inner thighs from lying in her own urine. Upon her entry to the hospi-
tal, medical workers even found maggots in her bed sores. The woman had
been tucked away in an upstairs bedroom of her son's home and he had done
his best to keep other members of the family from visiting her. The woman
was in great need of medical care but clearly unable to summon help for her¬
self. (Billingslea v. Texas). This type of neglect may obviously also be consid¬
ered to rise to the level of physical abuse.
A California Court was able to hold a woman liable for failing to help her
father even when she was not his direct caregiver, thereby extending liability
to people who are aware of possible abuse and do nothing within their pow¬
ers to halt it. The Court indicated that a stranger who saw an elderly person
in need on the street did not have a duty to help that person; the duty only
applied to a relative or someone close to that person. In the California case,
the decedent's daughter was required to maintain him to the extent of her
ability, and since she knew of the peril he was in while residing with her
brothers who could not properly care for him, she was required to exercise a
minimal duty of care that would avoid general negligence on her part.
Some elder abuse literature also lists "self-neglect" as one category of neg¬
lect. Certainly some older persons engage in behavior that threatens his or her
own safety or health, in the form of a failure to eat, take medications, or per¬
form proper hygiene. The issues involved in self-neglect are whether a person
who realizes that the elderly person is neglecting him or herself has a duty to
report that person. This issue becomes quite difficult, as an adult would have
to be considered incompetent before another adult could make decisions for
him/her. Many adult children of elderly parents do not want to deal with try¬
ing to take away his or her parent's autonomy.
The term "granny dumping" has also been used to refer to the ultimate
form of neglect where an elderly person, often suffering from Alzheimers or
some other form of dementia is abandoned in some public place by his or her
family. The person may not know their own name, much less who left them
there, and they then become a ward of the state.
PREVALENCE OF ELDER ABUSE: RATES AND STATISTICS
As more elderly people reside with adult caregivers, a higher possibility

exists that those people may ultimately be victims of abuse. Numerous studies
have been undertaken in the attempt to determine the amount of elder abuse
that takes place in various countries throughout the world. Clearly, like any
study of victimization, a number of factors make statistics inaccurate. As pre¬
viously discussed, there is always a "dark figure" of crime in any area, and this
figure exists most likely at a high rate in the area of elder abuse because many
elderly persons living with a caregiver do not report the abuse they are facing,
either because they are afraid to or because they are isolated and thus unable
to come into contact with anyone who they could report it to. However, results
of studies which have been done will be summarized herein.
The National Elder Abuse Incidence Study estimated that in 1996,449,924
persons aged sixty (60) and over experienced abuse and/or neglect in domes-
12 Fryling et al.
tic settings. That number was based on information from only 20 counties in
15 states. That study also reported that only twenty one percent (21%) of all
cases were actually reported to an agency or substantiated by an agency.
(National Center on Elder Abuse 1998). Findings from a random sample esti¬
mated that as many as 701,000 to 1,093,560 elderly persons are abused in our
nation. This correlates to an estimate of 32 elderly persons per 1000 that are
subjected to some form of maltreatment. (Pillemer and Finkelhor, 1988).
Research in Canada estimates that 98,000 to 137,000 elderly persons are
abused in Canada. (Podnieks, 1992). This survey estimated that approximate¬
ly 40 persons per 1,000 elderly individuals in Canada experienced some sort
of abuse or maltreatment at the hands of a caregiver or other relative, includ¬
ing partner violence.
Elderly people are exposed to home and institutional caregivers for
extended periods of time, allowing abuse to be "repeated," and the term
"elder abuse" generally refers to such repeated abuse. One time thefts,
assaults, or scams directed at the elderly, while prevalent in society, are theo¬
retically not considered "elder abuse." Obviously the biggest difficulty in
determining the prevalence of elder abuse is the fact that, as stated previous¬
ly, most elderly persons who are being abused are being controlled by their
caregiver. Thus, there is no way these persons can report their abuse. Hence,
the assumption is that findings in these areas are very low and that the preva¬
lence of abuse of the elderly is much higher than determined in any study that
has been undertaken thus far.
In 1980, more than twenty-five million Americans were age sixty-five or
older. By 1990, thirty one million Americans, almost thirteen percent of the
population of the United States were at least sixty-five years of age. It is esti¬
mated that by the year 2030, persons ages sixty and older will number 85 mil¬
lion, while the number of persons ages 85 and over will number 8 million
(Wallace at 239). High estimates indicate that five percent of the total elder
population is abused each year. This would mean that 1.5 million elderly peo¬
ple are currently abused each year. As the population of elderly people rises,
incidents of elder abuse will also rise. Despite the high incidence of elder
abuse in the United States, the problem has only recently gained attention as
an area for our legal system to deal with.
Studies performed by the National Center on Elder Abuse demonstrates
the rise in elder abuse, or at least a rise in reporting of elder abuse, in the past
decade. In 1986, 117,000 cases of elder abuse were reported; by 1990, that rate
had risen to 211,000 and in 1996 that number was 293,000. Specifically, the
numbers have broken down as follows: physical abuse (15.7 percent), sexual
abuse (.04 percent), emotional abuse (7.3 percent), neglect (58.5 percent),
financial exploitation (12.3 percent), all other types (5.1 percent) and unknown
(.06 percent). (Toshio, T. 1996). Mandatory reporting statutes and more educa¬
tion in the health care and social work settings regarding this problem may
have increased reporting; the rising number of elderly people in our society
and the number of persons living in institutions or with caregivers could also
have contributed to this jump in incidents.
Although mandatory reporting requirements exist in the area of elder

abuse, it is far less likely to be reported than is child abuse. Perhaps one rea¬
son for this discrepancy is that child abuse is often noticed by school officials
or day care center workers. Children often interact with others outside of the
home. In contrast, elderly people who are abused are often unable to leave the
abuser's home. Thus, there is little chance that a person from outside of the
home will even have the opportunity to become aware of cases of elder abuse.
Regarding nursing home violations, the percentage of nursing homes
cited for abuse violations has tripled since 1996. (Abuse, 2001). In 2000, sixteen
percent (16%) of all nursing homes in the United States were cited for abuse
violations during their annual inspections. This was a ten and one tenth per¬
centage (10.1%) increase since 1996. This increase may be a result of more
reporting, more incidents, or other political measures, such as a repeal of the
Boren Amendment, which guaranteed that nursing homes would receive
enough funding to provide adequate care to their residents. (Abuse, 2001).
Nursing home reports still are not 100% accurate, especially considering that
institutions that do not accept medicare or medicaid money do not have to
report to or be inspected by the federal government. In fact, the majority of
research done in the area of elder abuse in nursing homes has been done
based solely on official reports or complaints lodged with the state. There
would clearly be many victims who would not report their victimization,
either because of a fear of repercussions by staff or other residents, or because
they are unable to tell their experience to anyone due to dementia or an inabil¬
ity to communicate. However, with one out of every three nursing homes
being cited for violating federal standards which were promulgated to pre¬
vent elder abuse in nursing facilities, it is clear that abuse in nursing homes is
a very prevalent problem.
CAUSES/THEORIES OF ELDER ABUSE
Both an elderly person and his/her family must make very important
decisions when the elderly person needs care. Literature examining elder
abuse sometimes attempts to excuse abusers and find fault with the elderly
person in order to blame the victim for the abuse. Sociological studies empha¬
size the stress that an adult child goes through when taking an elderly parent
into the home, and then examine what the elderly person does that could anger
his/her caregiver. Emphasizing what the elderly person may do to cause the
abuse suggests that battering a parent is acceptable as long as there is a "good
reason" for the abuse. This type of attitude is unfortunate and may truly ham¬
per the possibility of remedying the growing problem of elder abuse.
General sociological theories that explain violence in general are often
used to explain elder abuse. Nadien (1995) suggests that the following theo¬
ries are applicable: psychoanalysis, social learning theory, social exchange the¬
ory, conflict theory, role-learning theory, situational theory, and functionalism.
The family stress theory is also a widely promulgated theory to explain elder
abuse. (Steinmetz, 1988). These theories will be expanded upon below.
14 Fryling et al.
The Decision to Care for an Elderly Parent
Adult children and other relatives of elderly persons assume a caregiving

role for various reasons. First, an adult child may feel that putting an elderly
parent in a nursing home would be a waste of the elderly person's assets,
which would instead be inherited by the child if not used up during the eld¬
erly person's life. In addition, adult children may expect that their elderly par¬
ents will act as live-in babysitters and will help with the housework, although
failing health and mental abilities may prevent the elderly person from
assuming any of these duties. Finally, while adult children are often motivat¬
ed to care for their elderly parents out of love, they may also feel a sense of
responsibility, duty, or guilt. Often, the decision to accept an elderly parent
into the home is hasty and the adult child feels as though no other alternative
exists. The forces that motivate someone to care for an elderly parent vary and
may not be focused towards furthering the parent's best interests.
The Decision to Enter an Abuser's Home
The elderly person also enters the home of his/her adult child for varying
reasons, and the decision to do so is often difficult. Most often, the elderly per¬
son has no resources and no alternative place to live. Once the elderly person
enters the other parties' household, his/her personal autonomy is challenged.
An elderly parent who once ruled a home with an iron glove may do the same
in a caregiver's home. In addition, the former caregiver now must be cared
for. The elderly person may resist the care offered by family members, which
can result in abuse by the caregiver, who will force care upon the elderly per¬
son. The elderly person may have no mechanism with which to avoid that
force except through violence to the caregiver; such violence invites further
abuse by the caregiver, who is usually stronger than the elderly person and,
consequently, more abusive.
The Difficulties in Caring for an Elderly Person
The elderly person's dependency on the caregiver signifies a role reversal

between the two parties. The adult child, who used to depend on a parent for
advice and support, is now expected to care for that person. In contrast, the
parent who used to be responsible for his son or daughter is now powerless
and in a position of dependency. This reversal of roles is overwhelming to the
adult child and humiliating to the parent.
This role reversal creates new rights, responsibilities, and obligations for
the caregiver. The caregiver experiences stress and anger because of a lack of
personal time or a lack of privacy, or by rivalry, especially between mothers
and daughters, of how to manage the household and the children. The duties
the caregiver is expected to perform are stressful and demanding. Caring for
an elderly person with physical or psychological problems is a constant, twen¬
ty-four hour per day job, often with no respite for the caregiver. Frustration
can often lead to physical violence or an apathetic attitude towards the elder¬
ly person, which in turn results in neglect.
Financial difficulties also lead to stress and abuse. Household resources
may not stretch far enough to accommodate the needs of the immediate fam¬
ily and the elderly person. Often, college or wedding plans for the caregiver's
children must be balanced with household income that is already decreasing
due to retirement. This leaves little money with which to care for an elderly
person and can cause resentment towards the elderly person; medication and
medical equipment needed to provide proper care to the elderly person is
costly. Medical costs are often not compensated by government programs and
therefore must be fully paid by the family out of the elderly person's already
dwindling assets.
The "social exchange theory" promulgates that when a victim depends on
a caregiver financially, emotionally, and physically, that dependence can lead
to abuse. The result of the dependence is that the caregiver may feel as though
he is being "taken advantage of" by the elderly person, which may lead to
resentment. Another form of the social exchange theory asserts that the abuser
is actually dependent on the victim; some caregivers depend on their victim for
financial assistance and/or housing. (Wallace 1998). Such dependence may
result in the caregiver trying to control all aspects of the elderly person's life.
Abuse can provide that desired control, as a victim is more likely to obey
a caregiver who has control. Conflict theories explain elder abuse in terms of
power and resources. The theory states that a caregiver will have money,
power, and control, and the elderly person may have none of those resources.
Thus, the person with control abuses the person who has none. Some abusers
may even obtain physical pleasure from controlling and tormenting a victim.
The abuser may have been an abused child, sometimes by the parent he/she
is now abusing. Such incidents support the "cycle of violence" theory which
suggests that those who are abused tend to abuse others. However, Galbraith
(1989) has determined that most cases of elder abuse do not involve a cycle of
violence. In any event, the use of social learning theories to explain elder
abuse has been the focus of much disagreement among researchers in the area
of elder abuse.
In addition to the above case-specific causes of abuse of the elderly, many
blame elder abuse on the presence of ageism in our society. Ageism is the
"widespread negative attitude about the class" of elderly people. While it may
seem that most people think of elderly people as "loving grannies," in fact,
many people see elderly people as a burden on our society. Our youth-orient¬
ed society often does not accept the problems that come with an aging popu¬
lation. While elder abuse may or may not be caused by ageism, the lack of
effective statutes and programs which deal with elder abuse may be a result
of this poor attitude toward the elderly. The "functionalism theory" states that
if a caregiver believes that an elderly person is stupid or weak, due to ageism,
they will be less likely to care appropriately for that person.
The elderly are often easy targets for abuse because they are almost
always in a position of financial dependency and psychological dependency
16 Fryling et al.
on the children with whom they reside. Elderly people look to their children
for social companionship after spouses and friends are gone. In addition, eld¬
erly people are often dependent on their children to take care of their legal
and financial obligations. However, the adult child may resent being the cen¬
ter of the elderly person's universe, and this resentment may lead to retalia¬
tion and abuse.
While women are often the primary care providers for the elderly in
homes, women are also increasingly members of the work force. The duties of
caregiver often fall on women, but the added stresses of job and family make
caring for an elderly person a great burden. Women ultimately take on the
duties of both the physical and financial support of elderly parents, and such
duties are often manifested through abuse. The "family stress theory" asserts
that elder abuse is caused by the stress brought on a family when an elderly
person is taken into the home. This includes financial stress and the general
stress of having more people living within a household. Similarly, psychoan¬
alytic theories blame the psychological makeup of the abuser for the abuse;
for example, a caregiver might be depressed or have an anger control prob¬
lem, which leads to abuse.
Abuse in nursing homes can be caused by different factors than abuse by
a general caregiver, although stress can also cause institutional abuse.
Although a caregiver in a nursing home is able to escape and perhaps detach
himself or herself from the situation more than someone caring for an elderly
person in his/her home, work in an institution can be extremely stressful. A
shortage of nursing staff, burnout, and inadequate training all contribute to
abuse in such settings.
Financial abuse exists as a result of the level of control such institutions
may have over a person's finances. Often an elderly person has no family
members to supervise his or her finances or advocate for him or her in cases
of questionable missing funds. Low wages also contribute to the temptation
of institutional employees to steal from the residents. Patients of a nursing
home are often out of their rooms for meals, appointments, doctors visits, and
other activities, which provides a time period for staff or visitors to steal from
that person's room. Additionally, a victim complaining that something was
stolen from him or her might be ignored and their complaints might be con¬
sidered to be due to dementia. In fact, staff may rationalize that a person with
dementia will not remember what possessions he or she had anyway. The
prevalence of theft from patients is difficult to gauge because many nursing
homes do not wish for researchers to pursue this issue and that many times
the victim may not be competent to discuss whether he or she was victimized.
Some suggest that one problem in adjudicating elder abuse cases results
from the difficulty at times to separate fact from fiction when an elderly per¬
son discusses his or her mistreatment. Elderly people can suffer from depres¬
sive paranoia, which could cause them to "make up" stories of abuse. While
this may make the job of the investigator of elder abuse more difficult, this
theory is a result of ageism. To assume that elderly people are less believable
than other people is an unfortunate, and often inaccurate, stereotype. If the
same theory was asserted for children who claim they are abused or for wives
who claim their husbands beat them, we would nevertheless take the steps to
examine whether the actual abuse occurred.
Additionally, a family member may simply lack the skills necessary to
properly take care of an elderly person. A parent with Alzheimer disease who
tends to wander and act out may be difficult for a caregiver who does not
understand the disease to deal with. The "role theory" explains elder abuse in
this manner; that the role of caregiver is basically thrust upon a person and
that by role playing, a caregiver or an elderly person might come to under¬
stand what is desired in their role as either caregiver or patient.
Understanding the perspective of the other person involved may be helpful in
avoiding abuse. Situational theory focuses on the isolation that a person
might feel if they are a caregiver. Being isolated and having little emotional
support may lead to abuse. The role theory and isolation may be particularly
applicable to persons who are giving care to their elderly spouses. An elderly
person may have a difficult time understanding why a spouse with dementia
or other mental health issues is acting out toward him and may have little
support from or little contact with the outside world. Such a scenario can eas¬
ily lead to frustration, extreme stress, and ultimately abuse.
Although universal agreement on the definition, prevalence and cause of
elder abuse is lacking there is ample evidence to suggest we have a major pub¬
lic health concern in our country. Furthermore, given the age demographic
(graying of America) there is the likelihood that the problem will continue to
escalate. Metaphorically, if this public health problem was seen as a forest fire
hazard, the index would read "Danger."
REFERENCES
Billingslea v. Texas, 780 S.W.2d 420, 424 (Tex. 1989).

"Elder Abuse." Infolink 1 (17). (National Victim Center, Washington D.C.) 1992.
Galbraith, M.W. (1989). "A Critical Examination of the Definitional, Methodological
and Theoretical Problems of Elder Abuse," in R. Filenson and S.R. Ingman (eds.).
Elder Abuse: Practice and Policy, Human Sciences Press, New York.
Garfield, Audery S. (1991). Note, Elder Abuse and the State's Adult Protective Services
Response: Time for a Change in California. 42 Hastings L.J. 859.
Greene, Jan (2001). When Not Treating Pain Equals Abuse. H and HN: Hospitals and
Health Networks, Vol. 75 Issue 10, p 34.
Harris, S. (1996). For Better or for Worse: Spouse Abuse Grown Old. Journal of Elder
Abuse and Neglect. Vol. 8, No. 1,1-33.
Krummel, S. (1996). Abuse of the elderly. In D.M. Busby (Ed.), The Impact of Violence on
The Family (pp. 123-148). Boston: Allyn and Bacon.
Nadien, M.B. (1995). Elder violence (maltreatment) in domestic settings: Some theory
and research. In L.L. Adler and F.L. Denmark (Eds.), Violence and the Prevention of
Violence (pp. 177-190). Westport, CT: Praeger.
National Center on Elder Abuse. (1998). The National Elder Abuse Incidence Study: Final
Report. Available at
Pillemer, K. and Finkelhor, D. (1988). The Prevalence of Elder Abuse: A Random
Sample Survey. Gerontologist, Vol. 28, No. 1, 51-57.
18 Fryling et al.
Podnieks, E. (1992). National Survey on abuse of the Elderly in Canada. Journal of Elder
Abuse and Neglect, Vol. 4, No. 1/2,5 - 58.
Rathbone-McCuan, E. and Voyles, B. (1982). Case detection of abused elderly parents.
American Journal of Psychiatry, 139(2), 189-192.
Steinmetz, S.K. (1988). Duty Bound: Elder Abuse and Family Care. Newbury Park,
California: Sage Publications.
Stone v. Brewster, 218 A.2d 41 (D.C. 1966).
Sullivan v. Craine (Ohio App. 10 Dist.)
Toshio, T. (1996). Elder Abuse in Domestic Settings. Elder Abuse Information Series #1.
Washington, D.C. National Center for Elder Abuse.
Wolf, R. and Pillemer, K. (1989). Elelping Elderly Victims. New York, Columbia
University Press.
_(1992). 138 Cong. Rec. H8969-01 (Older American Act Amendments of 1992)
(Thursday September 22).
_ (2001). Abuse of Residents Is a Major Problem in U.S. Nursing Homes,
Special Report prepared for Rep. Henry A. Waxman, U.S. House of
Representatives.
3
CARE PATHWAY MODEL AND

GUIDELINES FOR HEALTH CARE
PROFESSIONALS
Tom Miller
Health care professionals recognize the importance of standards of care

and standardized models of evaluation and intervention in cases of elder
abuse. This chapter focuses on risk factors, the trauma accommodation expe¬
rienced by elderly who are abused, physical and behavioral indicators of elder
abuse, a model algorithm of care for victims of elder abuse, a care pathway for
health care professionals to follow in cases of elder abuse and a case study
exemplifying the intervention strategies health care providers should consid¬
er in such an event. Algorithms and care pathways are being utilized to assure
consistency in the evaluation and interventions offered where the spectrum
symptoms of domestic violence are identified in the course of counseling. A
review of the literature on the use of treatment guidelines is offered, as are
treatment and legal considerations and community resources available to the
public health and health care professional.
Victims of elder abuse are seeking the assistance of health care profession¬
als with an understanding and sensitivity to their needs and with the expec¬
tation that a standardized model of care and treatment will be provided.
While each individual brings a unique and highly individualized case to the
health care provider, the need for standardized models of care becomes essen¬
tial to assure consistent standards of care for each person.
Health care providers have begun to utilize clinical algorithms and path¬
ways of care in order to standardize the clinical care provided to individuals
who are diagnosed and treated for domestic violence issues. Developments in
the health care system have driven important changes that have provided
shifts in traditional paradigms of service to more clinically relevant and stan¬
dardized approaches to assessment and treatment. This chapter describes a
model that includes algorithms and care pathways that have been developed
and implemented in order to coordinate a standard approach to treatment for
victims of domestic violence. The use of such treatment guidelines has gained
considerable attention in the managed care arena among health care profes¬
sionals (Griffith, 1999).
19
20 Miller
ASSESSING ELDER ABUSE
The presence of depression in traumatized victims of abuse has been well-

documented (Conte, Berlinger, Schwerman, 1987; Russell, 1983; Veltkamp and
Miller, 1994). The protracted depression is reported as a most common symp¬
tom along with aggravated depressive symptoms, hyperarousal, intrusive
thoughts, insomnia, psychosomatic symptomatology, and dissociation com¬
monly associated with the post traumatized period. The paralysis of apathy
and helplessness, the intense internalized anger, the debased self-image, and
ruminations of guilt, all are recognized within the cluster of depressive symp¬
tomatology frequently recognized in victims of prolonged abuse.
Long-term traumatized individuals who have been abused (Horowitz
and Soloman, 1978; Frayberg, 1980) show anxiety, agitation and hypervigi¬
lance which is most recognized not only in their insomnia and startle reac¬
tions, but also in tension headaches, abdominal pain, gastrointestinal distur¬
bances, and other forms of somatization. Victims of prolonged trauma are as
well users of the art of altered consciousness as a means of coping and con¬
trolling the situation and the perpetrator. Through dissociative experiences,
including suppression and denial, they are able to cope through the immedi¬
acy of the trauma but often suffer at later times from disturbances of memory
and concentration because of their conditioned experience to the dissociative
form of coping. Adult survivors of child sexual abuse and adult victims of
domestic violence use these dissociative capacities in their adaptation and
accommodation to stressful life experiences.
Victims of elder abuse (Miller and Veltkamp, 1996) may well experience a
more complex picture of psychopathology. They are, in fact, victims of a dis¬
order of extreme stress which must capture the manifestations of repeated
and prolonged abuse and its resultant impact on personality development
that is not usually seen in situations of more acute stressful nature. Counselors
have come to the realization that the significance of prolonged and repeated
traumatization as seen through domestic violence and physical and sexual
abuse warrant careful consideration in providing a counseling intervention.
RISK FACTORS IN ELDER ABUSE
Health care professionals recognition of "at risk" factors is crucial. The

"at-risk" factors in domestic violence focus on two elements: (1) a multigener-
ational pattern of abuse, and (2) a family constellation of "at-risk" factors as
reflected in the "victim-victimization" spectrum. Multigenerational patterns
of abuse on to subsequent generations, perpetuating a "cycle of violence"
(Walker, 1998). Persons most prone to violent behavior experience financial
problems, frequent moves, substance abuse, and isolation from peer groups
and family support systems, which often include ingredients that leads to
family violence. Efforts to recognize "high-risk" individuals and to provide
early intervention in the form of prevention and education may be of consid¬
erable benefit in reducing spouse and child abuse in all segments of the pop-
Table 1: Victim-Victimizer Spectrum
Survivor Victimizer
Isolation from others History or pattern of abuse
Feeling of helplessness Learned violent behavior
Vunerable Unstable
Secrecy Low self-esteem
Indecision Impulsive
Poor self-confidence Impaired judgment
Low self-esteem Narcissistic
Fear, anxiety, depression Alcohol and/or substance abuser
Impaired ability to judge Control and power seeking

trustworthiness in others
Accomodates to the victimization Perpetuates continued

forms of victimization
ulation. Table 1 identified as the victim-victimizer spectrum summarizes risk

factors for both the victim and the perpetrator.
In addition to the factors identified in the "victim-victimizer" spectrum,

the family constellation of at-risk factors in abusing families may include the
following characteristics:
• An elder partner may be extremely passive, dependent, and/or reluc¬

tant to assert oneself in the face of an abusive situation.
• Poor marital relationship, a lack of constructive communication or
poor interpersonal relationship.
• The perpetrator turns outside the family or toward the victim to
relieve and displace emotional tension and stress.
• The elderly person may feel emotionally deprived and turn to the
perpetrator for support and emotional nurturance, and in the process
becomes abused.
• The issue of control is a big factor in elder abuse situations
• Perpetrators use control to force victims to comply with their wishes.
• Generational boundaries are often unclear between the perpetrator
and elder abuse victim.
• There is a lack of social contacts outside the family.
22 Miller
• Caretakers have inadequate coping skills, particularly, under stress.

• Family problems become family secrets, therefore not allowing
change or intervention to occur within the cycle of violence.
• Substance abuse is sometimes a factor in cases involving domestic
violence.
There are specific behavioral indicators of abuse frequently seen in spous¬

es and children who have been abused. Any one of these behaviors may be the
victim's way of communicating to the physician or health care professional
that something is wrong, that he or she is being abused. A mistake frequently
made by health care professionals is that these behaviors are viewed as "the
problem," rather than the symptom of a far greater family problem, namely
domestic violence. The most prominent physical and behavioral indicators
are summarized in Table 2 and address both the child and the spouse. These
indicators become important to the counselor in screening for domestic vio¬
lence in the care pathway.
ACCOMMODATION OF TRAUMA AND ABUSE IN THE ELDERLY
The trauma of physical and/or psychological abuse for the victim is often
a difficult experience to understand and accommodate. The Trauma
Accommodation Syndrome (Miller and Veltkamp, 1998) is based on DSM IV
criteria (American Psychiatric Association, 1994) and outlines how the victim
processes trauma such as abuse. There is usually extreme difficulty in dis¬
cussing any aspect of the victimization. The victim confronted with such
abuse often passes through a series of stages in dealing with this trauma. The
initial stage is one of victimization, which is recognized as the stressor and is
usually realized as an acute physical and/or psychological traumatization.
The person's response is usually one of feeling overwhelmed and intimidat¬
ed, and the locus of control for the victim is more of an external nature. It is
not uncommon for the victim to think recurringly of the stressful experience
and to focus on the intimidating act, as well as the physical pain associated
with the abuse. Figure 1 summarizes the stages or phases the victim often
experiences along with clinical indicators present during each stage.
This acute stage of trauma involving feelings of helplessness and fear is fol¬
lowed by a stage involving more cognitive disorganization and confusion.
This stage is marked by a vagueness in understanding both the concept of
abuse and the expectations associated with the demands of the perpetrator.
The third stage may involve denial and a conscious inhibition wherein an
effort is made on the part of the victim to actively inhibit thoughts and feel¬
ings related to the abuse. This can involve revisiting the cognitive disorgani¬
zation phase and the earlier memories, with flashbacks to the acute physical
and psychological trauma. This stage can also realize avoidance involving
unconscious denial, wherein the victim is not aware of his effort to avoid the
psychological trauma associated with the abuse. The victim, therefore, uncon¬
sciously denies or minimizes the abuse and/or any efforts to respond to the
Table 2: Physical and Behavioral Indicators of Elder Abuse
Physical Indicators
Malnourishment and dehydration
Unexplained bruises and welts
Unexplained burns, especially on soles, palms, back or buttocks
Immersion burns, pressure sores or ulcers
Rope burns on arms, legs, neck or torso
Unexplained fractures to skull, nose, or facial structure; in various stages of
healing; multiple or spiral fractures
Unexplained lacerations or abrasions to mouth, lips, gums, eyes, or external
genitalia
Behavioral Indicators Material/Financial Indicators

Emotional constriction and blunted affect Lack of knowledge of financial
assets
Fear of adult contacts Unusual banking activity
Extreme withdrawal or aggressiveness Living conditions vary from value
of estate
Extreme rejection or dependence Documents for signature drawn
on caretakers without elders knowledge and
approval
Apprehension, fearfulness Lost or missing personal assets
Afraid to go home Isolation from family and friends
Depression and isolation Variation in signatures on legal
Phobias, anxiety papers and checks
Sleep disturbance
Withdrawn, inhibited behavior
Obsessive-compulsive behavior
Abuse of a Sexual Nature

Difficulty in walking or sitting
Torn, stained, or bloody underclothing
Bruises or bleeding in external genitalia, vaginal, or anal areas
Venereal disease or sexually transmitted disease
Sleep disturbances
Withdrawn or regressed behavior
Secondary enuresis or encopresis
Poor interpersonal skills
Self-report of abuse
Anorexia or loss of appetite
Extreme self-blame for the abuse
Extreme expressed fears
24 Miller
Figure I
Trauma Accomodation Syndrome in Elder Abuse and Neglect
(Miller and Veltkamp, 1996)
1 II III IV V
Victimization Acute Avoidant Therapeutic Accommodation
Stage Trauma Stage Re-evaluation Stage
Stage Stage
abusing experiencing. This results in stagnation, feelings of entrapment, and

often results in the victim accommodating the pain of the abuse.
This avoidant stage may be followed by a stage of therapeutic re-evaluation,
where a "significant other" usually supports the reasoning through and the
re-evaluation of this psychological and physical trauma associated with the
abuse. In this stage, the victim may begin to disclose specific content relevant
to the abuse. The phase of therapeutic re-evaluation and reasoning is signifi¬
cant in that it indicates that conscious support has been realized by the victim
in passing from the avoidant phase to the issues, activities, and trauma of the
abusing experience(s).
The final stage is one of accommodation, which involves coping and/or

resolution, wherein the victim has been able to deal with the issues of the
abuse and comes to a better understanding of the significance of the abuse
and the perpetrator. The victim is viewed at this stage as: (1) being more open
to talking about the incident, (2) being able to express thoughts and feelings
more readily, and (3) being committed to both assessment and therapy where
the victim may discharge some of the aggressive feelings toward the perpetra¬
tor. It is clearly at this stage that the victim has realized an alliance with the
counselor, significant others and/or other professionals in: (1) exploring the
original abusive experience, (2) dealing with both the physical and psycholog¬
ical stressors involved, (3) attending to the repressed material and the process
of either conscious inhibition or unconscious denial utilized during the
avoidant stage, (4) focusing on self-understanding, psychological and emo¬
tional support of others in comprehending the rationale for the abusing expe¬
riences, and (5) exploring appropriate psychosocial lifestyles to determine the
degree of therapeutic intervention yet required.
Risk factors once identified can best be monitored by the use of a practice
guideline which have been guided by clinical research studies (Miller and
Veltkamp, 1998). These studies and clinical evidence have identified the
effects of victimization in cases of elder abuse. Cicchette and Olsen (1987) in
the Harvard Maltreatment Project, realized that adult victims were often over
controlled in their management of feelings and impulses during the victimiza¬
tion process and therefore significantly at risk for developing psychopatholo¬
gy (Walker, 1998). Among the most relevant characteristics of at-risk individ¬
uals are children who: (1) have a history of family violence, abuse, or neglect;
(2) have recognized family disorganization; (3) experience a lack of acceptance
and a lack of interest on the part of the family of the victim; and (4) have poor
quality of communication with others in and beyond the family (Veltkamp
and Miller, 1990).
There is considerable evidence in the health care literature (Griffith, 1998,
Sackett, 1997, Eddy, 1996) that the use of algorithms and care pathways based
on clinical research will help in standardizing care and providing the neces¬
sary ingredients for effective diagnostic and counseling interventions. The
goal is to make the client management guideline the accepted professional
behavior and a reward in itself (Griffith, 1999). To the extent that this is suc¬
cessful, five components that occur: (1) the clinical guideline is widely used
and becomes habitual, (2) multidisciplinary professionals can use it to antici¬
pate care events, (3) counselors can use it as a shorthand or outline to guide
their decisions and their communications to others. The individual plan
becomes the exception to the guideline, (4) the logistics for delivering the
guideline components are convenient and reliable. Intermediate methods or
strategies in the guideline must be readily available and delivered uniformly
in terms of quality and timeliness, and (5) the guideline defines the measures
of performance and incorporates information collection that can be used for
its evaluation and improvement. The individualized plans counselors may
use also contribute information for guideline revision.
26 Miller
Figure 2
Model Algorithm for Elder Abuse Intervention
A MODEL ALGORITHM OF CARE FOR VICTIMS OF ELDER ABUSE
Clinical algorithms and care pathways delineate specific timelines in

which intervention should occur. They further address the decision-making
process, the clinical services offered and the potential interactions among
multi-disciplinary health care professionals and providers for specific needs
of patients referred. Clinical information systems capable of supporting the
functional requirements of comprehensive critical pathway also provide
direction to the development and implementation of algorithms appropriate
for change (Miller and Veltkamp, 1996). The clinical algorithm for an abusive
situation or for family violence is summarized in Figure 2. Sometimes the
client will present with symptoms or complaints not of the abuse but of some
other related symptomatology. The clinical algorithm moves through the his¬
tory and systems review, the identification of symptoms and the diagnostic
criteria for acute and/or chronic trauma. It also considers symptoms, specific
treatment and supportive care, and how the counselors can reassess and mon¬
itor an abusive situation over time.
The care pathway delineates the specific timelines in which assessment
and treatment or interventions must occur. Note with specificity the impor¬
tance of the legal and ethical responsibilities within the abuse spectrum.
Specific emphasis here is on reporting child and adult abuse to the appropri¬
ate local state Department of Social Services unit. In addition, specific infor¬
mation related to office management for clients who present with problems
associated with domestic violence are summarized in Figure 3, the care path¬
way or guideline for domestic violence. These become the critical ingredients
to be considered in a care pathway that would provide standardized care and
treatment for the victim of domestic violence and abuse.
CLINICAL INTERVENTIONS AND LEGAL CONSIDERATIONS
Counseling of an abused person and/or the perpetrator is a complex

process, which may involve a multidisciplinary team. Collaboration, cooper¬
ation, mutual respect, and understanding of each other's roles are essential to
the success of the therapeutic process. The reporting law recognizes the need
for open communication in the area of abuse and recognizes no privileged
relationships beyond the attorney-client relationship. Siblings must also be
addressed in abuse cases. In physical and sexual abuse cases, the siblings have
often been exposed to the same family themes as the victim; and in many
cases, the siblings may also have been abused. They may also feel guilty that
they had not attempted to intervene and stop the abusive pattern. The follow¬
ing are important areas for counselors to address:
1) Abide by all reporting laws and facilitate appropriate medical care

immediately.
2) Maintain the therapeutic relationship with the victim. The elder vic¬
tim's contact with the perpetrator should be monitored. Reducing the
28 Miller
Figure 3
Integrated Sample Care Pathway for Client
with Indicators of Elder Abuse
Activity Visit 1 Visits 2-5 Visit 6 Visit 8
Assessment Abuse PRN Depression

Screening Assessment Screening
Intervention Abide by Abuse focused Consider for

reporting Mental Health Individual
requirements Education & Counseling;
for abuse in Counseling Family
your Brief Therapy • Counseling
jurisdiction
Consults/ Internist Follow-up with Integrate

Assessment Psychologist consultant counseling and
Considered Psychiatrist recommenda¬
Mental Health tions
Counselor
OB/GYN
Client/Family Encourage client

Education and family edu¬
cation, review
“cycle of vio¬
lence” theory,
and encourage
victim-initiated
interventions
and control
degree of environmental change is crucial for children. Maintaining

the victim's relationship with peers, the community contacts, neigh¬
bors and church, are important to reduce risk of further problems.
3) Reduce risk for further abuse/neglect by providing suspected or
reported information to authorities as identified in state reporting
laws.
4) Refer to clinician specializing in elder abuse to monitor clinical indi¬

cators and assess if the victim is showing signs and symptoms of
abuse.
5) If victim cannot be protected in their home or living site, they should
be removed from the home environment through legal advocacy
referral often through the county attorney's office.
COMMUNITY RESOURCES
Miller and Veltkamp (1998) have summarized the spectrum of communi¬

ty resources available to the counselor and other health care professionals.
These include the following:
1) Safe shelters and 24-hour crisis line: Be aware of services that provide
a place where victims and perpetrators may call anytime, day or
night, to receive counseling, information, referrals, and screening for
abusive situations.
2) Counseling and casework services: These services are designed to
facilitate the victim's exploration of alternatives to being abused and
provide eventual return to the community and a non-explicated or
abusive relationship.
3) Legal advocacy programs: Programs such as these provide a legal
advocate to act as a liaison between the victim of domestic violence,
whether residing at a shelter or not, and the court system counselor's
should work closely with legal advocacy system.
4) Hospital advocacy program: This service provides a hospital advo¬
cate who will meet the victim at the hospital to provide information,
support, medical treatment and referrals to other medical and health
related professional services.
5) Perpetrator's Intervention Programs: This service provides perpetra¬
tors the opportunity to seek alternatives to violence and break down
the isolation they may feel and provide alternatives to physically, psy¬
chologically, and sexually abusive behaviors they have likely devel¬
oped as a part of their behavior pattern.
6) Community education: Counselors should participate in community
education and service programs on issues of domestic violence to
improve public awareness of the scope of abuse and family violence
in the community.
The Case of Asking Abuse Related Questions
Ron is a 67-year-old white married male veteran who suffered a brain

stem stroke seven years ago. He was currently in a semi-private room in a
skilled nursing facility. He is a quadriplegic with limited ability to communi¬
cate although his mental status shows he is oriented to time, place, person and
self.
30 Miller
He receives physical therapy, speech therapy and occupational therapy

along with routine medical and skilled nursing care. Ron has been showing
signs of depression and agitation but has been unable to communicate with
health care personnel other than through eye contact blinking and limited
efforts toward nodding his head.
During a monthly staffing, he was asked a number of routine medical and
clinically diagnostic questions with limited response. In a post staffing indi¬
vidual contact with the patient, he was asked the question "are you satisfied
with your care?" He responded with what seemed to be negative eye move¬
ments from left to right. Among the questions that followed, he was asked if
he was being abused in anyway. He indicated a positive response with his
eyes. Subsequently, it was discerned that he was being fondled regularly at
night by his roommate. The nursing home immediately moved the patient to
a private room, notified adult protective services by phone and initiated an
internal and external investigation. The perpetrator was isolated until the
investigation could be completed.
The results of both the internal and external investigation revealed a pat¬
tern of sexual abuse on the part of the perpetrator. The victim's depressive fea¬
tures subsided once he had been provided a safe environment and staff
responded to his abuse. Preventative steps taken included:
WEB-BASED RESOURCES
The Administration on Aging (AoA)
The Administration on Aging (AoA) is the only federal agency dedicated

to policy development, planning, and the delivery of supportive home and
community-based services to our nation's diverse population of older persons
and their caregivers. They provide critical information and assistance and
programs that protect the rights of vulnerable, at-risk older persons through
the national aging network. State elder abuse prevention activities include:
• Professional training, workshops for adult protective services person¬

nel and other professional groups, statewide conferences open to all
service providers with an interest in elder abuse, and development of
training manuals, videos, and other materials.
• Coordination among state services systems and among service
providers, creation of elder abuse hotlines for reporting, formation of
statewide coalitions and task forces, and creation of local multi-disci¬
plinary teams, coalitions and task forces;
• Technical assistance, development of policy manuals and protocols
that outline the proper or preferred procedures for assessment and
reporting.
• Public education, development of elder abuse prevention education
campaigns for the public, including media public service announce¬
ments, posters, flyers, and videos.
• AoA funds the national Center on Elder Abuse as a resource for pub¬
lic and private agencies, professionals, service providers, and individ¬
uals interested in abuse prevention.
Administration on Aging
U.S. Department of Health and Human Services
Washington, DC 20201
Email: aoainfo@aoa.gov
Website: http://www.aoa.gov
• Legislatures in all 50 states have passed some form of elder abuse pre¬
vention laws. Laws and definitions of terms vary considerably from
one state to another, but all states have set up reporting systems.
Generally, adult protective services (APS) agencies receive and inves¬
tigate reports of suspected elder abuse.
National Center on Elder Abuse (NCEA) - www.edlerabusecenter.org

Elder Abuse Prevention - www.oaktrees.ore/elder/
The National Elder Abuse Incidence Study -
www.aoa.gov/abuse/report/default.htm
Elder Abuse Preventon - Administration on Aging Fact Sheet -
www.aoa.gov/factsheets/abuse/html
NCPEA Home Page - www.preventelderabuse.org/
MEDLINEplus: Elder Abuse -
www. nlm.nih. go ve / medlineplus / edlerabuse .html
Elder Abuse and Neglect: In Search of Solutions -
www.apa.org/pi/aging/eldabuse.html
Elder Abuse Law - www.elderabuselaw.com/
Actions on Elder Abuse - freespece.virgin.net/man.web/aea/
Elder Abuse in the United Kingdom - www.elderabuse.org.uk/
CONCLUSION
In the case of elder abuse, health care professionals must be sensitive to a

standardized model and respond to the needs of individuals who have been
victimized through elder abuse. A model algorithm for abuse is summarized
herein as is a standardized care pathway that is beneficial to the new para¬
digms of health care delivery. Health care professionals must understand the
transforming paradigms effecting health care service provision through man¬
aged care and that practice guidelines are a critical ingredient in today's
health care environment.
Several therapeutic approaches may be beneficial with elder abuse situa¬
tions (Westcot and Dries, 1990) but much depends on the competencies and
abilities of the victim of elder abuse. All are dependent on therapists taking
the time to get to know the unique aspects of the victim-perpetrator situa¬
tions. Assessment of the unique as well as universal aspects of elder abuse
32 Miller
always precedes therapeutic interventions. To effectively treat victims of elder

abuse, therapists must help them work together as a team systematically.
(Gladding, 1998).
Solution-focused therapy may be particularly helpful to elder abuse vic¬
tims because it helps them focus on certain aspects of their lives by finding
exceptions to difficult situations and doing something different (deShazeer,
1991; O'Hanlon and Weiner-Davis, 1989). The emphasis on making small
changes is ideally suited to elder abuse victims in which there is much unrest
and the ability to participate in therapeutic work is limited because of
demands and fatigue. However, if victims perceive when they are in harmo¬
ny with each other, they can then focus their energy and efforts on cultivating
these exceptional times and in the process make significant and healthy
changes.
Bowen family therapy is employed because of its emphasis on resolving
the past and examining historical family patterns (Bowen, 1978). Through the
construction of a genogram, perpetrators may come to notice and deal with
the absent person or persons that have influenced them positively or nega¬
tively previously. For example, a solo parent may realize he is still trying to
live up to the words of his mother who admonished him to "stay married at
all costs" and "always put your children's needs before your own." In the
process of constructing a genogram, such "ghosts" from the past lose their
power to interfere with the family's present interactions because they are rec¬
ognized as historical figures over which one has control (Goldenberg and
Goldenberg, 1994).
Experiential family therapy, especially as advocated by Virginia Satir
(1967), may be useful for elder abuse victims in helping their family members
enact metaphorically—through sculpting and choreography—troublesome
and unresolved situations. The feelings that arise in connection with these
symbolic experiences often experience affective relief from circumstances they
can no longer influence or control.
Regardless of what theoretical approach is employed with elder abuse
victims, health care professionals should keep in mind the intervention must
be tailor made to the needs of the victim and the circumstances of the abuse.
This will require special attention to the physical, psychological, emotional,
and dynamic complexity of the abusive situation.
Health care professionals should determine the applicability of these
evolving concepts to their organizations and evaluate the impact on the qual¬
ity and continuity of health care delivery with respect to all clinical disorders
including the impact of elder abuse on health and adjustment of clients. The
algorithm and care pathway only provide a framework. Health care providers
should systematically operationalize and implement health care delivery to
victims of elder abuse. Success of prevention programs, as well as interven¬
tion strategies, will depend on competencies of health care providers in mak¬
ing fundamental use of standardized models of assessment and intervention
in cases of elder abuse.
Acknowledgements
The authors wish to acknowledge the assistance of Lane J. Veltkamp M.S.W., Brenda
Frommer, Dale Dubina, Tag Heister, Deborah Kessler, Breston Britner, Ph.D., Beth
Alexander, Ph.D,.Carrie Ogtz, Celena Keel, Shannon Nelson, Tina Lane, Amber Alexander,
and Robert Kraus, M.D for their contributions to the completion of this chapter.
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York: Plenum.
Conte, J.R., Berlinger, L., and Schwerman, J. R. (1987). The Impact of Sexual Abuse on
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Eddy, D.M. (1996). "Guidelines—How Should They Be Designed?" Clinical Decision
Making: From Theory to Practice. Sudbury, MA: Jones and Bartlett, 34-40.
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Gladding, S. T. (1998). Family Therapy. New Jersey: Prentice Hall Publishers.
Griffith, J.R. (1999). The Well Managed Health Care Organization. Chicago, Ill: Health
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Incidence and Severity of Child Abuse and Neglect. Washington, D. C.: U. S. Government
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Russell, D. (1983). The Incidence and Prevalence of Intrafamilial and Extrafamilial Sexual
Abuse of Female Children. Child Abuse and Neglect, 7,56-63.
Sackett, D.L. (1997). Evidence-Based Medicine: How to Practice and Teach EBM. New York:
Churchill Livingstone Publishers.
Veltkamp, L. J. and Miller, T. W. (1990). Clinical Strategies and Recognizing Spouse Abuse.
Psychiatric Quarterly, 61 (3): 181-189.
Veltkamp, L. J. and Miller, T. W. (1994) Clinical Handbook of Child Abuse and Neglect.
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Handbook of Adult Abuse and Exploration. Madison CT: International Unversities Press
Incorporated.
'
■
4
CAREGIVER STRESS AND
NURSE/HEALTH THERAPIST
IDENTIFICATION OF ABUSE IN THE
HOME
Denise Bender
In the late 1980s, responding to the national interest in elder abuse,

Congress used the Omnibus Budget Reconciliation Act to enact major reforms
for the nursing home industry (OBRA, 1987). Institutional standards required
in order to qualify for Medicare and Medicaid funds were amended to
improve the training and competency of caregivers working with the institu¬
tionalized elderly (42 USC §§ 1395i-3, 1987; 42 USC § 1396r, 1987). As a result,
health care providers working in hospitals and nursing homes became sensi¬
tized to watch for abuse, particularly among institutionalized patients.
Institutional initiatives such as ombudsman programs, increased staff
scrutiny, and training programs to educate those who came into contact with
the elderly residents did help to safeguard those living in long-term care set¬
tings. While these Federal actions brought about important reforms in the
management of the problem of elder abuse, the changes had little impact on
the safety of community dwelling elders. There is a lack of knowledge and
awareness in the general public about how to identify and appropriately
respond to abuse, especially when the questionable behavior occurs in a home
environment (Wieland, 2000). As already observed with the issues of child
abuse and domestic violence, social attitudes shape ideas about what type
and severity of behavior is required before an action is considered abusive
(Reay and Browne, 2001). Many adult children would deny that expressing
verbal frustration about the failure of a parent to function at a level of overly
high expectations could be considered mental abuse. Others would view their
failure to monitor the safety of an older adult as a momentary lapse in judg¬
ment, rather than as neglect (Nadworny, 1994). Health providers, keenly
aware of the piecemeal nature of many elder care arrangements, might ration¬
alize that a caregiver willing to provide even a marginal quality of care was
better than nothing at all. Episodes of elder abuse could be excused or over¬
looked, because busy home care providers did not know which questions to
ask or felt unprepared to label observed behaviors as abuse (Marshall, Benton,
and Brazier, 2000).
A study by Lachs (1998) reinforces the urgent need for some type of mon¬
itoring of elders living in the community. His research found that the risk of
35
36 Bender
death was more than three times higher for those elders with a history of
abuse (1998). National statistics from Adult Protective Services (APS) report¬
ed that 49% of the reports of abuse that it receives concerning community¬
dwelling elders could be substantiated (Teaster, 2000). Although another 39%
of the reports were eventually dismissed as unsubstantiated, the APS data
clarified that this dismissal does not mean that abuse did not occur. The dis¬
missal may have been granted because the burden of proof demanded by the
state was not met (NEAIS, 1998). Demographics on the frequency of elder
abuse uniformly agree that the reported rate of incidence of abuse reflects
only a small portion of the actual occurrence of abuse (Pillemer and Finkelhor,
1988). These statistics identified an under-protected group of elders that
encompasses all races, genders, and economic groups. The dignity of living
and aging safely in one's own home was denied to them and they often lived
at the mercy of their caregivers.
It is difficult to monitor what goes on in the privacy of a private home or
apartment. Many aging, but independently living adults do not routinely
interact with persons other than family. It is not atypical for an elder to have
outlived friends or to have moved away from long-term support systems in
order to live closer to a child. The onset of a noticeable decline in physical
mobility or development of an illness is often the first time that community
dwelling elder must begin on-going contact with outside persons.
Unfortunately, brief contact with medical persons is sometimes inadequate to
allow identification of an abusive situation.
The doctor usually has the first contact with an older adult who has prob¬
lems managing changes in medical or functional status. This point-of-entry
role identifies the physician as the first professional who has an opportunity
to screen for the possibility of elder abuse. Ideally, any suspicious changes
would be noticed immediately based on the long-standing relationship of
trust and familiarity that existed between the physician and the patient
(Jogerst, Dawson, Hartz, Ely, and Schweitzer, 2000). Since the onset of man¬
aged care, research shows that the doctor-patient relationship has changed
significantly. In a survey on the impact of managed care on physicians' prac¬
tice, results indicated physicians feel they have less time for their patients
because of an increased emphasis on productivity (Feldman, Novack, and
Gracely 1998). The shortened length of visits leaves physicians with little
opportunity to closely observe and question the patient for physical and emo¬
tional health issues related to abuse, especially if the patient is not forthcom¬
ing about the problem (Hoban, 2000).
Many older persons with significant changes in health status require multi¬
disciplinary home care services. A physician's referral to a home care agency
involves several other professional disciplines with the patient. This includes
home health agency nurses and physical therapists who fulfill an important role
in detection of elder abuse. In addition to the examination of discipline specific
health related issues, each of these professionals assesses the general well being
of the patient and family environment. This improves the likelihood that abuse
will be detected and addressed. (Swagerty, Takahashi, and Evans, 1999).
The home care nurse usually acts as the home care services coordinator
for a particular patient. The nurse monitors the care provided by therapists,
aides, and others to ensure that all of the patient's needs are met. Providers
such as physical therapists and nurses often have frequent enough interac¬
tions to develop on-going relationships of trust with the patient. During that
time, the physician may only be involved peripherally in the care, and actual¬
ly see the patient only a few times. Through shared documentation, routine
medical examination procedures, and peer conversations about interactions
with the patient, family, and/or caregivers, these team members have many
opportunities to share suspicions and work together to identify and intervene
in abusive or potentially abusive situations (Holland, Kasraian, and
Leonardelli, 1987; Wieland, 2000).
This on-going proximity to the older patient highlights the importance of
therapists and nurses recognizing and accepting a primary role in the identi¬
fication of abuse. All 50 states and the District of Columbia have passed laws
that established adult protective services and defined some level of profes¬
sional responsibility for reporting suspected abuse. Currently, the criteria for
determining which professionals are required to report abuse include physi¬
cal therapists and nurses (http://www.elderabusecenter.org). The American
Physical Therapy Association and the American Nursing Association both
require members to practice according to a strict code of ethics (APTA, 1999;
http://www.nursingworld.org/ethics/code). These codes charge members
of both professions with the duty to protect the safety and dignity of all
patients. Elder abuse puts both the dignity and the safety of older patients at
risk, and tolerance of abusive behaviors would violate these codes.
Home care professionals may overlook the signs and symptoms of elder
abuse in a home care patient because of preconceived beliefs about who typi¬
cally comprises the segment of the population (Wolfe, 1998). As in all other
forms of family violence, elder abuse statistics show that the problem occurs
in all social and cultural demographics (Nadworny, 1994). There is no area in
the United States that can be identified as having an abnormal prevalence of
elder abuse, although APS reporting percentages are higher in the western
states (NEAIS, 1998). The expected victim of elder abuse is a single Caucasian
female over the age of seventy-five who is financially dependent and either
physically or mentally impaired (Bradley, 1996; NEAIS, 1996). Within this cat¬
egory, certain sub-populations who are more at risk than others. Many abused
older persons are depressed or confused (Wolfe, 1998). Approximately 75% of
abuse victims are no longer independent in the performance of self-care activ¬
ities (NEAIS, 1998). The presence of one or any combination of these impair¬
ments significantly increases the physical and psychological demands of care
giving (Wolf, 1997).
There is no formula to distinguish between the caregiver who will be able
to cope with these responsibilities and the one who will retaliate with abuse.
Elder abuse is classified as a form of intimate abuse (Wolfe, 1998) and
although not always the case, the abusers often occupy a relationship of trust
with the older adult (Marshall, Benton, and Brazier, 2000). According to a
38 Bender
national report from APS; the abuser frequently fits within an identifiable pro¬
file. Typically, the abuser is a Caucasian male between the ages of 40 and 59
(NEAIS, 1998) who has a familial tie to the abusee (Teaster, 2000). The primary
relationship between abuser and victim is that of an adult child with the
spouse or life partner identified as the second most prevalent category (Wolfe,
1998; NEAIS, 1996). Caregiver involvement with alcohol or drug abuse is
commonly found among abusers (Hyde-Robertson, Pirnie, and Freeze, 1994;
Swagerty, Takahashi, and Evans, 1999).
There are various theories offered to explain the reasons that abuse
occurs. Some abuse is attributed more to caregiver stress than to a malicious
desire to hurt an older person (Marshall, Benton, and Brazier, 2000; Sengstock
and Barrett, 1993). Caregivers with a limited understanding of the burden
they have accepted, or with physical, financial, or emotional stresses directly
related to the care giving role may feel justified in engaging in abusive behav¬
iors toward the family member (Nadworny, 1994).
A home health care provider is in an ideal position to monitor family
dynamics and to continually assess both situational stress, and the quantity of
stressors occurring within a short period of time at each visit (Hyde-
Robertson, 1994; Sengstock and Barrett, 1993). Johnson (1991) identifies sever¬
al key primary and secondary caregiver stress factors that place a patient at
greater risk for abuse. The primary factors include isolation, perceived bur¬
den, dependency (financial and physical), and stress (Fusco, 1991; Holland,
Kasraian, and Leonardelli, 1987). Of secondary impact, but more remediable
from the nurse and therapists' viewpoint, are issues of amount of knowledge
and understanding about the process of aging, and lack of exposure to
resources to remediate this lack of awareness. Caregivers with little knowl¬
edge concerning which behaviors are typical in aging persons may develop
unreasonable expectations and feel increased levels of frustration with their
tasks. Unfamiliarity with the services available for respite, emotional support,
medical information, and financial assistance within the caregiver's commu¬
nity can contribute to a feeling of helplessness and isolation (Hoban, 2000).
The mere existence of any or all of these factors in a care giving relation¬
ship is not a definite harbinger of abuse. The individual caregiver's ability to
adjust to, and cope with, any or all of these factors on an on-going basis pro¬
vides the best indicator of the likelihood that abuse will occur. A nurse or
physical therapist who includes the home care patient's environment as an
essential component of their overall health assessment may be able to identi¬
fy and address coping problems exhibited by caregivers before the abuse
begins.
Despite great strides in awareness of the existence of elder abuse, the actu¬
al and suspected incidence of abuse, as documented by the NEAIS report and
the National Center on Elder Abuse strongly suggest that many potential
opportunities to identify abuse are missed (NEAIS, 1998). Even the compre¬
hensive nature of the nursing and physical therapy assessments may result in
observation of abuse-related symptoms but fail to properly identify or inter¬
vene when abuse has occurred. The fault for this can be attributed to two rea-
sons. Until recently, elder abuse was not viewed as an important and fre¬
quently encountered medical issue. As a result, didactic information on elder
abuse was either not included or addressed in an abbreviated manner in
many professional curriculums (Hazzard,1995; Woodtli and Breslin, 2002).
Students were not taught to routinely screen for abuse related findings or
instructed as to appropriate questioning techniques designed to elicit this
information (Woodtli and Breslin, 2002). Unless serious injury or a significant
number of unexplained physical injuries were present, busy home care prac¬
titioners often accepted the explanations provided by either the caregiver or
the older adult. The abused patients, often embarrassed by the events or in
fear of retaliation by the abuser, can add to the confusion by downplaying
injuries or attributing the suspicious findings to other, more benign causes
(Bradley, 2000; Harrell, Toronjo, McLaughlin, Pavlik, Hyman, and Dyer, 2002).
The second reason for failure to identify the problem relates to the expec¬
tation of the health provider to encounter normal and expected age-related
changes. The physical and cognitive signs and symptoms of elder abuse are
not always unexpected or clearly attributable to a specific cause. Seemingly
suspicious signs and symptoms such as hair loss, bruising, weight loss, dehy¬
dration, falls, and mental confusion are also signs and symptoms of medical
changes related to aging (Bradley, 1996; Wolf, 1997). This makes it difficult for
a home health provider to identify abuse with certainty. Elder abuse is more
likely to be detected if the initial and subsequent evaluations of a patient's
health status by a physical therapist or nurse consider the possibility that
physical abuse may have occurred since the last visit. A heightened sense of
awareness during all patient interactions increases the likelihood that a
provider can detect a pattern of atypical findings. This type of pattern indi¬
cates that further investigation is needed.
Detection of elder abuse begins when the multi-disciplinary home health
team members first encounter the patient (Swagerty, Takahashi, and Evans,
1999). A patient interview traditionally begins the evaluation process, allow¬
ing the nurse and therapist to gather related medical information while
assessing the cognition, psychological status, and home environment. Ideally,
the presence of the caregiver is minimized during the interview to allow the
provider a chance to develop a rapport with the patient (Swagerty, Takahashi,
and Evans, 1999). The refusal of a caregiver to leave a competent patient alone
with the practitioner during the interview is the first potential sign that the
care giving relationship may not be appropriate. This behavior can be the
result of a desire to help the provider obtain complete and accurate informa¬
tion, or it can suggest an attempt to direct and perhaps limit the interview
(Hoban, 2000). Although the provider should make every effort to interview
the adult patient in privacy, if the patient consents to the other person's pres¬
ence, the provider must allow it.
There are also times when the cognitive or physical status of the patient
limits the ability to accurately respond to questions. When it is necessary to
interview the caregiver for information, the therapist or nurse should perform
the interview in the presence of the patient (APTA, 2000). This interview
40 Bender
yields not only medical information, but allows the provider, to assess the
caregiver's knowledge of aging, environmental stressors, attitude toward the
patient and expectations concerning the amount of care needed by this patient
(Hoban, 2000). If possible, the patient can later be asked to confirm or modify
the responses provided by the caregiver.
The presence of the caregiver should not add a third person to the patient-
provider relationship. Caregiver involvement in the interview might be nec¬
essary to provide information, but the allegiance of the therapist or nurse is to
the patient alone. Behaviors including interruption of the patient, contradic¬
tion of the information provided by the patient, or attempts to either bond or
control the interview process should raise questions in the provider's mind
concerning the caregiver. These actions may suggest the existence of an abu¬
sive relationship. The therapist or nurse, while mindful of the need to avoid
antagonizing the caregiver, must explore this possibility further if any of these
behaviors are noted.
Through use of direct and indirect questioning, the provider can structure
an interview to create opportunities for the patient to confide (Swagerty,
Takahashi, and Evans, 1999). Direct questioning, which consists of asking
whether abuse has occurred or if anyone in the home has hurt the patient or
similar questions, is one option. Its benefits include a decreased likelihood of
misunderstanding the intent of the question and a chance to directly observe
the patient's response. In the early stages of establishing rapport, the patient
may not trust the provider enough to honestly answer the question. The
phrasing of questions could inadvertently suggest to the patient that there is
a particular response the provider wishes to receive. Other patients, particu¬
larly in situations where no abuse is occurring, may feel offended or uncom¬
fortable. The provider must make every effort to keep the questions and the
tone of the interview non-judgmental and comfortable (Marshall, Benton, and
Brazier, 2000).
Indirect questioning, which consists of asking more open-ended ques¬
tions about issues related to abuse, is another option. Questioning patients
about feelings of fear elicited by anyone involved in their life can provide
opportunities for unstructured conversation that yield information a provider
may not typically solicit. A potential problem with an indirect approach is the
vague nature of the questions. A patient may misinterpret the question and
respond inaccurately. Alternatively, a patient may respond to the question by
providing an equally indirect response, thus providing information that could
be wrongly interpreted by the provider.
Whether direct or indirect questioning is attempted, a nurse or therapist
should adopt a standardized series of questions to ensure that the screening is
adequate to detect all forms of elder abuse. There are many questionnaires in
use today. Most include a mixture of direct and indirect style questions and
build in a deliberate repetitiveness to the series of questions to allow exami¬
nation of answers for consistency. The Elder Assessment Instrument (EAI)
screening tool is one example of a comprehensive questionnaire that can be
quickly completed by any provider during a home visit to identify potential
issues of neglect and abuse (Fulmer, 2003). Originally intended for use in a
busy emergency room, it is equally suitable to incorporate into the initial
home care evaluation performed by either the nurse or the physical therapist.
(2003)
The physical examination portion of the evaluation is usually performed
after the interview. In addition to the routine assessments of medical status,
functional mobility, and self-care ability, there are particular behaviors,
responses, and physical findings that might suggest elder abuse is a problem.
Although the term "elder abuse" can encompass an entire gamut of behaviors
that cause injury to an older adult, the National Elder Abuse study identified
seven main categories of abuse (NEAIS, 1998). The four categories described
below are the types of abuse most likely to be encountered and identified by
therapist or nurse during home visits.
NEGLECT
Neglect is the considered the most common type of elder abuse (Bradley,
1996; Fisher and Dyer, 2003) and accounts for 48.7% of the occurrences
(NEAIS, 1998). Demographic figures indicate that women make up a dispro¬
portionate percentage of this category (NEAIS, 1998). The two distinct types
of neglect include caregiver neglect and self-neglect (APTA, 2000). In neglect,
as compared to physical abuse, the therapist or nurse is not always able to
find physical signs and symptoms to justify suspicions. It may be only a per¬
ceived inadequacy of care that makes a provider look more closely at a care
giving situation.
Caregiver neglect includes the failure to provide the physical and emo¬
tional supports necessary to either prevent harm to the patient or to ensure
that the patient is able to function at the highest possible level (AMA, 1994, p.
10). Possible explanations include, but are not limited to, caregiver ignorance
concerning appropriate care, inadequate level of assistance, financial con¬
straints, or unwillingness of the older adult to accept care giving assistance
(Marshall, Benton, Brazier, 2000). Self-neglect may be determined when a
patient engages in behavior that places health or safety at risk, whether the
decision stems from conscious choices or an inability to perform self-care.
According to a nationwide study (NEAIS, 1998), the APS receives more
reports of self-neglect than of caregiver neglect. Home health providers
should closely monitor independently living patients with a medical diagno¬
sis of depression for signs of self-neglect. Using these operational definitions,
nurses and therapists may identify the presence of neglect even in situations
where the older patient or the caregiver tries to provide an adequate level of
care (APTA, 2000; AMA, 1994; Marshall, Benton, and Brazier, 2000).
Neglect, whether self-initiated or due to inadequate assistance from a
caregiver, might easily be missed due to its subtle presentation. It can appear
deliberate, as seen in a refusal to provide the essential level of care required to
maintain health and safety or inadvertent, as shown by inadequate knowl¬
edge or a lack of concern for safeguarding the safety or health of a patient.
42 Bender
Caregivers may override questions concerning the appropriateness of care by

attributing the signs of neglect to depression, uncooperativeness, or general
cognitive deterioration. Although no single sign is indicative of neglect
(APTA, 2000; AMA, 1994; Bradley, 1996), home care providers should watch
for evidence of:
Inappropriate Decision-Making on Behalf of the Elder
Examples may include the provision of clothing that is inadequate for the
weather, minimal attention or concern about potential falls risks in the home,
or failure to comply with the recommended medication or treatment pro¬
grams. The nurse or therapist should question the caregiver if any of these are
observed, and monitor the situation to identify any observable pattern of
unsafe choices on behalf of the patient.
Living Environment
The caregiver of a dependent patient may have difficulty keeping the home
environment as clean as the health provider may desire, especially if there are
pets or a number of people living in the home. There are also cultural and soci¬
etal factors that affect how someone chooses to live. It is important to avoid
making a judgment of neglect merely because someone chooses to live in a
manner that is different than what is typically encountered. Therapists and
nurses should look for evidence that significant and potentially dangerous liv¬
ing conditions exist. These may include infestations of insects or rodents, food
and dirty dishes left on counters for extended periods of time, lack of heat, or
deterioration of the housing structure (APTA, 2000; AMA, 1994).
General Deterioration of Health and Well Being
The home care therapist or nurse should suspect neglect when the physi¬
cal appearance of the patient seems unsatisfactory. While isolated episodes of
soiled clothing or bedding, urine or fecal stains on clothing, body odor, or
untrimmed hair and fingernails can be found in any patient, repeatedly not¬
ing some combination of these elements should arouse suspicion. Failure to
provide or maintain dentures, glasses, hearing aids, and other assistive equip¬
ment necessary for the patient's daily function without adequate reason also
suggests neglect (Hoban, 2000). The home care team needs to first determine
that the caregiver and patient understand the importance of routinely using
these devices before making any determination that a caregiver is deliberate¬
ly withholding them.
EMOTIONAL ABUSE
Emotional abuse accounts for approximately 35.4% of the reported cases

(Bradley, 1996). The term "emotional abuse" includes conduct that causes psy-
chological anguish in older adults (AMA, 1994 p. 10). This distress may be
caused by either verbal or non-verbal behaviors (Hoban, 2000; Hogstel and
Curry, 1999; Marshall, Benton, and Brazier, 2000) exhibited by the caregiver.
These behaviors may include:
Inappropriate Interactions Between Caregiver and Older Person
The nurse or therapist may overhear or have a patient report receiving

threats of present or future harm insults, derogatory comments, or general dis¬
respect from a caregiver. For those statements not directly observed, the health
provider needs to evaluate the frequency of the statements and any special cir¬
cumstances surrounding the events before taking any action. Providers also
need to be alert to evidence of isolation of the older person, whether from com¬
munity activities or within the house itself. Locks placed on the outside of bed¬
room doors may suggest that a caregiver is locking the patient into the room.
Un-emptied commodes, evidence of previous meals, and unauthorized
restraint use may indicate that the patient remains in one room for most of the
day. Conversations with the caregiver can help the provider decide if these
action were taken to ensure the client's safety, to minimize the caregiver bur¬
den, or in an attempt to isolate or punish the older adult.
FINANCIAL ABUSE
Despite its prevalence (Bradley, 1996; Hogstell and Curry, 1999), financial
abuse is difficult for the nurse or therapist to identify. A certain amount of finan¬
cial co-dependency between the older adult and the caregiver can exist without
any incidence of abuse. An older adult may no longer have the ability or inter¬
est to manage financial issues and may choose to vest this authority in a care¬
giver. Abuse occurs when another person deliberately violates a position of
trust (either actual or implied) and misuses or misappropriates an older adult's
financial resources for personal gain (APTA, 2000; AMA, 1994), and was found
to occur in 30.2% of the reported incidents (Bradley, 1996; NEAIS, 1998).
The issue of financial abuse is difficult for the home care therapist or nurse
to recognize because they usually have few discussions with the patient or fam¬
ily about financial issues. Financial stability is a constant worry for many older
adults. Attitudes toward money vary according to culture, socialization, and
custom, and what may seem abusive behavior by an adult child could reflect a
personal money management choice by the parent. Some older adults fear out¬
living their resources and insist upon engaging in unnecessary cost-saving
activities in attempts to stave off poverty. Despite these variations, financial
behaviors that might trigger suspicions in the health care providers that impro¬
priety has occurred include:
Changes in Living Circumstances
When physical or cognitive health deteriorates, an adult caregiver may

move into the home of the older adult to provide supervision and assistance.
44 Bender
This arrangement sometimes results in a shared responsibility for shopping,

bill payments, and other money-related issues. This can be a mutually benefi¬
cial relationship. A health provider should become suspicious if valuable or
expensive items disappear from the home without the patient being able to
explain the absence. Overheard arguments between the older person and the
caregiver concerning the need to borrow money should also alert the provider
to the need to monitor for potential abuse in this area. Events that might sug¬
gest greater scrutiny should be paid to the potential for this type of abuse
include:
A Significant Change in The Older Adult's Standard of Living
The food or clothing supplied for the patient should be monitored to

detect any marked decrease in quality or quantity. This should be compared
to the standard of living enjoyed by the caregiver.
Reports of Unexpected Changes in an Elder's Ability to Meet

the Costs of Health Care
Medications, disposable supplies, and equipment are the most costly ele¬
ments in a home patient's plan of care. Many older adults living on a fixed
income do have problems covering unexpected or prolonged expenses. Health
providers should remain alert for comments that suggest an older person now
needs to ask the caregiver for permission to incur an expense, or was told that
he/she could no longer afford to purchase a necessary item. Home care services
may be abruptly discontinued, citing cost as the reason, even though the care is
still obviously needed and the costs have not significantly changed. An older
patient may confide that caregivers are demanding access to checks or to bank
accounts or insisting that modifications to wills are made. Although not specifi¬
cally health related, financial abuse affects the overall well being of the patient.
Its detection falls within the scope of practice of a home health practitioner.
(APTA, 1999; http://www.nursingworld.org/ethics/code).
PHYSICAL ABUSE
Physical abuse is identified in 25.6% of the reported incidents (Bradley,

1996; NEAIS, 1996). It is defined as actions that result in physical injury or
potential injury to the elder and includes all acts of violence that result in pain,
injury, impairment, or disease (AMA, 1994). Commonly identified acts of phys¬
ical abuse include slapping, pushing, shaking, inappropriately restraining,
pinching, and beating (APTA, 2000). Despite its lower rate of occurrence when
compared to neglect or financial abuse, this is the type of abuse that a nurse or
physical therapist may identify more readily, since it tends to elicit more recog¬
nizable signs and symptoms. Commonly observed findings may include:
Patches of Baldness with Bruising or Bloody Appearance in The Scalp
While thinning hair is commonly found with aging, someone who

remains supine in bed or restrained in a high-backed chair or recliner for pro¬
longed periods of time may show increased hair loss along the back of the
skull. The home care aide might report an unwillingness of the patient to have
the hair washed or combed, or an observation of blood on the bed linens.
Varied Colors of Bruising Layered in the Same Location
Bruising easily occurs in the geriatric population due to the fragile nature
of aging skin. A variety of colors of bruising may indicate the presence of
injuries in a variety of healing stages (Harrell, Toronjo, McLaughlin, Pavlik,
Hyman, and Dyer, 2002; Wolf, 1998). This suggests repeated trauma to the
area. The nurse or therapist should remain alert to environmental hazards that
could account for this finding, and should discuss these observations with the
patient and caregiver before concluding that abuse may have occurred.
Bruising in Atypical Locations or with a Shape that Suggests Contact with

a Cord, Tape, Hand, or Other Object
Bruises due to accidental trauma are often irregularly shaped and in areas
(e.g. tibial crests, shoulders, forehead or lateral hips) that frequently bump
against objects in the home environment. Bruising along the breasts,
abdomen, thighs, or buttocks are less commonly incurred in everyday activi¬
ties and discovery of these should be questioned (AMA, 1994; APTA, 2000;).
Findings of burns, handprints on upper arms or face, loosened teeth, broken
dentures or glasses, or any unexplained swelling without an associated
episode of trauma should also elicit suspicions of abuse (Harrell, Toronjo,
McLaughlin, Pavlik, Hyman, and Dyer, 2002).
Decubiti Present in an Ambulatory Patient
Older persons with limited mobility are at a higher risk for development
of pressure ulcers, even with the best of care (Brandeis, Berlowitz, and Katz,
2001). Prolonged sitting can lead to pathological tissue pressures within
hours. The pressure problem is exacerbated for a person with incontinence of
bowel or bladder since the prolonged pressure will affect tissues that are
already at risk due to moisture. Homebound patients who are restrained to a
chair for prolonged periods by belt, straps, or by elevation of the footrest are
at a greater risk to develop pressure sores (2001). Health professionals should
question the onset of redness, tenderness, or skin breakdown in the areas of
the coccyx, sacrum, or ischeal tuberosities, especially when noted in a patient
who is not bedridden (Hoban, 2000). Observation of the wrists, ankles, and
torso of the patient may reveal chafed and reddened areas that suggest unau¬
thorized restraint use has occurred.
46 Bender
Inappropriate Handling of Patient by Caregiver
Caregivers, especially informal family caregivers, may have little training

or experience in how to safely transfer or ambulate with older persons. Family
assistance offered during mobility activities often appears clumsy, rushed, or
inappropriate, even when provided with the best of intentions. Despite this,
therapists and nurses should not observe instances of rough handling, push¬
ing, pinching, or prodding when the caregiver interacts with the older person.
Careful attention to the attitude and the interaction between the caregiver and
the elder person during movement activities allows the provider to distin¬
guish between inexperience and malicious intention (Harrell, Toronjo,
McLaughlin, Pavlik, Hyman, and Dyer, 2002).
SEXUAL ABUSE
Older adults of sound cognition are still sexual beings capable of engaging
in consensual sexual activities. Abuse occurs when the adult does not consent
or is incapable of consent to behaviors ranging from exposure to rape. At a fre¬
quency of 0.3% (Bradley, 1996), the low percentage of reports of sexual abuse
seems to suggest that it is not much of a problem for the older population. Just
as is suspected for elder abuse in general, there is a strong likelihood that older
persons, particularly women, may not report sexual abuse. There are a variety
of reasons to explain this. Women who grew up in a time when sexual issues
were not routinely discussed might lack the words or the comfort level to dis¬
cuss what has happened. When the sexual abuser is a spouse or partner, the
abused person may not know that the behavior could qualify as abuse (Basile,
2002). The physical therapist may want to consider the possibility of sexual
abuse if unexplained changes in a patient's mobility or sitting comfort are
observed. The nurse and the aide may identify bruises along breasts, thighs,
and abdomen when assisting with the intimate tasks of toileting and bathing.
Other observations that might arouse suspicion in providers include:
Evidence of Sexual Activity
The presence of blood or semen on the sheets or undergarments of the

older adult who is sexually inactive suggests abuse.
Report of Sexual Abuse by a Patient
An older person may make a direct statement or indirect questioning by

the therapist or nurse about suspicious findings may elicit the report that sex¬
ual abuse has occurred (Pritchard, 1992).
INTERVENTION
The main responsibility of a home health provider is to identify that an

abusive situation actually exists. Accurate identification demands a high level
of evaluative skills and clinical judgment from the provider, as well as an

awareness of those subpopulations most likely to at risk for abuse (Sengstock
and Barrett, 1993). Most home care agencies have policies that direct a thera¬
pist or nurse to discuss suspicious findings with the health care team and
supervisor to confirm that abuse exists. Each provider should carefully docu¬
ment the behaviors, statements, and physical findings that indicated the pres¬
ence of abuse. If granted permission by the patient, the inclusion of photo¬
graphs of bruises, burns, or ligature marks provide additional visual support
for the statements (AMA, 1994; APTA, 1999;).
The next step, taking action to intervene, is a more involved task. There is con¬
siderable variation in both the reporting requirements, the investigatory authority
of each state's elder abuse statute, and in the severity of the civil and criminal
penalties associated with the elder abuse (http://www.abanet.org/aging/). All
states have a "good Samaritan" protections offering immunity from criminal or
civil liability if a health provider, acting in good faith, reports a suspicion of elder
abuse (AMA, 1994; APTA, 2000). Despite this protection, home health practition¬
ers might feel unprepared or unwilling to make the decision that abuse exists
and intervention is needed (Marshall, Benton, and Brazier, 2000). Reasons range
from a fear of legal reprisals (AMA, 1004), concern over possible misidentifica-
tion of abuse (Hazzard, 1995), and lack of familiarity with reporting standards
and procedures (Marshall, Benton, and Brazier, 2000). Information on identifica¬
tion, intervention, and management of elder abuse should be woven through the
didactic and the clinical components of all health providers' curriculum
(Hazzard, 1995). Expanding the number of opportunities for interdisciplinary
interaction with case studies and problem-based learning experiences help stu¬
dents to understand their roles and responsibilities in the detection of elder
abuse. These experiences also familiarize each discipline with the scope of exam¬
ination and assessment done by the other providers likely to interact with the
home care patient.
Professional development from continuing education courses is an
important part of improving the understanding and comfort of practicing
home health providers with the reporting requirements for elder abuse
(Jogerst, Dawson, Hartz, Ely, and Sweitzer, 2000). In addition to discussing the
requirements and procedures for a particular state, the educational module
must also explain the limitations of the APS ability to intervene. Professional
ethics demand that the home health providers document all findings and con¬
tact the APS about suspected abuse regardless of the patient's willingness to
seek help (APTA, 1999; http://www.nursingworld.org/ethics/code). When
notified of an abusive situation, APS will investigate and make recommenda¬
tions. At this point, the momentum of the intervention may halt. A competent
older adult, unlike an abused child, may choose to refuse intervention
(Harrell, Toronjo, McLaughlin, Pavlik, Hyman, and Dyer, 2002; Swagerty,
Takahashi, and Evans, 1999). Even if no intervention is presently accepted, the
information generated by the home health provider is still important. APS
and the home care agency will have a file of previous reports to use if more
episodes occur in the future.
48 Bender
Another important responsibility of home care nurses and physical ther¬

apists requires them to go beyond the step of simply identifying and report¬
ing episodes of elder abuse. The best interests of the patient are not served if
a health provider feels no responsibility to take action until abuse has
occurred. Patient-centered management of a home care patient requires an ini¬
tial evaluation of the caregiver-patient dynamics as part of the overall assess¬
ment of medical factors (Reay and Browne, 2001). The role in home care filled
by physical therapists and nurses allows close contact with any aides, family
members, and other persons who come into regular contact with the older
adult. Willingness to engage these persons in conversations about the impact
of the care giving responsibilities on their lives allows providers to proactive¬
ly identify potentially abusive situations and offer assistance (Hyde-
Robertson, 1994).
Decreasing the caregiver burden through enhancing awareness of com¬
munity resources is an essential duty of the health care team (Holland,
Kasraian, and Leonardelli, 1987). Appropriate community resources include
medical education seminars, support groups, and respite activities.
Depending on state and local resources, these community-based interventions
are designed to meet the family caregiver's need for access to current medical
information and emotional support through interaction with persons facing
similar stresses. The nurse or therapist needs to tailor these recommendations
to fit the circumstances of the caregiver. According to Alexy (2000), many care¬
givers who are referred and would like to participate in these community
activities face barriers to their participation in traditional support group. The
constant on-call nature of care giving responsibilities can make it impossible
for those who most need support to regularly attend any scheduled group
meeting. The therapist or nurse involved in the case has the level of knowl¬
edge of the range of available community resources to assist the caregiver in
finding one that fits. Suggestions for respite care, recommendations for more
appropriate assistive equipment, and frank conversations about the caregiv¬
er's perception of burden should be part of every initial patient contact.
Elder abuse is not an easy problem to manage. It typically comes to the
attention of the medical profession only after physical or emotional damage
has already occurred. More education and resources are required to prepare
health providers and community agencies to develop a more comprehensive
approach to support older adults in the community. Home health therapists
and nurses, because of their familiarity with the aging population, can pro¬
vide valuable insight concerning the physical, social, financial, and support¬
ive needs of community dwelling older adults.
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Marshall, C.E., Benton, D., and Brazier, J.M. (2000). Elder Abuse. Using Clinical Tools to
Identify Clues of Mistreatment. Geriatrics, 55(2), 45-53.
Nadwomy, S.W. (1994). In the Best of Families: Crossing the Line into Neglect. Caring,
46-48.
National Center on Elder Abuse. (1998). National Elder Abuse Incidence study(NEAIS):
Final Report. The National Center on Elder Abuse at the American Public Services
Association in Collaboration with Westat, Inc.
Omnibus Reconcilliation Act 1987.
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Pillemer, Kv and Finkelhor, D. (1988). The Prevalence of Elder Abuse: A Random Sample
Survey. The Gerontologist, 28(1), 51-57.
Physical Therapist Code of Ethics, Alexandria, Va: American Physical Therapy Association;
1999.
Reay, A.M., and Browne, K.D. (2001). Risk Factor Characteristics in Carers Who
Physically Abuse or Neglect Their Elderly Dependants. Aging and Mental Health,
5(1), 56-62.
Sengstock, M.C., and Barrett, S.A. (1993). Abuse and Neglect of the Elderly in Family
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Violence (pp. 173-208). St. Louis, MO: Mosby.
Swagerty, D.L, Takahashi, P.Y., and Evans, J.M. (1999). Elder Mistreatment. Am Pam.
Phys, 59(10), 2804-2808.
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5
UNDERSTANDING ELDER ABUSE
IN MINORITY POPULATIONS
Paulina Ruf
THE AGING OF MINORITY POPULATIONS IN THE UNITED STATES
According to the 2000 U.S. Census, there are approximately 35.0 million
people 65 years of age and over in the United States, representing 12.4 percent
of the total population (Hetzel and Smith, 2001). The Census Bureau projects
that the population age 65 and older will exceed 70 million by 2030 (Hollmann
et al., 2000). The "graying" of the U.S. population has received a great deal of
attention in the past decades. Until recently, however, this attention was
focused on the White, non-Hispanic population. The increasing numbers of
racial and ethnic minorities in the United States—what Henry (1990) called
"the browning of America"—has significantly changed the composition of the
elderly population (Angel and Hogan, 1992; Hayes-Bautista et al., 2002).
Currently, about 16 percent of those 65 years of age and over are members of
a racial/ethnic minority group. In the future, this percentage is expected to
increase significantly. For instance, by 2030, the older minority population is
expected to reach about 26 percent of the total 65 years old and over popula¬
tion in the United States (Day, 1996).
The youthfulness of the Hispanic population tends to overshadow the
growing number of Hispanics 65 years of age and over (Gelfand, 1994). In
2002, there were 37.4 million Hispanics in the United States, 5.1 percent of
whom were 65 years of age and over. In contrast, approximately 14.4 percent
of the White, non-Hispanic population was 65 years of age and older. The
highest proportion of individuals 65 and older was among Cuban Americans
(22.6 percent), and the lowest was among Mexican Americans (4.0 percent)
(Ramirez and de la Cruz, 2003). In addition, the number of elderly Hispanics
is expected to quadruple by the year 2020 (Andrews, 1989).
African Americans are now the second largest minority group in the U.S.
after Hispanics. In 2002, there were approximately 36 million African
Americans in the U.S., 8 percent of whom were 65 years of age and over
(McKinnon, 2003). Often referred to as the "model minority" (Hurh and Kim,
1989), the Asian and Pacific Islander population numbered 12.5 million in
2002, and 7 percent of this group were 65 years of age and over (Reeves and
Bennett, 2003). In the 2000 U.S. Census, 4.1 million or 1.5 percent of the popu¬
lation reported American Indian and Alaska Native ancestry (Ogunwole,
2002). Of these 259,663 or about 6 percent were age 65 and over (U.S. Census,
2002).
51
52 Ruf
Over the past decades, we have seen a significant increase in the number
of studies involving the older minority population. However, there are still
many areas where our understanding of the minority experience of growing
old is limited and plagued by misconceptions and stereotypes. One such area
is elder abuse. For many years it was assumed that elder abuse could not pos¬
sibly exist among racial and ethnic minorities because of family dynamics that
emphasize respect and solidarity (Anetzberger et al., 1996; Carson, 1995;
Sung, 2001).
ELDER ABUSE IN THE UNITED STATES: CULTURAL IMPLICATIONS
Our awareness of the existence and magnitude of elder abuse has

increased dramatically in the last decades (Wolf, 2000 and 1988). The best
available estimates suggest that between 1 and 2 million people age 65 and
over have been mistreated in some way by a care provider (Bonnie and
Wallace, 2003). With the baby boom generation approaching 65, we can spec¬
ulate that the incidence of elder abuse will increase significantly, and that
these violations will be reported.
According to the National Elder Abuse Incidence Study (1998), about
551,011 persons aged 60 and over experienced abuse, neglect, and/or self¬
neglect in homes in 1996. Of these cases, only 21 percent were reported to and
substantiated by adult protective service agencies. The same study revealed
that people aged 80 and older and women are more likely to be abused and
neglected. In terms of race /ethnicity, the findings of this study suggest that
although the majority of reported cases involve White, non-Hispanic elderly,
African-American elderly are over-represented in neglect, financial/material
exploitation, and emotional/psychological abuse. This finding was support¬
ed by Dimah and Dimah (2002), who found that 48 of the 107 substantiated
elder abuse cases from one elder abuse provider agency in Illinois, involved
African American victims.
In a 2000 survey conducted by the National Center on Elder Abuse, 17
percent of reported cases involved African Americans, about 10 percent
involved Hispanics, 0.9 percent involved Native Americans, and 0.4 percent
involved Asians and Pacific Islanders. Hudson et al. (1999) found that 9.2 per¬
cent of African Americans and 4.3 percent of Native Americans reported being
abused after age 65. In short, these data suggest that older minority popula¬
tions may be over-represented among victims of elder abuse (see also Hall,
1987). However, making such generalizations from the findings of these stud¬
ies is difficult. They generally include small numbers of minority elders, are
limited to specific locations around the country, and also differ in the types of
elder abuse studied.
The reality remains that the majority of the research studies about elder
abuse focus on the white, non-Hispanic population. Further, the authors of the
studies that included minority victims did not consider the effect race and eth¬
nicity have on perceptions of elder abuse (Brown, 1989; Griffin, 1994; Hudson
and Carlson, 1999; Moon and Williams, 1993). In fact, many states have only
recently started collecting race/ethnicity data involving elder abuse cases

(Tatara, 1999). In a survey of state adult protective services conducted by the
National Center on Elder Abuse (Teaster, 2000), only 24 states responded to
the "race/ethnicity of victims" question.
Definitions of abuse and neglect are socially constructed and reflect cul¬
turally defined norms and values regarding acceptable and unacceptable
behavior. In a diverse society such as the United States, considering the fast¬
growing older minority population, it is crucial that we clarify how elder
abuse and neglect are defined by the different racial/ethnic groups (Brownell,
1997; Chang and Moon, 1997; Davidhizar et al., 1998; Hudson et al., 1999;
Williams and Griffin, 1996; Wolf and Donglin, 1999). The few studies that have
considered the impact of culture on definitions of elder abuse have found sig¬
nificant differences in the ways racial/ethnic groups define elder abuse
(Hudson and Carlton, 1999; Hudson and et al., 1999; Moon and Benton, 2000;
Moon and Williams, 1993). For instance. Moon and Williams (1993) found that
Korean Americans were more tolerant of abusive behaviors than White, non-
Hispanic and African American elderly. Moon and Benton (2000) found that
White, non-Hispanic elderly were more tolerant of verbal abuse, while
Korean American elderly were more likely to tolerate financial exploitation. In
addition, Hudson and Carlson (1999) found that Native Americans rated
behaviors as more abusive than African Americans and White, non-Hispanics.
Further, some studies have found older minority populations more reluctant
to report abuse (Le, 1997; Moon and Williams, 1993; Moon and Benton, 2000;
Sanchez Y., 1999; Tomita, 1999).
The studies, then, suggest that cultural norms and values do influence
how individuals define abuse. And, although more research is needed, there
is sufficient evidence to suggest the need to increase our understanding about
the impact of culture on individuals and groups' definitions of abuse. This is
particularly important for policy-makers and service providers as they plan
and implement services and treatment protocols dealing with elder abuse.
ELDER ABUSE AMONG LATINOS
Although the Latino elderly population is the fastest growing segment of

the elderly population, there are still major gaps in our understanding of their
aging experiences in the United States. The research is particularly limited in
the topic of elder abuse (Sanchez Y., 1999). The National Center on Elder
Abuse (1998) found that Hispanic elderly were underrepresented among vic¬
tims of elder abuse. The most common type of abuse substantiated was neg¬
lect, and older Hispanics accounted for 2.7 percent of all these cases. However,
researchers speculate that because of language barriers, misinformation, and
legal status (i.e., illegal immigrants), the occurrence of elder abuse among
Hispanics, like among other non-English speaking populations, is underre¬
ported (Otiniano, et al. 1997).
In a study of elder abuse in the Mexican American communities of Carson
City, Nevada and Detroit, Michigan, Y. Sanchez (1999) found that 33 percent
54 Ruf
of the participants reported being aware of at least one incident of elderly

abuse among members of their Mexican American community. The most com¬
mon forms of abuse cited were denial of shelter (40.3 percent) and neglect
(22.6 percent). Physical abuse accounted for 11.3 percent of reports of abuse.
Also, over 70 percent of the participants stated that they would discuss the
problems with family members before contacting the authorities if they were
being mistreated by family members. Only 17.9 percent of the Michigan sam¬
ple and 10 percent of the Nevada sample stated that they would contact
authorities under these circumstances. The author found that shame was an
important factor in understanding elder abuse in Mexican American families.
In this context, shame is accompanied by a sense of "losing face," in that if a
family member is the perpetrator of abuse and/or neglect, it brings shame to
the whole family. This explains, at least in part, the participants' reduced like¬
lihood of contacting authorities about abuse when the perpetrator is a family
member. This lack of reporting also reflects familismo, a cultural value that
emphasizes family loyalty and integrity, which largely dictates the behavior
of individual family members. Thus, Mitchell and colleagues (1999) found
that understanding family dynamics is an important step in the provision of
protective services to Mexican American clients. Montoya (1997) said it best,
"Hispanic culture acts as both an asset that prevents abuse and provides
resources to combat it as well as a liability that acts to hide abuse" (p. 16).
According to official statistics cited by C. Sanchez (1999), the number of
reports of elder abuse in Puerto Rico increased from 342 reports in 1980 to over
5,000 reports in 1996. In addition, she examined the existing literature regard¬
ing elder abuse among Puerto Ricans. The first research study that attempted
to assess the existence of elder abuse in Puerto Rico was conducted by Munoz
in 1985 (as cited by C. Sanchez, 1999). This researcher found that neglect was
the most common form of abuse, and psychological abuse was the least com¬
mon form of abuse reported by the participants. In this study, slightly over 50
percent of the abuse was perpetuated by a son or daughter and only 10 percent
was perpetuated by a spouse. Munoz also found a correlation between age and
dependency, in that as each of these increased so did the frequency of abuse. C.
Sanchez (1999) also discusses research conducted by Arroyo and colleagues in
1992 where professionals and practitioners that provide services to older
Puerto Ricans in community centers and home healthcare services were inter¬
viewed regarding their experiences and awareness of elder abuse in the Island.
About 75 percent of the participants reported at least one incident of elder
abuse in the previous 12 months, and like in previous studies, a son or daugh¬
ter was most likely the perpetrator of the abuse.
However, as with other ethnic groups, the actual number of abuse and
neglect cases among older Hispanics is unknown. This is largely due to the
older person's unwillingness to report abuse when the perpetrator is a family
member, which is most often the case. Very much like within the Mexican fam¬
ily, familismo plays a significant role in the unwillingness to report an abusive
family member among Puerto Ricans. Another cultural value that appears to
prevent Hispanic victims, including Puerto Ricans, from disclosing both the
abuse and the abuser is personalismo. This value requires that the dignity of
individuals is maintained and respected. Also, personalismo means that service
providers should establish personal, trusting relationships where disclosure of
abusive behaviors can take place (Montoya, 1997; C. Sanchez, 1999). For serv¬
ice providers this means that developing trusting, personal relationships with
Hispanic clients is very important. It is likely to facilitate the provision of serv¬
ices, and more importantly, increase the likelihood that victims of elder abuse
would acknowledge the abuse and perhaps identify the abuser(s).
ELDER ABUSE AMONG AFRICAN AMERICANS
According to The National Center on Elder Abuse (1998), among the

reported cases of elder abuse 18.7 percent involved older African Americans
and 8.3 percent of substantiated cases of elder abuse involved this population.
The most common type of abuse experienced by this population was neglect
(17.2 percent), followed by emotional/psychological abuse (14.1 percent), and
physical abuse (9.0 percent). As mentioned earlier, older African Americans
appear to be overrepresented among victims of elder abuse. However,
research on elder abuse among African Americans is limited making any
assertions nearly impossible. As with other minority groups, the lack of focus
on the impact of culture on definitions of elder abuse is a barrier to our under¬
standing of this experience among African Americans (Cazenave, 1979;
Hudson, et al., 1999; Moon and Williams, 1993; Williams and Griffin, 1996).
The few studies that have examined how African Americans perceive
elder abuse suggest that there are differences between this population and
other groups in how elder abuse is perceived and defined (Anetzberger, et al.,
1996; Griffin, 1994; Hudson, et al., 1999; Moon and Williams 1993). For
instance, Anetzberger and colleagues (1996), who conducted focus group dis¬
cussions with middle-aged and older members of four ethnic groups, found
that African Americans were more likely to recognize the common forms of
elder abuse, and were the only participants to recognize financial exploitation
as a form of abuse. Interestingly, Griffin (1994) found that financial exploita¬
tion was the most prevalent type of elder abuse. Also, Moon and Williams
(1993) found that older African Americans were more likely than others to rate
the different scenarios presented to them as abusive. Hudson and colleagues
(1999), using a random sample of adults in North Carolina, found that a larg¬
er percentage of African Americans (9.2 percent) reported being abused as
elders than other groups, supporting the findings of the National Center on
Elder Abuse (1998). In addition, these researchers also found that African
Americans not only supported the common definitions of elder abuse, but
they also considered one occurrence of behaviors defined as elder abuse was
sufficient to merit the label. For these participants, older people should be
treated with love and respect, and thus elder abuse was unacceptable.
Changes in the family structure among African Americans, coupled with
the impact of economic forces, have resulted in an increasing number of older
African Americans living with other family members. These increasing num-
56 Ruf
bers of multigenerational households make older African Americans more

vulnerable to abuse and exploitation (Benton, 1999; Dimah and Dimah, 2002;
Griffin and Williams, 1992). Also, studies suggest that the lack of services
available for the caregivers of individuals suffering from dementia and frail
older family members is a contributing factor of elder abuse in the African
American community (Benton, 1999). These findings, along with the project¬
ed growth of the older African American population, indicate that the occur¬
rence of elder abuse in this population will grow in the future.
As in other populations, substance abuse is a risk factor for elder abuse
(Galbraith, 1989). In fact, Longres (1992) found that the perpetrator of elder
abuse among African Americans was less likely to live with the victim and
provide care, and more likely to have substance abuse issues. However,
research focusing on the perpetrator of elder abuse among ethnic minority
populations is particularly limited. Nonetheless, this finding poses an inter¬
esting question for future research, especially if we consider the impact of
illicit drug use and abuse among minority populations. Also, Benton (1999)
suggests that the high rate of domestic violence among African Americans is
a significant risk factor for elder abuse, since the abuse continues as the cou¬
ple ages.
ELDER ABUSE AMONG ASIAN AND PACIFIC ISLANDERS
According to the National Center on Elder Abuse (1998), older Asian and
Pacific Islanders are underrepresented among victims of elder abuse. For this
population, the most common types of abuse were emotional and physical
abuse, but Asian and Pacific Islanders represented only 0.4 percent of these
cases. In 2000, a survey of adult protective service agencies found that 0.4 per¬
cent of all substantiated cases of elder abuse involved Asian and Pacific
Islanders. However, there is evidence that the occurrence of elder abuse
among Asian and Pacific Islanders is significantly underreported. For
instance, in 2001 about 10 percent of active cases of elder abuse in San
Francisco, California, involved Asian Americans (Manigbas, 2002). The major¬
ity of these cases (6.8 percent) involved Chinese Americans. Still, because
Chinese culture prevents family members from sharing problems with non¬
family members, it is speculated that the actual number of elder abuse cases
among Chinese Americans, as well as other Asian and Pacific Islander groups,
is much larger. Also, Chang and Moon (1997) found that a significant percent¬
age of Korean immigrant elders (34 percent) reported seeing or hearing about
at least one incident of elder abuse. For these elders, lack of respect for the
elder and not allowing him/her to live with an adult child constitute mistreat¬
ment. Hence, abuse was perceived only within family relationships, particu¬
larly the parent-child relationship.
Traditional Asian cultural norms emphasize family allegiance and respect
for older members. Thus, not caring for one's parents would reflect negative¬
ly on the family (Gelfand, 1994; Sung; 2001). However, there is evidence that
traditional norms are changing both among Asians in the United States and in
Asian countries. These changes are largely due to the effects of moderniza¬
tion, where adult children live away from parents and women join the paid
labor force and are thus unavailable to care for older family members
(Gelfand, 1994).
The research examining the impact of Asian and Pacific Islander cultures
on perceptions of elder abuse is quite limited. Moon and Williams (1993)
found that Korean-Americans were less likely than other groups to both
define scenarios as abuse and to seek help, especially from formal service
providers. Pablo and Braun (1997) conducted a study in Honolulu where the
same scenarios used by Moon and Williams (1993) were utilized. Pablo and
Braun found the local Asian American groups provided answers similar to
those of the White participants in Moon and Williams' research, which was
conducted in Minnesota. Pablo and Braun speculate that the different
responses between the two Asian groups may be due to the fact that Asian
Americans in Honolulu have access to culturally-appropriate services, where¬
as the Korean-Americans in Minnesota may not. Because the Asian partici¬
pants in Honolulu had been in the United States for a longer period of time,
the authors speculate that the traditional attitudes and practices of these
groups change over time, while at the same time many elders identify with
their ethnic background and its traditions.
Le (1997) found that, among a small sample of Vietnamese elderly in
California, the most common type of abuse was emotional, followed by ver¬
bal abuse. The emotional abuse of these Vietnamese elderly involved being
isolated from others, receiving the silent treatment, being threatened with
nursing home placement, or being harassed. Because tradition dictates that
sons are responsible for the care of their parents, participants reported having
problems with their daughters-in-law as well as with their own children. They
believed their daughters-in-law were jealous of the filial piety exhibited by
their husbands. Chang and Moon (1997) found similar results among Korean
immigrant elders, where daughters-in-law were seen as disrespectful and as
mistreating their mothers-in-law (see also Sung, 2001). In addition, Le (1997)
found that the elders facing abuse were more likely to be newcomers to the
United States, and those that came to the country with their children, were
less likely to experience abuse. This finding suggests that because of the diffi¬
culty of adjusting to a new culture, older family members become very
dependent on younger ones, and in turn become more vulnerable to abuse
(see also Manigbas, 2002). Like other older ethnic minorities, the Vietnamese
elderly in this study were reluctant to disclose abuse and neglect. Doing so
would bring shame to the family since it would indicate that filial piety was
not observed. Also, Vietnamese culture, like other Asian cultures, emphasizes
family preservation and reliance, which contributes to the underreporting of
elder abuse (see also Pablo and Braun, 1997; Tomita, 1999).
Tomita (1999) explored domestic violence, including elder abuse, among
Japanese Americans. He found that Japanese cultural norms required that
individuals place the group above the self, and that the culture emphasized
silent suffering and quiet endurance. As a consequence of adhering to these
58 Ruf
norms, victims of abuse only admitted to the abuse when the abuser was dead
or when they were sure no negative consequences could impact the family or
the abuser. Hence, service providers might need to use conflict-avoidance and
conflict-management techniques. Interventions should emphasize group har¬
mony, safety, and respite, rather than the resolution of the situation which is
emphasized by mainstream interventions.
ELDER ABUSE AMONG NATIVE AMERICANS
Despite the growing interest in elder abuse among minority populations,

very little attention has been given to Native Americans (Brown, 1999). The
National Center on Elder Abuse (1998) found that 0.2 percent of substantiat¬
ed cases of abuse involved older Native Americans, all of whom experienced
physical abuse. In a survey of state adult protective service agencies (Teaster,
2000), the Center found that 0.9 percent of substantiated elder abuse cases
involved Native Americans. The issue of underreporting elder abuse among
Native Americans is compounded by their social isolation (i.e., residing in
remote, rural areas) and their unwillingness to pursue mainstream services
(Baldridge, 2001; Carson and Hand, 1999).
In one of the earliest attempts to examine elder abuse among Native
Americans, Brown (1989) surveyed older Navajos and their family members,
and found that elder abuse clearly existed in this population. The most com¬
mon type of abuse reported was neglect, and other types of abuse were not
found to be very prevalent in this population. Interestingly, the author found
that as the elder became more dependent, the family responded by providing
more care. However, the care tended to be shared among family members,
which tended to result in neglect, largely because no one in particular was
seen as responsible for the care. On the other hand, when a single person was
designated the primary caregiver (usually a single or widowed daughter with
children), the increased burden of the situation usually resulted in neglect
and/or psychological abuse.
Maxwell and Maxwell (1992) conducted a study of elder abuse among
two Plains Indian reservations. The authors found that the significant eco¬
nomic depravation found in one of the reservations resulted in many cases of
elder financial exploitation and neglect. Further, the remoteness of the reser¬
vation and the lack of employment opportunities for young people increased
their dependence on the elders, many of whom received Supplement Security
Income and who owned the best land in the area. These factors exacerbate the
risk for elder abuse.
Hudson et al. (1999), using a random sample of adults in several diverse
counties in North Carolina, found that Native Americans were more likely to
label scenarios as abuse compared to their White and African American coun¬
terparts, and that they generally supported common definitions of elder
abuse. Like the African American participants, the Native Americans sampled
felt that one occurrence of abuse warranted the label. Also, this population
indicated that professional assistance should be provided in elder abuse cases.
although the authors did not include questions regarding what type of serv¬
ices should be provided or who should provide them. Native Americans eld¬
ers felt that older people should not only be honored and respected, but they
should also receive care if needed.
Similar to other older minorities, becoming dependent and frail increases
the risk for elder abuse among older Native Americans (Baldridge, 2001;
Brown, 1989). This is of particular concern given the high rates of disability
among Native Americans. In addition, the lack of community—and institu¬
tionally-based long-term care services for older Native Americans reinforces
their need to depend on informal care providers, especially family members
that are largely ill-equipped to deal with the elders' failing health (Baldridge,
2001). Because Native American cultures, in general, emphasize family and
tribal unity and interdependence, it is crucial that interventions reflect these
cultural values. Also, the significant impact of the many social problems that
plague Native Americans must be addressed (Brown, 1999; Carson and Hand,
1999).
Much more research is needed to understand the aging experiences and
elder abuse among Native Americans. Like Latinos and Asian and Pacific
Islanders, Native American nations are very diverse and geographically wide¬
spread. Future research efforts should focus on increasing our understanding
of how elder abuse is defined by the different Native American nations, it
should clarify the types and prevalence of abuse that are common in these
populations, and research should also focus on determining if there are signif¬
icant differences among urban and rural Native American populations. The
latter is particularly important for the development and implementation of
adequate interventions (Carson and Hand, 1999). Also, increasing our under¬
standing of the experiences of Alaska Natives should be a research priority.
ELDER ABUSE AMONG MINORITY POPULATIONS:

DEVELOPING AND IMPLEMENTING SERVICES
A review of the existing literature clearly suggests that the lack of atten¬
tion on culture is a major problem with current efforts to address elder abuse
among minority populations (see Tatara, 1999). The few research studies that
have explored the impact of culture on perceptions of elder abuse suggest that
it plays a significant role. Cultural norms and values not only impact how
elder abuse is perceived but also the likelihood that its victims will seek
and/or accept services. Also, the types of services that minority victims accept
are determined by culture (Nerenberg, 1999; Tomita, 2000; Wolf and Donglin,
1999).
Efforts to increase awareness and reporting of elder abuse among ethnic
minorities have generally taken two approaches (Nerenberg, 1999). An exam¬
ple of a direct approach is found in New York City's "That's Abuse" cam¬
paign, where posters depicting abusive situations and diverse ethnic groups
have been utilized. San Francisco's "We Are Family" project depicts a non-
direct approach. Rather than focusing on abusive behaviors, this project
60 Ruf
emphasizes the contributions of extended families and ways to support fam¬

ilies. The author suggests that it is important to recognize that outreach cam¬
paigns consider the target population. For instance, in San Francisco, where
the majority of older minorities are Asian and Hispanics, de-emphasizing
abuse is probably more effective since these populations are concerned with
maintaining the family's honor and integrity (Nerenberg, 1999).
Older minorities that are vulnerable to elder abuse (e.g., those who need
assistance) tend to live with relatives. Thus, planning for services and pro¬
grams that attempt to eliminate elder abuse should not only be sensitive to
cultural differences but also focus on interventions that facilitate caregiving
responsibilities and strengthen the minority family (C. Sanchez, 1999).
Further, Nerenberg (1999) suggests that to the extent that the minority family
is experiencing additional stressors such as unemployment, poverty, sub¬
stance abuse, and racism, the methods utilized by service providers may not
be perceived as useful or appropriate, particularly if they are viewed as divi¬
sive to family relationships. The author suggests that holistic approaches that
address the multiple stressors experienced by many families may be more
successful.
Moreover, because the "community" remains of great significance for eth¬
nic minorities in the United States, Quinn and Tomita (1997) suggest that com¬
munity cooperation is essential for an effective elder abuse system. In this
light. Wolf and Donglin (1999) found that socioeconomic status is correlated
with the reporting of elder abuse. The authors found that reports of elder
abuse were higher in low income areas where the public, many of them
minorities, had frequent and direct contact with state and federal agencies
which are mandate reporters. Hence, we suggest that the concept of commu¬
nity not only include the ethnic minority group itself, but also other service
providers and agencies, including religious organizations, that potential vic¬
tims of elder abuse come in contact.
Research also suggests that as immigrant groups become acculturated,
their attitudes and practices tend to change and may resemble those of the
majority population. In this light, although it is important to develop cultur-
ally-appropriate services to serve older ethnic minorities, it is also important
not to stereotype them and believe all will behave according to their ethnicity
(Pablo and Braun, 1997).
Despite increasing awareness of elder abuse in the United States, there are
still significant gaps in our understanding of this phenomenon. The preceding
sections have highlighted the little we know about elder abuse among ethnic
minority groups. However, it is clear that cultural norms and values play a
significant role in how we define elder abuse, whether or not we seek help—
especially from outsiders—and the types of services that we are likely to
accept. The proportion of older minorities is expected to increase significant¬
ly in the next decades. Without significantly increasing our efforts to better
understand the intersection of aging and culture, we will continue to fail to
address the needs of the very groups that have made the United States a cul¬
turally rich nation.
REFERENCES
Andrews, H. (1989). Poverty and Poor Health Among Elderly Hispanic Americans.
Baltimore, MD: Commonwealth Fund Commission on Elderly Living Alone.
Anetzberger, G., Korbin, J., and Tomita, S. (1996). Defining Elder Mistreatment in Four
Ethnic Groups Across Two Generations. Journal of Cross-Cultural Gerontology, 11(2),
207-232.
Angel, J., and Hogan, D. (1992). The Demography of Minority Aging Populations.
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'
. .
6
INTERNATIONAL/CULTURAL
PERSPECTIVES ON ELDER ABUSE
Mary Newman
Elder mistreatment has attracted increasing attention and concern world¬

wide over the last three decades. As the older population expands in devel¬
oped, and particularly in developing countries, the urgency for addressing and
dealing with these human rights violations mounts. Burston (1975, cited in Yan
and So-Kum Tang, 2003), Baker (1975) and Burston (1977) (both cited in World
Health Organizations, 2002) published the earliest reports of what they called
granny battering in British journals. Serious examination of this social crisis
began in the United States. Gradually other nations joined in the effort to iden¬
tify and prevent elder abuse. The number of studies, committees, social serv¬
ice agencies, and laws dedicated to the identification and prevention of elder
abuse continues to climb. Many nations recognize a history of elder abuse
within their borders. Some, for instance, Norway (Johns and Hydle, 1995) and
India (Nagpaul, 1997) see this as a new trend. Either way, increasing numbers
of nations and organizations are following the lead of the World Health
Assembly and World Health Organization (WHO) (see Krug, Mercy, Dahlberg,
and Zwi, 2002; WHO, 2002) in a global effort to prevent mistreatment of older
adults. This chapter examines the international literature for defining, identi¬
fying and addressing mistreatment of older adults. An effort has been made to
point out similarities as well as differences between nations.
DEFINING ELDER ABUSE OUTSIDE THE US
Once the topic of elder abuse had been voiced in the United States, defin¬
ing abuse posed the first challenge. The American Psychological Association
(APA) (2003) provides the following guidelines: Elder abuse is the infliction of
physical, emotional, or psychological harm on an older adult. Elder abuse also can take
the form of financial exploitation or intentional or unintentional neglect of an older
adult by the caregiver. The National Center on Elder Abuse (NCEA) (2004) sug¬
gests that such harm refers to any knowing, intentional, or negligent act by a caregiv¬
er or any other person that causes harm or a serious risk of harm to a vulnerable adult.
Defining and identifying elder abuse is difficult enough for those who
seek to study and address the problem within the dominant culture of the
United States. Take it outside of that culture, and particularly outside the
nation, and these challenges are amplified. However, given that similarities
and differences in the assessment and identification of abusive behavior have
been demonstrated between minority groups and immigrants living in the
65
66 Newman
U.S., (e.g., Moon, 2000; Chang and Moon, 1997 [cited in Moon, 2000]; see
Tatara, 1999, and Chapter 5 of current volume for reviews), similar patterns
might be expected between nations. Therefore, scientists endeavored to devel¬
op definitions that are general enough to be used in a variety of cultures (e.g..
Action on Elder Abuse, 2000; Australian Network for the Prevention of Elder
Abuse, 1999; National Center on Aging Abuse 2004; WHO, 2002; Yan and So-
Kum Tang, 2003), or to develop measurements specific for particular cultures
(e.g., Le, 1997) in order to make comparisons between nations.
Some progress has been made in this regard. The following definitions are
representative of those used by many investigators around the world:
The Australian Network for the Prevention of Elder Abuse (1999) pro¬
posed that elder abuse:
.. is any act occurring within a relationship where there is an

implication of trust, which results in harm to an older person.
Abuse may be physical sexual, financial, psychological, social
and/or neglect."
Action on Elder Abuse (2000) (United Kingdom), Australian Network for

the Prevention of Elder Abuse (1999), and the United Nations Commission for
Social Development (2002) endorsed a very similar definition:
“A single or repeated act or lack of appropriate action occurring

within any relationship where there is an expectation of trust which
causes harm or distress to an older person."
The World Health Organization settled on the following guideline:
The intentional use of physical force or power, threatened or

actual, against oneself, another person, or against a group or com¬
munity, that either results in or has a high likelihood of resulting in
injury, death, psychological harm, maldevelopment or deprivation
(Krug et al., 2002).
Canadians (National Clearinghouse on Family Violence, 2003) aligned

their definition with that of the National Center on Aging Abuse (2004), using
subcategories of abuse rather than a general definition. Those subcategories
include physical, sexual, emotional, and psychological abuse, abandonment,
neglect, self-neglect, and financial or material exploitation.
The Secretary-General of the United Nations (2002) provides an extensive
list of abuse typologies and examples of each.
Subcategories of Abusive Behavior
Whereas investigators disagree about a comprehensive definition, they

generally agree about some aspects of abusive behavior. For instance, there is
consensus concerning three categories of abuse: Most recognize that abuse

and neglect occur in the home, in institutions, and at the hands of some eld¬
ers themselves. Similar to the United States (e.g., American Psychological
Association, 2003; National Center on Elder Abuse, 1998), a variety of interna¬
tional investigators consider some or all of the following abusive: Verbal,
physical, psychological, sexual, legal, and financial abuse, and neglect (e.g.,
Au Coin, 2003; Hailstones, 1992; Jenkins, Asif, and Bennett, 2000; McCreadie,
Bennett, and Tinker, 1998; Nagpaul, 1997; National Clearinghouse on Family
Violence, 2003; Perttu, 1996; Reis, 2000; Sharon and Zoabi, 1997; United
Nations Secretary-General, 2002; WHO, 2002); and some also include self-neg¬
lect (e.g., Krug et al., 2002; National Center on Aging Abuse, 2004; National
Clearinghouse on Family Violence, 2003; Sharon and Zoabi, 1997). The World
Health Organization (2002) described structural and societal (e.g., govern¬
ment) abuse (United Nations Secretary-General, 2002; WHO, 2002). Kurrle
and Sadler (1994) in Australia added social abuse (family or other caregivers
limiting an older adult's access to social support and recreation) to the list.
CULTURE AND ELDER ABUSE
One of the factors that impacts the identification and tolerance of elder
abuse is culture, meant here to include differences based upon religion, eth¬
nicity, race, sexual orientation, rural versus urban locales, geographic, and
national origin. Reports of abuse and neglect are increasingly available for
some minorities within the U.S. (e.g., Le, 1997 - Vietnamese immigrants;
Moon and Williams, 1993 - Korean-Americans; Nagpaul, 1997 - Asian
Indians; Pablo and Braun, 1997; see Moon, 2000, and Tatara, 1999, as well as
Chapter 5 of the current volume for reviews), but are still relatively small in
number. Far fewer reports are available on a global level. At least five factors
probably account for the difficulty in conducting international comparative
studies of elder abuse, and the scarcity of information for some regions and
populations: 1) Cultural differences in defining and identifying abuse; 2) dif¬
ferential focus of cultures on the individual versus family and community; 3)
varying rights and privileges of females and males; 4) differing and changing
attitudes toward the elderly; and 5) the failure of some investigators to appre¬
ciate cultural differences, to use culturally sensitive means of data collection,
and to consider cultural variation in interpreting their findings (however, see,
e.g., Le, 1997). Despite the challenges, however, scientists continue to make
headway in understanding the phenomenon of elder abuse.
FIRST MULTINATIONAL STUDY OF ELDER ABUSE
Scientists representing the World Health Organization (2002), in collabo¬

ration with the International Network for the Prevention of Elder Abuse
(INPEA), spoke with focus groups of older persons and primary health care
providers in five developing (Argentina, Brazil, India, Kenya, Lebanon) and 3
developed nations (Canada, Austria, Sweden) in the first multi-national study
68 Newman
of attitudes about, and perceptions of elder abuse. The purpose of this project
was " ... to raise the awareness among health professionals and the public at large
about the problem of elder abuse world-wide, and to develop a global strategy within
the context of Primary Health Care for the prevention of elder abuse." Data from
each of these countries were combined, and primary types of abuse identified:
"... structural and societal abuse, neglect and abandonment, disrespect and ageist
attitudes, psychological, emotional and verbal abuse, physical abuse, legal and finan¬
cial abuse."
Findings by the World Health Organization (2002) pointed to differences
between cultures, and inequities in the status of the elderly as sources of stress
and resulting abuse. In a sample of 48 older adults in Buenos Aires, Argentina,
35% endured some type of abuse. Reports from Kenya, India and Brazil sug¬
gested that abuse and abandonment result from lack of health care benefits
from the government. Representatives of India, Lebanon and Austria called
attention to frequent conflict between women and their mothers-in-law, even¬
tually leading to various types of mistreatment (including physical abuse) and
neglect of the older women (WHO, 2002). Similarly, Soeda and Araki (1999)
reported that daughters-in-law in Japan were more likely than spouses or
adult children to neglect older family members. These reports are consistent
with the findings of Le (1997), who interviewed twenty elderly Vietnamese
immigrants to the United States. Older women who spoke only Vietnamese
were most vulnerable, and daughters-in-law often inflicted verbal and/or
emotional abuse. For Vietnamese elderly, being ignored, or given the silent
treatment was the harshest form of punishment, even more devastating than
physical abuse. Overall, elders from all eight nations suggested that disre¬
spect, which was inflicted by family members as well as governmental and
commercial institutions, constituted the worst form of abuse, and was the root
of all other forms of abuse. Women (particularly widows and those without
children) and poor elders were reported to be most vulnerable. The investiga¬
tors noted the reluctance of elderly participants to discuss elder abuse.
Members of the focus group in India actively avoided the topic of "physical
abuse" but acknowledged "mistreatment" of older persons.
PREVALENCE OF ELDER ABUSE
The relative incidence and reporting of these different types of abuse

varies somewhat between nations and between studies. For instance, in the
United States (e.g., American College of Obstetricians and Gynecologists,
2003; National Center on Elder Abuse, 1998) and in Japan (Soeda and Araki,
1999), neglect is reported to be the most common form of abuse. In Canada,
Wolf and Pillemer (1989) and Podnieks (1992) reported that financial abuse
occurs more frequently than other forms of mistreatment. In contrast, Au Coin
(2003) found that physical abuse is most common in Canada. Results of one
study in England suggest that older adults suffer verbal abuse most often;
physical abuse is second to that, followed by financial abuse (Ogg, 1993).
Verbal abuse occurred most frequently in a Dutch study (Comijs et al., 1998,
cited in Bonnie and Wallace, 2003), and in a Canadian institutional study

(College of Nurses of Ontario, 1993). Jenkins and colleagues (2000) in the
United Kingdom, Perttu (1996) in Finland, and Nagpaul (1997) studying
Asian Indians found evidence that psychological abuse was more prevalent
than other types. Differences in results may be attributed to variations in lan¬
guage, culture, and research methodology.
Despite the challenges of conducting research on this topic, estimated
rates of mistreatment in some, but not all, developed countries are remarkably
similar. The World Health Organization (2002) reports abuse and neglect in
the U.S. of approximately 4-6%. Estimates of abuse in other countries are com¬
parable. For instance, Podnieks (1990) estimates an abuse rate of 4% based
upon a Canadian national survey. Other Canadian studies (e.g., Podnieks and
Pillemer, 1990; Podnieks, 1992) suggested a 3-5% abuse rate. An Amsterdam
study revealed that 5.6% of older adults were abused (Comijs, Pot, Smit and
Jonker, 1998, cited in Bonnie and Wallace, 2003). Ogg and Bennett (1992)
found a similar abuse rate in Great Britain. In a small Finnish town, Kivela,
Kongas-Saviaro, Kesti, Pahkala, and Ijas (1992; cited in Bonnie and Wallace,
2003) found a 5.7% rate of abuse. Australian figures also indicate a rate of
approximately 4.6% to 5.4% (Sadler, Kurrle, and Cameron, 1992).
However, there are studies from some regions that provide evidence of
much higher rates of abuse and neglect. For instance, Yan and So-Kum Tang
(2001) learned that 20.8% of older Chinese adults in Hong Kong had been ver¬
bally abused (e.g., insults, swearing, intimidation), and two percent reported
physical abuse (e.g., being hit, burned, physically restrained). The United
Nations Secretary General (2002) gathered information on developing nations
from crime and news reports, welfare reports and small studies, and conclud¬
ed that 20% of a sample of 50 older adults from rural India suffered neglect,
and 45% of a sample of older adults in Argentina reported abuse, frequently
psychological abuse.
The data from these and other projects should be interpreted with cau¬
tion. It will be necessary to interpret the data in cultural context; to verify the
validity and reliability of the data given variability in definitions and method¬
ology; and to determine the level of reliability of these reports given customs
in cultures as diverse as Argentina (Hurme, 2002; South Africa (United
Nations Population Fund, 2002), and Vietnamese (Le, 1997), and Chinese pop¬
ulations (Yan, So-Kum Tang, and Yeung, 2002) to deny or hide mistreatment
of elderly persons. More extensive research is required before any genuine dif¬
ferences between cultures can be more clearly identified. Another caveat
regarding these statistics: Most studies have been conducted in urban areas
and in developed countries (Nelson, 2002; WHO, 2002). In one of the few
studies of rural populations, the rate of abuse in northwest New South Wales
was estimated at 5.5%, similar to the findings in urban areas (Cupitt, 1997).
The United Nations Secretary General (2002) estimated physical abuse in a
rural area of India to be approximately 4%, whereas a 20% neglect rate was
found in an urban area. In a study of 120 abused and 120 non-abused Arabs
living in Israel, Sharon and Zoabi (1997) found a significantly lower incidence
70 Newman
of abuse (including self-neglect) at 2.5%. Persons over 65 years of age com¬

prise only 3.7% of the Arab population living in Israel. These authors report¬
ed higher rates of abuse in urban areas and lower rates in rural areas. A proj¬
ect in Western Australia suggested an abuse rate of less than 1% (Centre for
Research into Aged Care Services, 2002). Despite limitations in the volume
and interpretation of existing research, there is little doubt that violation of the
rights of older adults to adequate care and freedom from mistreatment is a
worldwide problem. Awareness of the abuse and commitment to its preven¬
tion began slowly, but continue to grow due to the efforts and dedication of
local, national and international organizations around the globe.
Several international organizations and campaigns provided the impetus
and guidance this movement needed. The World Health Assembly released a
report in 1996 calling attention to the problem of violence, including elder
abuse, worldwide. This organization set as its goal the prevention of violence.
The declaration of 1999 as the International Year of Older Persons by the
United Nations helped to raise awareness of the plight of the elderly. The
United Nations (1999) drafted the Principles for Older Persons. The intention of
this document was to add life to the years that have been added to life, based upon
the U.N.'s Declaration on the Rights and Responsibilities of Older Persons. The
United Nations Economic Council promoted the worldwide recognition of,
and attention to the mistreatment of older adults by providing a report on def¬
initions and types of elder abuse in anticipation of the World Assembly on
Ageing (United Nations Secretary General, 2002). This report discussed a
number of categories of abuse such as those listed above, as well as specific
examples of abuse and neglect within those categories. That same year, the
World Health Organization followed up with the first report of its kind, the
Global Campaign on Violence Prevention (see Krug, Mercy, Kahlberg and Zwi,
2002), hoping to gain support at all levels of society from local to internation¬
al, with particular involvement of public health professionals. Thirty-plus
nations subsequently joined in the dialogue, some developing policies
addressing the problem, and launching their own campaigns against violence
(WHO, 2002).
As motivation and guidance increased at the international level, individ¬
ual nations were inspired to follow suit for the protection of their older citi¬
zens. For instance, Kuwait adopted its own Declaration on the Rights of Elderly
at the 12th Medical Juristic Symposium on the Rights of Elderly from an
Islamic Perspective (1999). Numerous other countries have also adopted poli¬
cies and formed organizations for the support and protection of their older cit¬
izens. Those actively involved in the movement include New Zealand (Age
Concern New Zealand, 2004), New South Wales (1996), Australia (Prevention
of Elder Abuse Task Force, 2001), Canada (Canadian Network for the
Prevention of Elder Abuse; International Network for the Prevention of Elder
Abuse), Japan (Japanese Center for the Prevention of Elder Abuse), Latin
America (Latin American Committee for the Prevention of Elder Abuse), just
to name a few. As these and other nations reveal their findings, victimization
of older adults becomes increasingly visible.
WHO ARE THE PERPETRATORS AND VICTIMS?
The National Center on Elder Abuse published a report in the United

States (1998) that outlined typical characteristics of the victim and perpetrator.
Risk of abuse increased dramatically with age. Particularly vulnerable were
those individuals with the lowest incomes, those who required more care, or
who suffered from depression or confusion. Approximately equal numbers of
men and women were perpetrators, although women were much more likely
to neglect their victims, and men were guilty of other types of abuse.
Perpetrators tended to be younger than their victims, and most were family
members (mostly adult children) or spouses.
Much speculation concerning a profile of the typical perpetrator and vic¬
tim appears in the international literature. Conflicting reports suggest some
difficulty in characterizing these two groups (e.g., Jenkins et al., 2000;
National Clearinghouse on Family Violence, 2003; Reis, 2000; Reis and
Nahmiash, 1995; National Center on Elder Abuse, 1998) Estimations regard¬
ing the relative number of male versus female perpetrators vary. Some of this
variability depends upon the caregiving practices and traditions of individual
cultures. After examining phone calls made to a free helpline in the United
Kingdom, Jenkins and colleagues (2000) claimed that females were just as
likely to be abusive as males. A review by Hurme (2002) summarizes reports
on elder abuse from nations present at a Nongovernmental Organizations
(NGO) Forum workshop. These reports reflect cultural differences in mistreat¬
ment of older persons. In Japan women do most of the caregiving, and so
most perpetrators are female. In contrast, men are responsible for the greater
majority of abuse in Spain.
Women are usually the victims of mistreatment according to reports from
the United States, Spain, and Japan (Hurme, 2002), and the World Health
Organization (2002). Victims calling the United Kingdom helpline (Jenkins et
al., 2000) were much more likely to be female. Although callers to the hotline
are self-selected, these findings are consistent with the report from Hurme,
and the findings of Kivela in a small town in Finland (1992). Studies of
Chinese people living in Hong Kong, (Yan and So-Kum Tang, 2001), and eld¬
erly in Boston, Massachusetts (Pillemer and Finkelhor, 1988) revealed equiva¬
lent vulnerability of older men and women to abuse. (See Pritchard, 2001, for
a study of male victims of elder abuse in the United Kingdom.)
Consistent with the findings of Jenkins and colleagues (2000), Reis and
Nahmiash (1995) (cited in Reis, 2000) validated a checklist of factors that are
frequently associated with abuse. They found that the combination of these
factors reliably predicted the presence of abuse with 78-84.4% accuracy, and
the absence of abuse with 99.2% accuracy in a sample of 341 adults 55 years
of age or older. Characteristics and financial dependence of caregivers, as well
as lack of knowledge concerning the nature of the care recipients' physical
and/or mental limitations, increased the risk that a caregiver would become
abusive. Families with a history of abusive behavior, particularly directed
toward the care recipient, demonstrated increased incidence of elder abuse.
72 Newman
The degree of social support available for the care recipient also contributed
to the risk of abuse. These conclusions were supported by the findings of Reis
(2000). Contrary to the findings reported by Cupitt (1997), the National Center
on Elder Abuse (1998) and the National Clearinghouse on Family Violence
(2003), Reis emphasizes that some sources of stress (e.g., amount of assistance
needed by the care recipient, as well as his/her mental and physical health)
do not distinguish abusive from non-abusive relationships.
THE CHALLENGE OF PREVENTING ELDER ABUSE
Some investigators blame urbanization of developing nations (e.g., Litwin

and Zoabi, 2003), or changes in the status of older adults in traditional soci¬
eties, for elder mistreatment and neglect (e.g., Nagpaul, 1997; Sharon and
Zoabi, 1997; Soneja, 2001; Yan, So-Kum Tang, and Yeung, 2002). Violations of
long-standing cultural traditions (e.g., respect for elders, filial piety and
responsibility) increase as younger adults emulate their peers in developed
cultures. Older adults, raised to believe that family problems should remain
within the family, and that the welfare of the family supercedes the good of
the individual, are reluctant to report abuse.
ADDRESSING THE HUMAN RIGHTS OF

OLDER PERSONS WORLDWIDE
Although there is variability between studies and between nations, in the

end, similarities outnumber the differences. Overall many nations acknowl¬
edge that 1) elder abuse is a significant social problem; and 2) defining and
addressing the problem is difficult. Additionally some recognize the individ¬
ual's right to have some say in deciding what is and what is not abusive, and
what may or may not be done about interceding in individual abusive situa¬
tions.
Numerous nations and organizations across the globe initiated efforts to
understand and address violations of older adults' human rights. Many have
generated recommendations for an approach to the problem. The World
Health Organization leads the way in raising awareness concerning elder
abuse, and recommends the active involvement of the public health sector
(Krug et al., 2002). Suggestions from WHO (2002) include increasing aware¬
ness and education about mistreatment of old adults; attempts to improve
intergenerational relationships; training of professionals on the topics of aging
and elder abuse; enabling older adults to act on their own behalf; gaining the
cooperation of the media in attending to the images they portray the elderly;
advocating for laws to protect the older population, and health care plans
suitable for their needs; and finally, this report points out the need for more
research on mistreatment of older adults in particular cultural contexts.
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Acknowledgement: The author extends sincere thanks to Jean-Pierre Ruiz, STD, St.
John's University, for his assistance with this project, and Anita Evangelista, MSN, RN,
Southwest Missouri State University, for her thoughtful review of, and commentary on
this manuscript.
■
7
THE MORAL AND ETHICAL
IMPLICATIONS OF ELDER ABUSE
Dawn Oetjen and Reid Oetjen
In the past three decades, much attention has been paid to issues of
domestic violence and child abuse; however, the United States has been slow
to focus on comparable issues regarding the elderly (Moskowitz, 2003).
According to findings from the National Elder Abuse Incidence Study
(NEAIS), more than 500,000 Americans over the age of 60 were victims of
domestic abuse in 1996. Another statistic that is equally astounding is that
only six percent of the abusive situations are referred for help, leaving the
overwhelming majority hidden. America's increasing elderly population is
affecting every segment of the social, political, and economic landscape
(NEAIS, 1999).
The impetus for directing attention and resources toward elder abuse
does not stem from the size of the problem, but rather from the ethical princi¬
ples that are part of the fabric of American society. Elderly citizens, like oth¬
ers, are entitled to live in safe environments and to be treated with respect. A
unique aspect of elder abuse, unlike other issues afflicting the elderly, is that
it is both treatable and preventable (Pillemer and Finkelhor, 1988). Thus, an
understanding of the ethical underpinnings of elder abuse is important
because it can assist the provider in choosing and developing intervention
strategies, as well as shaping the provider's evaluation of the success of the
chosen strategy.
Another argument for the serious investigation into the problem of elder
abuse stems from the dramatic shift in thinking about basic health care values.
In the last twenty years, there has been a shift from paternalism, the idea that
the provider decides what the patient needs and provides it, to autonomy, in
which the patient determines what he /she needs. Although medical decision¬
making was guided by ethics, the quality of care was judged to the extent to
which it met professional standards, rather than the needs and objectives of
the patient (Shuman and Bebeau, 1994).
The evolving emphasis on patient self-determination places new respon¬
sibilities on providers. Aside from the standard duties of using technical
expertise to diagnose and treat illness, providers are now expected and
required to inform patients adequately regarding their care and gain consent
from the patients for treatment. Informed consent is the process by which a
competent and unimpaired patient can participate in choices about his/her
health care. It originates from the legal and ethical right the patient has to
direct what happens to her body and from the ethical duty of the physician to
77
78 Oetjen and Oetjen
involve the patient in her health care. If the patient is impaired, which is often
the case with elderly patients, this respect of self-determination is not consid¬
ered lost; only its implementation during the decision-making process differs
(Marsh, 1986). Due to the requirement of informed consent, the ethical obliga¬
tions of fidelity and honesty have assumed new importance in the physician-
patient relationship.
Coinciding with this shift toward the patient's right to self-determination in
health care, there has also been a shift in societal attitudes and values regarding
the right to health care. Until the 1960s, medical care was considered a privilege;
however, due to the growing concern of the social problems caused by this dis¬
parity in health care, a new philosophy based on equity and cost containment
has emerged. Due to this increased emphasis on justice and the coinciding
efforts to eliminate barriers to health care, providers will continue to be con¬
fronted with new ethical dilemmas (Shuman and Bebeau, 1994).
In order to aid detection, it is necessary for providers to be aware of the
many types of elder abuse. Three overarching categories of elder abuse are:
physical abuse (includes neglect), financial abuse, and psychological abuse. A
less common category of abuse is the violation of rights, also referred to as
social abuse (Lau and Kosberg, 1979; Valentine and Cash, 1986).
Social abuse is the denial of a senior's fundamental rights; the same rights
afforded to all citizens under state and federal law (such as the Bill of Rights,
and in health care, the Patient Bill of Rights). This can include ignoring an eld¬
erly person's right and capability to make their own decisions, especially
about private matters such as health care or living arrangements. Other exam¬
ples include withholding of information, denial of privacy, denial of visitors,
restriction of liberty, or mail censorship.
No one has the right to deny the human rights of another person, includ¬
ing the rights of an elder, unless that person has agreed or is certifiably incom¬
petent. When a person is denied their human rights, it not only affects their
self esteem and confidence, but also affects their morale.
PREDOMINANT ETHICAL VALUES OF HEALTH CARE
Webster's Dictionary defines ethics as "a set of moral principles and values;
the discipline dealing with what is good and bad and with moral duty and
obligation." Definitions of ethics and elder abuse vary among cultures, sub¬
cultures, political jurisdictions, and even among members of the same profes¬
sional discipline. Each looks to ethics as a means of preserving and protecting
older adults' rights. When viewed this way, ethics is a part of every aspect of
life whether personal or professional (Johnson, 1995).
Ethical conduct is based on values—words or phrases that signal what
one "ought to do or be." The predominant principles of medical ethics that
providers value are the same ethics that come into play with elder abuse.
These main ethical principles are: (1) nonmaleficence, which is encapsulated
in the Hippocratic Oath as "do no harm"; (2) beneficence, which implies a
duty to promote the patient's welfare; (3) justice, which means ensuring that
all individuals have an opportunity for health equal insofar as possible to the
health of others; (4) autonomy, meaning that we respect one another as
autonomous beings that are free to make choices that do not violate other
basic ethical requirements; (5) honesty, defined as integrity; sincerity; truthful¬
ness; freedom from fraud or guile; (6) fidelity, the obligation to keep promis¬
es; and (7) respect for persons, which implies treating others with respect, dig¬
nity, and compassion insofar as this is compatible with the other basic princi¬
ples to which individuals are bound (Beauchamp and Childress 1994;
Cameron 1995; Jonsen, 2000; and Veatch, Bartels, and LeRoy, 2001).
Beneficence and Nonmaleficence
The principles of beneficence and nonmaleficence are the guiding ethical

principles that require providers to intervene when elder abuse is occurring
or predicted to occur. Providers are ethically bound to halt this behavior by
recognizing the stress limits of the caregiver, educating the caregiver, perform¬
ing a risk assessment, and if necessary, removing the victim from the harmful
environment. (Benton and Marshall, 1991).
An ethical rule derived from the principle of beneficence is to remove
harm, to prevent harm, and to provide benefits. Mandatory reporting laws
attempt to satisfy the principle of beneficence by stopping elder abuse.
Although, there is no evidence to show that these laws have stopped elder
abuse, they have alerted health care professionals to the problem (Salend,
Kane, and Satz, 1984).
Mandatory reporting statues are beneficent because they may help to pre¬
vent harm. These statutes may provide data that will illuminate the problem
of elder abuse and thus justify funding for research. Once the issue of elder
abuse is fully understood, effective programs can be developed to prevent its
occurrence (Gilbert, 1986).
Lastly, the statutes are beneficent because the majority of states provide
services to the reported victim. In fact, protective services have been defined
as systems of preventive, supportive, and surrogate services for the elderly
living in the community to enable them to maintain independent living to
avoid abuse (Regan, 1978).
The principle of nonmaleficence includes the infliction of intentional and
unintentional harm, as well as acts of commission and omission (Beauchamp
and Childress, 1994). Statutes derived from nonmaleficence require that
health care professionals do no harm intentionally or unintentionally by act¬
ing or by failing to act. The rationale for mandatory reporting statutes is to
eliminate the possibility that health care professionals will permit continued
infliction of harm on elders by failing to act unless required to do so.
Justice
The principle of justice ensures that all individuals have an opportunity for
health that is equal, insofar as possible, to the health of others (Beauchamp and
Childress 1994; Cameron 1995; Jonsen, 2000; Veatch et al., 2001). Often, the dis¬
tribution of various resources in society is governed by different philosophies:
to each according to their need, their merit, or their "worth" to society; to each
an equal share; or to each according to their contribution. Health care in the
United States is a limited resource and is distributed to its citizens in a compli¬
cated manner governed by competing philosophies of justice.
As it applies to elder individuals, the principle of justice suggests that
each elder has a right to expect an equal effort on his/her behalf. From a social
perspective, elder justice means assuring adequate public-private infrastruc¬
ture and resources to prevent, detect, treat, understand, intervene in and,
where appropriate, prosecute elder abuse, neglect and exploitation. From an
individual perspective, elder justice is the right of every older person to be
free of abuse, neglect, and exploitation.
Just because a person has become older, may need medical care, or has
lost the ability to live on his/her own, does not mean they have forfeited any
of their rights as citizens - a point often lost on the abuser. The principle of jus¬
tice demands that all citizens are entitled to and afforded the same rights,
regardless of age, physical ability, and health. Abusers often diminish an
elder's right to citizenship and rationalize abuse by the fact that the elder is
no longer a full citizen because he/she requires assistance.
Autonomy
Autonomy is defined as self rule, and describes the principle that compe¬
tent adults have the right to make decisions for themselves, as long as those
decisions produce no serious harm to others. Autonomy emphasizes an indi¬
vidual's right to his/her own values, which may or may not be held by oth¬
ers. Autonomy applies to those who are deemed "competent" to exercise self
determination and has some limitations for adults who are totally or partial¬
ly "incompetent."
In the health care context, the principle of autonomy exists to protect an
individual's right to accurate and complete information from which he or she
can choose medical interventions. In the physician-patient relationship, this
principle leads to the necessity of fully disclosing information to patients (the
concept of informed consent). Without informed consent, patients cannot
make fully informed choices.
Autonomy also leads to confidentiality issues. Patients have the right to
determine to whom they want to disclose personal information. Providers
have a role in helping patients with difficult decisions, but autonomy man¬
dates that patients reserve for themselves the final decision-making authority.
Autonomy is a particularly sensitive issue to elders due to the potential
risk of them losing the ability to choose for themselves; this could be due to,
for example, the illnesses and/or weaknesses that sometimes accompany
aging, or because of well-intentioned efforts of others to limit the activities of
the elders. Autonomy is also important to elders because it is an important
predictor of their subjective well-being and successful aging.
Honesty
Honesty, defined as integrity, sincerity, truthfulness, and freedom from

fraud or guile, is a basic tenet of all codes of ethics. Common ethical values
dictate that individuals are inclined to establish reputations for being honest
and trustworthy. Nothing would jeopardize an individual's reputation more
than fraudulent, deceptive, and dishonest practices.
Honesty becomes even more important as individuals age. Most elderly
come from a generation where a handshake meant something, and honesty
was a quality you could assume others upheld. Too often, the elderly are the
victims of abuse due to their trusting nature. Proof of abuse preying on eld¬
ers' trustfulness is supported by numerous news headlines about scams that
target the elderly population.
Fidelity
Fidelity is defined as: the duty to keep promises; the duty to be true and
loyal to others; faithfulness; loyalty or devotion. Individuals are social beings
who engage in and pursue joint or common activities, in which they seek to
realize common or individual goals. They require the respect, recognition or
tolerance of others, and these individual acts can have an impact on others.
Relationships among individuals can take the form of either domination, sub¬
ordination, or reciprocity (Gould, 1983).
In the context of elder abuse, relationships between the elderly and the
abuser take the form of subordination and domination—there is little or no
reciprocity in the relationship. Wolf (1998) found that the nature of the rela¬
tionship and interaction between the elder and the caregiver affected the
probability of abuse. Relationships often become strained when the depend¬
ent person is perceived to be unappreciative, makes unreasonable demands,
fails to help the caregiver, or tries to manipulate the caregiver (Wolf, 1998).
Steinmetz (1998) found that abusive behavior by elders was not a reaction to
the caregiver's abuse, but rather part of an ongoing, well-established method
of behavior in the relationship. Unfortunately, abusive behavior by the elder
has been noted to lead to an escalation of elder abuse by the caregiver
(Pillemer, 1986).
Respect
Respect is defined as the polite attitude shown toward someone or some¬

thing that you consider important. Respect recognizes the fact that all individ¬
uals have a place in the community, their voices must be heard, and the indi¬
vidual's free will must be honored. There is a normative boundary to respect
within the scope of justice as solidarity which comes from the burden of reci¬
procity: "as one demands respect from other, so one ought to show respect for
others" (Sturm, 1998).
In elder abuse, there is a loss of respect for the elder. The dynamics of the
abuse are related to the abuser's need to gain and maintain control over the vic¬
tim. The abuser demands respect, but does not show respect to the abused.
Pillemer and Finkelhor (1988) state that victims are not dependent on the abus¬
er for care - rather, the abusers are dependent on the victim. Many abusers are
adult children still living at home, who rely on the resources of the parent.
Many abusive husbands or male partners believe women are responsible for
taking care of them and responding to their every desire. The abusers depend¬
ence may be financial, emotional or simply practical. Many victims of elder
abuse are independent and not physically or cognitively impaired; they are
older adults experiencing family abuse that is similar to abuse of young, bat¬
tered spouses (Pillemer and Finkelhor, 1988). In these instances, there is a lack
of respect for the needs and desires of the elderly person who is being abused.
ETHICAL ISSUES SURROUNDING ELDER ABUSE
It is critical that providers embrace these basic tenets of medical ethics and
ensure that their patients receive ethical care. Although only four percent of
elder abuse is perpetrated by health care professionals, most would agree that
the basic ethical values of health care also apply to greater society. Thus,
whether it is the health care provider or informal caregiver, the above ethical
principles apply to elder abuse.
Table I: Relationship Between Type of Abuse and Ethical Principles
Healthcare
Value/Ethics
Type of Elder Abuse
Violated
Physical Psychological Financial Social
Abuse Abuse Abuse Abuse
Beneficence X X X X
Nonmaleficence X X X X
Justice X X X X
Autonomy X X X X
Honesty X X
Fidelity X X X X
Respect for Persons X X X X

According to Benton and Marshall (1991), the type of abuse present often
predicts the most applicable ethical principle. This is illustrated in the follow¬
ing cases and Table 1. Table 1 demonstrates the relationship between the four
types of elder abuse and the ethical principles. Many of the same ethical prin¬
ciples are violated in each type of abuse as shown on the table and in the fol¬
lowing cases.
The cases discussed in this chapter illustrate both potential and actual
cases of elder abuse. The cases represent issues of physical, psychological,
financial, and social abuse. The cases are intended to represent the types of
mistreatment characterized by elder abuse that elders may encounter when
interacting with both professionals and informal caregivers. Any similarity to
actual cases is strictly coincidental.
Physical Abuse
John is an 82-year-old man who is morbidly obese and bedridden due

to complications from a stroke; his stroke left him partially paralyzed
on the right side of his body and he has diminished speech and motor
functions. After, recuperating from his stroke, John attempted to live
independently with a home health aid checking in daily on him; how¬
ever, due to a co-morbid condition of diabetes, John languished at
home alone, rarely left his bed, never bathed, erratically took his med¬
ications and continued to gain weight. The once-a-day visits from the
home health aid were not enough. Additionally, due to his inactivity
and diabetes, John developed severe ulcers on both of his lower legs
and was admitted to the hospital for care. As a result of this self-neg¬
lect, both of his legs required below-knee amputations.
After recovery from his double amputation, John was released to the
custody of his daughter, Susan, whom he depends on for his care.
John is now completely non-ambulatory and cannot move from his
bed to his wheelchair without assistance. John has severely impaired
speech, thus communication for him can be challenging. Susan works
full-time at home and feels obligated to take Care of her father.
Initially, Susan was devoted to the care of her father; however, after
several months, she has grown frustrated and resentful of this bur¬
den. Susan is unwilling to admit that she is incapable of caring for her
father, which adds to her feelings of frustration. As a result, John often
remains in his room for days at a time. Susan frequently verbally
assaults John for being a burden and calls him demeaning names
while caring for him. John's decreased verbal ability further frustrates
his daughter and the verbal insults often turn into physical abuse
when Susan is overwhelmed by her responsibility of caring for her
father. Susan's latest attack has left John with two fractured ribs, as
well as several cuts and bruises. Additionally, continued neglect with
regard to care has led to John developing more ulcers, similar to those
that led to his amputations.
A home health care nurse is called in to assess John's ulcers and pro¬
vide wound care. During the visit, the nurse notices that John is very
withdrawn and depressed. Upon physical examination, John's frac¬
tured ribs, cuts, and bruises are uncovered. John is quick to tell the
home health care nurse that he felt dizzy one day and fell out bed
when trying to get into his wheelchair. He asked the nurse not to
address these concerns with his daughter because he does not want to
burden her with his additional health problems. The nurse, however,
suspects the truth - that the daughter is physically abusing her father.
What John does not reveal to the nurse is that he is afraid of his
daughter and is embarrassed by this, yet he does not want to live the
rest of his life in a nursing home, a consequence that would surely
happen if the abuse were identified.
This case provides an example of both self neglect, initially, and then
physical abuse of the elderly. John's self-neglect while living alone led to his
need for supervised care. While receiving supervised care, John was physical¬
ly abused and neglected by his caregiver, his daughter Susan.
Physically abused elderly may feel ashamed about the abuse. They may
believe that providers cannot or do not want to help, but at the same time,
they may feel protective of their partner, family member, or friend who is
doing the abusing. Or they may fear that telling about the abuse will put them
at risk for more violence. In this case, John meets most of these criteria. He is
embarrassed by the act, protective of his daughter, and fearful that the abuse
will get worse if he allows it to be reported.
Factors that may prevent providers from asking elderly clients about
physical abuse include a lack of awareness of the prevalence of elder abuse, a
belief that identifying and intervening in physical abuse cases is not part of
the provider's role, discomfort with the feelings evoked by hearing about
elder abuse, concern about the time involved in asking about and dealing
with abuse if uncovered, and feeling helpless or not knowing how to inter¬
vene.
The ethical principles of beneficence and nonmaleficence require those
who are knowledgeable of the abuse to report it, thereby, removing or pre¬
venting harm and providing benefits. In this case, the nurse has conflicting
responsibilities: (1) report the abuse and work to have John removed from the
abusive setting, or (2) do not report the abuse and respect the confidentiality
and wishes of the patient/abused elder.
While most agree in principle that a patient's wishes come before the
organization's or provider's desires, providers often confuse what is good for
the patient with what the provider believes is good for the patient. At debate
is what constitutes good for a patient without infringing on the patient's
autonomy or letting the patient come to serious harm. Is it ethical to overrule

your patients' preferences?
On the surface, these requirements to notify authorities regarding sus¬
pected elder abuse seem to be an innocuous attempt at identifying abuse;
however, some observers have criticized such attempts as an ageist response
to the problem. These critics contend that older adults who are victims of fam¬
ily violence should have the same rights of younger adults to refuse referral
to an investigative agency. Mandatory reporting laws for elder abuse are sim¬
ilar to child abuse statutes and are based on the state's parens patriae to protect
persons who cannot or will not protect themselves (Aravantis et al., 1993).
Due to the aforementioned issues, mandatory reporting laws can create
difficult ethical dilemmas. On one hand, providers are bound by oaths to
maintain the confidentiality of the provider-patient relationship, but may be
required to violate that trust to comply with state laws. When faced with such
a dilemma where clear historical or physical evidence of abuse or neglect is
present, but a competent patient requests that a report not be made, how
should the provider respond? In such situation, the provider should explain
to the patient that he /she is obligated by law to report suspected abuse and
strive to maintain a positive provider-patient relationship, while keeping in
mind the medical necessity for intervention. (Aravantis et al., 1993). The
provider is not only bound by the duty to the victim to report suspected
abuse, but also the ethical duty to protect other potential victims.
The underlying rationale for reporting abuse stems from the desire to stop
abuse and secure access to help in the form of outside resources, not from the
desire to punish the individual and/or his/her family (Aravantis et al., 1993)
or from the need of the provider to exert a controlling or paternalistic attitude.
However, when faced with dilemmas such as these, providers often cannot
help but wield a degree of paternalism, albeit weak or strong, intentionally or
unintentionally, in their reporting decisions. According to Beauchamp and
Childress (1994), "weak" paternalism implies that the health care provider is
protecting the patient when the patient is unable to make decisions due to
medical or emotional problems. On the other hand, "Strong paternalism...
involves interactions intended to benefit a person despite the fact that the per¬
son's risky choices and actions are informed, voluntary, and autonomous"
(Beauchamp and Childress, 1994). Further complicating matters may be dif¬
ferences in state regulations as to what constitutes impairment, thus present¬
ing new ethical dilemmas for providers when caring for patients with
impaired decision-making.
The principles of beneficence and nonmaleficence also apply to the
daughter, even though she is an informal caregiver. The role of caregiver
implies that one will provide care with the intent of helping or healing, and
protecting one from harm or abuse. The daughter clearly violates this social
contract and the principles of beneficence and nonmaleficence when she
physically abuses her father and allows his physical condition to deteriorate.
Furthermore, the daughter violates the ethical principle of fidelity,
because acceptance of the role as caregiver, binds the daughter to provide care
and comfort to her father. The daughter unmistakably does not uphold this
ethical principle, when she crosses the line and lashes out in anger and phys¬
ically strikes him.
Justice is the right of every person to be free from abuse, neglect, and
exploitation. Also implied in the ethical principle of justice is freedom from
alienation, which is frequently a byproduct of elder abuse. Alienation is an
integral part of elder abuse because much of the mistreatment of elders occurs
in the family setting and thus, the elderly person is often simultaneously
embarrassed by the abuse, fearful of future mistreatment, and paradoxically
protective of the abuser (Moskowitz, 2001). Much of this abuse occurs prima¬
rily in private residences, such as in the preceding case, against persons who
have limited contact with outsiders (Moskowitz, 2001) and to people who are
isolated from the community, therefore compounding their alienation from
society (Pillemer and Finkelhor, 1988).
Providers are often confronted with the ethical dilemmas of: (1) the
patient's right to choose the extent of harm or the level of abuse in a particu¬
lar environment or situation; and (2) the right to decide on a placement deci¬
sion that appears hazardous from the provider's perspective. Autonomy
requires people to respect the self-determination of others and to cease from
constraining others' self-governing actions and choices (Beauchamp and
Childress, 1994). Rules derived from the principle of autonomy are to act only
with consent and to protect confidentiality. Herein lies the problem; the prin¬
ciple is often not applicable to elders because they may not be in a position to
act autonomously due to incompetence. Many of the mandatory reporting
laws require that the consent of the abused person be obtained; however,
many elders refuse to consent due to shame, fear of reprisal, guilt, and fear of
institutionalization. Thus, when the principle of autonomy and mandatory
reporting statutes interact, ethical dilemmas often arise.
The principle of autonomy is central to the case involving John. Is John
competent enough to make the decision to remain in this abusive environ¬
ment? Should the nurse report the suspected abuse by Susan to the authori¬
ties? If the abuse is reported, is John's right of self-determination being violat¬
ed?
Another area of elder abuse that is ripe with ethical dilemmas involving
autonomy is that of self-neglect. The phenomenon of self-neglect is subject to
the imposition of the observer's values, thus damaging the self-determination
of the individual. Given the fact that older adults are ethically entitled to
refuse treatment, even if such a refusal results in death, they are equally enti¬
tled to make less life-threatening choices regarding other parts of their lives,
including personal habits such as eating, grooming, dress, and other lifestyle
choices (Katz, 1980). Similarly, an older adult is entitled to subject
himself/herself to a hazard that many would not legitimately choose. Thus,
the grounds for not obtaining consent from older or self-neglected adults are
tenuous (Gilbert, 1986).
In the preceding case, John initially developed bed sores as a result of
improper care attributed to self-neglect. As a result of this self-neglect, med-
ical action was taken, and he was placed with his daughter for supervision
and care. John's self-neglect continues as more bed sores develop. Should
John's autonomy be challenged by the nurse due to his continued self-neglect,
or should John be able to continue with this detrimental lifestyle?
Confidentiality is equally questionable when considering autonomy and
mandatory reporting statutes. Because people have the duty to respect the
self-determination of others, it follows that others have the right to privacy
about their actions and unauthorized reporting (Beauchamp and Childress,
1984). By definition, all mandatory elderly abuse reporting statutes involve
making information known outside the provider-patient relationship, thus
opening a host of ethical conflicts. The provider must balance the self-deter¬
mination of older adults and adherence to the mandatory reporting require¬
ments of elder abuse statutes.
In the foregoing case, confidentiality comes into play as John's right to
confidentiality regarding his personal life is challenged by the provider duty
to report the suspected abuse. Which ethical principle has priority - confiden¬
tiality or the right to self determination? Is John competent to make his own
decision about his environment and maintain the right of self-determination?
Brandi (2000) states that some caregivers or family members hurt older
people to exert power and control. Many abusers harm older people to get
their own needs met, believing they are entitled to use any means necessary
to achieve their goals. Respect for the needs of the elderly person who is being
abused is non-existent. In this case, Susan is exerting control over the situation
that she is frustrated with by physically abusing her father when he does not
act in a manner acceptable to her.
Psychological Abuse
Sam was a 78-year-old man with Alzheimer's disease who recently

had been admitted to a nursing home. Although, he was confused,
there were also times when he seemed lucid. Because of his
Alzheimer's disease, Sam often soiled the bed during the night, at
which time he would use his call button to summon help from a cer¬
tified nursing assistant (CNA).
Marie, a CNA on the midnight shift, was responsible for caring for
Sam, as well as 23 other residents. Marie also worked part-time at a
retail store during the day in order to support her three small chil¬
dren. Most of the residents under her care slept through the night,
except for Sam.
When Marie first started working at the nursing home, she was very
attentive and caring towards her residents; however, as time wore on,
she became verbally abusive to the residents that she labeled as "trou¬
ble-makers."
Sam was one of her "trouble-makers." When he would soil himself

and ring his call bell, she would make him wait 15-20 minutes before
she would respond. She would then chastise and taunt him with
statements such as, "What are you, a baby?" "Even my babies are toi¬
let-trained. You must be stupid" and "I'm not your mama or your
babysitter. Use the toilet like a grown man should." She would then
threaten him by telling him that if he kept doing this, she wouldn't
change his soiled clothes and he could stay that way till morning.
On other occasions, Sam would cry during the night because he was
scared and confused. Marie continually berated Sam for being a baby
and causing her extra work. As his crying was waking up the other
residents, she threatened him with physical violence if he continued
to act out, stating "I'll give you something to cry about!"
Marie continued to verbally abuse Sam every night. Because it was

known that Sam had no family that regularly visited and that he had
Alzheimer's Disease, Marie justified his complaints of psychological
abuse to her supervisor as an episodes of dementia.
This case shares many of the same ethical principles and dilemmas that
are present in the case of John and Susan. The characteristics of physical and
psychological abuse and the underlying ethical principles are similar. The
principles of nonmaleficence, beneficence, justice, autonomy, fidelity, respect
for persons are present; thus, the similar ethical dilemmas exist.
It can be argued that the abuse in the preceding case is less acceptable
because it is being perpetrated by a health care provider. Most health care
providers abide by professional codes of ethics that denounce such abusive
behavior and all such actions that unintentionally or intentionally harm
patients. Health care providers are entrusted with the health and well being
of their patients, thus they have a higher moral duty than informal caregivers
to uphold this obligation.
The integrity in the relationship between Sam and Marie in the previous
example has deteriorated to the point of disaster. The caregiver burden model
suggests that abuse occurs because caring for the victim is too difficult and
blames the victims for being too needy, thereby, relieving the perpetrator of the
responsibility for abusive behavior (Brandi, 2000). Elder abuse victims are fre¬
quently given the message that if they would just try harder, the abuse would
stop, but abusers often change the rules and find new faults that continue the
battering. In the preceding case, Marie initially chastises Sam for his inconti¬
nence; however, she then criticizes him regarding his episodes of crying,
adding a new rule for Sam to violate and, thus, continuing the cycle of abuse.
Only abusers can take responsibility for their actions and therefore end the
abuse cycle (Brandi, 2000). Most abusers do not lose control when they abuse
another; they choose how and when to respond in anger. They respond when
it is most beneficial to them (Brandi, 2000). As a result of the pressures in
Marie's personal and professional life, the duty to care for Sam and her other
patients has become too much. Although it appears that Marie is not in control
of her emotions, she clearly chooses to target Sam because of his dementia,
knowing that if the abuse were brought to the attention of others, it could eas¬
ily be discounted.
Financial Abuse
Mary and her adult son, Bart, live in the same small house that he
grew up in. Mary has been widowed for over twenty years and enjoys
the company of her son, especially since her other three kids live out
of state. Bart is physically impaired due to a childhood episode of
polio and relies on his mother for care and financial support. Bart pre¬
viously worked as a dispatcher for the local sheriff's department, but
received a medical discharge when his condition worsened. The small
stipend that he receives each month from social security/Medicaid is
not enough for him to live independently. Mother and son have lived
together for the past fifteen years and enjoy the symbiotic relationship.
Mary is fulfilled because she has a purpose in life, to care for Bart; Bart
is well-taken care of by Mary, is financially secure, and assists his
mother by driving her on her errands.
As time progresses, Mary grows older and her physical and mental
health deteriorates. At one point, Mary is hospitalized with pneumo¬
nia. While in the hospital, Mary attempts to walk to the bathroom
without assistance and suffers a fall due to low energy levels. A hip
replacement surgery is performed and eventually Mary is discharged
to a nursing home for rehabilitation therapy until she fully recovers.
Mary seems to be progressing well physically; however, she suffers
from frequent bouts of dementia and associated memory lapses.
Meanwhile, Bart is worried about his financial future. Without his

mother's social security check, he is unable to maintain the household.
Bart visits his mother in the nursing home to see when she will be able
to return home and is advised by the facility's medical director that,
due to her hip therapy and the need for personal hygiene care, it is best
that Mary stay in the nursing home for an undetermined amount of
time.
Unable to live without his mother's financial resources, Bart convinces

his mother to appoint him as her Power of Attorney in case her men¬
tal capacity further deteriorates, putting him in charge of her property
and finances. Mary is reluctant, but concedes when Bart promises that
he will consult her regarding any financial decisions that arise. The
Power of Attorney status allows Bart to sign the deed to the house over
to himself, as well as access to his mother's savings account; therefore,
securing his financial future. Bart continues to drain Mary's financial

savings in order to finance his lifestyle, without consulting his mother.
Several weeks pass and Mary's physical condition has improved;

however, her mental state has declined and she need's increased assis¬
tance with her activities of daily living. Meanwhile, finances are tight
for Bart and he decides to remove her from the nursing home in order
to receive her social security check. He signs her out against medical
advice.
Concerned with his mother's health, Mary's oldest son Dan visits to
survey the situation. Dan finds that the house is messy and unkempt,
his mother is bed-ridden, and she has developed bed sores which
require immediate medical attention. Dan is upset with his brother for
taking advantage of his mother, and feels that she should be readmit¬
ted to the nursing home until she is able to take care of herself. Despite
Dan's urging to return to a skilled nursing facility, Mary defends her
son Bart and says that he is doing the best he can and that she loves
him.
Financial abuse is similar to other forms of abuse in that it can be devas¬

tating to the victim and is frequently traced to family members, trusted
friends, and caregivers. But unlike the other forms of abuse, financial abuse is
often done with the tacit knowledge and consent of the elder and can be more
difficult to detect and establish (NEAIS, 1999).
Financial abuse occurs when a caregiver or elder misuses money, property,
or possessions, as illustrated in the case above, or blocks access to these mate¬
rial goods. Frequently, in the case of financial abuse, the abuser is a spouse,
family member (often adult child), caregiver, friend, or a trusted person in the
elder's life. Financial abuse is often associated with the other forms of elder
abuse, such as emotional abuse, physical abuse, and the denial of rights. In the
above scenario, the live-in son Bart engages in financial as well as physical
abuse. By preventing /withholding needed medical care, he is indirectly phys¬
ically abusing his mother.
Financial abuse is also characterized by abrupt changes in a will or other
financial documents and the unexplained sudden transfer of assets to a family
member or someone outside the family. In the above case, Bart exerts his power
and exploits their close relationship when he coerces his mother into signing
the Power of Attorney. Bart seizes Mary's financial assets by preying on his
mother's emotional and mental instability. Thus, financial abuse is closely relat¬
ed to psychological abuse.
Bart violates the principles of beneficence and nonmaleficence that are
implicit in a custodial relationship of caregiver and patient, not to mention vio¬
lation of trust between a parent and child. Due to Bart's actions to seize his
mother's assets, he further violates the principle of nonmaleficence by infring¬
ing on his sibling's potential right to these same assets.
In issues involving financial exploitation, an individual's justice, or what

they perceive to be their justice, may be violated. In the preceding case, Mary's
justice is violated because her right to proper health care is denied by her son's
actions. Justice also provides that persons should be free from exploitation,
abuse, and neglect. Bart's manipulative and exploitive actions towards his
mother are clear examples of the violation of the principle of justice.
Furthermore, Bart violates his mother's autonomy over her personal assets
by coercing her to assign Power of Attorney to him. By virtue of the fact that he
now controls his mother's estate, he has denied her the ability to make deci¬
sions about her financial future and severely limiting her fight to self-determi¬
nation.
Honesty is also an ethical value that is breached because Bart fails to com¬
municate with his siblings regarding his mother's finances and care. He also is
dishonest in his actions to control his mother's assets when he convinces his
mother that the motive for his action is based on her mental wellbeing and he
will consult with her prior to making any financial decisions.
Bart also violates the tenets of fidelity and respect for person by way of his
actions. As caretaker of his mother and her financial assets, he ought to do what
is in his mother's best interest. Clearly, Bart's actions to seize Power of Attorney
and remove her from the nursing home can only be construed as self-serving.
Social Abuse
Walter, age 78, was a successful businessman in the community in

which he lived. Walter was always active in local politics, church and
community affairs. Walter was married to his wife Sandy for forty
years and had one son, who struggled to find a career. Walter reluc¬
tantly retired at age 70 at the urging of his wife and sold his insurance
company due to a bout with prostate cancer. The couple had always
dreamed of traveling extensively when Walter retired. Unfortunately,
shortly after recovering from prostate cancer, Sandy was diagnosed
with ALS. After a tough, but losing battle, Sandy died, leaving Walter
alone.
Although, Walter was a successful businessman, he always relied on

his wife for many of the household chores. Walter attempted to live
by himself; however, was unable to live independently and cope with
the daily responsibilities of caring for himself and his house. His son
hired a housekeeper to take care of household affairs; however, this
solution was short lived, as Walter was often combative due to the
early stages of Alzheimer's disease.
Walter's son, Andrew, moved home after a failed marriage to take

care of his father. Walter moved into the basement suite in order to
accommodate his son. Shortly after moving in, Andrew had the
phone disconnected, so that his father would not be "disturbed" by
friends calling to see how he was doing. Andrew had cellular phone
service with an unlisted number that he purposely kept hidden away
from his father. He would not allow his father to use the telephone.
Despite the early stages of Alzheimer's disease, Walter was mostly

alert, lucid, and mentally capable of handling social affairs. Andrew
started laying the groundwork for his father's mental incapacity.
When family, friends, and neighbors stopped by to visit, Andrew
would turn them away saying that his father wasn't seeing anyone
due to his poor health. Andrew further isolated Walter from society by
no longer taking Walter to church, selling his father's car, and destroy¬
ing any personal correspondence that came in the mail. He also gave
away most of his father's personal belongings (books, family photo
albums, and golf clubs) to the local Goodwill, telling his father that he
wasn't capable of using them anymore. Andrew told his father's
friends that his father had destroyed these possessions in a fit of anger,
often associated with advanced stages of Alzheimer's. Andrew also
told visitors that he may have to seek legal counsel to become his
father's legal guardian to more effectively take care of his father.
Andrew told his father that in his present mental condition he was
lucky to have someone help him at all. Andrew would often yell and
treat his father roughly when Walter would not do what he was told.
Concerned about Walter's withdrawal from society and his son's
excuses for why family and friends could not visit, his friend Joe con¬
tacted Adult Protective Services. A social worker investigated the sit¬
uation and was only allowed entrance into the home after threatening
to seek a court order. Walter appeared frail, depressed, and malnour¬
ished; however, refused help from the social worker. When pressed
further, Walter admitted to the social worker that Andrew often
yelled at him and denied him from seeing his friends. Despite these
feelings of resentment, Walter defended his son saying that Andrew
was under a great deal of stress due to his recent divorce. Walter felt
badly that his son had to take care of him and that it was not right for
a child to have to take care of their parents.
A psychiatric evaluation was ordered and it was deemed that Walter

had the mental capacity to understand the situation he was in and
able to make informed decisions, and was mildly depressed; howev¬
er, Walter did not require treatment. Despite the fact that Walter often
felt like a prisoner in his own home and became depressed at his cur¬
rent lifestyle, he felt obligated to his son and he felt that his role as a
father took precedence over concerns for his own personal safety and
happiness. Walter was offered the option of moving into an assisted
living facility; however, Walter decided to stay at home with his son
as his caregiver.
The case of Walter and Andrew is not uncommon. Like the preceding cases,
the ethical issues in this case of social abuse include beneficence, nonmalefi¬
cence, justice, autonomy, justice, honesty, fidelity, and respect for persons.
Victims of elder abuse often choose to stay in abusive environments, even
when offered less abusive environments. The principles of beneficence and
nonmaleficence call for the removal and/or prevention of harm. The abuse
reporting laws that most states have in place were developed with these prin¬
ciples in mind. Therefore, an obvious response to our case example would be
for the social worker who visited Walter and Andrew to report the activities
she suspected as abusive, and question Walter's competency by his desire to
stay in the abusive environment. This would most likely result in the place¬
ment of Walter in an assisted living facility, an option he refused when offered
due to his belief about familial responsibilities. Would more harm be done to
Walter by forcing him to move against his will and reporting Andrew or by
letting him remain in an abusive environment?
While in some states abuse reporting laws may support the right of oth¬
ers to intercede on behalf of those who are victims of abuse, issues with regard
to justice may surface. The resources to prevent, detect, treat, understand,
intervene in and, where appropriate, prosecute elder abuse, neglect, and
exploitation, may be limited.
When victims of elder abuse exercise their right of autonomy in ways that
seem reasonable to others, their choices are seldom questioned. However,
when the victim makes a choice to remain in an abusive environment, such as
in the above case, the ethical dilemma of the individual's right to choose ver¬
sus society's obligation to protect is broached. As adults, the elderly have the
right not to report any actions taken against them. The elder is the only one
who can determine the limits of behavior that are acceptable for him or her
and give permission for intervention. However, reporting laws in most states
require reporting of physical and other forms of abuse based on suspicion,
rather than tangible knowledge of the abuse.
The ethical mainstay of honesty is obviously violated by the abuser,
Andrew, many times throughout the case. Andrew was dishonest with his
father and violated the trust his father had bestowed on him when allowing
him to move in and look out for his father's best interests. Andrew was dis¬
honest with his father's friends and visitors about his father's health and
mental status.
The implied new relationship between Walter and Andrew is one in
which Andrew was supposed to care for Walter and, in return, Andrew was
allowed to move into Walter's home after his divorce. Fidelity requires one to
do what he or she has promised to do. Andrew blatantly disregards this ethi¬
cal principle when he does not uphold his promise and, instead, exerts his
power to the benefit of himself, disregarding the social, psychological, and
health needs of his father.
In this case, and in elder abuse in general, there is a loss of respect for the
elder. The dynamics of the abuse are related to the abuser's need to gain and
maintain control over the victim. Andrew illustrates this through his discon-
necting Walter's phone, his isolation of Walter from the friends and family
that came to visit, and his selling of Walter's possessions without permission.
In these instances, there is a lack of respect by Andrew for the needs and
desires of Walter, and Andrew utilizes these methods to keep Walter from
seeking help.
Many of the issues in the four types of elder abuse are similar. In each case
illustrated in this chapter, there may be one prevalent ethical issue, such as
autonomy, but it is not mutually exclusive of the other ethical issues. When
the principle of autonomy is violated, beneficence and nonmaleficence are
violated as well. In the same vein, when discussing the types of abuse, rarely
do the different types occur in isolated instances; often, when physical abuse
occurs, psychological abuse occurs as well.
Understanding the underlying ethical issues surrounding elder abuse will
enable health care providers and informal caregivers to better recognize how
abuse violates ethical principles. This knowledge will provide them with the
ability to intervene, when they or someone else crosses the line, in order to
protect the rights of the elderly.
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Counseling 10(2): 97-119.
Wolf, R. (1998). Caregiver Stress, Alzheimer's Disease and Elder Abuse. American
Journal of Alzheimer's Disease. 13(2), 81-83
'
8
HIDDEN WITHIN
THE GOLDEN YEARS:
INTIMATE PARTNER VIOLENCE AND
ABUSE AGAINST OLDER WOMEN
Bonnie Fisher, Therese Zink, and Saundra Regan
Mrs. S is 68 years old. She married right after graduation from college
and quickly became a stay-at-home mother. From the beginning of
their marriage and throughout their marriage, her husband made all
the decisions-where they would live, what car they would buy, where
she could go, whom she could see, how much money she could
spend, and even what clothes she wore and how she cut her hair.
Mr. S was a successful executive who was very active in the commu¬
nity and church. He was handsome, charming, kind, and well respect¬
ed by everyone. Then he would come home. Mr. S has hit, kicked,
slapped, and choked Mrs. S. He called her insulting names, told her
she was ugly and fat and that no one would ever want her if he ever
left her.
Early in her marriage, she attempted to leave him. Her mother told
her that her place was with her husband. How would she ever raise
five children on her own? Her doctor said that sometimes men are
just like that and she needed to be patient and try to ignore his behav¬
ior. Her minister told her that God believed her place was with her
husband and children because that is what a good wife does. She
would certainly be rewarded in heaven.
Mr. S is retired now. He has developed a heart condition. Mrs. S has

diabetes and arthritis, which makes it difficult for her to move
around. The children are grown and gone and it is just the two of
them. The physical violence stopped several years ago but the verbal
abuse and control still occurs on almost a daily basis.
Mrs. S questions what would happen if she left him now? Being alone
is terrifying to her as she does not drive and has no money of her
own. Their children are adults with their own families. Who would
take care of him she wonders? With no satisfactory answers, she
decides to stay with him.
97
98 Fisher et al.
Mrs. S is not a fictional character. You may know her. She is an older mar¬
ried woman who lives next door or down the block. If you do not personally
know her, you may have seen her as she shops at the neighborhood stores and
routinely attends religious services. You may not know her by name but Mrs.
S's story is a compilation of common themes that run throughout the stories
of older women who have experienced and continue to experience intimate
partner violence and abuse1 (IPVA) (Fisher, Zink, Rinto et al., 2003).
Mrs. S is similar to almost all women born before World War II who were
socialized primarily into domestic roles. When they did work outside the
home, they were often limited to low-paying occupations. This often resulted
in financial and social dependence on their husbands. In addition, powerful
cultural and social norms existed (and in some places, still exist today) about
the privacy of what took place within the home. Her abusive and violent
experiences are most likely hidden from the society and, most notably, have
generally been overlooked by "natural" advocates, including the domestic
violence2 (DV) and aging communities.
There are a variety of reasons for their collective oversight of IPVA against
older women. First, Vinton (2003) attributes this oversight to several "isms in
our society:" ageism, sexism, beautyism, and sometimes racism and classism.
She argues that convergence of these multiple "isms" of oppression have large¬
ly made older women invisible to the general public. Second, within the DV
community, the primary service and program emphasis has been on the needs
of younger battered women, especially those with children. For example, the
shelter movement, which began in the late 1970s, was a grassroots effort led by
feminists to provide safe havens for women and their children away from their
abusers. Even the DV research community prior to 1990 rarely mentioned the
experiences and needs of older battered women (Vinton, 2003). Third, within
the aging community, elder abuse advocates have historically not focused on
older women's experiences with violence by intimates but have rather focused
on elder abuse and neglect by caregivers or self-neglect.
The scant research, advocacy and practitioner materials addressing IPVA
against older women are disturbing when one considers the importance of
violence and abuse, and in particular acts committed by spouses/partners,
against women as a national problem that was acknowledged by Congress
aWe adopted the phrase "violence and abuse against women" as per the U.S.
Department of Health and Human Services (2000) suggestion that it become the stan¬
dard phrase used in research and practice. In this chapter, we will use the term to refer
to the combination of all five of the following major components of a range of maltreat¬
ment against women: 1) physical violence, 2) sexual violence, 3) threats of physical
and/or sexual violence, 4) stalking, and 5) psychological/emotional abuse (U.S.
Department of Health and Human Services, 2000, pgs. 6-7).
2Domestic violence is a broad term that can include any family member such as a
spouse, child, cousin, or non family member that is an intimate partner (male or
female).
and President Clinton in the passage of the Violence Against Women Act in
1994 and 1998 (VAWA) (Thomas: Legislative information on the internet, 2003).
The VAWA goals coupled with recent Census counts that show that older per¬
sons, in particular women, are plentiful makes the lack of attention given to
older women even more disturbing. The number of older people in the U.S.
has continued to increase rapidly. There are now approximately 56 million
people age 55 and over, with almost 31 million of them being women (US
Census Bureau, 2001). This number will continue to increase substantially
over the next 10 years as the baby boomers move into these older age cate¬
gories. The baby boom cohort aged 36 to 54 in the 2000 census make up 28%
of the U.S. population and the age category 50 - 54 was the fastest growing
segment of the population with an increase of 55% in the last decade (US
Census Bureau, 2001). There is no denying that a substantial proportion of
North Americans are aging!
Possibly heightened by the realization that in the coming decade there
will be a dramatic increase in the number of older women, there are some
signs that both the aging and DV communities' attention may be turning to
issues concerning older women and IPVA. In the earlyl990's the American
Association of Retired Persons (AARP) Women's Initiative held a special
forum that focused on the differences between abused elders and older bat¬
tered women (AARP, 1992). During this forum, participants acknowledged
that elder abuse and DV of older women were two very different areas in def¬
inition and in the scope of service provision. Among the recommendations
was to identify the types of violence so that prevention and service strategies
could be tailored to the type of violence. Throughout the 1990s a small group
of vigilant advocates and researchers across several disciplines were persist¬
ent in their efforts to document the experiences of older battered women.
Their results stimulated the development and implementation of innovative
programs and services tailored to the needs of these women (Brandi and
Raymond, 1997; Seaver, 1996; Tatara, 1993; Vinton, Altholz, and Thea, 1997).
Efforts have continued into the next century, but still only a handful of publi¬
cations concerning IPVA against older women exist in comparison to the
numerous publications that examine violence against all women, and more
salient to our interests, DV against older women (Brandi and Cook-Daniels,
2002; Fisher, Zink, Rinto et al., 2003).
More fully understanding IPVA against older women is one step toward
educating interested parties as to its scope. The next step is to address the spe¬
cific needs of these older women and prevention of such acts. In the first sec¬
tion of this chapter, we highlight what is known about the extent and nature
of IPVA against older women from a variety of sources, including older
women telling their stories of violence and abuse. Also included is a discus¬
sion of methodological limitations inherent in this young field of research. The
first section provides a backdrop for the second section that addresses the lack
of preparedness by those most likely to serve older women who are experi¬
encing IPVA, their physicians and domestic violence shelters. In the last sec¬
tion, a discussion of future directions is presented. Here, three important
100 Fisher et al.
points are discussed for researchers, advocates and practitioners from both
the aging and domestic violence fields to develop into an agenda for action.
VIOLENCE AGAINST OLDER WOMEN
Available data from various sources suggest that violence and abuse
against women are substantial public health and criminal justice problems
(Rennison, 2001; Tjaden and Thoennes, 1998a; US Department of Health and
Human Services, 2000). For example, across every victim age category for age
12 and over, females were more likely than males to be murdered by an inti¬
mate partner in 1999. In fact, intimate partners murdered 1,218 women dur¬
ing 1999 (Rennison, 2001). Point estimates regarding non-lethal violence vary
depending on the self-report survey and its context. However, the pattern
across two widely cited national-level surveys is consistent. First, findings
from the Violence Against Women Study (VAWS) revealed that 22,254,037
women had in her lifetime been physically assaulted by an IP. The most com¬
mon type of IP assault was being pushed, grabbed, or shoved (18.1% of the
women), followed by being slapped or hit (16%). The VAWS also estimated
that 7,753,669 women had been raped by an intimate partner in their lifetime
(Tjaden and Thoennes, 1998a). Eight percent of women had been stalked at
some point in their life, with 4.8% of these women having been stalked by an
intimate (Tjaden and Thoennes, 1998b). Second, the National Crime
Victimization Survey estimates that in 1999 671,110 rapes/sexual assaults,
robbery, simple assaults and aggravated assaults were committed against
females by intimate partners, a rate of 5.8 per 1,000 females age 12 years and
older (Rennison, 2001).
Estimating violence and abuse can be a daunting challenge under "ideal"
research design conditions (Fisher and Cullen, 2000). For example, there is a
lack of standard definitions of violence and abuse that is consistently used
across studies (Brandi and Cook-Daniels, 2002; US Department of Health and
Human Services, 2000). Consequently, comparisons across studies are difficult,
if not impossible due to the lack of standard definitions for the different forms
of violence (including the crime of rape /sexual assault) and abuse (see Fisher
and Cullen, 2000; U.S. Department of Health and Human Services, 2000).
Providing violence and abuse estimates for older women is further chal¬
lenging for several methodological reasons specific to an older population.
First, older women are typically undersampled in "big" national-level empir¬
ical studies. Therefore older women, say 55 or older or even those 65 and
older, are either overlooked as a separate age grouping or grouped with
younger women (for example, those 50 and older) because their numbers are
so small in the sample, reliable estimates of the extent of victimization are not
possible (Vinton, 2003). In some surveys, for example the NCVS, women 65
years and older were combined with women 50-64 years old because the
number of sample cases of women age 65 years and older were too small to
produce reliable estimates (Rennison, 2001). Second, when a study has been
designed to include older persons or women, such as The National Elder
Abuse Incident Study, IPVA was not among the primary focus of the study, so
the reporting of such results are limited. Related is the issue of researchers not
reporting a separate victim-perpetrator category for partner/spouse but
rather having a general "family member" category (Teaster, Roberto, Duke,
and Kim, 2000). Even when the victim-perpetrator relationship includes
spouse, there may be no reporting of this relationship by sex of the victim
(Tatara, 1993). In all these examples, estimates of IPVA against older women
cannot be produced. Third, some studies report estimates based on "official"
data sources, such as by Adult Protective Services (APS). Other studies are
based on a probability sample that was drawn from either a community¬
dwelling population or a clinical-based population (Fisher, Regan, Zink, and
Pabst, 2003; National Center on Elder Abuse, 1998). A comparison of estimates
from these different populations becomes challenging, if not, impossible to
accurately do. And last, there is much variation across the age requirement to
be designated "older." For example, some studies include women 50 and
older while other studies use age 55 as the criteria and still others use age 60
(Tatara, 1993; Teaster et al., 2000). Related, across studies the age categories
vary, too. For example, some researchers have measured age in terms of
decades: 50-59, 60-69, and 70-79 years old (Mouton, 2003) while others used
a five-year category (e.g., 60-64,65-69, etc.) (National Center on Elder Abuse,
1998). Other studies employed 10-year age categories as well but did not clus¬
ter the age dispersion by decades. For example, Fisher and her colleagues
(2003) used 55- 64,65 - 74 and 75 and older as age categories. Still others used
a gross age category such as 55 and older (Rennison and Rand, 2003).
As with any newly emerging field of research, the IPVA and older women
studies are at an early stage of scientific rigor and as such, there are method¬
ological differences and limitations that will need to be addressed by future
researchers. Putting these issues aside for the time being, there is a growing
body of research that sheds much insight into the extent and nature of IPVA
against older women. These methodological differences cannot be ignored;
they will need to be addressed as the measurement of IPVA against older
women research matures into a field of scientific study.
Below we discuss results from the growing body of research that has
examined the extent of IPVA against older women. In this section we also
highlight the gaps in the body of knowledge.
THE EXTENT OF THE PROBLEM
Estimates of elder abuse and violence against women abound from sever¬
al sources, yet the measurement of IPVA against older women is a relatively
young and fragmented field. The measurement of IPVA against older women,
nonetheless, is growing both within the more general elder abuse and DV
fields (Fisher, Zink, Rinto et al., 2003). There is some hint that an interdiscipli¬
nary view of IPVA is emerging among a new generation of researchers, many
of whom have been influenced by the new research and practices developed
as a result of the VAW Act (Fisher, Regan et al., 2003).
102 Fisher et al.
Only a handful studies have been conducted about elder abuse from
which we can extrapolate some baseline information about IPVA against older
women. One study was executed over 15 years ago by Pillemer and Finkelhor
(1988). Their landmark study was designed to produce reliable estimates of
abuse (physical violence, verbal aggression, and neglect) against both male
and female elders in a community-dwelling population. Prevalence abuse
data from a stratified random sample survey of 2,020 elders age 65 and over
living in metropolitan Boston revealed that physical violence was the most
widespread form of abuse against older women. They reported that 13 per
1,000 female elders had experienced physical violence since turning 65 com¬
pared to 9 per 1,000 female elders having experienced verbal aggression and
5 per 1,000 suffering from neglect. Noteworthy is that their results suggest
that the largest proportion of elder female abuse, is in fact, spouse abuse. To
illustrate, in 17% of the physical violence cases, the perpetrator-victim rela¬
tionship was husband to wife. In 10% of these cases the son was the perpetra¬
tor and in only 3% of the cases the daughter was the perpetrator. Similarly, in
27% of the chronic verbal aggression cases the perpetrator was the husband
compared to 8% of these cases where the perpetrators were the son or the
daughter, respectively.
Surprisingly, it took almost a decade for Pillmer and Finkelhor's IPVA
against older women results to capture the attention of a national-level
agency, in particular The National Center on Elder Abuse. Their sponsored
national-level study. The National Elder Abuse Incidence Study (NEAIS), col¬
lected data from 20 counties in 15 states from Adult Protective Service agen¬
cies and sentinels (banks, law enforcement agencies, hospitals, public health
departments, home care agencies, senior centers) in 1996 (National Center on
Elder Abuse, 1998). The NEAIS is groundbreaking because it provides, for the
first time, national-level incidence estimates of different forms of abuse: phys¬
ical abuse, sexual abuse, emotional or physical abuse, financial or material
exploitation, and abandonment, neglect, and self-neglect among elders.
Females aged 60 and older comprised 58% of the total national elderly
population at the time of the NEAIS study. However, the NEAIS results
showed that women were over-represented compared to their portion of the
total elderly population. The results revealed that 76.3% of the victims of emo¬
tional/psychological abuse were women. And 71.4% of the older women had
experienced physical abuse. For our interest in IPVA, the NEAIS did not break
down the victim-offender relationship by sex of the victim. What can be
gleaned from this study is that perpetrators of emotional/psychological abuse
were more likely to be the children of the victim (53.9%), followed by the vic¬
tim's spouse (12.6%). The same pattern is evident in physical abuse: 48.6% of
the perpetrators were a child of the victim compared to 23.4% who were the
victim's spouse.
One explanation for the discrepancy the results reported by the NEAIS
and Pillmer and Finkelhor (1988) is that the later gathered information from
the elder and did not rely on "official" cases. The difference may be attributed
to several methodological differences. First, elders may not report spousal
abuse to authorities, such as the APS, or even if reported, APS staff deter¬
mined that the case was unsubstantiated. The violence against women
research shows only a small percentage of victimizations committed by inti¬
mate partner are reported to authorities, such as law enforcement (Rennison,
2001). Second, Pillmer and Finkelhor's randomly selected respondents com¬
pleted the survey either in person or over the telephone. The responses were
self-reporting of experiences. The cases reported in the NEAIS consisted of
every reported case of suspected abuse during the data collection period
which lasted 2 months in every county sentinel agency and APS that was part
of the study. Hence, as critics have argued the NEAIS study did not include a
large (but unmeasured) segment of older persons who did not come in con¬
tact with community services (Brandi and Cook-Daniels, 2002). And yet
another reason for the discrepancy could be that the Pillmer and Finkelhor's
study was a single site set located in a large urban area whereas the NEAIS's
was a nationally-representative sample of 20 counties. We cannot say definite¬
ly why the discrepancy in the victim-perpetrator relationship exists, but it
does signal the need to further examine the victim-perpetrator relationship in
incidents involving older women.
Additional information as to the extent of IPVA against older women can
be taken from national-level criminal justice databases. Between 1993 and
1999 the overall rate of intimate partner violence rate reported from the NCVS
fell for females age 20-24,25-34, and 35-49. This downward trend was not evi¬
dent for women 50 and older (Rennison, 2001). Similarly, the murder rate for
women between 50 and 64 and age 65 and older did not decrease between
1993-1999. During this time, the murder rate per 100,000 women age 50 to 64
ranged from 0.5 to 0.8. The murder rate per 100,000 women 65 and older
ranged between. 0.5 to 0.7.
Rennison and Rand (2003) examined the extent of non-lethal intimate
partner violence (rape, sexual assault, aggravated, and simple assault) from
the 1993-2001 NCVS. Over the nine years, they estimated that 117,940 non-
lethal violent IP victimizations were committed against women 55 and older.
They reported a victimization rate of 2% for women age 55 and older. The
authors noted that offenders, as they become older, might reduce the frequen¬
cy of abuse or commit more psychological/emotional abuse. Noteworthy, is
that psychological/emotional abuse is not collected by the NCVS.
Smaller scale studies have contributed to our current body of knowledge
about the extent of IPVA against older women. These studies are typically a
single community-dwelling sample (Pillemer and Finkelhor, 1988) or clinic-
patient sample (Fisher, Regan et al., 2003; Mouton, 2003). Their generalizabilty
is limited but given the paucity of research in this area, they contribute to the
growing body of knowledge of IPVA against older women.
Supportive of the theme of the national-level studies, the golden years are
not golden for many older women. Three studies described the abuse these
women have suffered. First, Moutin (2003) studied community-dwelling
women, who were involved in a multi-site clinical trial of women's health in
San Antonio, Texas. His results showed that of the 1,245 women aged 50-79
104 Fisher et al.
years old, 58.5% report exposure to some type of abuse in their adult lifetime
by a spouse/partner, with 5.2%-22.8% reporting some type of abuse (physical
or verbal) in the past 12 months. Second, using a sample of 998 women aged
55 and older from a patient database located in the Cincinnati, Ohio area,
Fisher and her colleagues (2003) found that verbal abuse (40.7% of the
women) and emotional/psychological abuse (24.6%) were among the most
prevalent among these women. Other forms of violence and abuse while not
as prevalent still were experienced by a substantial number of older women.
For example, 4.4% of the women suffered control abuse (put on an allowance,
routinely checked on respondent in a way that made her afraid, refused to let
respondent go to work, social activities or see or talk with friends), 4.2% were
physically abused, and 3.2% had been sexually abused since turning 55 years
old. Further, they reported, of the women who were victimized since the age
55 a large proportion experienced violence and abuse at the hands of a
spouse/partner. Noteworthy, they found that since these women had turned
55 years old, 68% were sexually abused, 56% experienced control abuse, and
37% had been physically abused by their spouse/partner. A third study exe¬
cuted by Grossman and Lundy (2003) of women 55 years old and over who
sought services from domestic violence programs in Illinois examined race
and ethnicity similarities and differences among White, African Americans,
and Hispanics. Across all three groups, almost all the women reported having
experienced emotional abuse (White, 97%; African Americans, 96%, and
Hispanics, 96%) and physical abuse (71%, 74%, and 77%, respectively).
Possibly due to their marital status, a larger percent of older Hispanic women
suffered from sexual abuse (17%) compared to Whites (11%), or African
Americans (4%).
These studies have begun to bring much-needed attention to the extent of
IPVA against older women. Collectively, their results come to the conclusions
that IPVA against older women is 1) an emerging critical policy issue, and 2)
an important field of scientific inquiry that is in need of more research. As
noted, there are methodological limitations in this first generation of IPVA
research but with this in mind, researchers can only build more rigorous stud¬
ies that will broaden understanding of IPVA against older women and fill the
gaps in our knowledge. For example, no studies to our knowledge have exam¬
ined the extent of stalking, the co-occurrence of various forms of IPVA, repeat
IPVA victimization, or ethnic differences in IPAV against older women (and
violence against older women).
The Nature of IPVA: Victim and Incident Characteristics
Several obvious questions come to mind concerning the IPVA against

older women victim and incident characteristics. Below we discuss aspects of
older women's experiences with IPVA as reported in the very few studies that
have examined the characteristics of these women and their experiences.
One question that comes to mind is the relationship between IPVA victims
and their demographic characteristics. Results from the NCVS revealed that
black women had the highest rates of non-lethal IPV (56 per 1,000 women age
55 plus), followed by the "other" racial category (52 per 1,000) and white
women (42 per 1,000). Caution, however, must be exercised in interpreting
these NCVS estimates because two of the racial categories (black and others)
had 10 or less sample cases. Older women who were separated had a much
higher rate of non-lethal IPV (10.37 per 1,000) than other marital categories (all
of which were less than 0.90 per 1,000) (Rennison and Rand, 2003).
The results concerning the relationship between IPVA and income are
mixed at best. Mouton (2003) reported no significant differences across
income categories and abuse. Rennison and Rand (2003), however, reported
that income and non-lethal violence has a U-shaped relationship, with women
with annual household incomes of $20,000 and women with an annual house¬
hold income of $75,000 or more having the two highest rates of victimization
(.50 per 1,000 and .92 per 1,000 older females, respectively). Again, the NCVS
results must be taken with caution, as small cell sizes are present in three of
the four annual household income categories.
Among other questions posed about the nature of IPVA concerns the spe¬
cific victim-offender relationship. Recall that Pillemer and Finkelhor (1988)
were among the first researchers to find that a spouse primarily committed
older women's abuse. Rennison and Rand (2003) provide further insight into
the nature of this IP relationship. They reported that the perpetrators for older
women were the current spouse (62%), current or former partner (26%) and
ex-spouse (12%). Interestingly this victim-offender relationship pattern is
slightly different from women 25 to 64 years old. The perpetrator for this
group of women was the current spouse (44%), current or former partner
(38%), and ex-spouse (18%).
Contributing additional insight into our understanding of the victim-
offender relationship, Grossman and Lundy (2003) reported that among
racial/ethnic groups in their Illinois study, 71% of the Hispanic women
reported that their abuser was a husband or ex-husband. Sixty-one percent of
White women and 45% of African American clients were abused by a husband
or ex-husband.
Unlike younger women in which the majority of the perpetrators are
under the influence of drugs and/or alcohol, results from the NCVS show that
in 49% of the victimizations the perpetrators of older women were not under
the influence of either substance. In 85% of the IPV against older women vic¬
timizations, the perpetrator did not have a weapon. In those few cases where
a weapon was present, a firearm was the most likely type (Rennison and
Rand, 2003).
To date, little is reliably known about the nature of IPVA against older
women. This area of inquiry remains a large gap in our IPVA knowledge.
Knowing the victim and incident characteristics are critical to understanding
differences and similarities within the older women population and between
women, especially younger compared to older women. Recognition of these
commonalities and difference can then be used as the basis for developing
services and programs tailored to the needs of older women (see section
106 Fisher et al.
below). What is needed are rigorous cross sectional, panel and longitudinal,
multi-disciplinary studies that examine the characteristics of older women
who have experienced IPVA and the characteristics of their experiences. One
step in this direction is listening to oral histories of women who have suffered
violence and abuse at the hands of an intimate partner. In the next section, we
present oral histories of such women.
IN THEIR OWN WORDS: OLDER WOMEN TELL

THEIR STORIES OF VIOLENCE AND ABUSE
The importance of in-depth qualitative information about older women

and IPVA is apparent from the current state of research that has reported the
experiences of women in their own words. Prior qualitative work has focused
primarily on the experience of younger women, although a few studies have
included at least one woman over 55 (Hilbert, 1984; Langford, 1996; Lempert,
1996; Merritt-Gray and Wuest, 1995; Moss, Pitula, Campbell, and Halstead,
1997; Newman, 1993). However, to our knowledge, only one qualitative study
has focused exclusively on elderly women (Grunfeld, Larsson, Mackay, and
Hotch, 1996). In that study, four elderly abused women, ages 63-73, who had
received assistance from a hospital domestic violence program, completed
oral history interviews aimed at examining the effects of violence on their
lives. While the analysis focused primarily on the health-related effects of the
abuse, the authors also explored the women's barriers for leaving their rela¬
tionships. These included: limited financial resources, inability to obtain a
divorce, or worry about the effects on their children (Grunfeld et al., 1996).
To further add to the depth of our understanding, Zink, Regan, Jacobson,
and Pabst (2003) recruited women over 55 who were currently or had been in
an abusive relationship since age 55. Thirty-eight women, ranging from 55 to
90 years old, qualified and participated in an intensive conversation with an
interviewer. Eighty percent of the women were white and over half had
household incomes greater than $40,000. The length of the abusive relation¬
ship was not brief as the median length of the abusive relationship was 23
years. Although a majority (61%) had left their abuser, a large proportion,
39%, had remained in their marriage or relationship
The women's relationships were marked by physical, emotional, social,
financial and sexual abuse. Their stories show how extremely complicated
these relationships are. Societal ignorance and denial of different forms of
family violence (child, domestic, and elder) meant that those women who rec¬
ognized the abuse as abuse in their domestic lives—and many did, received
little social, mental, or financial support from either inside or outside their
family. Many women reported that at various times in the relationship they
made efforts to seek assistance to stop the abuse. Their experiences were often
discounted and they were told to return to the marriage and to make the mar¬
riage work—for the children, of course.
Institutions today such as the courts, law enforcement, medical personnel,
and social service agencies provide a variety of support services for victims of
IPV. This was not so 30 years ago. When faced with IPV then these institu¬
tions, as a whole, upheld the sanctity and privacy of the domestic sphere.
Society considered IPV as a family problem that needed to be addressed with¬
out any outside interference. It was not the place of the courts, law enforce¬
ment, doctors, or the church to interfere in marital affairs.
Reflecting back to previous decades, these older women commented that
stricter gender roles had defined their functions and obligations to their hus¬
bands. These women described their roles as housewife, mother, and sexual
partner. They were expected to submit to the physical and sexual wishes of
their husbands. Many of them tolerated abuse because that was the expecta¬
tion of the times.
Several of the women continue to remain even now because of their own
health problems and those of their spouse. Many spoke of the commitment to
care for their abusive spouse now that he was in failing health. Other women
remained because of their own health conditions, suggesting that they were
dependent on their abuser. Despite the abuse, the need to provide or receive
care because of failing physical or mental health became fundamental to why
they stay with the abuser.
Zink and her colleagues also uncovered that older women face many of
the same challenges experienced by younger women in abusive relation¬
ships—economics, family attachments, shame, and health. Given the years of
abuse and the complex moral dilemmas imposed by their upbringings the
risks of older women were magnified. Because of the social culture, older
women had less opportunity to develop skills for autonomy and years of
abuse and attachment resulted in more to lose if they left. In addition, years
of emotional abuse resulted in poor self-image and confidence. As a result,
some older women chose to remain in the abusive relationship, the life-gener¬
ated risks being too great to overcome.
The Zink et al. study is among the first to offer insight into the dynamics
of abusive relationships that older women have and continued to experience.
More work into these dynamics, especially studies where women provide an
oral history, are much needed to provide a life course perspective into both
long-term IPVA and that which began at the onset of old age.
RESOURCES FOR OLDER VICTIMIZED WOMEN: DO THEY EXIST?
The Health Care Provider
Who is most likely to see older women outside of their family and
friends? In many cases it is their primary care physician (PCP). Research has
shown that chronic health problems such as diabetes, arthritis, and hyperten¬
sion are experienced more often by older women than any other age category
(Desai, Zhang, and Hennessey, 1999). These diseases make it necessary for
women to see a primary care physician on a regular basis, sometimes as often
as once a month. This puts the PCP in a unique position to serve as a gateway
to resources about IPVA.
108 Fisher et al.
We know from the literature that primary care physicians are doing a
poor job of screening women of all ages for intimate partner violence (IOM,
2002; Lapidus et al., 2002; Rodriguez, Bauer, McLoughlin, and Grumbach,
1999). Physicians identify many barriers to screening for IPVA including time
constraints, discomfort with the subject, fear of offending the patient, frustra¬
tion with patient's denial, lack of skills and resources to manage IPVA (Sugg
and Inui, 1992; Sugg, Thompson, Thompson, Maiuro, and Rivara, 1999;
Waalen, Goodwin, Spitz, Petersen, and Saltzman, 2000). For these reasons,
and the fact that physicians do not think of older women as victims of IPVA,
screening for IPVA rarely occurs with older female patients (Rovi and
Mouton, 1999).
Zink and her colleagues (Zink, Regan, Goldenhar, and Pabst, 2003)
conducted focus groups with 47 primary care physicians, nurse practitioners
and physician assistants in Cincinnati, Ohio and surrounding suburban and
rural areas. They were interested in investigating the level of awareness of
IPVA in older women patients, screening behavior for the IPVA, and manage¬
ment, if any, of IPVA once detected.
They reported that PCPs tend to fall along a continuum of screening,
identifying, and managing IPVA in older women. One end of the continuum
they found that many health care providers are not screening for IPVA among
any of their patients regardless of age. Several providers, especially those with
suburban practices, clearly stated that they were not screening any patients
because they did not believe that IPVA was a problem in any of their patients
so there was no reason to screen. Other providers do not believe that IPVA is
a medical issue, they do not think there is a medical solution for the problem
and consequently do not see a role for the physician to screen, refer, or man¬
age a patient regardless of age.
A second group of providers fell into a middle category. They realized
IPVA was a problem but only among younger women. Many stated that
unless there was a physical sign such as bruising or broken bone or if the
woman brought it up, they would not screen for IPVA. These providers
reported calling the police or adult protective services to deal with an obvious
case of IPVA especially if it involved an older person. They knew something
needed to be done, but were unfamiliar with the range and nuances of
resources for older women with IPVA. Providers were identifying and man¬
aging their patients only at limited levels. These providers seemed to work
primarily with an "acute disease" model—identify and treat the problem and
then move on to the next issue. Examples included: treating depression or
anxiety, but not exploring the IPVA or providing unrealistic advice such as
telling the patient she needed to leave but not offering any suggestions on
how she should do that. In addition, some providers did not know the
nuances of managing an older victim with IPVA, again seeking simple solu¬
tions such as telling them to get a job or telling the husband to come in and
the doctor would talk to him.
The last category of providers was at the other end of the continuum—the
routine practice of thorough identification and management of older battered
women patients. Some providers made sure they saw certain clients on a reg¬
ular basis as a way of checking on their well-being, monitoring medication,
and referring them to counseling. These providers displayed a more "chronic
disease" mindset for managing IPVA, ongoing attention to a variety of factors,
and understanding the unique challenges of managing the older victim who
often needs to seek solutions other than leaving the relationship and the var¬
ied capacities of local resources to meet the needs of the older IPVA victim.
These physicians showed an understanding of the generational issues faced
by older women. They mentioned that many of their older women patients do
not want to complain too much and/or are less open about their situation.
Since many of these women have been in long-term marriages, the couple's
financial, social and emotional lives are intertwined. The physician's experi¬
ences had been that those women who had a higher household income may
be less forthcoming about an IPVA situation or reluctant to seek outside help
because they were embarrassed and took pride in their status. These women
feared that by addressing the IPVA a loss of privilege to which they have
become accustomed may occur. Those women with lower incomes may have
few, if any, resources (e.g., money, insurance, support network) that would
allow them to seek counseling or perhaps even to leave their situation. Several
providers noted that this is frustrating for them, especially the ones want to
provide resources but cannot because they are bound by insurance require¬
ments or other resource constraints.
The Domestic Violence Community
A second resource for older women experiencing IPVA is the networks of

domestic violence shelters and crisis lines. The needs of older women IPVA
victims are unique compared to those of younger women (Brandi, 1997;
Vinton, 1999). For example, since older women have been participating in
long marriages many do not want to leave their spouses, they typically just
want the abuse to end, their family life to remain intact, and to feel safe at
home for their remaining years. The usual assistance for younger women,
such as support groups or job training, is not^ always acceptable to older
women (Vinton, 1992; Vinton et al., 1997). Other assistance such as shelters
may be filled with children and may not be set up to manage the needs of
older women, such as handicap access, medication protocols, or accommodat¬
ing special dietary needs (Fisher, Zink, Pabst et al., 2003).
A few studies have been undertaken that shed some insight into services
and programs the DV community offers to older battered women. Vinton sur¬
veyed DV shelters in Florida and nationally about special programming for
older battered women. Overall, she found a relative lack of services for these
victims (1992, 1998; Vinton et al., 1997). To illustrate, Vinton (1998) reported
that only 14.8% of the shelters nationally offered any special programming for
older battered women. Outreach and individual intervention were among the
most common types of programming, yet only a few shelters, 34% and 19%,
respectively, did so.
no Fisher et al.
Extending Vinton's work, Fisher and her colleagues (2003) conducted a

survey of all the domestic violence shelters and crisis agencies in Ohio to
assess the capabilities for serving older women clients. They reported some
very positive results but similar to the results from Zink et al/s focus groups
with the primary care physicians several areas were identified that can be
addressed that would improve care to older women experience IPVA. One
important aspect of providing services to older women is whether staff mem¬
bers at DVCs are trained about aging. Close to 43% of the DVCs provided
training to their staff or volunteers about IPVA and older women. Of these
centers however, a little less than a third (32%) conduct routine training.
Fisher and her colleagues (2003) also reported that 36% of DVCs do out¬
reach to women 55 years and older to reach older women who have experi¬
enced IPVA. Outreach included brochures given to programs that service older
woman, presentations at senior centers, having an advocate at a senior center.
A large proportion, 94%, of DVC provided services or referred women to one-
on-one/ face-to-face interventions with DV victims/survivors. Nearly 30% of
these DVCs provided services or referred at least one woman over 55 years old
to one-on-one/face-to-face interventions. Eighty-nine percent of DVCs provid¬
ed a crisis line, with almost 20% of them having served at least one woman
over 55 years old via their crisis line. Eighty-five percent of DVCs ran support
groups. Forty percent of these DVC served at least one older woman in their
support groups. Nearly 80% of DVC (77%) operate a shelter. Seventy-eight per¬
cent of these DVC sheltered at least one women 55 years and older.
Clearly these studies highlight that there are few resources, especially
ones tailored to the needs of older women who suffer from abuse and vio¬
lence. The lack of resources is an opportunity to make suggestions as what
needs to be done to improve resources for older women. In the last section of
this chapter, we turn to these issues.
FUTURE DIRECTIONS
Although there are only a few studies about older women and IPVA, these
studies provide convincing evidence that a significant proportion of older
women have experienced abuse and violence at the hands of a spouse/partner
and that there is need for further review. In reviewing the state of this body of
research, three main themes emerged that researchers, advocates, and practi¬
tioners need to pay attention to so that both research and policy can move for¬
ward to prevent and respond to the quality of life of older women who have
faced or continue to face IPVA. First, one concern that has been confounded in
the research is identification of the perpetrator and the labeling of such experi¬
ence (that is, whether the abuse is intimate partner violence of older women or
elder abuse). Discerning between the two can be difficult for the provider but
can mean serious consequences for the injured party. Two, once the type of
abuse has been identified, the need for appropriate services are extremely
important and what is appropriate for younger women may not be appropriate
for older women. Three, gatekeepers for younger women experiencing abuse.
such as physicians, domestic violence shelters and service providers for the eld¬
erly must be better educated about both older women and IPVA. Each of these
groups must be encouraged to collaborate to create services and programs for
victims. Below we discuss each issue in more detail.
Distinguishing Between Elder Abuse and IPVA Among Older Women
Similar to other states, the state of Ohio's statute on elder abuse/neglect

(Ohio Revised Code, 2000) is for an adult, defined as 60 years of age or older
who is handicapped by the infirmities of aging or who has a physical or men¬
tal impairment which prevents the person from providing for their own care
or protection who is being abused physically, sexually, financially, or is being
neglected including self-neglect. Physicians and others who serve older peo¬
ple are encouraged to contact the local Adult Protective Services (APS) in the
area to report this type of abuse. Adult Protective Services focuses on physi¬
cal/ sexual abuse and neglect and the issue of competence. The law limits APS
in how aggressive APS workers can be about entering a person's home if the
individual seems competent, is unwilling to talk with them and there is no
legal reason to enter.
For many who work with the elderly. Adult Protective Services does tittle
to protect women who are being abused by a spouse or significant other, as is
the case in IPAV. In many cases, when violence against an older woman is iden¬
tified, caregiver stress is often considered the primary cause (Pillemer and
Finkelhor, 1988). Even in the case of abuse of an older woman by her husband
it is often thought to be due to an overburdened and stressed caregiver. The
intervention for caregiver abuse is focused on supporting the stressed caregiv¬
er with respite assistance, support groups and arranging additional services in
the home for the "patient" (Pillemer and Finkelhor, 1988). This type of response
is not appropriate in the case of an older woman who is being abused. This still
leaves her at the mercy of her abuser without any support for her.
The Violence Against Women Act (VAWA) of 2000 was signed into law by
President Clinton and provided continued funding for many of the programs
that were effective under the Act of 1994. Several other significant measures
passed as part of the final language including that it restored and strength¬
ened protections for battered immigrant women; improvements to Full Faith
and Credit provisions; pilot programs for transitional housing and supervised
visitation centers; and programs addressing violence against older or disabled
individuals among other programs such as stalking via the internet. It is
imperative that service providers who work with abused women and those
who work with older women begin to collaborate on education and program¬
ming to address this problem.
The Need For Services and Programs Tailored to the

Needs of Older Women
Generational issues make the situations older women face more compli¬
cated. There are more years of dependence, more years of control. Providing
112 Fisher et al.
support to women who want to remain means that service providers need to
think outside the box. The usual systemic responses used with younger abu¬
sive couples may not be appropriate. Leaving may not be an option.
Attending a support group with younger women may not be helpful to older
women who have had a different life experience or may have trouble with
transportation or driving in the dark. Residing in a shelter filled with children
or that does not accommodate the needs of older individuals (e.g., monitor
medications, handicap access, accommodate dietary preferences) may result
in an older women returning to her abuser. In addition, the realities of aging,
involving both physical and mental incapacities, limits options. Abusive rela¬
tionships are often marked by isolation from friends and family (Bowker,
1983). One can only imagine how loss of sight or inability to drive may fur¬
ther isolate the victim.
In addition, aging may also limit the ability of the abuser to leave the
house, meaning that the victim no longer has any break from the abuse. Mental
aging may result in confusion, potentially intensifying the abuse and care
required by either partner. Physical abuse declines with age (Harris, 1996), but
verbal abuse can be devastating to mental well being (Bowker, 1983). Again,
one must ask, how does society support the abusive older couple that seeks
assistance or enters the legal, health or social service system because of the
abuse? Because of aging, the usual responses may not be appropriate.
What can a community do to support an older woman who is experienc¬
ing IPAV? The most frequently given suggestion by physicians, domestic vio¬
lence shelter advocates and aging agency advocates was community aware¬
ness. Public service announcements that Intimate Partner Abuse and Violence
is a Life Course phenomenon are crucial. The more that the message can be
made public; the less stigma is attached to the abusive act. More information
about abuse must be made clear. It is important that people understand that
not all abuse is physical, sexual or neglect. The older women, in their own
words, made it clear in many cases that the physical abuse had stopped many
years ago but the verbal, emotional, psychological and control abuse still took
place on a daily basis. More information needs to be made available where
older women are more likely to go such as beauty shops, women's clubs, gro¬
cery stores, department stores, make-up counters, fabric shops, craft stores,
doctor's offices, senior centers, places of worship, and adult day cares.
There must be more facilitation between aging agency advocates and
domestic violence advocates. Vinton (2003) describes some very innovative
programs between these two types of agencies taking place in Florida. One
unique project was the building of a shelter room onto an existing senior cen¬
ter. The room was accessible from a private entrance. It was handicap accessi¬
ble. People using the senior center and domestic violence advocates were
aware of the room's existence. Police and other law enforcement agencies
could bring an older woman there where a shelter worker and a caregiving
assistant if necessary for personal care would meet them. In another case, cer¬
tain assisted living agencies volunteered a certain number of days in their
facilities for emergency shelter for older women who needed to leave abusive
homes. Again, the facilities were handicap accessible, medication could be

administered and personal care could be assisted while the woman received
assistance from the local domestic violence service agency. And in Ohio, one
agency provides foster care for pets. Many times older women who must
leave their homes do not want to leave beloved cats or dogs for fear that the
abuser may harm them, so a program is set up for the pet to go into foster care
with a family until other arrangements can be made.
Most important is dual education by both types of agencies. Domestic
violence agencies need to know about aging and aging agencies need to know
about the services available for older women experiencing domestic violence.
Many times, it is the personnel of aging agencies such as home care workers
and meals on wheels deliverers who are in the home on a daily basis and may
be good resources for screening for intimate partner violence with the right
training by domestic violence advocates. Domestic violence advocates would
be helped by knowing about transportation programs, meals on wheels and
home care programs. We must continue a move toward a coordinated effort
of research, advocacy, and services that seek innovative solutions to identify¬
ing, and providing services to older women who are victims of intimate part¬
ner violence and abuse.
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'
■
9
VERBAL ABUSE AND

COMMUNICATION NEGLECT IN
THE ELDERLY
Helen Sorenson
What you are speaks so loudly that I cannot hear what you say.
Ralph Waldo Emerson
As the population of older adults increases, so will the interaction

between those over age sixty-five and the younger generation. While inter-
generational blending can be a positive experience, it can also lead to misun¬
derstanding. Frustrations that arise based on the old vs. the new way of doing
things can result in conflict. When conflict is acted out, it becomes abuse.
This chapter focuses on a narrow but common aspect of abuse: verbal abuse.
Comparatively, verbal abuse occurs four times as often in nursing homes as
physical abuse. Communication neglect, while not a visible form of mistreat¬
ment, can be equally damaging to older adults. An awareness of what consti¬
tutes verbal abuse and communication neglect may foster a better communica¬
tion environment between health care professionals, patients and families.
COMMUNICATION DEFINED
Communication as a global concept is an exchange of information. Within

most species communication is innate. Whether with spoken words, a growl,
chirping or flattened ears, even between species some forms of communica¬
tion are universally understood. Communication implies two things; the mes¬
sage has been delivered and the message has been understood. Because there
are two components to this process, it is possible and even probable that at
times they are independent of each other.
To facilitate the relaying of information there are many forms of non-ver¬
bal communication. Tone of voice, body language, facial expressions and ges¬
tures are effective in getting the message across. In our society today we have
also become dependent on symbols to inform us when to safely cross the
street, to alert us when approaching a railroad crossing and even when to
refrain from smoking. It would seem that the overabundance of ways to
exchange information would avert most discrepancies in delivering a mes¬
sage. Unfortunately, this is not always the case. For many older or infirm
adults, communication is difficult. When transmission of vital information is
at risk, so is optimal patient care. The new paradigm, patient-centered care,
117
118 Sorenson
relies on the patient and care provider working as a team. Good teamwork
depends on good communication.
Training in effective communication skills is important, not only for
health care professionals, but also for the elderly and their families. Enhancing
the communication environment for older adults will ultimately affect their
quality of life. Providing for an improved environment however requires
understanding some of the potential barriers known to hinder effective com¬
munication.
BARRIERS TO COMMUNICATION
The most obvious barriers to conversing with many older adults are age
or disease related hearing loss, stroke related aphasia, Alzheimer's disease
and dementia. There are varying degrees of miscommunication related to:
• Message delivered, not heard

• Message delivered, partially heard
• Message delivered, heard but nor understood
• Message delivered, message understood, response not
physiologically possible
• Message delivered, message heard, message ignored
It cannot be presumed that because a conversation has taken place in the

presence of an older adult, that any understanding or comprehension of the mes¬
sage was received. The most obvious barrier to communication is hearing
impairment or hearing loss. Current data estimates there are as many as 28 mil¬
lion hearing-impaired individuals in the USA, with 75 percent being older than
age fifty-five. Prevalence varies greatly with age and gender, ranging from 10
percent in females aged 48 to 52 years to 97 percent in males over age eighty.
Presbycusis, the bilateral symmetric loss of auditory function, begins in middle
age and progresses with age. It is also possible that accumulated earwax or oto¬
toxicity, defined as hearing loss associated with some pharmaceuticals, play a
role in hearing impairment. Aphasia accounts for the disconnect between hear¬
ing and understanding. Loosely defined, aphasia is the loss of ability to speak
and/or comprehend language as a result of brain cell damage. More specific
forms of aphasia; expressive, fluent, non-fluent, receptive, sub-clinical and glob¬
al, in varying degrees, limit communication. Even after rehabilitation, chronic
aphasia presents a challenge, however a recent study revealed that over time,
communication for adults with aphasia does improve. Older adults, as a result
of both age-related and disease related decremental change, face situations in
which they are unable to communicate effectively. The inability to be connected
to a family member, a friend, a caregiver or a health care professional can leave
older adults very frustrated. This frustration can lead to self-imposed seclusion,
feelings of self-pity and even anger. Negative emotions, projected by the older
adults unfortunately are communicated quite effectively to those around them,
leading to a cycle of more rejection and more anger.
Communicating with older adults can be complex. The collective nature of

age and/or disease related physical and functional impairment, coupled with a
dependency vs. autonomy struggle, could result in dysfunctional dialogue.
Elderly individuals who have led very independent lives may choose to be reti¬
cent rather than risk speaking ineffectively. A lifetime of independence may also
be projected as an "I don't need help from anyone" attitude, which can stop con¬
versation before it starts. Lack of social opportunity, both in the community and
in health care environments is another barrier to communication. While not usu¬
ally considered a major problem, the insidious lack of verbal contact with anoth¬
er human can be quite harmful.
A relatively recent barrier to communication is lack of technology know¬
how. A textbook published in 2001 addresses the need to design computer pro¬
grams for older persons and train them to be computer literate. The book is
based on presentations from an international conference, which linked German
and American scientists working in the area of communication and technology/
For older adults with communication impairments, being able to adapt to the
new technology may be a critical component in improving interactions. Email
allows for a social connection and relationships that were not available a decade
ago.^ Defining the barriers to communication and proactively looking at ways to
circumnavigate the obstacles is an important task, given the growing population
of older adults. The saying "the elderly need so little but they need that little so
much" should be a central theme related to communication in the elderly.
Depression, which is estimated to affect 5% to 9% of community dwelling
older adults and be three to five times more prevalent in nursing homes / pro¬
duces it's own intricate web of communication malfunction. According to Blazer,
depression is perhaps the most frequent cause of emotional suffering in later life
and significantly decreases quality of life/ Although more prevalent in nursing
homes and long-term care facilities, depression is often under diagnosed and
untreated. A study of depression in older nursing home residents revealed that
of all the residents who had been diagnosed as having an active clinical condi¬
tion, identified on the Minimum Data Set (MDS) only 55% were receiving anti¬
depressant therapy/ Even when medication is available, not all older adults are
compliant with the scheduled drug dosing, leading to variable moods and
response patterns.
Patients who do not respond when greeted by caregivers are often just cate¬
gorized as non-responsive to verbal stimuli. All too often it is presumed that the
patients are sleeping or too tired to visit. Because of the prevalence of age relat¬
ed hearing impairment, non-responsive patients may not be given the attention
they deserve. If when more aggressively assessing the level of awareness of the
patient, caregivers notice sad facial expressions, frequent tears, or flat affect, the
patient's physician should be notified.
COMMUNICATION NEGLECT
Defining specific categories of elder abuse has not been easy. Referred to
as the "definitional disarray" by Pillemer and Finkelhor/ the difficulty seems
120 Sorenson
related to the development of definitions from different perspectives. Elderly

abuse victims, physicians, social workers and law enforcement officers may
all have distinct definitions of elder abuse based on personal feelings, profes¬
sional codes and agency policy.
Communication neglect may be classified as a form of psychological
insult inflicted on another individual. In the health care setting this can occur
when caregivers avoid talking to, touching or having any social contact with
a patient. Whether as an unintended oversight or a deliberate withholding of
any form of communication, both situations may be interpreted and/or
defined as abuse.
Unintentional Communication Neglect
Occasionally, the health care professional's concern for efficiency over¬

shadows the patient's need for social contact of some sort. Taking an extra 5
to 10 minutes to chat with a lonely older adult does not alleviate busy sched¬
ules and high patient loads. Taking the chance that a "good morning, how are
you?" question, may result in a long and detailed response instead of a sim¬
ple "fine, thank you" is not something we are always willing to risk.
Struggling to communicate with an older adult, whose stroke resulted in
aphasia, may be very time consuming and frustrating for both parties.
ICrowing this, it is sometimes easier not to even start a conversation. These are
not examples of willful disregard for humanity, they are the unfortunate con¬
sequences of learned behavior. Even when communication does take place,
body language may not match the spoken word. Herodotus, ca. 484-425 BC
wrote, "we are less convinced by what we hear than by what we see." Asking
someone how they feel while simultaneously looking at a chart, checking the
phone number on a pager, and/or conversing with someone out in the corri¬
dor speaks volumes. Could this be a consequence of a hectic schedule? Most
likely, yes. However, when a message is delivered and the response is not
acknowledged, a neglectful barrier to communication has been created.
Unintentional neglect does not imply lack of concern or caring, but it can be
interpreted as such by the elderly patient. Even facial expressions can relay
unintentional messages. A caregiver's quick glance at the patient as he/she
pass through the hallway, without any attempt to verbalize a greeting may be
perceived as punishment for some unknown deed. Without stereotyping all
older adults as worriers, it is possible that given enough time to ponder the
reasons why no greeting was forthcoming, some older patients may presume
that somehow they were at fault.
The term unintentional implies a lack of purposeful deliberation. Health
care professionals may be unaware that some of their unplanned actions or
lack thereof are causing adults under their care to feel neglected. Interventions
to avoid unintentional communication neglect will be covered in another sec¬
tion of this chapter.
Intentional Communication Neglect
Much more harmful to older patients or elderly residents of long-term

care facilities, is being on the receiving end of intentional communication neg¬
lect. This is akin to using the "silent treatment" as a form of punishment. The
deliberate withholding of warmth and caring by performing tasks in a cold,
detached manner could be classified as abusive. Setting a food tray down on
a patient's bedside table or taking the morning vitals on an alert patient with¬
out uttering a single word is neglectful. Another form of communication neg¬
lect is demonstrated by talking about, not to a patient in their presence or
referring to the patient in terms of their disease of prosthesis. An example of
this might be casually asking a coworker to "hold the elevator, I need to take
this trach down to radiology for a swallow study." Being referred to as an
object is dehumanizing and could precipitate or further deepen depression.
Something seemingly as innocent as inquiring, "has the liver transplant's lab
work come back yet?", if overheard by a patient or family member, sends a
detrimental message.
It is difficult to navigate around the new federal regulations for maintain¬
ing patient confidentiality in any institutional setting. Health care profession¬
als must sustain vigilance in preserving patient anonymity in a public hallway
without sacrificing the personal dignity of those under their care.
VERBAL ABUSE
Verbal abuse is an extreme example of ineffective and inappropriate com¬

munication. Because it is so common, mention of the possible causes need to
be addressed. In recent years, research on verbal abuse in nursing homes has
determined that the following situations are more often associated with
increased incidence of abuse:
• Failure of State laws and agencies to provide adequate oversight

and protection of patient's rights
• Managers and administrators failure to create and enforce policies
supportive of caregivers and residents
• Inexperienced personnel in crisis prevention and intervention
• Improper staff training in how to prevent verbal abuse
• Staff members under work related stress who are approaching "
burnout"
• Employees who have a history of solving problems by resorting to
violence
• Employees who harbor negative attitudes toward patients
• Staff members who are provoked by combative or verbally aggres¬
sive patients.
Addressing many of these situational eventualities during an educational

in-service and emphasizing that professional health care providers must take
122 Sorenson
personal responsibility for their attitudes and behavior, regardless of the cir¬
cumstances can positively enhance the communication environment.
Unintentional Verbal Abuse
"Why on earth have they decided to CODE this patient, he's been a DNR
for days and he's dying." Is this an atypical statement made in frustration in
front of a seemingly unconscious patient? Unfortunately, no. A careless
remark, often made to no one in particular, and with no harm intended, can
indeed be injurious. The terminally ill person hears very well. They may
know that they are dying, but to hear a comment similar to the one above
would dash all hope. Anything that causes the patient anguish or distress is
abuse. Another example of unintentional verbal abuse often relates to odors.
Older adults hospitalized for medical reasons and on a variety of prescription
drugs, are often incontinent. The room may smell terrible, but calling atten¬
tion to that fact, in a crude, or even joking manner may be embarrassing or
humiliating for the patient. There are many benefits to the use of humor in a
health care setting, but care must be taken not to make jokes at the expense of
particular patients. Those who work around older adults should be aware that
some words like idiot, deaf, and blind elicit strong negative feelings. Even
calling an elderly patient by a pet name, if permission has not been forthcom¬
ing, is inappropriate.
Many assumptions are made about older adults. The actual prevalence of
hearing loss, visual impairment and disease related cognitive changes could
lead one to falsely believe that these losses are always consistent with the
aging process. While it may be easier to converse with family members pres¬
ent in the room about the patient's condition, to do so is generally insulting.
Even when signs of frailty are evident, maintaining eye contact and speaking
directly to the geriatric patient is important.
Intentional Verbal Abuse
Much more malignant in nature are the cruel threats and intentional barbs
directed at older adults. Verbal abusers attempt to control behavior by using
threats of violence or threats of neglect, as in these examples: "If you wet the
bed one more time tonight, you'll just have to sleep on soggy sheets." "If you
don't eat all your supper, you are not getting any breakfast or lunch tomor¬
row." " If you don't stop crying I'll give you something to cry about." "If you
push that call light one more time tonight, you'll be sorry." If said in a threat¬
ening manner, by a caregiver with a scowl on their face, patients will take
these statements seriously. Unfortunately, some older adults have been on the
receiving end of both verbal and physical abuse. When intimidated and given
an ultimatum, they may see compliance as their only option. The helpless and
hopeless attitude that develops may become so ingrained that even when
kinder and gentler staff ask questions about how they are being treated, they
remain silent. Many older adults have no other residential options besides
institutional care. Once the pattern of abuse has been set, the elderly are more
likely to acquiesce than to rebel against unjust treatment.
Even making fun of patients or playing humiliating practical jokes on an
older adult is a form of verbal abuse. Patients in their 30s and 40s may wel¬
come some good-natured bantering as a means of lightening their day. Elderly
patients may seem amused, but may internalize the joking as something other
than what was intended.
Because verbal abuse and communication neglect are so prevalent, partic¬
ularly in long term care institutions, the prevention of any type of abuse or
neglect is the responsibility of every employee. In order to clarify what the dif¬
ferent forms of abuse and neglect look like from all points of view, educating
the staff is a necessary component of a continuing education program.
TOXIC TALK
Another form of unhealthy communication in the health care setting is

referred to as toxic talk. While not intended to intimidate or frighten patients,
toxic talk conveys an attitude of disrespect for person's humanity, the right to
privacy and self-determination.
It can be characterized by an attitude, a tone of voice or style of speaking.
Toxic talk includes conversations that may or may not happen in the vicinity
of the older adult being discussed. As opposed to many types of verbal abuse,
toxic talk may not be conducted with negative intent. Although harm is not
intended, toxic talk does insinuate that the individual or situation being dis¬
cussed is not worthy of polite conversation. For example, toxic talk may con¬
sist of:
• Using "baby talk" to communicate with an older cognitively

impaired older adult
• Using a frustrated tone of voice to call attention to a predicament;
• "Are you wet—again?" "What's your problem today?"
• Discussing a patient and/or situation outside of the room, presum¬
ing the patient cannot hear;
• "Have you seen his family? They are all idiots"; "Her whining is
just driving me nuts!"; "How can anyone let themselves get so fat?"
• Discussing patients in a detrimental or condescending manner when
giving report to the next shift;
• "Be careful when you go into the room—he's got a foul mouth and
he's not afraid to use it";
• "She need to be admitted to the psych ward—she's 'loony tunes'."
Although this type of information passing may have a semblance of truth,

it is also judgmental and can influence others the attitudes prior to even com¬
ing into contact with the older patient. The following case study (a true story)
is an example of how communication, both positive and negative examples,
can affect a patient's outcome.
124 Sorenson
"It's not Funny Grade"—A Case Study
Elmer, a 72 year-old homeless man was involved in a pedestrian-vehide

accident. He was transported to a trauma center via ambulance. Upon arrival
at the ER, Elmer said very little, except to repeat over and over "I got hit by a
damn truck."
Patient assessment revealed numerous cuts and abrasions on his face,
arms and torso. The X-rays showed a fractured arm and two fractured ribs.
Based on his injuries, coupled with the fact that he was dehydrated and mal¬
nourished, Elmer was admitted to the general floor. Two days after admission,
by looking at lab work and diagnostic testing results, internal bleeding was
confirmed. Elmer was taken to surgery and his spleen was removed. His
recovery was hindered by a number of physical and psychosocial issues, but
most harmful was his apparent lack of desire to get well. His face had been
"turned to the wall." In the intensive care unit, on a ventilator, Elmer received
no visitors. No get-well cards or signs decorated the walls of his room. No one
seemed surprised that he was becoming ventilator dependent. Elmer's condi¬
tion had become somewhat of a joke in the report room. Morning after morn¬
ing someone would ask; "what happened to Elmer," and a chorus of staff
members would reply, "He got hit by a damn truck."
One morning while my students and I were doing routine patient assess¬
ments and ventilator checks, Elmer's nurse asked me a question. "Do you
think we could cut Elmer's hair"? Elmer had been disheveled and unkempt
when admitted, but now, even though cleaned up he still looked pretty shab¬
by. I replied, "We would need his permission." We agreed to ask Elmer if he
would like us to cut his hair, and if he did not respond negatively, we would
take that as permission. A "no" response was not forthcoming, so we proceed¬
ed. The shampoo and haircut was followed by another question; "Elmer, it is
OK if we shave off your whiskers"? In the absence of a negative response, we
continued.
After finishing the grooming session, and putting the shampoo, razor,
and comb in his bedside table, we discovered his glasses, tucked away safely
in the drawer. We decided to put his glasses on, sit him up and turn on the tel¬
evision. Then it hit us both at about the same time. Elmer looked just like
George Burns. The resemblance was so remarkable that we called in other
caregivers to see the results of our hospital makeover.
An amazing thing happened as we stood there smiling at Elmer—he
smiled back at us. After that his recovery was amazingly quick. Within days
he was weaned off the ventilator. He gave Social Services the name and phone
number of his brother who lived in a nearby town. His brother visited him in
the hospital and less than two weeks later, the two of them walked out of the
hospital, together.
There are two issues related to this case study. The first is toxic talk. The
joking banter in the report room, while not audible to the patient or any other
caregivers, did affect the attitude of therapists caring for Elmer. Toxic talk, as
previously discussed, is harmful. Because of the serious nature of working in
an intensive care unit, comic relief is sometimes necessary, but should not
involve or be centered on any particular patient or family member.
The other issue is communication neglect. Why did it take 10 days to dis¬
cover that Elmer wore glasses? If that wonderful nurse had not gone above
and beyond her job that morning, would Elmer have survived? It is easy now
to look back on that incident and see how valuable and necessary her inter¬
ventions had been. However, given the fast-paced nature of our jobs where
time at the bedside is limited, do we really take the time to communicate with
our patients?
CONSEQUENCES
The consequences of verbal abuse and communication neglect are far

reaching. First and foremost is the harm inflicted on the patients. It would be
difficult to measure the degree of damage, as all people respond differently,
but if elders are being abused, they are being affected. There will also be an
impact on the family members. Not understanding why grandma has become
so quiet and withdrawn could lead to self-recrimination; family members
might presume that they had somehow caused this new behavior. Health care
providers not involved in the abusive treatment, or unaware that it was tak¬
ing place may presume it is a new medical problem, and subject the older
adult to additional painful testing.
Communication has a positive effect on a person's emotional and psycho¬
logical well-being. Lack of communication, or deviant forms of communica¬
tion will have a negative effect. There is a wealth of medical literature linking
patient and/or family dissatisfaction with the health care provided, to a fail¬
ure in communication. The consequences of abuse in older adults however
has not received as much attention in published articles. Depression, learned
helplessness, mortality and post-traumatic stress are some of the likely out¬
comes that are being investigated.
DETECTION AND INTERVENTION
Detecting verbal abuse and communication neglect is a complex paradox.

Symptoms exhibited by an older adult may indicate some form of abuse,
but when questioned he/she may adamantly deny everything. Some of the
recognized signs of psychological abuse, including verbal abuse and commu¬
nication neglect are:
• Being extremely withdrawn, non-responsive or non-communicative.

• Demonstrating unusual behavior often attributed to dementia, such
as sucking, biting or rocking.
• Being emotionally upset or agitated.
• Actually verbalizing that they are being abused
Because some of these signs are also consistent with depression, demen¬
tia and cognitive impairment, it becomes difficult to base an assumption of
126 Sorenson
abuse on signs/symptoms alone. Unless witnessed by reliable supervisors

and or co-workers, abuse is often disavowed by both by the older person and
the perpetrator. Abused elderly, for fear of retaliation, shame and/or the stig¬
ma of being labeled, fail to report inappropriate treatment. Cognitively and
physically challenged older adults may be unable to voice a complaint, which
unfortunately puts them at higher risk for being abused. In order to intervene
early and diffuse situations before serious harm ensues, there needs to be
recognition that a problem exists. Physicians and emergency room personnel
are on the front line in detecting signs of physical abuse, but verbal abuse is
subtler and leaves no visible scars.
Over the past decade, efforts have been made to create instruments/tech¬
niques to identify abuse and abusers. Profiles of those likely to engage in abu¬
sive behavior have been developed. Nursing homes and long-term care facil¬
ities have become more vigilant in screening prospective employees for evi¬
dence of past abusive tendencies. Since the 1970s regulatory safeguards have
been enacted to protect residents of long-term care facilities. These safeguards
include mandatory criminal background checks of all employees, and
ombudsman programs to hear complaints of abuse and neglect. Components
of the 1987 Omnibus Budget Reconciliation Act included resident's rights pro¬
visions. There have been changes in adult protective legislation and even
advances in creating protocols for detection and intervention, but there is
more work to be done.
A recent study conducted in assisted living facilities examined decision¬
making ability and awareness of abusive situations among elderly residents.
Videotapes with scenarios of physical, verbal, financial and neglectful abuse
were shown to the residents. While the majority (54%) of residents could iden¬
tify the abusive situations, the study suggested that the residents were poor¬
ly informed about options available through adult protective services. Many
could recognize abuse on the videotapes, but were uncertain about what to do
if they were actually the recipients of such treatment. Although this study had
a small sample size, it raised important questions.
Some interventional models have been developed to increase identifica¬
tion of elder abuse, improve care planning and promote prevention. Among
these are; education on what constitutes abuse, training of caregivers in com¬
munication skills, the use of "volunteer buddies" to listen and monitor for
abuse, the formation of a victim's empowerment group and the creation of a
handbook for caregivers to self-assess risk for elder abuse and to identify
community resources. Many of these interventions have been successful and
have not been cost-prohibitive in implementation.
Unfortunately, those who are under their care direct some of the verbal
abuse in institutional settings at caregivers. Older adults with aphasia occa¬
sionally repeat inappropriate phrases. Patients with dementia can lash out
with very offensive language. When caregivers are met with a constant bar¬
rage of profanity, they sometimes retaliate in kind. Education on the appropri¬
ate way for caregivers to respond is imperative. A cooperative communication
intervention for nursing home staff and family members of residents was sue-
cessful in improving family-staff relationships. While outside the scope of the

study to determine the effect that improved staff-family communication had
on the residents themselves, this might be an area where future research is
needed.
COMMUNICATING WITH ELDERLY PATIENTS
The following are examples of positive communication interventions.

Older adults are not always going to respond to questions, comments or even
a generic greeting. Our role as caregivers is not to make them talk, but rather
to provide a safe environment, which allows them the opportunity to talk if
they so desire.
Communication Tips
• Be accessible
• Listen and try to understand
• Invite rapport by exhibiting a smile and a friendly manner
• Give the patient your full attention—show them they are important
• Provide privacy if possible when talking about personal health
• Express an interest in their comments, both by facial and verbal
expression
• Talk with a reassuring non-threatening, non-authoritarian tone of
voice
• When talking to someone with a hearing impairment, keep lips visi¬
ble
• If patients are visually impaired, verbal instructions are imperative
• Maintain eye contact to see if patient appears puzzled or confused
• Avoid talking in "medical speak"
• Repeat instructions if needed, using short explanations to reinforce
the message
• Reinforce verbal explanation with written instructions (14 font, dou¬
ble-spaced black print on white paper)
• Give patients the opportunity to ask and re-ask the same question
• If patient appears confused, ask if there is a family member who can
be contacted
• Empathize - and treat every patient as if they were your elderly
loved one
FUTURE DIRECTIONS
In less than ten years, the leaders of the baby-boom wave will reach age
sixty-five. Numbers of older adults will swell. Increased awareness of disease
risk factors, life-style modifications, an improved attitude toward staying fit
and active, and new technology in health care will result in a healthier cohort
of elderly. Older adults are also becoming more independent. We live in a
128 Sorenson
society that values autonomy. It is difficult to project how these factors will
affect the prevalence or incidence of elder abuse in the future. For now, edu¬
cation, a heightened awareness of what constitutes abuse, and an improve¬
ment in communication skills seem to be the best weapons to guard against
verbal abuse and communication neglect directed at our elderly. Finding
answers does not rest merely on the shoulders of the researchers; detection of
abuse is not the sole responsibility of physicians, adult protective services is
not the only organization of interest in addressing abusive situations, it has to
be a multidisciplinary collaborative effort. Within a health care setting howev¬
er, it is the responsibility of every employee, regardless of their job status, to
prevent any type of abuse or neglect of those under their care, while they are
dependent on our care.
REFERENCES
Anetzberger, G.J., Palmisano, B.R., et al. A Model for Elder Abuse and Dementia. The
Gerontologist, 2000; Vol 40(4) 492-497.
Blazer, D.G. Depression in Late Life: Review and Commentary. The Journal of
Gerontology Series A: Biological Sciences and Medical Sciences, 2003; 58: M249-M265.
Brody, D.S., Hahn, S.R., Spitzer, R.L. et al. Identifying Patients with Depression in the
Primary Care Setting. Archives of Internal Medicine, 1998; 158: 2469-2475.
Brown, M.N., Lapane, K.L., and Luisi, A.F. The Management of Depression in Older
Nursing Home Residents. Journal of the American Geriatrics Society, 2002; 50: 69-76.
Burgio, L.D., Annen-Burge, R., et al. Come Talk with Me. The Gerontologist, 2001; Vol
41(4) 449-460.
Charness, N., Parks, D.C., and Sabel, B.A. (Eds). Communication, Technology and Aging:
Opportunities and Challenges for the Future. 2001. Springer Publishing Co. New
York, NY.
Filinson, R. and Ingram SR (Eds) Elder Abuse: Practice and Policy. 1989. Human Sciences
Press, New York, NY.
Hazzard, W.R. et al. (Eds). Principles of Geriatric Medicine and Gerontology, 5th Edition,
2003. McGraw-Hill Professional, New York, NY.
Hinckley J.J. Vocational and Social Outcomes of Adults with yhasia. Journal of
Communication Disorders, 2002; 35: 543.560.
Hintz, C.A. Communicating with Your Patients: Skills for Building Rapport. 2000;
American Medical Association, Chicago, IL.
National Clearinghouse on Family Violence Publication. Abuse and Neglect of Older
Adults: A Discussion Paper. Available at:
[http://canada.justice.gc.ca/en/ps/fm/adultsfs.html]
Pillemar, K. and Finkelhor, D. The Prevalence of Elder Abuse: Ayrvey. The Gerontologist,
1988; 29(3): 321-327.
Pillemer, K., Suitor, JJ, et al. A Cooperative Communication Intervention for Nursing
Home Staff and Family Members of Residents. The Gerontologist, 2003; Vol 43
(Supplement 2): 96 -106.
Reis, M. and Nahmiash, D. When Seniors are Abused: An Intervention Model. The
Gerontologist, 1995; Vol 35 (5): 666-671.
Ripich, D.N. Communication and Aging: Moving Toward a Unified, Systemic
Approach. The Gerontologist, 2003; 43 (1): 136-139.
Santo Pietro, M.J. and Ostuni, MA. Successful Communication with Person's with
Alzheimer's Disease. 2003; Butterworth-Heinemann; St. Louis, MO.

Wolf, R. Elder Abuse and Neglect: Causes and Consequences. Journal of Geriatric
Psychiatry, 1997; 30(1): 153-174.
Wood, S. and Stevens, M. Vulnerability to Elder Abuse and Neglect in Assisted Living
Facilities. The Gerontologist, 2003; 43: 753-757.
10
SEXUAL VIOLENCE AGAINST

ELDERLY WOMEN
Joanne Ardovini
OVERVIEW OF THE SEXUAL ABUSE OF ELDERLY WOMEN
Sexual assault is one of the most under-reported crimes identified by the FBI.
The public at large, administrators, law enforcement, legislatures, and
researchers are unaware of the actual rates at which sexual abuse of elderly
women occurs. It is an unsavory thing to think of, yet it occurs and possibly at a
much more frequent rate than we know (www.forensicnursemag.com/arti-
cles/331feat2.html).
A study surveying 300 women asked them to rank which crime they most
feared. The crimes included in the study were murder, burglary, robbery,
attempted murder, and rape. Women under the age of thirty-five noted that
rape was their number one fear. Women thirty-six to fifty noted that rape was
their number two. Women over sixty-six years old ranked rape as their ninth
greatest fear (www.archstone.org/usr_doc/silent_suffering.pdf).
While sexual violence against women in general does not appear to be
decreasing, our awareness of sexual violence against elderly women does not
seem to be increasing. Sexual abuse is thought to be the least perceived,
acknowledged, detected, and reported type of elder abuse. Adult Protective
Services have reported that sexual abuse constitutes less than one percent of
all types of abuse cases reported with the majority of its victims being female
(Teaster, Roberto, Duke, and Kim 2000: 1-16). The preliminary findings of a
study conducted by Teaster, Roberto, Duke, and Kim found that women con¬
stituted 95.2% of all the victims of sexual abuse reported within a three year
period in the state of Virginia (Teaster, Roberto, Duke, and Kim 2000: 5). It is
acknowledged that lack of reporting is not due to a lack of occurrences but
due to the stigma associated with sexual abuse.
DEFINITION OF SEXUAL ABUSE
Sexual assault is a crime of violence that preys on people who are vulnera¬
ble. Those who are the most vulnerable are the young and the elderly popula¬
tions. The National Center on Elder Abuse defines sexual abuse of the elderly as
any sexual behavior that is non-consensual sexual contact of any kind with an
elderly person (www.elderabusecenter.org/default.cfm?p=basics.cfm). Sexual
conduct with any person incapable of giving consent is also considered sexual
abuse. It includes, but is not limited to, unwanted touching, all types of sexual
131
132 Ardovini
assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit
photographing (www.elderabusecenter.org/default.cfm?p=basics.cfm). Rape is
defined as "unlawful sexual intercourse with a female who did not consent to
engaging in the sexual act (www.nursinghomeabuserresourcecenter.com/glos-
sary/r.html). Sodomy is defined as "oral or anal sex without consent
(www.nursinghomeabuserresourcecenter.com/glossary/r.html). A major com¬
ponent of these definitions are consent, "voluntary agreement of one who has
sufficient mental capacity to make an intelligent choice to do something pro¬
posed by another person" (www.nursinghomeabuserresourcecenter.com/glos¬
sary /r.html). If the elderly individual does not grant consent then the sexual
behavior is seen as being coerced. Coercion is the act of compelling by pressure,
threat, or force (www.nursinghomeabuserresourcecenter.com/glossary/r.html).
Sexual assault of elderly women may present itself in a variety of ways.
First, a victim of sexual abuse may exhibit physical signs, such as, difficulty
walking or sitting, recurring or unexplained injuries, combination of new and
old injuries, injuries without underlying diseases, injuries in areas usually
covered by clothing (www.keln.org/bibs/mcdaniel.html). A victim of sexual
abuse may also experience pain, itching, bruising, or bleeding in the genital
area. Other physical signs include an unexplained venereal disease or genital
infections (Brandi and FJoran 2002:43). The elder sexual assault victims
exposed to sexually transmitted diseases, including FIIV, may never receive
any medical care. In turn, they may not be given any emotional support fol¬
lowing the abuse as well. This leads to another sign of sexual abuse.
Second, social-psychological signs may present themselves. These signs
include depression or withdrawal, hesitation to speak openly, fearfulness of
caregiver or strangers, confusion, and denial. Post-traumatic rape syndrome
may also present itself after an assault. Post-traumatic rape syndrome is a rec¬
ognized phenomenon among sexual assault researchers (www.forensic-
nursemag.com/articles/331feat2.html). Elderly female victims of sexual
assault may experience the impact of this syndrome at a heightened level than
female victims of college age, for example. This maybe due to the indigestibil¬
ity of the nature of the offense and the perception that rape does not occur to
women 65 years of age and older. The elderly have the attitude that sexual
assault is not going to happen to them. It is not something they are concerned
about. This gives elderly women a false sense of security. They don't expect it,
therefore; when it does happen, the sexual assault is much more traumatic for
them (www.archstone.org/usr_doc/silent_suffering.pdf). These signs of sex¬
ual abuse of elderly women are often overlooked or not recognized. This leads
to a gross under-reporting of the crime (Tatara and Kusmeskus 1999:1).
VICTIMS OF SEXUAL ABUSE
Sexual abuse of women can affect women of all ethnic backgrounds and
social statuses. However, being elderly compounds the impact of victimization
for women. What makes an elder female vulnerable to sexual assault is depend-
ent upon a variety of factors such as social isolation, mental and/or physical
impairment, and financial variables, (www.archstone.org/usr_doc/silent_suf-
fering.pdf). Other social factors may also increase an elderly woman's potential
for sexual victimization. For instance, poor communication between themselves
and their caregiver may impede the victims' ability to express their disapproval
of the behavior and the abusers' inability to understand the lack of consent. An
elderly female who has abused the caregiver in the past may experience abuse
by the caregiver. An elderly female who lives constantly with their caregiver
also has an increased potential for victimization (Campbell Reay and Browne
2001: 60). All these variables are factors that give us insight into what makes an
older adult female vulnerable to sexual abuse by their caregivers.
OFFENDERS OF SEXUAL ABUSE
In general, abusers of older female adults are both male and female.
However, Adult Protective Services has reported that 62.6% of offenders of
physical abuse committed against the elderly are males
(www.aoa.gov/abuse/report/Gfindings-02.htm). Males also make-up the
majority of sexual offenders, who sexually abuse elderly females (Teaster,
Roberto, Duke, and Kim 2000: 9). Teaster, Roberto, Duke, and Kim in their
study of sexual victimization of older females reported in Virginia within a
three-year period found that all of the noted alleged offenders were identified
as male (Teaster, Roberto, Duke, and Kim 2000: 9).
The National Center on Elder Abuse has also compiled data concerning
the characteristics of an offender of elderly abuse. The NCEA has reported
that family members are more often the abusers than any other group. For
several years, the data indicated that adult children were the most common
abusers of family members. Recent information indicates spouses are the most
common perpetrators when state data concerning elders and vulnerable
adults is combined (www.Elderabusecenter.org/default.cfm?p=faqs.cfm).
However, this data is representative of offenders of elder abuse in general and
is not specific to sexual abuse.
Therefore, we must rely on the general characteristics of offenders of elder
abuse as potential indicators for sexual abuse. Some of these general charac¬
teristics include:
• A caregiver living constantly with their elderly dependents may view

the elder as a target for sexual abuse;
• A caregiver who is suffering from relationship conflict and often
exhibits hostile, threatening and/or aggressive behavior;
• A caregiver who is subject to high stress, strain, isolation, and lacks
community and personal support;
• A caregiver who has a history of mental health problems, sexual
abuse (as a victim and/or offender), anxiety disorder, depression,
and/or alcohol/drug use (Campbell Reay and Browne 2001:56).
134 Ardovini
In a study conducted over a three-year period, the researchers found in

year 1,28.6% of the offenders were family members, 28.6% were facility staff
members, 28.6% were residents in the older adult facility, and in 14.2% of the
cases the offender was unrelated to the older adult and was not a member of
the household or staff member of a facility (Teaster, Roberto, Duke, Kim 2000:
9). During year 2 and 3, the majority of the offenders were residents living in
the same facility as the older female adult, constituting 83.3% and 86.7%
respectively, of all cases of sexual abuse reported (Teaster, Roberto, Duke, Kim
2000: 9).
Other characteristics were found in the study. During year 1 of the
research, 12.5% of the offenders were dependent on the income of the older
female victim, 25.0% abused alcohol and/or drugs, and 12.5% suffered from
mental illness. Similarly for year 2,9.1% of the offenders were dependent eco¬
nomically, 18.2% abused alcohol and/or drugs, and 54.5% suffered mental ill¬
ness. Only 9.1% of the offenders were unemployed. During year 3 of the
study, there was little deviation from the previous years findings (Teaster,
Roberto, Duke, Kim 2000: 9-11).
RISK FACTORS OF SEXUAL VICTIMIZATION
Possible risk factors that may lead to the sexual victimization of older
female include the following:
• Personal Factors = Often relating to a pattern of abuse in the family.

The elder female perceives herself as helpless and dependent; sexual
victimization only serves to increase these feeling of vulnerability.
Often, when the elder female is confused and helpless, the stress on
the caregiver is magnified and thus the possibility of random
instances of abuse are increased;
• Interpersonal Factors = May include a variety of unresolved past con¬

flicts and lifelong histories of inadequate relationships. The caregiver
may feel that he is receiving insufficient gratification for his sacrifices
and attention. Power conflicts between the elder female and her care¬
giver may also exist;
• Situational Factors = the addition of a dependent family member pro¬
vides increased stress and possible conflict. The middle-aged abuser
can be described as being in the "sandwich generation," providing
care both to children and to the older female. Other factors include
unemployment, substance abuse, marital problems, economic diffi¬
culties related to providing care for the victim or other financial
stresses, the stress of providing constant care, and medical problems;
• Sociocultural Factors = these may include pervasive, negative atti¬
tudes toward older female (Paveza 1997: 2).
PROVIDER ATTITUDE TOWARDS THE SEXUAL VICTIMIZATION
Sexual violence is a significant problem that adversely affects the health

and safety of millions of women throughout their lifespan. Given the demo¬
graphics of aging women and their longer life expectancies, clinicians are
increasingly likely to see patients whose injuries or poor health status are
caused or affected by abusive relationships (Brandi and Horan 2002: 41).
Therefore, providers of elder care, as well as criminal justice professionals and
Adult Protective Service Workers, must expand their perceptions of potential
victims of sexual abuse in order to be able to identify victimization and estab¬
lish comprehensive intervention and prevention efforts.
Since the sexual violation of elder females is perceived as taboo, it is often
misread. Understanding how various individuals perceive their role in deal¬
ing with cases concerning elderly females is important, given the way that the
acts have been treated as social problems rather than systemic problems in the
past (Curry, Johnson and Sigler 1994:65-71). For example, surveys of law
enforcement officers suggested that elderly citizens presented a number of
aggravations to police. A study of 180 police department reported that 67% of
the police believed that the elderly lacked an understanding of the nature and
scope of the police. This same study also reported that 43% of the responding
departments indicated that they lacked an understanding of and training con¬
cerning the elderly (Blakely and Dolon 2000:73).
The gap in training and understanding of the victimization of elder
women is due to a variety of interrelated, systemic issues. The abuse of elder¬
ly individuals, including women, has been defined as criminal behavior since
the early 1990s. However, research showing the effectiveness of criminaliza¬
tion on the occurrences of sexual abuse is almost unheard of (Payne, Berg, and
Toussaint 2001: 607). Therefore, what is needed is not only research in this
area, but professional training; coordination among state service systems and
among service providers; technical assistance in the development of policy
manuals and protocols that outline the proper or preferred procedures; and
public education (www.aoa.gov/Factsheets/abuse.html).
PREVENTION
Adult Protective Service programs are designated as the primary agencies

in most states to receive and investigate reports of abuse (www.preventelder-
abuse.org/professionals/professional.html). Adult Protective Service work¬
ers, are the "front line" in elder abuse prevention and should receive training
on signs of sexual violence. Health and medical professionals also play an
important role in the identification of sexual abuse of elderly females. It is
important for these professionals to develop trust and respect with their
patients (www.preventelderabuse.org/professionals/professional.html). If
the victim is comfortable with their health care provider, they are more likely
136 Ardovini
to report abuse. In turn, if the health care provider respects their patient, they
are less likely to overlook signs of sexual abuse. This also holds true for law
enforcement personnel. These individuals are able to ensure victims' safety
and hold perpetrators accountable for their actions (www.preventelder-
abuse.org/professionals/professional.html.
Researchers have the ability to affect prevention through their work to
provide insight into the etiology, rates, and risk factors associated with the
sexual victimization of elderly females. The information that is uncovered
through research can be critical to professionals working in the field of aging,
health care and medical professionals, and law enforcement personnel.
Research may also impact the development of legislation which can assist in
the establishment of effective interventions and services (www.preventelder-
abuse.org / professionals / professional.html).
The media, an important agent of socialization, plays a fundamental role
in informing the public of the occurrences of the sexual victimization of eld¬
erly females. The media also plays a role in the construction of public percep¬
tions. It can enlist the public's help in identifying abuse, educate policy mak¬
ers about the need for improved services and public policy, direct victims to
needed services, and warn abusers about the consequences of their actions
(www.preventelderabuse.org/professionals/professional.html).
Concerned citizens can also play a vital role in the prevention of sexual
abuse of elderly females. This can be done by reporting potential cases of sex¬
ual abuse, helping raise awareness, volunteering at agencies, and advocating
for needed services and policies (www.preventelderabuse.org/profession-
als/ professional.html).
As noted, sexual abuse and abuse in general of elderly women is a multi¬
dimensional problem that requires broad expertise and a variety of resources.
The most common approach to preventing elder abuse is to provide profes¬
sional and public education programs at the community level. In addition to
established federal and state laws designed for reporting elderly abuse neg¬
lect, many states also provide informal caregivers and interested citizens with
training in eldercare. In most communities, both public and private agencies
work collaboratively to ensure the protection of vulnerable elders. Although
the causes of elderly abuse are complex and varied, a promising approach to
increasing self-determination for the elderly is based on empowerment con¬
cepts. The rationale for the application of an empowerment approach to the
sexual abuse of elderly females derives from the powerlessness these victims
experience based on social reconstruction theory, an orientation specific to
older age (Chima 2002:61-62).
Social reconstruction theory provides a perspective that assess planned
change at the societal level that will benefit older adults due to its analysis of
the breakdown and competence in older age (Chima 2002: 62). As a result of
the social reorganization that occurs in later life, older people are devalued,
develop negative self-images, and a loss of occupational roles and established
networks. Therefore, the empowerment perspective attempts to increase per¬
sonal, ,interpersonal, and political power so that individuals can take action
to improve their life situation (Chima 2002: 62). This is done in a variety of
ways:
1) Increasing self-efficiency by impacting one's ability to produce and to

regulate events in one's life;
2) Developing group consciousness among the general population and
the elderly;
3) Reducing self-blame by attributing their problems to the existing
power structure in society;
4) Assuming personal responsibility for change, which counteracts
some of the potentially negative results of reducing self-blame
(Chima 2002: 62-63).
Another approach to decreasing the sexual abuse of elderly females is the

intervention approach. There are three major tenets of this approach. They
include: awareness of policies and services, caretaker assistance, and advoca¬
cy. Those that take this approach argue that significant attention needs to be
paid to the provision of services. Although social workers and care providers
often receive clinical training and experience, they lack an awareness of their
potential impact in the policy making process. They must evaluate the servic¬
es that they provide on their impact on preventing abuse and not solely upon
their availability (Chima 2002: 64). They work closest with the elderly and are
more apt to detect problems and needed resources and policies.
Caretaker assistance is an important aspect of curtailing potential sexual¬
ly abusive situations. Caretakers can be provided and educated concerning
information regarding resources that are available to them (Chima 2002: 64).
While the roles of social workers in the field of aging are increasing, their
role as advocate is crucial in responding to the sexual abuse of elderly females.
A beneficial guideline for advocacy is the Older Americans Act of 1965 and its
amendments, which provide the basis for financial aid by the federal govern¬
ment to assist states and local communities to meet the needs of the elderly. A
major objective of this act is to provide advocates with systematic measures
and purpose of actions to decrease elder abuse and increase the chances of
more elderly needs being met (Chima 2002: 64).
Regardless of the theoretical approach taken when exploring the sexual
abuse of elderly females, we must remember that prevention is the goal.
Therefore, intervention must be tailored to the needs of the elderly females
and the circumstances of the sexual abuse. Success of prevention programs
and the development of policies should be based upon the needs of the pop¬
ulation it serves and education of the general public.
REFERENCES
Andermahr, Sonya, Terry Lovell, and Carol Wolkowitz 2000. A Glossary of Feminist
Theory. London: Arnold.
Bell, Christine, Mary F. Ferris, and Laura Criss. 2002. "Sexual Assault and the Elderly:
Shattering the Myths." Long Beach, CA: Archstone Foundation, Retrieved
138 Ardovini
September 10, 2003 (www.archstone.org/usr_doc/silent_suffering.pdf).

Blakely, B.E. and Ronald Dolon. 2000. "Perceptions of Adult Protective Services
Workers of the Support Provided by Criminal Justice Professionals in a Case of
Elder Abuse." Journal of Elder Abuse and Neglect 12:71-94.
Brandi, Bonnie and Deborah L. Horan. 2002. " Definitions and Dynamics of Elder
Abuse and Domestic Violence in yfe." Pp. 42-54 in Domestic ylence and Health Care:
Policies and Prevention, edited by Carolina Reyes, William J. Rudman, and Calvin
R. Hewitt. Binghamton, NY: Haworth Press, Inc.
Campbell Reay, A.M. and K.D. Browne. 2001. "Risk Factors Characteristics in Careers
who Physically Abuse or Neglect Their Elderly Dependants." Aging and Mental
Health 5:56-62.
Chima, Felix O. 2002. "Overview of Sources, Prevalence and Intervention Initiatives."
Free Inquiry in Creative Sociology 30:57-66.
Curry, B.S., I.M. Johnson, and R.T. Sigler. 1994. "Elder Abuse: Justice Problem, Social
Problem, or Research Problem." Free Inquiry in Creative Sociology 22:65-71.
Katayama, Barbara. 2003. "Sexual Abuse of the Elderly." Forensic Nurse. Retrieved
October 10, 2003. (www.forensicnursemag.com/articles/331feat2.html)
McDaniel, Christine. 1996. "Elder Abuse in the Domestic Setting." KELN.org
Bibliography.. Retrieved September 10, 2003. (www.keln.org/
bibs/mcdaniel.html).
NA. 2003. "Elderly Sexual Abuse: Nursing Home Resident Sexual Abuse." Nursing
Home Abuse Resource Center. Retrieved October 13, 2003. (www.aoa.gov/
abuse/report/Gfindings-02.htm)
NA. 2003. "The Basics: Major Types of Elder Abuse." National Center on Elder Abuse.
Retrieved June 30, 2003. (www.nursinghomeabuserresourcecenter.com/glos¬
sary/ r.html)
NA. 2003. "Frequently Asked Question." National Center on Elder Abuse. Retrieved
June 30, 2003. (www.elderabusecenter.org/default.cfm?p=faqs.cfm.)
NA. 2003. "Critical Issues in Elder abuse." National Committee for the Prevention of
Elder Abuse. Retrieved June 2, 2003. (www.preventelderabuse.org/
issues / issues.html).
NA. 2001. "Elder Abuse Prevention: Administration on Aging Fact Sheet."
Administration on Aging. Retrieved June 2, 2003. (www.aoa.gov/
Factsheets/abuse.html.)
Payne, Brian. K., Bruce L. Berg, and Jeff Tousaint. 2001. "The Police Response to the
Criminalization of Elder Abuse: An Exploratory Study." Policing: An International
Journal of Police Strategies and Management 24:605-625.
Paveza, Gregory. 1997. "Elder Justice: Medical Forensic Issues Concerning Abuse and
Neglect." National Institute for Justice. Retrieved September 10, 2003.
www.ojp.gov/nij/elderjust/elder_07.html.
Taeuber, Cynthia M. 1996. Statistical Handbook on Women in America (Second edition).
Phoenix: Arizona: The Oryx Press.
Tatara, Toshio and Lisa M. Kuzmeskus. 1999. Types of Elder Abuse in Domestic Settings.
Washington, DC: National Center on Elder Abuse.
Teaster, Pamela B., Karen A. Roberto, Joy O. Duke, and Myeonghwan Kim. 2000.
"Sexual Abuse of Older Adults: Preliminary Findings of Cases in Virginia." Journal
of Elder Abuse and Neglect 12:1-16.
11
HELPING VICTIMS:
SOCIAL SERVICES, HEALTH CARE
INTERVENTIONS IN ELDER ABUSE
James Anderson and Nancie Mangels
The problem of elder abuse is so pervasive that officials at the Centers for
Disease Control (CDC) have already declared it an epidemic in America (see
Rosenberg and Fenley,1991).
Elder abuse is a public health issue because of the medical and psycholog¬
ical consequences associated with this type of victimization. This chapter is
divided into four parts. Part One presents the epidemiological approach used
by the public health community to prevent injuries and premature deaths of
the greater population. Part Two provides several theories that explain the
causes of elder abuse. Part Three describes social services and health care
interventions. Part Four discusses preventions and policy implications that
can be used (at the local and state levels) to drastically lower the number of
cases while better dealing with victims and offenders. In the final analysis, the
chapter argues that elder abuse is a public health issue that can be prevented
and those who suffer this victimization can overcome its negative conse¬
quences.
EPIDEMIOLOGY AND THE EPIDEMIOLOGICAL APPROACH
Epidemiology is the basic science of public health (Gostin, 2000;

Schneider, 2000). It involves the study of epidemics and their impact on the
community at-large. While some people are confused about the similarities
between public health and medical care, the two are quite different. Medical
care is concerned with individual patients. Public health sees the community
as its patient. It tries to improve the health of the population. While medicine
tries to heal patients who are ill, public health focuses on preventing illnesses
(Schneider, 2000). Stated another way, medicine is individualized, while pub¬
lic health is concerned with the quality of health found within the population.
Proponents of public health argue that it contributes a great deal more to the
overall health of the population than medicine. For example, some researchers
contend that the longevity of the population has increased from 45 to 75 years
over the past century because of advances in medical technology and efforts
of public health. They cite improvements in the quality of public health as
being due, in part, to better nutrition, housing, sanitation, and occupational
safety. Proponents also argue that one responsibility of public health is to edu-
139
140 Anderson and Mangels
cate the public and politicians about the crucial role that a strong public health
system must play in maintaining and improving the health of the public.
Those in the public health community (e.g. clinics, hospitals, local and
state health departments, and the CDC, to name a few) use the epidemiologi¬
cal approach to assess the health of the population, diagnose its problems, seek
the causes of those problems, and devise strategies to cure them (Gostin,2000;
Schneider, 2000). Epidemiology examines the distribution and determinants of
disease frequency in human populations (Gostin,2000). Epidemiologists are
concerned with disease "frequency." However, they use the term "disease"
broadly to mean "health outcome." Epidemiology uses two types of frequen¬
cy measures: incidence and prevalence. More specifically, incidence rates
measure the probability that a healthy person in the population will develop a
disease or injury. The rates are useful in identifying causes of a disease or
injury. Prevalence is the total number of cases existing in a defined population.
Incidence and prevalence are related to each other, but the relationship is con¬
tingent upon how long people live with injury or disease.
The public health community is concerned about preventing elder abuse
for several reasons. First, violence against the elderly extends beyond the
reach of criminal justice. While the health consequences of violence are
tremendous, society has generally looked to the criminal justice system to pro¬
tect its citizens from violence. However, the injuries, disabilities, and prema¬
ture deaths associated with violence far exceed the resources and expertise of
most state criminal justice systems (Donziger,1996). For example, when the
perpetrator has been apprehended, arrested, and charged, this does not pro¬
vide the victim with the treatment that he or she needs to move toward recov¬
ery. As a result, the CDC has added a new component called the National
Center for Injury Prevention and Control (NCIPC) to reduce the human suf¬
fering and medical costs associated with injuries. Officials at the CDC contend
that fatal and nonfatal injuries resulting from interpersonal violence have
become one of the most important public health problems facing our country.
The crime of elder abuse is no exception. Second, the public health communi¬
ty introduces a primary prevention approach to the problem of violence.
While criminal justice concentrates on deterrence and incapacitation, the pub¬
lic health approach is focused on prevention (Anderson, Grandison, and
Dyson, 1996). Officials in public health do not believe their efforts alone can
solve the problem of elder abuse. In fact, they contend that criminal justice
must play a crucial role, but the role of public health must be proactive and at
the forefront. Criminal justice should take a reactive role to enhance the efforts
of the public health system. Scholars contend that the efforts of public health
will compliment the work of the criminal justice system (Donziger,1996).
Public health officials argue that since its strategies have been successfully
used in the past to combat the spread of infectious diseases, premature deaths,
and physical illnesses that include lung cancer, heart diseases and motor vehi¬
cle crashes, it is believed that they can reach the same results when focusing
on preventing elder abuse (Braithwaite and Taylor, 1992; Rosenberg and
Fenley, 1991).
The Epidemiological Approach
The public health community uses the epidemiological approach. This

approach consists of health-event surveillance, epidemiological analysis, and
intervention design and evaluation focused unwaveringly on a single, clear
outcome — the prevention of a particular illness or injury. Again, because of
its proven track record, experts at the CDC believe that the epidemiological
approach can prevent violence - namely, elder abuse, with similar success (see
Braithwaite and Taylor 1992; Rosenberg and Fenley,1991). The epidemiologi¬
cal approach is multi-disciplinary in nature. Because of the complexities of
infectious diseases and interpersonal violence, the approach draws on the
resources of various disciplines to better understand and address the issue of
violence. The disciplines included in the epidemiological approach are: (a)
biomedical sciences (bacteria, yeast, protozoa caused by micro-organisms), (b)
environmental health sciences (preventing the spread of diseases through
water, air, and food), (c) social sciences (social environmental impact on
behavior), and (d) the behavioral sciences (psychological and mental health)
(Schneider, 2000). With these, public health officials can mobilize resources in
medicine, mental health, social sciences, and substance abuse services to pre¬
vent injuries and premature death (see Rosenberg and Fenley, 1991).
Therefore, epidemiologists represent a coalition of professions united by their
shared mission and focus on disease prevention and health promotion.
PREVENTION AND INTERVENTION
To prevent injuries and minimize their consequences when they occur, the
NCIPC relies on the public health methodology that utilizes five steps to
address health issues and injuries. The public health methodology, or the epi¬
demiological approach, includes:
First defining the injury or health problem;

Second identifying the risk and protective factors associated with the
problem;
Third developing and testing prevention strategies to control the
problem;
Fourth implementing the interventions to improve the health of the
population;
Fifth monitoring those interventions to assess their effectiveness.
Epidemiologists believe that prevention must come through intervention

after a problem has been identified by either the assessment process of a pub¬
lic health agency or through community concerns. The public health system
uses several intervention methods: primary prevention, secondary preven¬
tion, and tertiary prevention. First, primary prevention seeks to avoid the
occurrence of an illness or injury by preventing exposure to risk factors (e.g,
preventing the occurrence of the act by being proactive in terms of educating
caregivers and the community at-large about elder abuse). Next, secondary
prevention seeks to minimize the severity of the illness or injury-causing
events once the event has occurred (e.g., quickly getting treatment and coun¬
seling for victims and offenders of elder abuse). Third, tertiary prevention
seeks to minimize disability by providing medical care and rehabilitation
services (e.g., develop emergency and medical services). Epidemiologists
view an injury as the result of a "chain of causation" involving an agent, a
host, and the environment (Braithwaite and Taylor, 1992).
Prevention is achieved by breaking the chain of causation at any step (see
Schneider, 2000). In the case of elder abuse, it could be as easy as removing
either the elder or the caregiver from the home or institutional setting and
offering treatment to both parties in order to prevent the continuation of the
behavior and to alleviate the pain and suffering associated with the behavior.
However, in some cases, the criminal justice system will be used to make
arrests when caregivers have committed crimes against an elder (Gaines,
Kaune, and Miller, 2000). When epidemiologists study patterns of diseases
and injuries in human populations and the causative factors that influence
these patterns, they detect signals of an emerging epidemic. Epidemiologists
look for common exposures or other shared characteristics in the people who
are sick or affected by violence in order to seek causative factors. Some ques¬
tions that epidemiologists typically ask are who, when, and where. They are
concerned with: First, who is being injured or contracting the disease under
investigation? Second, when is the injury or disease occurring? Third, where
is the injury or disease occurring? From this information, epidemiologists can
make better decisions about why the injury or disease is occurring. Their
main goal is to use this knowledge to control and prevent the spread of
injuries and diseases. Stated another way, public health officials believe that
it is more important to determine why people become violent and to devel¬
op strategies to reduce the risk factors that lead to interpersonal violence
(Donziger,1996).
THEORIES ON THE CAUSES OF ELDER ABUSE
In using the epidemiological approach to understanding the causes of

elder abuse, experts in public health (especially those in the social and behav¬
ioral sciences), examine the impact of the offender's social environment and
the quality of their mental and emotional health. The motivation to engage in
elder abuse is of interest to officials in public health, criminal justice, commu¬
nity treatment centers, and concerned citizens. In order to prevent the behav¬
ior, officials need to be able to identify, explain, and make predictions regard¬
ing who is likely to be an offender for these two reasons: First, identification
is necessary to prevent offenders from injuring the elderly. Second, it is impor¬
tant to remove and properly treat victims. Therefore, the work of researchers
is crucial. At the same time, people, in general, are intrigued by offenders who
engage in such activity considering the pain and injury this activity inflicts
upon the most vulnerable members of society. Concern exists over the types
of life experiences offenders may have endured for their actions to manifest
into this behavior. Scholars contend that explanations for engaging in elder
abuse may differ from one offender to the next. However, most scholars agree
that there are both micro-and-macro level explanations that could explain
elder abuse. In epidemiology, researchers focus on common exposures or
other shared characteristics in offenders, as well as victims, to isolate the caus¬
es of elder abuse. Some of the more widely accepted theories are: the cycle of
violence; psychopathology; social exchange; family stress; and the techniques
of neutralization, or "drift" (Centers for Disease Control,1997; Reiss and Roth,
1993; Adler, Mueller, and Laufer,2001).
Cycle of Violence Theory
A popular yet controversial theory used to explain elder abuse is the cycle
of violence theory. The theory argues that people who have been psychologi¬
cally, physically, or sexually abused as children have a greater likelihood of
becoming violent adults (Simons, Wu, Johnson, and Conger, 1995;
Spaccarelli,Coatsworth,and Bowden, 1995). Gelles (1993) suggests that the
physical punishment of children is the most effective way to teach violence.
Moreover, research finds that people who are victimized at an early age face
a higher risk of being arrested for committing crimes as adults (Widom,1992).
For example, Spaccarelli et al.(1995) report that young men are more likely to
engage in violent behavior if they were the targets of physical abuse and were
exposed to violent behavior by someone they knew or lived with. Similarly,
Doerner and Lab, (2002) contend that there is evidence that warn that children
who watch parents engage in violent outbursts will grow to accept these
behaviors as legitimate. Some experts refer to the cycle of violence as the inter-
generational transmission of violence. Essentially, they argue that violence is
handed down and the chain of aggressive behavior continues generation after
generation, because those exposed to violent and aggressive behavior devel¬
op a predisposition to use it (see Hunter and Kilstrsom,1979).
A major concern about the cycle of violence is that parents may be
unaware that they are perpetuating this behavior. In fact, they may indirectly
socialize children into using it as an acceptable response to life's problems.
Though many people embrace the cycle of violence argument, Wolf and
Pillemer (1989) report that not everyone who commits elder abuse was reared
in a home where violence took place. Similarly, Pagelow (1984) along with
Gelles and Cornell (1990) argue that though much of the research literature
does not support this position, the idea is commonly accepted—the cycle of
violence exists. While laypersons readily accept this theory, Wallace (1999)
reports that there is no way to prove or disprove the cycle of violence theory.
That is to say, violence committed by a family member who is a caregiver is a
manifestation of one's acting out violence earlier committed against himself
or herself. The inconsistent support of the theory makes the argument contro¬
versial.
Psychopathology
While some domestic violence experts may reject the argument of a cycle
of violence theory, a segment of scholars attribute family violence in general,
but elder abuse in particular, to a psychopathology found within offenders
(Wallace, 1999). For example. Young (1974) argues that clinicians and practi¬
tioners tend to attribute elder abuse and other forms of domestic violence to
sadistic personality traits. Rosenberg and Fenley (1991) find that intraindivid¬
ual dynamics may explain the cause of elder abuse. They suggest that psycho¬
logical well-being is related to the quality of the family relationship. In fact, it
can serve as a predictor of outcomes in domestic violence situations (Andrews
and Withy, 1979; Glenn and Weaver, 1981; Lee, 1978). Research supports that
in situations where the caregivers suffer personality disorders, the probabili¬
ty is greater that elder abuse is a likely outcome. Some research even suggests
that to cure child abuse, wife abuse, and other forms of interpersonal violence
will require targeting and treating emotional illnesses (Gelles, 1974).
Moreover, Hickey and Douglas (1981) argue that the manifestations of the dis¬
ease can be seen in either the physical or verbal abuse targeted at the elder.
These experts believe that such offenders may suffer from mental disorders
that cause them to engage in abusive behavior. For example. Wolf and
Pillemer (1989) contend that abusers suffer a form of flawed mental develop¬
ment. Wolf, Strugnell, and Godkin's (1982) research suggests that a high level
of mental illness is common among elder abusers. Similarly, Beckman and
Adelman (1992) find that many perpetrators of elder abuse have been hospi¬
talized and diagnosed with serious psychiatric disorders, such as schizophre¬
nia and other identifiable psychoses. In most cases, because psychological the¬
ories are based on untestable hypotheses rather than empirical data, psycho¬
logical explanations for criminal behavior are often considered inconclusive
and are therefore accepted with caution (Cleckley,1974; Gaines, Kaune, and
Miller, 2000).
Social Exchange Theory
Unlike the cycle of violence and psychopathology theories, the social

exchange theory argues that the more dependent the victim is on the abuser,
the greater the likelihood that abuse will occur. Stated another way, the social
exchange theory suggests that the increased dependency of the victim on the
abuser results in acts of abuse (Davidson, 1979). Rosenberg and Fenley (1991)
argue that the social exchange theory has led to two separate arguments that
relate dependency to elder abuse. The first argument emphasizes that the
level of stress experienced by the caregiver may account for violence inflicted
on the elder. This suggests that different types of abuse may result from
resentment that the abuser feels because he or she is the sole caregiver.
Domestic violence experts argue that when adult children invite an aging par¬
ent to live with them, they also agree to provide them with the care and atten¬
tion they need. However, despite what good intentions the adult child may
have, this new arrangement could create a strain since caring for the parent
could disrupt the adult child's life. The new addition could (1) strain an
already troubled marriage; (2) interfere with the caregiver's employment; or
(3) obstruct participation in social activities. As a result, the caregiver could
resent the parent and abuse him or her accordingly because his or her pres¬
ence is a constant reminder of the sacrifice that was made to accommodate
and assist the aging parent.
The second argument suggests the reverse is true. It holds that the more the
abuser depends on the elder for income, the greater the likelihood that abuse
will occur. Baruch and Barnett (1983); Cicirelli (1981); and Johnson and Bursk
(1977) find that the literature on family relations support the notion that
dependency on an older person leads to poor quality relationships with rela¬
tives. This research also finds that parents' health is positively linked to feelings
of closeness and attachment between parents and their adult children.
Furthermore, where abuser dependency is concerned, experts suggest that the
feeling of powerlessness is the main factor that explains abuse (see Finkelhor,
1983). Gerontologists suggest that the feeling of being dependent on one's par¬
ent is an intense source of strain on an adult child since it violates societal expec¬
tations for normal adult behavior (Rosenberg and Fenley,1991). Pillemer and
Suitor (1998) report that the dependent's embarrassment about his or her eco¬
nomic situation could be the source of the abuse. Moreover, evidence suggests
that mutual dependency exists from both the elder and the caregiver. For exam¬
ple, Wolf, Strugnell, and Godkin, (1982) find that in two-thirds of the cases, care¬
givers were economically dependent on the victim. Similarly, Hwalek et al.
(1989) report that in a case-control study, financial dependency was a high risk
factor of elder abuse. Furthermore, Anetzberger (1987) contends that survey
data reveal that economically dependent relatives is an important determinant
of elder abuse. Domestic violence experts contend that controversy exists in
these relationships over who is really dependent on whom.
Family Stress Theory
Another explanation that has gained widespread support is the family

stress theory (Steinmetz,1988). The family stress theory suggests that providing
care for an elderly person places a tremendous amount of stress on the entire
household. The theory holds that family stress comes from multiple angles such
as an economic hardship, alterations made to the home, intrusion into the pri¬
vacy of the family, and sleep deprivation. Experts advise that family stress is a
major factor that could cause elder maltreatment. Gelles (1983) argues that some
adult children may often forgo job security or greater employment opportuni¬
ties to provide care for an aging parent or relative. For example, some adult chil¬
dren may refuse to relocate to another state, or accept a promotion that pays
more money if it means spending less time in the home with an ill or aging par¬
ent or relative. Despite the good intentions of adult caregivers, Gelles also con¬
tends that the physical and psychological burden of providing for an elder with
declining health can lead to the loss of control and later abuse.
Techniques of Neutralization or "Drift" Theory
The "Techniques of Neutralization" or "Drift Theory" can also be used to

explain elder abuse (see Tomita, 1990). Sykes and Matza (1957) argued that
not everyone abides by laws all the time, but instead, some people have the
ability to engage in both conventional and deviant behavior after mastering
techniques of neutralization. These people may appear normal and law-abid¬
ing, yet they are criminals. Essentially, after perpetrators master denying
responsibility, injury, and a victim, along with learning to condemn their con¬
demned, and to appeal to higher loyalties, they also learn to justify, rational¬
ize, and excuse their behavior. The techniques of neutralization allow offend¬
ers to live double lives since they can move from being deviant and criminal,
to law-abiding. After committing crimes, offenders quickly justify it, and
"drift" back into conventional lifestyles with others who are grounded in
morality and mainstream values.
Denial of Responsibility
When offenders deny responsibility, they typically argue that the elder
abuse occurred because of circumstances beyond their control. For example,
the offenders may reason that because they were reared in a dysfunctional
home or the father was never present or because they were under the influ¬
ence of a mind-altering drug at the time of the crime, they therefore, bare no
responsibility for having committed the crime. For example, after physically
abusing a parent, adult caregivers may not admit responsibility for their
actions. They may contend that the physical abuse was a one time occurrence
that happened by accident or because of circumstances beyond their control.
Offenders believe that they bare no responsibility for committing physical
abuse against an elderly parent.
Denial of Injury
When offenders deny injury, they contend that no one suffered as a result
of the crime. For example, abusers who neglect or commit sexual abuse against
an aging parent or relative often believe that engaging in sexual intercourse has
no adverse impact on the victim, physically or psychologically. At the same
time, if the caregiver does not give the aged person medication on a regular
basis or maintain their hygiene, then no real injury occurred because the elder
person does not have any appointments to keep and others are unaware of the
neglect. Offenders often argue that because the elder suffers from mental dis¬
ease, he or she cannot remember. Therefore, no one suffered as a result of their
actions and believe no real harm has occurred from the victimization.
Denial of the Victim
When the offenders deny the victim, abusers may feel that the victim got
what he or she deserved. He or she may reason that the elder was just asking
to be victimized. This is a way of diminishing the personhood of the victim.

For example, when people participate in "granny-bashing" or other hate
crimes, they reason that elderly persons got what they deserved. From their
vulnerability of being physically weak and unaware, the victims were just
asking for it. Abusers often feel that victims get what they deserve, or that eld¬
ers secretly want to relive their youth and fantasize about having sexual inter¬
course with a younger adult. They often believe that victims were asking to be
victimized. This justification allows the offender to dehumanize or diminish
the personhood of the elder victim.
Condemnation of the Condemners
After being arrested and charged, adult children or institutional care¬

givers may retaliate by accusing officials in the criminal justice system. They
often argue that police are corrupt, and lawyers and judges take bribes. They
argue that everyone is tainted and engages in some type of questionable
behavior, yet the focus is on them and their behavior with an elder parent or
relative. Elder abusers often view mandatory reporting laws and protective
services as unfair and unjust. They contend that such services and laws repre¬
sent an unfair intrusion into their lives. They condemn social service agencies
for interfering with their family.
Appeal to Higher Loyalties
Offenders may justify abuse on the grounds that their behavior benefits
others and not themselves. For example, an adult child whose family is expe¬
riencing a strain because of the presence of his or her parent, may view their
physical abuse and neglect as a way of satisfying an unhappy spouse who
opposes the presence of the elder in the home and who is frustrated by the
attention and strain that the elder has placed on the family.
Social Services and Health Care Interventions
Family violence experts argue that because of a lack of knowledge about

the nature, extent, and dynamics of elder abuse, it has been difficult to create
uniform intervention strategies. They also contend that surveillance is limited
and the problem remains greatly hidden. Since there is no comprehensive
national policy regarding maltreatment of the elderly, states and communities
have created their own programs to meet the needs of the victims and fami¬
lies of elder abuse (see Rosenberg and Fenley, 1991). For example, a survey of
existing programs reveals a variety of strategies used to assist victims and per¬
petrators of elder abuse. Programs range from elder protective services to
family counseling to legal intervention (Meadows, 2004). However, family
violence experts believe that the different interventions adopted by practition¬
ers and policymakers can be categorized into three main areas that include: (1)
mandatory reporting laws; (2) protective services programs; and (3) service
options (see Rosenberg and Fenley, 1991). While these programs appear to be
the most often used in cases of elder abuse, there has been little evaluation
research conducted that supports their effectiveness. Therefore, little is known
about their ability to deter continued behavior. At the same time, success
could depend on the amount of resources devoted to these programs in their
respective jurisdictions. As such, it is possible for some states to have success
with a program and another state to implement the same program (perhaps
without committing adequate resources) and not have the same success. We
caution that since there have been few if any evaluations of these programs,
any signs of success should be critically evaluated.
Mandatory Reporting Laws
Mandatory reporting laws can be found in every state in America

(Kapp,1995; Macolini,1995; and Thobaben,1989). These laws alert social service
professionals to the problems of elder abuse so that they can take appropriate
actions (Doemer and Lab, 2002). More specifically, mandatory reporting laws
generally require that certain groups of people (e.g., health care professionals,
case managers, legal guardians, bank tellers, police officers, independent living
counselors, rehabilitation counselors, or conservators) report suspicious cases
of abuse to the proper authorities. Persons outside these categories do not have
a legal responsibility to report suspected cases of abuse. Despite this, experts
suggest that anyone who suspects elder abuse should report it to social and
rehabilitation services. In most states, the law has been crafted to foster a greater
participation by requiring that the reporter's identity remain anonymous
(Meadows, 2004). The promise of anonymity is believed by many to ensure suc¬
cessful reporting of the behavior. Mandatory reporting laws serve the twin pur¬
pose of identifying seniors who face abuse and allowing for intervention. In
fact, supporters of mandatory laws argue that were it not for such laws, many
cases of elder abuse would remain hidden, seniors would continue to be sub¬
jected to abuse, and may even suffer premature death. It should be noted that
because these laws vary from state to state, the definition of abuse also varies,
and the agency that is designated to receive the report of abuse is also respon¬
sible for conducting the investigation.
Criticisms of Mandatory Reporting Laws
Mandatory reporting laws are considered controversial because of sever¬

al criticisms. Some experts argue that the criticisms are fourfold. First, oppo¬
nents of mandatory reporting laws contend that these laws have not yet
proven to be effective in alleviating the problem, and that increased reporting
could be a product of the increased public attention about the problem of
elder abuse (see Davis and Medina-Ariza, 2001). Second, critics also contend
that legal penalties are not enforced because agencies fail to report abuse
(Blakely and Dolon,1991; Quinn and Tomita,1986; Thobaben,1989). A third
criticism is that most states do not take elder abuse seriously. Critics observe
that after mandatory reporting laws are passed, states believe that they have
done enough and quickly put the issue of elder abuse to rest. For example,
most states often fail to provide adequate resources to fund the services that
are desperately needed by victims and abusers (Crystal,1986;
Anetzberger,1989). A fourth criticism is that the reporting process frustrates
the relationship and confidentiality between professionals and clients. Cyrstal
(1986) and Macolini (1995) report that these laws require physicians to report
suspected cases of abuse. Doctors and public health officials argue this prac¬
tice violates patient-physician confidentiality. Stated another way, profession¬
als are faced with having to violate the law or breach the trust of a client and
conceivably jeopardize a long standing therapeutic relationship with the vic¬
tim and family. Opponents of these programs say they cannot stand alone and
if they are to be effective, they must be accompanied by a commitment of
resources from the designated reporting agency.
Protective Services
Protective services are designed to investigate concerns of elder abuse

and neglect. Many agencies and organizations are found in many jurisdictions
to meet the needs of abused and neglected elderly citizens. These agencies are
commonly referred to as Adult Protective Services (APS). Protective service
programs are generally supported by state legislation and are connected to
agencies such as Health and Human Services Departments. While protective
services are primarily concerned with assisting the elderly, they are also
involved in activities, such as granting licenses to nursing homes, funding
research, and training social service workers to meet the needs of clients (see
Doerner and Lab, 2002). The services given to elder abuse victims are also con¬
troversial because social workers usually are empowered to serve in a legal
intervention role. For example, social workers are those charged with the
responsibility for initially investigating cases of abuse followed by attempts at
treating the situation by providing services when needed. Protective service
programs generally include the use of a legal surrogate option (e.g., guardian¬
ship or conservatorship) when the elder is found to be incompetent
(Callendar,1982).
Criticisms of Protective Services
Similar to mandatory reporting laws, protective service programs also

have their share of criticisms. First, members of the legal community argue
that these programs intrude on the civil liberties of elderly citizens and
demean them. Critics argue that protective services may inadvertently reduce
elders to the status of needy infants or the mentally disabled (Doerner and
Lab, 2002). For example, under protective services, guardians can and often
do remove the rights and freedom that elderly citizens enjoy. Critics contend
that this is usually contrary to what elderly victims desire. Second, the legal
community argues that the definition that most states attach to elder abuse is
too broad. More specifically, some lawyers argue that such laws intrude in the
lives of families that may be experiencing the normal range of human prob¬
lems (Callahan, 1981). In fact, Dolon and Hendricks (1989) and Fiegener,
Fiegener, and Meszaros (1989) argue that because elder abuse is defined in an
ambiguous manner, the police or law enforcement is minimally involved as
an immediate contact source or aid. They argue that much elder abuse could
be a product of self-neglect. As such, many elderly victims have questionable
legal status. These critics also contend that one simply does not know whether
neglect is self-imposed or is the product of a caregiver. A third and perhaps
the main criticism of protective service programs is that they should be
designed to reduce tension within the legal community and alleviate the
ambiguity of tasks performed by protective service agencies (Bergman, 1989;
Bergeron,1989). They suggest protective service programs could be effective if
they offered a holistic approach in handling long-term problems instead of
serving as a quick-fix solution. More specifically, Bergman (1989) suggests a
combination of crisis intervention and protective service strategies, while
Bergeron (1989) advocates the integration of adult protective services with
human service providers.
Service Options
As stated earlier, because economic resources vary across states their

range of service programs to assist the elderly vary also. However, every pro¬
gram is premised on the notion that the elderly experience abuse because they
are dependent on the abuser (e.g., a domestic or institutional setting).
Consequently, most service programs utilize unclear health and social servic¬
es that are not specific to abuse. These services are tailored for victims who are
functionally-impaired and dependent on the caregiver. In most cases, the
abuse is probably caused by the strain that the caregiver faces. For example,
experts argue that providing care to the elderly can be overwhelming to some
especially when the elderly are in poor physical and mental health (Rosenberg
and Fenley,1991). Caregivers are responsible for making sure that the elderly
receive medication, are properly dressed and fed, and are assisted to make
routine visits to the doctor or receive hospitalization when needed. Again, the
responsibility of caring for the elderly can be an overwhelming experience
that could lead to abuse. In some cases, service options given to alleviate the
burden of care giving have included home care services, such as housekeep¬
ing and meal preparation. In other cases, victims can be relatively independ¬
ent elders who are abused by a dependent relative (Rosenberg and
Fenley,1991). In this instance, service options may require different types of
intervention—typically those that are often used in spouse abuse situations.
For example, some of the services may include increased social support for
the elderly or the use of group consciousness raising. Domestic violence
experts argue that like battered women, the elderly should be made aware
that they have a right to be free from violence and that abuse can never be jus¬
tified. Advocates, such as gerontologists and members of the American
Association of Retired Persons (AARP) have long argued that efforts should
be made to generate social consciousness among the elderly and the lay pub¬
lic about powerless groups in society. Meadows (2004) contends that elders
should also be made aware that they have the right to be treated with dignity
and respect and to have their personal worth protected.
Another option is the use of safe houses or emergency shelters for elder¬
ly victims. This option has been successful in aiding battered women who
have had to flee their abusers and seek shelter for their safety and the safety
of their children. This option is designed to provide the elderly with an alter¬
native that offers them escape and protection from continued abuse. At the
same time, the option sends the message that the victim can live independent¬
ly of the perpetrator and that he or she will no longer tolerate abuse because
there is somewhere to turn for help. A third service option is legal interven¬
tion. Some experts argue that criminal justice sanctions can be of invaluable
help in cases of domestic abuse. For example, in their seminal research,
Sherman and Berk (1984) reported that law enforcement intervention success¬
fully reduced domestic violence. More specifically, in a Minnesota experi¬
ment, they discovered that a formal arrest was a more effective method than
using an eight hour cooling off period or mediation to prevent continued wife
abuse. The study also revealed that since police are usually the first on the
crime scene, after they make an arrest, they can direct victims to effective com¬
munity services. In addition to police departments, some communities have
created task forces to provide the elderly with needed services. These groups
raise the consciousness of professionals and concerned citizens about the
plight and needs of elderly victims of abuse and neglect (Wolf and
Pillemer,1989; Hwalek, Hill, and Stahl,1989).
Elder Abuse: A Public Health Issue
Officials at the CDC argue that elder abuse is a public health issue because
of the pain, suffering, and diminished quality of life associated with this type
of violence. Both gerontologists and epidemiologists agree that the problem is
likely to get worse since the elderly comprise an increasing proportion of
Americans. Apart from the abuse, the elderly community already depends on
the health care community since many suffer from physical problems such as
diabetes, amputations, cancer, strokes, altered mental status, high blood pres¬
sure, urinary tract infections, syphilis, and congestive heart failure. Some may
even require special attention from a nurse or caregiver for being incontinent.
Furthermore, because of physical abuse, some elderly victims may need hos¬
pitalization and medical attention to recover from injuries sustained at the
hands of their caregiver. While experiencing abuse, the elderly may suffer
burns, gunshot wounds, punctures, injuries from rape, fractures or broken
bones, and stab wounds. Moreover, some caregivers have been known to
either intentionally or unintentionally withhold medication from those suffer¬
ing from diabetes, depression, glaucoma, Alzheimer's, hypertension, arthritis,
and shingles. Public health experts argue that elder abuse could lead some
victims to depression or even suicide. Elias (1986) argues that sometimes the
elderly may sustain debilitating injuries that can place limitations on their
already restricted freedom of movement which could take an even greater
psychological toll. What is more regrettable is that a segment of elderly vic¬
tims will experience premature death if health care interventions are not
forthcoming. Therefore, the health care community believes that because of
the problems associated with injuries, elder abuse is a public health issue
since many elderly victims will need both short-and long-term physical, as
well as psychological, treatment to aid them in recovery (Braithwaite and
Taylor,1992; Rosenberg and Fenley,1991).
Health care contributes significantly in patients' recovery. It often pro¬
vides needed health care service within the home. It can be used after acute
illnesses, hospitalization for chronic illnesses, or injuries sustained from abuse
that require the care of a skilled nurse. It is also needed to assist people in
accomplishing daily activities. Home health care services may include provid¬
ing the following:
• A skilled nurse (who assesses the needs of a patient and develops

treatment plans);
• Parenteral/enteral therapy (care for intravenous fluids, antibotics,
pain control or tube feedings);
• Ostomy and wound care (a comprehensive program to assist patients
with ostomies or other skin problems);
• Home health aide (nursing aides to assist with bathing, dressing, skin
care, and oral hygiene);
• Physical therapy (exercise, treatment and special equipment to restore
viability and decrease pain);
• Speech therapy (assist in the recovery of speaking, listening, and
learning new ways to communicate); and
• Social services (assist the patient and family with social and econom¬
ic problems caused by illness and acts as a liaison with community
resource agencies.
In addition to health care services, states such as Missouri and Kansas are
implementing senior clinics to care for the elderly. These clinics are designed
for homebound seniors and residents of long-term care and assisted living.
They were created to meet the challenges posed by health care needs. They
provide a comfortable, convenient, cost-effective setting in which patients'
special needs can be assessed, diagnosed, and treated by a primary care or
specialty physician. Moreover, these clinics provide access to treatment for an
improved quality of life, better monitoring through reduced hospitalization,
and they allow chronic illnesses and injuries to be monitored for better med¬
ical outcomes. Senior clinics provide services for patients who:
• Require diagnostic evaluation;

• Have been recently discharged from acute care to long-term care, and
who need follow-up care from primary and or speciality physicians; or

• Require specialty care services.
Health care professionals are responsible for assessing and treating phys¬
ical, as well as mental health, problems that are common among the aging
population. When the elderly are taken to a hospital for injuries caused by a
caregiver, case managers and social workers are duty bound to report inci¬
dents of suspected abuse to the appropriate authorities. After the elderly
receive treatment and are released, case management workers assess the
needs of patients. In most cases, they set up services and speak directly to the
caregiver. Case management workers and social workers make inquiries
about what type of equipment or service will be needed to aid the patient.
They may have to make arrangements for the delivery of special equipment
that will be needed for recovery. Depending on the condition of the elderly,
such items may include a hospital bed, a wheelchair, a neck brace, bedside
commode, or a rolling walker. Moreover, home health nurses typically visit
the patient's home several times a week or as often as needed to assess the
patient's progress.These nurses usually monitor vital signs, give medication
as needed, and teach the caregiver how to provide for the patient. These serv¬
ices are typically paid for by Medicaid and Medicare programs.
Health care professionals argue that elder abuse adds to an already
strained health care system. This is especially true for states' existing health
care programs, such as Medicaid. Despite this, health experts argue that the
elderly poor, unlike those who are affluent, experience unequal access to
Medicaid and Medicare (see Julian and Kornblum,1986). In fact, they argue
that minorities typically face differences in health and in effective access to
health services. Comparatively, they report that middle class elders have
greater access to health care and receive better quality of health care services,
such as medical attention, medication, and treatments. They argue that this is
not the reality for the minority elderly population that is disproportionately
made up of African-Americans and Hispanics. For example, Braithwaite and
Taylor (1992) contend that many elderly minorities suffer more since they
have major obstacles to health that include poverty or a lack of financial
resources, fragmented care or a lack of quality care, unemployment, and a
lack of qualified staff. What is more alarming is that when the minority elder¬
ly are in reasonably good health, it may soon decline because of factors, such
as an improper diet, lack of regular medication, medical attention, therapeu¬
tic equipments and routine checkups (Braithwaite and Taylor, 1992). Health
experts argue that access to the health care system is highly unequal because
it is based on the ability to pay (Calhoun, Light, and Keller, 1997).
PREVENTION STRATEGIES AND POLICY IMPLICATIONS
Despite the fact that elder abuse has existed for a long period of time, pre¬
vention strategies are in developmental or infancy stages (Doener and Lab,
2002). In fact, experts report that only within the past decade has formal leg-
islation seriously attempted to address the rights and needs of senior

Americans. Furthermore, there have been a number of interventions made to
alleviate the pain and suffering of elder abuse. Some of these efforts have
included the aforementioned programs, such as mandatory reporting laws,
protective services, and service options. While these intervention efforts have
contributed much in the way of assisting the elderly, some experts report that
legal remedies, a comprehensive program, and the creation of more gerontol¬
ogy programs may actually be more effective in preventing elder abuse. In
fact, some of these programs can help assist abused victims and put them on
the road to recovery.
Legal Remedies (Civil and Criminal)
During the 1980s, most practitioners who worked with elder adults were
reluctant to rely on the legal system as a means to protect their clients (Quinn
and Heisler, 2002). As a result, the legal system was under-utilized for pre¬
venting elder abuse. Today, however, practitioners, as well as senior adults,
have embraced the idea that the legal system can be used to protect the elder¬
ly's property interests and make perpetrators accountable for their misbehav¬
ior towards the elderly.The legal system provides two remedies: civil justice
and criminal justice. Essentially, the civil justice system addresses the person¬
al injuries and damages a defendant sustains at the hands of other persons or
entities. The criminal justice system addresses the harm committed against
persons and property. Both systems strive to restore balance and teach people
and entities to obey the law. However, in civil cases, if the plaintiff prevails, he
or she is awarded compensation for injuries. In criminal cases, if one is found
guilty of a crime, he or she could face a loss of life, freedom, pay a fine, or
make restitution to the victim depending on the seriousness of the crime.
Sometimes defendants face a combination of sanctions.
Where elder abuse is concerned, Heisler and Quinn (1995) write that civil
and criminal justice systems seek remedies to prevent and resolve elder mal¬
treatment. More specially, both justice systems strive to (1) stop the unlawful,
improper, or exploitative conduct that is inflicted on the victim; (2) protect the
victim and society from the perpetrator; (3) hold the offender accountable for
the behavior and communicate the message that the behavior is unacceptable;
(4) rehabilitate the offender; and (5) make the victim whole by ordering the
perpetrator to pay restitution or return property, as well as make payments for
expenses incurred by the victim. Again, legal remedies include the use of the
civil justice and criminal justice systems.
The Civil Justice System
Elder abuse or neglect is an issue that the civil justice system addresses.
To prevail in a civil proceeding, the elder victim or a surviving family mem¬
ber (the plaintiff) must show the injuries or damages that he or she sustained
with a "preponderance of the evidence." Essentially, the elderly victim
(injured party) must present more evidence to prove that the injuries were
sustained and inflicted or caused by the defendant (caregiver). The party that
has a majority of the evidence in his/her favor will win the case. In Rolando V.
del Carmen (1991), a criminal justice scholar argues that the degree of certain¬
ty required to win a civil lawsuit is the establishment of a preponderance of
the evidence. This typically requires more than fifty percent of the evidence in
one's favor. In other situations, such as a challenge for guardianship or con¬
servatorship, the courts require a higher degree of certainty and the burden of
proof is greater, del Carmen postulates that the degree of certainty needed to
prove that an elder is unable to care for himself or herself is "clear and con¬
vincing evidence." This generally requires 80 percent of the evidence. The
burden of proof is higher because elderly citizens may lose the freedom to
care for themselves and be placed in the custody and care of a guardian or
conservator.
The Criminal Justice System
Elder abuse or neglect is also an issue that the criminal justice system
addresses. For example, if a defendant is charged with an offense, such as neg¬
lect or a crime against an elderly person, he/she could lose freedom and civil
rights. He could also be forced to pay restitution. Subsequently, the state has
the heavy burden of proving "guilt beyond a reason doubt." Essentially, the
prosecutor must take 95 percent of the state's evidence and connect the
accused to the crime (del Carmen, 1991). If the jury is at least 6 percent sure that
the accused did not commit the crime, reasonable doubt exists and therefore,
the jury will be instructed to find the defendant "not guilty." Some legal schol¬
ars argue that of the two systems, the civil justice system is probably better
because the victim or surviving family members can bring a legal action
against the accused. These experts argue that this is not the case in the crimi¬
nal justice system. In criminal cases, the State, or the people, represent the
injured party, thus, removing the victim from the process. The prosecutor rep¬
resents the people. In fact, critics worry that the victim may be removed from
the process entirely. In some cases, however, victims may be called as witness¬
es. Sometimes, the victims are even allowed to give impact statements before
a jury pronounces its verdict and sentence.
Changes in the Civil Justice System Affecting Elder Abuse
Reforms have occurred in the civil justice system. Chief among them are
enhancement laws that require elder abuse and neglect to be reported to: (1)
Adult Protective Services; (2) law enforcement agencies; and (3) other authori¬
ties, such as a long-term Ombudsman (Quinn and Hiesler, 2002). Some states,
such as California, require cross reporting between these three agencies.
Moreover, when law enforcement discovers elder abuse is being committed,
they must report the abuse to the appropriate licencing agency. Furthermore,
issues are emerging in Medicaid-funded facilities that are being investigated by
local prosecutorial agencies. However, some of these cases are being reviewed
by federal prosecutors because they cross state lines (U.S. Department of Justice
and U.S. Department of Health and Human Services, 2000). Experts also con¬
tend that over the years, Adult Protective Services (APS) have expanded in
most states (APS is the section of local departments of Human Services agencies
responsible for receiving and investigating reports of elder abuse and neglect).
Current changes to APS include enhanced worker training and a mandatory
response time to each report. Other changes in response to elder abuse include
new laws and innovative causes of action (see Quinn and Hiesler, 2002). Some
states, including California, offer trial setting preference for cases involving the
elderly (see California Code of Civil Procedure Section 76; Penal Code Section 1048).
Another example comes from the U.S. House of Representatives (2001) which
provides that those who engage in nursing home abuse should be made civilly
and criminally liable. Some experts argue that a Congressional hearing is need¬
ed since many civil lawsuits had been filed against nursing homes. Charges in
these suits range from improper billing, failure to provide adequate training
and supervision of staff, inadequate care, failure to supervise and protect
patients from harm and neglect, and engaging in unfair business practices (see
People v. Casa Blanca Convalescent Homes, Inc, 1984). Another cause of action that
has emerged in California is entitled the California Elder Abuse and Dependant
Adult Civil Protection Act (see California Welfare and Institutional Code Section
11567-1167.3), and provides that victims of elder abuse can recover damages for
pain and suffering in addition to actual damages, attorney's fees, costs, and
punitive damages from physical abuse, neglect, and fiduciary abuse where the
defendant is guilty of recklessness, oppression, fraud, or malice in the commis¬
sion of the abuse.
Changes in the Criminal Justice System Affecting Elder Abuse
Reforms have also occurred in the criminal justice system to better assist
victims of elder abuse. For example, many states have created specialized laws
to enhance punishment for crimes committed against elderly citizens (see
Stiegel, 1995). Another effort is the creation of special training programs on
elder abuse. The programs provide special investigatory techniques to criminal
justice personnel. These programs are currently being used in states such as
Horida and South Carolina. Some agencies are following these examples by cre¬
ating special training programs to assist the elderly. They include the Police
Executive Research Forum (PERF) and the California Commission on Police
Officer Standards and Training (POST) (see Quinn and Hiesler, 2002). Another
emerging trend has been the creation of special units within police departments
and prosecutorial offices to address the special issues found in elder abuse and
neglect cases. Moreover, many states have also created specialty courts with
jurisdiction over particular issues in criminal justice. For example, some states
now have elder courts. These courts help to remove heavy caseloads from the
existing court system and focus primarily on the special needs of elderly vic¬
tims. They also allow court personnel to become experts (see Gaines, Kaune,
and Miller, 2000). Despite the help of legal remedies, Quinn and Tomita (1986)
argue that no one legal system can solve the problem of elder abuse. Moreover,
they also argue that legal remedies alone may not be enough. Another way to
effectively control and prevent elder abuse is to create comprehensive systems.
A Comprehensive Service System for the Elderly and Their Families
A comprehensive service system is needed to meet the needs of victims and

their families. Davis and Medina-Ariza (2001) report that elder abuse is a com¬
plex problem that goes beyond the resources of one agency or organization. In
fact, elder abuse remedies utilize the help of police, prosecution, abuser educa¬
tion, social services for victims and even medical assistance. Despite the assis¬
tance provided by each, these components address only a small part of the
problem. In fact, experts caution that none alone can provide an effective solu¬
tion to elder abuse. As such, what is needed is a coordinated effort or a multi¬
disciplinary approach among several agencies. A coordinated strategy could be
planned by agencies such as police, prosecutors, counseling organizations, shel¬
ters, emergency rooms and hospital, foster families, adult daycare, community
education, and the creation and development of gerontology programs. While
much is known about how police and the criminal justice system respond to
elder abuse, very little is understood about what other agencies can provide the
elderly. Therefore, attention is given to emergency rooms and hospitals along
with the creation of more gerontology programs.
Emergency Rooms and Hospitals
To help prevent elder abuse, emergency rooms and hospitals can quickly
take a proactive or a reactive role. For example, the Massachusetts Office of the
Attorney General (1992) provides that as part of a multidisciplinary approach
to prevent the continuation of elder abuse, emergency rooms and hospitals can
create protocol for abuse and neglect cases. According to the attorney general,
as soon as health care professionals recognize the warning signs of physical
abuse or neglect, they can question the patient to collect more facts to either con¬
firm or dispel suspicion that abuse is occurring. If their suspicion is corroborat¬
ed by information from the patient, the emergency room or hospital personnel
should immediately notify the proper authorities so that someone can investi¬
gate the matter. Experts contend that this will allow for the reduction and elim¬
ination of many cases of elder abuse, and aid in the prevention of premature
deaths. These experts also criticize emergency rooms and hospitals for not hav¬
ing a standard protocol in place to assist victims of elder abuse.
Increase Gerontology Programs
Some experts argue that the creation of more gerontology programs in the
nation's colleges and universities can help to increase awareness of and prevent
elder abuse. Gerontology is defined as the study of the aging process and peo-
pie as they grow from middle age through life (Calhoun, Light, and Keller,
1997). It is a multidisciplinary field that relies on biology, sociology and psychol¬
ogy to understand and assist the elderly. In short, gerontology focuses on the
study of physical, mental, and social changes in older people. It also investi¬
gates the changes in society that results from the aging population, such as the
family, economy, health services delivery, government and private programs,
and religious institutions. Those with educational backgrounds in gerontology
are referred to as gerontologists.They provide many services to the aging pop¬
ulation. For example, gerontologists work in areas such as community and
human services, health care and long-term care institutions, federal, state, and
local governmental agencies, retirement communities, academic and education¬
al research settings, professional organizations and other areas. Gerontologists
work either directly or indirectly with the elderly. Gerontologists have first¬
hand knowledge about the plight of elders, including issues of abuse. They can
use their knowledge to sensitize the public and make it aware of the needs and
experiences of elders. For example, gerontologists often use the public health
approach by visiting communities where elder abuse is a common occurrence
as discovered through health surveillance. They can educate residents on the
definition and consequences of elder abuse. They can also enlist the help of
police and health care professionals to assist them.
Officials at the CDC argue that while visiting targeted areas where elder
abuse is found, gerontologists and health care officials can educate a population
on the dangers of this epidemic by citing the sheer numbers of those affected
and how others in the environment are also affected by the cycle of violence,
exchange, and family stress theories. Gerontologists and health officials can also
use visual captions of injuries and even photos of victims who have been killed
by abuse. CDC officials believe that this technique can be instrumental in dram¬
atizing the harsh realities associated with elder abuse. Gerontologists can also
use their positions to advocate the interests of the elderly population. For exam¬
ple, they can apply their expertise to help transcend the quality of life for eld¬
ers, speak about aspects of aging in civic and community groups, and influence
agencies and organizations that serve the elderly. Most importantly, gerontolo¬
gists can positively influence legislation and policies that affect the elderly by
joining forces with such groups as AARP and similar organizations to lobby
elected officials to create better legislation and to vigorously enforce existing
laws. As the demographic composition of the U.S. continues to age, the need for
gerontologists becomes more apparent. Therefore, colleges and universities
around the country would do well to market their gerontology programs to
attract and train the next generation of gerontologists to serve in the areas of
service provision, administration, health professionals, and educator/
researchers to meet the demands of this emerging population.
Policy Recommendations
Politicians and public health officials agree that elder abuse is a serious
problem in the U.S. However, they may be at odds over which approach is the
best way to address the issue. In the U.S., there is no national crime or health
policy (Donziger, 1996). Each state legislature is responsible for creating its
separate policies. The results have been a mixture of liberal to moderate to
conservative approaches in dealing with the issue of crime and health care.
Experts warn that policymakers must view crime and health policies in the
larger context of society. Crime and health policies must make the country
safe and healthier and be crafted in a cost-effective manner (Donziger, 1996).
Both politicians and public health officials agree that in order for public poli¬
cy to be effective, they must address some of the causes that are associated
with elder abuse. Policy recommendations include the following:
• Public service announcements

• Expand the definition of hate crime to include elder abuse and repeat¬
ed cases of neglect
• Mandatory standardized protocol used by hospitals
• Publicizing the identity and photo of those who engage in elder abuse
• Better data collection
• Random unannounced inspections of nursing homes
• More social worker contact in high risk abuse cases
• Mandatory certification for home health care workers
• Aggressive enforcement of mandatory reporting laws
• Evaluation research to determine the effectiveness of existing pro¬
grams.
Public Service Announcements
As part of the public health approach to prevent disease and injury, CDC
officials rely on public service announcements to launch campaigns against
the dangers of tobacco, teenage pregnancy, child abuse and domestic violence
against women. Other health care professionals also use public service
announcements to increase social awareness of the dangers of these and other
epidemics. These announcements are strategically scheduled to be aired dur¬
ing prime time television viewing. In addition, public service announcements
are often made over radio programming and placed on community bill¬
boards. Gerontologists and epidemiologists contend that the same strategy
can be used to increase awareness and educate the public on the reality of
elder abuse. These announcements are used to show the vulnerability of eld¬
ers and the consequences of abuse on everyone in the household. They may
also imply that the behavior is intergenerational.
Expand the Definition of Hate Crime to Include Elder Abuse
Expanding the definition of hate crime to include elder abuse and repeat¬
ed cases of neglect followed by a sentence enhancement seems a logical poli¬
cy that may serve to reduce and prevent elder abuse. This seems a logical
course of action since other victimized groups in society have been included
in its definition. For example, under hate crime laws those who receive pro¬
tection include: Minorities, women, the handicapped, people with alternative
lifestyles, and others who are targeted for crime because of religion. As part of
their punishment, offenders should be forced to receive sensitivity counseling
and anger management courses prior to being released from confinement.
This may serve as an effective strategy since recent crime statistics reveal that
hate crimes are actually declining from several years ago (Uniform Crime
Reports, 2001).
Mandatory Standardized Protocol Used by Hospitals
Mandatory protocol should be used by all of the nation's hospitals. They

should create a uniform set of procedures to be invoked when cases of elder
abuse are suspected and confirmed. These cases should also be included in a
yearly compilation on the number of visits made by elderly persons. To do so
may prevent continued levels of abuse and make offenders more accountable
for their behavior. These data can also be used to establish that a hospital did
not act in a negligent way or a manner that was "deliberately indifferent" to
the plight of an elderly victim. If these data are collected around the nation,
they can help determine the nature and extent of the problem.
Publicizing the Identity and Photo of Those Who Engage in Elder Abuse
Shaming has been successfully used in the past as a deterrent to crime,

such as theft, prostitution, and child sexual abuse. Therefore, shaming should
also be used as a strategy to reduce and prevent elder abuse. States and local¬
ities should print the identity and publish photos of offenders found guilty of
engaging in elder abuse. This information should be printed in local newspa¬
pers and aired on television as a means of exposing this hidden problem. The
desired result is that it would force offenders into conformity and reduce lev¬
els of recidivism.
Better Data Collection
A national clearinghouse is needed that collects yearly statistics on cases

of elder abuse and neglect. This data collection can be similar to other crime
data such as the Uniform Crime Reports and the National Crime
Victimization Survey. By creating a national data compilation, it will enable an
accurate determination of the nature, extent, and dynamics of elder abuse. It
will also indicate if the number of elder abuse cases is increasing or decreas¬
ing. At the same time, it should allow for an examination of the trends and
patterns associated with elder abuse. It may be instrumental in indicating
whether resources are achieving their intended objective. If it is discovered
that they are not, it may reveal that other strategies are needed to reduce and
prevent elder abuse.
Random Unannounced Inspections of Nursing Homes
Health officials should engage in random and unannounced visits of

nursing homes to ensure compliance with state standards. In cases where
repeated violations occur, the nursing home should have its license revoked
and closed. If health officials discover that the administrator had prior knowl¬
edge of abuse but failed to discipline, terminate, or take corrective measures
against an employee, the administrator should be terminated and prosecuted.
Residents should also be immediately reassigned and even allowed to file a
tort claim in civil court for damages and injuries sustained. In cases, where
abuse is not egregious, the nursing home should simply replace its manager
and the residents should be interviewed in an attempt to uncover the extent
of abuse and neglect.
More Social Worker Contact In High Risk Abuse Cases
In cases where it has been reported that an elderly person is at high risk,
social workers should give priority to such cases by making routine visits to
ensure that the elder is safe. Moreover, in such cases, efforts should be made
to allow the elder to be more independent by setting up accounts that auto¬
matically deposit their social security and retirement funds and to automati¬
cally pay bills such as rent, utilities, and phone. This is believed to deter vio¬
lence that some elderly suffer at the hands of caregivers who have chemical
dependency problems (these are the high risk cases).
Mandatory Certification for Home Health Care Workers
An existing problem that appears to be pronounced in elder abuse is that

many in-home service providers who assist elderly patients with critical serv¬
ices on a daily basis lack the academic and training credentials to render these
needed services. Some experts report that because of the low pay that is given
to these workers, this area of employment is attractive to people who lack
skills to engage in other endeavors. While it does not appear to be an issue in
emergency rooms and hospitals around the country, the problem is found at
alarming rates within the context of many individual and nursing homes. In
order to ensure quality control and the safety of patients, home health care
workers should receive state certification before caring for elderly patients.
Aggressive Enforcement of Mandatory Reporting Laws
Criticisms exist over the lack of enforcement when those authorized to

report cases of elder abuse fail or refuse to act. Some advocates contend that
if violators were forced to pay a hefty fine or receive incarceration, this would
have both a specific and general deterrent effect because it would send the
message that compliance is not discretionary, but rather, it is what the law
requires. Essentially, it would create an obligation to act when one does not
feel compelled to act. Despite what most people believe, mandatory reporting
laws can easily be enforced because of the failure to act when there is a legal
obligation to act.
Evaluation Research to Determine the Effectiveness of Existing Programs
As stated previously, every state in the country has some type of program
in place to assist elderly victims of abuse. These typically include mandatory
reporting laws, protective services and service options. However, it is very
difficult to determine if these programs are having a positive effect on reduc¬
ing elder abuse. This is due, in part, to a lack of evaluation research conduct¬
ed on existing programs. It is vital that research be conducted to determine if
these programs are meeting their stated objectives. As of now, it is almost
impossible to know if states have genuine concerns about the effectiveness of
such programs or if states simply want to say that they have assistance or a
response in place to help elder victims of abuse. Moreover, state officials who
sponsor programs to assist the elderly should require that funded programs
receive evaluation to determine it the funds are being wisely spent. Otherwise
the money to defray the costs of existing programs could be better spent on
strategies that may be more viable in alleviating the problem of elder abuse.
Elder abuse is a criminal justice, as well as public health, issue in the U.S.
As the elderly population rises, the number of victimizations and the magni¬
tude of the resulting health problems will become even more serious. It is crit¬
ical that the response to elder abuse improves in order to successfully address
prevention and treatment issues now and in the future. Currently, states inter¬
vene with social services, such as mandatory reporting laws, protective servic¬
es, and service options. Yet, the effectiveness of these interventions is unknown
because of the paucity of program evaluation. As state budgets grow tighter it
is increasingly imperative that elder abuse funds are managed wisely. At the
same time, the approach to elder abuse needs to be interdisciplinary, since no
single program or agency can adequately address prevention and treatment.
We believe that the public health approach offers such a strategy. The authors
of this chapter suggest the following policies be adopted in order to accom¬
plish prevention and treatment goals: (1) public service announcements; (2)
expanding the definition of hate crime; (3) mandatory standardized protocol
used by hospitals; (4) publicizing the identity and photo of those who engage
in elder abuse; (5) better data collection; (6) random unannounced inspections
of nursing homes; (7) more social worker contact in high risk abuse cases; (8)
mandatory certification for home health care workers; (9) aggressive enforce¬
ment of mandatory reporting laws; and (10) evaluation research to determine
the effectiveness of existing programs. At the same time, we argue that the eld¬
erly should rely more on the help of the criminal justice and civil justice sys¬
tems. We caution that a failure to heed our policy recommendations may mean
that more cases of elder abuse will continue to go unreported, and unfortu¬
nately others may even experience a premature death.
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Cases Cited
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Code of Civil Procedure: 76; Penal Code Section 1048.
12
CONCLUSION
Randal Summers and Allan Hoffman
We would like to believe that our retiring parents and our beloved grand¬
parents are enjoying the latter part of their lives and receiving the honor and
respect that they so deserve. Unfortunately, for millions of elderly this is only
an idealistic figment of imagination. The sobering truth is that a significant
number of our elderly are being abused by family members and caregivers in
the home or to a lesser extent by the staff and residents in our institutional set¬
tings. There are projections that our elderly population 65 years and older will
exceed 70 million by the year 2030. A conservative elder abuse estimate of 5%
of this population would suggest that there will be over 3 million elders vic¬
timized in the U.S alone. This is sad commentary for one of the most educat¬
ed, wealthy and powerful countries in the developed world.
RECOMMENDATIONS FOR ACTION
Despite this harsh reality, there is hope. We are slowly coming to the real¬
ization that much has to be done if we are to stem the tide of elder abuse.
Throughout this volume recommendations for action have been identified in
regard to the specific topics being addressed.
In regard to Intimate Partner Violence and Abuse (IPVA) and older
women the research body of knowledge is at a very early stage of scientific
maturity. We need to have a better understanding of and ways for identifying
the perpetrators. Currently there are few resources that specifically deal with
the needs of older women. We need to identify what constitutes the appropri¬
ate services and educate our physicians and shelter service providers.
Very little is known about the offenders in the sexual victimization of our
elders. Current research into sexual abuse often overlooks elderly women. We
need to help providers of elder care, criminal justice and adult protective serv¬
ice workers expand their perception of sexual abuse in order to more ade¬
quately identify and protect victims.
There is a great need for more research on the effectiveness of criminaliza¬
tion and the coordination among statistical service systems and service
providers. We have seen advances in adult protection legislation and creating
protocols for detection and intervention but more has to be done in this area.
In the area of communication, we need to design computer programs for older
persons and train them to be computer literate. We should assist nursing
home staff and family members with better ways of communicating with the
elderly residents. Cooperation from the media is critical if we are to have any
167
168 Summers and Hoffman
influence over prevailing negative attitudes toward the elderly. We need to

ensure that the images we portray of the elderly are respectful. More research
is needed on the cultural aspects of elder abuse as well as a more accurate
international perspective. We should have a better understanding of elder
abuse among Native Americans especially in regard to differences between
urban and rural situations. This, in turn, will help us to develop more relevant
interventions. Since elder abuse is both a criminal justice and public health
issue we need to advocate effective laws to protect the older population. There
are mandatory reporting laws in most states and protective services but we
need to do more research on their effectiveness. There must be more reliance
on the criminal justice and civil justice systems and recognize that we must
accept an interdisciplinary approach to elder abuse since no single agency can
address all aspects of prevention and treatment. In addition, we need to
enhance elder abuse awareness through public service announcements,
encourage more social work contact in high risk situations, and enhance the
competencies of home health care workers. In reference to elder abuse, we are
in a state of crisis. All of these actions require the courage and commitment to
affect change in a world gone awry. Although the remarks of the Deputy
Secretary of Defense Paul Wolfowitz were aimed at terrorism, they are espe¬
cially poignant in regard to our challenge in the area of Elder Abuse:
"Building a Better World: One Path from Crisis to Opportunity"
Remarks delivered by Deputy Secretary of Defense Paul Wolfowitz, at the

Brookings Institution, Washington, DC, Thursday, September 5, 2002.
ADDITIONAL RESOURCES
SeniorCitizens.com: Elder Abuse and Neglect

www.Elder-Abuse-Information.com
www.Elderly-Abuse-Nursing-Home.com
National Citizens' Coalition for Nursing Home Reform
www.nccnhr.org/
www.nursinghomealert.com /
www.oaktrees.org/elder/
www.preventelder abuse, org /
www.eldercare.gov/
SeniorCitizens.com: Elder Abuse and Neglect
In California: Califomias Attorney Crime and Violence Prevention Center
http:/ / www.safestate.org/index.cfm7navkH14
National Center on Elder Abuse (NCEA)
1201 15th Street N.W., Suite 350, Washington , DC
Major source of data and funds the Clearinghouse on Abuse and Neglect
of the Elderly at the University of Delaware
http:// www.elderabusecenter.org
Index
Abuse-related questions, 29-30 neglect by, 41

Abusive behavior, subcategories, 66-67 as offenders of sexual abuse,
Accommodation stage, 24f, 25 133-134
Action on Elder Abuse, 66 stress, 35-48
Active neglect, 6,10-11 Caregiving institutions, abuse in, 8
Acute stage of trauma, 22, 24f Care pathway model, 19-33
Administration on Aging (AoA), 30-31 client with indicators of abuse, 28f
Adult Protective Services (APS), 36 Centers for Disease Control (CDC),
African-American population elder abuse as an epidemic, 139
aging of, 51 Civil justice system
elder abuse in, 55-56 changes, 155-156
Ageism, 15 in elder abuse, 154-155
Age-related changes, signs of abuse Clinical interventions, elder abuse,
versus, 39 27-29
Alcohol use, among abusers, 38 Communication neglect, 117-121
Algorithms for elder abuse intervention, barriers, 118-119
19, 25-27, 26f consequences, 125
American Association of Retired detection and intervention, 125-127
Persons (AARP), Women's Communication tips, 127
Initiative, 99 Community-dwelling elders, monitor¬
American Psychological Association, ing of, 35-48
definition of elder abuse, 65 Community resources, 29-30
Appeal to higher loyalties, Comprehensive service system, elderly
by offenders, 147 and their families, 157
Asian and Pacific Islander population Condemnation of the condemners, by
aging of, 51 offenders, 147
elder abuse in, 55-58 Counseling, abused person and/or
Australian Network for the Prevention perpetrator, 27-29
of Elder Abuse, 66 Criminal justice system
Autonomy, in health care, 77, 80 changes, 156-157
Avoidant stage, trauma, 24, 24f in elder abuse, 155
Cultural implications
Bald patches, indication of abuse, 45 elder abuse in the U. S., 52-53
Behavioral indicators of abuse, 22, 23t elder abuse on a global level, 67
Beneficence, 78-79 Cycle of violence theory, 143
Blood, indication of abuse, 45
Bowen family therapy, 32 Data collection, in elder abuse, 160
Bruising, indication of abuse, 45 Decision to care for elderly patient, 14
Decision to enter abuser's home, 14
Caregiver Decubiti, in ambulatory patient, 45
difficulties in caring for elderly Definitional disarray, 119
person, 14-15 Denial of injury, in elder abuse, 146
financial difficulties in care, 15 Denial of responsibility, in elder
inappropriate decision-making on abuse, 146
behalf of elder, 42 Denial of the victim, in elder abuse,
inappropriate handling of 146-147
patient, 46 Depression, in traumatized victims, 20
inappropriate interactions with Difficulties in care, 14-15
older person, 43 Doctor-patient relationship, impact on
keeping appropriate living screening for elder abuse, 36
environment, 42 Domestic violence, 98
169
170 Index
Domestic violence community, role in Web-based resources, 30-31

older victimized women, 109-110 Elder Assessment Instrument (EAI), 40
Drugs Emergency rooms, role in
inappropriate use of, 9 prevention, 157
use among abusers, 38 Emotional abuse, 42-43
Epidemiology, 139-141
Elder abuse Ethics
adjudicating cases, 16 elder abuse, 77-94
assessment of, 20 types of abuse and, 82-94, 82t
Canada, 12 Ethnicity, elder abuse, 2, 53
causes/theories, 13-17 Experiential family therapy, 32
challenge of prevention, 72
community resources, 29-30 Familismo, Latino cultural value, 54
cultural implications, 52-53 Family constellation of risk factors, 20
dealing with the problem, 2-3 Family stress theory, 16,145
definition by different racial/ethnic Fidelity, 81
groups, 53 Financial abuse, 9-10
in the definition of hate crime, ethical issues, 89-91
159-160 identification by health care
definition outside the U. S., 65-67 providers, 43-44
definitions, 5-8 in institutions, 16-17
deterioration of health and support of elderly parents, 10
well-being, 42 Financial difficulties, in care
epidemiology, 139-141 of elderly, 15
first multinational study, 67-68
global implications, 67 Gerontology programs
identification in the home, 35-48 research to determine
integrated sample care pathway effectiveness, 162
for client, 28f role in prevention, 157-158
international / cultural perspectives, Granny battering, WHO definition, 65
65-72 Granny dumping, 11
IPVA or, in older women. 111 Guardians and/or family members
in minority populations, 51-60 abuse by, 6-7
model algorithm for intervention, skills needed for elder care, 17
26f
moral and ethical implications, Harvard Maltreatment Project, 25
77-94 Hate crimes, include elder abuse in,
particular groups in society, 2 159-160
perpetrators and victims, 71-72 Health and well-being, general
prevalence, 1 deterioration, 42
international reporting of, 68-70 Health care
rates and statistics, 11-13 elder's ability to meet costs, 44
prevention and intervention, interventions in elder abuse, 139-162
141-142 predominant ethical values, 78-82
as a public health issue, 151-153 strategies for interventions, 147-148
recommendations for action, Health care providers
167-168 communication neglect and, 120
risk factors, 20-22 ethical issues, 86
social and cultural demographics, guidelines for, 19-33
37 identification of abuse in the home,
social services and health care 35-48
intervention, 139-162 identification of emotional abuse,
theories on causes, 142-153 43-43
types, 9-11 identification of financial abuse,
underlying causes, 1-2 43-44
identification of neglect, 41^42 Medical examination routine

identification of physical abuse, procedures, caregiver team, 37
44-46 Mental abuse, 9
identification of sexual abuse, 46 Minority populations
intervention responsibilities, 46-48 developing and implementing serv¬
mandatory certification, 161 ices, 59-60
role in older victimized women, elder abuse in, 51-60
107-109 Moral implications, elder abuse, 77-94
Health care values, 77 Multidisciplinary home care services,
Helping victims, 139-162 36, 39
High-risk individuals for elder Multigenerational pattern of abuse, 20
abuse, 20
Hispanic population, aging of, 51 National Center on Aging Abuse, 66
Home care nurse, as care services National Center on Elder Abuse, 9,12
coordinator, 37 abuse against older women,
Honesty, 81 100-102
Hospitals actual and suspected incidence of
mandatory standardized protocol, abuse, 38
160 African American population, 55-56
role in prevention, 157 Asian and Pacific Islander population,
House Select Committee on Aging, 6 55-58
Human rights, older persons world¬ definition of elder abuse, 65
wide, 72 definition of sexual abuse, 131-132
Native Americans, 58-59
International/cultural perspectives, perpetrators and victims, 71-72
elder abuse, 65-72 1998 study, 1,12
Intervention 2000 survey, 52
clinical, elder abuse, 27-29 National Clearinghouse on Family
by health care providers, 46-48 Violence (Canada), 66
helping victims, 139-162 National Elder Abuse Incidence Study,
prevention and, 141-142 11-12, 41, 52, 77
strategies for social services and older women, 100-102
health care, 147-148 Native Americans, elder abuse in, 58-59
Intimate abuse, elder abuse and, 37-38 Neglect, 41M2
Intimate partner violence and abuse active or passive, 6
(IPVA), 97-113 communication, 117-121
older women, 101-106, 111 definitions, 10-11
recommendations for action, Nonmaleficence, 78-79
167-168 Nursing homes
victim and incident characteristics, abuse in, 8
104-106 factors in abuse, 16
Isolation, elderly persons, 9 random unannounced inspections,
161
Justice, 78-80 statistics on violations, 13
Latinos, elder abuse among, 53-55 Offenders (perpetrators)

Legal considerations, elder abuse, 27-29 characteristics, 7-8
Legal remedies (civil and criminal), 154 publicizing identity and photo, 160
Life necessities, failure to provide, 10-11 recommendations for action,
Living circumstance changes, indicator 167-168
of financial abuse, 43-44 Older women
Living environment, 42 distinguishing between elder abuse
and IPVA, 111
Mandatory reporting statutes, 79 extent of problem, 101-106
Material abuse, 6 future directions, 110-113
172 Index
need for services and programs, sexual victimization, 134

111-113 Role reversal, 14-15
resources for, 107-110 Role theory, 17
sexual violence against, 131-137
stories of violence and abuse, Satir, Virginia, 32
106- 107 Self-neglect, 11, 41
violence against, 100-101 ethical issues, 86
Ombudsman programs, 35 Sexual abuse/violence
Omnibus Budget Reconciliation Act, complaints in nursing homes, 8, 9
nursing home industry reforms, 35 definition, 131-132
Overmedicating, 9 against elderly women, 131-137
identification by health care
Passive neglect, 6,10-11 providers, 46
Patient harming another patient, offenders, 133-134
nursing homes, 8 prevention, 135-137
Patient interview, 39^10 proper attitude toward victimiza¬
Patient self-determination, 77 tion, 135
Peer conversations, caregiver team, 37 risk factors of victimization, 134
Personalismo, Latino cultural value, 55 victims, 132-133
Physical abuse, 6, 9 Sexual activity, evidence of, 46
ethical issues, 83-87 Shared documentation, caregiver
identification by health care team, 37
providers, 44-46 Social abuse, ethical issues, 91-94
Physical indicators of abuse, 22, 23t Social exchange theory, 15,144-145
Physicians Social services
role in older victimized women, in elder abuse, 139-162
107- 109 research to determine effectiveness,
screening for elder abuse, 36 162
Policy recommendations, 158-159 strategies for interventions, 147-148
Pressure ulcers, indication of abuse, 45 Societal attitudes, health care, 78
Prevention strategies, policy Sociological theories, 13
implications and, 153-162 Solution-focused therapy, 32
Professional curriculums, information Special Investigations Division,
on elder abuse in, 39 Committee on Government
Protective services, 149-150 Reform, U. S. House of
service options, 150-151 Representatives, 8
Psychological abuse, 6 Spousal abuse, 7
ethical issues, 87-89 Standard of living changes, indicator of
Psychopathology, 144 financial abuse, 44
Public service announcements, 159 Statistical data, elder abuse, 1
Statutes on elder abuse, 7
Questioning, in suspected abuse, 39-40
Techniques of neutralization or drift
Reporting theory, 146
abuse by family members, 6 Technology, as a barrier to elder com¬
aggressive enforcement of laws, munication, 119
161-162 Therapeutic re-evaluation stage, trauma,
failure in nursing homes, 8 24, 24f
mandatory requirements, 13 Toxic talk, 123-125
mandatory statutes, 79,148-149 Trauma Accommodation Syndrome, 22,
suspected abuse, 37 24f
Research, 162 Treatment guidelines, elder abuse, 19-33
Respect, 81-82
Restraint use, 45 Unsanitary living conditions, 10-11
Risk factors, 20-22
Verbal abuse, 8,121-123 Violence Against Women Act (VAWA),

consequences, 125 1994 and 1998, 99
detection and intervention, 125-127 Violence and abuse against women, 98
intentional, 122-123
unintentional, 122 Web-based resources, 30-31
Victim and incident characteristics, World Health Organization (WHO)
104-106 elder abuse, 65-66
Victimization stage, trauma, 22, 24f multinational study, 66-68
Victim-victimization spectrum, 20-22,
21t
ABOUT THE EDITORS
Allan M. Hoffman, Ed.D. CHES
Allan M. Hoffman, Ed.D. CHES, is a nationally recognized expert on

issues associated with violence and violence prevention. He is a frequent
guest on radio, television and often quoted in news articles concerning vio¬
lence issues.
Currently, Dr. Hoffman is Vice President at Hartnell College in Salinas,
California. Among his previous positions, he served as Director of the Center
for the Prevention of Community Violence and is an experienced educator
and human services administrator. He has held executive-level positions in
higher education and health care, having served as dean, associate dean, exec¬
utive officer, and faculty member. Dr. Hoffman has been a visiting scholar,
adjunct professor, clinical professor, and professor at several institutions. Dr.
Hoffman has published extensively and authored several books including:
Domestic Violence: A Global View (Greenwood, 2002), Teen Violence: A Global
View (Greenwood, 2001), Schools, Violence and Society (Praeger Publishers,
1996), Violence on Campus (Aspen Publishers, 1998), Teen Violence: A Global View
(Greenwood, 2000), Managing Colleges and Universities: Issues for Leadership
(Bergin and Garvey, 2000), Total Quality Management: Implications for Higher
Education (Prescott Publishing, 1995).
He has served on the editorial board or as a manuscript reviewer for the
Journal of Allied Health, Journal of Public Health, and Police Practice and Research:
an International Journal. He has provided consulting services to schools, col¬
leges, and business organizations in multinational settings. His consulting
efforts focus on violence in schools, colleges, and the workplace and leader¬
ship issues. He earned his B.S. magna cum laude from the University of
Hartford, and received two M. A. degrees and an Ed.D. from Teachers College,
Columbia University where he was named a Kellogg Fellow. He is a Certified
Health Education Specialist. Dr. Hoffman is the recipient of numerous awards
and honors associated with his teaching and his efforts to prevent violence
and resolve conflict creatively. He received a Certificate of Special
Congressional Recognition from the Congress of the United States of America
and a Special Recognition Award from the Executive Office of the President of
the United States, Office of National Drug Control Policy.
Dr. Hoffman lives in Montery County, California, and can be contacted by
email at: drallan52@sbcglobal.net
175
176 Editors and Contributing Authors
Randal W. Summers Ph.D. ,

Currently, Dr. Summers is a principle in the organization effectiveness
consulting practice of Summers and Associates. He provides consulting serv¬
ices to schools, colleges, and business organizations in multinational settings.
He has served as an internal consultant for a number of Fortune 100 compa¬
nies in the areas of organization effectiveness and leadership development.
His previous academic positions included adjunct faculty member with the
Center for the Prevention of Community Violence (Iowa), adjunct professor in
Business Administration at the University of Phoenix, adjunct senior profes¬
sor in Business Administration and Health Care Administration at the
University of LaVerne. He has served as a Clinical Psychologist in a large
teaching hospital in Canada as well as in private practice. He has developed
programs and managed psychologists and social workers in large institution¬
al settings related to youth corrections and the developmentally handicapped;
advocating "normalization," transition back into the community.
Dr. Summers has authored several books including: Domestic Violence: A
Global View (Greenwood, 2002), Teen Violence: A Global View (Greenwood,
2001), Managing Colleges and Universities: Issues for Leadership (Bergin and
Garvey, 2000) and he has been a contributing author in Schools, Violence and
Society (Praeger Publishers, 1996), Violence on Campus (Aspen Publishers,
1998), and Total Quality Management: Implications for Higher Education (Prescott
Publishing, 1995).
Dr. Summers lives in the San Francisco Bay area and can be contacted by
email at: ransum@thegrid.net
ABOUT THE
CONTRIBUTING AUTHORS
James F. Anderson is Associate Professor of Criminal Justice and Criminology at
the University of Missouri at Kansas City. Prior to joining the faculty in 1999,
he was employed at Eastern Kentucky University in the Department of Police
Studies. He has published several books and articles in the areas of crimino¬
logical theory, intermediate sanctions, legal rights of prisoners, and crime and
public health care. He is currently working on a book for police procedures.
Dr. James F. Anderson, University of Missouri at Kansas City, Department of
Sociology/Criminal Justice and Criminology, 5100 Rockhill Road, Kansas
City, MO 64110; andersonjf@umkc.edu
Joanne Ardovini, Ph.D., Assistant Professor, Metropolitan College of New

York, 75 Varick Street, New York, NY 10013-1919
Denise Gaffigan Bender, JD, PT, GCS is an associate professor in the College
of Allied Health, Department of Rehabilitation Sciences at the University of
Oklahoma Health Sciences Center (OUHSC) in Oklahoma City, OK. She also
has an adjunct appointment as clinical associate professor at the OUHSC
Donald W. Reynolds Department of Geriatric Medicine. She is certified by the
American Board of Physical Therapy Specialties as a geriatric clinical special¬
ist and is also a licensed member of the Oklahoma Bar Association. Professor
Bender gives presentations on the topic of elder abuse to professional and
community groups. Denise Gaffigan Bender, Department of Rehabilitation
Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City,
OK 73190
Bonnie S. Fisher, Ph.D., is a Professor in the Division of Criminal Justice at the

University of Cincinnati and a senior research fellow at the Criminal Justice
Research Center. Her most recent work examines the abuse and violence
against older women and the domestic violence community's response, issues
surrounding the sexual and violent victimization of college women, and work¬
place violence. She coedited, along with Sandra Regan and Therese Zink, a
special issue of Violence Against Women entitled "Overlooked Issues During the
Golden Years: Domestic Violence and Intimate Partner Violence Against Older
Women." She is the author of more than 80 articles and chapters on topics that
include college student campus victimization, the measurement of sexual vic¬
timization, violence and sexual victimization of female college students, abuse
and violence against older women, and domestic violence in the workplace.
She is also the co-editor of the Security Journal and serves on the editorial board
of several journals. Bonnie S. Fisher, PO. Box 210389, University of Cincinnati,
Cincinnati, OH 45221-0389; Bonnie.Fisher@uc.edu
Tina M. Fryling, Assistant Professor, Department of Criminal Justice,

Mercyhurst College, 509 E. 38th Street, Erie, PA 16546
Nancie J. Mangels is doctorate fellow at the University of Missouri at Kansas

City. She is a student in the Department of Sociology, Criminal Justice and
Criminology. She has published two books and several articles in the areas of
criminal justice and criminological related issues. She is currently working on
a project involving sentencing disparities among African-American males.
Thomas W. Miller, Ph.D., ABPP is a tenured Professor and Head, School of

Allied Health, University of Connecticut. He spent the last two decades as a
Professor in the Department of Psychiatry, College of Medicine, University of
Kentucky. He is a graduate of the State University of New York at Buffalo, is
a Diplomate of the American Board of Professional Psychology in Clinical
Psychology and is a Fellow of the American Psychological Association, the
American Psychology Society and the Royal Society of Medicine. Dr. Miller
has served as a trainer and consultant to the Governor's Task Force for inter¬
disciplinary clinical treatment of abused persons. He has supervised the psy-
178 Editors and Contributing Authors
chology service of the Domestic Violence Clime, University of Kentucky, and

has conducted research on interdisciplinary treatment of victims of abuse
including the elderly. The American Psychological Association recognized
him with a Special Achievement Award for his contributions to education,
prevention and clinical services to children, adolescents, adults and the elder¬
ly, who are victims of abuse in our society. Dr. Miller was awarded the Master
Teacher Award at the University of Kentucky; College of Medicine and is the
recipient of the prestigious RHR International Award for Excellence in
Consulting Psychology from the American Psychological Association.
Mary C. Newman, Ph.D., is a developmental neuropsychologist specializing

in aging and age-related disorders. She has an appointment as an associate
professor in the Department of Psychology, Missouri State University, and
serves as the Coordinator for the Gerontology Program. Dr. Newman also has
an appointment as Director of the Center for Multidisciplinary Health
Education, Research and Services in the College of Health and Human
Services. Mary C. Newman, Department of Psychology, Southwest Missouri
State University, 901 S. National, Springfield, MO 65804
Dawn Oetjen, Ph.D., Assistant Professor, Director, Graduate HSA Studies,

College of Health and Public Affairs, University of Central Florida, HPA II,
Room 214, Orlando, FL 32816-2200
Reid M. Oetjen, MSHS, Doctoral Candidate, Department of Public Affairs,

University of Central Florida, Orlando, FL 32816-2200
Saundra Regan, Ph.D., is a Research Associate in the Department of Family

Medicine at the University of Cincinnati. She earned a Masters Degree in
Gerontology at Miami University, Oxford, Ohio and a doctorate in Sociology
at the University of Cincinnati, Cincinnati, Ohio. Saundra has 20 years of
experience in geriatric research and teaching. Over the past few years she has
concentrated on elder abuse and domestic violence of older women, physician
home care visits of homebound elderly and increasing patient safety of older
patients at family medicine clinics. Recently she has presented the domestic
violence research work of her colleagues and herself at several national pri¬
mary care, family violence and gerontological meetings and has co-authored
several articles pertaining to domestic violence and older women. Saundra
Regan, Ph.D., Department of Family Medicine, P.O. Box 0582, University of
Cincinnati, Cincinnati, Ohio 45267-0582; regansl@fammed.uc.edu
Paulina X. Ruf, Ph.D., M.D. A., and M.A. is assistant professor of Sociology at
the University of Tampa. She is a graduate of Western Michigan University,
where she also completed a Graduate Certificate in Gerontology. Dr. Ruf stud¬
ies different aspects of aging among ethnic/racial minorities, in particular
their use and non-use of health and social services, family support and care¬
giving patterns, including grandparents raising grandchildren, and the
impact of traditional caregiving roles on women's labor force participation

throughout their life course. In addition. Dr. Ruf's current interests include
the culture of honor and gender-based violence around the world
Helen M. Sorenson, MA, RRT, FAARC, is an Assistant Professor in the

Department of Respiratory Care at The University of Texas Health Science
Center at San Antonio. She has been a respiratory therapist for 27 years, with
experience as a floor therapist, a department manager and for the past 20
years, as an educator. In 2000 Helen received an MA in Social Gerontology
from the University of Nebraska-Omaha. In 2001 she was inducted as a
Fellow in the American Association for Respiratory Care. Helen regularly
gives presentations on geriatric respiratory care topics and has published
numerous articles and book chapters related to geriatric patient assessment/
geriatric care. Helen M. Sorenson, Assistant Professor, Department of
Respiratory Care, University of Texas Health Science Center at San Antonio,
7703 Floyd Curl Drive, MSC 6248, San Antonio, Texas 78229-3900; Phone:
(210) 567-8857; Fax : (210) 567-8852
Dr. Therese Zink, MD, MPH. Board certified in family medicine with a
Masters in Public Health, Dr. Zink is an assistant professor in the Department
of Family and Community Medicine at the University of Minnesota. She has
had foundation and government funding to examine family violence. The
long term goals of her research are to help primary care providers identify and
manage families living with domestic violence. From 1998-2004 she was an
Associate Professor in the Department of Family Medicine at the University
of Cincinnati where she collaborated with her co-authors on papers that
examined the services available to older women living with domestic violence
and the incidence and prevalence of different types of abuse against older
women and their health effects. Therese Zink, M.D., MPH , Department of
Family Medicine, P.O. Box 0582, University of Cincinnati, Cincinnati, Ohio
45267-0582; zinktm@fammed.uc.edu
• LIBRARY
Amazing Help.
http://nihlibrary.nih.gov
10 Center Drive
Bethesda, MD 20892-1150
301-496-1080
Elder abuse and mistreatment in America
is a widespread public health and social
problem that is often under-recognized
and under-reported. This comprehensive
volume addresses the following:
* What is Elder Abuse?

* How extensive is this Public Health issue?
* Who are the victims?
* Who are the perpetrators of these crimes?
* Is it only a U.S.A. crisis or does it affect
other countries/cultures?
* Is the problem more prevalent in the family
home or in caregiver institutions?

* What is our response from a Public Health
perspective?
* What can we do to stop the suffering?
Elder Abuse: A Public Health Perspective

helps foster and create a national dialogue
that focuses on systems and methods
concerning identification of the problem
and prevention.
www.apha.org
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HV

NATIONAL INSTITUTES dp HEALTH

American Public Health Association

© 2006 by the American Public Health Association

Library of Congress Cataloging-in-Publication Data

Georges C. Benjamin, MD, FACP

Publications Board Liaison: Burt Wilcke

Printed and bound in the United States of America

Another significant theme in the volume is the importance of understand¬

HOW PREVALENT IS ELDER ABUSE?

It is difficult to accurately portray the extent of this problem because so

WHAT ARE THE UNDERLYING CAUSES?

or adult child or a non-family caregiver. A number of chapters, in this volume

IS ELDER ABUSE UNIQUE TO PARTICULAR GROUPS IN OUR

HOW CAN WE DEAL WITH THIS PROBLEM?

ELDER ABUSE: DEFINITION AND

DEFINITION OF ELDER ABUSE

Abuse by Guardians and/or Family Members

if the elderly person is actually permitted by his or her caregiver to actually

We see some of these theories operationalized when we examine the

• Neglect: 52.4% female offenders, 47.6% male offenders

• 65 % of offenders are 59 years and younger

It is often thought that abuse occurs at the hands of institutional or non¬

• Adult Children: 47%

Abuse in Nursing Homes and Other Institutions

Employees of nursing homes and other caregiving institutions also engage

Any infliction of anguish, pain, or distress in an elderly person is consid¬

PREVALENCE OF ELDER ABUSE: RATES AND STATISTICS

As more elderly people reside with adult caregivers, a higher possibility

Although mandatory reporting requirements exist in the area of elder

CAUSES/THEORIES OF ELDER ABUSE

The Decision to Care for an Elderly Parent

Adult children and other relatives of elderly persons assume a caregiving

The Decision to Enter an Abuser's Home

The Difficulties in Caring for an Elderly Person

The elderly person's dependency on the caregiver signifies a role reversal

Billingslea v. Texas, 780 S.W.2d 420, 424 (Tex. 1989).

CARE PATHWAY MODEL AND

Health care professionals recognize the importance of standards of care

ASSESSING ELDER ABUSE

The presence of depression in traumatized victims of abuse has been well-

RISK FACTORS IN ELDER ABUSE

Health care professionals recognition of "at risk" factors is crucial. The

Table 1: Victim-Victimizer Spectrum

Isolation from others History or pattern of abuse

Feeling of helplessness Learned violent behavior

Secrecy Low self-esteem

Poor self-confidence Impaired judgment

Low self-esteem Narcissistic

Fear, anxiety, depression Alcohol and/or substance abuser

Impaired ability to judge Control and power seeking

Accomodates to the victimization Perpetuates continued

ulation. Table 1 identified as the victim-victimizer spectrum summarizes risk

In addition to the factors identified in the "victim-victimizer" spectrum,

• An elder partner may be extremely passive, dependent, and/or reluc¬

• Caretakers have inadequate coping skills, particularly, under stress.

There are specific behavioral indicators of abuse frequently seen in spous¬

ACCOMMODATION OF TRAUMA AND ABUSE IN THE ELDERLY

Table 2: Physical and Behavioral Indicators of Elder Abuse