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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2003)

Chapter:10 Elder Mistreatment: Epidemiological Assessment Methodology

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Suggested Citation:"10 Elder Mistreatment: Epidemiological Assessment Methodology." National Research Council. 2003. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, DC: The National Academies Press. doi: 10.17226/10406.
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Suggested Citation:"10 Elder Mistreatment: Epidemiological Assessment Methodology." National Research Council. 2003. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, DC: The National Academies Press. doi: 10.17226/10406.
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Suggested Citation:"10 Elder Mistreatment: Epidemiological Assessment Methodology." National Research Council. 2003. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, DC: The National Academies Press. doi: 10.17226/10406.
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10 Elder Mistreatment: Epidemiological Assessment Methodology Ron Acierno, Ph.D.* E pidemiological data on elder mistreatment can be obtained through (1) agency record review, (2) sentinel reports (trained observers in agencies that serve older adults but do not document abuse in official adult protective service [APS] records), (3) translation of criminal justice statistics using age and perpetrator data fields, (4) caretaker/family member interviews (in person or via telephone), and (5) interviews of eld- erly respondents themselves (in person or via telephone). Each of these assessment formats has been used with older adults, either in isolation or in combination with other methods to generate population estimates of physi- cal, sexual, or emotional abuse, neglect, and financial exploitation. These mistreatment categories are typically divided according to perpetrator iden- tity as either familial/spousal abuse or caretaker abuse. A final category of stranger abuse (i.e., stranger assault: physical, sexual, or emotional) may arguably be included under the heading elder mistreatment (with the caveat that risk factors will probably be different) because (a) psychological and health effects are similar to those caused by abuse by family members; (b) a significant proportion of elder mistreatment, particularly in the area of financial exploitation, is perpetrated by strangers; and (c) failure to assess similarly assaultive behaviors by strangers ignores potential mediating fac- tors that might interact with familial abuse to predict medical health and mental health outcome. *Ron Acierno, Ph.D., is an assistant professor of psychiatry at the National Crime Victims Research and Treatment Center of the Medical University of South Carolina. 261

262 ELDER MISTREATMENT Another assessment issue of considerable importance that has not re- ceived sufficient attention, at least insofar as elder abuse is concerned, is the categorization of elder mistreatment along lines of cognitive impairment. Although the same behavior of physical abuse might be manifest against two individuals, one demented and the other nondemented, by the same class of perpetrator, the optimal method of assessing these two events may vary widely. Research to date has not thoroughly considered cognitive status as the major parameter determining relevance of assessment method- ology. Rather, as mentioned above, assessment of elder mistreatment has been divided into abuse versus assault studies according to perpetrator identity. This is problematic in that researchers attempting to document the extent and rate of elder abuse (irrespective of cognitive status) have adopted methodologies that are better suited for one class or the other of older adults. That is, methods 1, agency record review, and 2, sentinel reports, may be effective in assessing abuse against cognitively impaired elders, whereas they will not be very effective in assessing abuse against nonimpaired elders, who may actually avoid these individuals and agencies. Similarly, method 5, anonymous older adult assessment, is probably pre- ferred when cognitive status is intact but is precluded in instances of demen- tia. Method 4, caretaker assessment, walks the line between these two, in that its effectiveness is not determined by an elder’s cognitive status and may therefore be an appropriate stopgap or supplemental technique (see Pillemer and Finkelhor, 1988). However, this method is less statistically sensitive than respondent interviews (i.e., when cognitive status is intact) and probably should not be relied on exclusively. A distinction based on the mistreated elder’s cognitive status is concep- tually, as well as methodologically, important in that the social context of abuse or assault of nondemented older adults by family members appears to more closely resemble domestic violence, whereas the social context of abuse of cognitively impaired older adults appears to be more akin to child abuse. This is particularly the case when one considers the nature of the relationship between violence perpetrators and recipients (Finkelhor and Pillemer, 1988; Utech and Garrett, 1992;Whittaker, 1996). Thus, violence between two individuals of equal or near-equal societal status, and of equal or near-equal cognitive development, describes both domestic violence and abuse of noncognitively impaired elders (Finkelhor and Pillemer, 1988). By contrast, violence between individuals of varied social status and depen- dency resulting from differences in cognitive functioning or independence (due to either dementia or lack of development) describes both child abuse and abuse of cognitively impaired elders.1 1Additional justification for this conceptual distinction is provided by empirical, sociopolitical, and legal sources. For example, epidemiological data demonstrate that most

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 263 This conceptual distinction becomes even more important when con- sidering that risk factors for violence against older adults probably vary as a function of cognitive status. Hence primary prevention strategies for abuse of cognitively impaired elders will differ from those for abuse of unimpaired elders, just as strategies to prevent child abuse differ from those used to prevent domestic violence. Thus, cognitive status of the respondent is pragmatically important in that it will determine the risk factors and intervention strategies most useful and important for a particular class of individuals. Cognitive status of the respondent is methodologically and conceptually important in that it will largely determine which assessment strategies from the domestic violence field and from the child abuse field, both of which are more developed than those of the elder mistreatment field, may be applied to older adults. The appropriateness of this application will vary in terms of the cognitive status of the respondent in that an assessment strategy that does not rely on victim report (which will be significantly affected by cognitive status) is indicated in cases of abuse of young children and cognitively impaired older adults. The National Elder Abuse Incidence Study methodology, for example, is appropriate in these instances. By contrast, methods involving some degree of self-report will be indicated in instances where cognitive impairment is not severe. These methods are described at length below. elder abuse is in fact spouse abuse, leading Pillemer and Finkelhor (1988) to state: “In the past, elder abuse was described primarily in analogy with child abuse. The present study suggests that elder abuse has much more in common with spouse abuse than child abuse” (p. 55). Utech and Garrett (1992) go even further, writing, “ . . . such parallels with child abuse have had an unfortunate impact on the study of elder abuse, including a tunnel vision effect, which precludes a comprehensive analysis of the problem” (p. 419). Considering sociopolitical factors, investigators have warned against the dangers of infantilizing the older adult victim, as illustrated by Finkelhor and Pillemer (1988): “much elder abuse does not conform to the child abuse model, and elder abuse victims are not necessarily in a structural relationship to their abusers parallel to that of children. . . . We argue that it may be useful to start examining elder abuse for more parallels with the spouse abuse situation: legally independent adults, living together out of choice for a variety of emotional and material reasons” (see also Whittaker, 1996). Finally, legal support for the conceptualization of mistreatment of non- cognitively impaired elders as spouse abuse, rather than child abuse, is provided by the fact that a debate is currently underway regarding mandatory reporting of mistreatment of unim- paired elders (the same debate is underway across the nation with respect to domestic vio- lence), whereas no such debate exists with respect to mandatory reporting mistreatment of cognitively impaired elders (see Daniels, Baumhover, and Clark-Daniels, 1989; Gordon and Tomita, 1990; Macolini, 1995).

264 ELDER MISTREATMENT ISSUES RELEVANT TO ASSESSMENT OF VIOLENCE AGAINST OLDER ADULTS There are two major points to consider when interviewing older adults, relative to younger adults. First, older adults are frequently more reluctant to disclose psychological and interpersonal problems of the past or present. Second, their verbal reports are more affected by physical factors (e.g., fatigue, hearing difficulty) (Ouslander, 1984; Patterson and Dupree, 1994). With respect to the first point, older adults may actually be less likely to disclose abuse than are their abusers (see Homer and Gilleard, 1990, Pillemer and Finkelhor, 1988). Older adults who have been abused or assaulted by family members may be unlikely to report these events for a variety of reasons. Among hypothesized explanations that require further study is the supposition that older adults feel responsible, at least in part, for their children’s abusive behavior because they “taught them to be that way.” That is, they blame their own parenting style for their adult child’s behavior. Another hypothesized explanation is that older adults may also feel extremely embarrassed that their offspring or spouses are abusing them and that they are powerless to stop the abuse. They may be very motivated to hide this powerlessness, both out of pride, and in order to deny any physical or cognitive declines associated with aging. Older and younger adults also report that simply being stigmatized or labeled as a victim is aversive, particularly in instances of sexual assault (Kilpatrick et al., 1992). As with younger victims of domestic violence, abused older adults may fear retribution or more intense assaultiveness from the perpetrator or other abusive parties. Financially or physically dependent older adults also face the very real fear that if the perpetrator is arrested or removed from the household following disclosure, they may be institutionalized or lose other freedoms. Indeed, adults of all ages who have never made or experienced a report of abuse probably do not have information about resources or out- comes of reporting abuse and hence may deny any query, considering truth- ful responses as potentially damaging but not potentially helpful. Finally, older adult victims may care deeply for or love the perpetrator and may try to avoid hurting or embarrassing the perpetrator in any way through dis- closure to epidemiological researchers or authorities. Physical health barriers to reporting victimization events include defi- cits in cognitive functioning, hearing loss, increased susceptibility to fa- tigue, inability to remain sitting for extended durations (e.g., due to arthri- tis), and effects of medication on concentration and memory. Other factors to consider when assessing older adults include ageism, interview stress, increased somatic presentations that may mirror psychopathological symp- toms, increased time needed to build trust and rapport, and increased medi- cation use. Ageism refers to “a personal revulsion to, and distaste for, growing old, and a fear of powerlessness, uselessness, and death” (Patterson

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 265 and Dupree, 1994:374). Not only must assessors be trained to avoid ageist thinking or actions, but the assessment instrument itself must not be ageist in tone or content. Focusing on specific behaviors and events during assess- ment (e.g., using very clear, specific descriptions of behavioral events, rather than culturally or generationally defined phrases) appears to be an objective means by which to limit ageism, and, as illustrated below, is an important methodological strategy to increase sensitivity and accuracy of victimiza- tion assessment (Patterson and Dupree, 1994). In addition, it is important to conduct some assessment of cognitive functioning in order to determine the best form of violence assessment, and whether or not assessment of the older adult is even appropriate. Greater susceptibility to fatigue and concentration problems related to disclosure of highly personal content make it advantageous to limit stress during inter- views (Gurland et al., 1978). This is particularly the case when interview disclosures potentially affect the interviewee’s life, or at least such potential impact is perceived (e.g., disclosing abuse, which then might be reported, leading to social service intervention). ASSESSMENT OF ELDER MISTREATMENT: EXISTING METHODS AND MEASURES The following review summarizes specific measures of elder mistreat- ment and their advantages and disadvantages. Measures are categorized in terms of the five forms of elder mistreatment assessment methodology out- lined above. In general, factors such as feasibility, sensitivity, reliability, validity, and cost guide overall conclusions and recommendations for each strategy and measure. Agency Record Review Agency records provide a readily available source of information re- garding investigated and substantiated cases of elder abuse, neglect, and exploitation. These data are not collected for the purpose of epidemiologi- cal or preventive research, however, and the specific information is not always exactly what a particular researcher desires. Moreover, the criteria by which cases are designated substantiated or not and the definitions for particular forms of elder mistreatment vary widely across social service agency, county, and state. The National Center on Elder Abuse (Tatara, 1997) collects and com- piles into reports nationwide data from those social service agencies charged with protecting the health and welfare of older adults. Thus, these reports describe actual investigated and indicated cases of abuse and neglect in which family members were interviewed, households were visited, and in-

266 ELDER MISTREATMENT spections were conducted. Although the rate of reported cases has been increasing each year, the sensitivity of this method is extremely low because most cases of elder mistreatment are not reported to any social service authorities (Pillemer and Finkelhor [1988] found only 7 percent of cases reported to authorities), and those incidents that are reported must be judged as valid to be considered substantiated. Again, the criteria by which a report is considered founded vary widely by center, as do the definitions of abuse. Ultimately, it is the judgment of individual caseworkers that determines whether or not a mistreatment event has occurred. A notable strength of agency record review studies such as that con- ducted by the National Center on Elder Abuse is the highly detailed nature of the data regarding the abuse event. Specifically, the context of elder mistreatment, the perpetrator characteristics, demographic variables, and social structures are usually specified and documented somewhere in agency records. Moreover, there is a relatively strong level of confidence that indicated cases did, in fact, occur. Relative to epidemiological surveys that are conducted solely for data collection and analysis (as opposed to service delivery), information from agency records exists independent of research protocols and is therefore relatively inexpensive to transfer to the research realm. By contrast, several significant weaknesses characterize agency record- based investigations. This method requires collecting data from a wide variety of agencies that may use dissimilar definitions of mistreatment. Even more problematic is that individual agencies vary widely in the re- sources directed to investigation of cases, training of caseworkers, and follow-up and substantiation of cases. Thus, even when standard defini- tions and criteria are used, the means by which agencies determine whether an event meets these criteria will differ. As such, sensitivity and reliability of findings will suffer. The utility of this approach for epidemiological researchers is further affected by the quality of agency record maintenance, accessibility to records, accessibility of the agency personnel, and overall quality of record keeping by an agency. Overall, the agency record review methodology is indicated when the population of older adults suffers from cognitive impairment and cannot otherwise be interviewed. However, this method is less sensitive than in other methods applicable to cognitively impaired populations and should probably be used only to guide initial efforts insofar as gross approxima- tions of elder mistreatment are needed. Sentinel Reports The National Elder Abuse Incidence Study (NEAIS) sponsored by the Administration for Children and Families and the Administration on Aging

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 267 expanded its data sources from APS reports to include trained sentinel reports of substantiated or presumed substantiated cases. The NEAIS- targeted people living in their own homes, age 60 and above. This was an incidence study (new cases during a set time frame), not a prevalence study. Importantly, this study did not interview older adults themselves. Sentinels were professionals who served older adults and were randomly selected from more than 200 agencies. Sentinels were trained to complete data entry forms identical to those used by APS workers for elder abuse. The logic of the sentinel approach is based on the supposition that sentinels enhance sensitivity by detecting those older adult victims of abuse who are nonreporters or are not involved with APS but who nonetheless interact in some way with community-based service agencies. NEAIS data were gath- ered on domestic (i.e., noninstitutionalized) elder abuse and neglect cases from a nationally representative sample of 20 counties in 15 states. Reports from APS agencies were considered only when substantiated and reports from sentinels were presumed to be substantiated. The methodology of combining agency record reviews with sentinel reports to detect mistreatment has previously demonstrated success in three studies of child abuse. Moreover, the method is cost-effective, and identi- fied cases are very likely true positives. Multiple data sources are consulted, and these typically have a very thorough familiarity with cases. Finally, multiple forms of mistreatment are identifiable. Weaknesses of this method include the fact that no direct assessment is made of the population in question. Thus, it is very likely that mistreat- ment rates derived from this study greatly underestimate the true scope of the problem of elder victimization because a great majority of cases go both unreported and undetected by existing formal and informal monitoring agents. Although this approach has been used three times with child abuse, there are several problems with this method when applied to elder abuse. First, and perhaps most relevant, is the fact that child abuse reporting statutes and subsequent education of an extremely wide range of service providers (e.g., schoolteachers, doctors, nurses, counselors, day-care work- ers, etc.) regarding these statutes is formally established and mature. That is, awareness of the problem of child abuse is far greater among the general and professional public, and thus sentinels in the child arena will be more familiar with the problem and its symptoms. Moreover, child abuse man- datory reporting and provisions for anonymous voluntary reporting have been in place nationwide and have been accompanied by national educa- tion campaigns. As such, it is likely that child protective services receive a significantly larger proportion of existing cases than APS. Indeed, manda- tory reporting of elder abuse is not consistent across the nation and is still actively debated. National education campaigns for the general public and for health and social service providers on child abuse also increase the

268 ELDER MISTREATMENT likelihood that noncompelled reporters will approach sentinels for child abuse, relative to elder abuse. Thus, sentinels for child abuse have access to greater conduits of information than their older adult counterparts. Overall, the unresolved issue of mandatory reporting of elder abuse, the relative infancy of elder abuse public education, and the limited con- duits of information on elder abuse cases flowing to potential sentinels may severely limit the application of this form of child abuse assessment to elder mistreatment in that the method may lack sensitivity. This lack of sensitiv- ity will be particularly problematic for the population of non-cognitively impaired, relatively independent mistreated older adults who wish to avoid formal service agency involvement in their abuse situations. Criminal Justice System Statistics Translation There are several sources of victim statistics describing rates of violent crime in this country (e.g., National Crime Victimization Survey [NCVS], Federal Bureau of Investigation [FBI] Uniform Crime Reports [UCR], FBI National Incident Based Reporting System [NIBRS]). Official police or government estimates of assaultive violence are typically lower than those obtained by social scientists conducting epidemiological research. These differences are largely attributable to methodological variance across sur- veys (e.g., use of gateway versus behaviorally specific preliminary screening questions, or aggregation of official police reports versus population sur- veys, see discussion of this below). This variance is informative: failure to use direct, behavioral questions leads to failed case identification. The FBI’s UCR is a frequently cited index of violent crime that has been reported to police. The UCR is a case-based report, in which the worst FBI index crime (murder, rape, robbery, aggravated assault, burglary, larceny, motor vehicle theft, arson) reported by an individual is the only one that is recorded for that individual. However, since many crimes are not reported to police, and because many individuals are multiply victimized, UCR re- sults are somewhat misleading. The Bureau of Justice Statistics overcomes this weakness in its annual NCVS of approximately 80,000 to 100,000 adults aged 12 years and older from approximately 45,000 households. Randomly contacted U.S. citizens are asked about both reported and unreported victimization experiences. In 1992, older adults (age 65 years and older) comprised 14 percent of survey respondents (Bachman, 1992). According to the NCVS, adults over age 50 were the least likely to be physically or sexually assaulted, with an annual violent crime rate of 12.5 per 1,000. However, once assaulted, older adults were more than twice as likely to be seriously injured and require

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 269 hospitalization following crime. Fully half of older injured victims, com- pared to about 25 percent of younger injured victims, required hospitaliza- tion. Moreover, elderly victims were more likely than younger victims to be assaulted or robbed by a stranger and were more likely to be victimized in or around their home. Half of elderly victims, compared to 26 percent of those under 65, experienced violence in or around their homes and were more likely than younger adults to face offenders armed with a gun (Bachman, 1992). Elderly men were at greater risk of violent crime than elderly women. Low income, minority racial status, and geography also contributed to increased risk of assault (Bachman, 1992). For example, African American older adults were victimized at twice the rate of Cauca- sian elderly, and older adults living in urban settings were three times as likely to experience crime. McCabe and Gregory (1998) used the FBI’s NIBRS to assess crime against the elderly. This system differs from the UCR in that each incident, not only the worst incident, of crime is recorded. Moreover, like the NCVS, the NIBRS includes information on the perpetrator’s relationship to the victim, permitting assessment of abuse versus assault rates. The NIBRS also includes demographic and gender information, providing some ability to conduct risk-factor research. Finally, the NIBRS differs from the UCR in that additional, nonindex crimes are also covered. Unfortunately, only crime reported to police is included in these records. An advantage of using criminal justice system (CJS) statistics is its nationwide data collection frame. That is, many CJS studies are actual population derivations, not sample estimates. In addition, information on reported (to police) crime includes data regarding gender, race, and perpe- trator status. Moreover, older adults are more likely to report some forms of crime to police than younger adults, increasing the relative validity of published rates of reported crime. However, crimes of abuse and neglect are less likely to be reported, mitigating this advantage somewhat. In contrast to these strengths, CJS data generally have very poor sensi- tivity (excepting the NCVS). Furthermore, CJS data collection requires criminal justice system interaction for case identification (excepting NCVS), an activity that may be specifically avoided by older adults. Another weak- ness is that UCR and NIBRS data are entirely record-based and are re- moved from direct reports of victims. As a result, they are affected by subjective interpretations by police officers of (1) whether an event actually occurred and (2) classification of the event by police departments across the country. Overall, these forms of assessment methodology represent pre- liminary, as opposed to comprehensive, epidemiological data regarding elder mistreatment.

270 ELDER MISTREATMENT Caretaker/Family Member Assessment Caretakers do, in fact, report their abusive behaviors. Coyne et al. (1993) reported that 12 percent of caregivers calling a dementia care hot line indicated that they had abused the individual under their care. Homer and Gilleard (1990) studied respite care patients and caregivers in England and found that 45 percent of caregivers admitted either verbal (41 percent) or physical (14 percent) abuse. Interestingly, frequency of patient reports of abuse was less than that of caregivers. Similarly, Pillemer and Suitor (1992) interviewed family members of dementia patients and found that 6 percent reported violence. Pillemer and Finkelhor (1988) interviewed prox- ies when older adults were unable to participate as respondents and found higher rates of abuse than in victim reports (although this group of proxies arguably represented elders at increased risk, and higher levels should be expected). These studies, and studies cited below, demonstrate that caregiver assessment may be an acceptable, albeit unidimensional, method of detecting elder abuse in the subset of abusers willing to disclose these behaviors. Sensitivity can be expected to be increased if provisions for anonymity are enhanced. When using caregivers as the data source, researchers have either as- sessed abusive behaviors directly through interviews or screens, or assessed risk factors associated with perpetrating elder mistreatment. Risk factors include alcoholism, social isolation, psychopathology, low socioeconomic status, overdependence on the older adult, and inexperience or reluctance to provide care (Reis and Nahmiash, 1998). In addition, caregiver risk- factor assessment can be augmented by studying care-receiver risk factors, such as being older, female, isolated, aggressive, or provocative. Reis and Nahmiash (1998) developed the 29-item (from an original 48 items) Indicators of Abuse (IOA) screen based on previous risk factor re- search (Kosberg, 1988) with both caregivers and receivers. Although this is a screen, it requires prior in-depth knowledge of caregiver and care-receiver characteristics obtained through interview. The items were selected based on their discriminant ability to detect elder mistreatment derived as part of the major health and social services assessment offered in a North Ameri- can city. Using the 29 items of the IOA that discriminated abuse from nonabuse, sensitivity was about 85 percent and specificity was 99 percent. Approximately 70 cases were reexamined by a panel to assure criterion accuracy. Using these criterion references, 28 of the original 29 items (caregiver age was dropped) achieved a sensitivity of 78.4 percent and a specificity of 100 percent. Factor analyses failed to identify separate the- matic problem areas. Notably, items such as needing help with activities of daily life or cognitive or physical impairment did not contribute to discrimi- nant ability. The overall findings indicate that caregiver rather than care

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 271 receiver risk factors were most important in predicting abuse and neglect. Using a cutoff of 16, about 22 percent of cases were missed (compared to 36 percent of cases missed by the Hwalek-Sengstock Elder Abuse Screening Test, see below, which is completed by seniors, not interviewers). A no- table strength of this tool is that it assesses multiple forms of abuse and assesses both caregiver and care-receiver. Weaknesses include a high false negative rate, limited applicability of the scale to assess domestic violence in elder marital relationships (the Conflict Tactics Scale is useful for this, see below), and the requirement of in depth knowledge of both caregiver and care receiver. While risk factor assessment is most certainly a clinically valid tool for social service workers, its usefulness in epidemiological studies, particularly in initial investigations, is limited. This is because epidemiological studies are often conducted with the aim, at least in part, of identifying risk factors. Thus, using risk factors to select perpetrators in order to identify additional risk factors is a tautological methodology, and should be avoided in epide- miological efforts. The Caregiver Abuse Screen (CAS) (Reis and Nahmiash, 1995) is com- pleted by caregivers, not interviewers, as was the case with the IOA. The CAS is very short, only eight items, which somewhat superficially assess forms of abuse and neglect. That is, direct questions regarding mistreat- ment behaviors are avoided. The authors state that wording is based on “control theory” in which a perpetrator’s sense of external locus of control predicts abuse (Bendik, 1992). Conceptualization is also based on neutral- ization theory, in which abuse is seen as justified and rationalized by the abuser (Tomita, 1990). The CAS is specifically worded so as to be non- blaming. The instrument was validated on 44 abusive caregivers and 45 nonabusive caregivers (the abusive caregivers and 45 controls were receiv- ing services from a social services center). Designation as an abuser was made on the basis of a thorough interview. Results indicated that overall scores of abusers were significantly higher on the CAS (mean = 3.2) than nonabusers (mean = 1.9). CAS scores were positively correlated (0.41) with IOA scores. Unfortunately, no discriminant analyses were conducted, and classification accuracy and optimal cutoff scores for detecting abuse and neglect were not available (rather, only the mean scores of each group were reported as significantly different; note, however, that scores differed by only about one point). Weakness of this measure in terms of its applicabil- ity to epidemiological efforts mirrors those of the IOA. Specifically, it is clinically relevant but lacks detailed descriptions of mistreatment events, as well as comprehensive psychometric validation. The health, attitudes toward aging, living arrangements, and finances (HALF) is presented by Ferguson and Beck (1983) with no psychometric data. This is a clinician-based tool to identify elders at risk in a health

272 ELDER MISTREATMENT service setting. Questions are answered by the interviewer following a meeting with both the caretaker and older adult. Items are categorized in terms of the scale’s name on a three-point Likert scale from “almost al- ways” to “never.” The instrument is based on previous risk factor research and probably covers relevant areas of assessment for elder mistreatment. However, items in each section often bear no resemblance to the section heading (e.g., under “health” and regarding “caregiver” comes the item “limited capacity to express own needs,” or “poor self-image”). Neither factor analysis nor discriminant analysis were conducted to validate con- structs measured by item groups or to identify sensitivity or specificity. Many items (e.g., “negative attitudes toward aging”) are extremely vague and open to cultural speculation or subjectivity. Other items are clearly physician-relevant (e.g., “shows evidence of dehydration or malnutrition”). Although the screen generally addresses areas of mistreatment, including physical abuse, neglect, and exploitation, no area is specifically assessed. Moreover, the screen is clinically oriented and requires interviews of both caregivers and care receivers. The lack of psychometric validation com- bined with the vagueness of questions and the need for medical expertise renders this screen of little use in epidemiological efforts. However, its use in medical settings is probably justified. Fulmer and Cahill (1984) developed the Elder Assessment Protocol, a tool for critical care nurses. The measure is relatively unstructured and intended for use in clinical settings. A checklist of physical symptoms that could be the result of abuse forms the core of the mistreatment assessment protocol. However, these symptoms could have other origins. For ex- ample, physical abuse is measured by the item, “physical abuse: present or absent, suspect high risk.” In effect, this protocol is a reminder checklist for clinicians but does not directly apply victimization assessment techniques (discussed below) to enhance sensitivity. No psychometric data are pro- vided. Fulmer also developed the Elder Assessment Instrument (EAI) a 35- item screen that includes subjective and objective items regarding mistreat- ment (Fulmer and O’Malley, 1987; Fulmer and Cahill, 1984). This screen is designed to identify individuals at high risk of mistreatment who should be referred for further assessment. There is no scoring system, and the tool is designed for clinical rather than epidemiological use. Overall, several indices and interviews exist and have been used suc- cessfully with caregivers to measure elder mistreatment. Caregivers can be asked directly about their abusive or neglectful behaviors, or they can be assessed in terms of risk factors. However, risk factor assessment is more appropriate in clinical than in epidemiological settings. Caregiver assess- ment can be used in cases where older adults suffer from cognitive deficits and to augment direct assessment of care receivers. Caretaker assessment

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 273 appears to be the most sensitive method of detecting elder mistreatment in instances where older adults live with family members and suffer from significant cognitive impairment. Indeed, when older adults cannot serve as reliable historians or reporters of mistreatment, family caretaker assess- ment maybe the only available alternative. However, when cognitively impaired older adults reside in care facilities, the usefulness of caretaker assessment is less well established. This is because there are multiple care- taking staff for any single individual, the turnover rate of these staff is extremely high, precluding accurate long-term (i.e., multiyear retrospective) assessment, and the consequence of disclosure of abusive behavior is more immediately apparent (e.g., immediate suspension or termination). Assessment of Older Adults Epidemiological investigations with young adults and adolescents sup- port direct interviewing of potential victim populations to determine the extent and character of mistreatment. It is logical to conclude that, for cognitively unimpaired older adults, direct assessment will also be useful. The following measures have been used with older adults. An additional interview methodology is proposed later. The Hwalek-Sengstock Elder Abuse Screening Test (HSEAST) is a pa- per-and-pencil index of elder mistreatment with some psychometric evalu- ation. Neale et al. (1991) validated the 15-item screen and found that 9 of these items identified abused or exploited individuals. Items are scored yes or no, and a score of 3.5 or higher is indicative of abuse. Three domains of elder abuse are assessed: overt symptoms, victim risk characteristics, and victim symptom characteristics (the authors categorize these as violation of personal rights or direct abuse, characteristics of vulnerability, and poten- tially abusive situation). The test has some psychometric support of its construct, concurrent, and discriminant validity. The authors compared responses from 170 older adults who were agency referred with founded abuse cases with agency-referred nonfounded cases (n = 47) and a non-APS agency comparison group of elderly women (n = 47). Significantly higher scores were noted for the abused group, and item-level analysis indicated that nine items provided the basis for this difference. Discriminant function analyses of the nine relevant items revealed correct classification 74 percent of the time, with false negatives (35.7 percent) more likely than false posi- tives (9.3 percent). Advantages of the HSEAST include its preliminary psychometric vali- dation, along with the fact that it is based on factor analysis of a large item pool. The test is able to assess risk factors along victim and situation lines and can facilitate direction or allocation of additional resources or assess- ment measures when risk is present. Although it assesses aspects of physi-

274 ELDER MISTREATMENT cal abuse, exploitation, and neglect, no specific assessment of any type of mistreatment is made. One replication study of 100 elders in public hous- ing (Moody et al., 2000) was recently completed to measure discriminant ability of the test again. Factor analysis indicated some differences in loadings from the original study; however, discriminant analyses indicated that the test again classified correctly about 70 percent of respondents as abused or not abused. False positives (17 percent) were more likely in this study than false negatives (12 percent). The HSEAST suffers from some specific deficits. Several items are extremely vague and lack behavioral specificity when describing events. That is, actual events cannot be determined from this screen, as they can from the Conflict Tactics Scale. However, this screen is designed to be followed by a more in-depth interview when indicated by higher scores. Some items are not directly related to abuse (e.g., a response of “someone else” to the question, “who makes decisions about your life?” or the ques- tion, “Do you feel that nobody wants you around?”). Some questions measure potentially abusive situations instead of actual events (e.g., “Can you take your own medication and get around by yourself?” “Are you helping to support someone?”). As a screen, the typical preference is that false-positive rates exceed false-negative rates, and the opposite was ob- served here. Moreover, there is limited replication of discriminant ability at this point. Overall, this tool may be useful more clinically than epidemio- logically. According to the NEAIS, two-thirds of elder mistreatment cases in- volved spouses or children. Similarly, Pillemer and Finkelhor (1988) found that 65 percent of elder abuse cases involved spouses as perpetrators. For this reason, and for the conceptual similarities between domestic violence and mistreatment of non-cognitively impaired elders, inclusion of domestic violence assessment methods when measuring elder mistreatment is justi- fied. The Conflict Tactics Scale (CTS) (Straus, 1979) and the Revised Con- flict Tactics Scale (CTS2) are well known, studied, and used indexes of relationship violence. The CTS2 (Straus et al., 1996), originally developed by Straus (1979), is a widely used (over 70,000 empirical studies have used it) and thoroughly evaluated (approximately 400 papers) measure of inter- personal violence for married or cohabiting partners; it has been modified for use with caregivers to the elderly (Pillemer and Finkelhor, 1988). Note that it is not a measure of attitudes toward violence, but rather a measure of conflict-resolution events that involve violence. The scale also measures psychological abusiveness and the use of negotiation and reasoning by either party to reduce conflict. Although the CTS has undergone numerous revisions in the past 15 years, its basic structure has remained the same. The most recent version contains several scales: reasoning/negotiation (6

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 275 items), psychological aggression (8 items), physical assault (12 items), sexual coercion (7 items), and consequence (physical injury) (6 items). The 39 items are rated on an 8-point frequency scale (never, once, twice, 3 to 5 times, 6 to 10 times, 11 to 20 times, and more than 20 times, not in the past year but it did happen before). Interpersonal problem-resolution behaviors range from benign (e.g., “When you had a dispute has spouse discussed the issue calmly?”) to dangerous (e.g., “Has your spouse threatened you with a knife or gun?”). Each question is asked in terms of both respondent’s and partner’s behavior. Reliability ranges from 0.79 to 0.95, and initial evi- dence of construct validity has been obtained (reliability and validity of the scale are well established, and early factor analysis revealed constructs representing (1) verbal reasoning, (2) psychological abuse/aggression, (3) physical aggression, and (4) life-threatening violence. The CTS allows different types (physical and sexual) and intensities of violence to be docu- mented and collects data on specific behavioral aspects of violent events. It can be used in both clinical and epidemiological settings. Weaknesses of the CTS include a potential overfocus on physical and sexual violence incident identification in that the CTS does not assess financial exploitation or neglect. Using a modified version of the CTS (in addition to other queries) Pillemer and Finkelhor (1988) directly studied over 2,000 randomly se- lected older adults in the Boston metropolitan area. A two-stage interview was used in which a 30-minute screening interview (conducted either via telephone or in person) was followed by a more thorough interview to assess the context and specific aspects of abuse. The decision to use tele- phone or in person interviews was made on the basis of respondent avail- ability, ability, and preference to use the telephone (telephone was the default method). An oversample of older adults living with others (a major abuse risk factor) was studied to increase likelihood of interviewing abuse victims. Proxy interviews were also conducted in instances where older adults were incapable of being interviewed. Modified CTS questions were used to assess physical abuse. Modified Older Americans Resources and Services questions were used to assess neglect. Precise wording of assess- ment questions was not provided in the report. The strengths of this modified elder mistreatment assessment method- ology included combining the CTS with a prescreen to limit assessment time. In addition, multiple assessment formats were used, including tele- phone, in-person, and proxy interviews. Weaknesses were few. Most no- tably, event-based interviews cannot study neglect and abuse of demented individuals, and of course caregivers or proxies must be assessed in these instances, but this weakness is not inherent in this assessment method, per se. Several other measures have been used to study elder abuse, ranging

276 ELDER MISTREATMENT from simple questions regarding mistreatment behaviors to clinical inter- view protocols. Some of these measures provide little or no psychometric validation or actual specification of items. Others measure constructs re- lated to elder mistreatment, but not mistreatment per se. They are men- tioned here in the interest of achieving comprehensiveness. The modified Elder Abuse Attitudes and Behavior Intention Scale-re- vised (Childs et al., 2000) assesses attitudes toward abuse, intentions to abuse, and actual behaviors of abuse in caregivers. Although this scale measures both attitudes and intentions (e.g., potential risk factors) as well as behaviors, it is not specifically designed to measure prevalence or inci- dence of abuse. Childs and colleagues report some indication that perpetra- tors tend to “fake good.” Coyne and colleagues (1993) sent anonymous questionnaires to 1,000 caregivers who called a dementia hot line. Three hundred forty-two com- pleted and returned questionnaires, which contained 30 items assessing caregiver characteristics, demented senior characteristics, and specific abu- sive behaviors. Functioning was also assessed. The manner and type of abusive behaviors for which data were collected were not specified further than “punching, shoving, biting, kicking, and striking.” This measure was inexpensive, and confidence in reports of abuse is high. However, confi- dence in nonreports is low. Moreover, no psychometric data were available on reliability or validity. No assessment of financial exploitation, neglect, or psychological abuse was indicated in the article, and a low response rate to the mailed questionnaire mitigated results. Cooney and Mortimer (1995) also sent anonymous postal question- naires to 200 British caretakers who participated with a dementia support organization. Questions followed the format of Pillemer and Finkelhor (1988), thus apparently some form of the CTS was used for physical abuse, although the report gave no specifics. Physical abuse, verbal abuse, threats and verbal aggression, and neglect were measured. Data were collected on caregivers (substance use, psychiatric history, length of care) and victims (physical dependency, behavioral disturbance). The response rate was 33.5 percent. Strengths included assessment of multiple forms of abuse and seemingly high sensitivity, with 55 percent of respondents reporting some abuse. However, low response rate to survey must be considered. Finally, Sengstock and Hwalek (1986) reviewed items (not the mea- sures as complete indices) from seven assessment indices from the early 1980s. Most of the items on these scales assessed risk rather than incidents of elder mistreatment (57.6 percent of all items). Sixteen percent measured neglect and 14.3 percent measured physical abuse. Sexual abuse, emotional abuse, and exploitation were largely omitted. The measures from which items were collected consisted of two social service intake-screening sheets (South Carolina, Ohio), an index from a conference paper presentation

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 277 (Hooyman, 1982; Tomita, 1982), an unpublished index from the Univer- sity of Massachusetts Medical Center, and three published manuscripts (Block and Sinnott, 1979; Johnson, 1981). The review authors described these measures as largely driven by caseworker familiarity with the older adult’s case and indicated that “such depth of information may require many months to develop.” Moreover, these measures were described as depending “a great deal upon the judgment of the service provider” and may be overly subjective, producing results of questionable validity. A final group of purely clinical assessment protocols includes the Screen- ing Protocol for Identification of Abuse and Neglect of the Elderly (Johnson, 1981), the Elder Abuse Detection Indicators (Bloom et al., 1989), Tomita’s (1982) Detection and Treatment of Elderly Abuse and Neglect: Protocol for Health Care Professionals, and the Community Based Education Model for Identification and Prevention of Elder Abuse (Weiner, 1991). Although clinically useful, these tools have little or no psychometric validation, gener- ally use little behavioral description (see “Issues Pertaining to Assessment of Victimization,” below) when posing queries about mistreatment, and are inappropriate for epidemiological efforts. They may also lack sensitivity in clinical realms due to the method and context within which questions are vaguely asked. Examples come from Johnson (1981): “8. Can patient relate instances of: being shaken, shoved?” and from Tomita (1982): “Ask patient if he/she experiences: (a) being shoved, shaken, or hit.” These questions, while seemingly relevant, lack specificity and do not employ contextually orienting preface statements or behaviorally specific descrip- tions about queried events. Research with younger adults indicates that these two characteristics are essential for violence assessment, and further definition and discussion of these aspects is provided in the following sec- tion. As such, these protocols represent guidelines, rather than specific assessment manuals or strategies. ISSUES PERTAINING TO ASSESSMENT OF VICTIMIZATION: WHAT WE’VE LEARNED FROM RESEARCH ON VIOLENCE AGAINST CHILDREN AND YOUNG ADULTS The following discussion involves techniques used with cognitively in- tact adolescents and young adults to determine violence prevalence and characteristics. These methods are not appropriate for use with cognitively impaired or demented older adults. For these individuals, the NEAIS meth- odology in which APS reports and sentinel reports are used to estimate the rate of abuse, combined with caretaker interviews, are indicated to assess the multiple forms of elder mistreatment (see below).

278 ELDER MISTREATMENT The research on violence against young adults and children, particu- larly that research involving direct assessment of victims (as opposed to agency/sentinel report sources of data) is more advanced than that on older adults. From this research it is evident that prevalence estimates for crimi- nal victimization, including sexual assault, physical assault, and domestic violence may vary widely according to parameters of assessment methodol- ogy, including assessment context, assessment structure, assessor character- istics, and trauma definition (Breslau et al., 1991; Hanson et al., 1995; Kilpatrick et al., 1989; Koss et al., 1993; Resnick et al., 1993, 1996). For example, in interview studies, contextual cues may prime participants to respond in a particular manner. That is, assessment by medical doctors conducted in a primary care facility may be less likely to detect victimiza- tion than assessment by criminal justice system epidemiologists conducting crime surveys because respondents in the former situation are primed to answer questions about their health, whereas respondents in the latter situ- ation are expecting to answer questions about victimization. Moreover, definitions of assault vary among respondents (Koss et al., 1993). For example, asking, “Have you ever been raped?” may mean different things to different people (e.g., “It’s not rape if my husband does it.”). Such culturally, generationally, or ethnically charged questions, if not restruc- tured, will produce inaccurate estimates of violence prevalence. In addition to definitional and contextual problems, violent crime, par- ticularly that type of crime associated with interpersonal, psychological, or cultural stigma (e.g., elder abuse), is not readily reported by all victims, particularly older adults. Indeed, victims of assault do not openly identify themselves as such. For example, only 2 percent of sexually abused young adult women discuss their victimization history with their doctor (Spring and Friedrich, 1992). Therefore, victim self-identification to strangers con- ducting epidemiological surveys cannot be taken for granted. In fact, in order to report to an investigator that a particular type of mistreatment or crime has occurred, a victim must (1) recall the assault, (2) label the assault as such, (3) be queried by an investigator who is using a matching label/ definition, (4) be willing and psychologically able to disclose the assault, and (5) not feel that safety is jeopardized (e.g., when the perpetrator lives with the respondent and might be listening to the interview). While straight- forward, these factors must not be overlooked. For example, many respon- dents do not label aggravated assault as such when the perpetrator is a relative or spouse, or when there was only limited force or threat of force used, or when the psychological effects of such a label are too distressing. Furthermore, many victims are very reluctant to disclose their victimization experiences. Reasons for willful nondisclosure include: (1) fear of retribu- tion by an assailant, particularly if the assailant is known or proximate to victim; (2) fear of stigma attached to being a victim of a particular type of

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 279 crime (e.g., rape, domestic violence); (3) fear of being blamed; (4) history of negative outcomes following previous disclosure (e.g., placement in a nurs- ing home, court involvement leading to acquittal); (5) lack of encourage- ment to discuss victimization; and (6) fear of psychological consequences of disclosure (e.g., depression, anxiety on revisiting the event) (Kilpatrick, 1983; Koss et al., 1993; Resnick et al., 1996). It should be obvious that investigators conducting prevalence studies must not assume that all victim- ization events will be specifically and easily reported. Unfortunately, this stipulation has not always been met (e.g., FBI Uniform Crime Reports, 1991; Bachman, 1992; Helzer et al., 1987). Given that the above factors will combine to reduce the likelihood that a crime event will be reported, what procedural modifications have been used with young adults and children to maximize sensitivity? Two compo- nents appear crucial: (1) contextually orienting, empathetic preface state- ments and (2) extremely specific behavioral descriptions of index events that elicit closed-ended responses. Because traumatic events such as violent crime are associated with extremely aversive emotional and cognitive states, it is important, both to respondent welfare and to experimental integrity, to preface criminal victimization queries in such a way as to convey accep- tance, empathy, normalization, and encouragement. Obviously, victims will disclose extremely personal and frequently humiliating information only when they feel that such disclosure is worthwhile and relevant. Of equal import, preface statements must also provide contextual orientation so that the likelihood of reporting that information sought by the investiga- tor is maximized. For example, if questions regarding elder abuse follow a crime survey in which reported crimes are investigated, and no preface statement is used to specifically direct respondents to disclose all assaults, including those not reported to authorities, then respondents might be biased toward disclosing only those events that have been reported to police (Koss et al., 1993). Similarly, if questions regarding assault follow a psy- chopathology survey, then respondents might be biased toward disclosing only those assaults that are of a relatively bizarre nature (Koss et al., 1993). Epidemiological researchers studying violence against younger adults and children are typically interested in all experienced events. Thus, it must be made clear to the respondent that the individual collecting these data is interested in any assault perpetrated by any individual, at any time in their lives (e.g., assaults by family members years ago, as opposed to just assaults by strangers in the recent past). The National Women’s Study (Kilpatrick et al., 1992) and the National Survey of Adolescents (Kilpatrick et al., 2000), both population-based violence assessment projects, employed con- textually orienting preface statements similar to the one below. Note that after normalizing the experience somewhat, respondents are oriented to

280 ELDER MISTREATMENT disclose all assaults (reported to authorities or not), by all perpetrators (including family members), occurring at any time (even distant past events). Another type of stressful event that many people have experi- enced is unwanted sexual advances. These experiences are not always reported to the police or other authorities or even discussed with family or friends. The person making the advances isn’t always a stranger, but can be a friend, boyfriend, or even a family member. Such experiences can occur anytime in a person’s life—even as a child. Regardless of how long ago it happened or who made the advances. In successful studies of violence against younger populations, contextu- ally orienting preface statements are followed by detailed, behaviorally specific, closed-ended descriptions of trauma events under investigation. Early CJS surveys of violence employed gateway screening questions char- acterized by very limited behavioral specificity (e.g., “Have you ever been physically abused?”). If respondents endorsed the gateway question, fur- ther questions about assault followed. Gateway questions shorten the overall interview process for those respondents not endorsing the gateway item. Unfortunately, gateway questions without preface statements lack specificity and do not adequately orient respondents to the type of re- sponses the assessor is seeking (i.e., they fail to state that one is interested in all abuse/assaults, not just those reported to police or perpetrated by strang- ers). Most problematic, however, is that gateway questions are extremely subject to an individual’s interpretation of queries (i.e., definitional vari- ance) (Koss et al., 1993), and a respondent’s own victimization history will affect his or her personal definitions of elder abuse (Childs et al., 2000). Behaviorally specific, closed-ended (i.e., yes/no) questions are an alternative to gateway questions. Behaviorally specific descriptions of assault events minimize variance associated with cultural differences, personal differences in intellect, psychological stability, general willingness to disclose, or under- standing of criminal justice terminology (e.g., rape, aggravated assault). These questions should be designed with great detail and require only yes or no answers in response to whether or not a specifically described event was experienced. In addition to removing definitional and cultural variance associated with gateway questions, closed-ended yes or no questions sim- plify the role of the respondent and minimize the risk that anyone will overhear disclosure of highly personal events, particularly during telephone interviews, where at least the queries are unintelligible to others not on the phone. The following are examples of behaviorally specific questions from the National Womens Study. These questions follow directly after the preface statement outlined above and leave very little room for interpreta-

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 281 tion or error in assessment of a particular type of victimization, in this instance, rape. 1. Has a man or boy ever made you have sex by using force or threatening to harm you or someone close to you? Just so there is no mistake, by sex we mean putting a penis in your vagina. 2. Has anyone, male or female, ever made you have oral sex by using force or threat of harm? Just so there is no mistake, by oral sex we mean that a man or a boy put his penis in your mouth or someone, male or female, penetrated your vagina or anus with their mouth or tongue. 3. Has anyone ever made you have anal sex by using force or threat of harm? Just so there is no mistake, by anal sex we mean that a man or boy put his penis in your anus. 4. Has anyone, male or female, ever put fingers or objects in your vagina or anus against your will by using force or threats? (Kilpatrick et al., 1992) Note that each of the above questions is entirely event-based. That is, priority is given to establishing that mistreatment has or has not occurred. Follow-up questions are asked only in instances where affirmative responses to violence type queries have been given. Thus, secondary questions about the event context and perpetrator status are skipped out when the respon- dent says “no” to a query. Importantly, computerized protocols can be programmed with complex skip-out patterns resulting in dramatically short- ened interview times for those respondents who do not endorse victimiza- tion events. For those who indicate that a specific form of violence has occurred, additional questions regarding relationship to the perpetrator, whether or not the event was one in a series, the first and most recent times the event occurred, etc., can be asked. Combining highly specific behavior- based questions with computer-assisted skip out patterns achieves the same brevity of interviews found in gateway surveys, without a loss in sensitivity. Most importantly, this method allows assessment of both abuse by family or caretakers and assault by strangers. TELEPHONE VERSUS IN-PERSON INTERVIEW SURVEY METHODOLOGY The previous discussion involved methodology used with younger adults in at least three prior population-based studies. This survey tech- nique can be conducted in person or via telephone using random digit dialing methodology, in which stratified samples are derived and randomly called. Several advantages exist for each format. In-person interviews permit visual contact between interviewers and respondents. In-person interviewers can also modulate their volume to a relatively greater extent than telephone interviewers. In addition, conducting in-person interviews

282 ELDER MISTREATMENT allows surveyors to select an appropriate assessment location (i.e., a quiet, undisturbed room, as opposed to wherever the respondent happens to have his or her phone). In-person interviews may also facilitate expressions of empathy, honesty, and respect, which then might encourage more complete self-disclosure (Goodstein, 1980). Finally, in-person interviews can be con- ducted in households that do not have telephones. (However, the advan- tage of in-person interviews over telephone interviews insofar as telephone availability is concerned may be illusory. For example, according to the 1990 census, only 5 percent of U. S. households did not have telephones.) By contrast, data indicate that telephone-based interviewing is an effi- cient method for collecting information from large representative samples of respondents at a relatively low cost with insignificant response bias in detection of critical variables of interest when compared to in-person inter- view approaches (Weeks et al., 1983; Bradburn, 1984). These issues have been examined specifically in terms of detection of rates of victimization using in-person versus telephone interview methods (Catlin and Murray, 1979). Based on objective police report data, no differences in rates of detection of victimization were observed, supporting both the reliability and validity of the telephone method. One study (Paulsen et al., 1988) compared telephone and in-person assessment of DSM-III Axis I disorders, including anxiety disorders, affective disorders, alcoholism, and no mental disorder using a structured diagnostic interview. Kappa ranging from 0.69 to 0.84 was obtained, even with a delay between in-person and telephone methods of 12 to 19 months. There are several additional advantages to telephone assessment of victimization and psychopathology, particularly when considering inter- viewing older adult respondents. Many older adults indicate that they are hesitant to allow a stranger into their home for a variety of reasons (e.g., safety, feeling compelled to clean the house for the interviewer). The tele- phone format may also be perceived as relatively more anonymous and less intimidating than in-person disclosures of personal victimization, particu- larly when perpetrators are family members. Indeed, this anonymity may facilitate disclosure of embarrassing or potentially problematic material. Moreover, this anonymity may reduce the risk of negative outcomes on disclosure of abuse events. That is, if an interview is conducted in person, the interviewer is present in the house and clearly noticed by the abuser. The abuser may even overhear the interview questions and be aware of the older adult’s responses. This is not a problem during telephone-based interviews. Telephone-based interviewing also has the advantage of improving ac- cess to participants from across the socioeconomic status range. Thus, the very rich, rich, middle class, lower class, and poor are equally approach- able, if they have a telephone. It is unlikely that the upper and lower ends

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 283 of the socioeconomic spectrum would be available for in-person interviews. Another important concern and advantage of telephone assessment is inter- viewer safety. In order to achieve national representativeness, all geo- graphic and economic areas must be surveyed and interviewers must enter high-crime areas where they will be at increased risk for victimization. Telephone-based assessment overcomes the risk of victimization that inter- viewers would certainly face. Another advantage of telephone interviews, particularly those that employ computer-assisted telephone interview tech- nology, is greater and more easily verified standardization (e.g., supervisor spot checks via remote computers). That is, interviewers following a com- puter generated script with computer-prompted skip-outs who are ran- domly monitored by supervisors are far less likely to suffer from inter- viewer drift than interviewers who are not so prompted or supervised. Thus, the integrity of the interview and subsequent collected data are more thoroughly preserved by the telephone interviewing methodology. More- over, telephone interviews are far less expensive than in-person interviews and generally require significantly less time to complete. Finally, logistic factors such as scheduling, dealing with mandatory reporting issues, over- coming participant hesitation at having strangers in the house, and so on, are relatively less problematic for telephone-based interviews. COLLECTING SUPPLEMENTAL DATA IN ADDITION TO THE VIOLENT EVENT In addition to verifying that a particular form of assault has occurred, social and health science researchers are typically interested in determining health outcomes of such events. In order to derive conceptual models that outline assault-to-pathology pathways, multiple aspects of trauma and trau- matic response must be considered. Unfortunately, most studies of assault- related pathology have been somewhat limited in their assessment of vari- ables that play potentially important roles in emotional and physical functioning. Specifically, assault events are routinely examined in isolation, with little consideration given to the differential effects of multiple versus single assault, early-childhood versus later-life assault, assault by stranger versus acquaintance assault, and so on. This point is particularly relevant when considering that approximately 50 percent of physically and sexually assaulted individuals have prior victimization histories (e.g., Kilpatrick et al., 1992). Kilpatrick et al. (2000) suggest that new studies be designed in accord with the following: (1) Temporal boundaries of prevalence rates should be widened to include all adult, or even all lifetime, events. Failure to attend to crime occurring across the life span (e.g., the NCVS) produces artificially bounded prevalence rates. Such methodology might oversim- plify causal models involving events that contribute to mental and medical

284 ELDER MISTREATMENT pathology. (2) Multiple or complex victimization histories for each respon- dent should be collected and considered in causal models of psychopathol- ogy, as opposed to focusing on one type of crime, occurring at one point in time, committed by one type of assailant (e.g., the FBI’s UCR, in which only the most serious victimization is included in prevalence rates; assessment of abuse by family members or caretakers, but not by strangers). (3) Studied samples should be representative of the population of interest. (4) Both quantitative aspects (e.g., level of physical injury experienced, number of perpetrators, presence of weapon during assault) and qualitative aspects (e.g., perceptions of life threat during assault, fear of crime) of victimization history should be obtained and studied. (5) Other contextual factors that influence postviolence outcome, including familial and personal history of psychopathology, social and vocational adjustment, and level of social sup- port, should be assessed. CONCLUSIONS AND SUGGESTIONS FOR FUTURE RESEARCH There are two very distinct groups of elderly victims: those without significant cognitive impairment living independently, with a relative or caretaker, or in a care setting, and those with cognitive impairment, typi- cally in the last two settings. These two classes of victims very likely require different assessment methodologies for two major reasons. First and most obvious, the nature of cognitive impairment limits one’s ability to partici- pate in survey research. Second, the type of elder mistreatment very likely varies with the level of cognitive impairment. Moreover, the location of the elder also determines, in some part, the type of mistreatment to which she or he will be exposed (e.g., familial abuse is less likely in institutionalized elders). Existing methods to identify elder abuse fall into five groups: (1) agency record review, (2) sentinel reports, (3) criminal justice statistics, (4) caretaker/family member interview, and (5) interviews of elderly respon- dents themselves (in person or via telephone). In the past, research made a distinction when studying victimization of older adults in that assessment efforts were confined to investigating either elder abuse/neglect by family members (including caregivers) or nonfamilial criminal violence, but not both. This distinction may be artificial for three reasons. First, the physical and emotional effects of such events, particu- larly elder abuse and nonfamilial physical and sexual assault, are often very similar, or at least share a number of similarities (Acierno et al., 1997). Second, both forms of violence appear to have several risk factors in com- mon (e.g., poverty, limited resources, previous victimization), indicating that victims of one type of assault may be more likely to experience the other type of assault than nonvictims. Third, both forms of victimization are amenable to assessment through similar methodological strategies. Stud-

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 285 ies that endeavor to delineate risk factors for abuse or violence toward older adults should, therefore, simultaneously assess both forms of victim- ization when possible. Similarly, studies conducted to outline effects of these events on the elderly, and studies conducted to inform preventive interventions for both violence and effects of violence should use a method- ology that assesses both forms of victimization. One such method is event- based interviewing such as that used in the National Women’s Study and National Survey of Adolescents, in which all forms of elder mistreatment are first identified, followed by perpetrator specification. As such, both assault by strangers and abuse by caretakers/relatives are measured in the same population with the same instrument. Feasibility, Sensitivity, and Cost: Older Adults Without Cognitive Impairment For the group of elderly victims with no cognitive impairment, the most feasible methodology to produce population prevalence estimates for physi- cal, sexual, and emotional forms of violence, as well as for financial exploi- tation, is direct respondent survey via telephone, similar to that used by Pillemer and Finkelhor (1988). However, a major departure from previous efforts would be to widen the net of assessed violence against older adults to include all violent events using behaviorally specific close-ended ques- tions, with a determination of perpetrator status following determination of event occurrence. This methodology has been used with adolescents and young adults effectively to measure both domestic violence and stranger assault, and could be applied to older adults as well. Thus, combining the methodology of Pillemer and Finkelhor with the content structure of Kilpatrick et al. (National Women’s Study) yields “comprehensive violence against the elderly” assessment data. In the past, telephone survey random digit dialing (RDD) procedures were precluded when the target population was significantly represented by individuals in institutions that used inter- nal telephone switchboards for residents’ telephones. However, newer and upgraded assisted care institutions and facilities for those who are physi- cally, as opposed to cognitively, disabled often have direct lines to residents’ rooms and apartments. As such, this group is also potentially reachable by RDD techniques. This methodology also has the significant advantage of assessing a variety of categories of elder mistreatment simultaneously, com- pared to record review or FBI UCRs, in which types of mistreatment are largely limited to specific crime types that may or may not be in line with elder abuse definitions (e.g., verbal assault and emotional abuse). Finally, comparisons of criminal justice system/victimization studies using incident- based methodology (FBI UCR) to RDD methodology indicate tremendously

286 ELDER MISTREATMENT improved sensitivity for the latter. Although in-person interviewing is also extremely sensitive, telephone methodology is far more cost-effective. Feasibility, Sensitivity, and Cost: Older Adults with Significant Cognitive Impairment For the group of older adults suffering from dementia, survey interview methodology, whether in person or over the telephone, is probably not feasible or sensitive. For this group, a combination of agency record review and sentinel reporting, such as that employed in the NEAIS, would be indicated. However, until elder abuse statutes that compel reporting are unified and implemented across states, and until service-providing profes- sionals are educated about this compulsion to report instances of elder abuse and neglect—that is, until elder abuse is treated similarly to child abuse for cognitively disabled elders—estimates derived by agency records and sentinel systems will lack sensitivity. To improve sensitivity, these methods might be augmented by caretaker interviews. Note that studies with victims of domestic violence have asked potential perpetrators of as- sault about their sexually and physically abusive behaviors. Interestingly, these respondents reported significant levels of abuse. Precedent also exists in the elder abuse literature for such methodology. For example, Pillemer and Finkelhor (1988), who interviewed proxies when the older adults des- ignated respondent was incapable of providing self report, found even higher rates of elder abuse (of course, the conclusion that use of proxy report is more sensitive is premature because the group of disabled older adults has been identified as at greater risk of abuse, and hence higher numbers were expected). Thus, interviewing potential perpetrators may provide good information, particularly if used in conjunction with other methodologies. Random sample in person epidemiological interviews are very likely the most sensitive at detecting cases of elder abuse by virtue of their ability to allow interviewers to “lay eyes on” the respondent and his or her environ- ment. However, in-person interviewing is the least feasible and most costly of all methodologies. Tables 10-1 and 10-2 outline the author’s impres- sions of the aforementioned assessment methodologies, and those covered above, in terms of feasibility, sensitivity, and cost. SUMMARY Abuse assessment of older adults with significant dementia or other cognitive impairment is most appropriately accomplished by agency record review and sentinel reports, as in the NEAIS. However, these endeavors could be significantly enhanced by including caretaker interviews. For those older adults who are not cognitively impaired, direct interview ap- pears most appropriate. Assessment of this group might also be enhanced

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 287 TABLE 10-1 Assessment of Seniors with No Significant Cognitive Impairment Feasibility Sensitivity Cost Record review + _ + Sentinel reports ? _ ? Criminal justice statistic translation + _ + RDD telephone survey: victims + + + RDD telephone survey: family/caretakers + ? + In-person interview: victims _ + _ In-person interview: family/caretakers – ? – TABLE 10-2 Assessment of Seniors with Significant Cognitive Impairment Feasibility Sensitivity Cost Record review + ? + Sentinel reports ? ? ? Criminal justice statistic translation + _ + RDD telephone survey: victims _ _ + RDD telephone survey: family/caretakers + ? + In-person interview: victims _ _ _ In-person interview: family/caretakers _ ? _ by caretaker interview; however, care must be taken to protect respondents in such studies from perpetrator violence triggered by assessment (e.g., if the perpetrator is aware that the older adult has participated in a survey of violence and has incriminated the perpetrator, albeit anonymously, the perpetrator may be angered). Research with young adults and children demonstrates specific techniques to enhance sensitivity of assessment proto- cols, and these methodologies should be incorporated into assessment stud- ies of elder mistreatment.

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292 ELDER MISTREATMENT Spring, F.E., and W.N. Friedrich 1992 Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clinic Procedures 67:527–532. Stokes, S.S., and S.E. Gordon 1988 Development of an instrument to measure stress in the older adult. Nursing Research 37:16–19. Straus, M.A. 1979 Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. Journal of Marriage and the Family 41:75–88. Straus, M.A., S.L. Hamby, S. Boney-McCoy, and D.B. Sugarman 1996 The revised conflict tactics scales (CTS2). Journal of Family Issues 17:283–316. Tatara, T. 1997 The National Elder Abuse Incidence Study: Executive Summary. New York: Human Services Press. Tomita, S.K. 1982 Detection and treatment of elderly abuse and neglect: A protocol for health care professionals. Physical and Occupational Therapy in Geriatrics 2:37–51. Tomita, S.K. 1990 The denial of elder mistreatment by victims and abusers: The application of neutralization theory. Violence & Victims 5:171–184. Utech, M., and R. Garrett 1992 Elder and child abuse: Conceptual and perceptual parallels. Journal of Interper- sonal Violence 7:418–428. Vida, S. 1994 An update on elder abuse and neglect. Canadian Journal of Psychiatry 39:S34– S40. Weeks, M.F., R.A. Kulka, J.T. Lessler, and R.W. Whitmore 1983 Personal versus telephone surveys for collecting household health data at the local level. American Journal of Public Health 73:1389–1394. Weiner, A. 1991 A community-based education model for identification and prevention of elder abuse. Journal of Gerontological Social Work 16:107–119. Wetle, T. 1986 An elder abuse assessment team in an acute hospital setting. The Gerontologist 26:115–118. Whittaker, T. 1996 Violence, gender and elder abuse. In Violence and Gender Relations: Theories and Interventions, B. Fawcett and B. Featherston, eds. Thousand Oaks, CA: Sage Publications. Wolf, R.S. 1988 Elder abuse: Ten years later. Journal of American Geriatrics Society 36:758–762. 1992 Victimization of the elderly: Elder abuse and neglect. Reviews in Clinical Geron- tology 2:269–276. 1997 Elder abuse and neglect: An update. Reviews in Clinical Gerontology 7:177–182. Wolf, R.S., and K. Pillemer 1994 What’s new in elder abuse programming? Four bright ideas. The Gerontologist 34:126–129. 2000 Elder abuse and case outcome. The Journal of Applied Gerontology 19:203–220.

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 293 APPENDIX ASSESSMENT TOOLS From Hwalek and Sengstock (1986). Elder Abuse Screening Test 1.** Do you have anyone who spends time with you, taking you shopping or to the doctor?3 2.*** Are you helping to support someone? 3.** Are you sad or lonely? 4.* Who makes decisions about your life—like how you should live or where you should live? 5.*** Do you feel uncomfortable with anyone in your family? 6.** Can you take your own medication and get around by yourself? 7.*** Do you feel that nobody wants you around? 8.*** Does anyone in your family drink a lot? 9.* Does someone in your family make you stay in bed or tell you you’re sick when you’re not? 10.* Has anyone forced you to do things you didn’t want to do? 11.* Has anyone taken things that belonged to you without your OK? 12.*** Do you trust most of the people in your family? 13.*** Does anyone tell you that you give them too much trouble? 14.*** Do you have enough privacy at home? 15.* Has anyone close to you tried to hurt you or harm you recently? 3A response of “no” to items 1, 6, 12, and 14; a response of “someone else” to item 4; and a response of “yes” to all others was scored in the “abused” direction. Identified factors: *violation of personal rights or direct abuse, **characteristics of vulner- ability, and ***potentially abusive situation

294 ELDER MISTREATMENT From Fulmer and Cahill (1984). Elder Assessment Tool 1. Date________________ 2. Person completing form____________________________ 3. Patient age___________ 4. Patient sex Male____ Female____ 5. PAYMENT STATUS __Medicare __Private Pay __Other 6. RESIDENCE __Home __Nursing Home __Other 7. ACCOMPANIED BY __Family __Friend __Alone 8. MENTAL STATUS __Alert __Confused __Unresponsive 9. REASON FOR VISIT __Orthopedic __Changed Mental Status __Other GENERAL ASSESSMENT 10. Hygiene ____yes ____no 11. Nutrition ____good ____fair ____poor 12. Clothing ____good ____fair ____poor USUAL LIFESTYLE 13. Maintenance of hygiene ____self ____assist 14. Continent of bowel/bladder ____self ____assist 15. Feedings ____self ____assist 16. Ambulatory ____self ____assist 17. ____Housebound ____Outings 18. ____Sedentary ____Active 19. Personal contact with ____family ____friends ____nursing home personnel 20. Happy with living situation ____yes ____no 21. Who manages finances ____self ____family ____other? 22. Does financial arrangement work well ____yes ____no? 23. If care provider is present, is the observed relationship ____good ____poor ____indifferent ____doesn’t apply 24. History of recent life crisis ____yes ____no ____unsure 25. PHYSICAL ASSESSMENT (evidence of) ___bruising ___lacerations ___abrasions ___diarrhea ___urine burns ___decubiti ___dehydration ___malnutrition ___alcohol abuse

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 295 MEDICATIONS 26. Any duplication of similar medications? (i.e., multiple laxatives, seda- tives, etc.) ___yes ___no 27. Any unusual doses of medications? ___yes ___no 28. If yes to #26, please comment__________________________________ 29. Who gives medications? ___self ___family ___nursing home 30. If patient or family gives medications, do they have an adequate under- standing of medications? ___yes ___no ASSESSMENT 31. Physical Abuse ___present ___absent ___suspect/high risk 32. Psychological Abuse ___present ___absent ___suspect/high risk 33. Material Abuse ___present ___absent ___suspect/high risk 34. Outcome ___Referral to Elder Abuse team ___Referral to Clinical Advisor 35. Summary Statement ___Too busy to fill out ___No abuse/neglect suspected

296 ELDER MISTREATMENT From Reis and Nahmiash (1998). INDICATORS OF ABUSE Indicators of abuse are listed below, numbered in order of importance.4 After two- to three-hour home assessment (or other intensive assessment) please rate each of the following items on a scale of 0 to 4. Do not omit any items. Rate according to your current opinion. Scale: Estimated extent of problem: 0 = nonexistent 00 = not applicable 000 = don’t know 1 = slight 2 = moderate 3 = probably/moderately severe 4 = yes/severe Caregiver Age ____years Caregiver and Care Receiver Kinship ___spouse ___nonspouse Caregiver Care Receiver __ 1. Has behavior problems __ 4. Has been abused in the past __ 2. Is financially dependent __ 5. Has marital/family conflict __ 3. Has mental/emotional __ 8. Lacks understanding of difficulties medical condition __ 6. Has alcohol/substance __ 11. Is socially isolated problem __ 15. Lacks social support __ 7. Has unrealistic expectations __ 16. Has behavior problems __ 9. Lacks understanding of __ 18. Is financially dependent medical condition __19. Has unrealistic expectations __ 10. Caregiver reluctancy __ 20. Has alcohol/medication __ 12. Has marital/family conflict problem __ 13. Has poor current __ 21. Has poor current relationship relationship __ 14. Caregiver inexperience __ 22. Has suspicious falls/injuries __ 17. Is a blamer __ 23. Has mental/emotional __ 24. Had poor past relationship difficulties __ 25. Is a blamer __ 26. Is emotionally dependent __ 27. No regular doctor 4The majority of the most important indicators are the caregiver ones.

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 297 From Reis and Namiash (1995). Caregiver Abuse Screen Please answer the following as a helper or caregiver YES NO 1. Do you sometimes have trouble making (___) control his/her temper or aggression? ___ ___ 2. Do you often feel you are being forced to act out of character or do things you feel bad about? ___ ___ 3. Do you find it difficult to manage (___’s) behavior? ___ ___ 4. Do you sometimes feel that you are forced to be rough with (___)? ___ ___ 5. Do you sometimes feel you can’t do what is really necessary or what should be done for (___)? ___ ___ 6. Do you often feel you have to reject or ignore (___)? ___ ___ 7. Do you often feel so tired and exhausted that you cannot meet (___’s) needs? ___ ___ 8. Do you often feel you have to yell at (___)? ___ ___

298 ELDER MISTREATMENT From Ferguson and Beck (1983). HALF Assessment HEALTH Almost Some of Always the Time Never 1. Aged Adult Risk Dynamics 1.1 Poor health _______ ________ ______ 1.2 Overly dependent on adult child _______ ________ ______ 1.3 Was extremely dependent on spouse who is now deceased _______ ________ ______ 1.4 Persists in advising, admonishing and directing the adult child on whom he/she is dependent _______ ________ ______ 2. Aged Adult Abuse Dynamics 2.1 Has an unexplained or repeated injury _______ ________ ______ 2.2 Shows evidence of dehydration and/or malnutrition without obvious cause _______ ________ ______ 2.3 Has been given inappropriate food, drink, and/or drugs _______ ________ ______ 2.4 Shows evidence of overall poor care _______ ________ ______ 2.5 Is notably passive and withdrawn _______ ________ ______ 2.6 Has muscle contractures due to being restricted _______ ________ ______ 3. Adult Child/Caregiver Risk Dynamics 3.1 Was abused or battered as a child _______ ________ ______ 3.2 Poor self-image _______ ________ ______ 3.3 Limited capacity to express own needs _______ ________ ______

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 299 HEALTH Almost Some of Always the Time Never 3.4 Alcohol or drug abuser _______ ________ ______ 3.5 Psychologically unprepared to meet dependency needs of parent _______ ________ ______ 3.6 Denies parent’s illness _______ ________ ______ 4. Adult Child/Caregiver Abuse Dynamics 4.1 Shows evidence of loss of control, or fear of losing control _______ ________ ______ 4.2 Presents contradictory history _______ ________ ______ 4.3 Projects cause of injury onto third party _______ ________ ______ 4.4 Has delayed unduly in bringing the aged person in for care, shows detachment _______ ________ ______ 4.5 Overreacts or underreacts to the seriousness of the situation _______ ________ ______ 4.6 Complains continuously about irrelevant problems unrelated to injury _______ ________ ______ 4.7 Refuses consent for further diagnostic studies _______ ________ ______ 5. Attitudes Toward Aging 5.1 Aged adult views self negatively due to aging process _______ ________ ______ 5.2 Adult child views aged adult negatively due to aging process _______ ________ ______ 5.3 Negative attitude toward aging _______ ________ ______ 5.4 Adult child has unrealistic expectations of self or the aged adult _______ ________ ______ 6. Living Arrangements 6.1 Aged insists on maintaining old patterns of independent functioning that interfere with the child’s needs or endanger aged adult _______ ________ ______

300 ELDER MISTREATMENT HEALTH Almost Some of Always the Time Never 6.2 Intrusive, allows adult child no privacy _______ ________ ______ 6.3 Adult child is socially isolated _______ ________ ______ 6.4 Has no one to provide relief when uptight with the aged person _______ ________ ______ 6.5 Aged adult is socially isolated _______ ________ ______ 6.6 Has no one to provide relief when uptight with adult child _______ ________ ______ 7. Finances 7.1 Aged adult uses gift money to control others, particularly adult children _______ ________ ______ 7.2 Refuses to apply for financial aid _______ ________ ______ 7.3 Savings have been exhausted _______ ________ ______ 7.4 Adult child financially unprepared to meet dependency needs of aged adult _______ ________ ______ M.T.C.S. PLEASE COMPLETE IF YOU HAVE HAD A ROMANTIC PART- NER IN THE PAST YEAR. No matter how well a couple gets along, there are times when they disagree on major decisions, get annoyed about some- thing the other person does, or just have spats or fights because they are in a bad mood or tired or for some other reason. They also use many different ways of trying to settle their differences. The following is a list of some things that you and your partner or spouse might have done when you had a dispute. For each item on the list, please check the box that indicates how often each has occurred in the past year.

EPIDEMIOLOGICAL ASSESSMENT METHODOLOGY 301 More Than Never Once Twice 3–5 6–10 11–20 20 Times Times Times Times 1. A. Have you discussed the issue calmly o o o o o o o B. Has your spouse discussed the issue calmly o o o o o o o 2. A. Have you gotten information to back up your side of things o o o o o o o B. Has your spouse/partner gotten information o o o o o o o 4. A. Have you tried to bring in someone to help settle things o o o o o o o B. Has your spouse/partner o o o o o o o 5. A. Have you insulted or sworn at your spouse/ partner o o o o o o o B. Has your spouse/partner o o o o o o o 6. A. Have you sulked and/or refused to talk about it o o o o o o o B. Has your spouse/partner o o o o o o o 7. A. Have you stomped out of the room, house, or yard o o o o o o o B. Has your spouse/partner o o o o o o o 8. A. Have you cried o o o o o o o B. Has your spouse/ partner cried o o o o o o o 9. A. Have you done or said something to spite your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 13. A. Have you threatened to hit or throw something at your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o

302 ELDER MISTREATMENT More Than Never Once Twice 3–5 6–10 11–20 20 Times Times Times Times 14. A. Have you thrown, smashed, hit, kicked something o o o o o o o B. Has your spouse/partner o o o o o o o 15. A. Have you hit or tried to hit your spouse with something o o o o o o o B. Has your spouse/partner o o o o o o o 16. A. Have you thrown something at your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 17. A. Have you pushed, grabbed, or shoved your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 18. A. Have you slapped your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 19. A. Have you kicked, bit, or hit your spouse/ partner with a fist o o o o o o o B. Has your spouse/partner o o o o o o o 22. A. Have you beat up your spouse/partner o o o o o o o B. Has your spouse/partner o o o o o o o 23. A. Have you threatened spouse/partner with a knife or gun o o o o o o o B. Has your spouse/partner o o o o o o o 24. A. Have you used a knife or gun on your spouse/ partner o o o o o o o B. Has your spouse/partner o o o o o o o

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Since the late 1970s when Congressman Claude Pepper held widely publicized hearings on the mistreatment of the elderly, policy makers and practitioners have sought ways to protect older Americans from physical, psychological, and financial abuse. Yet, during the last 20 years fewer than 50 articles have addressed the shameful problem that abusers—and sometimes the abused themselves—want to conceal.

Elder Mistreatment in an Aging America takes a giant step toward broadening our understanding of the mistreatment of the elderly and recommends specific research and funding strategies that can be used to deepen it. The book includes a discussion of the conceptual, methodological, and logistical issues needed to create a solid research base as well as the ethical concerns that must be considered when working with older subjects. It also looks at problems in determination of a report's reliability and the role of physicians, EMTs, and others who are among the first to recognize situations of mistreatment.

Elder Mistreatment in an Aging America will be of interest to anyone concerned about the elderly and ways to intervene when abuse is suspected, including family members, caregivers, and advocates for the elderly. It will also be of interest to researchers, research sponsors, and policy makers who need to know how to advance our knowledge of this problem.

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