Meeting the Challenge of Cultural Complexity
Finally, it is imperative to vertically integrate cultural sensitivity training into the current health care professional training and education. Such curriculums should encourage health professionals to become better listeners and humble students of the older adults, which are essential steps to comprehend the cultural variations of health, aging, and elder abuse issues (Chang et al., 2010). Culturally appropriate training and resources for the Adult Protective Services (APS) and other front-line workers will also be critical to alleviate factors exacerbating abusive situations in the Chinese communities, and to prevent elder abuse recidivism.
Elder abuse is a pervasive public health issue, yet there are major gaps in understanding the cultural and social complexities with respect to elder abuse among the diverse Chinese population worldwide. We need representative longitudinal research to better define the incidence, risk/protective factors, and consequences of elder abuse in Chinese communities. Moreover, due to the vast diversities within the Chinese population, we need national and international studies to provide in-depth data on the abuse of older persons. From the policy perspectives, communities, cities, and states should take a critical lead in reducing social isolation, and increasing social networks and companionship for this group of older adults. Incorporating the cultural, social, and community contexts that affect their health and well-being will contribute to the salience of practice and policy impact of prevention, intervention, detection, and reporting of elder abuse for the global Chinese aging population.
In 2007, an Institute of Medicine (IOM) workshop took a novel approach to global violence prevention, examining violence horizontally—from war and suicide, to child, gender, sexual, domestic, and elder abuse. At that workshop little was said (and there was not much to say) about research focused on the prevention of elder abuse. Thus, it represents real progress that the IOM, in April 2013, convened a workshop focused on elder abuse and its prevention.
Recent research indicates that elder abuse is a significant and growing problem, victimizing about 1 in 10 Americans age 60 and older living at home, who have and are able to use a phone. For those with limited function, disability, or means to communicate, the numbers appear to be much higher (Acierno et al., 2010; Lifespan of Greater Rochester et al., 2011).1 Rates of elder abuse rise sharply among people with dementia (Wiglesworth, 2010).2 In hospitals, nursing homes, and other care settings, research is needed to illuminate current prevalence rates of abuse and neglect; older data and recent cases3 indicate reason for concern.
As the population ages, caregiver shortages grow, and more people live to an age where they experience physical and cognitive incapacity, the number of people vulnerable to elder abuse will grow. But the problem remains largely hidden. For every case of elder abuse that comes to light, 23 others do not (Lifespan of Greater Rochester et al., 2011). This paper, based on a discussion at the April 2013 IOM workshop, gives an overview of seven policy priorities to enhance the public health response to elder abuse.4
Develop Policy to Recognize Elder Abuse as a Public Health Issue
One reason the response to elder abuse lags so far behind comparable issues is that it has not been recognized or treated as a public health issue requiring a public health response. Like other forms of violence, abuse, and neglect, elder abuse is associated with law enforcement, prosecution, social services, and financial issues. Yet it is also a problem that causes premature death and untold suffering, and has major health consequences and costs for individuals, families, and society.
The Centers for Disease Control and Prevention (CDC) and the National Institutes of Health, as well as other public and private entities, have spent billions of dollars to develop a public health response to child abuse and domestic violence. The knowledge and infrastructure relating to elder abuse lag decades behind. To address this gap and the absence of a public health paradigm to address elder abuse, one should begin by collecting
1 The New York state prevalence study found rates of about 7.6 percent, whereas the Acierno study found rates between 11 and 14 percent. Thus, this report uses “about one in ten.”
2 This study, based on 159 dyads of people with dementia and their caregivers, concluded that 47 percent of people with dementia were abused or neglected. Researchers in this study did not screen for financial exploitation.
3 See, e.g., United States v. Hauser (NDGA, 2012); United States ex rel. Absher v. Momence Meadows Nursing Ctr., Inc., No. 2:04-cv-02289 (C.D. Ill. Feb. 8, 2013); United States v. United States of America ex rel., Kimball and Juelfs v. Cathedral Rock Corporation, Cathedral Rock Management I, Inc. (EDMO, 2010).
4 These seven points were originally presented in a brief talk that was given at the IOM workshop on elder abuse and its prevention.
data, doing surveillance, and determining (in a methodologically sound way) what types of prevention and intervention programs are effective. Until this is done, elder abuse will remain in the shadows.
Another aspect of this public health problem is the serious shortage of a workforce trained to identify, address, prevent, and study elder abuse. There are roughly 10 times as many pediatricians (most of them trained about child abuse) as geriatricians (few of whom are trained about elder abuse), and the number of geriatricians is falling even as the patient cohort skyrockets (Eldercare Workforce Alliance, 2013). Few geriatricians have training about elder abuse, and even fewer do research to illuminate the problem (this coincides with a general dearth of academic geriatricians). A subspecialty of experts in child abuse, cross-trained in both pediatrics and forensic pathology, has made a difference in shaping how we respond to the problem. There is no comparable subspecialty of forensic geriatricians.
These shortages extend to most fields of health and social service workers focused on aging—including nurses, nurse practitioners, physician assistants, geropsychiatrists, and social workers. To improve the response to elder abuse, it is critical that an adequate workforce is developed—trained in how to identify, address, and prevent the problem, and interested in advancing knowledge about it. For these reasons and more, it is critical to recognize elder abuse as a serious public health issue and allocate resources to it accordingly.
Research Priorities Critical to Inform Policy
and Practice Relating to Elder Abuse
Responsibly formulating policy is difficult without good data to inform it. More than a decade ago, the National Academy of Sciences (NAS) noted:
In [prior reports] the National Research Council was able to map out a comprehensive blueprint for research in the adjacent domains of child mistreatment and intimate partner violence. However, so little is now known about elder mistreatment that it would be premature to draw up a detailed research agenda for this nascent field…. Abuse and neglect of older individuals in society breaches a widely embraced moral commitment to protect vulnerable people from harm and to ensure their well-being and security. To carry out this commitment, one cannot rely on good intentions alone. A substantial investment in scientific research … is imperative. (NRC, 2003, pp. xiii-xiv)
Scientific research has not yet been funded to fulfill this commitment. Five areas to begin, where egregious gaps in knowledge undermine effective policy development, include intervention, defining success, prevention, data collection, and cost.
Given the dearth of intervention research, it is unknown whether the programs in place to address elder abuse actually work, or which approaches are more effective than others. APS, mandatory reporting laws, and multidisciplinary teams are three examples of interventions that are broadly relied on, but whose efficacy remains untested. Data are needed so the field can coalesce around strategies and programs that work best.
In assessing the efficacy of an intervention, we must begin by defining success. Elder justice advocates have begun to measure the impact of some programs by assessing whether they increase the numbers of reports to law enforcement, prosecutors, or state agencies. Although such information is useful, it does not tell us whether the client, patient, or victim—the person the program is designed to help—considers the intervention a success. Thus, a critical precursor to developing intervention research is determining how to pinpoint success from the perspective of the target population. For those unable to define success for themselves, alternative ways to measure whether the intervention improved well-being need to be used.
The field suffers from a critical lack of data on how to prevent elder abuse. Awareness campaigns can be critical means of prevention, but they must be done right. Before undertaking such a campaign (which requires significant resources), it is critical to determine: What do we want to accomplish? Who is the target audience for the message (e.g., older people, families, caregivers, policy makers, or geriatric or public health communities)? What language and message will resonate with that audience? What is the impact of delivering that message to that audience? (Does delivering that message to that audience actually reduce elder abuse? How? What is the most cost-effective dissemination strategy?) Without careful focus and planning, awareness campaigns easily can fall on deaf ears and waste precious resources.
Collecting data about elder abuse is critical to all aspects of policy development. The child abuse field began collecting data in the 1970s in part because a group of experts convened and worked with key state officials to develop a consensus about which standard data points to collect.
The Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services (HHS) issued a report in March 2010 concluding that it is feasible to collect elder abuse data (Office of the Assistant Secretary for Planning and Evaluation, 2010). Although federal law mandates collection of elder abuse data, the data have not yet been collected, nor does a system in place to do so exist. There is no need to reinvent the wheel. State officials and experts in the relevant areas should be convened to lay a foundation and develop a pilot for this critical and long overdue effort.
Given the massive cost of health care in this nation, research is needed to calculate the unnecessary economic burden elder abuse adds to it. The current knowledge indicates that elder abuse is a hugely expensive problem costing tens of billions of dollars annually: Victims are four times more likely than non-victims to be admitted to nursing homes (Lachs et al., 2007) and three times more likely to be admitted to hospitals (Dong and Simon, 2013). Taxpayers (primarily through Medicare and Medicaid) foot the lion’s share of the bill for those increased care needs. Financial exploitation also has serious economic consequences, leading to higher rates of dual eligibility and increased reliance on other public programs (Gunther, 2011); for example, victims whose assets are depleted are more likely to need public housing. In addition, elder abuse leads to economic losses for employers, businesses, families, and individuals.
Elder abuse tips over otherwise autonomous older people’s lives, causing increased dependence. Victims who do not go to facilities are likely to become more dependent on informal caregivers. Voluminous data have shown that caregiving takes a huge health and financial toll on caregivers (MetLife Mature Market Institute, 2011). This is another massive, uncalculated downstream cost of elder abuse. As policy makers grapple with how to reduce the price of health care, they need data about the many ways in which elder abuse drains an overburdened system with avoidable costs.
Policy Opportunity: Translate What We Do Know into Practice
Amidst the dire gaps in knowledge, there are some data about elder abuse. Yet these data are too rarely applied (Acierno et al., 2010).5 For example, older people with good social supports and services are known to be less likely to become victims of elder abuse, neglect, and financial exploitation than those who lack those resources (Acierno et al., 2010). Yet effective
5 This is not only a problem in the elder abuse field. Atul Gawande has noted that, in medicine, “good ideas take an appallingly long time to trickle down.”
coordination is not assured or adequately promoted between (1) those in the elder abuse field and (2) the entities that provide or coordinate social support, including those in the aging network, caregiving field, care managers and planners, Alzheimer’s and dementia policy makers and programs, faith-based organizations, and home- and community-based services.
Second, APS workers and others charged with making decisions about when and how to intervene in the face of alleged elder abuse often have insufficient training or outdated tools to decide whether and when to seek expert capacity assessment of the person they are trying to help. Though capacity will remain a challenging issue, the data that do exist could be used more effectively, and APS could ensure correct use of the right instruments to inform and enhance the decisions of APS workers and others (Karlawish, 2013).
Third, health, social service, and law enforcement responders often encounter older people with bruises and must decide whether those bruises are reason for concern. Research is now available about such forensic markers to help responders distinguish between inflicted and accidental bruises and determine whether a case should be referred for further investigation (Mosqueda et al., 2005). But the bruising data are not well disseminated, so many people who could use the data do not.
Resources and Policy: Chicken and Egg
The biggest reason there is so little research to guide elder justice policy, and so few researchers do elder abuse research, is the dearth of funds to support such research. The General Accountability Office (GAO) highlighted the issue in March 2011. The GAO found the following funding amount to elder abuse research (in 2009):
• National Institute on Aging (NIA): $1.1 million, which is about 1/1000th of its budget;
• CDC: $50,000, which is 0.0008 percent of its budget (CDC has spent millions and been a leader on child abuse and domestic violence issues); and
• National Institute of Justice (NIJ), the Department of Justice (DOJ) research arm: $450,000 of its funds, plus other DOJ dollars, totaling $1.2 million.
The total—$2.35 million for elder abuse research (as last calculated by GAO in 2009)—is a tiny fraction of federal funds spent annually for research on analogous issues (GAO, 2011).
The same disparity appears in the distribution of victim assistance funds, relatively few of which are allocated to older victims or to better
understand how to address older victims’ needs (often different from those of younger crime victims). The same GAO study found that the Office for Victims of Crime expended only 0.5 percent of its budget on older victims (GAO, 2011). One possible reason for this disparity is that unlike victims of child abuse and sexual and domestic violence, some of whom can and do speak out very effectively, few elder abuse victims are able to do so.
The dearth of resources available to address elder abuse diminishes the quality of the response to the problem, undermines policy development, and impedes efforts to recruit people to the field. Allocation of resources is one way societies, agencies, foundations, and other funders show what issues they believe to be important. Young researchers and practitioners carefully observe such funding trends and are understandably hesitant to choose a field that lacks priority or resources. The relationship between resources and policy is circular. Policy helps determine where to send resources. Resources fund research and programs that inform policy.
Implement Law and Develop Policy Infrastructure
The Child Abuse Prevention and Treatment Act and the Violence Against Women Act (VAWA), with other laws, created offices at HHS and DOJ that for decades have assured leadership, research, funding, programmatic efforts, and policy development to redress child abuse and domestic violence. Such offices are a low-cost, high-impact way to bring sustained attention, coordination, momentum, and more effective use of existing resources relating to elder abuse.
Creation of offices and other infrastructure promoting ongoing, thoughtful policy attention to elder abuse was a central catalyst for the Elder Justice Act (EJA), the first comprehensive federal law to address elder abuse. First introduced in 2002, the law took 8 years to pass. Its 2010 enactment was met with great anticipation. As of 2013, however, the law has not been funded and, in most part, not implemented. The section that would have created an office was not part of the law that was enacted.
Develop a Political Constituency
Why has a law that once had broad bipartisan support not been funded or implemented? Why have elder abuse concerns not been better integrated into existing programs relating to aging, disability, health, law, caregiving, and consumer protection? Why are public leaders and the public not more engaged in an issue with a profound impact on the lives of millions of people? Why do good ideas, good programs, important research, and promising innovations remain isolated in pockets, rarely translating into policy or systems change? The answer in large part is that the elder justice
movement lacks nearly every aspect of a political constituency—grassroots and grasstops networks, strategic policy development, strategic legal action and communication plans, diverse constituencies joining to address the problem, and high-profile champions.
The initial enactment and recent reauthorization of VAWA illustrate the importance of a strong political constituency (including the critical role of a high-level champion like Vice President Joe Biden, first in the Senate, then in the White House). The National Alzheimer’s Project Act (NAPA) provides another example in a related field. NAPA was enacted in 2011 after the EJA, but its Federal Advisory Committee was promptly convened (in 2011). Compare this with the EJA’s Advisory Board that has yet to be convened, though its report was due to Congress in March 2011. The EJA-created Elder Justice Coordinating Council finally met for the first time in 2012 with participation of HHS Secretary Kathleen Sebelius and Attorney General Eric Holder. The field is awaiting the results of that federal coordination.
While we were working on the EJA Judy Salerno, then Deputy Director of NIA, provided a critical piece of advice. Support innovation. Not all people who have great potentially life-changing ideas can get them funded by entities like NIA, NIJ, or elite foundations. We thus included a section in the EJA that would have created an innovation fund. Coast to coast, people create new programs, try new approaches, and think up new ideas based on their experience and expertise. We need to find better ways to harness that innovation, to figure out which innovations work and replicate them. Unfortunately, the innovation section did not find its way into the final EJA, but there are other paths to this goal. By funding the recent prevention grants, HHS has offered such an opportunity using another vehicle.
A critical innovation is the proliferation of different types of multidisciplinary teams, such as elder abuse (forensic) centers (by whatever name) and financial abuse specialist teams at the federal, state, and local levels all over the country. The EJA-created federal Elder Justice Coordinating Council is also such a team. These teams promote development of new ways to respond to elder abuse within disciplines, and allow groups of people and disciplines to innovate new ways of doing things together. Although it is an article of faith that multidisciplinary teams (MDTs) are effective, there are many models and many challenges, and little data to tell us what works best. Taking a more analytic approach to evaluating them could elicit valuable information to those guiding and forming such teams and to policy makers shaping policy related to them.
Countless billions of dollars have been spent to lengthen life. The time has come to honor that widely embraced moral commitment cited by the