The prevalence of abuse and the context in which it occurs provide an important but incomplete picture of the overall burden of elder abuse. As presented by Robert Wallace from the University of Iowa and XinQi Dong from the Rush Institute for Healthy Aging, factors have been identified that are associated with an increased risk for elder abuse, and adverse health outcomes have been shown to be associated with occurrences of abuse. Understanding these risk factors and health outcomes could help demonstrate the magnitude of elder abuse and opportunities for prevention.
Identifying and understanding factors that are associated with both predicting and protecting from occurrences of elder abuse is key to determining how to prevent abuse, particularly through primary prevention. Planning committee member Jeffrey Hall from the Centers for Disease Control and Prevention elaborated: “When we know what factors combined make perpetration more or less likely and when we understand what processes and conditions may create vulnerabilities, we first can act meaningfully and decisively to protect and promote the health of older adults, and, secondly, we can gain insights on the kinds and configurations of strategies that prevent further abuse, neglect, or exploitation by a variety of different perpetrator categories that we know exist.” Hall also noted that, within the context of the ecological framework, consideration needs to be given to how risk factors originate in different levels of social interaction—between individuals,
TABLE 3-1 Risk Factors for Elder Mistreatment and Being a Perpetrator
|Risk Factors for Elder Mistreatment
|Risk Factors for Being a Perpetratora
• Victim dependency/vulnerability
o Poor health; disability/functional impairment; poor personal defenses; poverty; possibly dementing illnesses (responses to behavior)
• Abuser dependency/deviance
o Alcohol and drug abuse; mental illness; poor employment record
• Social isolation
o Abuse undetected; lack of social support to buffer stress
• Living arrengements
o Shared living arrangements; greater opportunity for tension and conflict; long-term care facilities
• Resources to exploit
• Alcohol and substance abuse
• Mental health problems: depression/personality disorder; behavioral problems; caregiver burnout, inexperience
• Poor interpersonal relationships; permorbid relations
• Current marital, family conflict
• Lack of empathy, understanding of care needs and issues
• Financially dependent on victim
a Abusive Caregiver Characteristics (Reis and Nahmiash, 1998).
SOURCE: Presented by Robert Wallace, University of Iowa.
within relationships and communities, and in the social environments that surround them. It is also important to explore and understand how such influences operate in different settings and cultural contexts.
Workshop speaker Robert Wallace from the University of Iowa acknowledged that there is a range of risk factors for both perpetrating and being a victim of elder mistreatment—some that are rather straightforward and others that are complicated to both identify and address (see Table 3-1). He noted that these known risk factors have been derived mostly from case-control studies; however, prospective studies are needed to better describe the range of risk factors and be able to make significant progress toward prevention. Workshop speaker Ron Acierno from the University of South Carolina noted that, while elder mistreatment perpetrated by strangers and caregivers is different, there are risk factors that overlap, and understanding the overlap is important for designing effective interventions.
Possible New Approaches to Addressing Elder
Mistreatment Risk Factors and Prevention
Wallace noted several newer approaches to addressing elder mistreatment risk factors and prevention that have the potential to move the field forward:
• Considering aging in society through the lenses of ageism, human rights, larger social and cultural attitudes, going beyond interpersonal relations, and social exchanges and transactions.
• Geographic context and information through violent crime mapping.
• Life course experience and victimization: possible role for adverse childhood experiences.
• Possible genetic effects.
• Development of potential screening “biomarkers.”
• Role of forensic science.
• Elder monitoring and telemedicine.
Potential Areas for Further Research
The following section of the report outlines several areas in which further research on specific factors was suggested by workshop speakers.
Several workshop speakers suggested that increasing social support through community integration could help protect vulnerable adults from elder abuse. For example, better access to public transportation was discussed as a potential avenue for decreasing isolation. However, Acierno pointed out that research is needed to understand what types of social support are effective for preventing elder abuse and how they can be amplified, as well as which types are not effective, or possibly even harmful. Agnes Tiwari from the University of Hong Kong expanded on this point by commenting that, within the field of domestic violence prevention, which has been grappling with the issue of social support for years, one thing that has been learned is that even though the same principles may apply, different people need different social support. For instance, some people may prefer to have family members or friends involved in an intervention, while others might prefer that the people they know are not involved. The context in which the abuse or potential abuse occurs matters and the role of social support as a protective factor for elder abuse prevention needs to be better understood.
Evidence suggests a relationship between substance abuse and violence, both in victimization and perpetration, and some limited research suggesting a relationship between substance abuse and elder abuse specifically (Bushman and Cooper, 1990; Dolan, 1999; Sripada et al., 2011; Jogerst
et al., 2012). Wallace noted that alcoholism often does not start in late life, but rather is a factor that may have been ongoing across a lifetime that has results in complicated long-term social interactions. Several speakers agreed that there is need for more research on the relationship between substance abuse and elder abuse, and alcohol abuse and elder abuse.
Life Course Perspective
Wallace asked, “When does elder mistreatment begin?” He referenced some work that has been done in other areas of violence and abuse, such as violence against women, that links previous victimization with future victimization or perpetration. He suggested that researchers should be asking questions about previous experiences of violence to older adults as well, so the lifecourse perspective and early childhood adverse-experience effects on elder abuse can be better understood as a potential risk factor. Workshop speaker E-Shien Chang from the Rush Institute on Healthy Aging noted that from the data from the Pine Report, one-third of the victims who screened positive for elder abuse had experienced other types of abuse earlier in life before the age of 60 (Dong, 2013).
Forum member Michael Phillips from the Shanghai Jiao Tao Medical School commented on the relationship between depression and elder abuse, particularly neglect and self-neglect. Depression can be a factor contributing to one’s decision to self-neglect; also, neglect can further exacerbate depression, creating a vicious cycle. The extent of depression in mistreated older adults is not known and, if left untreated, can lead to more abuse and other types of mistreatment. Phillips also noted that depression is treatable and that fact should not be overlooked, even in older adults. He suggested that more research should be pursued on the relationship between elder abuse and depression.
Hall asked, “Why focus on the aftermath of the abuse?” He noted that in assessing the magnitude and effect of elder abuse, the prevalence and incidence data only reveal a small portion of the public health burden of this problem. Abuse, neglect, and exploitation adversely affect physical and mental capacity and impairments, social positions, and structures. In addition, they may exacerbate existing health conditions that already affect an older person’s well-being and can render disease and prevention promotion activities ineffective or unrealistic. Abuse may place older adults on health
trajectories where they will die earlier than older adults with no history of elder abuse victimization (Lachs et al., 1998).
Workshop planning committee co-chair and Forum member XinQi Dong from the Rush Institute for Healthy Aging presented an overview of adverse health outcomes of elder abuse. Data in this area was first presented in 1998 with the New Haven cohort study of residence that matched data to Adult Protective Services and demonstrated an independent relationship between elder abuse and mortality (Lachs et al., 1998). In the same cohort, the relationship with the long-term care placement was shown as well. Some of the later work by Margaret Baker and colleagues (2009) suggested that perhaps there was not as strong a link with mortality as previously thought. The Chicago Healthy Aging Project (CHAP), a 14-year prospective population-based study conducted in Chicago of nearly 10,000 community-dwelling older adults, has produced data showing the association between elder abuse and mortality, as well as associations with other health outcomes and indicators of health outcomes. Dong presented findings from the CHAP, which are summarized in Table 3-2.
Despite the contributions from the research that has been done to date, Acierno noted that still very little is known about elder abuse association with health outcomes, such as depression, stress, and other mental health consequences. More research is needed to better understand the relationship between elder abuse and a wider range of health outcomes.
TABLE 3-2 Summary of Chicago Healthy Aging Project (CHAP) Findings
Elder abuse and mortality
The data from the CHAP study has shown 5.9 deaths per 100 for those without elder abuse and 18.3 per 100 people with elder abuse. Mortality risk was higher among those with greater cognitive and functional impairment. Cardiovascular-related mortality risk was particularly high. Because the study was done over 14 years, the health of the participants changed over time and that was taken into consideration (Dong et al., 2009).
Elder self-neglect and mortality
The CHAP study data have shown reported elder self-neglect was associated with a significantly increased risk of 1-year mortality (Dong et al., 2009).
Elder self-neglect and emergency department (ED) use
Elder self-neglect is associated with increased rate of ED use and greater self-neglect severity is associated with greater increase in ED use (Dong et al., 2011b).
Elder abuse and mortality: psychosocial well-being
Mortality risk associated with elder abuse was most prominent among those with highest levels of depressive symptoms and lowest levels of social network and social engagement (Dong et al., 2011a).
Elder self-neglect and hospitalization
Elder self-neglect is associated with higher rate of hospitalization. This relationship was not moderated by medical comorbidities or cognitive or physical function (Dong et al., 2012; Dong and Simon, 2013d).
Elder self-neglect and hospice use
Elder self-neglect is associated with increased risk of hospice use, shorter length of stay in hospice care, and shorter time from hospice admission to death (Dong and Simon, 2013c).
Elder self-neglect and elder abuse
Elder self-neglect reporting is associated with increased risk for subsequent elder abuse reporting to social services agency (Dong et al., 2013).
Elder abuse and ED use
Elder abuse was associated with increased rates of ED use, and specific subtypes of elder abuse had differential association with increased rate of ED use (Dong and Simon, 2013a).
Elder abuse and hospitalization
Elder abuse was associated with increased rates of hospitalization (Dong and Simon, 2013d).
Elder abuse and skilled nursing facility (SNF) admissions
Elder abuse was associated with increased rates of admission to SNF. Specific subtypes of elder abuse had a differential association with an increased rate of admission to SNF (Dong and Simon, 2013b).
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