The occurrence of violence within our families contradicts popular societal affirmation of individual rights and personal liberties. The American public and professionals alike abhor incidences of child, spouse, and elder abuse. Although public awareness of this phenomenon is relatively recent, the existence of family violence has probably been longstanding. Research into family violence began in the 1960s with child abuse. Studies of marital conflict followed in the late 1970s. In this decade a great deal of attention has been focused upon elder abuse. This article will review factors involved in elder abuse, and describe an original validated instrument designed to evaluate the risk of elder abuse in the home (REAH).
Professionals involved in care of the elderly are unable to agree upon one universal definition of elder abuse.1 Most, however, agree upon the following use of certain describers as nonaccidental, causing harm, an act or omission, against an elderly person, involving two or more persons.2 Beating, roughing up, pushing, shoving, neglect, misuse of medication, inadequate diet, and homicide are all considered forms of physical abuse. Verbal and psychological abuse include actions as infanti lization, derogation, threats of institutionalization, and threats of abandonment. Stolen or misused funds and property as well as appropriation of social security checks by the caregivers for use other than for care of that elderly person are all considered forms of financial abuse.
Estimates of the incidence of elder abuse are based upon reported cases. It is believed that at least 500,000 and as many as one million older persons are abused.3,4 Elder abuse is often denied, unrecognized, unseen, and therefore not reported. Lack of data and denial by involved persons, however, do nothing to remove this societal tragedy. There are few acceptable alternatives for the abused person. Many elderly would prefer to remain where they are and tolerate the abuse. Other elderly are afraid or unable to share this secret with anyone else.
In an extensive literature review, Giordano and Giordano summarize the theoretical explanations of elder abuse to include: 1) family dynamics where violence is a normative behavior pattern; 2) impairment and dependence of the elder that increases abusive situations because of greater mental and physical demands; 3) personality pathologies of the abuser; 4) filial crisis or unresolved parent-child conflicts leading to abuse; 5) internal stress caused by overwhelming burdens of parent care; 6) external stress arising from the environment, working arena, or illness of the caregiver; and 7) negative attitudes toward the elderly that create dehumanization and distortions sufficient to suppress guilt when abusive situations occur.5
Through the use of literature review, Patwell has presented and described four patterns that may be helpful in identification of potential abuse situations: the dependent elderly individual, the caregiver under stress, violence in the family, and the pathological caregiver.6
Once elder abuse occurs, solutions are difficult and less than satisfactory. Prevention-oriented interventions in high-risk situations should be implemented prior to the initiation of abusive behavior. Recognition of situations with a high risk of elder abuse can be achieved through 1) studying family function using a family systems approach; 2) monitoring the intergenerational relationship; 3) evaluating the vulnerability of the elderly person; and 4) evaluating the strains on the caregiver.
The Family System
Family systems theory defines the family as a holistic entity. All members have attachments with previous generations and with one another. Behavior patterns and degree of differentiation tend to pass from one generation to the next. Differentiation is a characteristic that can be attributed to a family and to family members. For ease of understanding, the level of differentiation can be equated with emotional maturity. A low differentiation will predispose to emotional rather than intellectual behavior. Such behavior may be rigid and less adaptable, particularly in times of stress.7
Individual family members form family subsystems and function in ways that contribute to the overall family performance. Interacting personalities are organized into positions, roles, and norms including the spouse subsystem, parent-child subsystem, and the aged parent-adult child subsystem. Growth and maturity of the subsystems serve to strengthen and differentiate the function of the entire family system. Dysfunctioning subsystems are signs of low differentiation of the family.8 For example, marital conflict, impairment of one or more children, or a dysfunctional spouse may indicate a maladaptive family.
To function effectively, the family system should be an open system, exchanging information and resources with its environment. The community, health, and educational systems will interact with the family. A differentiated family system is open to its surrounding environment. It will use resources, information, and opportunities to resolve problems and maintain homeostasis.
Conversely, a closed, undifferentiated family keeps rigid boundaries. If too inflexible, family maladaptive behavior patterns may emerge.9 Such a family would be less able to maintain homeostasis in times of a crisis. A family showing high levels of differentiation will be able to use the community resources to relieve tensions and strains that otherwise could upset family equilibrium.
Signs of a maladaptive family relationship are best detected by the provider who has an opportunity to observe family interactions closely, often in the home environment. Alcoholism or substance abuse, mental illness, mental retardation, and past or present family violence are all indicative of an undifferentiated family system. In the presence of these variables, a higher risk of elder abuse exists . 10 A refusal to use outside support systems available through the community or friends may indicate a closed family system. Signs of this may be punctuated by the caregiver's desires to keep the aged person out of an institution "at all costs." Repeated conflict among family members, infantilization, and assumption of an authoritative role by the elder are indicative of undifferentiated personalities within the family system.
The Intergenerational Relationship
Surveys of disabled and ill community-based elderly persons indicate that spouses, relatives, and friends are the primary care providers. Wives more often than husbands provide care to disabled spouses due to the fact that women outlive men by seven years.11 With increasing age of the elder, the adult children replace the spouse in providing increased amounts of help to the parents. They may give care in spite of rather than because of past relationships. Reasons for this care vary but include such themes as a sense of responsibility, personal satisfaction, and a desire to avoid nursing home placement. Other motivations include items such as a sense of obligation, fulfillment of social expectations, value judgments, reciprocity, or cultural patterns.12,13 The focus of this discussion is upon the strains that occur when the adult child is the caregiver.
REAH-AN INDEX FOR ASSESSING THE RISK OF ELDER ABUSE IN THE HOME
Regardless of the amount of responsibility and love the adult child exhibits toward the dependent aged parents, strains will develop if care must be intensive or protracted. In a study exploring the relationship between aged parents and their adult children, there was a positive correlation between health and the quality of the relationship. l4 Under certain circumstances of high risk, strains in intergenerational relationships can develop into elder abuse. There are two parties involved in the abuse of the elderly: the aged person receiving care, and the caregiver. These individuals interact in harmony or discord. Elder abuse is exceptional behavior that occurs as a result of severe and unresolved intergenerational strains.
Vulnerability of the Elderly Person
Not without personal misgivings does the parent come into the child's home. Elderly people do not want to be a burden to their children. Efforts are made throughout later life to maintain independence. The old person may sacrifice companionship, comforts, and convenience to maintain an individual home. Although there is visiting and sharing between the generations, separate living quarters are maintained as long as possible. Illness and resulting needs will force changes that the aged parent may have difficulty accepting. Coping with physical and emotional losses will become complicated by having to relinquish autonomy.
Indeed, the aged person will find adjustment to a new living situation difficult at best, and intolerable at worn. Compounding this adjustment, the elder will be reminded by others that he or she is fortunate to have such attentive children. Few will understand the plight of the parent, and emotional support will be scarce. A dependent parent may allow infantilization and domination by the adult child; this same parent may at another time be assertive and establish parental authority. Such behavior is likely to arouse anger and personal resentment within the caregiver, particularly if past conflicts have not been resolved.15
SASC- STRESS ASSESSMENT SCORE OF THE CAREGIVER
Several common characteristics are identifiable among the abused family members. Studies indicate: that the victims are often middle-class, vulnerable, and dependent women with physical and/or mental disabilities. Some live alone, but some live with a spouse or relative. Their income is poor.5,16,17
Strains on the Caregiver
Needs of the dependent parent often become evident at about the same time as the adult daughter is looking for work and self-fulfillment. She may have been anticipating new educational or occupational challenges. Activities that lead to the accomplishment of developmental tasks will be deferred. The adult child will feel anxiety and strains proportionate to the personal desires that have been suppressed. Menopause, changing physical appearance, and illness may serve to remind her of her own aging processes and accentuate the anxiety that accompanies non-fulfilled developmental tasks.
Studies show that the caregiver at high risk of becoming an abuser is often a daughter or daughter-in-law, white, and 45 and older.15,18 The daughter in her middle years is often immersed in multiple roles that demand large quantities of energy and time. As a mother, wife, and employee, she will be experiencing strains that leave her with little opportunity to pursue any other activities. Care of a dependent parent at this point in time may trigger a crisis.
Instruments have been designed to assess for elder abuse within the family. Ferguson and Beck have developed a data collection tool that measures (H)ealth status within the family; (A)ttitudes toward aging; (L)iving arrangements; and (F)inances (H.A.L.F.). This checklist instrument was designed to assess for risk factors for family functioning and the occurrence of abuse. Completion will assist the nurse in identifying abuse or risk of abuse. In discussion of the use of this instrument, two case studies were cited. Tlie instrument was shown to be useful in identifying abusive factors within the home situation.16 However, the abuse in both cases was already present. Evidence of formal validation was not offered.
CRITERION-RELATED VALIDATION OF THE REAH COMPONENTS
Fulmer and Canili developed an Elder Assessment Protocol (TEAP) that was used on all elderly persons who were seen in the emergency room of a major urban hospital. Data taken from this protocol can be used as a baseline for data of elderly persons who are being assessed for elder abuse.19 This instrument makes no attempt to distinguish abused from non-abused elders.
Based on an interpretation of past research and the salient factors just described, an original assessment instrument was designed to evaluate the risk of elder abuse in the home (REAR). The REAM is the sum of two components, the vulnerability assessment score of the aged person (VASAP) and the stress assessment score of the caregiver (SASC). The VASAP and the SASC are added to find the REAH (see Figures 1 and 2). This combined score will provide an objective measure of strains and the potential for abuse.
Content validity was established through soliciting and receiving input from experts who have published research articles about elder abuse. Experts were asked to rate the describers included on the instruments on a continuum of I to 5 (least to greatest) for relevance and importance. Of 15 questionnaires sent, 67% (N=10) were completed. Variables receiving a mean score of 3 or under were dropped from the instrument and the instrument was thus revised.
In spring 1986, clinical validation of the REAH was done by the Family Counseling Service in Camden, New Jersey. Six social workers/counselors used the instrument in 38 homes. Families were visited periodically; a mean of three assessments were completed for each family, a total of 120 forms. Social workers recorded their subjective clinical evaluation of the risk of elder abuse in the home for comparison with the REAH score. Criterion-related validity was established by a positive correlation that was statistically significant for both profiles (p < .02 by Goodman's and Kruskal's gamma coefficient). Social workers using the instruments offered comments and valuable suggestions regarding the REAH's usefulness.
Family Monitoring and Prevention Measures
The professional health provider regularly visiting the home should offer ongoing holistic care to the entire family. Many strains and subtle family dynamics will not be evident on the first home visit, when an assessment is traditionally made. Furthermore, responses to the parameters within this assessment instrument may change over time. Subtle changes in relationships between the caregiver and the care receiver are often difficult to discern, particularly when visits are frequent. With an objective measure such as the REAH, the provider will maintain a high level of awareness toward the possibility of elder abuse.
If the REAH Index is calculated on a regular basis (such as monthly), changes in risk level can be objectively tallied. With a high REAH index in the presence of an undif ferenti ated and maladaptive family system, the risk of elder abuse is compounded.
A family therapist or social worker may help the caregiver to develop selfawareness. An educational program will increase insights and understanding of the aging process. At the same time, community resources may be useful for both the aged person and the caregiver. When possible, independence of the elderly person should be augmented and maintained. The caregiver may be able to return to employment or enjoy respite activities if some daily tasks of care are assumed by community agencies.
Many frail, dependent elderly within the community are receiving support and care from their families. Intentions may be good, but strains of relationships may develop over time. The professional health provider and case manager, whether a community health nurse, counselor, or social worker, has the opportunity to offer care, support, and ongoing assessments within this family system. Using the REAH parameters, family problems can be identified early and interventions can be planned and implemented. Holistic care to the entire family may avert the crisis of elder abuse.
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CRITERION-RELATED VALIDATION OF THE REAH COMPONENTS