Violence and abusive behavior continue to ravage homes, institutions, and communities across the country (Federal Bureau of Investigation, 2015). Elder abuse is part of this atrocity (Acierno et al., 2010). In previous versions of Healthy People, no specific elder abuse objectives were found (U.S. Department of Health and Human Services [USDHHS], 2000). In the 2020 version, the injury and violence prevention section mentions the goal to “prevent unintentional injuries and violence, and reduce their consequences,” and recognizes the need to understand the trends, causes, and prevention strategies of elder maltreatment (USDHHS, Office of Disease Prevention and Health Promotion, 2018, para. 1). In addition, a new section entitled Older Adults was added with a goal to “improve the health, function, and quality of life of older adults” (USDHHS, Office of Disease Prevention and Health Promotion, 2018, para. 1). The report notes that 1 to 2 million older adults are mistreated or injured by a caregiver or loved one (USDHHS, Office of Disease Prevention and Health Promotion, 2018). Individuals 65 and older are projected to comprise 20% of the United States population in 2030, compared to 13% in 2010 (Ortman, Velkoff, & Hogan, 2014). There are approximately 48 million individuals 65 and older in the United States; by 2030, this number is projected to be more than 70 million (Ortman et al., 2014). As the population ages, more individuals will be at risk for elder mistreatment. Further evaluation of elder abuse issues is required to achieve a reversal of unfavorable trends in abusive behaviors.
The purpose of the current evidence-based practice guideline is to facilitate health care professionals' assessment of older adults in domestic and institutional settings who are at risk for elder abuse, and to recommend interventions to reduce the incidence of mistreatment. Self-neglect (i.e., the failure of older adults to satisfy their own basic needs) is excluded from this guideline as it is not a crime.
The current article is a condensed version of the evidenced-based practice guideline, Elder Abuse Prevention (Daly, 2017), published by the Barbara and Richard Csomay Center at the University of Iowa College of Nursing. The full guideline may be purchased and downloaded in electronic format (access http://www.iowanursingguidelines.com).
Defining Elder Abuse
Elder abuse and neglect have been identified by various terms, including battered elder syndrome (Block & Sinnott, 1979), elder mistreatment (Hickey & Douglass, 1981), old age abuse (Eastman, 1984), parent battering (U.S. House of Representatives, Select Committee on Aging, 1978), older adult maltreatment, elder maltreatment, and abuse of older adults. The term elder abuse:
has the broadest public and professional recognition, has the capacity to accommodate the broadest variety of conceptually relevant behavioral categories, and can be appropriately used as an omnibus label for various situations where older adults or elders have been harmed as a result of being handled, treated, or used wrongly or improperly by caregivers or other persons in relationships where there is an expectation of trust.
The National Center on Elder Abuse supported by the Administration on Aging, now Administration for Community Living (access https://ncea.acl.gov), supports elder abuse definitions as shown in Table 1.
Definitions of Elder Abuse
Recent evidence indicates that elder abuse is associated with a range of adverse health outcomes. Substantiated reports of elder abuse have been linked to increased dementia, delusions, depression, and disability (Cooper et al., 2006; Cooper, Manela, Katona, & Livingston, 2008; Coyne, Reichman, & Berbig, 1993; Dyer, Pavlik, Murphy, & Hyman, 2000; Giraldo-Rodríquez, & Rosas-Carrasco, 2013; Pillemer & Suitor, 1992; Schofield, Powers, & Loxton, 2013), as well as to shorter life span after adjusting for other factors related to increased mortality in older adults (Lachs, Williams, O'Brien, Pillemer, & Charlson, 1998) and stroke (Homer & Gilleard, 1990).
Older adults in a shared living situation are more likely at risk for abuse than those living alone (Burgess, Brown, Bell, Ledray, & Poarch, 2005; Lachs, Williams, O'Brien, Hurst, & Horwitz, 1997; Peterson et al., 2014; Pillemer & Finkelhor, 1988; Pillemer & Suitor, 1992). Risk of abuse is also evident for individuals who have low income; are socially isolated or have a poor social network (Brozowski & Hall, 2010; Lachs, Williams, O'Brien, Hurst, & Horwitz, 1996); have low self-esteem (Brownell & Heiser, 2006; Sirey et al., 2015); have a history of an abusive relationship (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002); and abuse alcohol (Anetzberger, Korbin, & Austin, 1994; Conrad, Liu, & Iris, 2016). Women are abused more often than men, even after adjusting for proportion of gender in the aged population. Individuals 75 and older are abused and neglected two to three times more than the overall older adult population (Lachs, Berkman, Fulmer, & Horwitz, 1994; Laumann, Leitsch, & Waite, 2008; Wolf & Pillemer, 1989, 1997). Based on research, specific assessment criteria may indicate patients who are likely to benefit the most from use of this evidence-based practice guideline (Table 2) (American Medical Association, 1992; Bonnie & Wallace, 2003; Cohen, 2008; Cooper et al., 2006; Dyer et al., 2000; Lachs et al., 1994; Lachs et al., 1997; Sandmoe & Kirkevold, 2010; Shugarman, Fries, Wolf, & Morris, 2003; Vida, Monks, & Des Rosiers, 2002; World Health Organization, 2016).
Tools For Identifying Elder Abuse
Assessment Tools, Instruments, and Forms
Several instruments/tools are available to assess potential victims of abuse. Screening tools or in-depth assessments are appropriate depending on the practice setting. In a clinic or office setting, a few screening questions may be appropriate. In a home setting, where an allegation of abuse has been filed, a simple screening instrument would be only the beginning, with a detailed assessment to follow. Table 2 includes important assessments/instruments/tools that may be used in a variety of settings. The Figure is an algorithm for elder abuse assessment, which includes several of the instruments listed in Table 2.
Elder abuse assessment algorithm (Daly, 2017).
Preventing Elder Abuse
Prevention of elder abuse requires involvement of multiple sectors of society. Education and dissemination of information are vital for health care professionals and the public. Interventions for prevention of elder abuse have been suggested but have not been tested. Bonnie and Wallace (2003) stated, “no efforts have yet been made to develop, implement, and evaluate interventions based on scientifically grounded hypotheses about the cases of elder mistreatment, and no systematic research has been conducted to measure and evaluate the effects of existing interventions” (p. 121). Unfortunately, only 16 elder abuse intervention studies have been conducted, with the majority focused on education interventions for caregivers (Daly, Merchant, & Jogerst, 2011; Khanlary, Maarefvand, Biglarian, & Heravi-Karimooi, 2016; Mariam, McClure, Robinson, & Yang, 2015; Ploeg, Fear, Hutchison, MacMillan, & Bolan, 2009). Other interventions attempted were support groups for caregivers, which did not alleviate stress (Hsieh, Wang, Yen, & Liu, 2009), and daily money management to hinder financial exploitation (Wilber, 1991).
Appropriate interventions for preventing elder abuse include legislation, education, caregiver support/respite, social support, batterer interventions, money management programs, multidisciplinary teams, and circle of friends. Mariam et al. (2015) noted, “the first substantive component of most elder abuse interventions is the development of a relationship or alliance between a vulnerable elder and a service provider” (p. 20).
By 1985, every state had instituted adult protection programs and all states had enacted laws addressing adult and elder abuse in domestic and institutional settings by 1993 (Tatara, 1995). Because there has been no federally mandated structure, states have developed independent responses to elder mistreatment, which, in turn, have led to diverse investigative approaches. Jogerst, Daly, Brinig, et al. (2003) reviewed all 50 states' and the District of Columbia's adult protective services (APS)–related statutes and regulations to evaluate the impact of state APS legislation on the rates of investigated and substantiated domestic elder abuse. The following is a list of significant findings:
- States that require public education regarding elder abuse had higher abuse report rates, suggesting that heightened public awareness increases reporting of elder abuse.
- States that have mandatory reporters had a significantly higher investigation rate.
- Thirty-three states had a provision for penalties for failure to report abuse, which was significantly associated with higher investigation rates.
- Investigation rates were almost identical between states with or without a criterion of adult dependence or vulnerability.
- The higher the number of abuse definitions in the regulations, the higher the substantiation rates and ratios of substantiation/investigations.
- Caseworkers who investigated only elder abuse reports had a higher substantiation ratio than caseworkers assigned to child and elder abuse work.
- A state's administrative decision to track reports of abuse led to significantly higher investigation and substantiation rates as well as substantiation ratios.
- A higher proportion of total population categorized as elderly was associated with lower substantiation rates.
In another study evaluating the relationship of county/district APS investigative systems (investigative structure and investigator characteristics) on the rates of reported, investigated, and substantiated domestic elder abuse, questionnaires were sent to an APS director, supervisor, or investigator from each APS office (N = 1,763) nationwide with 1,409 (80%) returned questionnaires (Jogerst, Daly, & Ingram, 2001). Elder abuse reports, investigations, and substantiations were obtained from state APS administrators. Sixty-nine percent of respondents believed an older adult was better off “most of the time” after an elder abuse investigation and interventions were implemented, and 31% believed the older adult was better off “some of the time.” Respondents who reported “most of the time” worked in offices that had significantly higher investigation and substantiation rates compared to respondents who answered “some of the time.” Higher minimum educational level of respondents was significantly related to higher substantiation ratios, and those with a social work degree had significantly higher investigation and substantiation rates. Substantiation rates and ratios grew with increasing length of training. Investigators who had responsibilities for child and elder abuse investigations had significantly lower investigation and substantiation rates (Jogerst, Daly, Brinig, et al., 2003).
Nine state protective services statutes address multidisciplinary teams with the main purpose of diverse disciplines coming together to provide a comprehensive assessment and consultation for individuals at risk for abuse and those who are victims of abuse. States with statute language mandating multidisciplinary teams have significantly higher elder abuse investigation rates than states that do not have such language (Daly & Jogerst, 2013).
Iowa is the only state that requires education for mandatory reporters. An individual required to report allegations of dependent adult abuse must complete 2 hours of training within 6 months of initial employment and every 5 years thereafter (IA ST § 235B.1 I.C.A. § 235B.1). Comparing the investigation and substantiation rates for elder abuse allegations before and after July 1988, when the Iowa statute was revised to ensure training of mandatory reporters, elder abuse investigation and substantiation rates did not change, indicating required education may not have impacted cases of abuse (Jogerst, Daly, Dawson, Brinig, & Schmuch, 2003).
Although legislation and public policy impact elder abuse rates, there are other interventions specific to the type of abuse that are also beneficial. Approximately eight educational interventions have demonstrated use in prevention or reduction of elder abuse and have focused on caregivers (Desy & Prohaska, 2008; Goodridge, Johnston, & Thomson, 1997; Hsieh et al., 2009; Pillemer & Hudson, 1993; Richardson, Kitchen, & Livingston, 2002, 2004; Uva & Guttman, 1996; Vinton, 1993). Education interventions range from 1 hour to 3 days and are taught by many different methods, such as one-to-one instruction, education in a classroom or at a conference, or education with group support (Teitelman & O'Neill, 2000). Evidence from a systematic review indicates that interactive sessions are more beneficial than print material, providing opportunities to ask questions, engage in discussion, network, and learn from others' experiences (Alt, Nguyen, & Meurer, 2011). Improvements were noted by increased knowledge (Desy & Prohaska, 2008), use of assessment tools (Desy & Prohaska, 2008), improved job performance (Goodridge et al., 1997), and declines in reports of abusive actions of staff (Pillemer & Hudson, 1993).
Pillemer and Hudson (1993) developed and implemented a model abuse prevention curriculum for nursing assistants employed in nursing facilities. The eight-module curriculum included video, lecture, problem solving, role-playing, and group support (Hudson, 1992). Following the intervention, the number of conflicts with residents had declined and a reduction in resident aggression was reported. Another educational intervention comprising a video, booklet, and interactive workshop was conducted with nursing assistants in nursing facilities in Hawaii. The pre-/posttest design indicated improved job satisfaction (Braun, Suzuki, Cusick, & Howard-Carhart, 1997).
A recent study involved the Family-Based Cognitive-Behavioral Social Work intervention to reduce elder abuse in a randomized clinical trial where 12 older adults received and 15 older adults did not receive the intervention. Five education sessions were provided to all family members to understand the concepts of elder abuse and its triggers, neglect, principles of elderly caretaking, and principles and techniques of conflict resolution. Family members took an active role in the sessions and their respective homework, resulting in a significant decrease in emotional neglect, care neglect, financial neglect, psychological abuse, curtailment of personal autonomy, and financial abuse, with no significant difference in physical abuse (Khanlary et al., 2016).
Respite, as an intervention to prevent elder abuse, has not been shown to reduce or prevent elder abuse. Respite literature is found in two categories: studies that measure and describe outcomes and studies that evaluate use. Three types of respite care are available: adult day care, in-home, and institutional (Townsend & Kosloski, 2002). Among families and service providers, respite services are desired and needed by individuals caring for those who are dependent. “Respite is one way in which the strain of caregiving may be relieved” (Nicoll, Ashworth, McNally, & Newman, 2002, p. 479).
Respite is temporary relief for caregivers that is available when needed. This relief may reduce caregivers' level of stress and burden, which may then enhance the quality of interactions between caregivers and dependent individuals, which may in turn alleviate some abuse. Rates of physical abuse by caregivers have been documented from 5% (Paveza et al., 1992) to 12% (Coyne et al., 1993).
Through 10 in-depth qualitative interviews of caregivers, the need to support the caregiver's role was identified (Lane, McKenna, Ryan, & Fleming, 2003). The stress of caring for someone 24 hours per day impacts caregivers' psychological well-being. In-home respite was suggested to relieve the burden without causing additional problems for dependent individuals related to relocation. Family support was another suggestion to relieve caregiver burden (Lane et al., 2003). Townsend and Kosloski (2002) identified factors related to client satisfaction and found that caregivers who were able to dress and transport the dependent individual to adult day care services were more satisfied than caregivers who were unable to do so. Use of adult day care services was also a significant finding by Montgomery, Marquis, Schaefer, and Kosloski (2002). Caregiver health or inability to transport the dependent individual is not an issue for in-home respite. Piloting a weekend respite program, Perry and Bontinen (2001) found that caregivers need to be reassured their loved ones are safe in a respite program and that caregivers and dependent individuals benefit from the experience. In addition, social support is an important factor in a caregiver's satisfaction with respite care (Nicoll et al., 2002). Demonstrating an alternative to respite, Korn et al. (2009) used polarity therapy, a touch therapy that uses gentle pressure on energy points and biofields to help the client achieve physiological relaxation. Comparing caregivers randomized to polarity therapy or enhanced respite, caregiver stress, depression, vitality, and general health improved in the polarity therapy group (Korn et al., 2009).
McNally, Ben-Shlomo, and Newman (1999) attempted to conduct a meta-analysis of respite intervention studies to determine its effect on caregivers. Twenty-nine studies were appropriate for analyses, but because of the variety of respite interventions offered, a true meta-analysis was not possible. The researchers determined that “although caregivers often exhibit improvements in well-being during respite periods, these gains are short-lived,” suggesting respite does not provide a long-term social support system (McNally et al., 1999, p. 13).
Caregivers have identified a need for social support, which varies with an individual's stage of life, length of time as a caregiver, and acuity and intensity of the caregiving situation (Norbeck, Chaftez, Skodol-Wilson, & Weiss, 1991). For example, care for individuals who have total hip replacements is dramatically different than care for individuals with dementia. A meta-analysis of 18 studies providing interventions for caregiver distress demonstrated that respite services and individual psychosocial interventions were moderately effective and group psychosocial interventions were slightly effective (Knight, Lutsky, & Macofsky-Urban, 1993). In another literature review, Tilford, Delaney, and Vogels (1997) reviewed the effectiveness of mental health interventions for long-term caregivers of highly dependent individuals and concluded psychosocial interventions promoting support and coping help reduce caregiver stress.
In a qualitative study, four themes of caregiver support were identified: need for a social life, need for instrumental support, need for informational support, and need for emotional support (Ploeg, Biehler, Willison, Hutchison, & Blythe, 2001). It was recommended that telephone support services have the potential to provide informational, emotional, and social support. In summary, the research literature provides a wealth of information on social support and its measurement, but it has not been tested as an intervention to prevent elder abuse.
A support program established as an elder abuse intervention and prevention program, Eliciting Change in At-Risk Elders, provided community partnerships with law enforcement and program staff of the Heritage Clinic and Community Assistance Program for Seniors. Law enforcement referred individuals who had elder abuse prevention or intervention needs, and trained outreach specialists worked with older adults to identify their needs and put services in place. Evaluating these services over a few months' time (individualized to the older adult's needs) resulted in a decrease in risk factors for elder abuse, and participants made progress in reaching their goals (Mariam et al., 2015).
Vinton (1991) notes that abuse of women is evident across the life span, with the prevalence of spouse abuse decreasing with age. Batterer intervention programs to prevent further violence are available after the fact for individuals who stay with the perpetrator. However, a U.S. Department of Justice (2003) report summarizing the research literature indicated batterer intervention programs do not have positive results.
Batterer intervention programs are established and implemented based on different theories, such as men control their partners, batterer has errors in thinking, and battering has multiple causes. Thus, programs are different and focus on helping batterers confront their attitudes about control, learn skills in anger management, use cognitive therapy, use couples therapy, or a combination of these approaches. In 88% of 34 programs offering cognitive-behavioral therapy, the reoffense rates were significantly lower in treatment groups (U.S. Department of Justice, 2003). Batterer interventions remain marginally effective and researchers propose that adding principles of effective intervention to batterer intervention programs could be more effective (Radatz & Wright, 2016).
Money Management Programs
Intervention trials to prevent exploitation have not been completed, but daily money management (DMM) programs have emerged as a result of professionals in diverse settings observing their clients having exploitation problems. DMM programs assist individuals who have difficulty managing their personal financial affairs, which include preparing checks, making bank deposits, dispensing cash, negotiating with creditors, maintaining home payroll for attendants, calculating federal and state taxes, and providing personal financial assistance. The roles of DMM are educators, client advocates, debt managers, bill payers, paying agents, representative payees, attorneys-in-fact, trustees, and guardians (Nerenberg, 2003). DMM services are offered to older adults in different delivery mechanisms, which include older adult assistance agencies or area agency on aging/protective service agencies, which may be non-profit and through other programs that are for-profit. Private, for-profit services may be concerning and are not regulated by the federal or state governments. Referrals by trusted sources and individuals associated with the American Association of Daily Money Managers (access https://www.aadmm.com) are reputable.
Wilber (1991) examined whether DMM services would divert vulnerable older adults from conservatorship (i.e., legal arrangement under which an individual is appointed by the court to manage the affairs of an adult). Sixty-three community-dwelling older adults ages 60 to 96 were assigned to usual customary screening or money management groups. After 12 months of intervention, there were no significant differences in rates of conservatorship between groups, suggesting individuals who require conservatorship may be different from those who need DMM services (Wilber, 1991).
Spreng, Karlawish, and Marson (2016) note that changes in older adults' cognitive and socioemotional functioning can lead to exploitation risk through poor decision making. Poor financial skills are associated with increasing cognitive changes, and declining social capacity can lead to coercion and deception, both of which increase risk for financial exploitation.
Circle of Friends
A new elder abuse prevention intervention concept, circle of friends, has been discussed on the National Center on Elder Abuse listserv (access https://ncea.acl.gov/connectwithus/stayintouch-listserv.html). No literature, research or otherwise, has been found regarding this concept. However, the focus of a circle of friends is a group of individuals sharing a common interest. That circle of friends may be a card club, quilters group, or faith community. The main aspect of an intervention with a circle of friends is that the concept of elder abuse is discussed. Specific topics or general concepts could be discussed, but the idea is that the group starts talking and someone who may be vulnerable begins to ask questions. Particularly relevant are internet or e-mail fraud, such as investment schemes where e-mails are sent touting investments with high rates of return, or the romance scam where a stranger pretends to be romantic and wins the affection of the victim to gain his/her money.
Individuals who are involved with a circle of friends can reach out to those they think need help by listening to their experiences, being respectful of their decisions, encouraging them to keep track of any problems, and providing them with information on who can help them.