FINAL EXAM

Chapter 12: Abuse of Elderly and Disabled Persons

Lecture Outline

I. Scope of the Problem

a. Defining Elder Abuse

i. American Psychological Association definition

1. infliction of physical, emotional, or psychological harm on an older adult; can take the form of financial exploitation or intentional or unintentional neglect of an older adult by the caregiver

ii. Public definitions of elder abuse

1. 63% or more of the individual endorsed all of physical abuse items (e.g., “hit”) as always signifying elder abuse

2. majority also endorsed the neglect items as abusive but did so at a lower level

3. emotional abuse items (e.g., “criticizing the elder”) endorsed as abusive grew over the years

4. people had a fairly accurate idea of what behaviors constitute elder abuse

iii. Definitional limitations

1. requires that the parties involved be immediate family members or intimate partners, but it leaves out an essential subgroup of abusers (i.e. unrelated caregivers)

b. Examples of Specific Abuses

i. Emotional/psychological abuses

1. verbal assaults, insults, threats, intimidation, humiliation, harassment

2. treating an elder person like an infant, isolating the person from his/her/family, friends, or regular activities, giving the person the silent treatment, and enforced social isolation

3. not illegal

ii. Physical abuses

1. striking a person with or without an object, hitting, beating, pushing shoving, shaking, slapping, kicking, pinching, and burning

2. inappropriate use of drugs, physical restraints, force-feeding, and physical punishment

iii. Financial abuse

1. abuse of a durable power of attorney, bank account, or guardianship

2. failing to compensate transfers of real estate

3. charging excessive amounts for goods and services delivered to an elder

4. using undue influence to gain control of an elder’s money or property

5. confiscating pension or Social Security checks

6. denying medical care to avoid paying the cost of care

7. refusing to repay loans

iv. Sexual abuse

1. direct

a. intercourse, molestation, sexualized kissing, oral/genital contact, and digital penetration

2. indirect

a. unwanted sexual discussions, exhibitionism, and exposed masturbation

v. Internet pornography

1. still photographs of elderly women posed in every conceivable sexual activity

2. video clips of elderly women engaged in sexual activities

3. classified as pornography, but laws regarding the use of older women hinge on the adults’ ability to consent

vi. Neglect

1. failure to provide an elderly person with food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety

vii. Self-Neglect

1. failure of an elder to provide food, water, clothing, shelter, personal hygiene, and medication for himself

2. threatens his life or safety

3. exclude a mentally competent adult who understands the consequences of his actions

viii. Abandonment

1. examples

a. putting an elder demented person on a bus to another state

b. dropping an elder off at the hospital with no identification (i.e., granny dumping)

2. “patient dumping” at hospitals and nursing homes

ix. Violation of Human Rights

1. caregiver withholds an elder victim’s mail

2. removing all the doors from the elder’s room to deprive her of privacy

3. interfering with the elder’s religious observances

4. ignoring the elder person’s preferences in his selection of friends

x. Scams by strangers

1. valueless “sweepstakes” that elder must pay to collect

2. fraudulent investment schemes

3. requiring cash deposits for repairs

4. predatory lending

5. lottery scams

c. Attitudes toward Abuse of Elderly Persons

i. six viewpoints that promote elder abuse

1. ageism

2. sexism

3. proviolence attitudes

4. reactions to abuse

5. negative attitudes toward people with disabilities

6. family caregiving imperatives

ii. Ageism

1. postmaturity—the idea that elders are living too long

2. elders cast in the role of second class citizens

3. three types of ageism

a. personal (one’s own beliefs)

b. institutional (e.g., mandatory retirement age)

c. unintentional/unaware practices (e.g., elders are unproductive)

4. elders were the target of workplace abuse (usually emotional)

5. mock jurors question the credibility of elders’ testimony in cases of elder sexual abuse

6. elder caregivers and males were less likely to acknowledge the severity of elder abuse

iii. Media stereotyping

1. media shows great bias in depicting characters in terms of both sexism and ageism

2. male characters outnumber major female characters (73% vs. 27%) and the number of elder males and females continually drops off with age

3. few depictions of elders who lead rewarding lives

4. only role in life is to serve as a supportive character to children and grandchildren

5. media portrays them as cranky and laughable

iv. Criminalization of elder abuse

1. individuals who do commit crimes against the elderly are categorized as criminals

2. police chiefs tended to evaluate street crimes as more serious than crimes against elderly people

3. nursing home ombudsmen judged crimes against elderly persons as more serious

II. Prevalence

a. Disclosure reluctance

i. failure-to-disclose rates as high as 50%

b. Beliefs of elders

i. one-third of the women participants were victims of intimate male partners

ii. some elder women did not disclose their husband’s abuse for fear of upsetting their adult children or fear of not being believed

iii. Barriers to disclosure

1. powerlessness

2. self-blame

3. secrecy

4. protecting family

5. hopelessness

c. Methodological Issues

i. lack of clear definitions of elder abuse has led to inadequate reporting by community worker

ii. reporters receive no feedback about the results of an investigation

iii. sample differences

iv. setting of the interview and the context of questions (e.g., relationships of seniors, daily lives of seniors) affects disclosure rates

d. Types of Injuries and Estimates

i. 55.4%) of elders treated were men

ii. primary injuries

1. contusion/abrasion: 31.9%

2. laceration: 21.1%

3. fracture: 12.7%

iii. primary sources of assaults

1. by body part: 20.3%

2. by blunt object: 17.1%

3. by pushing: 14.4%

4. undetermined: 31.8%

iv. most likely perpetrators were family members or acquaintances

III. Consequences of Elder Abuse

a. Health Consequences

i. intimate partner abuse victims suffered significantly more chronic pain, depression, and high blood pressure

b. Reactions of Professional Practitioners

i. Social service agencies

1. screening elderly clients for abuse and refer the client to Adult Protective Services is a basic responsibility of senior centers, adult day services, and community-based health services

ii. Adult Protective Services (APS)

1. implement legal policies concerning elders

2. determine whether the information available is sufficient to warrant an investigation

3. substantiate whether abuse/neglect actually occurred

4. assess the elder’s decision-making capacity about his or her care

5. evaluate what services are needed to sustain the elder

iii. Investigations by APS

1. statutory power to investigate reported abuse in domestic settings

2. some needs of elder abuse victims exceed APS agencies’ functions

iv. In-home assessments

1. APS workers prescribed one or more interventions for 46% of the elderly clients

2. APS referrals

a. institutional placement: 36%

b. guardianship: 36%

c. urgent medications: 25%

d. acute hospitalization: 20%

c. Refusing service

i. not uncommon for elders to refuse the services offered by APS workers, but only 16% of elders contacted by APS refused services

ii. elders who refused care often did so because the services offered (respite care and homemaker services) did not meet their needs when these women needed emergency shelters and restraining orders

iii. APS “discharges” elder victims from various support systems if APS personnel judge the elder to be capable of acting on her own behalf

IV. Patterns of Abused Elders and Elder Abusers

a. Characteristics of Abused Elders

i. Age

1. fastest-growing group of elders in the United States today is made up of individuals 80 years old and older

2. these elders are targets of abuse and neglect significantly more often than others

ii. Gender and relationship of abuser and victim

1. Victims

a. Male: 32% (as parent victim)

b. Male: 20% (as spouse victim)

c. Female: 68% (as parent victim)

d. Female: 80% (as spouse victim)

iii. Race

1. Victims

a. 77% White

b. 21% Black

c. 4% Hispanic

d. 0.5% Asian

e. 0.5% Native American

b. Characteristics of Elder Abusers

i. Age

1. 75.1% of elder abusers were under the age of 60 (Teaster et al., 2006, APS study)

2. 75% were over age 50 and 20% were over 70 (Pillemer & Finkelhor, 1998, community survey)

3. abusers who are elders themselves may suffer from dementia or other problems that render them less able to care for dependent elders and more likely to abuse those elders

a. some abuse may result from ignorance or incompetence

b. some neglect by such elders may be conscious and premeditated

ii. Gender of abusers

1. 52.7% of abusers of elders 60+ years were female

2. 47.3% of abusers of elders 60+ years were males

3. sons were more abusive than daughters toward elderly parents

4. daughters perpetrated more when neglect was included as a category of abuse

iii. Relationship of abusers to victim

1. family members are the primary perpetrators of elder abuse

2. intimates (spouses, partners, ex-intimates) also comprise a very large group of abusers

3. relationship to the victim

a. adult child: 32.8%

b. other family member: 21.5%

c. unknown: 16.3%

d. partner: 11.3%

V. Explaining Abuse

a. Social Learning Theory

i. children exposed to violence are likely to grow up to adopt proabuse norms that eventually contribute to their abusing their own parents or grandparents

ii. retaliatory response for past abuse—You hurt me then; now I’ll hurt you

iii. research has not strongly supported a learning connection

b. Social Exchange Theory

i. social interactions involve exchange of rewards and punishments between people and that people seek to maximize rewards and minimize punishments in these exchanges

ii. elders have little to offer in the way of rewards, so interacting with them is costly and rarely pays off

iii. high costs of assuming responsibility for elder care with the few tangible rewards can result in abuse

c. Stress and Dependency Theories

d. Caregiving burdens

i. “36-hour day”

ii. “sandwich generation”

iii. theory that caregiver stress causes elder abuse

e. Dependency of abused elders

i. elder dependency is a strong predisposing factor for abuse

ii. Alzheimer’s-impaired elders were at greater risk for abuse than elders without the disease

iii. caregiver stress was a risk factor for emotional and financial mistreatment of elders

iv. majority of published studies do not support the caregiver-stress model

f. Abuse by the severely mentally ill (SMI)

i. most abusers are not mentally ill

ii. of 0.028% people with severe mental illness/major mental disorder, 28.9% experienced 2 or more stressful life events, 25.0% suffered from impaired social support, and 8.3% were violent

iii. risk of violence increased with levels of stressful life events and impaired social relationships, and targets were most frequently family members

g. Alcohol and drug use of mentally ill abusers

i. risk factors for being abused

1. being a mother co-resident of a mentally ill person who has a substance abuse disorder

2. being an immediate family member who has a relationship with the SMI

3. duration of time spent in co-residency with the SMI

4. whether the SMI is financially dependent on the family member

h. Criminality of elder abusers

i. elder abusers have high rates of criminality and adult children who are abusive can be considered predatory offspring

i. Revictimization studies

i. 20% of elder victims had been revictimized:

1. 84.6% by the original abuser

2. 17.1% by different abuser

3. 3.3% by same and different abuser

ii. 64% had experienced some form of child abuse

iii. 41% of the women had suffered intimate partner violence for an average of 14.5 years

VI. Practice, Policy, & Prevention

a. Practice Issues for Treating Elder Abuse

i. Recognizing elder abuse

1. many students were unable to detect abuse and neglect in the a vignette study

2. medical students were able to specify behaviors that were not abusive/neglectful (e.g., getting an ID bracelet for the elder)

3. hands-on experience as a professional caregiver substantially improved their detection rates of victims

4. university instruction on elder abuse/neglect did not improve detection rates

5. Asian medical students were less likely to recognize abuse when compared with Anglo students

ii. Practitioner training

1. three most important group targets of elder abuse education

a. professionals

b. community leaders

c. elderly themselves

2. 33% of a group of various types of service providers said they would like more training

3. 40% had received no training

a. failing to validate cases of real abuse leaves victims vulnerable to ongoing or even escalating abuse

b. falsely judging a situation to be elder abuse may cause extreme harm

i. lawsuits

ii. forced registration of individuals on central registries

iii. criminal prosecutions

iv. loss of licenses

v. other sanctions

iii. Guardianship dilemmas

1. social workers need a basic understanding of the decision-making process undertaken to determine the need for a guardianship appointment

b. REACH program for elder women (to identify problems including abuse)

i. avoided using stigmatizing terms such as domestic violence and battered woman when placing advertisements about support groups

ii. fashioned ads that used terminology suitable for attracting needy and isolated older women

iii. referring to the “concerns of older women,” were more palatable to their target audience than ads that mentioned the “abuse of older women”

iv. social support was positively associated with proactive coping and was negatively associated with depression and functional disability

c. Helping elders abused by offspring

i. help the victim-parent deal with feelings of guilt, fear, and embarrassment

ii. avoid blaming either the victim or the offender and build rapport

iii. individualize treatment

iv. help raise victim’s self-esteem

v. know what services are available for the problematic offspring

vi. help victim-parent set ground rules if offender-offspring stays in the house

vii. challenge victim’s thinking errors (e.g., offspring cannot control behavior)

viii. for treatment of anxiety, cognitive behavior therapy is most effective

d. Social Service (APS) Responses to Elder Abuse

i. Treatment of elder abusers

1. find ways for the abused elder victim to help the caregiver

2. ineffective approach is to enroll elder abusers in batterer counseling groups since the counseling needs of elder abusers seem not to parallel those of younger batterers

3. least effective approach was to try to effect changes in the circumstances of the perpetrator

ii. Research findings on programs for elders

1. reduction in elders’ loneliness by day care participation

2. reduction in depression through a life-review (i.e., focused reminiscence)

3. reduction in mortality associated with participation in day care services

4. higher rates of victim compliance (follow-through) with recommended agency referrals if abuser had substance abuse/mental illness problem

iii. Criminal Justice System Responses

1. Police responses

a. police were not reluctant to arrest elder abuse suspects

b. arrest, prosecution, and incarceration, nonetheless, did not prevent reabuse, and revictimizers were particularly prone to violating orders of protection

2. Prosecutors

a. prosecution of elder abuse and fraud is rarely successful

b. few prosecutions continue beyond the investigatory phase

c. most cases have been closed because evidence is lacking

d. prosecutors were more likely to charge elder abusers than abusers of younger women with felonies instead of misdemeanors

e. drop-offs between arrest, decision to prosecute, guilty verdict, and incarceration

f. elder victims (60+) were as cooperative with prosecutors as younger victims (50–59)

e. Legal Issues

i. preventions or punishments

1. denying sex offenders residency and sex offender employment in nursing homes

2. identifying “gray murders” (unidentified murders)

3. completely overhauling APS (in Texas)

4. placing undercover patients in homes to identify abuse

ii. new types of abuse or new definitions

1. abduction—removing a vulnerable adult from California or preventing the return to state

2. abandonment―a caregiver’s desertion at a time when a reasonable person would continue providing care

3. isolation―false imprisonment or preventing the elder from communicating with the outside world

iii. The Elder Justice Act

1. bill aimed to change the age of an elder to 60 years, down from 65

2. bill aimed to enact or strengthen laws protecting elders

3. has not passed legislation

iv. Legal access

1. attorneys can execute court and non-court actions as well as legal and “non-legal” actions that have the potential to help the elder person threaten court action to prevent abuse

2. over 40% of senior citizens suffer from some form of disability

a. poor hearing

b. mobility problems (cannot access the court building)

c. no transportation to court

d. deafness or other communication problems

e. limited stamina

f. some tendencies toward mental confusion

v. Legal needs of elders

1. an order of protection to remove the abuser from the residence

2. guardianship of the elder and/or his or her estate

3. representative payeeship to safeguard certain types of the elder’s income, such as social security

4. protection against involuntary commitment to a mental health care facility

vi. Reducing financial exploitation

1. laws protecting elderly people from financial abuse generally require a complete overhaul

2. laws are aimed at minimizing opportunities for exploitation by an incapacitated elder’s agent

3. power of attorney in common law or mandated in civil law systems is an authorization to act on someone else’s behalf in a legal or business matter

4. standard of care owed

a. to act in the best interests of the principal

b. to keep the principal’s property separate from the property of the agent

c. to keep records of the agent’s transactions on behalf of the principal

d. to make records and a copy of the power of attorney available upon the request of key individuals

e. to avoid conflicts of interest

5. now the principal must personally “check” boxes giving the agent any special powers

6. two individuals must sign that they witnessed the principal’s check-offs and the whole document must be notarized

7. third parties may refuse to honor certain powers of attorney under certain circumstances

vii. Medicare/Medicaid fraud

1. $60 billion of annual Medicare expenditures are fraudulent

2. siphoning off of these funds is an indirect form of elder abuse because it reduces the amount of funding available for other needed elder services

3. over 90% of the coding was incorrect, a practice undertaken to make higher claims for benefits

4. fraud committed by drug companies has been exceptional

f. Medical Responses

i. Medical screening

1. most hospital and medical center emergency departments have screening protocols for identifying and reporting elder abuse

2. lack psychometric assessment tools

3. medical experts in nearly every field (e.g., ophthalmology, neurology) should participate in screening elders suspected of being victims of elder abuse

ii. Assessment tools

1. valuable advance has been the development of a one-page assessment and management tool for identifying elder abuse (e.g., Expanded Indicators of Abuse)

iii. Documenting abuse

1. nurses can check an elder’s body for physical signs of abuse or inadequate care and conduct a psychological assessment

2. nurses and other medical personnel should photograph and document any evidence of elder abuse

iv. Possible physical signs of abuse

1. certain conditions should be “red flags” to physicians that abuse may be or has been a problem for an elderly patient

v. Perceptions of abuse by care providers

1. over 95% EMS workers believed that elder abuse was not a rare event

2. yet 51.3% said they had no reason to suspect that any of their clients had been abused

3. EMS had trouble with the ambiguity between abuse/neglect and self-abuse/self-neglect

vi. Mandatory reporting compliance

1. most states have resource hotlines that anyone can call for assistance in matters of elder abuse

2. when states require mandated reporting, significantly higher rates of investigations take place

vii. Failure to report

1. medical personnel are often reluctant to report suspected cases of elder abuse

2. doctors (36%) and nurses (60%) feared becoming involved in lengthy court appearances

3. others were unaware of reporting laws, believed that the problem was not serious enough, the evidence was insufficient, services were inadequate, and the report would disrupt family relationships

4. reasons for doctors’ reluctance to report

a. working diligently to establish rapport with a patient can be undermined by disclosing suspected abuse

b. reporting elder abuse may lead to a response by APS or law enforcement that diminishes the victim’s quality life

c. reporting abuse may lead to a loss of the physician’s decision-making power about what needs to be done in the “best interest” of the elder patient

viii. Physician education about elder abuse

1. 72% said they had received no exposure to elder abuse

2. did not believe it was a significant problem

3. did not ask any patient about being abused

4. medical schools are slowly adding elements to their curriculums on managing elder abuse

5. emergency medicine and internal medicine should add clinical experience with abused elders to their training

g. Policy Issues for Combating Elder Abuse

i. Non-Collaboration between Adult Protective Services and Domestic Violence Programs

1. better coordination between adult protective services and domestic violence groups

ii. Successful collaboration

1. Elder Abuse Forensic Center at the University of California at Irvine

2. Team Membership

a. Adult Protective Services

b. long-term care ombudsman

c. Sheriff’s department

d. district attorney’s office

e. Vulnerable Adult Specialist Team

f. public guardian’s office

g. Older Adult Services

h. Victim Witness Assistance Program

i. Human Options (domestic violence services)

iii. members thought working together was both time-saving and more effective than working independently

iv. members’ satisfaction with the collaboration was high

v. members from the district attorney’s office ranked the experience higher

h. Shelters for elderly abused women

i. access to battered women’s shelters, however, may not be as helpful to elderly women as better access to elder care facilities

ii. one school of architecture designed special furniture for a cottage housing abused elders

iii. converting an assisted living center into a shelter is an excellent solution as because it is suitable for housing women of any age and their families

iv. even when there are shelters available, victims usually have no idea about their accessibility

i. Emergency disaster care

i. need for policy change in evacuating ill elders during disasters became evident during Hurricane Katrina

ii. APS workers’ disaster training was inadequate

iii. databases containing clients’ names are not available to help workers keep track of elder clients

j. Criminal Justice System responses

i. Training needs

1. when to report abuse to social service agencies

2. dissemination of effective police procedures should help increase the arrest rate

3. establish medical forensic forms for use with abused elders

4. videotapes for police training

5. specialized elder abuse police units

ii. Funding police

1. police departments need funding

a. develop on-scene protocols for cases of possible elder abuse and abuse of the disabled

b. purchase special transportation vehicles (e.g., for transport of wheelchair-bound victims)

c. hire specialists (e.g., sign-language interpreters)

iii. Improving the court’s oversight of guardianship matters

1. Concerns

a. 25% do not require guardians to file status reports

b. 33% do not require verification of information in the reports, although 16% verify every report

c. 40% do not designate anyone to visit the incapacitated person

d. many courts (for legal requirements governing judges’ informal communications outside of the courtroom) decline to act on complaints about a guardian’s behavior without a formal petition

e. complicated procedures make it nearly impossible to locate specifics about guardianships

f. lay people find it nearly impossible to follow procedural requirements for making complaints

2. current improvements

a. placing English and Spanish versions of court forms on the Internet

b. using court accountants to review the financial accounting of guardians’ reports

c. inputting on the computer the due dates for guardians’ reports to be filed

d. charging fees for filing of guardianship papers to offset the costs for the court’s supervision

iv. Improving the court’s response to elder mistreatment

1. complicating factors for courts

a. the nature of a case

i. tenant eviction case may actually be a case of elder neglect requiring a conservatorship

ii. criminal, civil, and probate, may eventuate into an elder abuse case

b. the slow pace of legal proceedings hinders prosecution of elder abusers

i. one advance would be to allow elders to submit testimony via videotape to resolve situations in which elders die or lose the capacity to testify before a trial starts

v. help prevent financial exploitation by setting up restricted accounts which require a court order for withdrawal of money and restricting the sale of property

k. Legislation

i. Needs

1. pass laws governing gifting of assets to members of professional organizations, such as doctors and attorneys

2. modify bankruptcy laws to prevent elder abusers from confiscating an elder’s assets and then declaring bankruptcy to escape responsibility for the abuse

3. refashion their laws taking the opinions of these two groups into account (police representatives and elder care experts)

ii. University courses on aging

1. often failed to include the topic of elder abuse, but progress is starting to occur

2. American Psychological Association committee on aging addressed the U.S. Congress about the need for more geropsychologists

3. states should require licensed professionals to take continuing education courses in health care, gerontology, elder abuse, and abuse of the disabled

iii. Community involvement

1. need to make a large number of changes in practices and policies to protect vulnerable elders

2. reduce the fragmentation of service delivery

iv. n. Multidisciplinary teams

1. agency teamwork is the most viable form of response to the multifaceted problem of elder abuse

2. improve victim identification as well as the quality of decision making concerning the most effective methods of intervening and which agencies are best suited to the task

3. personnel working in the field of elder abuse seem more willing than personnel working in other areas of family violence (e.g., violence against female partners, rural workers) to join forces to provide protection and services

4. Teams

a. The Weinberg Center uses a comprehensive multidisciplinary team that works with a network of private and government agencies to address multiple needs, such as legal advocacy, housing, and education and support for informal caregivers

b. Project Gatekeeper, Think S.A.F.E. (Wayne County Michigan)

i. Senior Alliance dedicated to preserving and enhancing the independence of elder persons and those with disabilities

ii. network of 50 programs and services, such as home delivery of meals, care management, and chore services

iii. provide training to increase abuse awareness of caregivers

c. “Gray Murder” teams review deaths to detect murders that may go undetected because medical doctors determined that there was considerable amount of death certificate inaccuracy and underreporting of injuries in elderly people

d. Elder Abuse Forensic Center (Orange County, California). A medical doctor, social worker, and police detective team meets at least once a week to assist each other in handling elder abuse reports and making decisions about cases, such as whether to prosecute alleged abusers or whether to provide caregiver support

e. Financial Abuse Specialist Teams

i. district attorney, a stock broker, a bank trust officer, a retired probate judge, and public guardian staff

ii. duties include training APS representatives, public guardians, and ombudsmen in how to detect financial abuse of elders

iii. acts as a fiduciary SWAT team by sweeping into banks and other areas to safeguard seniors by suggesting that administrators put a hold on the seniors’ assets

f. Project C.A.R.E. (Caregiver Alternatives to Running on Empty)

i. available in 38 states

ii. provides assistance to caregivers of elders with dementia

iii. developed a network of community-based, comprehensive care support

iv. grants $2,000 annually to minority and rural caregivers for such services as in-home and overnight respite care

v. Research agenda

1. lack of empirical research on elder abuse and the abuse of disabled persons is lacking

2. interdisciplinary group of researchers formulated a national agenda of research priorities on the subject of elder abuse

vi. Expanded research topics

1. topics of research were quite limited and only included prevalence estimates, typologies of abuse, and definitions

2. academic training of the first authors was also restricted, primarily to medicine, nursing, and social sciences

3. disproportionate number of professionals, personnel, cases, and charts used, rather than elder participants

l. Prevention

i. Public awareness campaign

1. California State Legislature produced a booklet titled “A Citizen’s Guide to Preventing and Reporting Elder Abuse”

a. no published outcomes yet

ii. Improving official evaluations of the following:

1. efficacy of interventions

2. strategies for changing recognized cultural norms supportive of abuse

3. training programs for elder abuse and health professionals

4. health consequences of abuse

5. surveillance methods used for abuse

6. models for integrated community services

7. examine how individuals come to be at risk for both perpetration and victimization

iii. Social support/social connectedness

1. most important target of intervention should be the social environment of elders

2. social support needs

a. emotional

b. instrumental (tangible aid)

c. informational

d. appraisal (evaluation)

3. social connectedness is positively correlated with self-reported good health

4. lack of social connectedness (loneliness) is associated with chronic health problems such as arthritis and lung disease

5. need for modifying senior centers to focus more intensely on providing opportunities for elders to make friendships

iv. Living arrangements—housing

1. challenges faced by battered elderly women

a. insufficient money

b. no available roommates to share expenses

c. limited job opportunities

d. dependency on younger family

e. being considered a credit risk

2. needing housing in a rural community presents even more acute challenges because shelters are nonexistent or too far away

v. Innovative assisted living facilities

1. The Eden Alternative

a. holistic setting

b. elders take care of pets, visit school children, and accomplish other tasks that empower them

c. costs of care greatly declined and health greatly improved

2. d. newest conception for elder care is the Green House Project

vi. Aging in place

1. finding ways to enable seniors to stay in their own homes

2. services such as Meals on Wheels may allow seniors to avoid going into long-term care

m. Help from organizations

i. Journal of Housing for the Elderly provides articles such as one on the use of high-tech equipment for monitoring seniors in order to meet their needs more completely

n. Elder fraud prevention

i. “death bed marriages”

1. a much younger person marries a wealthy senior, slowly isolate him/her, and manages to get access to bank accounts, become the beneficiary in a will, or at least try to exert spousal privilege for a share of the state

2. adult children or other relatives trying to get the marriage annulled face stiff legal challenges

3. competency and undue influence come into question

o. Faith community fraud prevention programs

i. Denver, Colorado

1. fraud prevention program collaboration between the district attorney’s office and 200 faith communities to prevent, intervene, and provide services for elder fraud victims

a. clergy training seminars

b. monthly fraud alerts

c. “Power Against Fraud Seminars” provided for the whole congregation, or often provided at a lunch for seniors at the faith community’s building (e.g., churches, temples)

d. establishment of a fraud assistance line to encourage disclosure

e. specialized program staff to function in needed capacities

p. Steps seniors can take themselves

i. make a suitable choice for the agent of their power of attorney

ii. set up standards with respect to gifting of the senior’s assets

iii. require regular accountings of and elder’s assets and needs to designate someone to review the accounts

iv. help with daily money management

v. help pay his bills and help with budgeting

vi. Social Security Administration can appoint a payee for the incapacitated elder and has put several safeguards in place (i.e. requiring an affidavit of incapacitation)

q. Role of attorneys

i. screen their elderly clients for financial exploitation

ii. help elderly victims set up legal documents that prevent elder fraud

iii. focus on the stipulations included in a durable power of attorney

1. a third party without a vested interest in the estate needs to have access to the activities of the elder’s agent in order to prevent fraudulent transfers

VII. Same-Sex Elder Abuse

a. Prevalence of abuse

i. emotional psychological abuse: 64.8%

ii. healthcare discrimination: 30.9%

iii. sexual assault: 12.7%

iv. self-neglect: 27.3%

v. abusive caregivers threaten to “out” their partner, a type of abuse unique to persons whose sexual orientation varies

b. Gay, Lesbian, Bisexual, and Transgendered Elders

i. Housing

1. serious problems in gaining access to housing motivates some victims to remain and live in fear of abuse

2. might have to live alone because other elders will not share housing with them

3. some long-term care establishments deny them admission

4. concerns are so acute that GLBT retirement villages have sprung up to serve this population

a. Palms of Manasota in Florida

ii. Medical treatment

1. some doctors will not provide treatment and nurses may mistreat this population

a. Veterans Administration

c. Needs of homosexual elders

i. legal discrimination

1. denial of senior center services

2. noneligibility of longtime same-sex partners for spousal Social Security benefits, despite their having made payments into the system

3. noneligibility of same-sex partners for pensions automatically set aside for spouses

4. restriction of access to federally subsidized senior housing

5. barriers to receiving health care and long-term health care

ii. lack of a family to provide social support

VIII. Cross-Cultural Elder Abuse

a. Prevalence of Cross-Cultural Elder Abuse

i. review of international types of elder abuse

1. showing disrespect to elders occurs frequently and is an especially painful type of abuse

2. Korea: being abusive in public (i.e. failing to “save face”)

3. Somalia: disregarding the opinions, advice, and feelings of elders

4. Lebanon: failing to enact one’s appropriate gender role

5. Japan: failing to be a good conversational partner

6. Nicaragua: placement in a nursing home

7. China: isolating/hiding them in cupboards and other place

b. Asian Countries

i. Korea

1. elder abuse rate 6.3%

ii. China

1. 5% of elders reported hitting a partner

2. one-child policy

a. fewer adult children are available to care for their parents

b. more elders need to live in nursing homes

c. Israel

i. 18.4% rural older adults said they had been abused

1. neglect: 18.0%

2. verbal abuse: 8.0%

3. economic abuse: 6.6%

4. physical or sexual abuse: 2.0%

5. limitation of freedom: 2.7%

ii. hospital workers found evidence of abuse much more frequently than the elder residents disclosed it

d. Spain

i. prevalence of abuse ranged from 25.8% to 32.8% for any kind of abuse

1. neglect: 16.0%

2. psychosocial abuse: 15.2%

3. financial abuse: 4.7%

4. physical abuse: 0.1%

ii. risk factors for abuse victimization

1. living with family members, excluding spouse

2. 85+ years of age

3. cognitive impairment

4. depression

5. social isolation

6. frequent bladder incontinence

e. United Kingdom

i. 75% of elders had disclosed their abuse to someone, such as a family member, friend, health professional, or social workers

1. few official reports to social services occurred

ii. 2.6% reported abuse

1. underestimate because of reluctance to disclose and dementia

iii. more women than men were victimized

iv. risk factors for abuse victimization

1. loneliness

2. depression

3. poor quality of life

v. types of elder abuse

1. neglect: 1.1%

2. financial exploitation: 0.7%

3. psychological abuse: 0.4%

4. physical abuse: 0.4%

5. sexual abuse/harassment: 0.2%

IX. Ethnic Elder Abuse

a. African Americans

i. found physical elder abuse especially intolerable

ii. less aware of financial exploitation of elderly persons and they expressed less concern about it

b. American Indians

i. elders housed in assisted living facilities were significantly happier, less lonely, and felt they had significantly more social support than nonresident elders

c. Chinese Americans

i. 7.1% of women and 5.6% reported being victimized by minor physical violence

ii. men were more likely to believe that intimate partner violence (IPV) was justified

iii. more men believed that IPV was a growing problem

iv. men were generally more acculturated than women, and less acculturated persons were less likely to think male-to-female violence was a form of IPV

d. Korean Americans

i. participate in a type of co-ownership of elder parents’ financial assets, an arrangement that many African Americans and Whites consider a form of financial exploitation

ii. especially likely to blame elder victims for their own abuse

e. Cultural Competence

i. most professionals who work with elder abuse victims lack the competencies needed to work with members of marginalized groups

X. Abuse of Disabled Persons

a. Defining Disability

i. sensory, physical, mental, or emotional conditions, lasting six months or more that make it difficult to perform activities of daily living, such as walking, climbing stairs, dressing, bathing, learning, or remembering

ii. intersection between the traits of the individual (i.e., specific handicaps, mobility, socioeconomic status) and the characteristics of their environment (natural, structural, social, and cultural)

iii. society’s concepts of disability play a role in the definition of disability, not just the individual’s impairments

1. society’s assumptions that disabled people cannot function in the workplace prevents employers from providing jobs that disabled people can do effectively (e.g., bag groceries)

b. Types of abuse of disabled person

i. common forms of mistreatment (e.g., hitting)

ii. terrorizing behaviors, severe rejection, isolation, ignoring behaviors, and use of physical and medical restraints

iii. withholding services that the disabled person cannot perform unaided, such as toileting, bathing, and feeding

iv. withhold food and water

v. unplug an assistive device or place a walker just out of reach

vi. utilization of targeted behaviors like moving furniture around in the house so that a blind person will stumble and fall

c. Attitudes Toward Disabled Persons

i. society oppresses, socially devalues, and dehumanizes disabled persons, thus making them even more vulnerable to abuse than others

ii. negative stereotyping

1. disabled mothers cannot perform satisfactorily as mothers

2. disabled women are either asexual or promiscuous

3. disabled women cannot discuss serious matters

d. Estimates of Abuse of Disabled Persons

i. disabled people are more likely to be abused than nondisabled people

ii. the handicapped population as a whole is older than the nonhandicapped population

iii. category of abusers of disabled persons can be anyone who provides care whether an intimate partner, a family member, or a paid caregiver

iv. Statistics

1. male-to-disabled female IPV: 16.1%

2. female-to-disabled male IPV : 5.4%

3. 56% of crimes against disabled persons were those against multiply disabled persons

4. age-adjusted rates of nonfatal crimes against disabled persons were 1.5 times higher than the rate for persons without disabilities

5. 34% of crimes against persons with disabilities were nonfatal violent crimes (e.g., rape)

6. disabled women suffer more abuse than nondisabled women and disabled men

7. nondisabled women experience abuse almost exclusively from their male partners

8. disabled women who experience multiple forms of abuse are older than nondisabled women

9. disabled abused women are less educated, less employed, and less likely to be in a relationship than nondisabled women

10. disabled women suffering multiple forms of abuse are less employed than disabled men

11. adults who are both mentally ill and have a substance abuse disorder are more likely to be victimized by physical abuse and IPV than those without a disability

12. homeless and seriously mentally ill women experience a victimization rate of 97%

13. studies of male IPV against women with severe psychiatric disorders (e.g., schizophrenia) have rates varying from 21% to 75%

14. disabled women suffer an average of 3.9 years of physical and sexual abuse before escaping compared with 2.5 years for nondisabled women

e. Sexual Assault

i. Sexual abuse rate is twice the rate of nondisabled women

ii. 47.6% of the disabled group of women suffered adult sexual assault/abuse

iii. Capacity to consent criteria

1. safety

2. voluntariness

3. non-exploitiveness

4. non-abusiveness

5. ability to say “no”

6. appropriateness of a time and location

f. Perpetrators of Abuse of Disabled Persons

i. Institutionalized disabled person and abuse

1. 35% said they had been implicated in or witnessed a violent incidence toward a disabled adult

2. 14% admitted to being the perpetrators in a violent incident

3. 61% said they had been the victim of a disabled adult’s violence

4. most of the abuse was physical and occurred in helping situations when the disabled person did not cooperate (e.g., receiving a bath)

g. Characteristics of Abused Disabled Adults

i. disabled women suffer from a multitude of disabilities that included arthritis, cerebral palsy, visual and hearing impairments, multiple sclerosis, traumatic brain injuries, strokes, post-polio symptoms, spina bifida, spinal cord injuries, and amputations

ii. 41% were laid-off or unemployed

iii. 77% lived independently, yet 60% had used at least one personal assistance service

iv. 42% were single, 28% were divorced or separated, 24% were married, and 5% were widowed

v. 53% said their male partners were using alcohol or drugs at the time of the abuse

h. Disclosure of Abuse and Helpseeking Activities

i. safety-promoting behaviors:

1. seeking abuse-related safety information

2. building abuse-related safety-promoting skills

3. using relationship support

4. planning for emergencies

5. taking legal action

6. managing safety in personal assistance relationships

ii. disclosure to police

1. reported that police did not respond to their calls

2. disabled sexually assaulted women do not as readily turn to rape crisis centers after an assault

3. only 2.5% of those served were disabled

4. those who were disabled received more hours of services, specific services, family and phone counseling, and medical and other advocacy services

iii. barriers facing deaf individuals

1. facing stereotypes of both deaf people and sexual assault victims

2. closeness of the deaf community, a situation that compromises privacy and anonymity, especially if the perpetrator is deaf

3. service providers’ failure to recognize that deaf people have established a deaf “culture,” and do not necessarily view deafness as a medical problem

4. obtaining help via teletypewriter (TTY) devices when responders, such as those at 911, the police department, and social service agencies, do not know how to operate them

iv. these impediments often create a strong sense of isolation among deaf sexual assault victims

v. language impairments may also place females and possibly males at elevated risk for sexual assault

i. Practice, Policy, and Prevention Approaches

i. psychologists and other professionals need to be aware of their own prejudices against disabled people

ii. electronic memory aids that can be programmed for disabled persons (e.g., doctor’s appointments)

iii. development of learning DVDs with input from disabled persons

iv. 32.3% of family-based disabled adult need financial support; 40% of these live in household where the primary income earner is 60+ years

v. transitional services for young disabled persons going to college

vi. fostering independence through health-promoting activities in readiness for the Special Olympics

XI. Abuse in Nursing Homes

a. Complaints

i. top 6 complaints

1. physical abuse

2. resident to resident abuse

3. verbal/mental abuse

4. gross neglect

5. other abuse or exploitation

6. financial abuse

7. sexual abuse

ii. 6.2% of the cases in long term care compared with 89.3% in domestic settings experienced abuse

iii. abuse of elders is less likely to occur in nursing homes than elsewhere

iv. disturbing findings

1. 94% of for-profit nursing homes sustained citations for various violations

2. about 17% of the facilities received citations for actual harm to patients

v. types of abuse

1. infected bedsores

2. poor nutrition

3. medication mix-ups

4. neglect

5. polyvictimization

vi. some nursing home residents are registered sex offenders

b. Operations of DHHS

i. core mission is to promote honesty, economy, and efficiency in its oversight role of nursing home abuse

ii. established regulations governing elder care in long-term facilities

1. establishes minimum standards of care

2. translate these laws into regulations and provide guidance and instructions for implementation

3. routinely report events/infractions to the state agencies

4. license/monitor their long-term health homes

5. report infractions/events

6. inspects/monitors, withholds government funds, and informs law enforcement as necessary to combat abuse

c. Costs

i. 2005: amount spent on long-term care in US was $206.6 billion

ii. costs are borne by the federal government, the states, private insurance, out-of-pocket funds, and by other sources

iii. to avoid increased costs, state officials may falsely reports by claiming that nursing homes are in compliance with government regulations

d. Nursing home personnel

i. less than 10% have enough personnel to provide good care

ii. understaffing, low pay, and characteristics of the facility contribute to burnout and a high turnover rate of employees

iii. quality of care decreased for patients whose cases required extensive history-taking, counseling, medication prescribing, and diabetes

iv. certified nursing aides who provide approximately 90% of patient care are the employees most likely to abuse patients; and are the employees most likely to be abused by nursing home residents

v. caregivers suffer a higher rate of injury from patient assaults and physical overextension (e.g., lifting) than do many other types of workers. The median of abusive acts by nursing home residents is 26 but the number reported is only about 5%

e. Situational factors

i. staff burnout and level of staff-patient conflict were strongly related to CNAs’ propensity to be abusive

ii. nursing home administrators do not routinely require nursing homes to use hiring safeguards

1. checking prospective employees for criminal backgrounds

2. screening unlicensed employees

3. reporting candidates with questionable abuse backgrounds to appropriate nurses’ registries

4. reporting suspected abuse to local law enforcement agencies

f. Registries of abusive nursing home workers

i. only 21 states maintain central registries/databases of abusive workers

ii. Missouri has provided other states with an example of an excellent response system to elder abuse

g. Accountability

i. no one is held accountable for unsatisfactory conditions in nursing homes

ii. inability to prevent nursing home abuse rests on cost

iii. suing a nursing home for failure to protect its residents may be one remedy

h. Preventing long-term care abuse

i. augmentation of government subsidies for Certified Nursing Assistants

1. CNAs usually pay to be trained for certification and then ear minimum wages

ii. better training for CNAs

1. effective training consists of stress and anger management, conflict resolution skills, and abuse reporting information

iii. class action lawsuits on behalf of patients may be the best approach when regulatory protection in nursing homes has failed

iv. using gerontological clinical nurse specialists to support improvement

v. adopting national standards against which compliance could be judged empirically