Prepared by Mary Twomey, MSW, Co-Director and Elaine Chen, MSG, Manager, Center of Excellence on Elder Abuse and Neglect, Division of Geriatric Medicine and Gerontology, University of California, Irvine.
America is in the midst of experiencing a “silver tsunami.” People over 85 are the fastest growing segment of the population in the United States; this is also the segment most vulnerable to abuse and neglect. Research indicates that about one in ten community-dwelling Americans age 60 and older experienced abuse in one year. Those rates rise dramatically to nearly 1 in 2 among people with dementia. Abuse of residents of nursing homes and other long-term care facilities continues to be reported, although researchers believe that the reports made to authorities represent only a fraction of the abuse experienced by these particularly vulnerable individuals. Elder abuse can be physical, psychological and sexual, and can also include neglect, abandonment or financial exploitation. The number of abuse victims has been rising steadily over the past decade and the rise is expected to continue.
** Please also review a related GIA Issue Brief on elder financial exploitation.
Societal and governmental responses have come a long way since people first began describing “granny battering” in literature in the mid-1970s. Designated agencies to address elder abuse exist in each state, and some support has been available for research on the extent of the problem and innovative detection and intervention efforts.
Notwithstanding this recent progress, elder abuse still lags behind the fields responding to child abuse and violence against women, in federal funding, in our knowledge about the problem, and in our response systems.
However, we can learn from and adapt the systems developed for child abuse and IPV (intimate partner violence). In recent years, elder abuse has drawn more attention from media, from the public.and from government
and community-based organizations than ever before. Knowing what we do about the scope of the problem and its devastating personal and societal consequences, we can’t afford to wait to take action to improve our existing response systems and strive toward preventing elder abuse.
Not only is elder abuse more common than most people think, its consequences are dire. Older adults who experience mistreatment and self-neglect face a 3x greater risk of dying sooner. Elders who had experienced psychological abuse, physical abuse, caregiver neglect and/or financial exploitation were twice as likely as non-abused elders to be hospitalized. Those with reported self-neglect were 1.5 times as likely to be hospitalized as other seniors.
A study of abuse in older women found that those who experienced psychological or emotional abuse (alone or with other kinds of abuse) had significantly increased odds of reporting joint, heart and digestive problems; depression or anxiety; and chronic pain. Survivors of elder mistreatment suffer significantly higher levels of psychological distress than non-victims. Social support had a beneficial effect on survivors' psychological distress.
While families often play a crucial role in supporting abuse survivors and advocating for dignity and justice, family members can also be part of the problem. Perpetrators of elder abuse are most often family members. For example, Acierno and Associates found in their study that 25% of emotional abuse perpetrators were partners/spouses and 19% children/grandchildren. In the same study, 57% of physical abuse perpetrators were partners/spouses and 10% children/grandchildren.
Diverse populations are not exempt from abuse, and might be less likely to report its occurrence. The studies below were conducted with different methodologies and different populations, but here are key findings from several sources:
- In a survey of New York State LGBT elders age 55 and older, 26.4% of respondents reported experiencing intimate partner violence and 21.5% reported they had experienced stalking. These crimes were reported to police less than 25% of the time.
- A telephone survey of 900 Pennsylvanians age 60 and older compared prevalence rates of financial exploitation and psychological mistreatment since turning 60 for African Americans vs. non-African Americans. Reported financial exploitation (23.0% vs. 8.4%) and psychological mistreatment (24.4% vs. 13.2%) were significantly higher for African American elders.
- In a study based in Los Angeles, Spanish-speaking promotores (community health workers) conducted door-to-door interviews with 200 Latino elders. They found past-year prevalence rates of about 40%, with reported psychological abuse (25%) and financial exploitation (16.7%) being the most common.
- In a community health study of over 3,000 Chicago area Chinese American elders, in-person interviewers found that 24% of Chinese elders had experienced some type of abuse, with psychological abuse (10%) and financial exploitation (10%) being the most common.
- Using National Elder Mistreatment Study data, researchers compared prevalence rates for emotional, physical, and sexual abuse, in terms of ethnicity and race. They found no significant differences for any of these three mistreatment types with respect to ethnicity. They found that non-whites were at twice the risk of whites (3.0% vs. 1.4%) for physical mistreatment, but found no significant differences for emotional or sexual abuse by race.
The field needs more input from elders themselves on how best to talk about this stigmatized topic, and how response and prevention efforts can be improved. Existing models involving older adults include peer support groups of survivors of domestic violence in later life, and training academies of senior volunteers who provide peer trainings on elder abuse prevention. A new grassroots movement of stakeholders of all ages, the Ageless Alliance, invites survivors, family members, and anyone else concerned to take action in the community by raising public awareness and by educating policy-makers.
Current Programmatic Interventions
Taking a public health approach, one way to describe trending interventions is by separating them into these categories:
- Primary – prevention of abuse
- Secondary - intervention while the abuse is occurring
- Tertiary – responding to the problem after the abuse has occurred
Below are a few examples of promising innovations in detection, response, and prevention of elder abuse:
1. Primary - Prevention Efforts
- Education on detecting abuse for lay and professional audiences, including targeting:
Professional “gatekeepers” (e.g., pharmacists, physicians, clergy, hospital discharge planners, legal aid attorneys)
Using e-learning technology to widely disseminate educational curriculum
- Programs to identify and support caregivers who are at “high risk” of abusing
- Registries of those who have been convicted of elder abuse (similar to sex offender registries)
- Caregiver support programs
- Programs that assist elders to plan ahead for incapacity (e.g., legal and financial tools)
- Public awareness campaigns
- Research on prevention strategies, risk and protective factors, cultural factors
- Passing laws that require screening of clients at intake or at some regular interval
2. Secondary - Intervention Efforts
- Emergency shelter for victims
- Medical and psychological evaluations in home
- Counseling for victims (group or individual)
- Transportation assistance to court, etc.
- Legal services for restraining orders, etc.
- Home security repairs
3. Tertiary - Response Efforts
- Justice system efforts, including:
Elder Abuse Court or Elder Court programs
Elder abuse vertical prosecution units
Elder abuse victim services units
- Multi-disciplinary approaches to elder abuse cases:
Establishment of multi-disciplinary teams for case consultation
Financial abuse specialist teams (FAST)
Elder Abuse Forensic Centers
Elder Death/Fatality Review Teams
- Services to victims to reduce re-victimization:
In all of these areas, we need research to help identify evidence-based practices that can be brought to scale to strengthen states’ and the nation’s work to eliminate elder abuse. We also need to engage leaders in related fields to build collaborations in elder abuse research and training. These efforts would help our field identify the most feasible and crucial areas to allocate resources to address the existing gaps in our systems of elder abuse detection, intervention and prevention.
This is an cruical time to be working in the field of elder justice and there are several “hot topics” to explore.
New discoveries in the linkages between diminished capacity and elder mistreatment
- Studies indicate that nearly one in two community-dwelling people with dementia experience abuse by their caregivers
- Financial decision-making is among the first things to go in individuals with emerging cognitive impairment
- Given the risk for abuse of people with dementia, abuse prevention is part of the National Plan to Address Alzheimer's Disease
Potential for innovative and testable interventions through the use of multi-disciplinary teams (MDTs) to intervene in complex elder abuse cases
In the 1980s, MDTs were established to address complex cases of elder abuse. In the decades since then, new models of MDTs have evolved to address specific kinds of abuse, such as financial abuse, or to conduct certain kinds of tasks related to abuse, such as reviewing suspicious deaths. Elder Abuse Forensic Centers have also begun in seven U.S. cities. While further study is needed, preliminary findings demonstrate the efficacy of the Forensic Center model. For more information on multi-disciplinary teams: Multidisciplinary Teams, National Center on Elder Abuse; Community Response, National Committee for the Prevention of Elder Abuse.
Consensus on the need for increased public awareness and engagement
Public awareness campaigns about elder abuse have generally been left to local or state governments or non-profit organizations. These efforts usually result in an increase of reports to Adult Protective Services, proving that their message resonates with the public. Engaging people of all ages in public awareness and public engagement activities not only raises awareness of elder abuse, but it provides a constructive outlet for those who feel powerless when someone they love has experienced abuse. Engaging victims, survivors and those who love them in advocacy, awareness and engagement activities also puts a real face on an issue that is often hidden behind shame and embarrassment (see “Paying Tribute”). The GAO recently opined that public awareness on the subject of elder abuse should be a priority of the federal government. Additionally a Presidential Proclamation was made regarding Elder Abuse Awareness.
Elder abuse as a human rights issue
A recent World Health Organization report characterized elder abuse as a violation of human rights and a significant cause of injury, illness, lost productivity, isolation and despair. Positioning elder abuse within this context provides a useful model and the possibility of exciting partnerships with global NGOs. Valuable resources on this topic include:
Integration of technology into elder abuse education and intervention
Elder abuse has existed for centuries. In the early 17th century Sir Francis Bacon wrote about a case of elder abuse but innovative approaches have made it a 21st century issue. Telemedicine is being tested in one Elder Abuse Forensic Center to increase access to medical expertise for social workers and law enforcement. At least two communities have launched elder abuse mobile applications designed to provide busy professionals easy access to information via tablets and cell phones. Resources include:
- Research data from the Center of Excellence on Elder Abuse & Neglect, UC Irvine
- 368+ Mobile App Elder and Dependent Adult Abuse Guide for CA Law Enforcement, from the Center of Excellence on Elder Abuse & Neglect, UC Irvine and the Institute on Aging (San Francisco)
- App to help first responders with elder abuse cases, William Mitchell College of Law
The push toward coordinated research agenda setting and data collection
National leaders have long recognized the need for coordination of research efforts. Fortunately, federal departments have recently begun to fund research on prevention, intervention, forensic markers and have brought researchers together to facilitate coordination. Some examples include:
- Elder Justice Coordinating Council, Proposals for Increased Federal Involvement
- Institute of Medicine
- Screening Tools (example: CMS Elder Maltreatment Quality Measurement Initiative)
Understanding oversight of residential care facilities for elders and adults with disabilities
Residents of long-term care are particularly vulnerable to abuse and neglect. Stories have started to receive attention from national media outlets which exemplify the problems residents often encounter in these facilites. Resources and tools to evaluate residences have started to surface including:
- Comparisons of nursing home deficiencies that incurred penalties
- Examination of assisted living facilities
- Clearinghouses for long-term care information
Philanthropic Contributions to Elder Abuse Prevention
Recognizing the terrible epidemic facing the older adult population, the Archstone Foundation launched the Elder Abuse and Neglect Initiative in 2005 with the goal of improving the quality and coordination of such targeted services in the state of California. The criteria for selecting elder abuse as a focus area was:
- The Foundation’s past history with the topic area
- The issue posed a significant problem to society
- Outside resources were required in order to move the field forward
Projects included support for forensic centers, multidisciplinary teams, education and training of mandated reporters, and financial protection projects.
Lessons learned from the Archstone Initiative include:
- Make a commitment to strategic grantmaking. In order to change the culture around the way elder abuse is perceived in our society and to develop lasting systems to respond to the crisis, there needs to be a long-term, multi-year investment in the issue.
- Encourage innovation in your grantmaking. Each community will have unique approaches to providing quality services. Using a general format and common core elements, such as a multidisciplinary team, encourages individual communities to create a structure that will best serve that community’s needs and optimize services for victims. Exhibiting flexibility in implementation will help seed new ideas and create best practices.
- And finally, leveraged resources. In total, for every dollar that the Archstone Foundation invested, an additional $1.93 was leveraged. We believe that because there is still so much need in the field of elder abuse, funders will likely see a large return on investment if they support projects to address this issue.
Other grantmakers funding elder justice efforts and examples of funded projects include:
- The UniHealth Foundation helped fund the Elder Abuse Forensic Telemedicine Project, based in Orange County, California. The project housed educated, responsive professionals who remotely provided medical advice and assisted in cases of elder abuse and neglect.
- The Harry and Jeanette Weinberg Foundation funded the establishment of the Weinberg Center for Elder Abuse Prevention, an elder abuse shelter at the Hebrew Home in Riverdale, NY.
- The Vladimir and Araxia Buckhantz Foundation and FJC, supported the development of the New York City Elder Abuse Center. The Center was launched in 2009 to improve the way professionals, organizations and systems respond to elder abuse, neglect and financial exploitation.
- In 2011, the MacArthur Foundation awarded one of its Fellowships (“Genius Grants”) to Marie-Therese Connolly, an Elder Justice Advocate.
The movement to bring elder justice issues into their place in the consciousness of the American public, media and policy makers has made great strides in the last decade. Important research findings, legislative successes and improved communication and coordination at state and national levels have created a culture ripe for further growth. Philanthropy has played a pivotal role. While there is still a lot of work to be done, the next twenty years hold great promise for the field. Advancements cannot come a moment too soon for the millions of older Americans who are abused and neglected each year. The projects described above are dedicated to the principle that all older Americans deserve to age with dignity and respect, free from fear and shame.
Source: Center of Excellence on Elder Abuse and Neglect, Division of Geriatric Medicine and Gerontology, University of California, Irvine February 2014
"An Age for Justice: Elder Abuse in America", video from the National Council on Aging, 2009.
Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, Richard J. Bonnie and Robert B. Wallace, editors, National Academies Press, 2003.
“Preventing Elder Abuse,” MetLife Mature Market Institute and the National Committee for the Prevention of Elder Abuse, 2013.
Frequently Asked Questions from the National Center on Elder Abuse.
Testimony of Marie-Therese Connolly, elder justice advocate, on “Justice for All: Ending Elder Abuse, Neglect, and Financial Exploitation” (U.S. Senate Special Committee on Aging, March 2011).
Organizations with Expertise on Elder Abuse
Administration for Community Living/Administration on Aging, Elder Rights Protection Programs
Center of Excellence on Elder Abuse & Neglect, the University of CA, Irvine
Centers for Disease Control, Injury and Violence Prevention Section
Weill Cornell Medical College, Project on Elder Abuse & Neglect