Elder AbuseWHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Elder abuse is the last form of family violence to gain public attention. Like the other types of family violence, elder abuse has always existed. During pre-industrial times, family conflict was present as the young desired to inherit the land and the elderly feared that they would be neglected. In addition, it was postmenopausal women who were more often viewed as witches and burned at stakes. In general, throughout the ages and certainly in today's society, cultural norms dictate what is considered "productive" during the various cycles of the life span. In the United States, ideas for elder abuse protection were closely linked with the concept of child abuse. By the mid-1980s, the gerontology literature began including works on elder abuse and in 1980, the House Select Committee on Aging heard testimony about the "social problem" of elder abuse in the United States. Consequently, policies and programs were tailored to look like the child abuse and neglect model. For example, both child abuse and elder abuse models require the reporting of incidences of abuse through specific channels, the designation of certain professionals to report if incidences of abuse are learned, and penalties for violations. In addition, in both forms of family violence, a third party can intervene if there is suspected child or elder abuse.
The purpose of this document is to enhance the knowledge base of the healthcare providers about elder abuse, assessment, and intervention. Particular emphasis is placed on the role of culture, race, and ethnicity and how it influences definitions, attitudes, and experiences of elder abuse among ethnic minority groups. Four ethnic minority groups are emphasized -- African Americans, Asian Americans, Hispanics/ Latinos, and Native Americans. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted.
Prevalence and Scope of Elder Abuse:
It is predicted that by the year 2025, the global population of those aged 60 years and older will be more than double, from 542 million in 1995 to about 1.2 billion. The total number of older people living in developing countries will also be more than double by 2025, reaching 850 million. Throughout the world, 1 million people reach the age of 60 years every month, 80% of whom are in the developing world. Women outlive men in nearly all countries of the world, rich or poor. This gender gap is, however, considerably narrower in developing countries, mainly because of higher rates of maternal mortality and in recent years, also because of the AIDS epidemic. The U.S. House Select Committee on Aging estimated that 1.5 million elderly Americans were victims of abuse in 1989. Overall prevalence rate of abuse was 3.2%; specifically 2% had experienced physical abuse, 1.1% experienced verbal abuse, and 0.4% neglect. The prevalence rate of elder abuse in institutional settings is not clear. However, in one non-probability study, 36% of nursing and aid staff disclosed to having witnessed at least one incident of physical abuse by other staff members in the preceding year. Obtaining prevalence rates to indicate the scope of elder abuse has been difficult. Problems stem from a lack of consensus of a definition of elder abuse. Issues such as sampling and recruiting participants complicated since elder abuse is a private and sensitive topic. When race, culture, and ethnicity are added to the equation, it becomes even more complicated. Consequently, to get a sense of the scope of elder abuse in ethnic minority communities, it is crucial to remember that the lack of research in this area does not imply that elder abuse does not exist in ethnic minority communities.
Definitions of Elder Abuse:
The definition developed by Action on Elder Abuse in the United Kingdom and adopted by the International Network for the Prevention of Elder Abuse states that: "Elder abuse is a single or repeated acts, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person". Such abuse is generally divided into the following categories:
- Physical abuse -- the infliction of pain or injury, physical coercion, or physical or drug-induced restraint. Examples includes slapping, punching, kicking, restraining etc.
- Psychological or emotional abuse -- the infliction of mental anguish. Infliction of distress, anguish, and/ or pain through verbal or non-verbal acts. Behaviors include criticizing, verbal harassing, making obscene statements, threatening, stalking, intimidating, controlling movement, isolation, threatening safety of children and family members.
- Financial or material abuse -- the illegal or improper exploitation or use of funds or resources of the older person. Violation of civil rights include behaviors including forcing out of one's home or forcing into home setting (i.e., institution) against one's will, forcing to change one's will, improper use of the elder's resources, property, funds, and/or assets without the consent of the elder.
- Sexual abuse -- non-consensual sexual contact of any kind with the older person.
- Neglect -- the refusal or failure to fulfill a caregiving obligation. This may or may not involve a conscious and intentional attempt to inflict physical or emotional distress on the older person.
In general, the elder abuse literature has identified three basic categories of abuse and neglect: (1) domestic elder abuse; (2) institutional abuse; (3) self-neglect or self-abuse. In addition, most researchers and practitioners agree that there are three types of abuse: physical; psychological/emotional; and financial. How we conceptualize or define a social problem greatly influences our perceptions of the problem, its attributes, etiology, and the policies and interventions.
What are the risk factors for elder abuse?
The six broad theoretical models to explain how practitioners and researchers have conceptualized why elder abuse occurs are:
- The Overburden Caregiver -- the level of stress of caregivers is seen as a risk factor that linked elder abuse with care of an elderly relative. Because the locus of caring is shifting from institutions to the family, families are expected to provide care and support to impaired elders. The pressures on caregivers are very real. Caregiver stress is caused when the demands of providing for the elderly individuals are perceived as exceeding the available resources. Caregiver burden comprises the range of physical, psychological, social, and financial strains. It is increased by the awareness of having a family member with a chronic illness. Typically, the caregiver is female, middle age and has a family of her own. She provides much of the caregiving with minimal assistance from other family members. She has very little respite and is saddled with the responsibilities of caregiving and the needs of her own family.
- Dependency of the victim and abuser -- this theoretical explanation is premised on exchange theory. Living arrangements, particularly overcrowded conditions and a lack of privacy have been associated with conflict within families. The increasing cost in providing emotional, economic, and physical care to the elderly parent without the mutual exchange in the relationship may be viewed as unfair to the caretaker. Thus, this imbalance may increase the risk of elder abuse. Because of the sense of imbalance in the relationship and the violation of social expectations regarding independent adult behaviors, the perpetrator attempts to restore some sense of control by using violence. In many instances of elder abuse, the abusers are financially and emotionally dependent on the elder.
- The impaired abuser -- substance abuse and psychiatric illnesses are risk factors contributing to elder abuse. For example, caregivers who consumed alcohol tended to perpetrate increased physical abuse. Elders who live in their proximity are then on the receiving end of the violence. However, caregivers who experienced depression and anxiety were more likely to use verbal abuse against the elder.
- Social learning theory (childhood of abuse and neglect) -- individuals' learning patterns occur through observations of others. The intergenerational transmission theory argues that the dynamics of abusive behavior get perpetuated and this is the reason why some abused children become abusers themselves. Abused children are more likely to exhibit aggressive behavior toward family members and to engage in crime outside the family. Societal factors are currently considered important as risk factors for elder abuse in both developing and industrialized countries. Cultural norms and traditions -- such as ageism, sexism and a culture of violence are also now recognized as playing an important underlying role.
- Feminist theory (imbalance of power in male/female relationships) -- violence against women is broadly defined as male coercion of women. In other words, patriarchy and male domination contribute to violence against women. The root of violence against women stems from power imbalances in male and female relationships and male domination in the family, which is reinforced through current economic structures, social institutions, and the sexist division of labor. Domestic violence or the battered women's movement emerged in the late 1960s when feminist and social activism was active. Then in the mid-1980s, elder abuse emerged as a separate, distinct social problem and was primarily depicted as a social problem where the perpetrators were caretakers.
- Political Economic theory -- this theoretical perspective maintains that American societal norms and attitudes may contribute to elder abuse. First, negative attitudes about the elderly create an atmosphere that breeds elder abuse. Our stereotypical views of the elderly include images of elders losing their memory, being less than flexible and resilient, grouchy, and unproductive. Although there is no empirical research that directly links ageism to elder abuse, the argument is that these stereotypes and myths play a role in dehumanizing elders. Consequently, social problems, including elder abuse and neglect, do not receive the same attention.
Culture, Race and Elder Abuse:
It is inevitable that race, culture, and ethnicity can have a profound effect on how we think, feel and act. Race, culture, and ethnicity become the lens through which we view the world and touch on all aspects of human life. Consequently, healthcare providers will need to become more culturally aware and sensitive to the cultural norms, belief systems, and needs of culturally diverse patients in order to provide culturally relevant services and interventions. Cross-cultural competency is defined as a dynamic attribute that professionals develop in the areas of attitude, knowledge and skills to work with an increasingly multi-ethnic and diverse society.
Cultural values and belief systems influence norms about family life and structure. It is vital to examine various ethnic groups' norms of family life since every family system shapes and guides rules, obligations, roles and labor divisions. A person's family or origin is the foundational building block to socialization, understanding general views about gender roles, beliefs about family authority, and views about elderly family members. Realizing this will assist us in understanding the intersection of culture, race, and ethnicity and family norms on elder abuse.
Culture and ethnicity provide the content of the worldviews. These worldviews and paradigms provide individuals with rules and assumptions about how the world works. Consequently, how a group labels or constructs abuse or maltreatment is influenced by their cultural beliefs and values, which ultimately affect how domestic violence is perceived, exhibited, and reported. Furthermore, the social realities of the lives of older abused immigrant women may be uniquely different from their younger counterparts because of generation, acculturation, and gender role socialization differences. These factors may distinguish how elder abuse victims label their situations and what services they may seek.
Certain ethnic minority groups may be more vulnerable to violence because of the existence of environmental risk factors such as poverty, racism, oppression, and discrimination. The socio-cultural backdrop of slavery, oppression, and economic deprivation may have contributed to violent behavior in the African-American community. Finally, culture, race, and ethnicity influence help-seeking patterns. There are a host of factors that influence ethnic minority families and elders in seeking outside professional assistance. This might include financial limitations, suspicion or wariness of professionals, and inconvenience in locating and traveling to agencies. An ethnic minority elder who is being abused by another family caretaker may not seek help because he/she does not label the "event" as a problem. Instead, the victim believes that the event must be something that should be preserved. The victim shares a "cognitive map" or explanatory model about the explanations and expectations regarding illness, symptoms, or other events like violence.
Family values, Cultural norms and The Elderly:
It is crucial that, as helping professionals, we understand cultural values since they are often the driving forces guiding daily behavior. Cultural norms of family life and the role of elderly family members will have an impact on how the elderly are treated within society and the family and, ultimately, how elder abuse is perceived. It is important to remember that there is tremendous diversity within groups. Factors such as acculturation, age of immigration, education level, socio-economic status, and religion all contribute to the heterogeneity within each sub-group.
African Americans -- the family is very important in African-American history, and values related to the family are rooted in African traditions. According to the U.S. Census (2000), African-Americans constitute about 33.9 million or about 12.1%. Many African-American family structures are multi-generational and interdependent. The extended family network system pools resources to help during the hard times. These strong kinship networks are the key element in helping African-American families copes with the economic stressors as well as structural issues such as racism, oppression and discrimination. Economic reasons are not the only reasons why African-Americans share households; they also adhere to cultural beliefs about closeness and connectedness. The elderly are highly valued in African-American families. African-American elders tend to live in multigenerational households; however, they do not go to live with their children. Rather, it is their children who move in with them. For example, daughters who are divorced, widowed, or separated commonly return with their children to live with their parents.
Asian Americans -- generally, traditional Asian families can be characterized as hierarchical. Family authority and structure is defined by family position, which is defined by age and gender. Mutual support, cooperation, and interdependence also characterize the family. Because of the close-knit nature of Asian American families, there is a strong sense of obligation and duty to others. Problems are generally solved within the family, and a sense of family honor and pride limits outside information to be shared with counselors or other professionals. In addition to the hierarchical structure, traditional Asian American families are also patriarchal in nature. The father maintains authority and sons are more desired and valued because they symbolically carry on the family line and care for their aged parents. In the 1990s, the numbers of Asian Americans increased tremendously due to high levels of immigration from Asian countries. According to U.S. Census the population in year 2000 was 10.5 million and it is projected that this number will reach 40 million by the year 2050, which would be 10% of the total population. More than half (60%) are foreign-born, and may settled in the United States after 1980.
Hispanics/Latinos -- this population is also a very diverse ethnic group. The Latino/Hispanic population grew at a very rapid rate, increasing from 22 million in 1990 to 35 million in the year 2000, surpassing the population of African Americans. It is estimated that the Latino/Hispanic population will increase to 81 million by the year 2050. The family is of paramount value, which is influenced by both the Spaniards' Catholic religion as well as the values stemming from the indigenous people of the Americans. Community is another value that is emphasized. Unlike individualism, this is the hallmark of many of the values in the United States, Hispanic/Latinos focus on the collective, which extends to valuing community life. Consequently, fictive kinship is a part of the fabric of life. Stemming from this is value of cooperation versus competition.
Native Americans -- or American Indians, like other minority groups, encompass people with many different languages, religions, organizations, and relationships with the U.S. government. They identify themselves as belonging to a specific tribe, each with unique customs and values. According to the 2000 US Census, the number of people living in the United States who reported their ethnicity or race as American Indian or Alaska Native was 2.5 million. This represents 0.9% of the US population, which is a 26% increase compared to the 1990 Census. There are about 500 different tribes and 314 representatives. Of those who live on reservations, many may spend a majority of their time away from the reservation seeking employment, education or other opportunities. The family is regarded as the cornerstone for emotional, social and economic well-being for individuals. Elderly family members are highly regarded. The aged are believed to be the repository of wisdom, and their role is to teach the young traditions, customs, legends, and myths of the tribe. Consequently, in their old age they are taken care of by the tribe.
Assessments and Interventions:
It has been said that ethnic minority elders experience multiple jeopardy. In other words, they are vulnerable to life stressors because of their age, being an ethnic and class minority, not being proficient in the English language, being unfamiliar with American institutions, and not having transportation or social support networks. Furthermore, most ethnic minority elderly do not voluntarily seek out social, community, and mental health services. The reasons for reluctance to seeks help are because of language barriers; geographical and operational accessibility of services; financial difficulties; stigma/shame in asking help; importance of keeping individual problems from outsiders; mistrust of mainstream services. Abuse and mistrust take on host connotations and then, given the layers of barriers, many elders are reluctant to seek assistance from mental health professionals, physicians, and other authority figures.
Assessment and identification of elder abuse is two-step process. The first step concerns identifying elders who may be at-risk for elder abuse, and the second step involves verifying instances of abuse. Any elder, who is incapable of taking care of his / her own daily needs and is dependent on another person, is automatically in an "at-risk" situation, healthcare providers can easily incorporate these questions into their assessment, and positive responses should raise suspicion of elder abuse:
- Has anyone close to you tried to hurt or harm you recently?
- Do you feel uncomfortable with anyone in your family?
- Has anyone ever threatened you?
- Has anyone ever touched you when you didn't want to be touched?
- Does anyone ever talk or yell at you in a way that makes you feel lousy or bad about yourself?
- Does anyone tell you that you give him or her too much trouble?
- Has anyone forced you to do things that you did not want to do?
- Do you feel that nobody wants you around?
- Who makes decisions about your life, how you should live or where you should live?
Medical professionals must play a role in patient education and the dissemination of information. It is important to educate the victims by providing them with information about the nature of the problem, their options, and assuring them that they are not responsible for what has happened. Distribute literature about elder abuse when appropriate, and have your staff provide a list of emergency community resources -- lock replacement, counseling, hot-lines, shelters, meals-on-wheels, visiting nurse, adult day care, home-maker services.
Safety Planning -- healthcare providers and/or their staff should review safety planning with the elder. Components of safety planning involve: encouraging the patient to have emergency numbers on hand, being able to identify warning signals that the violence might escalate, having bags packed in the event that the elder needs to leave immediately, and forming an escape plan by identifying all the exits. The elders should be encouraged to replace locks if necessary.
Alternative Housing -- providing services to elders at risk of abuse or who are victims of elder abuse is complicated. Healthcare providers must deal with the issues of self-determination, mental competency and inconsistency of statutes from state to state. It is helpful to begin with the least restrictive arrangements; for example, does the elder have someone to stay with him/her? In addition, explore options such as home care arrangements and the possibility of temporary or permanent alternative residences, i.e. senior citizen residence, nursing home and shelters etc.
Mandatory Reporting Laws:
All fifty states in the United States have enacted legislation dealing with elder abuse and they share many features with child abuse statues. They provide legal definitions of elder abuse, establish administrative channels for the investigation of the intervention in elder abuse, define who is mandated to report, and designate penalties for violations. Unlike child abuse statues that mandate professionals in all states to report incidences of child abuse, there is less consistency among the states regarding mandatory reporting for elder abuse. As with child abuse statutes, the healthcare providers does not have to prove that the abuse occurs before reporting; the healthcare providers must report even if he/she only suspects abuse. 75% of the state laws on elder abuse include a criminal penalty for failure to report. In all fifty states and the District of Columbia, an Adult Protective Services (APS) agency has been designated to investigate reports of elder abuse.
American Bar Association
Commission on Legal Problems for the Elderly
The overall health and psychosocial well-being of elderly, whose vulnerability to mistreatment has thereby increased includes: the growing pauperization of significant parts of society; high unemployment; a lack of stability and social security; the outward expression of aggressiveness especially among the young. Several reasons have been suggested for the mistreatment of older people includes: a lack of respect by the younger generation; tension between traditional and new family structures; restructuring of the basic support networks for the elderly; and migration of young couples to new towns leaving elderly parents in deteriorating residential areas within town centers. Studies on elder abuse have tended to focus on interpersonal and family problems. However, an integrated model encompassing individual, interpersonal, community and societal perspectives is more appropriate, and reduces some of the bias evident in the earlier studies. Such a model takes into the difficulties faced by older people, especially older women. Elderly often live in poverty, without the basic necessities of life and without family support -- factors that increase their risk of abuse, neglect and exploitation.
Women's Health and Education Center (WHEC) addresses through its publications the most pressing public health concerns of populations around the world. To ensure the widest possible availability of authoritative information and guidance on public health matters, WHEC encourages its translation and adaptation. Its principle objective is the attainment by all people the highest possible level of health. For the obstetricians and gynecologists, the importance of elder abuse relates to the increasing number of older women in the population. Currently 60% of the population aged 65 years and older are women. Identification of abuse in this population may be difficult because few physicians are fully aware of domestic violence in the elderly or the extent of the problem. Incorporating screening related to elder abuse and neglect into these encounters will increase identification of abuse. Healthcare providers should assess patients for elder abuse and respond to patients who are victims of elder abuse as they would to domestic violence in general.Women's Health & Education Center
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