Understanding Elder Abuse: Types, Risk Factors, and Impact

1. Elder Abuse Victims and Services Lisa Nerenberg MSW, MPH The 11th Asian Post Graduate Course on Victimology and Victim Assistance July 22, 2011 University of Indonesia, Jakarta

2. f What is Elder Abuse? • The definition is evolving • Traditionally, referred to mistreatment by family members or people in positions of trust or confidence, and required that elders be “vulnerable” or “dependent.” • Definition has expanded to include victims of consumer fraud targeted against elders, abuse in institutions. • Increasingly viewed as “elder rights” issue.

3. Extent of Problem • One in 10 older adults in U.S. report emotional, physical, sexual mistreatment, or potential neglect each year (Acierno et. al., 2009) • Emotional abuse: 4.6% • Physical abuse 1.6% • Sexual abuse: 0.6% • Potential neglect (need for assistance not addressed): 5.1% • Current financial abuse: 5.2% • Lifetime financial exploitation by non-family: 6.5%. • N=5777

4. Physical Abuse Use of physical force that may result in bodily injury, physical pain, or impairment. It includes inappropriate physical and chemical restraint.

5. Sexual Abuse Non-consensual sexual contact of any kind with an elder person. Includes rape, sodomy, molestation, and sexual contact with anyone who is incapable of giving consent.

6. Emotional Abuse Infliction of anguish, pain, or distress through verbal or non-verbal acts. Includes verbal abuse, humiliation, harassment, coercion, and isolation.

7. Financial, or Material, Exploitation Illegal or improper use of an elder's funds, property, or assets. May include robbery, theft, fraud, extortion, forgery, identity theft, and withholding care in order to preserve an elder’s estate or hasten his/her decline (by someone who stands to benefit or inherit).

8. Abandonment Desertion of an elder by an individual who has physical custody of the elder or by a person who has assumed responsibility for providing care to the elder.

9. Neglect Refusal or failure to fulfill any part of a caregiver’s obligations or duties to an elderly person

10. Isolation • Preventing elders from having visitors, receiving mail, or using the phone or computer • Confining elders to rooms, homes, or apartments • Preventing elders from using assistive devices like canes, glasses, or hearing aids that enable them to receive information or communicate with others • Preventing elders from using social services or reporting problems • Blocking elders’ access to radios, televisions, or newspapers

11. Institutional Abuse • Abuse committed in long-term care facilities (nursing homes, residential care facilities, and assisted living facilities)

12. Reasons for Abuse • Financial gain • Dysfunction (including substance abuse and mental illness) • Caregiver issues • Power and control • History of conflict

13. Risk Factors of Older Persons • Depends on: • Type of abuse • Setting • Culture or country

14. General Risk factors • Isolation • Gender. More reports of abuse to women • Women over-represented in higher age brackets • Men may actually be at greater risk • Physical and/or cognitive impairments • Shared living arrangement • Physically or verbally aggressive • Recent losses • Residents of facilities who lack families, advocates, or friends

15. Risk factors by type of abuse • Victims of neglect more likely to have physical impairments (Pillemer & Finkelhor, 1988) • Victims of physical abuse more likely to live with abusers (Pillemer & Finkelhor, 1988) • Victims of financial abuse vary by type of abuse • Victims of misused documents likely to have cognitive impairments (Rabiner, O'Keeffe, & Brown, 2006) • Victims of consumer fraud (e.g. investment fraud) less likely to have cognitive impairment (NASD Investor Education Foundation, WISE Senior Services, & AARP Foundation, 2006). • Dementia. 48% of caregivers for dementia patients were psychologically or physically abusive (Wiglesworth et. al., 2010)

16. Victims’ perceptions of abuse is culturally determined • Study of attitudes of European-American, African-American, Puerto Rican and Japanese-American older adults found that African-American and Japanese-American seniors view psych abuse as worst form (Anetzberger, Korbin, & Tomita, 1996). • Korean elders identify financial, psychological, and physical abuse, and neglect within context of "hyo," the traditional value of filial piety (Chang & Moon, 1997). • In Japanese, German, Brazilian, Israeli, and African American cultures, placing parents in nursing homes is viewed as abuse (Patterson & Malley-Morrison, 2006).

17. Impact of abuse • Increased mortality(Lachs, Williams, O'Brien, Pillemer & Charlson, 1998) • Depression(Mouton, Rodabough, Rovi, Brzyski, & Katerndahl, 2010; Begle, Strachan, Cisler, Amstadter, Hernandez, & Acierno, 2010). • Shame • Hopelessness • Isolation • Financial

18. Risk Factors of Abusers • Criminal record or a history of violence, substance abuse, gambling and other debt • Sense of entitlement to the elder’s resources • Mental health problems including mental illness • Stress • Social isolation • Recent changes in family relationships or living arrangements • Slightly more likely to be male

19. T Treatment and interventions reatment and interventions Treatment and interventions • Draw from multiple disciplines • Child abuse/mandatory reporting in U.S. • Mandate professionals and encourage concerned citizens to report to public agencies • Public agencies investigate and offer services • Services are voluntary (many victims refuse out of fear, shame, loyalty to abusers, etc. • Domestic violence • Prosecution (special prosecution units, forensics research, elder courts) • Shelters adapted for elders • Safety planning • Restraining orders

20. Treatment and interventions (cont.) • Public health • Public awareness to promote intergenerational respect • Universal screening by health care professionals • Caregiving • Screening of caregivers to detect high risk • Support to caregivers, including monetary aid, respite, training • Victimology/victim rights • Restorative Justice • Mediation • Restitution

21. International Focus • International Network for the Prevention of Elder Abuse (INPEA) • World Elder Abuse Awareness Day (June 15) to raise awareness • Studies elder abuse worldwide • International NGO Coalition for the Rights of Older People (includes AARP, Global Action on Aging, HelpAge International, International Network for the Prevention of Elder Abuse, and others)

22. Who WHO-INPEA Study • Goal: To identify key themes, perceptions, beliefs, and attitudes about abuse by elders and health care workers in developing and developed countries • Developing countries: Argentina, Brazil, India, Kenya, Lebanon • Developed countries: Austria, Canada, Sweden • Participants asked: • What do you consider to be abusive conduct? • Contexts in which it occurs • Causes • Consequences • Seasonal patterns • Overall status, well-being, unmet needs of elders

23. Key findings • Focus groups viewed abuse as societal concern with gender and socio-economic status emerging as key factors. • Disrespect identified as most painful form of mistreatment by older adults in all countries.

24. Themes • Poor suffer most. • Childless,widowed women most affected. • Lack of pensions (worldwide, only 30% of elders covered by pension schemes). • Lack of access to health care and social services. • Decreasing rates of communicable diseases in developing world have increased prevalence of long-term, disabling diseases. • Worst off are poor, elderly, and women • Negative attitudes about long-term care facilities

25. The Themes (cont.) • Changing social roles and breakdown of family responsibilities • Fewer women stay at home and provide care • Breakdown of family responsibilities, loss of filial piety Lack of training and resources for health care providers, and negative treatment results in poor treatment of patients. • Economic crises contribute • The media promotes ageist attitudes and negative stereotypes. • Low status of health care providers results in lack of training and resources results in poor treatment of patients.

26. UN i UN Initiatives • Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) • Established working group to draft recommendations on older women’s rights. Recommendations approved by General Assembly in 2010: • Defines older women as a separate category. • Recognizes elder abuse as a form of domestic violence. • Efforts to create a new UN convention on the Rights of Older Persons • Madrid International Plan of Action on Ageing (MIPAA), an “aspirational document” endorsed by 159 governments at 2nd World Assembly on Ageing in 2002. Encourages governments to include older people in policies and social and economic development policies; • Some nations and associations have taken steps