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- Importance of Risk Factors
- Understanding Risk Factors
- Risk Factors for Elder Abuse
- Risk Factors for Victims
- Risk Factors for Perpetrators
- Environmental Risk Factors
- Cultural Risk Factors
- Risk Factor Screening and Assessment
Assessing the risks of elder abuse involves applying what has been discovered about this type of abuse through research to detect problems before they become serious, or before they emerge at all. Researchers have uncovered certain risk factors, as they are called, which are really characteristics of victims, perpetrators, or environments that suggest the possibility of the occurrence of elder abuse. In a given situation in which one notices such risk factors, elder abuse may not have happened yet. Indeed, it may never happen. However, the circumstances are ripe for the problem to surface.
Identifying and assessing risk factors requires those in contact with older adults to maintain a high level of suspicion and remain watchful and alert to instances or signs of elder abuse. This will allow clinicians and caregivers who provide care to older adults to take measures to reduce the risk of abuse occurrence.
Importance of Risk Factors
Identifying risk factors is at the heart of problem prevention. More specifically, in order to stop a problem from happening, it is important to know what is causing or could potentially cause the problem. By removing the cause, it may be possible to prevent the occurrence, or at least reoccurrence, of the problem.
It is difficult to determine through research the causes, exactly, of elder abuse. Because empirical demonstration of cause and effect has not been achieved with regard to elder abuse, it is more appropriate to use the term ‘‘risk factors’’ rather than ‘‘causes’’ to describe conditions that appear to be closely linked with abuse according to theories of the presumed causation of elder abuse.
The risk factors of elder abuse provide a framework for developing individual and community strategies for problem prevention. For example, social isolation is a widely regarded risk factor for abuse occurrence. Problem prevention in this regard may involve increasing social contact and support for older adults. On an individual level, this might mean arranging for friendly visitors to spend time with a homebound and vulnerable elder on a regular basis. On a community level, it might mean establishing a publicly funded Senior Companion Program, whereby low-income people age fifty-five and above are linked with frail elders for in-home socialization and limited assistance.
Looking for risk factors also contributes to problem detection. Detecting elder abuse represents an attempt to answer three interrelated questions pertaining to particular situations with older adults. First, have there been known occurrences of elder abuse? This involves identifying specific examples of abuse occurrence—for example, abuse situations that are personally observed or reported by the victim or some other knowledgeable source. Examples of physical elder abuse include slapping, shoving, or beating an older adult.
The second question is, Is elder abuse suspected? Answering this question involves identifying signs, symptoms, or indicators of abuse occurrence. Signs represent the consequences or effects of elder abuse—e.g., for physical abuse, signs might include bruises, lacerations, and broken bones. However, signs can have origins other than abuse occurrence. Bruises, for instance, can result from accidental falls or even certain medications. Therefore, unlike examples, signs are not conclusive and require delving deeper into investigating the situation. Known (as evidenced by examples) or suspected (as suggested by signs) elder abuse is the usual precondition for referring a situation to authorities under state adult protective services or elder abuse reporting laws.
The third question one should ask is whether elder abuse is likely in a particular situation. This involves identifying the presence of risk factors for abuse occurrence. These ‘‘red flags’’ suggest that conditions are such that elder abuse may take place and that consequently one should be on the lookout for examples and signs of it. For example, alcoholism on the part of the adult child who serves as the elderly person’s primary caretaker is a risk factor for physical abuse. When combined with the adult child’s financial dependency on and coresidence with the elderly person, the probability of abuse occurrence is high.
Finally, risk factors are prompts for elder abuse assessment. The presence of risk factors or signs necessitates a thorough evaluation of the situation, the possible victim, and the suspected or potential perpetrator. Assessments serve multiple purposes. They allow one to appraise the need for assistance, the urgency of that need, the availability of assistance resources, and priorities for extending assistance. Assessments are used to consider the nature of the elder abuse as well as such risk-factor domains as mental and cognitive status, recent family or life crises, and financial issues. They can be layered. For example, identifying an elderly person’s feelings of depression may suggest the need for application of depression symptom scales or even psychiatric evaluation.
Understanding Risk Factors
The presence of risk factors increases the chance that elder abuse will occur. Correlatively, this usually means that the higher the number of risk factors present in any situation, the greater the probability of abuse occurrence. Similarly, longer exposure to risk factors also enhances the likelihood of abuse occurrence. Returning to the earlier identified risk factors for physical abuse noted above, alcoholism alone on the part of the potential or suspected perpetrator is not nearly as powerful a risk factor for elder abuse as it is when combined with his or her financial dependence on the victim and the victim’s social isolation. Likewise, the continuance of these risk factors over time makes it more and more likely that elder abuse will happen, and when it does, that it will be repeated.
To understand elder abuse risk factors, several points should be kept in mind. First, there have been few studies to date which explore elder abuse risk factors using acceptable research designs. Typically, investigations lack a comparison group of some kind and/or collect data from sources other than victims or perpetrators. These deficits mean that researchers do not have a clear theory on what constitutes the risk factors for elder abuse and do not know the relative importance among proposed risk factors for predicting the problem.
Second, existing research suggests that risk factors may differ by form of elder abuse. This implies variation in etiology and problem intervention by abuse form as well. For instance, physical abuse and neglect are two of several forms of elder abuse. Physical abuse is the infliction of injury or pain on an older adult by a trusted person, such as a spouse, adult child, or other caregiver. Neglect is the failure of a caregiver to provide a dependent older adult with necessary goods or services. These concepts of abuse involve different behaviors. In addition, they often suggest different relations between victim and perpetrator and result in different consequences. It is understandable that risk factors for physical abuse will not be the same as those for neglect. Rosalie Wolf, Michael Godkin, and Karl Pillemer (1986) discovered this in their pioneering study of the subject. In evaluating 328 cases of elder abuse, they found victims of physical abuse to be more independently functioning but suffering from poor emotional health; perpetrators had a history of mental illness or alcoholism, recent decline in health or mental status, increased dependency on the victim, and poor relations with the victim. In contrast, victims of neglect had problems performing daily living tasks and diminished capacity in both orientation and memory; perpetrators found victims to be a source of stress and exhibited no dependency issues.
Third, no one risk factor is sufficient to indicate the probability of elder abuse. Instead, risk factors in combination and complex interaction provide the condition for abuse occurrence. Additionally, risk factors lack a single source, thereby making the search for risk factors in specific situations even more challenging. Risk factors reside in characteristics of the victim, perpetrator, and/or environment. Those of the perpetrator tend to be more predictive of abuse occurrence than those of the victim. Environmental risk factors can be either situational or cultural in nature. For instance, using the previously identified risk factors for physical abuse, emotional problems represent a risk factor for the victim, while mental illness and alcoholism represent risk factors for the perpetrator. Co-residence represents a situational or environmental risk factor. Social isolation may be a cultural risk factor, if, for example, it originates from being a member of a stigmatized minority, such as gays or lesbians.
Fourth, risk factors relate to theoretical explanations for elder abuse. Many such explanations have been suggested, but none have been rigorously tested. An example of a theoretical explanation that may have relevance to neglect is role theory, which posits that neglect results from a lack of ability or willingness on the part of a caregiver to provide appropriate and sufficient assistance.
Lastly, conceptual models have been proposed for integrating elder abuse risk factors. An early one offered by Eloise Rathbone-McCuan and Joan Hashimi (1982) considers isolators in the lives of victims. Isolators can be biophysical, psychological, economic, or social. They render older adults vulnerable to elder abuse by diminishing their resources or providing barriers to accessing help. More recently, Georgia Anetzberger (2000) proposed a conceptual model in which elder abuse is primarily a function of perpetrator characteristics and secondarily of victim characteristics. These characteristics merge and provide the underlying etiology for abuse occurrence. Context is important in this model as well, initially the context that brings the victim and perpetrator in contact with one another and later the context that triggers abuse occurrence. To illustrate these two kinds of contexts: Co-residence may bring the victim into contact with the perpetrator; refusal of the victim to comply with the expectations of the perpetrator may trigger abuse occurrence. In this situation, an elder abuse perpetrator may think, ‘‘When I was a kid, my parents said that as long as I was under their roof, I had to do what was asked of me. Now Mom is under my roof, and I am in control.’’
Risk Factors for Elder Abuse
Risk factors for elder abuse reflect characteristics of the victim, perpetrator, and environment. In addition, a set of risk factors relate to cultural norms. Research on the various characteristics may be minimal, deficient, and challenging to carry out or analyze. However, research is nearly nonexistent on risk factors for elder abuse related to cultural norms, and even more difficult to conduct. Nevertheless, characteristics of the larger society provide the milieu for elder abuse. All people are social beings, and it is through group interaction that one is socialized to become a member of society. During this process, one learns certain responses as normative activities. Select responses produce a context rich for abuse occurrence.
Risk Factors for Victims
Elder abuse can happen to any older adult. Still, some seem to be at greater risk than others. The characteristics that appear to make older adults most vulnerable are those which reduce their functional capacity or spawn problem behaviors. Sometimes these two types of characteristics are related.
Reduced functional capacity can result from frailty, poor health, physical or mental impairment, or disability. Its effects may leave older adults unable to fend off or escape from elder abuse, and in some instances may even render them unable to recognize the seriousness of the problem. In addition, reduced functional capacity can render older adults dependent for care on others who are ill-equipped to provide it or resentful about having to do so. Finally, reduced functional capacity can limit an elderly person’s ability to seek help. For instance, mental illness may make them suspicious of outside assistance, sensory loss may inhibit use of telephones or other communication devices to signal need, and cognitive impairment may limit the ability of older adults to problem-solve and thereby identify sources of help and make contact with them.
Problem behaviors can originate in cognitive impairment, mental illness, or personality traits. Personality traits which seem to render older adults most vulnerable to elder abuse include hostility, aggression, and passivity. For example, in a study conducted in the Netherlands (Comijs, Pot, Smit, and Jonker 1998), victims of physical, verbal, and financial abuse showed higher levels of aggression along with more passive and avoidant coping styles than did nonvictims. Similarly, perpetrators often perceive the behavior of victims as demanding, disagreeable, complaining, and uncooperative. According to one physically abusive adult child, he becomes angry and violent toward his elderly father when he ‘‘argues with me, talks back, gets contrary.’’
Dementia is a disorder that often results in both reduced functional capacity and problem behavior. It is one of only a handful of elder abuse risk factors that has been validated by substantial evidence. Dementia is a term used to describe a decline in mental functioning severe enough to bring about significant incapacity in such areas as memory, decision making, and judgment. There are many diseases which can cause dementia. Some are progressive and irreversible. The most common of these is Alzheimer’s disease, which represents half of all cases of dementia in older adults.
Various studies have shown a two to three times greater prevalence of physical abuse by family caregivers of persons with dementia. The care recipients also abuse the caregivers in 16 to 33 percent of these situations. Indeed, over half of persons with dementia are reported to be physically or verbally aggressive during the course of the disorder.
The National Elder Abuse Incidence Study conducted by the National Center on Elder Abuse (1998) found that three-fourths of identified victims had some degree of confusion, typically resulting from Alzheimer’s disease or other dementia. Family caregivers of persons with dementia report aggression as the most serious problem they confront. It can precipitate institutionalization. Catherine Hawes (in Bonnie and Wallace 2003) found that in nursing home settings, staff view aggression by residents as purposefully hurtful and intentional attempts to be difficult. When residents abuse staff, staff are five times more likely to reciprocate.
Risk Factors for Perpetrators
Characteristics of the perpetrator represent the dominant risk factors for elder abuse. They are better predictors of the problem than victim or environmental characteristics. There is compelling evidence that perpetrator pathology and dependency particularly contribute to abuse occurrence. More controversial, and far less substantiated by empirical study, are such other risk factors as caregiver stress and the cycle of violence.
Perpetrator pathology can take several forms, with alcoholism and mental illness most commonly cited in the research literature. Various case control investigations suggest that alcoholism is frequently found among elder abuse perpetrators. More than nonabusers, elder abusers are likely to use alcohol, to consume it regularly, and to be self-identified or identified by others as having an alcohol problem. Although the precise relationship between alcoholism and elder abuse is unclear, several propositions have been offered. Alcoholism may provide an excuse for unacceptable behavior. It may remove inhibitions and increase impulse response. It may foster dependency between perpetrator and victim, leading to resentment and hostility. Actually, it may be that all three of these factors are linked. More specifically, mistreating an older adult breaches social taboos. Those who do so risk severe negative reaction, and perhaps criminal penalty. Alcoholism provides the vehicle for overcoming the taboo, committing the act, and rationalizing it away. It also provides the justification for the perpetrator being financially and otherwise dependent on the victim. This may be especially true when alcoholism is viewed as a disease, rather than self-selected behavior. Personal responsibility is less likely to be an expectation under these circumstances.
Mental illness and emotional distress on the part of the perpetrator are risk factors for elder abuse. Several studies have shown that perpetrators are more likely to have a diagnosed mental illness, especially depression, and more likely to have been psychiatrically hospitalized. They also are more likely to express emotional distress, often related to interaction with the victim. Besides depression, other forms of mental illness identified among perpetrators include schizophrenia, personality disorder, and anxiety. There also may be a complex interaction between mental illnesses like depression or anxiety and elder abuse, where one fosters the other, without a clear sense of which happened first.
Perpetrator dependency is most likely to involve financial or housing needs, although dependency can take other forms, including psychological and social. Perpetrators are frequently financially dependent on their victims for food and other life essentials. They may expect victims to support their habits, addictions, and dreams. Additionally, perpetrators often require the shelter provided by their victims. The reasons for this dependency are complex and may include personality traits such as selfishness and greed or may relate to the unemployment or underemployment of the perpetrator; indeed, because of alcoholism, mental illness, or other dysfunction, the perpetrator may be unemployable. The victim, as a family member, ordinarily feels obligated to offer assistance, only to find that it becomes the source of frustration and conflict. For example, an unemployed, alcoholic son may reside in the home of his eighty-year-old father and depend on the older man for food and spending money. Yet, the son becomes angry and abusive whenever his father tells him to stop drinking and get a job. The grandsons of the victim, who are the sons of the perpetrator, regularly visit, timing this with the arrival of their grandfather’s Social Security and pension checks. They expect money to finance their drug habits and become abusive to both their father and grandfather when they are not given the amount demanded.
Other perpetrator characteristics have been suggested as risk factors for elder abuse. They include poor health and lack of empathy for older people. The most popular among the other suggested risk factors are caregiver stress and the cycle of violence, neither of which has been substantiated as a risk factor for elder abuse through research. Caregiver stress or burden was the favorite explanation for elder abuse during its early recognition as a health problem and an aspect of family violence, beginning in the mid- to late 1970s. The demands associated with providing care to frail or impaired older adults, the necessity of juggling multiple roles and responsibilities, and the lack of resources to accomplish caregiving tasks were seen as contributing to abuse occurrence. The appeal of naming stress as a risk factor was threefold:
- Experiencing stress was nearly universal among caregivers and, perhaps as a result, blameless. This made elder abuse more understandable. It was something anyone was capable of inflicting, and since it was related to caregiving, it was amenable to resolution through supportive services.
- Systems already were in place to provide supportive services for those experiencing stress. Nothing new had to be developed.
- The origins of elder abuse were found in the frailty or impairment of older adults. This perception tended to reinforce long-standing American ageism and stereotyping of persons with disabilities. It also reinforced a ‘‘blame the victim’’ notion that was gaining momentum at the time. However, with rare exceptions, research has not found that elder abusers are more stressed or burdened by caregiving than nonabusers.
Called by various names, including transgenerational or intergenerational abuse, the cycle of violence remains an important explanation for child abuse. According to this theory, abused children grow up to be child abusers themselves. Applied to elder abuse, the explanation suggests that children abused by their parents or other relatives grow up to abuse these very people when they are vulnerable in later life. As of this writing, only a couple of studies have addressed this issue. Neither found evidence to support it. Still, the notion seems to have some popular appeal. Some scholars, as well as some elder abusers who had been victims of child abuse, would argue that being abused as a child can lead someone to commit elder abuse as an adult.
Environmental Risk Factors
The most important environmental risk factors are shared living arrangements and social isolation. Research and anecdotal evidence suggest that living alone is a protection against elder abuse. Conversely, sharing a residence with someone increases the likelihood of abuse occurrence. Co-residence promotes contact and, therefore, possible tension and conflict between people. The greater the proximity and intimacy of the contact and the longer it takes place, the greater the probability of discord and abuse when co-residence is combined with perpetrator and victim risk factors.
Social isolation is another validated elder abuse risk factor. Both victims and perpetrators tend to have fewer social contacts and lower levels of social support than those not affected by elder abuse. In some instances, isolation is perceived, as opposed to real. Still, for those convinced of this perception, the effect can be the same as if it were. They feel alone, without sources of necessary assistance or reassurance. Social isolation also means that others are not present to monitor interactions between perpetrator and victim, diffuse tensions, or identify and report abuse occurrence. Isolation can happen for any number of reasons, such as marginalized lifestyle, estrangement from family and friends, and poor health or disability. It also can be imposed upon the victim by the perpetrator as a form of psychological abuse, to create conditions for undue influence or to prevent abuse detection.
Cultural Risk Factors
Elder abuse is widely regarded as a global problem. However, there is some evidence to suggest that its forms, meanings, and prevalence may vary by country. In part, this may reflect differences in cultural norms, particularly as they relate to attitudes toward and treatment of vulnerable populations. Although unsubstantiated by research, some gerontologists believe that American values promoting violence, material acquisition, youth, and individualism contribute to elder abuse. Likewise, American attitudes of ageism and stereotyping of persons with disabilities create a climate in which older and disabled people are ignored or regarded as less than human. The American emphasis on personal and family responsibility also means that those incapable of taking care of themselves or their relatives have fewer sources of outside help available than in other developed countries. Moreover, using these outside sources of help can result in feelings of guilt or shame, because it contradicts cultural ideals.
Risk Factor Screening and Assessment
Detecting possible elder abuse is a precursor for preventing occurrence or reoccurrence and treating any manifestations of the problem. Screening or risk assessment instruments aid in the detection process. There are a number of instruments or tools that screen or assess elder abuse risk factors. Nearly all are developed for clinicians, such as physicians or social workers. Some are designed for use in specific clinical settings, like hospitals or home care agencies. Some also are focused on revealing only select forms of elder abuse, such as the Conflict Tactics Scales for physical or psychological abuse and the Elder Assessment Instrument for neglect or inadequate care.
Elder abuse screening or risk assessment instruments are important for three reasons. First, they provide assurance that important clues in elder abuse detection are not missed. Screening or risk assessment instruments are used to identify commonly recognized varieties of elder abuse and to describe their characteristics. Second, instruments provide a framework for gathering data on older adults and their circumstances. They foster a more complete and accurate collection of essential information about the elderly. Third, data gathered through instrumentation tends to be more useful for research and court proceedings.
Clinicians need to assume a greater role and responsibility in detection and reporting, because others who come in contact with elder abuse situations often cannot or do not do so. According to findings from the 2004 Survey of State Adult Protective Services (National Committee for the Prevention of Elder Abuse and National Adult Protective Services Association 2005), 30 percent of elder abuse reports came from clinicians. This represents nearly twice the number that came from family members, three and a half times that from friends and neighbors, and five times the number that came from the victims themselves.
Victims may not report elder abuse, even when it is severe and long-term, out of fear of retaliation, their wish to protect the perpetrator, the lack of ability to report, fear of possible institutionalization, or a sense that nothing can be done. In addition, victims may redefine behaviors as other than abusive based on cultural background. For instance, in focus group discussions with older adults and baby-boom caregivers representing four ethnic populations, Puerto Ricans were much less likely to emphasize psychological abuse as the worst thing that family can do to elderly members than were Japanese Americans (Anetzberger, Korbin, and Tomita 1996). Family, friends, and neighbors may fail to report elder abuse out of a desire to remain uninvolved, a belief in the sanctity of the family to handle its own concerns, suspicion of authorities, or a lack or awareness that help is available.
Although elder abuse can be detected in clinical settings, it is more commonly uncovered through observation or interview in the older adult’s own home. It is here that the signs of abuse occurrence tend to bombard the senses—seeing burnt flesh, smelling urine-soaked mattresses, hearing words that belittle or condemn the victim. It is here, too, that elder abuse risk factors are most likely to be revealed in the separate and group interviews with the victim and perpetrator. Masking signs and risk factors is difficult where life circumstances are most abundantly clear, as they are at home. Therefore, it should not be surprising that clinicians most likely to detect and report elder abuse are those who see older adults as clients or patients at home. These include visiting nurses, social work case managers, and home care aides.
Screening or risk assessment instruments come in various formats, such as the checklist employed by the Indicators of Abuse Screen or the narrative guidelines developed for diagnostic and treatment purposes by the American Medical Association. Similarly, the content and methods of these instruments vary. Most include questions on demographics, common signs and risk factors for elder abuse, and degree of endangerment. Beyond this, instruments can be simple or complex in their level of inquiry. The HALF assessment, for example, examines simply health, attitudes toward aging, living arrangements, and finances. In contrast, the Screening Tools and Referral Protocol (STRP) combines three screening tools (one each for examples, signs, and risk factors of elder abuse) and a referral protocol with twenty-four extended tools that further assess such identified risk factors as functional ability and depression. The greater the complexity and comprehensiveness of the instrument, the more costly its application and the less likely it is to be used. Conversely, instruments that lack comprehensiveness may have insufficient detail for abuse detection. This is a particular issue for elder abuse, estimated to affect only one in twenty older adults.
Few elder abuse screening and risk assessment instruments have universal acceptance, and few have been tested for reliability and validity. Instrument accuracy and efficiency are important, given the demands on clinicians’ time and the potential negative consequences attached to mistakes in case identification. To address these concerns, some clinical settings use two levels of detection, with different instruments employed at each level. A prescreen seeks to identify situations of elevated risk within large vulnerable populations. A screen attempts to narrow detection to situations of such high risk that investigation is warranted.
The use of screening and risk assessment instruments is enhanced within a multidisciplinary or interdisciplinary team. Some such teams are created by specific organizations for their own use. Other teams are formed by and for communities or elder abuse networks. However, all multidisciplinary teams provide a more holistic evaluation of elder abuse situations than can be accomplished by any single clinical discipline alone. Team assessments tend to be more complete because they combine the orientations and expertise of several disciplines, typically medicine, law, social work, and nursing at least.
Screening and risk assessment instruments help provide clinicians with the special skills needed for elder abuse detection, documentation, and case referral. These instruments can improve the capacity of clinicians to penetrate situations involving vulnerable older adults and find out what might be going on that indicates risk or danger. They also can sequence discovery so that it represents judicious use of scarce resources and improves the prospects for elder abuse identification.
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