PART II: ASPECTS OF FAMILY LIFE

PART III: COMMUNITIES

PART IV: PUBLIC POLICY

PART V: SOURCES OF ADDITIONAL INFORMATION

PART VI: REVIEWERS

ABOUT THE AUTHORS

Billie H. Frazier, Certified Family Life Educator, is an Associate Professor and Human Development Specialist with the Cooperative Extension Service, University of Maryland System, College Park, MD.

This is the fourth bibliography in a series on aging that Dr. Frazier has produced in cooperation with the National Agricultural Library, U.S. Department of Agriculture.

Kathleen C. Hayes, Certified Home Economist, is Coordinator of the Technology Transfer Information Center for the National Agricultural Library, Beltsville, MD, and previously was employed by the Cooperative Extension Service, The Pennsylvania State University.

The authors express their appreciation to Cluey W. Hargrove for expediting the progression of this publication.

INTRODUCTION

Although all 50 states have elder abuse laws similar to those aimed at preventing child abuse, it is difficult to determine the actual number of elder abuse cases. However, experts conservatively estimate that 1.5 million elderly people are victims of moderate to severe abuse each year. This amounts to about 1 in every 25 older persons. Authorities indicate that only about 1 out of 8 cases is reported. Congressional reports conclude that elder abuse is increasing.

For the most part, elder abuse remains a hidden social problem, which recently has become the subject of serious study. Research has indicated that certain elderly persons are more at risk, and that certain caregivers are more likely to abuse than others. Even in 1991, much less is known about elder abuse than child abuse. As social scientists continue to study the etiology of elder abuse in detail, the contributing factors of this deplorable national disgrace will come into clearer focus.

The types of elder abuse identified in the literature include: physical abuse and neglect, financial abuse, psychological abuse, sexual abuse, and violation of rights.

Dominant theories for why elder abuse and neglect occur include: retaliation, violence as a way of life, unresolved conflict from childhood to midlife, lack of close family ties, lack of financial resources, resentment of dependency, increased life expectancy, history of mental problems, unemployment, history of alcohol and drug abuse, and environmental conditions.

Americans live in a violent society. The American family and the American home are perhaps as violent or more violent than any other single American institution or setting, with the exception of the military, and that is the case only in time of war. Americans run the greatest risk of assault, physical injury, and even murder in their own homes by members of their own families.

Elder abuse will not simply go away. Swift and determined action must be taken to deal with this shameful situation. Individuals who work with older people need to get involved with the issues of elder abuse and neglect in two ways: (1) understand the problem and develop detection, intervention, and prevention strategies; and (2) examine underlying societal attitudes and institutional policies that set the stage for the mistreatment of the older population. These actions can reduce the incidence and prevalence of elder abuse and neglect. This will become increasingly important because of the escalating numbers of elders in the Nation.

SELECTED RESOURCES ON ELDER ABUSE: AN ANNOTATED BIBLIOGRAPHY FOR RESEARCHERS AND EDUCATORS was developed to assist professional personnel from the National Agricultural Library with their information and referral services. It also provides state Cooperative Extension Service specialists and agents with supplementary research for developing programs related to elder abuse and neglect.

The mutidisciplinary approach of the bibliography will appeal to researchers, educators, students, practitioners, and policymakers in the fields of aging, mental health, social services, family violence, and other related disciplines and settings. The literature reviews will be helpful to those concerned about the victimization of the elderly in domestic and institutional settings.

SELECTED RESOURCES ON ELDER ABUSE: AN ANNOTATED BIBLIOGRAPHY FOR RESEARCHERS AND EDUCATORS is divided into the following categories: Background On Elder Abuse, Aspects of Family Life, Communities, Public Policy, Sources of Additional Information, and Reviewers. Citations are appropriate for researchers and educators.

The inclusion of a publication in this Special Reference Brief does not necessarily reflect U.S. Department of Agriculture (USDA) policy, nor does it imply any form of endorsement by USDA. USDA does not ensure the accuracy of the information in this publication.

PART I: BACKGROUND ON ELDER ABUSE

Definition, Detection

"Abuse of the Elderly." Christiane Harris. British Medical Journal; 1988; 297(6652): 813-814.

The British Geriatrics Society sponsored a multidisciplinary conference in which elder abuse was defined as "misuse of power resulting in a reduction of the quality of an elderly person's life". Reluctance to intervene in family affairs, difficulty in knowing how to cope with the problem when it is identified, and defining the problem are reasons given for why elder abuse has been ignored.

Eight types of abuse are identified: nutritional deprivation; maladministration of drugs; verbal, sexual, and financial abuse; failure to attend to health needs; isolation or confinement; and assault. Caring for a dependent elderly person has serious consequences for the health of the elder and the caregiver. Abuse occurs in all social classes, and anyone is capable of becoming an abuser when under persistent and unrelenting stress.

People with dementia and Parkinson's disease are most vulnerable. Abuse of the elderly in long term care wards is similar to that in residential homes and includes lack of privacy, poor decor, inflexible routines, inadequate shoes or slippers, inadequate laundry facilities, and overuse of restraints. Most of the elderly who are abused are not identified by the protective networks. Advocacy schemes such as those in Sweden are helpful. A confidential system for dealing with suspected abuse in the home is needed.

"Causes of Elder Abuse: Caregiver Stress Versus Problem Relatives." Karl Pillemer and David Finkelhor. American Journal of Orthopsychiatry; 1989; 59(2): 179-187.

Elder abuse victims and a non-abused control group were compared for the purpose of testing the widely accepted proposition that elder abuse results from the burden and stress placed on caregivers of infirm and dependent elderly persons. Data suggest that a small, but significant, percentage of the elderly are abuse victims. The study found substantial support for the idea that abuse is associated with personality problems of the caregiver, rather than characteristics of the elderly victim. The study also indicated that spouses make up a greater proportion of elder abusers than do adult children. It is suggested that victims would benefit from services like emergency shelters and support groups. Services would help elderly victims break the bonds of dependence by offering them other alternatives, instead of spending their lives with an abusive relative.

"A Definitional Discussion of Elder Maltreatment." Deborah Valentine and Tim Cash. Journal of Gerontological Social Work; 1986; 9(3): 17-28.

Currently, there is no uniformly accepted definition of elder maltreatment. This article differentiates between the legal and the social work definitions, and provides a classification system for defining elder maltreatment from a social work orientation. Distinctions within each of three major categories of elder maltreatment (elder neglect, elder abuse, and violation of the elder's rights) are presented.

"Detecting Elder Abuse: A Guide for Physicians." Judy S. Bloom, Pamela Ansell, and Matthew N. Bloom. Geriatrics; 1989; 44(6): 40-56.

The problem of detecting elder abuse is similar to that of detecting child abuse. It is contingent upon the physicians' awareness of the problem and an understanding of the risk factors that often appear before a crisis occurs. When practicing physicians better understand how to detect elder abuse, they will be better able to identify and treat the abuse.

The purpose of this article is to provide physicians with detection and intervention strategies. It is suggested that physicians use their unique relationship with their patients to promote further investigations of this growing social problem.

Developing An Index of Elder Abuse: Final Report. Melanie Hwalek and Mary C. Sengstock. Detroit, Michigan: Wayne State University: The Institute of Gerontology; April 1, 1985.

Two indices were developed to identify victims of elder abuse and neglect during this two year project. The Hwalek-Sengstock Risk Assessment Tool is a 17-item screening instrument for identifying at-risk elderly. The Sengstock-Hwalek Comprehensive Index of Elder Abuse can be used to systematically document the presence of six types of elder abuse/neglect: (1) physical abuse, (2) physical neglect, (3) psychological abuse, (4) psychological neglect, (5) material abuse, and (6) violation of personal rights.

This index helps the user determine if the abuse/neglect is intentional, and if so, if it is a case of abuse or self-neglect. The index documents the demographic characteristics of the elderly victim. It also offers information relative to services provided, and thus enhances the potential for interagency case management. Slide-tape and videocassette training materials also were produced to train professionals to use the index.

NARCEA's Suggested State Guidelines For Gathering and Reporting Domestic Elder Abuse Statistics for Compiling National Data. Toshio Tatara. Washington, DC: National Aging Resource Center on Elder Abuse; July 1990.

The guidelines presented in this report were conceptualized by the author in consultation with staff of the NARCEA consortium organizations. The purpose was to help ensure greater comparability among state level data which will enhance the credibility of aggregated statistics at the national level.

The guidelines were targeted toward state agencies that routinely collect and analyze data on domestic elder abuse. The successful implementation of the suggested data gathering and reporting guides by states is clearly a first important step toward the development of a creditable national data system on domestic elder abuse.

"The Prevalence of Elder Abuse: A Random Sample Survey." Karl Pillemer and David Finkelhor. The Gerontologist; 1988; 28(1): 51-57.

Interviews were conducted with 2,020 elderly persons, who lived in a community within the Boston metropolitan area, regarding their experience of physical violence, verbal aggression, and neglect. The prevalence rate for overall maltreatment was 32 elderly persons per 1000. Spouses were found to be the most likely abusers. About equal numbers of men and women were victims, although women suffered more serious abuse. Implications for public policy are discussed. This study represents the first large-scale random sample survey of elder abuse and neglect.

"A Profile of Elder Abuse and Neglect in Tennessee." H.I. Paul Villas. Dissertation Abstracts International; March 1989; 49(9): 2548-A.

A survey of elder abuse cases reported to the Tennessee Department of Human Services was conducted. It was found that the typical abused elder in Tennessee is a 76 year old white female who lives alone or with relatives and obtains most of her income from social security. When geographical considerations are taken into account, a black female has the same chance as a white female of being abused in western and urban counties in Tennessee. Neglect and self-neglect are the most common types of abuse reported in Tennessee.

"The Recognition of Elder Abuse Among Health Service Professionals." Emma Turner Lucas. Dissertation Abstracts International; February 1990; 50(8): 2651-A.

The author investigated whether or not the ability of health care professionals to recognize abuse and recommend an intervention is affected by specific attitudes toward the elderly. Results indicate that the study population tended to hold positive attitudes toward the elderly. They also tended to recognize elder abuse and to recommend intervention strategies. The impact of the worker's age, length of time with agency, and experience in the field were used to examine the impact on the relationships between attitude, attribution, recognition, and intervention.

"A Review and Analysis of Measures for the Identification of Elder Abuse." Mary C. Sengstock and Melanie Hwalek. Journal of Gerontological Social Work; 1987; 10(3/4): 21-36.

This study examines seven measures for identifying elder abuse. Symptoms of actual abuse in the measures were most often related to physical abuse or neglect. The authors recommend ways for improving the methods of identifying elderly victims of abuse.

The need to diagnose the problem clearly is critical to determining its prevalence and the types of services needed. Research is underway, but more work is needed to provide a clearer definition of the problem.

"A Study of Selected Environmental Variables Associated With Non-Institutional Settings Where There is Abuse or Neglect of the Elderly." Linda Raedene Rounds. Dissertation Abstracts International; 1984; 45(05-A): 2221.

This study investigates the following environmental variables that are associated with abuse and neglect in non-institutionalized elderly persons: physical, psychosocial, financial, and health status of the abused and the abuser. Forty five reported cases of elder abuse were reviewed for demographic data. Findings revealed that the most frequently abused person was a widowed female in her seventies with health related dependency needs. The most common types of abuse were neglect and self-neglect. The least common were physical abuse and violation of rights. The abuser was most often a relative with no formal support system.

Prevention

Collaborative Elder Abuse Prevention Project Final Report. Garry L. McDaniel. Austin, Texas: Office of Strategic Management, Research, and Development; September 30, 1989.

An interagency group developed a comprehensive, long-range plan for the prevention of elder abuse; a method for achieving a coordinated service delivery system for abused and neglected elders in Texas; and a statewide public awareness campaign to increase the public's ability to identify and report elder abuse and neglect.

The following major activities were included as part of the public awareness campaign: three national adult protective services conferences; numerous media products to increase public awareness of elder abuse and neglect; a catalog of media products and services provided by each of the 14 interagency members; and 11 public awareness seminars.

"Elder Abuse Awareness Project." Kathleen Doyle and Marilyn J. Morrow. Health Education; October/November 1985; 16(15): 11-13.

The Elder Abuse Awareness Project was undertaken to determine the incidence of abuse and neglect in seven counties and to develop, produce, and distribute educational materials to the professional service provider and senior citizens as a component of domestic violence.

Signals that allude to abuse include: medical concerns; inconsistent behavior; changes in interpersonal relationships, home and living environments, finances, and emotional stability; and evidence of neglect and physical disintegration. Trust and communication between the older client and service provider is crucial. It requires repeated contact and develops only over a period of time. Confidentiality needs to be stressed. The results of this project provide evidence that both elder abuse and neglect are prevalent in our society.

"Preventing Elder Abuse: Identification of High Risk Factors Prior to Placement Decisions." Jordan I. Kosberg. The Gerontologist; 1988; 28(1): 43-50.

In the 1960's, research focused on child abuse, and in the 1970's, research focused on spouse abuse. In the 1980's, the focus was elder abuse. For many reasons, elder abuse often remains invisible. Professionals and others should not assume that family membership prevents people from engaging in abusive behavior. Family members have been found to be major perpetrators of elder abuse.

The author provides the following characteristics of older persons that appear to make them vulnerable to abuse: female, advanced age, dependent, problem drinker, intergenerational conflict, internalizes blame, excessive loyalty, past abuse, stoicism, isolation, impairment, and provocative behavior.

Clues to characteristics of the caregivers who may be abusive include: problem drinker, medication or drug abuser, senile dementia or confusion, mental or emotional illness, caregiving inexperience, economically troubled, abused as a child, stressed, unengaged outside the home, blamer, unsympathetic, lacks understanding, unrealistic expectations, economically dependent, and hypercritical.

The following characteristics need to be assessed in any evaluation of the family care system: lack of family support, caregiver reluctance, overcrowding, isolation, marital conflict, economic pressures, intra-family problems, and desire for institutionalization. Elder abuse will continue as long as ageism and violence exist.

The following societal values contribute to elder abuse: ageism, attitudes toward the disabled, sexism, and greed. Elder abuse results from the dynamic interaction between personal, family, social and cultural values, priorities, and goals. Therefore, attention must be given to those factors which, although not causing abuse, contribute to its likelihood: poverty and unemployment, lack of community resources, intra-family cycles of abuse, and personal hedonism.

The assessment of potential caregivers, prior to the placement of an elderly person, is suggested as one method for dealing with the problem of elder abuse.

"The Prevention of Elder Abuse: An Educational Model." Deborah T. Gold and Lisa P. Gwyther. Family Relations; January 1989; 38(1): 8-14.

Recent research on elder abuse highlights the importance of communication and conflict resolution in the families of older people. Although methods of handling detection and intervention of elder abuse exist, few prevention programs are available for use with community groups.

The authors review the literature on elder abuse and describe an educational curriculum designed to prevent elder abuse and neglect. The curriculum provides flexibility so it can be adapted for different groups and for programs of varying length. Each of the four modules--financial, functional, social, and emotional--takes approximately one hour to complete using both spousal and intergenerational family segments. This includes time for group discussion. The curriculum emphasis is on finding mutually satisfactory compromises to problems between family members. Communicating and verbalizing feelings and preferences are perceived as essential to the prevention of family violence in older families. The curriculum encourages participants to look for ways to relieve stress within the family.

Intervention

Abuse and Religion: When Praying Isn't Enough. Anne L. Horton and Judith A. Williamson. Lexington, Massachusetts: D.C. Heath and Company; 1988.

This book addresses the special needs of victims, and the clergy and religious leaders who advise them. It is a practical, "how to" book that provides basic information, referral sources, and alternatives that are needed for effective and sensitive intervention and assistance with domestic violence. Chapter 4 covers abuse of the elderly in the home, including: a definition; characteristics of abused elders and their abusers; and the ways in which people abuse.

"'Self-Neglect': The Frail Elderly as Victims of 'System Neglect'." Susan Elizabeth Geiger. Masters Abstracts International; Spring 1989; 27(1): 51.

The author compares a group of self-neglecting elders with a group of physically abused elders. The self-neglect group was found to be both physically and mentally more frail than the physical abuse group. The self-neglect group used more services for a longer period of time than did the less frail comparison group. Adult Protective Services assisted this vulnerable group to obtain necessary services. Intervention programs like Adult Protective Services may improve the status of this at-risk population.

Strategies for Helping Victims of Elder Mistreatment. Risa S. Breckman and Ronald D. Adelman. Newbury Park, CA: Sage; 1988.

Authors provide a guide for students, physicians, social workers, clergy, nurses, and other professionals who work with old people. Comprehensive theoretical "how to" information on detection, assessment, and intervention are discussed within the context of geriatric practice.

"When the Elderly Are Abused: Characteristics and Intervention." Sharon Powell and Robert C. Gerg. Educational Gerontology; 1987; 13(1): 71-83.

The authors systematically reviewed 60 cases of elder abuse. The research questions examined the characteristics of victims and abusers; types and duration of abuse; descriptions of abusive situations; the reporting and verification of abuse; case management strategies used by caseworkers, and the consequences of those strategies.

The study provides descriptions of the various types of abuse: physical, financial, emotional, passive neglect, and active neglect. Financial abuse was noted most frequently. Multiple types of abuse were noted in most cases, with the combination of physical, financial, and emotional abuse being observed most frequently.

The study discovered that one out of five abuse victims resides in the home of the abuser, and the victim is likely to be experiencing physical and/or emotional impairment. Elderly victims often want information, reassurance, and someone to talk with about the abuse. Elder abuse will probably continue until the elderly can be offered viable alternatives to remaining in an abusive situation and until society begins to address some of the issues surrounding our nation's elderly. Perhaps the answers can be found when society begins to recognize the importance of valuing human life as well as extending it.

General Information

Abuse of the Elderly: A Guide to Resources and Services. Joseph J. Costa. Lexington, Massachusetts: D.C. Heath and Company; 1984.

Estimates of the national scope of elder abuse in 1983 varies from 500,000 to 1 million persons a year. Elder abuse is a modern social problem that demands increased attention and public awareness. Resources in this subject area are limited. Topics covered in this book include: an overview of the problem, fear of crime among the aged, victimization in old age, and a projection of needs and services of the future elderly. Strategies to reduce the incidence and impact of crime, and improve education and programs in crime prevention also are included.

Abuse of the Elderly: Issues and Annotated Bibliography. Benjamin Schlesinger and Rachel Schlesinger, Eds. Toronto: University of Toronto Press; 1988.

This practical sourcebook is for all concerned professionals working with and interested in elder abuse. Therapists, health care providers, educators, policymakers, and students can learn from the 10 essays which represent diverse specialties within the area of elder abuse. Abuse of the elderly is defined along with the contexts within which it occurs. The editors write about the knowns and unknowns regarding elder abuse which they gleaned from the literature.

The article on "Grannybashing" provides statistics on the incidence and projections of abuse in Canada. An annotated bibliography of literature from 1978 until 1987 is divided into 43 categories such as agencies dealing with abuse, caregiving, ethnicity and abuse, incidence, protocols, justice system, and volunteers.

"Abuse of the Elderly: Misuses of Power." Eric J. Cassell. New York State Journal of Medicine; March 1989; 89(3): 159-162.

Abuse of anyone is wrong, and abuse of the elderly is especially offensive. To be in a relationship with another person is in some sense to be responsible to the person. This article examines abuse of the elderly by their children, and in hospitals, in legal considerations, and medical therapy. The author concludes that abuse of the elderly occurs primarily because the exercise of power by others is unchecked by obligation or responsibility. Law and regulation are poor sources in restraining the powers others have over the helpless elderly. In general, it is the web of mutual obligations and responsibilities that regulate the power of the participants in social relationships.

Elder Abuse and Neglect: A National Research Agenda. Karen F. Stein. Washington, DC: National Aging Resource Center on Elder Abuse; January 1991.

The National Aging Resource Center on Elder Abuse convened a panel of nationally recognized experts in the fields of elder abuse and social sciences research to recommend priority research issues in the field of elder abuse. This publication reflects the conclusions of the expert panel.

The public and private sector are urged to read this document, to give serious consideration to the panel's concerns, and to work toward initiating and supporting research that will help provide for a more reliable and valid knowledge base. This needed research will lead to knowledge vital to preserving the wellbeing of elderly persons at risk for abuse, neglect, and exploitation.

"Elder Abuse: 10 Years Later." Rosalie S. Wolf. Journal of the American Geriatrics Society; 1988; 36(8): 758-762.

The first reference in the literature on elder abuse appeared in 1975 in the British Medical Journal entitled "Granny-battering," followed by Robert Butler's Pulitzer Prize winner, "Aging in America: Why Survive?" where Butler describes the "battered old person syndrome."

There are now elder abuse laws in all 50 states. Although there is still a great deal that is unknown about mistreatment of the elderly and what can be done to prevent it, there have been a number of achievements. Efforts of the past decade have: (1) provided insight into the nature of familial and marital relationships in later life; and (2) brought together social services and law enforcement personnel, health care providers, mental health professionals, legal services, domestic violence groups, and protective services to discuss common problems. These efforts have led to the creation of new intracommunity agency structures for dealing with families that have many problems.

"Elder Abuse: The Latest 'Crisis'." Stephen Crystal. Public Interest; Summer 1987; 88: 56-66..

With the "discovery" of elder abuse in the 1980's, political and professional attention became rather substantial. New legislation was enacted in a majority of states. One report describes elder abuse as a full-scale national problem. A major question considered is what the Federal government could do to provide safety to seniors in their own homes. Elder abuse and neglect includes psychological abuse, exploitation, and self-neglect. The author discusses elder abuse, the child abuse analogy, the dilemma of definition, and the perils of legislation. The issues, problems, and concerns related to elder abuse are considered.

"Elder Abuse: A Multi-Case Study." Sharon Leigh Powell. Dissertation Abstracts International; February 1987; 47(8): 2963-A.

This study examines 60 cases of elder abuse. Results point to the probability of the elderly-abuse victim being 75 years of age or older, female, white, and widowed. There does appear to be some connection between race and type of abuse, with white victims being more likely to experience physical and financial abuse. About half of the abuse victims have severe limitations in physical and/or mental functioning, which leads to some degree of dependence upon their abusers. Eighty percent of the victims resided in their own homes and half of these were functionally independent. This study provides descriptions of the following types of abuse: physical, financial, emotional, passive neglect, and active neglect. Financial abuse was noted most frequently. No evidence was found that those who abuse the elderly are prosecuted.

"Elder Abuse: Perspectives on an Emerging Crisis." Vol 3, Mid-America Congress on Aging. Michael W. Galbraith, Ed. Journal of Gerontological Social Work; 1989; 14 (1/2): 209-211.

This volume contains 11 chapters and is appropriate for a wide audience including practitioners, researchers, and policymakers. The book provides a thorough description of the range of issues and intervention methods for elder abuse and neglect. Existing literature on the topic and state statutes are reviewed. Comprehensive definitions for abuse and neglect also are presented. Various perspectives on causes of abuse are examined, and an overview of assessment tools and potential modes of intervention is offered. Gerontologists and practitioners must become more aware of the scope of the problem. This is the first step toward meeting the goal of reducing elder abuse and neglect.

Helping Elderly Victims: The Reality of Elder Abuse. Rosalie S. Wolf and Karl A. Pillemer. New York: Columbia University Press; 1989.

This book focuses on three evaluative components of a research project on elder abuse. Objectives were to: determine the extent of elder abuse in a geographical area; develop knowledge of existing responses; demonstrate improved mechanisms for reporting and investigating treatment and prevention programs; and design social and legal remedies to restore the rights and well-being of abused elderly. The book is divided into four parts: Introduction: Background and Risk Factors; Victims, Perpetrators, and Maltreatment; Organizational Analysis; and Realities and Recommendations. Findings suggest that federal and state attempts to shift even more responsibility to relatives should be carefully evaluated.

"The Paradox and Perplexity of Elder Abuse." Donald G. Sukosky. Family Life Educator; Winter 1990, 9(2): 7-12.

Elder abuse is becoming a critical problem in contemporary society. According to the American Medical Association's Council on Scientific Affairs, ten percent of our elderly are abused, and as many as 1 percent may be victims of severe abuse! Data indicate that elder abuse occurs in a variety of settings, including the family.

The present study explores the question of: How and why do abuse and neglect originate and continue? The authors address four aspects of elder abuse: (1) the problem of definition; (2) the covert nature of abuse and neglect; (3) psychosocial profiles of the abuser and the abused; and (4) possible interventions. Although there is no single answer to the problem of elder abuse and neglect, one viable approach is through family life education. By sensitizing themselves to the dimensions of the problem, family life educators may, in turn, heighten student awareness, increase knowledge of possible causes, and stimulate creative thinking about the realistic possibilities of prevention and intervention.

Summaries of National Elder Abuse Data: An Exploratory Study of State Statistics Based on a National Survey of State Adult Protective Service and Aging Agencies. Toshio Tatara. Washington, DC: National Aging Resource Center on Elder Abuse; July 1990.

The purpose of this report is to provide summaries of the elder abuse statistics for FY 86, FY 87, and FY 88. Data were collected by the National Aging Resource Center on Elder Abuse from state adult protective service and aging agencies.

The national estimates of elder abuse reports included represent undercounts because the elder abuse information systems of reporting agencies are incomplete, and because elder abuse is grossly underreported across the country. Although data summaries are exploratory, the estimates and summaries presented are useful in highlighting important aspects of elder abuse problems for which information has previously been limited.

"The Vexing Problem of Elder Abuse." Rosalie S. Wolf. Public Welfare; 1988; 46(2): 5-6.

Because it is largely hidden, and not well understood, elder abuse is difficult for the professional community to address effectively. Only with the support of the general public can professionals ensure that cases are brought to light and appropriate action taken. There are increasing efforts to: explore the causes of the problems; to strengthen programs that respond to reports of alleged abuse and neglect; improve the quality of treatment and preventive services; broaden public awareness; and expand funding. This edition is designed to provide an overview of issues and point the way toward a system that compassionately and effectively offers the elderly the protection they greatly deserve.

PART II: ASPECTS OF FAMILY LIFE

Family Caregiving

"Attacking Elderly Abuse." Paul Chance. Psychology Today; September 1987; 21(9): 24-25.

Results of a survey by social scientists helped influence Texas law to protect the elderly and their caretakers. Alcohol and drug abuse by the caretaker were the most commonly cited causes of elder abuse, followed by pressures on the caretaker. Respondents with little experience with elder abuse were more likely to blame alcohol and drug abuse.

More experienced professionals put greater emphasis on the burdens of the caretaker. Therefore, the main villains seem to be the mental, physical, and emotional burdens of caring for feeble, often uncooperative old people. Also, young people frequently need help in knowing how to get community assistance for their elders. A police sergeant stated that people who mistreat their pets are subject to punishment, but a person can let his or her mother starve without fear of prosecution. The author emphasizes the fact that the problem will not be solved by simply sending people to jail.

"A Case-Comparison Analysis of Elder Abuse and Neglect." Michael A. Godkin, Rosalie S. Wolf, and Karl A. Pillemer. International Journal of Aging and Human Development; 1989; 28(3): 207-225.

This study examines factors that contribute to abuse and neglect of the elderly by their caregivers in a domestic setting. A rigorous research design was used. Fifty-nine abused elders from a model project site for the study of elderly abuse were compared with 49 non-abused clients from a home care program in the same agency.

The study indicates that members of abusive families are more likely to have emotional problems which contribute to interpersonal difficulties. Abused elders are not more dependent on caregivers for many of their daily needs. However, the abused elderly and their caregivers have become increasingly interdependent prior to the onset of abuse because of the loss of other family members, increased social isolation, and the increased financial dependency of the perpetrator on the elderly person.

In summary, both the abused elders and the abusers experience emotional problems which contribute to interpersonal difficulties in their relationship. Study results indicate an important need for indepth research that examines the role of family dynamics in elder abuse and neglect. Abuse cases involve complex and long-term family problems, and unresolved conflicts.

"Elder Abuse." Melvin White. In Aging and the Family. Stephen J. Bahr and Evan T. Peterson, Eds. Lexington, Massachusetts: Lexington Books; 1989.

This chapter is divided into seven sections. The first section is a brief review of data on the incidence and prevalence of elder abuse. Major forms of elder abuse are identified. Characteristics of the abused and abuser are discussed in the third and fourth sections. Section 5 reviews major risk factors that were found to be associated with elder abuse, and Section 6 discusses prevention and treatment. The last section explores questions that require additional research.

The author states that, although attempts have been made to determine the extent and nature of elder abuse, it is difficult to compare the various studies because of a lack of acceptable standards of definition and methodology.

Many questions were raised pertaining to the abuser, the abused, the family, social policy, and the interaction of all of the above. Research that focuses upon the causes of abuse and neglect rather than on symptoms alone will prove much more useful in developing effective programs to prevent and minimize the elder abuse problem.

Elder Abuse in the Family. Karl Pillemer and Rosalie S. Wolf, Eds. Massachusetts: Auburn House; 1986.

This book of readings includes articles focusing on historical data concerning elder abuse, family neglect, caregiver burdens, current research reviews, definitions, and findings from special studies. Prevention and treatment aspects of elder abuse are discussed.

Duty Bound: Elder Abuse and Family Care. Susanne K. Steinmetz. Newbury Park, CA: Sage Publications, Inc.; 1988.

This book represents one of the first studies on elder abuse to focus exclusively on abuse occurring within the family setting. The author gathered data from caregivers, and used face-to-face in-depth interviews. One of the confounding aspects of elder abuse by adult children is that it is not always possible to separate the victims from the perpetrators. The adult children were caring, thoughtful, loving children who were duty bound to provide the best possible care for their elderly parent. The overwrought, exhausted, and stressed adult child who uses psychological, verbal, physical, or medical means to maintain control often does so with the best intentions.

Elders and their caregivers both used a variety of positive and negative methods in their attempt to gain or maintain control. Over one-third of the elders used verbal abuse methods and crying in attempts to maintain control. The method used most frequently by elders was pouting, and 63 percent used some form of manipulation, usually through inducing guilt or sympathy. Calling the police or another authority, refusing to eat or take medicine, and hitting or throwing things at the caregiver to gain control were other methods used.

In families where more negative forms of interactions occur, more dependency tasks are performed. It was observed that some elders are easier to care for because of health or personality, and some caregivers have personalities better suited to caring than others.

"Elder Abuse by Family Caregivers: Processes and Intervention Strategies." Susan K. Steinmetz. Contemporary Family Therapy; 1988; 10(4): 256-271.

This study of 104 family caregivers, who provided care to 119 elderly kin, focuses on the stress and conflict that can result when the older person, the caregivers, and the family are unprepared to fulfill the caregiving tasks. The sources of stress that contribute to physical and psychological abuse of the elderly are examined. Suggestions (such as setting guidelines, establishing support groups, providing respite and household care, and increasing awareness about the aging process and elder abuse) are offered as useful mechanisms for preventing abusive interactions and increasing the quality of life for the elderly and their families.

Elder Abuse: Conflict in the Family. Karl A. Pillemer and Rosalie S. Wolf, Eds. Dover, MA: Auburn House Publishing Company; 1986.

This book provides a thorough review of family conflicts in later life, and the major theoretical thought and research concerning elder abuse and neglect. The editors discuss issues of definitions, theories, current research, and risk factors. There is a lack of consensus in each of these major areas, and there are many statements about gaps in knowledge. Multiple viewpoints are presented.

Elder abuse may be conceptualized as a separate field of domestic violence. The editors attempt to provide a sense of reason, rather than one of political sensationalism, on the topic.

"The Elderly: Abused or Abusers?" Stanley E. Goldstein and Arthur Blank. Canadian Medical Association Journal; 1982; 127(6): 455-456.

The elderly are often physically, verbally, psychologically and financially abused. However, the problem is sometimes viewed from only one side. Most caregivers do care. Although attitudes of society are changing, the elderly are still not seen as "important". Their feelings of self-worth are undermined; their roles are ill defined. The relationship between the elderly and their families is complex. Although the lives of the aged are often difficult, the problems of caregivers also deserve consideration. We can best help the elderly and the caregivers involved when we look at the situation from both points of view.

"Family Care of Elders: Myths and Realities." Susan K. Steinmetz. In Family Strength 4: Positive Support Systems, Nick Stinnet et al., Eds. Lincoln, Nebraska: University of Nebraska Press; 1982.

The author addresses the increasing number of families who are experiencing stress when a frail, elderly parent, who requires care for a prolonged period of time, moves in with the family. The term "generational inversion" is used to describe the reversed roles of parent and child. In a generationally inverted family, the child generation takes on the responsibilities and privileges of the parent generation while the parent generation becomes the "dependent child" generation. A situation which is increasingly common today is the three or four-generation family, where several generations are dependent upon the adult child. In such cases: the adult child provides care for a frail, elderly parent; the adult child provides babysitting for a grandchild; and the adult child provides financial support to a recentlylaunched adult child.

"Family Mediated Abuse of Noninstitutionalized Frail Elderly Men and Women Living in British Columbia." E. Bristowe, and J. Collins. Journal of Elder Abuse & Neglect; 1989; 1(1): 45-64.

Characteristics of 66 frail elderly men and women and their family caregivers living in British Columbia are reported in this descriptive study. The authors determined factors which differentiated between appropriate and abusive care situations. Data sources include Homemakers, an in-home support service, and media-initiated community reports.

Authors report that caregiver, rather than victim characteristics are important. The typical victim is an old woman who exhibits fewer mental and physical health problems than a recipient of appropriate care. It is alcohol use by a male caregiver that is significantly related to abuse.

"Historical Perspectives on the Role of the Elderly: The Most Ancient Evidence." Gerald A. Larue. In Values, Ethics and Aging. Gari Lesnoff-Caravaglia, Ed. New York, NY: Human Sciences Press, Inc.; 1985.

Present day fears, hopes, beliefs and questions echo those of our ancient ancestors. Myths, legends, historical accounts, folk concepts, law, and social customs are discussed under the following headings: (1) the concept of family and family tensions; (2) the vulnerability of the aged; (3) attitudes towards aging; (4) the significance of life experiences; (5) insights for our time; and (6) suggestions.

The following suggestions are offered. There is a growing need for educational emphasis on the total maturation process and less emphasis upon age differences that separate us into opposing groups. There is need for awareness of the vulnerability of the aged. Programs for the aging need to be tied into life purposes. The slowly developing interest in family history needs to be augmented. Finally, if we are to decrease the disintegration of the family and the sense of uselessness that haunts so many of the elderly, we need an education in life, living, maturation, and death. This educational process should begin at a very early age.

"An Inquiry Into the Relationship of Caregivers and Care Receivers in Elder Abuse Situations." Mary Gebhard Thomasina. Dissertation Abstracts International; April 1989; 40(10): 3157-A.

The author investigated the relationship of caregivers and care receivers in abusive or neglected households in relation to: reaction formation; amount of expressed stress; conflict tactics; and sense of burden as related to health, income, and household head. The following conclusions emerged. Caregivers used reaction formation more often than care receivers. There was no difference in the amount of stress felt by caregivers and care receivers, but each experienced stress in a unique way. Both caregivers and care receivers used physical and verbal abuse as part of conflict tactics. The relationship of household head and the caregiver type contributed to the sense of burden.

"Neglect and Abuse of Older Family Members: Professionals' Perspectives and Case Experiences." Tom Hickey and Richard L. Douglass. Gerontologist; April 1981; 21(2): 171-176.

The authors provide a framework for understanding domestic mistreatment of older people by family members. Professionals were interviewed about their experiences with neglect and abuse of the elderly. Most respondents worked with such cases on a regular basis. Neglect was more common than abuse. Several causes of mistreatment were suggested. It appears that environmental contexts and situational problems serve to trigger abusive or neglectful behavior. This typically occurs as a result of some specific dysfunctional characteristics of the abuser and family relationships.

"Role Reversal of the Elderly: Intervention and Prevention." Donald G. Sukosky. Family Life Educator; Fall 1987; 6(1): 14-17.

The author focuses on one significant type of subtle elder abuse--role reversal. He provides an overview of role reversal, an examination of the subtle manner with which it occurs, its implications for family functioning, and resources for addressing the problem through family life education. The position is taken that educators can perform a valuable service by sharing contextual information to help young people understand that most forms of role reversal can be minimized or prevented. Possible preventions identified include: retaining high self-esteem, coping, maintaining initiative, sustaining authenticity, and remaining patient.

Role reversal among the elderly and their family is viewed as dysfunctional when it deprives each generation of its legitimate functions, and when it is used as a channel of abuse. Role reversal may stem from cultural and individual misconceptions about the nature of aging.

Family Violence

"Abused Parents: A Hidden Family Problem." Robert Lee Pierce and Rosilee Trotta. Journal of Family Violence; 1986; 1(1): 99-110.

Abuse of elderly parents by their adult children has only recently come to the attention of professionals and the general public. Not much is known about these elderly victims and their circumstances. This paper explores the characteristics of elderly victims and their perpetrators, frequency of abuse, factors that may cause abuse, intervention strategies, and policies that have an impact on this life-threatening behavior. Suggestions for future work in this area are offered.

"Caregiver Support for the Rural Homebound Elderly at Risk for Family Violence." Malessa Dean. Dissertation Abstracts International; February 1988; 48(8): 2260-B.

The purposes of this study were to: (1) identify indicators of abuse in the homebound elderly, and (2) test the efficacy of a caregiver support program in alleviating stress of the primary caregiver of the homebound elderly. Data reveal statistical significance between caregiver stress and quality of care for the homebound elderly. There was an association between physical and social indicators of abuse and caregiver stress. There also was a difference in quality of care given by those who attended a caregiver support program and those who did not.

"Dependent Adult Children and Elder Abuse." Jan R. Greenberg, Martha McKibben, and Jane A. Raymond. Journal of Elder Abuse & Neglect; 1990; 2(1/2):73-86.

The authors report characteristics of dependent adult children in substantiated cases of elder abuse. The data come from the Wisconsin elder abuse reporting system in which 204 substantiated cases of abuse by an adult child were reported during a period of 18 months. Analysis indicated that the abusers were financially dependent adult children under the age of 40 who lived with the elder, and had personal problems related to alcohol and drugs. A second but smaller group of adult children were dependent because of problems related to mental illnesses. Substantial depression was reported among this population of abused elders. Implications for further research are discussed.

Domestic Violence in Context. Robert T. Sigler. Lexington, Massachusetts: D.C. Heath and Company, Lexington Books; 1989.

This research was a preliminary, exploratory examination of the public's perception of domestic abuse. It focused on the denotative definitions in use, and the placement of domestic violence in the context of violence.

Chapter 3 explores elder abuse in the home. With elder abuse, there appears to be greater levels of psychological abuse and misappropriation of assets than is the case with either child abuse or spouse abuse. The most common form of elder abuse appears to be neglect, with varying levels of abuse reported by different authors.

"Elder Abuse." Karl Pillemer and J. Jill Suitor. In Handbook of Family Violence. Vincent B. Van Hasselt, Randall L. Morrison, Alan S. Bellack, and Michel Hersen, Eds. New York: Plenum Press; 1988.

The authors present case studies, definitional issues, the prevalence of elder abuse, and a framework for understanding elder abuse. A summary of predisposing factors and direct precipitants of elder abuse is gleaned from literature reviews from the family violence and family relations fields. Interventions are suggested.

"Elder Abuse: The Status of Current Knowledge." Claire Pedrick Cornell. In Family Violence. Richard J. Gelles. Newbury Park, California: Sage Publications, Inc.; 1987.

The state of current research is such that four fundamental questions about elder abuse are asked: What is it? What is the extent of it? Who are the most likely offenders and victims? What causes people to abuse elderly relatives? All questions can be answered with "We do not know". More research is needed so that appropriate programs and policies can be developed. Until such time that the knowledge base and services are developed, practitioners will have to cope the best they can.

A number of steps can be taken: (1) be aware that the elderly are abused by family members; (2) use existing domestic violence services; and (3) recognize that support services such as homemakers, visiting nurses, and home health visitors can alleviate family stress and reduce the risk of future abuse.

The Etiology of Elder Abuse by Adult Offspring. Georgia Jean Anetzberger. Springfield, IL: Charles C. Thomas; 1988.

The author investigated social isolation, the burden of elder caregiving, social intimacy, and conflict tactics to determine the causes of elder abuse by adult children.

This book provides a discussion of physical abuse of elderly parents. The author analyzes interviews of filial caregivers. Findings portrayed the typical abusing adult offspring as an unmarried, middle-aged man with pathological characteristics. He typically abuses his natural mother who is very old and both physically and mentally impaired. The adult male child has typically lived with his mother for several years and provides considerable care. He is burdened by her disturbing behaviors and his lack of available time for personal pursuits. He perceives himself as being socially isolated in the caregiving role, particularly from a supportive extended family. He did not grow up in an abusive family. The author identifies specific steps that typically trigger abuse and suggests implications for social policy, programming and further research.

"Family Violence: Past, Present, and Future." Susanne K. Steinmetz. In Handbook of Marriage and the Family. Marvin B. Sussman and Suzanne K. Steinmetz, Eds. New York: Plenum Press; 1987.

The author discusses: the historical roots of violence between family members; definitions, methods, and methodological problems and levels of violence that are used by family members on each other; theoretical perspectives; and present and future research needs. Historical evidence suggests that family violence is not a new social problem. It has only recently been identified as a social problem by researchers, journalists, social planners, and those involved with the legal system.

Handbook of Family Violence. Vincent B. Van Hasselt, Randall L. Morrison, Alan S. Bellack, and Michel Hersen, Eds. New York: Plenum Press; 1988.

Funding of family violence research has increased because of additional clinical and investigative activity. This handbook was published to aggregate an increasingly large body of empirical data that appeared in various journals and books. The handbook is divided into four parts: Overview of the Field, Theoretical Models, Forms of Family Violence, and Special Issues. Chapter 11, "Elder Abuse", provides information on case studies, definitional issues, prevalence of elder abuse, a framework for understanding elder abuse, interventions, summary and conclusions, and references.

"Individual and Family Correlates of Elder Abuse." Nan Heravig Giordano. Dissertation Abstracts International; January 1983; 43(07): 2463-A.

One purpose of this study was to determine whether or not elders who were abused differed from elders who were not abused. Other purposes were to develop a profile of abused elders, and identify predictors of various types of abuse.

The author found that: (1) Abused elders were more likely than non-abused elders to have marital problems, be intellectually impaired, and to live with others. (2) Elderly victims of physical, psychological, and multiple abuse were typically white females, 66-83, with incomes of $7,000 or less, and not severely ill. The victims lived with the perpetrator, typically, the spouse. When a victim was not married, a son was usually the perpetrator in physical and psychological abuse cases, while a daughter was typically the perpetrator in multiple abuse cases. (3) Living with the abuser, more than one incidence of abuse, and lack of severe physical illness were stable predictors of physical abuse. The abuser's age, financial problems, marital status, relationship to victim, victim's income, and living with the abuser were stable predictors of financial exploitation.

The Violent Family: Victimization of Women, Children, and Elders. Nancy Hutchings. New York, NY: Human Sciences Press, Inc.; 1988.

Authors attempt to explain some causes of family violence and also review the legal system for victims of violence. Problems of battered women, child abuse and family violence, "Granny-bashing", rape victims, and pornography and its relationship to violence are discussed. In the chapter on abuse of the elderly, the author discusses the dilemmas and the causes of elder abuse and social work interventions.

The author states that the complexities of coordinating the delivery of services are compounded by the nature of elder abuse which sometimes requires an emergency response. Issues of professional ethics and confidentiality emerge. The most appropriate approach would include coordinating the efforts of various disciplines to provide essential supportive services. One way to coordinate services would be to link computers and other existing resources that have the capacity to dispense data nationally. The cost of services also could be lowered by pooling information among agencies that serve the aged.

Community Settings

"Abuse of Patients in Nursing Homes: Findings from a Survey of Staff." Karl Pillemer and David W. Moore. The Gerontologist; 1989; 29(3): 314-320.

Research on abuse of nursing home residents is limited. The author surveyed nurses and nursing aides working in long-term care facilities. Rates of abuse, based on staff self-reports are presented, and subgroups of staff who are more likely to engage in abusive behaviors are identified.

Data presented indicate that abuse in nursing homes is sufficiently extensive to merit public concern. Substantial proportions of staff report that abusive behaviors occur, and that they happen more than once in the course of a year. A significant minority of staff, themselves, have committed physically or psychologically abusive actions. It does not appear that maltreatment occurs only in isolated, well-publicized incidents, but that it may instead be a common part of institutional life.

The authors suggest ways to decrease the occurrence of abuse in nursing homes. Federal and state agencies must work with the nursing home industry to upgrade the quality of nursing home staff and to reduce the stress and tension experienced by staff members. Funding needs to be increased for nursing homes to permit the hiring of more and better qualified workers. Training is critical to effectively manage difficult patient care situations, resolve conflicts, and reduce stress levels. This study presents a picture of staff who are working in highly stressful, difficult environments. By reducing this stress, while increasing the ability of staff to resolve conflicts in more positive ways, nursing homes can become more humane environments.

"A Community Response to Elder Abuse." George A. Foelker, Jr., Joan Holland, Mary Marsh, and Bobbie A. Simmons. The Gerontologist; 1990; 30(4):560-562.

The 1987 Amendments to the Older Americans Act of 1965 required that State Offices on Aging identify agencies involved in identifying and treating abused, neglected, and exploited elders and determine the need for appropriate services for such individuals. The authors discuss how the Dallas, Texas Area Agency on Aging met this requirement and what the community did to increase services for those in need.

The creation of an Elder Abuse Task Force had a radiating impact on state law, the statewide adult protective service system, and regional policymaking bodies.

Elder Abuse: Questions and Answers: An Information Guide for Professionals and Concerned Citizens. Toshio Tatari. Washington, DC: National Aging Resource Center on Elder Abuse; June 1991.

This Information Guide was assembled to help both professionals working with older people and concerned citizens to enhance their awareness of the problems of abuse, neglect, and exploitation of the elderly in America. The publication provides basic information about elder abuse problems, and the programs and services that are available to serve victims, their families, and at-risk elders.

Elder Abuse Video Resources: A Guide for Training and Public Education. Debra Broughton. Washington, DC: National Aging Resource Center on Elder Abuse; March 1991.

The purpose of this video resource guide is to assist state aging and adult protective service agencies and other organizations administering elder abuse programs in selecting appropriate video materials for their training and public education activities.

"The Emergency Shelter: A Model for Building the Self-Esteem of Abused Elders." Jessica Cabness. Journal of Elder Abuse & Neglect; 1989; 1(2): 71-82.

"Dwelling Place" is an emergency shelter for abused, neglected, and exploited elderly persons. It is funded by the District of Columbia's Office on Aging and administered by So Others Might Eat (SOME), a non-profit organization. During the first two years of operation, the shelter served 58 clients and identified long-term, community-based housing for 49 of them.

The clients reported feeling better about themselves, their prospects for housing, and their future in general. They attributed these feelings of self-awareness to their involvement with the program. The author explores the esteem-building characteristics of the shelter. Suggested intervention strategies to build self-esteem include supportive counseling, Alcoholic Anonymous support groups, health promotion efforts, peer and intergenerational activities, and active case management.

"Foster Care for the Frail Elderly: Implications of the Johns Hopkins Experience." Patricia J. Volland. Adult Foster Care Journal; 1988; 2(1): 72-82.

This article summarizes the results of a Johns Hopkins experiment in providing foster care for the frail elderly. The evaluation showed that foster care, at a substantially lesser cost, was no less effective than nursing home care. In the author's opinion, however, foster care could lead to abuse or neglect of elderly patients unless careful supervision and monitoring is provided.

"'Gatekeepers' Do the Casefinding in Spokane." Ray Raschko. Aging; 1990; 361: 38-40.

This article describes the Gatekeeping program in Washington state. Apartment managers, meter readers and other service personnel identify high-risk seniors, including alcoholics. "Gatekeeper" is the term used to describe nontraditional referral sources, such as bank personnel, fuel dealers and others who are in a position to identify isolated and high-risk elders in the community. Once the elders are identified as needing help, their lives can change dramatically.

"Helping and Hurting: Predictors of Maltreatment of Patients in Nursing Homes." Karl Pillemer and Ronet Bachman-Prehn. Research on Aging; 1991; 13(1): 74-95.

Despite evidence indicating that deliberate maltreatment of patients exists in nursing homes, little is known about factors that increase the likelihood that such abuse will occur. This study used data from a random sample survey of 577 nurses and nursing aides working in long-term care facilities to identify predictors of maltreatment of patients by staff. Three sets of variables were proposed to predict the occurrence of physical and psychological abuse: institutional characteristics, staff characteristics, and the situational characteristics. Data analysis revealed that situational characteristics are the best predictors of patient maltreatment. Staff burnout and level of staff-patient conflict were both strongly related to abuse of patients.

"Linking Systems and Community Services: The Interdisciplinary Team Approach." Lisa Nerenberg, et al. Journal of Elder Abuse; 1990; 2(1/2): 101-135.

A panel of experts from the legal, medical, adult protective services, criminal justice, family counseling, and mental health professions discusses two difficult elder abuse case studies. The purpose was to showcase an interdisciplinary team approach in developing solutions to the problems of victims of abuse and their abusers.

"Maltreatment of Patients in Nursing Homes: Overview and Research Agenda." Karl Pillemer. Journal of Health and Social Behavior; 1988; 29(3): 227-238.

This article provides a review of the social science literature regarding the maltreatment of patients in nursing homes. Problems in defining maltreatment and a rationale for sociological study of the phenomenon are addressed. A theoretical model for potential causes of patient maltreatment, includes exogenous variables, nursing home environment, and staff and patient characteristics. A research agenda is outlined.

"National Survey of Dentists' Awareness of Elder Abuse and Neglect." Joseph M. Holtzman and Thomas Bomberg. Special Care in Dentistry; 1991; 11(1): 7-11.

This paper presents the results of a national survey of 1,321 general practitioners regarding their level of awareness of and experiences with the treatment of older victims of abuse and neglect. More than 90% were aware of elder abuse and neglect as a social and medical problem. More than 10% had personal knowledge or had treated a victim of abuse or neglect. The author suggests that dentists will increasingly come in contact with victims. They must be trained to recognize, treat, and report such incidents.

Resident Abuse in Nursing Homes: Understanding and Preventing Abuse. Richard P. Kusserow. Washington, DC: Office of Inspector General, Department of Health and Human Services; April 1990.

The Office of Inspector General (OIG) conducted this study to promote a better understanding of abuse in nursing homes. The inspection relied on 232 interviews with respondents representing state, federal, and national organizations.

Nearly all respondents indicate abuse is a problem in nursing homes. However, respondents differ regarding the severity of the problem. A majority of the state oversight agencies and resident advocates for nursing homes perceive abuse as a serious problem, while many nursing home administrators and industry representatives perceive the problem as minor.

Physical neglect, verbal and emotional neglect, and verbal or emotional abuse are perceived as the most prevalent forms of abuse. Aides and orderlies, according to this report, are the primary abusers for all categories of abuse except medical neglect.

Respondents believe nursing home staff lack training to handle some stressful situations. They also believe staff certification and training will help to deter resident abuse.

Crimes and Violence

"Assistance To Crime and Abuse Victims." Jordan I. Kosberg. In Handbook of Gerontological Services. Abraham Monk, Ed. New York: Von Nostrand Reinhold Company; 1985.

Those working in the helping professions are in vantage points to detect, prevent, and treat the elderly who are victimized by the criminal or abusive behavior of others. This chapter deals with: the victimization of the elderly on the street and in their homes by strangers; and the abuse of the elderly by informal care providers, i.e., family members, friends, and neighbors.

The Battered Elder Syndrome: An Exploratory Study. Marilyn R. Block and Jan D. Sinnott, Eds. College Park, Maryland: Center on Aging, University of Maryland; November 1979.

Scientists examined robbery, burglary, auto theft, theft, swindling, purse snatching, assault, rape, and murder data. It was determined that no group of citizens suffers more painful psychological, financial, and physical losses than our Nation's elderly do at the hands of America's criminal predators.

The purpose of this project was to determine the feasibility of approaches and methods for investigating the national incidence of maltreatment of older persons, including neglect and physical or mental abuse. The research project provides estimates of the prevalence of the phenomenon in the over-60 population, and a description of the syndrome based on the findings.

The report is comprised of six sections: Violence in American Society; Forms of Family Violence; Additional Factors Related to Elder Abuse; Methodology and Results of Data Analysis; Elder Abuse and Public Policy; and Comprehensive Bibliography.

Note: This document represents one of the first exploratory studies conducted on elder abuse. It is included here because of the impact it had on elder abuse research.

Crimes Against The Elderly. Hearing Before Senate Subcommittee on Children, Family, Drugs and Alcoholism. Washington, DC: U.S. Government Printing Office; 1986.

Experts testified on how con artists and violent criminals prey upon the most defenseless, most trusting, and often the physically weakest elders. Testimony explored the emotional, physical, and financial scars that are inflicted on the elderly by violent crimes. The third panel revealed some of the startling fraud schemes of the decade. The subcommittee chair emphasized that everyone in America needs to be willing to be a part of the solution.

"Domestic Violence Against the Elderly: A Case-Control Study." Karl Andrew Pillemer. Dissertation Abstracts International; September 1985; 46(03): 807-A.

The author matched 42 physically abused elderly persons with a non-abused control group to identify factors associated with maltreatment. Major findings were that: (1) The abused were much more likely than the control group to be identified as having mental and emotional problems, and as abusing alcohol. They also were more likely to have been hospitalized for psychiatric reasons. (2) Abused elders did not report more physical punishment as children, nor did they indicate that the perpetrator had been a victim of child abuse. (3) Abused elders were not found to be more ill or functionally impaired than the control group. However, they were less impaired in a number of areas. The abusers were more dependent on their elderly victims than were the relatives of the control group. (4) The two groups showed no major difference in the number of external stressful events experienced in the preceding year, or in chronic financial stress. (5) The abused group had fewer overall social contacts and were less satisfied with those they did have.

Several recommendations evolved: (1) conflict in families of the aged should be more thoroughly explored; and (2) policymakers and planners should consider new, improved services that deal directly with the problem of dependent, impaired abusers, rather than focusing entirely on the stress caused by the victim.

"Homecare Worker Crime: One Problem For Police Senior Affairs Unit." Aging; 1990; 361: 45-48.

This article describes a program of the Manchester Township Police Department in New Jersey. In this town, protecting the citizenry means protecting the senior citizens, because 70% of the residents live in retirement communities!

The biggest problem faced by the seniors is theft and neglect by unscrupulous home care workers. The older and more frail the residents get, the more vulnerable they are to being victimized. Elders fail to turn in the abuser because of psychological dependence or fear.

"Peer Counseling for Elderly Victims of Crime and Violence." Special Issue: Support Groups. Margaret J. Burke and Richard L. Hayes. Journal for Specialists in Group Work; May 1986; 11(2): 107-113.

This article describes the efficacy of a community-based training program in which elderly peer counselors work with elderly victims of crime and violence. Beyond direct benefits to the victims themselves in terms of reduced anxiety, decreased vulnerability, and increased social mobility, the participants in the programs report renewed capacities to relate to others. Use of the elderly as peer counselors once again demonstrates the wisdom of using indigenous paraprofessionals to provide counseling services.

"A Survey on Elder Abuse at One Native American Tribe." Arnold S. Brown. Journal of Elder Abuse & Neglect; 1989; 1(2): 17-37.

A study of elder abuse was conducted on the Navajo Indian Reservation in Arizona, northwest New Mexico and Southeast Utah. The purpose was to determine: the extent that elder abuse exists among very traditional Navajos, the types of abuse that are prevalent, the severity of existing patterns of abuse, and the most prevalent causal variables associated with abuse. Data collected from a survey of elderly people and their family members indicate that the single most frequent type of abuse experienced by the elder was being left alone and neglected when they needed help.

Abuse tended to be associated with dependency, mental problems, family crises due to suddenly having caregiving responsibilities for which family members were unprepared, and personal problems of the primary caregivers.

"Rape and Older Women." Linda J. Davis. In Rape and Sexual Assault: Management and Intervention. Doris Spaulding, Ed. Rockville, MD: U.S. Dept. of Health and Human Services; 1980.

Reported rates of rape increased rapidly between 1965 and 1980, especially in urban settings in the United States. This knowledge has aroused an acute awareness of vulnerability in many older people and often causes them to severely reduce their social activities. This decreases the independence of elders and lowers their overall life satisfaction. Even though the information is more than 10 years old, it sensitizes the reader to the prevalence and problem of rape and sexual assault on older women and suggests ways to reduce the vulnerability of older women to sexual crimes.

"The Role of the Victim Advocate." Doris Spaulding. In Rape and Sexual Assault. Carmer G. Warner, Ed. Germantown, MD: Aspen Systems Corporation; 1980.

The chapter focuses on general concepts related to victim advocacy. Because of the psychological trauma that accompanies rape, it is essential that victims have the support of an objective, knowledgeable, and nonjudgmental advocate. Early crisis intervention is mandatory. It can mean the difference between an effective resolution to the trauma or a lengthy, poor adjustment. The information is relevant to many audiences, but it also is most appropriate for seniors.

Health Care

"Elder Abuse: An Analysis of the Current Problem and Potential Role of the Rehabilitation Professional." Laurie Recker Holland, Karen Romanowski Kasraian, and Carol A. Leonardelli. Physical and Occupational Therapy in Geriatrics; 1987; 5(3): 41-50.

"Old age used to be looked upon as a time of peace, a time to enjoy. Too often today the person who reaches this goal is faced with poor health, death of spouse and friends, and, ultimately, the hidden dreadful threat of abuse. What greater tragedy can there be than to grow into old age and find, not serenity, but a roleless existence and the sad knowledge that you are an inconvenience to your family, caretakers and society!"

As physical and occupational therapists move into home health care settings, they are in opportune positions to detect instances of elder abuse and facilitate remedial or preventive services. The author reviews the current problem of elder abuse and describes some roles for the allied health professionals.

"An Elder Abuse Assessment Team in an Acute Hospital Setting." The Beth Israel Hospital Elder Assessment Team. The Gerontologist; 1986; 26(2): 115-118.

Response to public concerns regarding elder abuse and neglect has resulted in mandatory "elder abuse reporting laws" in many states. The authors describe a hospital-based, multidisciplinary team at Boston's Beth Israel Hospital, that assesses and responds to cases of suspected elder abuse or neglect that occur in institutional and community settings. The presence of the team has increased the hospital staff's awareness of elder abuse and neglect, and increased their willingness to refer suspected cases for further assessment.

"Elder Abuse: From Definition to Prevention." Michael D. Bourland. Postgraduate Medicine; 1990; 87(2): 139-144.

Medical students and physicians may have difficulty in recognizing maltreatment of the elderly. The elderly have difficulty admitting maltreatment because they typically are embarrassed or fearful of reprisal. The author offers an overview of elder abuse that includes causes, profiles of the victim and abuser, clues to identifying abuse, and steps to take when abuse is suspected.

"Elder Abuse: What Role Do Hospitals Play?" Suzanne Powills. Hospitals; 1988; 62(7): 84-85.

In 1985, there were 200,000 reported cases of elder abuse, and 60 percent of them were confirmed. This article discusses the prevalence of elder abuse, steps being taken to address the problem, and legislation. The author states that elder abuse will be a new malpractice area, and that the hospital industry has not even begun to realize the potential liability involved in allowing suspected elder abuse to continue.

"Highlights from a Study of Abuse of Patients in Nursing Homes," Karl Pillemer and David W. Moore. Journal of Elder Abuse, 1990; 2(1/2): 5-29.

The authors report some major findings from a random sample survey of nurses and nurses' aides in 32 long-term care facilities. After defining key terms, the authors review the literature to establish what is known about patient maltreatment in nursing homes. Data from the survey are presented to profile the staff and to highlight difficulties in nursing home work. Findings on the extent and correlates of physical and psychological abuse of patients are then reported. Recommendations to reduce patient abuse are made.

Inadequate Care of the Elderly: A Health Care Perspective on Abuse and Neglect. Terry T. Fulmer and Terrence A. O'Malley. New York, N.Y.: Springer Publishing Company; 1987.

This book is written for the health care professional who suspects that an elderly client may be receiving inadequate care. It presents a practical perspective on abuse and neglect of the elderly. It provides suggestions on how to confront the ethical and logistical issues that make cases of abuse and neglect so difficult to manage. An assessment and functional evaluation form is included.

"Influencing Reluctant Elderly Clients to Participate in Mental Health Counseling." Floyd F. Robison, Marlowe H. Smaby, and Gary L. Donovan. Journal of Mental Health Counseling; July 1989; 11(3): 259-272.

Many elders are reluctant to use mental health counseling. This article presents several interventions through which counselors can influence reluctant elderly clients' willingness to participate in mental health counseling. These interventions are integrated within the conceptual framework of the Power Strategies Model. This model describes interpersonal power and influence in professional relationships that vary according to levels of mutually perceived attractiveness, expertness, and trustworthiness between counselors and clients. It is suggested that counselors use reciprocal influencing strategies to reduce initial client reluctance. As relationships develop, the level and quality of client participation also can increase.

"Reporting Elder Abuse." James W. Davis, Jr. Western Journal of Medicine; 1989; 151(3): 315-316.

This article focuses on the reporting of elder abuse, a malady thought to be as common as child abuse. Victims are typically women who are more than 75 years old, and either physically or mentally disabled. Victims typically come to the attention of health providers who have an obligation to report the problem. Although all 50 states have adopted mandatory reporting laws, definitions of abuse and reporting requirements vary from state to state. Elder abuse typically includes physical abuse, neglect, mental abuse, and exploitation. However, only physical abuse that includes battery, sexual assault, and unreasonable physical restraint has a mandatory reporting requirement. Instances of elder abuse may be reported to the police, or to the county adult protective service office closest to the victim's residence. Since caring for victims is generally a team effort, a careful medical evaluation and the identification of factors that led to the abusive situation are important. Reporting elder abuse by a trained social worker is an important first step in providing relief for the victim, mobilizing community resources, and documenting what seems to be a growing societal concern.

Protective Services

"Adult Foster Care for the Exploited Elderly: A Case Study in Protective Service Intervention." George A. Foelker Jr. and Dawn Chapman. Adult Foster Care Journal; Summer 1988; 2(2): 89-99.

Adult foster care is presented as an intervention technique for elders who are abused, neglected, and exploited. Concerns with defining maltreatment and estimating the prevalence of maltreatment, current theories about causes of abuse and neglect, and principles and techniques of interventions are discussed. Emphasis is placed on the use of various techniques and their effects on the older person's lifestyle. A case study is presented to demonstrate the use of adult foster care as an effective adult protective service intervention.

"Domestic Abuse of the Elderly: Which Cases Involve the Police?" Mary C. Sengstock and Melanie Hwalek. Journal of Interpersonal Violence; 1985; 1(3): 335-349.

The authors examined the role of police in elder abuse cases. The study analyzed 77 cases of elder abuse reported by medical and social service providers in the Detroit Metropolitan Area. Analyses of the cases suggest that there is a lack of involvement of the police in elder abuse cases. The observations were confirmed in interviews with two supervisors of the only Adult Protective Services unit in Wayne County, along with an analysis of a random sample of 75 of the 360 cases reported to the Adult Protective Services Division of Wayne County Department of Social Services in 1983. Case examples and reasons why the Adult Protective Services workers do not refer elder abuse cases to the police are discussed.

Elder Abuse and Neglect: Causes, Diagnosis, and Intervention Strategies. Mary Joy Quinn and Susan K. Tomita. New York, N.Y.: Springer Publishing Company; 1986.

The authors predict that the incidence of elder abuse will increase because of the rapidly growing numbers of frail old people in our society. This increase will be exacerbated by the pressures associated with inflation, the high rate of divorce, changing of family roles, geographical mobility, and political unrest around the world. There needs to be widespread understanding of the phenomenon of elder abuse and neglect. Society needs to make a commitment to a wide range of reform and assistance in both government and the private sector. Sections in the book include the phenomenon of elder abuse and neglect, elder abuse diagnosis and intervention, and practical issues.

"Elder Abuse: Ethical and Practical Dilemmas for Social Work." Jane R. Matlaw and Jane B. Mayer. Health and Social Work; 1986; 11(2): 85-94.

This article describes the efforts of a hospital's interdisciplinary acute-care team to assess cases of elder abuse. It focuses on the role of the social worker and the dilemmas that arise when the problem of elder abuse is confronted by helping professionals.

"Elder Abuse: Issues for the Practitioner." Deborah Bookin and Ruth E. Dinkle. Social Casework; 1985; 66(1): 3-12.

Workers assigned to elder abuse cases typically experience significant problems related to their own feelings, biases, and attitudes about violence and the elderly. This article examines the problems professionals typically have in relation to their clientele. It offers practical strategies for dealing with them.

Faces of Neglect. Bettina Adelberg Dubin, Jacqueline Lelong, and Bert Kruger Smith. Austin, Texas: Hogg Foundation for Mental Health, The University of Texas; 1989.

The authors reviewed 260 cases of reported elder neglect, and found that the causes included lack of: strength, funds, information, and often, lack of assistance from family and other support systems. Findings show that neglect occurs three times more frequently than abuse or exploitation.

The concept of neglect includes dilemmas such as where does self-determination end and self-neglect begin? Who has the right to make the decision? It is sometimes difficult to ascertain whether the victim is the caregiver or the elder.

"Making Decisions About Elder Abuse." Linda R. Phillips and Veronica R. Rempusheski. Social Casework; 67(3): 131-140.

The primary responsibility for intervention in cases of elder abuse lies with adult protective service agencies. However, initial case detection and preliminary interventions, such as referrals, are responsibilities shared by all health care providers who work with elders. Comprehensive intervention can be delayed when health care workers do not recognize abuse or hesitate to institute appropriate intervention strategies. This study indicates that, for some health care providers, determining whether abuse is present in a given situation is a complex and value-laden matter. Additional research and observations are needed to develop guidelines for both detection and intervention.

"Testimony About Elder Abuse and Guardianship." Stanley L. Brodsky. Journal of Elder Abuse and Neglect; 1989; 1(2): 9-15.

The author focuses on the process involved in obtaining guardianship for an elder. Elder abuse is a fairly recent and socially sensitive subject, and the knowledge base on this topic is still in the early phases of development. The expert witness who testifies about suspected abuse of elderly persons, or their competence, is faced with cross-examination in four areas: the nature of the bruises, the challenge to data, mental competency of the elder, and knowledge of guardianship.

PART IV: PUBLIC POLICY

PART V: SOURCES OF ADDITIONAL INFORMATION

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