Nature of Elder Mistreatment

With some diseases or conditions, attribution of cause can be fairly simple and straightforward; a salmonella outbreak serves as an example. Other conditions have very complex causation, and indeed the condition itself may be difficult to define and identify. Elder mistreatment clearly fits the latter pattern.

The complexity of elder mistreatment can be highlighted by reference to the concept of a “geriatric syndrome”—that is, common clinical problems that typically do not have a single underlying pathophysiological process, but instead have several contributing factors that shape presentation (Lachs and Pillemer, 1995). Examples of geriatric syndromes include falls, urinary incontinence, and functional decline.

Geriatric syndromes share several characteristics: environmental factors play an important role; interventions must be multifaceted and directed at both specific pathophysiological problems as well as at contributing factors in the environment; and such syndromes are often underdiagnosed and undermanaged by health and social service providers. Elder mistreatment shares these characteristics of a geriatric syndrome. Most important for the purposes of this chapter, contributing etiologies can be related to the relative (or person in a trust relationship), to the elder, or to the environment. Thus, the search for risk factors is both complex and challenging and necessarily must look for sources of risk in the host (the elderly person), the agent (the perpetrator), and the environment. As well, it must study the interplay of factors in these three domains in affecting the risk of elder mistreatment.

Weaknesses of Existing Studies

The first major limitation of previous risk factor research results from unclear definition of the object of study. Findings from most studies are confused in that they do not differentiate the various types of abuse and neglect articulated earlier in this report. It is likely that the etiology of these elder mistreatment types differs. Second, different criteria have been used to determine the population at risk of elder mistreatment. Some researchers have included persons under age 60 in their studies, while most others have chosen 60 or 65 as the entry point. Some researchers have restricted their studies to caregivers of elderly persons or to persons sharing a residence, while others have included all categories of elderly people.

Third, studies of risk factors have employed widely differing sampling methods, including random sample surveys, interviews with patients in medical practices or caregivers in support programs, and reviews of agency records. Fourth, few studies that have purported to address risk factors have in fact included control groups in their designs. In the absence of controls, the validity of associations between elder mistreatment and putative risk factors cannot be assessed. Furthermore, even those studies that have included control groups have often failed to ascertain that the controls were actually free of elder mistreatment. Fifth, a number of studies have not employed reliable and valid measurement of the indicators of risk.

Sixth, with one exception (Lachs et al., 1994, 1997a), prospective studies of elder mistreatment do not exist. As Lachs and colleagues (1994) point out, retrospective research designs contain several potential biases: recall bias—the respondent reinterpreting key facts or feelings from a later vantage point; information bias—the respondent (especially if cognitively impaired) may not be able to recall or provide valid information about exposure to maltreatment; and the failure of studies to take into account the timing and duration of events and their progression over time.

For these reasons, a clear framework of known risk factors for elder mistreatment cannot be derived from previous research on elder abuse. Despite a large number of review articles over the past two decades, it must be acknowledged that any statements about relative risk among the elderly should be viewed with caution.

However, the small number of studies using acceptable research designs do reveal some associations that are of interest. In this chapter, findings from these studies are summarized. For the purposes of the discussion, an attempt has been made to focus on studies that meet two criteria. First, priority was given to studies that involve a comparison group of some kind. In such studies, elderly victims (or perpetrators) have been compared to nonabuse cases uncovered in a survey or to a comparison group of some kind. Because the literature is so sparse, however, in a few cases, studies are referred to that have an “implied” comparison group. Second, the study must have collected information directly from victims and perpetrators and not from agency records (for problems with using agency records in elder mistreatment research, see Chapter 2).

Living Arrangement

Both clinical accounts and limited empirical research suggest that a shared living situation is a major risk factor for elder mistreatment, with older persons living alone at lowest risk (Pillemer and Finkelhor, 1988). Paveza et al. (1992) found that risk of mistreatment of Alzheimer's disease patients by caregivers was greatest when the patient resided with immediate family members (other than the spouse). Lachs et al. (1997a) found living alone to be an important protective factor against mistreatment. Pillemer and Suitor (1992) also found a shared living arrangement to be a risk factor for violence by Alzheimer's disease caregivers.

The mechanisms for the effect of living arrangement are straightforward. A shared residence increases the opportunities for contact, and thus conflict and mistreatment. Furthermore, tensions that may be relieved by simply leaving the immediate situation can escalate into mistreatment (see Wolf and Pillemer, 1989). Exploration of the differential role of living arrangement according to type of elder mistreatment needs to be conducted. For example, neglect (as the panel has defined it) by its very nature suggests a shared living situation, but financial exploitation may occur even when abuser and victim live apart.

Social Isolation

Social isolation has been found to be characteristic of families in which other forms of domestic violence occur. This is in part because behaviors that are considered to be illegitimate tend to be hidden. Detection of abusive actions can result in informal sanctions from friends, kin, and neighbors and formal sanctions from police and the courts. Thus, elder mistreatment is hypothesized to be less likely in families embedded in strong social networks.

Research provides support for this view. In the Lachs et al. (1994) prospective, community-based study of risk factors for elder abuse, having a “poor social network” significantly increased risk of mistreatment. Compton et al. (1997) found low levels of social support to be associated with verbal and physical abuse by caregivers, as did Wolf and Pillemer (1989). Grafstrom et al. (1993) found both caregivers and care recipients to be more socially isolated in families in which abuse occurred. The case comparison by Phillips (1983) also found abused elder persons to be more socially isolated.

Dementia

There are two types of evidence that implicate Alzheimer's disease or related dementia as a risk factor for the mistreatment of elderly persons. First, several studies have estimated prevalence rates of elder mistreatment in samples of dementia caregivers; these rates can then be compared with rates in general population surveys. Coyne et al. (1993) found that 11.9 percent of the dementia caregivers in their sample reported having committed physical abuse. Paveza et al. (1992) found a rate of severe physical violence toward care recipients of 5.4 percent, which is close to Pillemer and Suitor's (1992) finding of 5 percent in a similar sample. Homer and Gilleard (1990) found physical abuse occurring in 14 percent of caregivers to Alzheimer's disease patients in a respite care program. Given the prevalence findings of rates of physical abuse in the 1-3 percent range in the general population, dementia patients would appear to be at greater risk of such mistreatment.

Second, a few studies have contrasted abusive and nonabusive caregivers, examining dementia in the victim as one among a number of risk factors. The results are contradictory. Lachs et al. (1994) did not find cognitive impairment to be a risk factor, and Reis and Nahmiash (1998) did not find dementia to discriminate between probable abuse and nonabuse cases. However, Lachs et al. (1997a) found that dementia predicted identification as an abuse victim.

One explanation for this contradictory set of findings comes from Pillemer and Suitor's (1992) finding that Alzheimer's caregiver violence is strongly related to experience of violence from the care recipient, and Compton et al.'s (1997) finding that behavior problems are related to both verbal and physical abuse. It may be that dementia itself is not the risk factor, but rather disruptive behaviors that result from dementia. Such an explanation would be consistent with research that has shown disruptive behaviors by Alzheimer's disease patients to be an especially strong cause of caregiver stress. Future research of the relationship between dementia and elder mistreatment should differentiate the cognitive, functional, and behavioral effects of dementia and examine the independent association between each and the risk for elder mistreatment.

Intraindividual Characteristics of Abusers

Intraindividual theories of mistreatment locate the causes of abuse in some pathological characteristic of the abuser, usually mental illness, personality characteristics, or alcohol or drug abuse. This approach has a lengthy history in the study of child and intimate partner abuse, including a long-standing debate over the role of intraindividual factors as risk factors for the forms of mistreatment. In the field of elder mistreatment, there is compelling evidence that certain characteristics of perpetrators constitute major risk factors for elder mistreatment, with surprising unanimity on this issue among studies using different methods.

Abuser Dependency

Related to the previous risk factor, findings from early research on elder mistreatment suggests that perpetrators tended to be dependent on the individual they were mistreating. In 1982, Wolf and colleagues surveyed community agencies in Massachusetts regarding elder abuse cases they had encountered (Wolf et al., 1982). The authors identified a “web of mutual dependency” between abuser and abused. In two-thirds of the cases in that study, the perpetrator was reported to be financially dependent on the victim. Another early study by Hwalek et al. (1984) also reported that financial dependence on a relative was a risk factor in abuse. Other studies, without control groups, have found substantial percentages of financially dependent abusers (Anetzberger, 1987; Greenberg et al., 1990).

A number of studies have confirmed this finding. Pillemer (1986; Wolf and Pillemer, 1989) found that abusers were substantially more dependent on the victim for housing and financial assistance than were members of a comparison group. In Pillemer and Finkelhor's (1989) analysis of cases from a random-sample survey, nearly identical results emerged.

Gender

Adult protective services reports and other studies of agency samples universally find that the majority of victims are female (Wolf, 1997b). However, it is not clear whether this is due to higher risk for victimization or to women's greater numbers in the population of seniors. Pillemer and Finkelhor's (1988) survey suggested that the latter may be the case; in their study, they found that the victimization rate for men was higher at 5.1 percent, compared with 2.5 percent for women. They attributed this in part to the fact that elderly women are much more likely to live alone, which reduces their risk. Furthermore, their sample included intimate partner abuse among the well elderly, in which the victim would not necessarily have been classified as vulnerable according to our definition.

Pillemer and Finkelhor (1988) also noted the important caveat that women tended to sustain more serious abuse and to suffer greater physical and emotional harm from mistreatment. This may in turn explain their greater representation as victims in adult protective services caseloads.

Relationship of Victim to Perpetrator

Despite suggestions that adult children are the most likely perpetrators of elder abuse, the only survey-based study of this topic found that spouses were more likely to be abusers (Pillemer and Finkelhor, 1988). However, there are insufficient data on this risk factor to make a determination.

Personality Characteristics of Victims

Comijs et al. (1998) found that certain personality traits of elderly persons increased their risk of being an abuse victim. In a community survey conducted in the Netherlands, they examined whether hostility and coping style were related to being a victim of chronic verbal aggression, physical aggression, and financial mistreatment. Victims of chronic verbal aggression scored lower on a locus of control scale than did the nonabused members of the sample and higher on one indicator of hostility. Victims of all three abuse types showed higher levels of aggression as measured by the hostility scales and were generally more likely to use passive and avoidant ways of coping, rather than active problem-solving strategies. Because of the cross-sectional nature of this study, it is impossible to determine whether these characteristics are indeed risk factors, or whether they are consequences of the abuse. However, the findings are sufficiently suggestive to merit further exploration of personality factors in longitudinal studies.

Race

Lachs and colleagues (1994, 1997a) found that being black was a risk factor for reported elder mistreatment. However, they noted that this may be an artifact of the definition of elder mistreatment, which was “being reported to an [adult protective services] agency.” No other study has found significant differences in elder abuse risk based on race.

Physical Impairment of the Older Person

The role of victim health and functional status as a risk factor for elder abuse is a complex one. For the purposes of this report, some degree of physical vulnerability is considered to be a necessary component of the definition of elder mistreatment. That is, mistreatment necessarily implies a weaker individual who is mistreated by a stronger one. Greater impairment diminishes the individual's ability to defend himself or herself or to escape the situation. It therefore is reasonable to consider physical health problems as a predisposing factor for elder mistreatment, which increases the likelihood of abuse in the presence of other risk factors.

However, research has generally failed to find support for the view that frailty of elderly persons is in itself a risk factor for elder mistreatment. That is, case-control studies have not found a direct relationship between elder mistreatment and functional impairment or poor health. Reis and Nahmiash (1998) did not find impairment in activities of daily living to be associated with elder abuse. Neither Cooney and Mortimer (1995), Paveza et al. (1992), Bristowe and Collins (1989), nor Phillips (1983) in case-comparison studies found functional impairment to be a risk factor for abuse by caregivers. Lachs et al. (1997a) found that impairment in activities of daily living was associated with being an abuse victim, but the researchers acknowledged that the dependent variable—protective services intervention for elder abuse—may have led to these results, and that findings may differ for elder mistreatment that is not detected by an agency.

There is as yet no evidence as to whether this pattern of nonfindings holds for all types of mistreatment. In the only study to address this issue Wolf and Pillemer (1989) found that victims of elder neglect were more likely to be impaired than victims of either physical or psychological abuse.

Victim Dependence and Caregiver Stress

If there can be said to be a “traditional” view in the field of elder mistreatment, then it can be summed up in the following way. Elderly people become frail, difficult to care for, and sometimes demanding. These characteristics cause stress for their caregivers; as a result of this stress, the caregivers become abusive or neglectful toward the elder. In this view, elder mistreatment is seen as an outgrowth of the aging process, which leads to the need for care by others. Much early writing emphasized the dependence of the elderly person and resulting caregiver stress as the predominant (and sometimes sole) cause of elder abuse (Davidson, 1979; Hickey and Douglass, 1981; Steinmetz, 1988).

However, there is a lack of evidence that an older person's need for assistance or that caregiver stress in fact lead to greater risk for elder mistreatment. First, it is clear from the gerontological and geriatric literature that a substantial number of elderly persons are dependent on relatives for some degree of care. However, findings about the prevalence of elder mistreatment indicate that only a small minority of the elderly is mistreated. Since abuse occurs in only a small proportion of families, no direct correlation can be assumed between the dependence of an elderly person and abuse, as sometimes has been done.

Second, case-comparison studies have generally failed to find either higher rates of elder dependence or greater caregiver stress in elder abuse situations. Bristowe and Collins (1989), Homer and Gilleard (1990), Phillips (1983), Pillemer (1985), Wolf and Pillemer (1989), Pillemer and Finkelhor (1989), Pillemer and Suitor (1992), and Reis and Nahmiash (1997) did not find greater dependence or caregiver stress among victims and their family members, when compared with nonvictims. One exception, a study by Coyne et al. (1993), found that callers to a help line who had committed abuse had been providing care for a longer time and for more hours a day than nonabusers and had higher burden scores.

Intergenerational Transmission

Social learning theory gives rise to the hypothesis that when individuals experience violent behavior from parents or other role models in childhood, they tend to revert to these learned behaviors when provoked as adults. Indeed, it has by now become a commonplace that victims of child abuse may grow up to themselves become child abusers, a pattern often described as the “cycle of violence.” The cumulative research evidence supports this hypothesis, with experiencing violence from parents or witnessing violence between parents in childhood strongly related to perpetrating child or intimate partner abuse (See Newberger, 1998; Stark and Flitcraft, 1998).

Despite this evidence from other fields, the only two studies that have addressed this issue (Anetzberger et al., 1994; Wolf and Pillemer, 1989) found no evidence of intergenerational transmission of physical violence against elderly relatives. This issue, however, is worthy of further study, given the importance of childhood experience of aggression as a risk factor for other forms of interpersonal violence. The importance of early childhood experiences of perpetrators as risk factors for types of elder mistreatment other than physical violence should be explored. In addition, given that in the elder mistreatment field the victim and perpetrator have been in a long-standing personal relationship, as spouses or as parent and child, it may be more important to assess the type of relationship between the abuser and the victim as a risk factor for elder mistreatment.