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Statutory and Organizational Responses to Elder Abuse
The Older Americans Act (OAA) became law on July 14, 1965. Among the OAA’s primary objectives was advancing the physical, mental, and financial well-being of older persons living independently in the community and in group residential settings and institutions. Title VII of the OAA explicitly includes protection against abuse, neglect, and exploitation. Congress established the Administration on Aging (AoA), the only federal agency responsible for the administration of programs under the OAA, to accomplish the act’s objectives. These programs include training medical professionals and law enforcement officers to identify and respond to elder abuse, providing technical assistance, creating state and local elder abuse prevention programs and coalitions, and conducting public awareness and educational promotions (AoA 1965). AoA funds the National Center on Elder Abuse (NCEA), which serves as a source of information and assistance on elder abuse (NCEA website 2006).
All fifty states have some form of elder abuse prevention laws. In general, states define elder abuse as abuse against a person aged sixty or older who is handicapped by the infirmities of aging or who has a physical or mental impairment which prevents the person from providing for his/her own care or protection and who is (1) being abused physically or (2) sexually, (3) exploited financially/materially, (4) neglected, including (5) self-neglect, or (6) has been abandoned (see Bonnie and Wallace 2002; Brandl and Cook-Daniels 2002). Domestic elder abuse (DEA) generally refers to any of these several forms of maltreatment of an older person by someone who has a special relationship with the elder. This may be a spouse, a sibling, a child, a friend, or a caregiver in the older person’s own home or in the home of a caregiver (NCEA website 2006).
All fifty states have set up systems to report elder abuse. Generally, state Adult Protective Services (APS) receive and investigate reports of suspected elder abuse, including DEA. Mandatory reporting laws, including penalties for not reporting elder abuse, exist in forty-four states and the District of Columbia (Daly, Jogerst, Brinig, and Dawson 2003). Depending on the state, certain types of professionals, including social workers and elderly service and health care providers, are required to report DEA to APS. As of this writing, there is no federal law on elder abuse in the United States.
The ‘‘Hidden’’ Nature of Domestic Elder Abuse
There are no official national DEA estimates for three reasons: (1) Definitions of elder abuse vary across states, (2) state statistics vary widely and there is no uniform reporting system, and (3) comprehensive national data are not collected (NCEA website 2006).
Despite these limitations, each year hundreds of thousands of older persons are abused, neglected, and exploited by family members (most likely spouses or children) or other caregivers (AoA website 2006). This finding is based largely on four sources: (1) state APS reports, (2) a review of the fifty-four elder abuse and domestic violence studies done between 1988 and 2002 (see Brandl and Cook- Daniels 2002), (3) the results from national studies such as the National Elder Abuse Incidence Study (NEAIS) (see NCEA 1998) or the National Crime Victimization Survey (Rennison and Rand 2003), and (4) a growing body of single-state studies using data from women living in domestic or institutional settings (see, for example, Burgess 2000; Mouton, Rodabough, Rovi, Hunt, Talamantes, Brzyski, and Burge 2004; Teaster and Roberto 2004; Teaster, Roberto, and Duke 2000; Zink, Fisher, Regan, and Pabst 2005). Even with these resources, many elder abuse advocates have long suspected that any studies estimating elder abuse, especially DEA, are likely underestimating the ‘‘true’’ amount of abuse elders experience (NCEA 1998).
Much of DEA is shrouded in secrecy for two primary reasons. First, today’s generation of older women grew up in a time when values and beliefs about family were rapidly changing. Anetzberger (1997) and others (see Flanagan 2003; Zink, Jacobson, and Regan 2003) argue that the current generation of older women are more willing to endure abusive situations due to (1) a set of cultural and social values that often discounted their abuse or (2) having no socially or morally acceptable options for financial, legal, or emotional support. For example, among the themes Zink et al. (2003) uncovered in their interviews with thirty-six older women who experienced domestic violence was being told by police, clergy, and their own families to return to the marriage and ‘‘try to make it work.’’ Second, older women rarely report their domestic violence to any authorities such as clergy, law enforcement, or doctors, or someone they know, such as a friend. Zink et al. (2005) found that of the women aged fifty-five and older who experienced physical and sexual abuse, 68.7 percent and 33.3 percent, respectively, had told anyone about their abuse. If they told anyone, it was most likely a friend. Older women, like their younger counterparts, are more reluctant to report for a variety of reasons, including fear, shame, and/or isolation, a belief that their experience is a taboo, and/or a financial and emotional dependence on their abuser (see Zink et al. 2005).
Physical and Mental Health Consequences of Domestic Elder Abuse
Even after years of elder abuse research, only recently have domestic violence and elder abuse researchers and advocates collaborated to examine domestic violence, including intimate partner violence (IPV), in the lives of the elderly (see Fisher, Zink, Rinto, Regan, Pabst, and Gothelf 2003). Both research efforts and advocacy attention have been increasingly drawn to the dynamic between aging women and their spouses/partners, as witnessed by an increasing number of published works documenting that IPV is among the most common categories of elder abuse (see Harris 1996; Penhale 2003).
There is a paucity of studies that explicitly examine DEA and its consequences on older victims’ physical and mental health. Isolating the source of DEA can be a daunting measurement task, as DEA can be a continuation of lifelong domestic violence incidents perpetrated by a chronic batterer, may have begun at the onset of the aging process due to dementia or caregiver stress, may change from physical abuse to neglect, or may be a function of all of these factors. Wolf (1997) asserts that unlike domestic violence experienced by younger women, the consequences of elder abuse may be confounded with the aging process and diseases common among the elderly. Disentangling the causal nature of these relationships, she argues, is not only very difficult but costly.
Research has only recently examined the relationship between DEA and health consequences. This published research has focused on older women, not older men. Two studies done in the United States focused on the effects on postmenopausal women, and both come to the same conclusion: Domestic violence takes a negative toll on the physical and mental health of older women. First, Mouton, Rovi, Furniss, and Lasser (1999), using data from the Women’s Health Initiative, examined domestic violence and its effect on general health among a clinical-patient sample of 257 women aged fifty to seventy-nine. They reported that women who were threatened with physical abuse had significantly lower mental health scores on the Medical Outcomes Study Short Form 36 (Ware, Kosinski, and Keller 1994). Women who were physically abused also had lower physical health scores, but the results did not reach statistical significance. More recently, Zink et al. (2005), using a sample of older women from primary care practices in southwestern Ohio, found that women experiencing abuse (psychological/emotional, threatening, controlling, sexual, physical) reported a significantly higher number of chronic health conditions than non-abused women. Abused women also suffered significantly higher rates of depression and chronic pain than non-abused women.
Supportive of the results from these studies done in the United States are studies conducted in Australia (Schofield and Mishra 2004), Ireland, Italy, the United Kingdom (Ockleford et al. 2003), and the Netherlands (Comijs, Penninx, Knipscheer, and van Tilburg 1999). To illustrate, Comjis et al.’s (1999) study of psychological distress as a result of verbal, physical, and financial abuse and neglect examined both older men and older women in the Netherlands. Using a case-control design, participants were selected from a larger random sample of four five-year strata groups between the ages of sixty-five and eighty-four; non-abused elder controls were matched. The abused elders had significantly higher rates of psychological distress, lower emotional support, less mastery and feelings of self-efficacy, and a more passive and avoidant style of coping than their non-abused counterparts. Similar to Mouton et al. and Zink et al., this study was cross-sectional; consequently causal inference cannot be established.
Ultimately the most alarming consequence of elder abuse is mortality. In a prospective cohort study with a nine-year follow-up of a cohort of 2,812 community-dwelling adults aged sixty-five and older, Lachs, Williams, O’Brien, Pillemer, and Charlson (1998) reported that older people seen for elder mistreatment had significantly higher mortality than self-neglecting or non-abused subjects at the end of the study. Those who suffered self-neglect also had significantly higher mortality than those with no substantiated abuse reports.
A second study of morbidity and mortality, Shields, Hunsaker, and Hunsaker (2004), conducted a ten-year retrospective chart review of morbidity and mortality among elders age sixty and over in a large metropolitan area of Kentucky and Indiana. They reported that of the 1,099 autopsy cases, fifty-two victims age sixty and over were homicide victims and twenty-two persons age sixty and over were victims of neglect. They found that 50 percent of the gunshot victims died at the hand of a spouse or other family member; however, one case involved a wife who shot and killed her husband after being beaten and then doused in Drano by him. Of the twenty-two persons who suffered from neglect, 31.8 percent were living with a family member and 9.1 percent were alone with a family member at the time of death. Nearly 82 percent of the neglect cases were found, postmortem, to have physical injuries, including abrasions and contusions.
Programmatic and Service Consequences
DEA is often hidden from the advocacy efforts of the aging, domestic violence, and medical communities and the investigations of the APS and law enforcement (see Fisher et al. 2003).DEA resources, including domestic violence shelters and hotlines, are not tailored to the specific needs of older abused victims, little outreach is done to older domestic violence victims, and cross-training of domestic violence and aging experts is infrequent (Fisher Zink, Pabst, Regan, and Rinto 2004; Vinton 1992; Vinton, Altholz, and Lobell-Boesch 1997). Consequently, nationally, services and programs targeted specifically to DEA victims are woefully lacking.
There are very few elder domestic violence support groups across a limited number of states, with Wisconsin having the most support groups (eleven) for older abused women (Brandl, Hebert, Rozwadowski, and Spangler 2003). In Florida, as part of the Elder Domestic Violence Collaborative Project, interagency collaboration has led to the development of model policies for making their domestic violence centers more elder ready and a training manual for elder domestic violence case managers (Vinton 2003).
Research has shown that the health care needs of older DEA victims are largely not routinely addressed. Many health care providers, including primary care physicians, do not routinely screen for IPV among older patients (Kennedy 2004; Zink, Jacobson, Regan, and Pabst 2004).
Demographic projections signal that elder abuse, notably DEA, will remain a policy issue for some time. The elderly population is expected to increase from approximately thirty-six million today to about eighty-five million by the year 2050, in which over 56 percent will be older women (U.S. Census Bureau 2004). The projected increase in the number of older women will likely increase the number of DEA victims. DEA will continue to take negative tolls on the health and well-being of our elders and society if the current level and content of interventions and responses provided by the health care, law enforcement, domestic violence, and aging communities are not tailored to the needs of aging adults and their perpetrators.
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