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SPECIAL ARTICLE Elder Abuse: Systematic Review and Implications for Practice Xin Qi Dong, MD, MPH This article is based on the lecture for the 2014 American Geriatrics Society Outstanding Scientific Achievement for Clinical Investigation Award. Elder abuse is a global pub- lic health and human rights problem. Evidence suggests that elder abuse is prevalent, predictable, costly, and some- times fatal. This review will highlight the global epidemiol- ogy of elder abuse in terms of its prevalence, risk factors, and consequences in community populations. The global literature in PubMed, MEDLINE, PsycINFO, BIOSIS, Sci- ence Direct, and Cochrane Central was searched. Search terms included elder abuse, elder mistreatment, elder mal- treatment, prevalence, incidence, risk factors, protective factors, outcomes, and consequences. Studies that existed only as abstracts, case series, or case reports or recruited individuals younger than 60; qualitative studies; and non- English publications were excluded. Tables and figures were created to highlight the findings: the most-detailed analyses to date of the prevalence of elder abuse according to continent, risk and protective factors, graphic presenta- tion of odds ratios and confidence intervals for major risk factors, consequences, and practical suggestions for health professionals in addressing elder abuse. Elder abuse is common in community-dwelling older adults, especially minority older adults. This review identifies important knowledge gaps, such as a lack of consistency in defini- tions of elder abuse; insufficient research with regard to screening; and etiological, intervention, and prevention research. Concerted efforts from researchers, community organizations, healthcare and legal professionals, social service providers, and policy-makers should be promoted to address the global problem of elder abuse. J Am Geriatr Soc 63:1214–1238, 2015. Key words: AGS award; elder abuse; systematic review T his article is based on the lecture for the 2014 Ameri- can Geriatrics Society Outstanding Scientific Achieve- ment for Clinical Investigation Award. Elder abuse is a global public health and human rights problem that crosses sociodemographic and socioeconomic strata. Elder abuse, sometimes called elder mistreatment or elder mal- treatment, includes psychological, physical, and sexual abuse; neglect (caregiver neglect, self-neglect); and financial exploitation. 1 Physical abuse consists of infliction of physi- cal pain or injury to an older adult and may result in bruises, welts, cuts, wounds, and other injuries. Sexual abuse refers to nonconsensual touching or sexual activities with older adults when they are unable to understand, unwilling to consent, threatened, or physically forced into the act. Psychological abuse includes verbal assault, threat of abuse, harassment, or intimidation, which may result in resignation, hopelessness, fearfulness, anxiety, or with- drawn behaviors. Neglect is failure by a caregiver (care- giver neglect) or oneself (self-neglect) to provide the older adult with necessities of life and may result in being under- weight or frail, unclean appearance, or dangerous living conditions. Financial exploitation includes the misuse or withholding of an older adult’s resources to their disadvan- tage or the profit or advantage of another person and may consist of overpayment for goods or services; unexplained changes in power of attorney, wills, or legal documents; missing checks or money; or missing belongings. 2 Although elder abuse is a newer field of violence research than domestic violence and child abuse, research indicates that elder abuse is a common, fatal, and costly yet understudied condition. 36 An estimated 10% of U.S. older adults have experienced some form of elder abuse, yet only a fraction is reported to Adult Protective Services (APS). 1 For decades, professionals and the public have viewed elder abuse and broader violence as predominantly social or family problems. Since the first scientific literature citing in the British Medical Journal in 1975, 7 there has been increasing attention from public health, social services, health, legal, and criminal justice professionals. In 2003, the National Research Council brought together national experts to examine the state of science on elder abuse and recommended priority strategies to advance the field. 8 Despite multidisciplinary efforts to screen, treat, and From the Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, Illinois. Address correspondence to Xin Qi Dong, Professor of Medicine, Behavioral Sciences and Nursing, Director, Chinese Health, Aging and Policy Program, Associate Director, Rush Institute for Healthy Aging, 1645 West Jackson Blvd, Suite 675, Chicago, IL 60612. E-mail: [email protected] DOI: 10.1111/jgs.13454 JAGS 63:1214–1238, 2015 © 2015, Copyright the Author Journal compilation © 2015, The American Geriatrics Society 0002-8614/15/$15.00
Transcript
Page 1: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

SPECIAL ARTICLE

Elder Abuse Systematic Review and Implications for Practice

Xin Qi Dong MD MPH

This article is based on the lecture for the 2014 AmericanGeriatrics Society Outstanding Scientific Achievement forClinical Investigation Award Elder abuse is a global pub-lic health and human rights problem Evidence suggeststhat elder abuse is prevalent predictable costly and some-times fatal This review will highlight the global epidemiol-ogy of elder abuse in terms of its prevalence risk factorsand consequences in community populations The globalliterature in PubMed MEDLINE PsycINFO BIOSIS Sci-ence Direct and Cochrane Central was searched Searchterms included elder abuse elder mistreatment elder mal-treatment prevalence incidence risk factors protectivefactors outcomes and consequences Studies that existedonly as abstracts case series or case reports or recruitedindividuals younger than 60 qualitative studies and non-English publications were excluded Tables and figureswere created to highlight the findings the most-detailedanalyses to date of the prevalence of elder abuse accordingto continent risk and protective factors graphic presenta-tion of odds ratios and confidence intervals for major riskfactors consequences and practical suggestions for healthprofessionals in addressing elder abuse Elder abuse iscommon in community-dwelling older adults especiallyminority older adults This review identifies importantknowledge gaps such as a lack of consistency in defini-tions of elder abuse insufficient research with regard toscreening and etiological intervention and preventionresearch Concerted efforts from researchers communityorganizations healthcare and legal professionals socialservice providers and policy-makers should be promotedto address the global problem of elder abuse J Am GeriatrSoc 631214ndash1238 2015

Key words AGS award elder abuse systematic review

This article is based on the lecture for the 2014 Ameri-can Geriatrics Society Outstanding Scientific Achieve-

ment for Clinical Investigation Award Elder abuse is aglobal public health and human rights problem thatcrosses sociodemographic and socioeconomic strata Elderabuse sometimes called elder mistreatment or elder mal-treatment includes psychological physical and sexualabuse neglect (caregiver neglect self-neglect) and financialexploitation1 Physical abuse consists of infliction of physi-cal pain or injury to an older adult and may result inbruises welts cuts wounds and other injuries Sexualabuse refers to nonconsensual touching or sexual activitieswith older adults when they are unable to understandunwilling to consent threatened or physically forced intothe act Psychological abuse includes verbal assault threatof abuse harassment or intimidation which may result inresignation hopelessness fearfulness anxiety or with-drawn behaviors Neglect is failure by a caregiver (care-giver neglect) or oneself (self-neglect) to provide the olderadult with necessities of life and may result in being under-weight or frail unclean appearance or dangerous livingconditions Financial exploitation includes the misuse orwithholding of an older adultrsquos resources to their disadvan-tage or the profit or advantage of another person and mayconsist of overpayment for goods or services unexplainedchanges in power of attorney wills or legal documentsmissing checks or money or missing belongings2

Although elder abuse is a newer field of violenceresearch than domestic violence and child abuse researchindicates that elder abuse is a common fatal and costlyyet understudied condition3ndash6 An estimated 10 of USolder adults have experienced some form of elder abuseyet only a fraction is reported to Adult Protective Services(APS)1

For decades professionals and the public have viewedelder abuse and broader violence as predominantly socialor family problems Since the first scientific literature citingin the British Medical Journal in 19757 there has beenincreasing attention from public health social serviceshealth legal and criminal justice professionals In 2003the National Research Council brought together nationalexperts to examine the state of science on elder abuse andrecommended priority strategies to advance the field8

Despite multidisciplinary efforts to screen treat and

From the Rush Institute for Healthy Aging Rush University MedicalCenter Chicago Illinois

Address correspondence to Xin Qi Dong Professor of MedicineBehavioral Sciences and Nursing Director Chinese Health Aging andPolicy Program Associate Director Rush Institute for Healthy Aging1645 West Jackson Blvd Suite 675 Chicago IL 60612 E-mailxinqi_dongrushedu

DOI 101111jgs13454

JAGS 631214ndash1238 2015

copy 2015 Copyright the Author

Journal compilation copy 2015 The American Geriatrics Society 0002-861415$1500

prevent elder abuse speed of progress has lagged behindthe scope and effect of the issue

In March 2011 the Senate Special Committee onAging held a hearing ldquoJustice for All Ending Elder AbuseNeglect and Exploitationrdquo Based on a GovernmentAccountability Office report9 individuals who had beenabused and experts highlighted the lack of research educa-tion training and prevention strategies The GovernmentAccountability Office estimated that in 2009 nationalspending by federal agencies was $119 million for allactivities related to elder abuse ($11 million according tothe National Institutes of Health) which is much less thanthe annual funding for violence against women programs($649 million) and for child abuse programs ($7 billion)10

On June 14 2012 the World Elder Abuse Awareness Daycommemoration was held at the White House and Presi-dent Obama proclaimed the importance of advancing thefield of elder abuse11 In March 2013 the Centers forMedicare and Medicaid Services held a national sympo-sium to highlight elder abuse as a Physician QualityReporting System measure (181) to promote screening ofelder abuse in healthcare settings12 In April 2013 theInstitute of Medicine held a 2-day workshop dedicated toelder abuse prevention bringing together global experts toadvance the field In October 2013 the US PreventiveServices Task Force recommended elder abuse as aresearch priority area in its report to Congress13

This review highlights the global epidemiology of elderabuse in terms of its prevalence risk factors and conse-quences It covers major gaps in research and policy issuesfor the field of elder abuse and discussed implications forresearchers health professionals and policy-makers

METHODS

Data Source and Study Selection

The global literature in PubMed MEDLINE PsycINFOBIOSIS Science Direct and Cochrane Central wassearched The search was limited to studies published inEnglish Search terms included elder abuse elder mistreat-ment elder maltreatment prevalence incidence risk fac-tors protective factors outcomes and consequencesReview studies were identified and their reference listsexamined for relevant articles Studies existing only asabstracts case series or case reports or that recruitedindividuals younger than 60 qualitative studies and non-English publications were excluded (online Figure S1)

For prevalence studies it was not the intention topresent every published study in community populationsRather this study aimed to demonstrate the heterogeneityof elder abuse definitions and prevalence on the major con-tinents North America South America Europe Asia andAfrica Because there is limited research in developingcountries studies were included from as many differentcountries as available For studies in developed countries(eg North America and Europe) studies representative ofcultural diversity definitional variations and psychometrictesting and large-scale epidemiological studies wereselected

For risk and protective factors only studies in whichelder abuse was clearly defined as the primary dependent

variable potential confounding factors were considered inthe analyses and the risks and confidence intervals wereshown were included A similar approach was used forconsequences and only studies in which elder abuse wasthe primary independent variable and confounding factorswere used were included Studies in which primary analy-ses were bivariate in nature were not included articlesidentified using the search methods were independentlyreviewed and studies were selected according to thecriteria

Data Synthesis

Epidemiology of Elder Abuse

Elder abuse is a worldwide health problem Prevalence ofelder abuse varies depending on the population settingsdefinitions and research methods (Table 1 and online Fig-ure S2)3414ndash22 In North and South America the preva-lence of elder abuse in this review ranges from 10 incognitively intact older adults to 473 in older adultswith dementia323 In Europe the prevalence has beenfound to vary from 22 in Ireland to 611 in Croa-tia2425 In Asia the highest 1-year prevalence in thisreview has been found in older adults in mainland China(362) and lowest was in India (140)212627 Onlytwo studies conducted in Africa have been found and theprevalence ranged from 30 to 4372028 A more-detailed version of Table 1 showing the specific cutoffpoint methods for prevalence estimates is supplied asonline Table S1

Elder abuse is common in minority older adultsFinancial exploitation is three times as high and psycho-logical abuse four times as high in black populations4 Astudy of Hispanics indicated that 40 had experiencedelder abuse yet only 2 was reported to authorities14 Ina study of 4627 older adults in the Chicago Health andAging Project older black men were three times as likelyto experience elder self-neglect as older white men andolder black women were two times as likely to report elderself-neglect as older white women16 In a Chinese popula-tion despite cultural expectations of filial piety 35 ofolder adults self-reported elder abuse29 Understanding cul-turally specific elements of elder abuse will be critical todesigning prevention and intervention strategies used inculturally specific contexts

Although there is no consensus on a singular measurethe Conflict Tactic Scale (CTS)30 remains one of the mostwidely used to measure physical psychological and sexualabuse Despite using the same measurement the cutoffpoint for definite elder abuse differs greatly across studiesleading to large variation in prevalence estimates Forinstance one study used the revised CTS and regardedolder adults who endorsed any item of the measurement ashaving experienced verbal abuse and found a 1-year preva-lence of 2131 Another study used the modified CTS butincluded those who endorsed 10 or more items as havingexperienced psychological abuse and therefore found a1-year prevalence of only 1224 A third likewise usedthe ldquo10 or more itemsrdquo criteria and suggested a 1-yearprevalence of psychological abuse of 3232 Such incon-sistency in definitions was also observed in measuring elder

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1215

Table

1

Prevalence

Estim

atesofElder

Abuse

Accordingto

PopulationSurvey

MethodandDefinition

AuthorYear

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

NorthSou

thAmerica

Don

g20

1433

315

9elderlyChinese

inChicago

ge60

589

female

Inperson

919

H-SEAST

VASS

10ge1

items

150

sinceage60

Don

g20

1433

315

9elderlyChinese

inChicago

ge60

589

female

Inperson

919

CTS

caregiverneglect

assessmentfin

ancial

exploitationassessment

56a

139ndash258

sinceage

60

Deliema

2012

14

198Hispanics

inLo

sAng

eles

ge66

56

female

Inperson

65University

ofSou

thern

California

Older

Adu

ltCon

flict

Scale

54ge1

items

1-year40

4multiple

21

Don

g20

1258

462

7adults

inChicago

ge65

644

female

Inperson

NA

Chicago

ElderSelf-

Neglect

Scale

21ge1

items

Blackmen13

2

wom

en10

9

Whitemen24

wom

en26

Lachs

2011

54

415

6En

glish-

orSpanish-

speaking

commun

ity

cogn

itively

intact

older

New

Yorkers

60ndash1

0135

5

female

190

black

755

white

60

Hispanic

08

American

Indian12

Asian

Teleph

one

NA

CTS

31a

141

sinceage60

Acierno

20

103

577

7cogn

itively

intact

UScommun

itypo

pulation

60ndash9

760

female

88

white7

black

4Hispanic

2American

Indian1

Asian

Rando

m-digitdialing

andcompu

ter-assisted

interview

69InterpersonalViolenceMeasure

andAcierno

EMMeasure

22ge1

items

Any

elderabuse

(exclude

financial)10

Wiglesw

orth

2010

23

129olderadults

with

dementia

andtheircaregivers

771

80

457

female

938

white85

Hispanic

In-personsurvey

ofcaregivers

NA

CTS

ElderAbu

seInstrumentSelf-Neglect

Assessm

entScale

NA

a1-year

473multiple

146

Beach20

1037

903UScommun

ity-

dwellingolderadults

with

land

line

English-speaking

no

severe

cogn

itive

impairment

ge60

733

female

233

black

728

white39

other

Rando

m-digitdialing

in-person

self-

administered

377

Mod

ified

CTS

12a

6-mon

thfin

ancial

exploitation

35

6-

mon

thpsycho

logical

mistreatm

ent82

Laum

ann

2008

17

300

5olderadults

inthe

NationalSocialLifeHealth

andAging

project

57ndash8

551

2

female

807

white10

0

black

68

Hispanic

25

other

In-personandmail

survey

755

H-SEAST

VASS

3ge1

items

1-yearverbal9

fin

ancial35

ph

ysical02

Buri20

0681

498olderadults

inthe

IowaMedicaidWaiver

Program

65ndash1

0170

9

female

96

white3

black

Mailsurvey

49ElderAbu

seScreen

5ge1

items

2091type15

8

2types

40

3types

10

Europe

Lind

ert

2013

19

446

7olderadults

from

sevencoun

triesin

Europe

60ndash8

457

3

female

In-personandmail

survey

452

Mod

ified

CTS

52ge1

items

1-year12

7ndash3

08

Naugh

ton

2011

24

202

1commun

ity-dwelling

olderpeop

lein

Ireland

ge65

55

female

Inperson

83CTS

UKandNY

prevalence

stud

ies

NA

a1-year22

Kissal20

1182

331olderadults

inIzmir

Turkey

ge65

568

female

Inperson

NA

Investigator-determined

5a

6-mon

th13

3

(Continued)

1216 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Biggs20

0983

211

1olderadults

inthe

commun

ityin

United

Kingd

om

ge66

Inperson

65Builton

literature

34a

26

with

neglect

16

withou

tneglect

Ajdukovic

2009

25

303olderadults

inCroatia

65ndash9

776

6

female

Inperson

NA

ElderAbu

sein

the

Family

questionn

aire

20NA

1-year61

1

Coo

per20

0984

220UKcaregivers

ofpeop

lewith

dementia

58ndash9

972

female

Inperson

69Mod

ified

CTS

10Score

ge23-mon

th52

Garre-Olmo

2009

85

676commun

ity-dwelling

olderadults

inGiron

aSpain

ge75

582

female

Inperson

82AMAScreen

9ge1

items

1-year29

32types

36

3types

01

Perez

Carceles

2008

86

460olderadults

inhealth

center

inSpain

ge65

533

female

Inperson

NA

CanadianTask

Force

AMAScreen

19ge1

items

446

Com

ijs19

983132

179

7olderpeop

leliving

independ

ently

inAmsterdamthe

Netherlands

69ndash8

962

8

female

Interview

444

CTS

Measure

ofWife

Abu

seViolenceAgainst

Man

Scale

NA

a1-year56

ge2

types

04

AsiaAustria

Wu

2012

21

203

9Chinese

olderadults

inruralChina

ge60

599

female

Inperson

908

H-SEAST

VASS

NA

ge1items

1-year36

2

ge2types

105

Som

jinda

Cho

mpu

nud

2010

87

233cogn

itively

functioning

olderadults

inTh

ailand

60ndash9

073

4

female

Inperson

733

Interview

guidelinefor

screeningforelder

abuse

6ge1

items

1-year14

61tim

e99

ge2

times47

Lowenstein

2009

27

104

5commun

ity-living

olderadults

from

thefirst

nationalsurvey

inIsrael

ge65

625

female

Inperson

75CTS

2shortsituational

descriptions

Respo

ndentsrsquoReactions

toAgg

ression

NA

a1-year35

0

Oh

2009

22

15230

olderadults

inSeoulKorea

ge65

653

female

Inperson

NA

Com

piledthroug

hliterature

25ge2

times

1-mon

th63

Lee

2008

88

100

0primarycaregivers

offamily

mem

bers

with

disabilitiesin

SeoulKorea

65ndash1

0269

5

female

Inperson

NA

NA

6a

Not

answ

ered

question

105yelled

109

confi

ned

18hit

97

neglected

136

Don

g20

0744

412cogn

itively

intact

commun

ity-livingperson

sfrom

medical

clinicsin

China

ge60

34

female

Self-administered

survey

824

H-SEAST

VASS

13ge1

items

352

sinceage60

1

type64

2types

16ge3

types

20

Sasaki20

0789

412pairsof

disabled

older

adults

andfamily

caregivers

inJapan

Mean80

560

1

female

Self-administrated

survey

700

Checklistdevelopedby

literature

9ge1

items

6-mon

th34

9

Cho

kkanathan

2006

26

400commun

ity-living

cogn

itively

intact

older

adults

inIndia

ge65

495

female

Inperson

80CTS

18a

1-year14

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1217

neglect with some studies using the ldquoany itemrdquo approachand others using the ldquo10 or more itemsrdquo approach Incomparison the operational definitions of physical andsexual abuse remain more consistent across studies withthe majority of studies using the ldquoany itemrdquo approach Arecent study used different operational definitions to exam-ine elder abuse and its subtypes in the same populationcohort and suggested that the prevalence of elder abuseand its subtypes varied with the strictness of the defini-tion33

Risk factors for elder abuse are highlighted in Table 2and visually plotted in Figure 1 Associations between so-ciodemographic and socioeconomic characteristics andelder abuse have been inconsistent42224 2634ndash36 Physicalfunction impairment has been linked with elder abuse37ndash43

as has psychological distress and social isolation364044ndash47

Of various risk factors cognitive impairment seemed to beconsistently associated with greater risk of elder abuse Forexample 254 caregivers and 76 older adults with dementiawere surveyed and it was found that older adults withAlzheimerrsquos disease were 48 times as likely to experienceelder abuse as those without48 Another study assessed2005 samples of reported APS cases and found that cogni-tive impairment was significantly associated with elderself-neglect49 The wide variations of odds ratios and con-fidence intervals in Figure 1 represent the diversity of thestudies with respect to population sample size settingsdefinitions and categorization of independent and depen-dent variables

Elder abuse is associated with significant adversehealth outcomes (Table 3) including psychosocial dis-tress50ndash52 morbidity and mortality553ndash55 Two longitudi-nal cohort studies have demonstrated and associationbetween elder abuse and premature mortality554 espe-cially in black populations56 Elder abuse is also associatedwith greater health service use57ndash59 especially emergencydepartment use60 and hospitalization and 30-day readmis-sion rates585961 See online Appendix for references forTables 1 2 and 3

DISCUSSION

Elder abuse is prevalent in older adults across five conti-nents especially minority older adults Because differentresearch methodologies are used in the literature a varietyof risk factors have been found to be associated with elderabuse Among the risk factors cognitive and physicalimpairment and psychosocial distress seem to be consis-tently associated with elder abuse Elder abuse may lead todeleterious health outcomes and increase healthcare use

There are various limitations in the field of elder abusethat add to the challenges of synthesizing data in this sys-tematic review One particular limitation is that no consis-tent elder abuse instrument has been used to measure elderabuse making it difficult to compare the prevalence andunderstand the risk factors between studies Despite usingthe same instrument the cutoff for definite elder abusevaries greatly across studies Many studies have used anldquoany positive itemrdquo approach whereas others have moresystematically considered the heterogeneity of thedefinitions and have been stricter in the categorization ofelder abuse cases In addition some studies have used anT

able

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Yan20

0131

355commun

ity-livingolder

adults

inHon

gKon

gChina

ge60

62

female

Self-administered

NA

Revised

CTS

25ge1

items

1-year21

4multiple

types

171

Africa

Cadmus

2012

20

404elderlywom

enin

Oyo

state

southw

estern

Nigeria

ge60

100

female

100

Yorub

aSem

istructured

questionn

aires

NA

Stand

ardized

questionn

aire

developed

byWorld

Health

Organization

18Score

ge11-year30

Rahman

2012

28

110

6olderadults

livingat

homein

ruralarea

ofMansouracityDakahilia

GovernateEg

ypt

ge60

532

female

In-personinterview

953

Questionn

aire

toelicit

abuse

15ge1

items

1-year43

71type

3542types

38

3types

38

4types

06

Fordetailed

table

onthedefinitionalcriteria

forspecificsubtypes

ofelder

abuse

anditsprevalenceseeonlineTable

S1

aCutoff

varies

accordingto

subtypeofabuse

andmore

detailed

inform

ationregardingthecut-off

pointofeach

typeofabuse

please

seetheappendix

H-SEAST

=Hwalek-SengstokElder

Abuse

ScreeningTestVASS=Vulnerabilityto

Abuse

ScreeningScaleCTS=ConflictTacticsScaleAMA

=AmericanMedicalAssociationNA

=notapplicable

1218 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2

RiskFactors

AssociatedwithElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1258

PS

615

9elderlyadults

from

CHAP

ge65

61

female

Physicalfunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocialnetwork

andsocialparticipation

Physicalperformance

testing

(OR=113

95

CI=106ndash1

19)

lowesttertile

ofph

ysical

performance

testing(OR=492

95

CI=139ndash1

746

)Don

g20

1034

PS

551

9elderlyadults

from

CHAP

ge65

61

female

64

black

Cog

nitivefunction

SN

Sociodemog

raph

icmedical

cond

ition

ph

ysical

function

depression

socialnetworks

Executivefunction(OR=101

95

CI=100ndash1

02)

Don

g20

1034

PS

557

0elderlyadults

from

CHAP

ge65

669

female

Physicalfunction

SN

Sociodemog

raph

icmedical

cond

ition

depression

cogn

ition

socialnetworks

Declinein

physical

performance

(OR=106

95

CI=104ndash1

09)

increase

inKatzimpairment

(OR=108

95

CI=103ndash1

13)

Rosow

-Breslau

impairment

(OR=123

95

CI=114ndash1

32)

Nagiimpairment(OR=107

95

CI=102

ndash113)

Tierney

2007

43

PS

130commun

ity-living

participants

who

scored

lt13

1on

DRS

ge65

708

female

Executivefunction

judg

mentattentionand

concentration

verbal

fluency

SN

Agesex

education

CharlsonCom

orbidity

Index

MMSE

Rey

Aud

itory

VerbalLearning

Test

recogn

ition

(OR=094

95

CI=

089

ndash098)Trail-Making

Test

PartB(OR=101

95

CI=100

ndash102)WechslerAdu

ltIntelligenceScale-Revised

similarities(OR=088

95

CI=081

ndash098)

Tierney

2004

90

PS

139commun

ity-living

adults

who

scored

lt13

1on

DRS

ge65

708

female

MMSE

medical

cond

ition

smedications

OARS

SN

Agesex

education

internationalclassification

ofdisease

Charlsonindex

OARSMMSE

HigherMMSEscore(OR=087

95

CI=078ndash0

97)chronic

obstructivepu

lmon

arydisorder

(OR=772

95

CI=244ndash

2443)high

erOARSscore

(OR=070

95

CI=066ndash0

89)

stroke

(OR=309

95

CI=120

ndash796)

Abram

s20

0235

PS

281

2elderlyadults

from

New

Haven

EPES

Ecoho

rt

ge65

654

female

Depressivesymptom

scogn

itive

impairment

SN

Agesex

raceeducation

income

maritalstatus

livingsituation

medical

morbidity

Depressivesymptom

s(CES

-Dscorege1

6)(OR=238

95

CI=126

ndash448)cogn

itive

impairment(ge4errors

onthe

Pfeiffer

Sho

rtPortableMental

StatusQuestionn

aireOR=463

95

CI=232ndash9

23)

Lachs

1997

42

PS

622

2elderlyadults

inEP

ESEcoho

rtge6

564

8

female

ADLimpairment

cogn

itive

disability

EAAgesexualraceand

income

New

ADLimpairment(OR=14

95

CI=04ndash46)new

cogn

itive

impairment(OR=51

95

CI=20ndash

127)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1219

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1433

CS

78olderChinese

inUnitedStates

ge60

52

female

Depressivesymptom

atolog

yEA

Sociodemog

raph

icmarital

statushealth

status

quality

oflife

physical

function

lonelinessand

social

supp

ort

Depressivesymptom

atolog

y(OR=201

95

CI=123

ndash348)

Cho

kkanathan

2014

26

CS

902olderadults

inNadu

India

ge61

543

female

Older

adultsph

ysically

abusefamily

mem

bers

Family

mem

bersage

education

alcoho

lconsum

ption

mistreatm

entof

other

family

mem

bers

Environm

entfamily

cohesion

stress

EAOlder

adults

(agesex

employmentdepend

ency

physically

abused)

Family

mem

ber(age

education

alcoho

luse

mistreatothers)

Environm

ent(fam

ilycohesion

family

stress

wealth

index)

Older

adultsph

ysically

abusing

family

mem

bers

(OR=906

95

CI=282ndash2

904

)Family

mem

bersmiddleage

(OR=206

95

CI=101

ndash423)

tertiary

education(OR=032

95

CI=011ndash0

97)alcoho

l(OR=308

95

CI=168

ndash570)

mistreatm

entof

otherfamily

(OR=624

95

CI=211

ndash18

41)repo

rted

moreconfl

icts

with

theirfamily

mem

bers

(OR=14

14

95

CI=663ndash

3014)low

family

cohesion

(OR=175

95

CI=143

ndash215)

Don

g20

1361

CS

10333

olderadults

inChicago

ge65

39

female

Elderself-neglect

EASociodemog

raph

icmedical

comorbidities

cogn

itive

andph

ysical

functionand

psycho

social

well-being

Elderabuse(OR=175

95

CI=118

259

)fin

ancial

exploitation(OR=173

95

CI=101

295

)caregiverneglect

(OR=209

95

CI=124

352

)multiple

form

sof

elder

abuse(OR=206

95

CI=122

348

)Lichtenb

erg

2013

91

CS

444

0olderadults

from

Health

andRetirem

ent

Study

Mean65

861

9

female

854

white

Education

depressive

symptom

sfin

ancial

satisfaction

social

needs

Financial

abuse

Sociodemog

raph

icmarital

statusCES

-Dph

ysical

function

self-ratedhealth

financial

status

psycho

logicalfactors

Moreeducation(OR=109

95

CI=103ndash1

16)moredepressive

symptom

s(OR=109

95

CI=101ndash1

18)less

financial

satisfaction(OR=076

95

CI=063ndash0

90)greaterADL

needs(OR=101

95

CI=078

ndash130)greaterdiseasebu

rden

(OR=103

95

CI=088

ndash121)

Strasser20

1347

CS

112olderadults

who

participated

inlegal

prog

ram

ge60

682

female

Sexethn

icity

depression

EASexethn

icitycohabitation

depression

visits

toa

mentalhealth

provider

Male(OR=554

95

CI=185

ndash16

57)Hispanic(OR=11

73

95

CI=106ndash1

3006)

depression

(OR=607

95

CI=154ndash2

309

)

(Continued)

1220 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 2: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

prevent elder abuse speed of progress has lagged behindthe scope and effect of the issue

In March 2011 the Senate Special Committee onAging held a hearing ldquoJustice for All Ending Elder AbuseNeglect and Exploitationrdquo Based on a GovernmentAccountability Office report9 individuals who had beenabused and experts highlighted the lack of research educa-tion training and prevention strategies The GovernmentAccountability Office estimated that in 2009 nationalspending by federal agencies was $119 million for allactivities related to elder abuse ($11 million according tothe National Institutes of Health) which is much less thanthe annual funding for violence against women programs($649 million) and for child abuse programs ($7 billion)10

On June 14 2012 the World Elder Abuse Awareness Daycommemoration was held at the White House and Presi-dent Obama proclaimed the importance of advancing thefield of elder abuse11 In March 2013 the Centers forMedicare and Medicaid Services held a national sympo-sium to highlight elder abuse as a Physician QualityReporting System measure (181) to promote screening ofelder abuse in healthcare settings12 In April 2013 theInstitute of Medicine held a 2-day workshop dedicated toelder abuse prevention bringing together global experts toadvance the field In October 2013 the US PreventiveServices Task Force recommended elder abuse as aresearch priority area in its report to Congress13

This review highlights the global epidemiology of elderabuse in terms of its prevalence risk factors and conse-quences It covers major gaps in research and policy issuesfor the field of elder abuse and discussed implications forresearchers health professionals and policy-makers

METHODS

Data Source and Study Selection

The global literature in PubMed MEDLINE PsycINFOBIOSIS Science Direct and Cochrane Central wassearched The search was limited to studies published inEnglish Search terms included elder abuse elder mistreat-ment elder maltreatment prevalence incidence risk fac-tors protective factors outcomes and consequencesReview studies were identified and their reference listsexamined for relevant articles Studies existing only asabstracts case series or case reports or that recruitedindividuals younger than 60 qualitative studies and non-English publications were excluded (online Figure S1)

For prevalence studies it was not the intention topresent every published study in community populationsRather this study aimed to demonstrate the heterogeneityof elder abuse definitions and prevalence on the major con-tinents North America South America Europe Asia andAfrica Because there is limited research in developingcountries studies were included from as many differentcountries as available For studies in developed countries(eg North America and Europe) studies representative ofcultural diversity definitional variations and psychometrictesting and large-scale epidemiological studies wereselected

For risk and protective factors only studies in whichelder abuse was clearly defined as the primary dependent

variable potential confounding factors were considered inthe analyses and the risks and confidence intervals wereshown were included A similar approach was used forconsequences and only studies in which elder abuse wasthe primary independent variable and confounding factorswere used were included Studies in which primary analy-ses were bivariate in nature were not included articlesidentified using the search methods were independentlyreviewed and studies were selected according to thecriteria

Data Synthesis

Epidemiology of Elder Abuse

Elder abuse is a worldwide health problem Prevalence ofelder abuse varies depending on the population settingsdefinitions and research methods (Table 1 and online Fig-ure S2)3414ndash22 In North and South America the preva-lence of elder abuse in this review ranges from 10 incognitively intact older adults to 473 in older adultswith dementia323 In Europe the prevalence has beenfound to vary from 22 in Ireland to 611 in Croa-tia2425 In Asia the highest 1-year prevalence in thisreview has been found in older adults in mainland China(362) and lowest was in India (140)212627 Onlytwo studies conducted in Africa have been found and theprevalence ranged from 30 to 4372028 A more-detailed version of Table 1 showing the specific cutoffpoint methods for prevalence estimates is supplied asonline Table S1

Elder abuse is common in minority older adultsFinancial exploitation is three times as high and psycho-logical abuse four times as high in black populations4 Astudy of Hispanics indicated that 40 had experiencedelder abuse yet only 2 was reported to authorities14 Ina study of 4627 older adults in the Chicago Health andAging Project older black men were three times as likelyto experience elder self-neglect as older white men andolder black women were two times as likely to report elderself-neglect as older white women16 In a Chinese popula-tion despite cultural expectations of filial piety 35 ofolder adults self-reported elder abuse29 Understanding cul-turally specific elements of elder abuse will be critical todesigning prevention and intervention strategies used inculturally specific contexts

Although there is no consensus on a singular measurethe Conflict Tactic Scale (CTS)30 remains one of the mostwidely used to measure physical psychological and sexualabuse Despite using the same measurement the cutoffpoint for definite elder abuse differs greatly across studiesleading to large variation in prevalence estimates Forinstance one study used the revised CTS and regardedolder adults who endorsed any item of the measurement ashaving experienced verbal abuse and found a 1-year preva-lence of 2131 Another study used the modified CTS butincluded those who endorsed 10 or more items as havingexperienced psychological abuse and therefore found a1-year prevalence of only 1224 A third likewise usedthe ldquo10 or more itemsrdquo criteria and suggested a 1-yearprevalence of psychological abuse of 3232 Such incon-sistency in definitions was also observed in measuring elder

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1215

Table

1

Prevalence

Estim

atesofElder

Abuse

Accordingto

PopulationSurvey

MethodandDefinition

AuthorYear

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

NorthSou

thAmerica

Don

g20

1433

315

9elderlyChinese

inChicago

ge60

589

female

Inperson

919

H-SEAST

VASS

10ge1

items

150

sinceage60

Don

g20

1433

315

9elderlyChinese

inChicago

ge60

589

female

Inperson

919

CTS

caregiverneglect

assessmentfin

ancial

exploitationassessment

56a

139ndash258

sinceage

60

Deliema

2012

14

198Hispanics

inLo

sAng

eles

ge66

56

female

Inperson

65University

ofSou

thern

California

Older

Adu

ltCon

flict

Scale

54ge1

items

1-year40

4multiple

21

Don

g20

1258

462

7adults

inChicago

ge65

644

female

Inperson

NA

Chicago

ElderSelf-

Neglect

Scale

21ge1

items

Blackmen13

2

wom

en10

9

Whitemen24

wom

en26

Lachs

2011

54

415

6En

glish-

orSpanish-

speaking

commun

ity

cogn

itively

intact

older

New

Yorkers

60ndash1

0135

5

female

190

black

755

white

60

Hispanic

08

American

Indian12

Asian

Teleph

one

NA

CTS

31a

141

sinceage60

Acierno

20

103

577

7cogn

itively

intact

UScommun

itypo

pulation

60ndash9

760

female

88

white7

black

4Hispanic

2American

Indian1

Asian

Rando

m-digitdialing

andcompu

ter-assisted

interview

69InterpersonalViolenceMeasure

andAcierno

EMMeasure

22ge1

items

Any

elderabuse

(exclude

financial)10

Wiglesw

orth

2010

23

129olderadults

with

dementia

andtheircaregivers

771

80

457

female

938

white85

Hispanic

In-personsurvey

ofcaregivers

NA

CTS

ElderAbu

seInstrumentSelf-Neglect

Assessm

entScale

NA

a1-year

473multiple

146

Beach20

1037

903UScommun

ity-

dwellingolderadults

with

land

line

English-speaking

no

severe

cogn

itive

impairment

ge60

733

female

233

black

728

white39

other

Rando

m-digitdialing

in-person

self-

administered

377

Mod

ified

CTS

12a

6-mon

thfin

ancial

exploitation

35

6-

mon

thpsycho

logical

mistreatm

ent82

Laum

ann

2008

17

300

5olderadults

inthe

NationalSocialLifeHealth

andAging

project

57ndash8

551

2

female

807

white10

0

black

68

Hispanic

25

other

In-personandmail

survey

755

H-SEAST

VASS

3ge1

items

1-yearverbal9

fin

ancial35

ph

ysical02

Buri20

0681

498olderadults

inthe

IowaMedicaidWaiver

Program

65ndash1

0170

9

female

96

white3

black

Mailsurvey

49ElderAbu

seScreen

5ge1

items

2091type15

8

2types

40

3types

10

Europe

Lind

ert

2013

19

446

7olderadults

from

sevencoun

triesin

Europe

60ndash8

457

3

female

In-personandmail

survey

452

Mod

ified

CTS

52ge1

items

1-year12

7ndash3

08

Naugh

ton

2011

24

202

1commun

ity-dwelling

olderpeop

lein

Ireland

ge65

55

female

Inperson

83CTS

UKandNY

prevalence

stud

ies

NA

a1-year22

Kissal20

1182

331olderadults

inIzmir

Turkey

ge65

568

female

Inperson

NA

Investigator-determined

5a

6-mon

th13

3

(Continued)

1216 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Biggs20

0983

211

1olderadults

inthe

commun

ityin

United

Kingd

om

ge66

Inperson

65Builton

literature

34a

26

with

neglect

16

withou

tneglect

Ajdukovic

2009

25

303olderadults

inCroatia

65ndash9

776

6

female

Inperson

NA

ElderAbu

sein

the

Family

questionn

aire

20NA

1-year61

1

Coo

per20

0984

220UKcaregivers

ofpeop

lewith

dementia

58ndash9

972

female

Inperson

69Mod

ified

CTS

10Score

ge23-mon

th52

Garre-Olmo

2009

85

676commun

ity-dwelling

olderadults

inGiron

aSpain

ge75

582

female

Inperson

82AMAScreen

9ge1

items

1-year29

32types

36

3types

01

Perez

Carceles

2008

86

460olderadults

inhealth

center

inSpain

ge65

533

female

Inperson

NA

CanadianTask

Force

AMAScreen

19ge1

items

446

Com

ijs19

983132

179

7olderpeop

leliving

independ

ently

inAmsterdamthe

Netherlands

69ndash8

962

8

female

Interview

444

CTS

Measure

ofWife

Abu

seViolenceAgainst

Man

Scale

NA

a1-year56

ge2

types

04

AsiaAustria

Wu

2012

21

203

9Chinese

olderadults

inruralChina

ge60

599

female

Inperson

908

H-SEAST

VASS

NA

ge1items

1-year36

2

ge2types

105

Som

jinda

Cho

mpu

nud

2010

87

233cogn

itively

functioning

olderadults

inTh

ailand

60ndash9

073

4

female

Inperson

733

Interview

guidelinefor

screeningforelder

abuse

6ge1

items

1-year14

61tim

e99

ge2

times47

Lowenstein

2009

27

104

5commun

ity-living

olderadults

from

thefirst

nationalsurvey

inIsrael

ge65

625

female

Inperson

75CTS

2shortsituational

descriptions

Respo

ndentsrsquoReactions

toAgg

ression

NA

a1-year35

0

Oh

2009

22

15230

olderadults

inSeoulKorea

ge65

653

female

Inperson

NA

Com

piledthroug

hliterature

25ge2

times

1-mon

th63

Lee

2008

88

100

0primarycaregivers

offamily

mem

bers

with

disabilitiesin

SeoulKorea

65ndash1

0269

5

female

Inperson

NA

NA

6a

Not

answ

ered

question

105yelled

109

confi

ned

18hit

97

neglected

136

Don

g20

0744

412cogn

itively

intact

commun

ity-livingperson

sfrom

medical

clinicsin

China

ge60

34

female

Self-administered

survey

824

H-SEAST

VASS

13ge1

items

352

sinceage60

1

type64

2types

16ge3

types

20

Sasaki20

0789

412pairsof

disabled

older

adults

andfamily

caregivers

inJapan

Mean80

560

1

female

Self-administrated

survey

700

Checklistdevelopedby

literature

9ge1

items

6-mon

th34

9

Cho

kkanathan

2006

26

400commun

ity-living

cogn

itively

intact

older

adults

inIndia

ge65

495

female

Inperson

80CTS

18a

1-year14

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1217

neglect with some studies using the ldquoany itemrdquo approachand others using the ldquo10 or more itemsrdquo approach Incomparison the operational definitions of physical andsexual abuse remain more consistent across studies withthe majority of studies using the ldquoany itemrdquo approach Arecent study used different operational definitions to exam-ine elder abuse and its subtypes in the same populationcohort and suggested that the prevalence of elder abuseand its subtypes varied with the strictness of the defini-tion33

Risk factors for elder abuse are highlighted in Table 2and visually plotted in Figure 1 Associations between so-ciodemographic and socioeconomic characteristics andelder abuse have been inconsistent42224 2634ndash36 Physicalfunction impairment has been linked with elder abuse37ndash43

as has psychological distress and social isolation364044ndash47

Of various risk factors cognitive impairment seemed to beconsistently associated with greater risk of elder abuse Forexample 254 caregivers and 76 older adults with dementiawere surveyed and it was found that older adults withAlzheimerrsquos disease were 48 times as likely to experienceelder abuse as those without48 Another study assessed2005 samples of reported APS cases and found that cogni-tive impairment was significantly associated with elderself-neglect49 The wide variations of odds ratios and con-fidence intervals in Figure 1 represent the diversity of thestudies with respect to population sample size settingsdefinitions and categorization of independent and depen-dent variables

Elder abuse is associated with significant adversehealth outcomes (Table 3) including psychosocial dis-tress50ndash52 morbidity and mortality553ndash55 Two longitudi-nal cohort studies have demonstrated and associationbetween elder abuse and premature mortality554 espe-cially in black populations56 Elder abuse is also associatedwith greater health service use57ndash59 especially emergencydepartment use60 and hospitalization and 30-day readmis-sion rates585961 See online Appendix for references forTables 1 2 and 3

DISCUSSION

Elder abuse is prevalent in older adults across five conti-nents especially minority older adults Because differentresearch methodologies are used in the literature a varietyof risk factors have been found to be associated with elderabuse Among the risk factors cognitive and physicalimpairment and psychosocial distress seem to be consis-tently associated with elder abuse Elder abuse may lead todeleterious health outcomes and increase healthcare use

There are various limitations in the field of elder abusethat add to the challenges of synthesizing data in this sys-tematic review One particular limitation is that no consis-tent elder abuse instrument has been used to measure elderabuse making it difficult to compare the prevalence andunderstand the risk factors between studies Despite usingthe same instrument the cutoff for definite elder abusevaries greatly across studies Many studies have used anldquoany positive itemrdquo approach whereas others have moresystematically considered the heterogeneity of thedefinitions and have been stricter in the categorization ofelder abuse cases In addition some studies have used anT

able

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Yan20

0131

355commun

ity-livingolder

adults

inHon

gKon

gChina

ge60

62

female

Self-administered

NA

Revised

CTS

25ge1

items

1-year21

4multiple

types

171

Africa

Cadmus

2012

20

404elderlywom

enin

Oyo

state

southw

estern

Nigeria

ge60

100

female

100

Yorub

aSem

istructured

questionn

aires

NA

Stand

ardized

questionn

aire

developed

byWorld

Health

Organization

18Score

ge11-year30

Rahman

2012

28

110

6olderadults

livingat

homein

ruralarea

ofMansouracityDakahilia

GovernateEg

ypt

ge60

532

female

In-personinterview

953

Questionn

aire

toelicit

abuse

15ge1

items

1-year43

71type

3542types

38

3types

38

4types

06

Fordetailed

table

onthedefinitionalcriteria

forspecificsubtypes

ofelder

abuse

anditsprevalenceseeonlineTable

S1

aCutoff

varies

accordingto

subtypeofabuse

andmore

detailed

inform

ationregardingthecut-off

pointofeach

typeofabuse

please

seetheappendix

H-SEAST

=Hwalek-SengstokElder

Abuse

ScreeningTestVASS=Vulnerabilityto

Abuse

ScreeningScaleCTS=ConflictTacticsScaleAMA

=AmericanMedicalAssociationNA

=notapplicable

1218 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2

RiskFactors

AssociatedwithElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1258

PS

615

9elderlyadults

from

CHAP

ge65

61

female

Physicalfunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocialnetwork

andsocialparticipation

Physicalperformance

testing

(OR=113

95

CI=106ndash1

19)

lowesttertile

ofph

ysical

performance

testing(OR=492

95

CI=139ndash1

746

)Don

g20

1034

PS

551

9elderlyadults

from

CHAP

ge65

61

female

64

black

Cog

nitivefunction

SN

Sociodemog

raph

icmedical

cond

ition

ph

ysical

function

depression

socialnetworks

Executivefunction(OR=101

95

CI=100ndash1

02)

Don

g20

1034

PS

557

0elderlyadults

from

CHAP

ge65

669

female

Physicalfunction

SN

Sociodemog

raph

icmedical

cond

ition

depression

cogn

ition

socialnetworks

Declinein

physical

performance

(OR=106

95

CI=104ndash1

09)

increase

inKatzimpairment

(OR=108

95

CI=103ndash1

13)

Rosow

-Breslau

impairment

(OR=123

95

CI=114ndash1

32)

Nagiimpairment(OR=107

95

CI=102

ndash113)

Tierney

2007

43

PS

130commun

ity-living

participants

who

scored

lt13

1on

DRS

ge65

708

female

Executivefunction

judg

mentattentionand

concentration

verbal

fluency

SN

Agesex

education

CharlsonCom

orbidity

Index

MMSE

Rey

Aud

itory

VerbalLearning

Test

recogn

ition

(OR=094

95

CI=

089

ndash098)Trail-Making

Test

PartB(OR=101

95

CI=100

ndash102)WechslerAdu

ltIntelligenceScale-Revised

similarities(OR=088

95

CI=081

ndash098)

Tierney

2004

90

PS

139commun

ity-living

adults

who

scored

lt13

1on

DRS

ge65

708

female

MMSE

medical

cond

ition

smedications

OARS

SN

Agesex

education

internationalclassification

ofdisease

Charlsonindex

OARSMMSE

HigherMMSEscore(OR=087

95

CI=078ndash0

97)chronic

obstructivepu

lmon

arydisorder

(OR=772

95

CI=244ndash

2443)high

erOARSscore

(OR=070

95

CI=066ndash0

89)

stroke

(OR=309

95

CI=120

ndash796)

Abram

s20

0235

PS

281

2elderlyadults

from

New

Haven

EPES

Ecoho

rt

ge65

654

female

Depressivesymptom

scogn

itive

impairment

SN

Agesex

raceeducation

income

maritalstatus

livingsituation

medical

morbidity

Depressivesymptom

s(CES

-Dscorege1

6)(OR=238

95

CI=126

ndash448)cogn

itive

impairment(ge4errors

onthe

Pfeiffer

Sho

rtPortableMental

StatusQuestionn

aireOR=463

95

CI=232ndash9

23)

Lachs

1997

42

PS

622

2elderlyadults

inEP

ESEcoho

rtge6

564

8

female

ADLimpairment

cogn

itive

disability

EAAgesexualraceand

income

New

ADLimpairment(OR=14

95

CI=04ndash46)new

cogn

itive

impairment(OR=51

95

CI=20ndash

127)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1219

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1433

CS

78olderChinese

inUnitedStates

ge60

52

female

Depressivesymptom

atolog

yEA

Sociodemog

raph

icmarital

statushealth

status

quality

oflife

physical

function

lonelinessand

social

supp

ort

Depressivesymptom

atolog

y(OR=201

95

CI=123

ndash348)

Cho

kkanathan

2014

26

CS

902olderadults

inNadu

India

ge61

543

female

Older

adultsph

ysically

abusefamily

mem

bers

Family

mem

bersage

education

alcoho

lconsum

ption

mistreatm

entof

other

family

mem

bers

Environm

entfamily

cohesion

stress

EAOlder

adults

(agesex

employmentdepend

ency

physically

abused)

Family

mem

ber(age

education

alcoho

luse

mistreatothers)

Environm

ent(fam

ilycohesion

family

stress

wealth

index)

Older

adultsph

ysically

abusing

family

mem

bers

(OR=906

95

CI=282ndash2

904

)Family

mem

bersmiddleage

(OR=206

95

CI=101

ndash423)

tertiary

education(OR=032

95

CI=011ndash0

97)alcoho

l(OR=308

95

CI=168

ndash570)

mistreatm

entof

otherfamily

(OR=624

95

CI=211

ndash18

41)repo

rted

moreconfl

icts

with

theirfamily

mem

bers

(OR=14

14

95

CI=663ndash

3014)low

family

cohesion

(OR=175

95

CI=143

ndash215)

Don

g20

1361

CS

10333

olderadults

inChicago

ge65

39

female

Elderself-neglect

EASociodemog

raph

icmedical

comorbidities

cogn

itive

andph

ysical

functionand

psycho

social

well-being

Elderabuse(OR=175

95

CI=118

259

)fin

ancial

exploitation(OR=173

95

CI=101

295

)caregiverneglect

(OR=209

95

CI=124

352

)multiple

form

sof

elder

abuse(OR=206

95

CI=122

348

)Lichtenb

erg

2013

91

CS

444

0olderadults

from

Health

andRetirem

ent

Study

Mean65

861

9

female

854

white

Education

depressive

symptom

sfin

ancial

satisfaction

social

needs

Financial

abuse

Sociodemog

raph

icmarital

statusCES

-Dph

ysical

function

self-ratedhealth

financial

status

psycho

logicalfactors

Moreeducation(OR=109

95

CI=103ndash1

16)moredepressive

symptom

s(OR=109

95

CI=101ndash1

18)less

financial

satisfaction(OR=076

95

CI=063ndash0

90)greaterADL

needs(OR=101

95

CI=078

ndash130)greaterdiseasebu

rden

(OR=103

95

CI=088

ndash121)

Strasser20

1347

CS

112olderadults

who

participated

inlegal

prog

ram

ge60

682

female

Sexethn

icity

depression

EASexethn

icitycohabitation

depression

visits

toa

mentalhealth

provider

Male(OR=554

95

CI=185

ndash16

57)Hispanic(OR=11

73

95

CI=106ndash1

3006)

depression

(OR=607

95

CI=154ndash2

309

)

(Continued)

1220 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 3: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

1

Prevalence

Estim

atesofElder

Abuse

Accordingto

PopulationSurvey

MethodandDefinition

AuthorYear

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

NorthSou

thAmerica

Don

g20

1433

315

9elderlyChinese

inChicago

ge60

589

female

Inperson

919

H-SEAST

VASS

10ge1

items

150

sinceage60

Don

g20

1433

315

9elderlyChinese

inChicago

ge60

589

female

Inperson

919

CTS

caregiverneglect

assessmentfin

ancial

exploitationassessment

56a

139ndash258

sinceage

60

Deliema

2012

14

198Hispanics

inLo

sAng

eles

ge66

56

female

Inperson

65University

ofSou

thern

California

Older

Adu

ltCon

flict

Scale

54ge1

items

1-year40

4multiple

21

Don

g20

1258

462

7adults

inChicago

ge65

644

female

Inperson

NA

Chicago

ElderSelf-

Neglect

Scale

21ge1

items

Blackmen13

2

wom

en10

9

Whitemen24

wom

en26

Lachs

2011

54

415

6En

glish-

orSpanish-

speaking

commun

ity

cogn

itively

intact

older

New

Yorkers

60ndash1

0135

5

female

190

black

755

white

60

Hispanic

08

American

Indian12

Asian

Teleph

one

NA

CTS

31a

141

sinceage60

Acierno

20

103

577

7cogn

itively

intact

UScommun

itypo

pulation

60ndash9

760

female

88

white7

black

4Hispanic

2American

Indian1

Asian

Rando

m-digitdialing

andcompu

ter-assisted

interview

69InterpersonalViolenceMeasure

andAcierno

EMMeasure

22ge1

items

Any

elderabuse

(exclude

financial)10

Wiglesw

orth

2010

23

129olderadults

with

dementia

andtheircaregivers

771

80

457

female

938

white85

Hispanic

In-personsurvey

ofcaregivers

NA

CTS

ElderAbu

seInstrumentSelf-Neglect

Assessm

entScale

NA

a1-year

473multiple

146

Beach20

1037

903UScommun

ity-

dwellingolderadults

with

land

line

English-speaking

no

severe

cogn

itive

impairment

ge60

733

female

233

black

728

white39

other

Rando

m-digitdialing

in-person

self-

administered

377

Mod

ified

CTS

12a

6-mon

thfin

ancial

exploitation

35

6-

mon

thpsycho

logical

mistreatm

ent82

Laum

ann

2008

17

300

5olderadults

inthe

NationalSocialLifeHealth

andAging

project

57ndash8

551

2

female

807

white10

0

black

68

Hispanic

25

other

In-personandmail

survey

755

H-SEAST

VASS

3ge1

items

1-yearverbal9

fin

ancial35

ph

ysical02

Buri20

0681

498olderadults

inthe

IowaMedicaidWaiver

Program

65ndash1

0170

9

female

96

white3

black

Mailsurvey

49ElderAbu

seScreen

5ge1

items

2091type15

8

2types

40

3types

10

Europe

Lind

ert

2013

19

446

7olderadults

from

sevencoun

triesin

Europe

60ndash8

457

3

female

In-personandmail

survey

452

Mod

ified

CTS

52ge1

items

1-year12

7ndash3

08

Naugh

ton

2011

24

202

1commun

ity-dwelling

olderpeop

lein

Ireland

ge65

55

female

Inperson

83CTS

UKandNY

prevalence

stud

ies

NA

a1-year22

Kissal20

1182

331olderadults

inIzmir

Turkey

ge65

568

female

Inperson

NA

Investigator-determined

5a

6-mon

th13

3

(Continued)

1216 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Biggs20

0983

211

1olderadults

inthe

commun

ityin

United

Kingd

om

ge66

Inperson

65Builton

literature

34a

26

with

neglect

16

withou

tneglect

Ajdukovic

2009

25

303olderadults

inCroatia

65ndash9

776

6

female

Inperson

NA

ElderAbu

sein

the

Family

questionn

aire

20NA

1-year61

1

Coo

per20

0984

220UKcaregivers

ofpeop

lewith

dementia

58ndash9

972

female

Inperson

69Mod

ified

CTS

10Score

ge23-mon

th52

Garre-Olmo

2009

85

676commun

ity-dwelling

olderadults

inGiron

aSpain

ge75

582

female

Inperson

82AMAScreen

9ge1

items

1-year29

32types

36

3types

01

Perez

Carceles

2008

86

460olderadults

inhealth

center

inSpain

ge65

533

female

Inperson

NA

CanadianTask

Force

AMAScreen

19ge1

items

446

Com

ijs19

983132

179

7olderpeop

leliving

independ

ently

inAmsterdamthe

Netherlands

69ndash8

962

8

female

Interview

444

CTS

Measure

ofWife

Abu

seViolenceAgainst

Man

Scale

NA

a1-year56

ge2

types

04

AsiaAustria

Wu

2012

21

203

9Chinese

olderadults

inruralChina

ge60

599

female

Inperson

908

H-SEAST

VASS

NA

ge1items

1-year36

2

ge2types

105

Som

jinda

Cho

mpu

nud

2010

87

233cogn

itively

functioning

olderadults

inTh

ailand

60ndash9

073

4

female

Inperson

733

Interview

guidelinefor

screeningforelder

abuse

6ge1

items

1-year14

61tim

e99

ge2

times47

Lowenstein

2009

27

104

5commun

ity-living

olderadults

from

thefirst

nationalsurvey

inIsrael

ge65

625

female

Inperson

75CTS

2shortsituational

descriptions

Respo

ndentsrsquoReactions

toAgg

ression

NA

a1-year35

0

Oh

2009

22

15230

olderadults

inSeoulKorea

ge65

653

female

Inperson

NA

Com

piledthroug

hliterature

25ge2

times

1-mon

th63

Lee

2008

88

100

0primarycaregivers

offamily

mem

bers

with

disabilitiesin

SeoulKorea

65ndash1

0269

5

female

Inperson

NA

NA

6a

Not

answ

ered

question

105yelled

109

confi

ned

18hit

97

neglected

136

Don

g20

0744

412cogn

itively

intact

commun

ity-livingperson

sfrom

medical

clinicsin

China

ge60

34

female

Self-administered

survey

824

H-SEAST

VASS

13ge1

items

352

sinceage60

1

type64

2types

16ge3

types

20

Sasaki20

0789

412pairsof

disabled

older

adults

andfamily

caregivers

inJapan

Mean80

560

1

female

Self-administrated

survey

700

Checklistdevelopedby

literature

9ge1

items

6-mon

th34

9

Cho

kkanathan

2006

26

400commun

ity-living

cogn

itively

intact

older

adults

inIndia

ge65

495

female

Inperson

80CTS

18a

1-year14

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1217

neglect with some studies using the ldquoany itemrdquo approachand others using the ldquo10 or more itemsrdquo approach Incomparison the operational definitions of physical andsexual abuse remain more consistent across studies withthe majority of studies using the ldquoany itemrdquo approach Arecent study used different operational definitions to exam-ine elder abuse and its subtypes in the same populationcohort and suggested that the prevalence of elder abuseand its subtypes varied with the strictness of the defini-tion33

Risk factors for elder abuse are highlighted in Table 2and visually plotted in Figure 1 Associations between so-ciodemographic and socioeconomic characteristics andelder abuse have been inconsistent42224 2634ndash36 Physicalfunction impairment has been linked with elder abuse37ndash43

as has psychological distress and social isolation364044ndash47

Of various risk factors cognitive impairment seemed to beconsistently associated with greater risk of elder abuse Forexample 254 caregivers and 76 older adults with dementiawere surveyed and it was found that older adults withAlzheimerrsquos disease were 48 times as likely to experienceelder abuse as those without48 Another study assessed2005 samples of reported APS cases and found that cogni-tive impairment was significantly associated with elderself-neglect49 The wide variations of odds ratios and con-fidence intervals in Figure 1 represent the diversity of thestudies with respect to population sample size settingsdefinitions and categorization of independent and depen-dent variables

Elder abuse is associated with significant adversehealth outcomes (Table 3) including psychosocial dis-tress50ndash52 morbidity and mortality553ndash55 Two longitudi-nal cohort studies have demonstrated and associationbetween elder abuse and premature mortality554 espe-cially in black populations56 Elder abuse is also associatedwith greater health service use57ndash59 especially emergencydepartment use60 and hospitalization and 30-day readmis-sion rates585961 See online Appendix for references forTables 1 2 and 3

DISCUSSION

Elder abuse is prevalent in older adults across five conti-nents especially minority older adults Because differentresearch methodologies are used in the literature a varietyof risk factors have been found to be associated with elderabuse Among the risk factors cognitive and physicalimpairment and psychosocial distress seem to be consis-tently associated with elder abuse Elder abuse may lead todeleterious health outcomes and increase healthcare use

There are various limitations in the field of elder abusethat add to the challenges of synthesizing data in this sys-tematic review One particular limitation is that no consis-tent elder abuse instrument has been used to measure elderabuse making it difficult to compare the prevalence andunderstand the risk factors between studies Despite usingthe same instrument the cutoff for definite elder abusevaries greatly across studies Many studies have used anldquoany positive itemrdquo approach whereas others have moresystematically considered the heterogeneity of thedefinitions and have been stricter in the categorization ofelder abuse cases In addition some studies have used anT

able

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Yan20

0131

355commun

ity-livingolder

adults

inHon

gKon

gChina

ge60

62

female

Self-administered

NA

Revised

CTS

25ge1

items

1-year21

4multiple

types

171

Africa

Cadmus

2012

20

404elderlywom

enin

Oyo

state

southw

estern

Nigeria

ge60

100

female

100

Yorub

aSem

istructured

questionn

aires

NA

Stand

ardized

questionn

aire

developed

byWorld

Health

Organization

18Score

ge11-year30

Rahman

2012

28

110

6olderadults

livingat

homein

ruralarea

ofMansouracityDakahilia

GovernateEg

ypt

ge60

532

female

In-personinterview

953

Questionn

aire

toelicit

abuse

15ge1

items

1-year43

71type

3542types

38

3types

38

4types

06

Fordetailed

table

onthedefinitionalcriteria

forspecificsubtypes

ofelder

abuse

anditsprevalenceseeonlineTable

S1

aCutoff

varies

accordingto

subtypeofabuse

andmore

detailed

inform

ationregardingthecut-off

pointofeach

typeofabuse

please

seetheappendix

H-SEAST

=Hwalek-SengstokElder

Abuse

ScreeningTestVASS=Vulnerabilityto

Abuse

ScreeningScaleCTS=ConflictTacticsScaleAMA

=AmericanMedicalAssociationNA

=notapplicable

1218 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2

RiskFactors

AssociatedwithElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1258

PS

615

9elderlyadults

from

CHAP

ge65

61

female

Physicalfunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocialnetwork

andsocialparticipation

Physicalperformance

testing

(OR=113

95

CI=106ndash1

19)

lowesttertile

ofph

ysical

performance

testing(OR=492

95

CI=139ndash1

746

)Don

g20

1034

PS

551

9elderlyadults

from

CHAP

ge65

61

female

64

black

Cog

nitivefunction

SN

Sociodemog

raph

icmedical

cond

ition

ph

ysical

function

depression

socialnetworks

Executivefunction(OR=101

95

CI=100ndash1

02)

Don

g20

1034

PS

557

0elderlyadults

from

CHAP

ge65

669

female

Physicalfunction

SN

Sociodemog

raph

icmedical

cond

ition

depression

cogn

ition

socialnetworks

Declinein

physical

performance

(OR=106

95

CI=104ndash1

09)

increase

inKatzimpairment

(OR=108

95

CI=103ndash1

13)

Rosow

-Breslau

impairment

(OR=123

95

CI=114ndash1

32)

Nagiimpairment(OR=107

95

CI=102

ndash113)

Tierney

2007

43

PS

130commun

ity-living

participants

who

scored

lt13

1on

DRS

ge65

708

female

Executivefunction

judg

mentattentionand

concentration

verbal

fluency

SN

Agesex

education

CharlsonCom

orbidity

Index

MMSE

Rey

Aud

itory

VerbalLearning

Test

recogn

ition

(OR=094

95

CI=

089

ndash098)Trail-Making

Test

PartB(OR=101

95

CI=100

ndash102)WechslerAdu

ltIntelligenceScale-Revised

similarities(OR=088

95

CI=081

ndash098)

Tierney

2004

90

PS

139commun

ity-living

adults

who

scored

lt13

1on

DRS

ge65

708

female

MMSE

medical

cond

ition

smedications

OARS

SN

Agesex

education

internationalclassification

ofdisease

Charlsonindex

OARSMMSE

HigherMMSEscore(OR=087

95

CI=078ndash0

97)chronic

obstructivepu

lmon

arydisorder

(OR=772

95

CI=244ndash

2443)high

erOARSscore

(OR=070

95

CI=066ndash0

89)

stroke

(OR=309

95

CI=120

ndash796)

Abram

s20

0235

PS

281

2elderlyadults

from

New

Haven

EPES

Ecoho

rt

ge65

654

female

Depressivesymptom

scogn

itive

impairment

SN

Agesex

raceeducation

income

maritalstatus

livingsituation

medical

morbidity

Depressivesymptom

s(CES

-Dscorege1

6)(OR=238

95

CI=126

ndash448)cogn

itive

impairment(ge4errors

onthe

Pfeiffer

Sho

rtPortableMental

StatusQuestionn

aireOR=463

95

CI=232ndash9

23)

Lachs

1997

42

PS

622

2elderlyadults

inEP

ESEcoho

rtge6

564

8

female

ADLimpairment

cogn

itive

disability

EAAgesexualraceand

income

New

ADLimpairment(OR=14

95

CI=04ndash46)new

cogn

itive

impairment(OR=51

95

CI=20ndash

127)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1219

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1433

CS

78olderChinese

inUnitedStates

ge60

52

female

Depressivesymptom

atolog

yEA

Sociodemog

raph

icmarital

statushealth

status

quality

oflife

physical

function

lonelinessand

social

supp

ort

Depressivesymptom

atolog

y(OR=201

95

CI=123

ndash348)

Cho

kkanathan

2014

26

CS

902olderadults

inNadu

India

ge61

543

female

Older

adultsph

ysically

abusefamily

mem

bers

Family

mem

bersage

education

alcoho

lconsum

ption

mistreatm

entof

other

family

mem

bers

Environm

entfamily

cohesion

stress

EAOlder

adults

(agesex

employmentdepend

ency

physically

abused)

Family

mem

ber(age

education

alcoho

luse

mistreatothers)

Environm

ent(fam

ilycohesion

family

stress

wealth

index)

Older

adultsph

ysically

abusing

family

mem

bers

(OR=906

95

CI=282ndash2

904

)Family

mem

bersmiddleage

(OR=206

95

CI=101

ndash423)

tertiary

education(OR=032

95

CI=011ndash0

97)alcoho

l(OR=308

95

CI=168

ndash570)

mistreatm

entof

otherfamily

(OR=624

95

CI=211

ndash18

41)repo

rted

moreconfl

icts

with

theirfamily

mem

bers

(OR=14

14

95

CI=663ndash

3014)low

family

cohesion

(OR=175

95

CI=143

ndash215)

Don

g20

1361

CS

10333

olderadults

inChicago

ge65

39

female

Elderself-neglect

EASociodemog

raph

icmedical

comorbidities

cogn

itive

andph

ysical

functionand

psycho

social

well-being

Elderabuse(OR=175

95

CI=118

259

)fin

ancial

exploitation(OR=173

95

CI=101

295

)caregiverneglect

(OR=209

95

CI=124

352

)multiple

form

sof

elder

abuse(OR=206

95

CI=122

348

)Lichtenb

erg

2013

91

CS

444

0olderadults

from

Health

andRetirem

ent

Study

Mean65

861

9

female

854

white

Education

depressive

symptom

sfin

ancial

satisfaction

social

needs

Financial

abuse

Sociodemog

raph

icmarital

statusCES

-Dph

ysical

function

self-ratedhealth

financial

status

psycho

logicalfactors

Moreeducation(OR=109

95

CI=103ndash1

16)moredepressive

symptom

s(OR=109

95

CI=101ndash1

18)less

financial

satisfaction(OR=076

95

CI=063ndash0

90)greaterADL

needs(OR=101

95

CI=078

ndash130)greaterdiseasebu

rden

(OR=103

95

CI=088

ndash121)

Strasser20

1347

CS

112olderadults

who

participated

inlegal

prog

ram

ge60

682

female

Sexethn

icity

depression

EASexethn

icitycohabitation

depression

visits

toa

mentalhealth

provider

Male(OR=554

95

CI=185

ndash16

57)Hispanic(OR=11

73

95

CI=106ndash1

3006)

depression

(OR=607

95

CI=154ndash2

309

)

(Continued)

1220 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 4: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Biggs20

0983

211

1olderadults

inthe

commun

ityin

United

Kingd

om

ge66

Inperson

65Builton

literature

34a

26

with

neglect

16

withou

tneglect

Ajdukovic

2009

25

303olderadults

inCroatia

65ndash9

776

6

female

Inperson

NA

ElderAbu

sein

the

Family

questionn

aire

20NA

1-year61

1

Coo

per20

0984

220UKcaregivers

ofpeop

lewith

dementia

58ndash9

972

female

Inperson

69Mod

ified

CTS

10Score

ge23-mon

th52

Garre-Olmo

2009

85

676commun

ity-dwelling

olderadults

inGiron

aSpain

ge75

582

female

Inperson

82AMAScreen

9ge1

items

1-year29

32types

36

3types

01

Perez

Carceles

2008

86

460olderadults

inhealth

center

inSpain

ge65

533

female

Inperson

NA

CanadianTask

Force

AMAScreen

19ge1

items

446

Com

ijs19

983132

179

7olderpeop

leliving

independ

ently

inAmsterdamthe

Netherlands

69ndash8

962

8

female

Interview

444

CTS

Measure

ofWife

Abu

seViolenceAgainst

Man

Scale

NA

a1-year56

ge2

types

04

AsiaAustria

Wu

2012

21

203

9Chinese

olderadults

inruralChina

ge60

599

female

Inperson

908

H-SEAST

VASS

NA

ge1items

1-year36

2

ge2types

105

Som

jinda

Cho

mpu

nud

2010

87

233cogn

itively

functioning

olderadults

inTh

ailand

60ndash9

073

4

female

Inperson

733

Interview

guidelinefor

screeningforelder

abuse

6ge1

items

1-year14

61tim

e99

ge2

times47

Lowenstein

2009

27

104

5commun

ity-living

olderadults

from

thefirst

nationalsurvey

inIsrael

ge65

625

female

Inperson

75CTS

2shortsituational

descriptions

Respo

ndentsrsquoReactions

toAgg

ression

NA

a1-year35

0

Oh

2009

22

15230

olderadults

inSeoulKorea

ge65

653

female

Inperson

NA

Com

piledthroug

hliterature

25ge2

times

1-mon

th63

Lee

2008

88

100

0primarycaregivers

offamily

mem

bers

with

disabilitiesin

SeoulKorea

65ndash1

0269

5

female

Inperson

NA

NA

6a

Not

answ

ered

question

105yelled

109

confi

ned

18hit

97

neglected

136

Don

g20

0744

412cogn

itively

intact

commun

ity-livingperson

sfrom

medical

clinicsin

China

ge60

34

female

Self-administered

survey

824

H-SEAST

VASS

13ge1

items

352

sinceage60

1

type64

2types

16ge3

types

20

Sasaki20

0789

412pairsof

disabled

older

adults

andfamily

caregivers

inJapan

Mean80

560

1

female

Self-administrated

survey

700

Checklistdevelopedby

literature

9ge1

items

6-mon

th34

9

Cho

kkanathan

2006

26

400commun

ity-living

cogn

itively

intact

older

adults

inIndia

ge65

495

female

Inperson

80CTS

18a

1-year14

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1217

neglect with some studies using the ldquoany itemrdquo approachand others using the ldquo10 or more itemsrdquo approach Incomparison the operational definitions of physical andsexual abuse remain more consistent across studies withthe majority of studies using the ldquoany itemrdquo approach Arecent study used different operational definitions to exam-ine elder abuse and its subtypes in the same populationcohort and suggested that the prevalence of elder abuseand its subtypes varied with the strictness of the defini-tion33

Risk factors for elder abuse are highlighted in Table 2and visually plotted in Figure 1 Associations between so-ciodemographic and socioeconomic characteristics andelder abuse have been inconsistent42224 2634ndash36 Physicalfunction impairment has been linked with elder abuse37ndash43

as has psychological distress and social isolation364044ndash47

Of various risk factors cognitive impairment seemed to beconsistently associated with greater risk of elder abuse Forexample 254 caregivers and 76 older adults with dementiawere surveyed and it was found that older adults withAlzheimerrsquos disease were 48 times as likely to experienceelder abuse as those without48 Another study assessed2005 samples of reported APS cases and found that cogni-tive impairment was significantly associated with elderself-neglect49 The wide variations of odds ratios and con-fidence intervals in Figure 1 represent the diversity of thestudies with respect to population sample size settingsdefinitions and categorization of independent and depen-dent variables

Elder abuse is associated with significant adversehealth outcomes (Table 3) including psychosocial dis-tress50ndash52 morbidity and mortality553ndash55 Two longitudi-nal cohort studies have demonstrated and associationbetween elder abuse and premature mortality554 espe-cially in black populations56 Elder abuse is also associatedwith greater health service use57ndash59 especially emergencydepartment use60 and hospitalization and 30-day readmis-sion rates585961 See online Appendix for references forTables 1 2 and 3

DISCUSSION

Elder abuse is prevalent in older adults across five conti-nents especially minority older adults Because differentresearch methodologies are used in the literature a varietyof risk factors have been found to be associated with elderabuse Among the risk factors cognitive and physicalimpairment and psychosocial distress seem to be consis-tently associated with elder abuse Elder abuse may lead todeleterious health outcomes and increase healthcare use

There are various limitations in the field of elder abusethat add to the challenges of synthesizing data in this sys-tematic review One particular limitation is that no consis-tent elder abuse instrument has been used to measure elderabuse making it difficult to compare the prevalence andunderstand the risk factors between studies Despite usingthe same instrument the cutoff for definite elder abusevaries greatly across studies Many studies have used anldquoany positive itemrdquo approach whereas others have moresystematically considered the heterogeneity of thedefinitions and have been stricter in the categorization ofelder abuse cases In addition some studies have used anT

able

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Yan20

0131

355commun

ity-livingolder

adults

inHon

gKon

gChina

ge60

62

female

Self-administered

NA

Revised

CTS

25ge1

items

1-year21

4multiple

types

171

Africa

Cadmus

2012

20

404elderlywom

enin

Oyo

state

southw

estern

Nigeria

ge60

100

female

100

Yorub

aSem

istructured

questionn

aires

NA

Stand

ardized

questionn

aire

developed

byWorld

Health

Organization

18Score

ge11-year30

Rahman

2012

28

110

6olderadults

livingat

homein

ruralarea

ofMansouracityDakahilia

GovernateEg

ypt

ge60

532

female

In-personinterview

953

Questionn

aire

toelicit

abuse

15ge1

items

1-year43

71type

3542types

38

3types

38

4types

06

Fordetailed

table

onthedefinitionalcriteria

forspecificsubtypes

ofelder

abuse

anditsprevalenceseeonlineTable

S1

aCutoff

varies

accordingto

subtypeofabuse

andmore

detailed

inform

ationregardingthecut-off

pointofeach

typeofabuse

please

seetheappendix

H-SEAST

=Hwalek-SengstokElder

Abuse

ScreeningTestVASS=Vulnerabilityto

Abuse

ScreeningScaleCTS=ConflictTacticsScaleAMA

=AmericanMedicalAssociationNA

=notapplicable

1218 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2

RiskFactors

AssociatedwithElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1258

PS

615

9elderlyadults

from

CHAP

ge65

61

female

Physicalfunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocialnetwork

andsocialparticipation

Physicalperformance

testing

(OR=113

95

CI=106ndash1

19)

lowesttertile

ofph

ysical

performance

testing(OR=492

95

CI=139ndash1

746

)Don

g20

1034

PS

551

9elderlyadults

from

CHAP

ge65

61

female

64

black

Cog

nitivefunction

SN

Sociodemog

raph

icmedical

cond

ition

ph

ysical

function

depression

socialnetworks

Executivefunction(OR=101

95

CI=100ndash1

02)

Don

g20

1034

PS

557

0elderlyadults

from

CHAP

ge65

669

female

Physicalfunction

SN

Sociodemog

raph

icmedical

cond

ition

depression

cogn

ition

socialnetworks

Declinein

physical

performance

(OR=106

95

CI=104ndash1

09)

increase

inKatzimpairment

(OR=108

95

CI=103ndash1

13)

Rosow

-Breslau

impairment

(OR=123

95

CI=114ndash1

32)

Nagiimpairment(OR=107

95

CI=102

ndash113)

Tierney

2007

43

PS

130commun

ity-living

participants

who

scored

lt13

1on

DRS

ge65

708

female

Executivefunction

judg

mentattentionand

concentration

verbal

fluency

SN

Agesex

education

CharlsonCom

orbidity

Index

MMSE

Rey

Aud

itory

VerbalLearning

Test

recogn

ition

(OR=094

95

CI=

089

ndash098)Trail-Making

Test

PartB(OR=101

95

CI=100

ndash102)WechslerAdu

ltIntelligenceScale-Revised

similarities(OR=088

95

CI=081

ndash098)

Tierney

2004

90

PS

139commun

ity-living

adults

who

scored

lt13

1on

DRS

ge65

708

female

MMSE

medical

cond

ition

smedications

OARS

SN

Agesex

education

internationalclassification

ofdisease

Charlsonindex

OARSMMSE

HigherMMSEscore(OR=087

95

CI=078ndash0

97)chronic

obstructivepu

lmon

arydisorder

(OR=772

95

CI=244ndash

2443)high

erOARSscore

(OR=070

95

CI=066ndash0

89)

stroke

(OR=309

95

CI=120

ndash796)

Abram

s20

0235

PS

281

2elderlyadults

from

New

Haven

EPES

Ecoho

rt

ge65

654

female

Depressivesymptom

scogn

itive

impairment

SN

Agesex

raceeducation

income

maritalstatus

livingsituation

medical

morbidity

Depressivesymptom

s(CES

-Dscorege1

6)(OR=238

95

CI=126

ndash448)cogn

itive

impairment(ge4errors

onthe

Pfeiffer

Sho

rtPortableMental

StatusQuestionn

aireOR=463

95

CI=232ndash9

23)

Lachs

1997

42

PS

622

2elderlyadults

inEP

ESEcoho

rtge6

564

8

female

ADLimpairment

cogn

itive

disability

EAAgesexualraceand

income

New

ADLimpairment(OR=14

95

CI=04ndash46)new

cogn

itive

impairment(OR=51

95

CI=20ndash

127)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1219

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1433

CS

78olderChinese

inUnitedStates

ge60

52

female

Depressivesymptom

atolog

yEA

Sociodemog

raph

icmarital

statushealth

status

quality

oflife

physical

function

lonelinessand

social

supp

ort

Depressivesymptom

atolog

y(OR=201

95

CI=123

ndash348)

Cho

kkanathan

2014

26

CS

902olderadults

inNadu

India

ge61

543

female

Older

adultsph

ysically

abusefamily

mem

bers

Family

mem

bersage

education

alcoho

lconsum

ption

mistreatm

entof

other

family

mem

bers

Environm

entfamily

cohesion

stress

EAOlder

adults

(agesex

employmentdepend

ency

physically

abused)

Family

mem

ber(age

education

alcoho

luse

mistreatothers)

Environm

ent(fam

ilycohesion

family

stress

wealth

index)

Older

adultsph

ysically

abusing

family

mem

bers

(OR=906

95

CI=282ndash2

904

)Family

mem

bersmiddleage

(OR=206

95

CI=101

ndash423)

tertiary

education(OR=032

95

CI=011ndash0

97)alcoho

l(OR=308

95

CI=168

ndash570)

mistreatm

entof

otherfamily

(OR=624

95

CI=211

ndash18

41)repo

rted

moreconfl

icts

with

theirfamily

mem

bers

(OR=14

14

95

CI=663ndash

3014)low

family

cohesion

(OR=175

95

CI=143

ndash215)

Don

g20

1361

CS

10333

olderadults

inChicago

ge65

39

female

Elderself-neglect

EASociodemog

raph

icmedical

comorbidities

cogn

itive

andph

ysical

functionand

psycho

social

well-being

Elderabuse(OR=175

95

CI=118

259

)fin

ancial

exploitation(OR=173

95

CI=101

295

)caregiverneglect

(OR=209

95

CI=124

352

)multiple

form

sof

elder

abuse(OR=206

95

CI=122

348

)Lichtenb

erg

2013

91

CS

444

0olderadults

from

Health

andRetirem

ent

Study

Mean65

861

9

female

854

white

Education

depressive

symptom

sfin

ancial

satisfaction

social

needs

Financial

abuse

Sociodemog

raph

icmarital

statusCES

-Dph

ysical

function

self-ratedhealth

financial

status

psycho

logicalfactors

Moreeducation(OR=109

95

CI=103ndash1

16)moredepressive

symptom

s(OR=109

95

CI=101ndash1

18)less

financial

satisfaction(OR=076

95

CI=063ndash0

90)greaterADL

needs(OR=101

95

CI=078

ndash130)greaterdiseasebu

rden

(OR=103

95

CI=088

ndash121)

Strasser20

1347

CS

112olderadults

who

participated

inlegal

prog

ram

ge60

682

female

Sexethn

icity

depression

EASexethn

icitycohabitation

depression

visits

toa

mentalhealth

provider

Male(OR=554

95

CI=185

ndash16

57)Hispanic(OR=11

73

95

CI=106ndash1

3006)

depression

(OR=607

95

CI=154ndash2

309

)

(Continued)

1220 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 5: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

neglect with some studies using the ldquoany itemrdquo approachand others using the ldquo10 or more itemsrdquo approach Incomparison the operational definitions of physical andsexual abuse remain more consistent across studies withthe majority of studies using the ldquoany itemrdquo approach Arecent study used different operational definitions to exam-ine elder abuse and its subtypes in the same populationcohort and suggested that the prevalence of elder abuseand its subtypes varied with the strictness of the defini-tion33

Risk factors for elder abuse are highlighted in Table 2and visually plotted in Figure 1 Associations between so-ciodemographic and socioeconomic characteristics andelder abuse have been inconsistent42224 2634ndash36 Physicalfunction impairment has been linked with elder abuse37ndash43

as has psychological distress and social isolation364044ndash47

Of various risk factors cognitive impairment seemed to beconsistently associated with greater risk of elder abuse Forexample 254 caregivers and 76 older adults with dementiawere surveyed and it was found that older adults withAlzheimerrsquos disease were 48 times as likely to experienceelder abuse as those without48 Another study assessed2005 samples of reported APS cases and found that cogni-tive impairment was significantly associated with elderself-neglect49 The wide variations of odds ratios and con-fidence intervals in Figure 1 represent the diversity of thestudies with respect to population sample size settingsdefinitions and categorization of independent and depen-dent variables

Elder abuse is associated with significant adversehealth outcomes (Table 3) including psychosocial dis-tress50ndash52 morbidity and mortality553ndash55 Two longitudi-nal cohort studies have demonstrated and associationbetween elder abuse and premature mortality554 espe-cially in black populations56 Elder abuse is also associatedwith greater health service use57ndash59 especially emergencydepartment use60 and hospitalization and 30-day readmis-sion rates585961 See online Appendix for references forTables 1 2 and 3

DISCUSSION

Elder abuse is prevalent in older adults across five conti-nents especially minority older adults Because differentresearch methodologies are used in the literature a varietyof risk factors have been found to be associated with elderabuse Among the risk factors cognitive and physicalimpairment and psychosocial distress seem to be consis-tently associated with elder abuse Elder abuse may lead todeleterious health outcomes and increase healthcare use

There are various limitations in the field of elder abusethat add to the challenges of synthesizing data in this sys-tematic review One particular limitation is that no consis-tent elder abuse instrument has been used to measure elderabuse making it difficult to compare the prevalence andunderstand the risk factors between studies Despite usingthe same instrument the cutoff for definite elder abusevaries greatly across studies Many studies have used anldquoany positive itemrdquo approach whereas others have moresystematically considered the heterogeneity of thedefinitions and have been stricter in the categorization ofelder abuse cases In addition some studies have used anT

able

1(C

ontd)

Author

Year

Population

AgeSexRaceand

Ethnicity

SurveyMethod

Participation

rate

Measure

No

item

Cutoff

Points

Prevalence

Yan20

0131

355commun

ity-livingolder

adults

inHon

gKon

gChina

ge60

62

female

Self-administered

NA

Revised

CTS

25ge1

items

1-year21

4multiple

types

171

Africa

Cadmus

2012

20

404elderlywom

enin

Oyo

state

southw

estern

Nigeria

ge60

100

female

100

Yorub

aSem

istructured

questionn

aires

NA

Stand

ardized

questionn

aire

developed

byWorld

Health

Organization

18Score

ge11-year30

Rahman

2012

28

110

6olderadults

livingat

homein

ruralarea

ofMansouracityDakahilia

GovernateEg

ypt

ge60

532

female

In-personinterview

953

Questionn

aire

toelicit

abuse

15ge1

items

1-year43

71type

3542types

38

3types

38

4types

06

Fordetailed

table

onthedefinitionalcriteria

forspecificsubtypes

ofelder

abuse

anditsprevalenceseeonlineTable

S1

aCutoff

varies

accordingto

subtypeofabuse

andmore

detailed

inform

ationregardingthecut-off

pointofeach

typeofabuse

please

seetheappendix

H-SEAST

=Hwalek-SengstokElder

Abuse

ScreeningTestVASS=Vulnerabilityto

Abuse

ScreeningScaleCTS=ConflictTacticsScaleAMA

=AmericanMedicalAssociationNA

=notapplicable

1218 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2

RiskFactors

AssociatedwithElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1258

PS

615

9elderlyadults

from

CHAP

ge65

61

female

Physicalfunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocialnetwork

andsocialparticipation

Physicalperformance

testing

(OR=113

95

CI=106ndash1

19)

lowesttertile

ofph

ysical

performance

testing(OR=492

95

CI=139ndash1

746

)Don

g20

1034

PS

551

9elderlyadults

from

CHAP

ge65

61

female

64

black

Cog

nitivefunction

SN

Sociodemog

raph

icmedical

cond

ition

ph

ysical

function

depression

socialnetworks

Executivefunction(OR=101

95

CI=100ndash1

02)

Don

g20

1034

PS

557

0elderlyadults

from

CHAP

ge65

669

female

Physicalfunction

SN

Sociodemog

raph

icmedical

cond

ition

depression

cogn

ition

socialnetworks

Declinein

physical

performance

(OR=106

95

CI=104ndash1

09)

increase

inKatzimpairment

(OR=108

95

CI=103ndash1

13)

Rosow

-Breslau

impairment

(OR=123

95

CI=114ndash1

32)

Nagiimpairment(OR=107

95

CI=102

ndash113)

Tierney

2007

43

PS

130commun

ity-living

participants

who

scored

lt13

1on

DRS

ge65

708

female

Executivefunction

judg

mentattentionand

concentration

verbal

fluency

SN

Agesex

education

CharlsonCom

orbidity

Index

MMSE

Rey

Aud

itory

VerbalLearning

Test

recogn

ition

(OR=094

95

CI=

089

ndash098)Trail-Making

Test

PartB(OR=101

95

CI=100

ndash102)WechslerAdu

ltIntelligenceScale-Revised

similarities(OR=088

95

CI=081

ndash098)

Tierney

2004

90

PS

139commun

ity-living

adults

who

scored

lt13

1on

DRS

ge65

708

female

MMSE

medical

cond

ition

smedications

OARS

SN

Agesex

education

internationalclassification

ofdisease

Charlsonindex

OARSMMSE

HigherMMSEscore(OR=087

95

CI=078ndash0

97)chronic

obstructivepu

lmon

arydisorder

(OR=772

95

CI=244ndash

2443)high

erOARSscore

(OR=070

95

CI=066ndash0

89)

stroke

(OR=309

95

CI=120

ndash796)

Abram

s20

0235

PS

281

2elderlyadults

from

New

Haven

EPES

Ecoho

rt

ge65

654

female

Depressivesymptom

scogn

itive

impairment

SN

Agesex

raceeducation

income

maritalstatus

livingsituation

medical

morbidity

Depressivesymptom

s(CES

-Dscorege1

6)(OR=238

95

CI=126

ndash448)cogn

itive

impairment(ge4errors

onthe

Pfeiffer

Sho

rtPortableMental

StatusQuestionn

aireOR=463

95

CI=232ndash9

23)

Lachs

1997

42

PS

622

2elderlyadults

inEP

ESEcoho

rtge6

564

8

female

ADLimpairment

cogn

itive

disability

EAAgesexualraceand

income

New

ADLimpairment(OR=14

95

CI=04ndash46)new

cogn

itive

impairment(OR=51

95

CI=20ndash

127)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1219

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1433

CS

78olderChinese

inUnitedStates

ge60

52

female

Depressivesymptom

atolog

yEA

Sociodemog

raph

icmarital

statushealth

status

quality

oflife

physical

function

lonelinessand

social

supp

ort

Depressivesymptom

atolog

y(OR=201

95

CI=123

ndash348)

Cho

kkanathan

2014

26

CS

902olderadults

inNadu

India

ge61

543

female

Older

adultsph

ysically

abusefamily

mem

bers

Family

mem

bersage

education

alcoho

lconsum

ption

mistreatm

entof

other

family

mem

bers

Environm

entfamily

cohesion

stress

EAOlder

adults

(agesex

employmentdepend

ency

physically

abused)

Family

mem

ber(age

education

alcoho

luse

mistreatothers)

Environm

ent(fam

ilycohesion

family

stress

wealth

index)

Older

adultsph

ysically

abusing

family

mem

bers

(OR=906

95

CI=282ndash2

904

)Family

mem

bersmiddleage

(OR=206

95

CI=101

ndash423)

tertiary

education(OR=032

95

CI=011ndash0

97)alcoho

l(OR=308

95

CI=168

ndash570)

mistreatm

entof

otherfamily

(OR=624

95

CI=211

ndash18

41)repo

rted

moreconfl

icts

with

theirfamily

mem

bers

(OR=14

14

95

CI=663ndash

3014)low

family

cohesion

(OR=175

95

CI=143

ndash215)

Don

g20

1361

CS

10333

olderadults

inChicago

ge65

39

female

Elderself-neglect

EASociodemog

raph

icmedical

comorbidities

cogn

itive

andph

ysical

functionand

psycho

social

well-being

Elderabuse(OR=175

95

CI=118

259

)fin

ancial

exploitation(OR=173

95

CI=101

295

)caregiverneglect

(OR=209

95

CI=124

352

)multiple

form

sof

elder

abuse(OR=206

95

CI=122

348

)Lichtenb

erg

2013

91

CS

444

0olderadults

from

Health

andRetirem

ent

Study

Mean65

861

9

female

854

white

Education

depressive

symptom

sfin

ancial

satisfaction

social

needs

Financial

abuse

Sociodemog

raph

icmarital

statusCES

-Dph

ysical

function

self-ratedhealth

financial

status

psycho

logicalfactors

Moreeducation(OR=109

95

CI=103ndash1

16)moredepressive

symptom

s(OR=109

95

CI=101ndash1

18)less

financial

satisfaction(OR=076

95

CI=063ndash0

90)greaterADL

needs(OR=101

95

CI=078

ndash130)greaterdiseasebu

rden

(OR=103

95

CI=088

ndash121)

Strasser20

1347

CS

112olderadults

who

participated

inlegal

prog

ram

ge60

682

female

Sexethn

icity

depression

EASexethn

icitycohabitation

depression

visits

toa

mentalhealth

provider

Male(OR=554

95

CI=185

ndash16

57)Hispanic(OR=11

73

95

CI=106ndash1

3006)

depression

(OR=607

95

CI=154ndash2

309

)

(Continued)

1220 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 6: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

2

RiskFactors

AssociatedwithElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1258

PS

615

9elderlyadults

from

CHAP

ge65

61

female

Physicalfunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocialnetwork

andsocialparticipation

Physicalperformance

testing

(OR=113

95

CI=106ndash1

19)

lowesttertile

ofph

ysical

performance

testing(OR=492

95

CI=139ndash1

746

)Don

g20

1034

PS

551

9elderlyadults

from

CHAP

ge65

61

female

64

black

Cog

nitivefunction

SN

Sociodemog

raph

icmedical

cond

ition

ph

ysical

function

depression

socialnetworks

Executivefunction(OR=101

95

CI=100ndash1

02)

Don

g20

1034

PS

557

0elderlyadults

from

CHAP

ge65

669

female

Physicalfunction

SN

Sociodemog

raph

icmedical

cond

ition

depression

cogn

ition

socialnetworks

Declinein

physical

performance

(OR=106

95

CI=104ndash1

09)

increase

inKatzimpairment

(OR=108

95

CI=103ndash1

13)

Rosow

-Breslau

impairment

(OR=123

95

CI=114ndash1

32)

Nagiimpairment(OR=107

95

CI=102

ndash113)

Tierney

2007

43

PS

130commun

ity-living

participants

who

scored

lt13

1on

DRS

ge65

708

female

Executivefunction

judg

mentattentionand

concentration

verbal

fluency

SN

Agesex

education

CharlsonCom

orbidity

Index

MMSE

Rey

Aud

itory

VerbalLearning

Test

recogn

ition

(OR=094

95

CI=

089

ndash098)Trail-Making

Test

PartB(OR=101

95

CI=100

ndash102)WechslerAdu

ltIntelligenceScale-Revised

similarities(OR=088

95

CI=081

ndash098)

Tierney

2004

90

PS

139commun

ity-living

adults

who

scored

lt13

1on

DRS

ge65

708

female

MMSE

medical

cond

ition

smedications

OARS

SN

Agesex

education

internationalclassification

ofdisease

Charlsonindex

OARSMMSE

HigherMMSEscore(OR=087

95

CI=078ndash0

97)chronic

obstructivepu

lmon

arydisorder

(OR=772

95

CI=244ndash

2443)high

erOARSscore

(OR=070

95

CI=066ndash0

89)

stroke

(OR=309

95

CI=120

ndash796)

Abram

s20

0235

PS

281

2elderlyadults

from

New

Haven

EPES

Ecoho

rt

ge65

654

female

Depressivesymptom

scogn

itive

impairment

SN

Agesex

raceeducation

income

maritalstatus

livingsituation

medical

morbidity

Depressivesymptom

s(CES

-Dscorege1

6)(OR=238

95

CI=126

ndash448)cogn

itive

impairment(ge4errors

onthe

Pfeiffer

Sho

rtPortableMental

StatusQuestionn

aireOR=463

95

CI=232ndash9

23)

Lachs

1997

42

PS

622

2elderlyadults

inEP

ESEcoho

rtge6

564

8

female

ADLimpairment

cogn

itive

disability

EAAgesexualraceand

income

New

ADLimpairment(OR=14

95

CI=04ndash46)new

cogn

itive

impairment(OR=51

95

CI=20ndash

127)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1219

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1433

CS

78olderChinese

inUnitedStates

ge60

52

female

Depressivesymptom

atolog

yEA

Sociodemog

raph

icmarital

statushealth

status

quality

oflife

physical

function

lonelinessand

social

supp

ort

Depressivesymptom

atolog

y(OR=201

95

CI=123

ndash348)

Cho

kkanathan

2014

26

CS

902olderadults

inNadu

India

ge61

543

female

Older

adultsph

ysically

abusefamily

mem

bers

Family

mem

bersage

education

alcoho

lconsum

ption

mistreatm

entof

other

family

mem

bers

Environm

entfamily

cohesion

stress

EAOlder

adults

(agesex

employmentdepend

ency

physically

abused)

Family

mem

ber(age

education

alcoho

luse

mistreatothers)

Environm

ent(fam

ilycohesion

family

stress

wealth

index)

Older

adultsph

ysically

abusing

family

mem

bers

(OR=906

95

CI=282ndash2

904

)Family

mem

bersmiddleage

(OR=206

95

CI=101

ndash423)

tertiary

education(OR=032

95

CI=011ndash0

97)alcoho

l(OR=308

95

CI=168

ndash570)

mistreatm

entof

otherfamily

(OR=624

95

CI=211

ndash18

41)repo

rted

moreconfl

icts

with

theirfamily

mem

bers

(OR=14

14

95

CI=663ndash

3014)low

family

cohesion

(OR=175

95

CI=143

ndash215)

Don

g20

1361

CS

10333

olderadults

inChicago

ge65

39

female

Elderself-neglect

EASociodemog

raph

icmedical

comorbidities

cogn

itive

andph

ysical

functionand

psycho

social

well-being

Elderabuse(OR=175

95

CI=118

259

)fin

ancial

exploitation(OR=173

95

CI=101

295

)caregiverneglect

(OR=209

95

CI=124

352

)multiple

form

sof

elder

abuse(OR=206

95

CI=122

348

)Lichtenb

erg

2013

91

CS

444

0olderadults

from

Health

andRetirem

ent

Study

Mean65

861

9

female

854

white

Education

depressive

symptom

sfin

ancial

satisfaction

social

needs

Financial

abuse

Sociodemog

raph

icmarital

statusCES

-Dph

ysical

function

self-ratedhealth

financial

status

psycho

logicalfactors

Moreeducation(OR=109

95

CI=103ndash1

16)moredepressive

symptom

s(OR=109

95

CI=101ndash1

18)less

financial

satisfaction(OR=076

95

CI=063ndash0

90)greaterADL

needs(OR=101

95

CI=078

ndash130)greaterdiseasebu

rden

(OR=103

95

CI=088

ndash121)

Strasser20

1347

CS

112olderadults

who

participated

inlegal

prog

ram

ge60

682

female

Sexethn

icity

depression

EASexethn

icitycohabitation

depression

visits

toa

mentalhealth

provider

Male(OR=554

95

CI=185

ndash16

57)Hispanic(OR=11

73

95

CI=106ndash1

3006)

depression

(OR=607

95

CI=154ndash2

309

)

(Continued)

1220 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 7: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

1433

CS

78olderChinese

inUnitedStates

ge60

52

female

Depressivesymptom

atolog

yEA

Sociodemog

raph

icmarital

statushealth

status

quality

oflife

physical

function

lonelinessand

social

supp

ort

Depressivesymptom

atolog

y(OR=201

95

CI=123

ndash348)

Cho

kkanathan

2014

26

CS

902olderadults

inNadu

India

ge61

543

female

Older

adultsph

ysically

abusefamily

mem

bers

Family

mem

bersage

education

alcoho

lconsum

ption

mistreatm

entof

other

family

mem

bers

Environm

entfamily

cohesion

stress

EAOlder

adults

(agesex

employmentdepend

ency

physically

abused)

Family

mem

ber(age

education

alcoho

luse

mistreatothers)

Environm

ent(fam

ilycohesion

family

stress

wealth

index)

Older

adultsph

ysically

abusing

family

mem

bers

(OR=906

95

CI=282ndash2

904

)Family

mem

bersmiddleage

(OR=206

95

CI=101

ndash423)

tertiary

education(OR=032

95

CI=011ndash0

97)alcoho

l(OR=308

95

CI=168

ndash570)

mistreatm

entof

otherfamily

(OR=624

95

CI=211

ndash18

41)repo

rted

moreconfl

icts

with

theirfamily

mem

bers

(OR=14

14

95

CI=663ndash

3014)low

family

cohesion

(OR=175

95

CI=143

ndash215)

Don

g20

1361

CS

10333

olderadults

inChicago

ge65

39

female

Elderself-neglect

EASociodemog

raph

icmedical

comorbidities

cogn

itive

andph

ysical

functionand

psycho

social

well-being

Elderabuse(OR=175

95

CI=118

259

)fin

ancial

exploitation(OR=173

95

CI=101

295

)caregiverneglect

(OR=209

95

CI=124

352

)multiple

form

sof

elder

abuse(OR=206

95

CI=122

348

)Lichtenb

erg

2013

91

CS

444

0olderadults

from

Health

andRetirem

ent

Study

Mean65

861

9

female

854

white

Education

depressive

symptom

sfin

ancial

satisfaction

social

needs

Financial

abuse

Sociodemog

raph

icmarital

statusCES

-Dph

ysical

function

self-ratedhealth

financial

status

psycho

logicalfactors

Moreeducation(OR=109

95

CI=103ndash1

16)moredepressive

symptom

s(OR=109

95

CI=101ndash1

18)less

financial

satisfaction(OR=076

95

CI=063ndash0

90)greaterADL

needs(OR=101

95

CI=078

ndash130)greaterdiseasebu

rden

(OR=103

95

CI=088

ndash121)

Strasser20

1347

CS

112olderadults

who

participated

inlegal

prog

ram

ge60

682

female

Sexethn

icity

depression

EASexethn

icitycohabitation

depression

visits

toa

mentalhealth

provider

Male(OR=554

95

CI=185

ndash16

57)Hispanic(OR=11

73

95

CI=106ndash1

3006)

depression

(OR=607

95

CI=154ndash2

309

)

(Continued)

1220 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 8: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Vandeweerd

2013

48

CS

254caregivers

and76

olderadults

with

dementia

ge60

59

female

85

white10

3

Hispanic

45

black

Sexfunctional

impairmentdementia

symptom

sviolence

byolderadultself-esteem

caregiveralcoho

lism

Phy

ASexnu

mberof

dementia

symptom

slevelof

functionalimpairment

violence

byolderadult

caregiverself-esteem

caregiveralcoho

lism

Sex

(OR=082

95

CI=042ndash

095

)functionalimpairment

(OR=205

95

CI=109ndash4

91)

dementia

symptom

s(OR=482

95

CI=351ndash1

252

)older

adults

used

violence

OR=416

7(218ndash

840

)depression

(OR=053

95

CI=023ndash1

22)

caregiverwith

high

self-esteem

(OR=066

95

CI=059ndash8

40)

Don

g20

1260

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Physicalfunction

EASociodemog

raph

ic

hypertension

heartdisease

diabetes

mellitusstroke

cancerhipfracture

depression

symptom

s

Lowestlevelof

physical

performance

testing

EA(OR=271

95

CI=158

ndash464)

psycho

logicalabuse(OR=269

95

CI=127ndash5

71)caregiver

neglect(OR=266

95

CI=122

ndash579)fin

ancial

abuse

(OR=235

95

CI=121ndash4

55)

Naugh

ton

2012

24

CS

202

1olderpeop

lein

Ireland

ge65

55

female

Mentalhealthsocial

supp

ort

EAAgesex

income

physical

healthmentalhealthsocial

supp

ort

Mentalhealth

belowaverage

(OR=451

95

CI=222ndash9

14)

lower

socialsupp

ort(OR=311

95

CI=129ndash7

46)

Wu

2012

21

CS

203

9adults

inthree

ruralcommun

ities

inHub

eiChina

ge60

599

female

Maritalstatusph

ysical

disability

living

arrang

ement

depression

EAEd

ucation

livingstatus

livingsourcechronic

disease

physical

disability

labo

rintensitydepression

Not

beingmarried

(OR=180

95

CI=140ndash2

40)ph

ysical

disability(OR=150

95

CI=110

ndash220)livingwith

spou

seandchildren(OR=070

95

CI=050ndash0

90)depression

(OR=550

95

CI=410ndash7

30)

Yan20

1231

CS

937married

orcohabitingolderadults

inHon

gKon

g

ge60

424

female

Agesex

education

income

living

arrang

ementchronic

illnesssocial

supp

ort

Intim

atepartner

violence

Sociodemog

raph

icliving

arrang

ementimmigrantsor

notem

ploymentreceiving

socialsecurity

indebtednesschronic

illnesssocial

supp

ort

Age

(OR=097

95

CI=095

ndash099

)female(OR=080

95

CI=059

ndash108)educationlevels

le3years(OR=183

95

CI=096

ndash347)no

income

(OR=073

95

CI=040ndash1

35)

livingwith

children(OR=088

95

CI=064ndash1

19)chronic

illness

(OR=109

95

CI=081

ndash147)lower

socialsupp

ort

(OR=117

95

CI=077ndash1

77)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1221

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 9: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Amstadter20

1192

CS

902commun

ity-

dwellingolderadults

60ndash9

759

9

female

77

white17

3

black

19

Native

American01

Asian

Functionalstatusrace

socialsupp

ortand

health

status

Psycholog

ical

financial

abuse

Ageincome

having

experiencedpriortraumatic

event

Emotionalmistreatm

entlow

social

supp

ort(OR=351

95

CI=163

ndash753)needing

assistance

with

ADLs

(OR=228

95

CI=106ndash4

93)

Neglectno

nwhite

(OR=349

95

CI=137ndash8

89)low

social

supp

ort(OR=674

95

CI=154

ndash2962

)po

orhealth

(OR=379

95

CI=146

ndash981)

Financialexploitation

needing

assistance

with

ADLs

(OR=275

95

CI=117ndash6

48)

Don

g20

1116

CS

893

2elderlyadults

from

CHAP

ge65

76

female

Cog

nitivefunction

EASociodemog

raph

icmedical

cond

ition

sdepressive

symptom

ssocial

network

socialparticipation

Lowestturtlesof

cogn

ition

(OR=418

95

CI=244

ndash715)

lowestlevels

ofglob

alcogn

itive

functionandph

ysical

abuse

(OR=356

95

CI=108

ndash11

67)em

otionalabuse

(OR=302

95

CI=

141

ndash644)caregiverneglect

(OR=624

95

CI=

268

ndash1454

)fin

ancial

exploitation

(OR=371

95

CI=188

ndash732)

Friedm

an20

1141

CS

41elderlyadults

from

traumaun

itin

Chicago

and12

3controls

from

traumaregistry

ge60

585

female

Havinganeurolog

ical

ormentaldisorder

Physicalabuse

Ageinjury

severity

hospitalleng

thof

stay

Eurologicalor

mentaldisorder

(OR=910

95

CI=250

ndash3360

)

Beach20

104

CS

Pop

ulation-basedsurvey

of90

3adults

inAllegh

enyCou

nty

Pennsylvania

ge60

73

female

23

black

73

white4

other

Race

Psycholog

ical

abuse

Sociodemog

raph

icmarital

statusho

usehold

compo

sition

cogn

itive

function

physical

disability

anddepression

symptom

s

Black

race

(OR=230

95

CI=055

ndash962)

Cho

i20

0949

CS

Assessm

entof

200

5samples

repo

rted

toAPSforself-neglect

gt60

64

4

female

442

white15

9

black

275

Hispanic

Econ

omicresources

healthcare

andsocial

serviceprog

rams

SN

Agesex

racemarital

statuslang

uageliving

arrang

ement

Econ

omic

resource

deficit

(OR=460

95

CI=233

ndash908)

anyADLimpairment(OR=13

53

95

CI=552ndash3

314

)cogn

itive

impairment(OR=11

39

95

CI=420

ndash3090

)Don

g20

095

CS

905

6elderlyadults

from

CHAPcoho

rtge6

562

2

female

Socialnetworkssocial

engagement

SN

Agesex

raceeducation

medical

morbidityph

ysical

function

depression

bo

dymassindex

Lower

socialnetwork(OR=102

95

CI=101ndash1

04)lower

social

participation(OR=115

95

CI=109

ndash122)

(Continued)

1222 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 10: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Oh

2009

22

CS

15230

olderadults

inSeoulKorea

ge65

653

female

Sexage

supp

ort

physical

function

healthliving

arrang

ementecon

omic

levelfamily

relationships

EAElderly

sex

age

education

econ

omic

capacityADLs

IADLssick

days

Familyho

useholdtype

econ

omic

levelfamily

relations

Older

men

(OR=134

95

CI=121

-161

)aged

65ndash6

9(OR=133

95

CI=105ndash1

68)

partially

supp

orted(OR=074

95

CI=057

ndash096)ADLs

(OR=096

95

CI=091ndash0

99)

IADLs

(OR=103

95

CI=100

ndash106)livingwith

family

ofmarried

children(OR=196

95

CI=116ndash3

32)lowestecon

omic

level(OR=484

95

CI=303ndash

775

)go

odfamily

relations

(OR=002

95

CI=001ndash0

04)

Coo

per20

0893

CS

86commun

ity-living

adults

with

Alzheimerrsquos

diseaseandtheir

caregivers

Mean82

469

8

female

Caregiversex

burden

Carerecipient

behavioralcogn

itive

physical

function

EACaregiverbu

rdenanxiety

Carerecipientreceiving

24-hou

rcareADLs

irritability

Caregivermale(OR=680

95

CI=170ndash2

780

)repo

rting

greaterbu

rden

(OR=110

95

CI=100ndash1

10)

Carerecipientclinically

sign

ificant

irritability(OR=38

30

95

CI=460ndash3

2600)less

functional

impairment(OR=110

95

CI=100ndash1

20)greatercogn

itive

impairment(OR=120

95

CI=100ndash1

40)

Don

g20

0894

CS

412individu

alsin

nurbanmedical

center

inNanjing

China

ge60

34

female

Depression

EAAgeincome

numberof

children

levelof

education

Dissatisfactionwith

life

(OR=292

95

CI=151ndash5

68)

beingbo

red(OR=291

95

CI=153ndash5

55)feelinghelpless

(OR=279

95

CI=135ndash5

76)

feelingworthless

OR=216

(110ndash

422

)depression

(OR=326

95

CI=149ndash7

10)

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Loneliness

EAAgesex

education

income

maritalstatus

depressive

symptom

s

Loneliness(OR=274

95

CI=119ndash6

26)lacking

companion

ship

(OR=406

95

CI=149ndash1

110

)leftou

tof

life

(OR=169

95

CI=101ndash2

84)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1223

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 11: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

2(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Don

g20

0744

CS

412adults

inamedical

clinic

inNanjing

China

ge60

34

female

Agesex

education

income

maritalstatus

EAAgesex

Aged65ndash6

9(OR=079

95

CI=045

ndash137)female

(OR=155

95

CI=101ndash2

38)

illiterate

(OR=303

95

CI=143

ndash645)no

income

(OR=286

95

CI=133ndash6

16)

widow

ed(OR=156

95

CI=092

ndash266)

Ogion

i20

0795

CS

463

0adults

receiving

homecare

inItaly

ge65

596

female

Behavioralsymptom

sEA

Agesex

maritalstatus

ADLscogn

ition

delirium

depression

medical

cond

ition

loneliness

distresssocialsupp

ort

pain

Behavioralsymptom

s(OR=156

95

CI=121ndash2

00)

Sasaki20

0789

CS

412pairsof

disabled

olderadults

and

caregivers

inJapan

Mean80

560

1

female

Behavioraldisturbance

adultchild

ascaregiver

Potentially

harm

ful

behaviors

Severity

ofph

ysical

impairmenthearing

prob

lems

caregiverbu

rden

Greater

behavioral

disturbance

(OR=361

95

CI=165ndash7

90)

adultchild

ascaregiver

(OR=269

95

CI=123ndash5

89)

VandeWeerd

2006

48

CS

254caregivers

and76

elderlyadults

Mean78

659

female

Agesex

cogn

itive

impairmentph

ysical

function

depression

Psycholog

ical

abuse

Agesex

racedementia

symptom

sfunctional

impairmentdepression

medication

verbal

aggression

violence

Age

(OR=043

95

CI=031

-064

)sex(OR=048

95

CI=004

ndash534)nu

mberof

dementia

symptom

s(OR=034

95

CI=015ndash0

88)levelof

functionalimpairment(OR=154

95

CI=061ndash3

85)depression

(OR=057

95

CI=024ndash0

73)

Beach20

0537

CS

265caregiverndashcare

recipientdyadsfor

impairedcommun

ity-

dwellingfamily

mem

bers

ge60

58

female

ADLandIADLneeds

caregivercogn

itive

impairmentcaregiver

physical

symptom

scaregiverdepression

Potentially

harm

ful

behaviors

Carerecipientage

sex

education

cogn

itive

status

self-ratedhealth

Caregiver

age

sex

education

self-ratedhealth

Greater

care

recipientADLand

IADLneeds(OR=112

95

CI=103

ndash122)spou

secaregiver

vsother(OR=800

95

CI=171

ndash3747

)greater

caregivercogn

itive

impairment

(OR=120

95

CI=104ndash1

38)

morecaregiverph

ysical

symptom

s(OR=107

95

CI=101ndash1

13)

caregiverat

risk

forclinical

depression

(OR=347

95

CI=158

ndash762)

Cho

kkanathan

2005

26

CS

400commun

ity-living

cogn

itively

intact

older

adults

inChenn

aiIndia

60ndash9

073

4

female

Sexsocial

supp

ort

subjectiveph

ysical

health

EASexmaritalstatus

education

livingstatus

subjectivehealthincome

socialsupp

ort

Female(OR=255

95

CI=103

ndash628)less

social

supp

ort(OR=107

95

CI=104

ndash109)po

orer

subjective

health

status

(OR=326

95

CI=143

ndash742)

(Continued)

1224 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 12: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

2(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

IndependentVariables

Outcome

ConfoundingFactors

KeyFindingsofRiskforEA

Shu

garm

an

2003

46

CS

701adults

seeking

home-

andcommun

ity-

basedservices

inMichigan

ge60

713

female

Mem

oryprob

lems

disease

abuses

alcoho

lno

tat

ease

interacting

with

othersexpresses

confl

ictwith

family

orfriend

sindicatesfeels

lonelybrittlesupp

ort

system

EASexcogn

itive

symptom

sdiseasediagno

ses

physical

functioning

behavioral

prob

lems

social

functioning

supp

ort

Mem

oryprob

lems(OR=266

95

CI=128

ndash534)psychiatric

disease(OR=248

95

CI=118ndash5

23)alcoho

l(OR=10

26

95

VI=273

ndash385)

notat

ease

interactingwith

others

(OR=275

95

CI=121ndash6

21)

confl

ictwith

family

orfriend

s(OR=213

95

CI=108ndash4

23)

lonely(OR=349

95

CI=170

ndash718)brittlesupp

ort(OR=376

95

CI=158

ndash893)

Com

ijs19

9932

CS

147elderlyadults

repo

rtingchronicverbal

aggression

ph

ysical

aggression

and

financial

abusein

Amsterdam

ge65

Hostility

andcoping

capacity

EAAgesex

othermatching

variables(Buss-Durkee

Hostility

Inventory

Utrechtse

Cop

inglijst)

Verbalaggression

direct

aggression

(OR=131

95

CI=105ndash1

62)locusof

control

(OR=119

95

CI=101ndash1

41)

Physicalaggression

coping

(OR=124

95

CI=101ndash1

51)

avoidance(OR=126

95

CI=108ndash1

47)

Financialmistreatm

entindirect

aggression

(OR=123

95

CI=107ndash1

42)perceivedself-

efficacy(OR=111

95

CI=102ndash1

20)

PS=prospective

CS=cross-sectionalCHAP=ChicagoHealthAgingProjectOR

=oddsratioCI=confidence

intervalSN

=self-neglectDRS=

Dem

entiaRatingScaleMMSE=Mini-MentalState

Exami-

nationOARS=

Older

AmericanResources

andServicesEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyCES-D

=CenterforEpidem

iologic

StudiesDepressionScaleADL=activity

ofdailylivingIA

DL=instrumentalactivityofdailylivingGDS=Geriatric

DepressionScale

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1225

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 13: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

extensive version of the screening instrument whereas oth-ers chose a shorter version that may contain only onequestion Recently to address the question of inconsisten-cies in elder abuse instruments operational definitions ofdifferent strictness have been used to examine elder abuse

in the same population cohort and the prevalence of elderabuse and its subtypes varied greatly in the same popula-tion through using different measurements33 The presentstudy provided important empirical evidence of the effectof different instruments on the prevalence but future

0 1 2 3 4 5 6

Odds Ratio and 95 Confidence Intervals

Author(yr) Risk Factor Outcome OR (95 CI)

Age180 (083minus387)EAlt 71Chokkanathan 2014093 (083minus103)EAuarr AgeDong 2014102 (099minus105)EAuarr AgeDong 2013176 (059minus521)PhyAuarr AgeVandeweerd 2013100 (097minus104)EAuarr AgeDong 2012103 (101minus106)EAuarr AgeDong2012097 (095minus099)PsyAuarr AgeYan 2012054 (038minus077)PsyA60minus64 yrsBeach 2010105 (104minus107)SNuarr AgeDong 2010487 (418minus567)SNge 80Dong 2010079 (045minus137)EA65minus69 yrsDong 2007101 (094minus108)SNuarr AgeTierney 2007133 (105minus168)EA65minus69 yrsOh 2006043 (031minus064)PsyA60minus70 yrsVandeweerd 2006100 (095minus106)HBuarr AgeBeach 2005107 (100minus114)SNuarr AgeTierney 2004110 (105minus115)SNuarr AgeAbrams2002 110 (100minus120)SNuarr AgeLachs1997

Sex060 (030minus119)EAMaleChokkanathan 2014058 (016minus210)EAFemale Dong 2014055 (038minus081)EAMaleDong 2013082 (042minus095)PhyAFemaleVandeweerd 2013554 (185minus1657)EAMaleStrasser 2013045 (029minus072)EAMaleDong2012066 (047minus093)EAMaleDong2012080 (059minus108)PsyAFemaleYan 2012350 (140minus880)PAFemaleFriedman 2011115 (103minus129)SNFemaleDong2010079 (068minus093)SNMaleDong2010175 (082minus373)EASNFemaleChoi2009155 (101minus238)EAFemaleDong 2007146 (057minus373)SNFemaleTierney 2007134 (121minus161)EAMaleOh 2006048 (004minus534)PsyAFemaleVandeweerd2006039 (014minus110)HBMaleBeach2005255 (103minus628)EAFemaleChokkanathan 2005119 (047minus303)SNFemaleTierney 2004283 (158minus505)SNMaleAbrams2002100 (050minus170)EAMaleLachs 1997

Race1173 (160minus13006)EAHispanicStrasser 2013398 (227minus698)EAAfri AmDong 2013499 (254minus979)EAAfri AmDong2012455 (288minus717)EAAfri AmDong2012102 (046minus226)PsyANonminuswhiteArmstadter 2011230 (055minus962)PsyAAfri AmBeach2010366 (313minus429)SNAfri AmDong2010470 (375minus589)SNAfri AmDong2010126 (047minus336)EASNAfri AmChoi2009104 (053minus204)SNNonminuswhiteAbrams 2002400 (220minus720)EANonminuswhiteLachs 1997

Education093 (079minus109)EAuarr EducationDong 2014098 (093minus103)EAuarr EducationDong2013109 (103minus116)FEuarr EducationLichtenberg 2013098 (092minus105)EAuarr EducationDong2012104 (099minus109)EAuarr EducationDong2012183 (096minus347)PsyAle 3Yan 2012167 (034minus817)PsyAle High schoolBeach2010101 (097minus104)SN0minus7 yearsDong2010097 (095minus099)SNuarr EducationDong2010303 (143minus645)EANo EducationDong 2007111 (097minus128)SNuarr EducationTierney 2007161 (125minus207)EANo EducationOh 2006181 (071minus463)HBle High schoolBeach 2005072 (036minus149)EAuarr EducationChokkanathan 2005112 (097minus129)SNuarr EducationTierney 2004

Income105 (097minus114)EAuarr IncomeDong2013095 (086minus105)EAuarr IncomeDong2012092 (085minus099)EAuarr IncomeDong2012163 (067minus395)EAlteuro220ndasheuro438Naughton2012073 (040minus135)PsyANo IncomeYan 2012173 (080minus372)PsyAHigher IncomeArmstadter 2011460 (233minus908)EASNEcon DeficitChoi2009286 (133minus616)EANo IncomeDong2007191 (101minus359)SNlt$5000Abrams 2002210 (090minus470)EAlt$5000Lachs 1997

Figure 1 Risk Factors for Elder Abuse

1226 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 14: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

studies should expand efforts to develop a more-consistentinstrument and cutoff score Another limitation is thatmost of the existing studies do not provide reliability andvalidity information for the instrument Lack of consis-tency and precision in the assessment of elder abuse may

prevent clear understanding of the accurate prevalence andrisk and protective factors and impede the development ofprevention and intervention programs

In addition the number and quality of studies variedgreatly according to region and cultural group The

0 1 2 3 4 5 6

Author(yr) Risk Factor Outcome OR (95 CI)

Family Composition088 (064minus119)PsyALive with ChldnYan 2012070 (050minus090)EALive with SpoChldnWu2011180 (140minus240)EANot being married034 (019minus061)PsyADivorcedSeparatedBeach 2010164 (049minus553)PsyALive with Son112 (047minus268)EASNDivorcedSeparatedChoi 2009156 (092minus266)EAWidowedDong 2007081 (035minus190)EAMarital StatusChokkanathan 2005104 (048minus226)EALiving arr265 (103minus685)SNLive AloneAbrams2002272 (076minus970)SNSeparatedDivorced030 (010minus080)EALive AloneLachs 1997

MedicalComorbidity (MC)113 (096minus133)EAuarr MCDong2013103 (088minus121)FEuarr Disease BurdenLichtenberg 2013089 (074minus108)EAuarr mcDong 2012125 (109minus144)EAuarr MCDong 2012109 (081minus147)PsyAChronic IllnessYan 2012152 (144minus160)SNuarr MCDong2010109 (099minus119)SNuarr MCDong2010114 (091minus144)SNuarr ComorbidityTierney 2007772 (244minus2443)SNCOPDTierney 2004 310 (120minus796)SNCerebrovascular299 (151minus590)SNStrokeAbrams 2002429 (191minus961)SNHip Fracture060 (040minus080)EAuarr Chronic ConditionsLachs 1997

Cognitive Function073 (056minus094)EAuarr Cognitive FuncDong 2013482 (351minus1252)PhyAuarr Dementia SxVandeweerd 2013095 (090minus099)EAuarr Cognitive FuncDong2012418 (244minus715)EAdarr Cognitive FuncDong 2011910 (250minus3360)PAa Neurmental DisorFriedman 2011105 (097minus114)PsyAuarr Cognitive FuncBeach 2010101 (100minus102)SNdarr Executive FuncDong 2010087 (076minus099)SNuarr Global CognitionDong 20101139 (420minus3090)SNEAuarr Cognitive ImpChoi 20093830 (465minus32600)EASig IrritabilityCooper 2008120 (100minus140)EAuarr Cognitive Imp101 (100minus102)SNdarr Executive FuncTierney 2007156 (121minus200)EAuarr Behavioral SxOgioni 2006034 (015minus088)PsyAdarr Dementia SxVandeWeerd 2006097 (091minus102)HBuarr Cognitive FuncBeach2005087 (078minus097)SNuarr MMSETierney 2004141 (047minus427)EAuarr Cognitive PerfShugarman2003463 (232minus923)SNMental Perf Errors gt=4Abrams 2002510 (200minus1270)EA New Cognitive ImpLachs 1997

Physical Function092 (088minus097)EAuarr Phys FuncDong 2013101 (078minus130)FEuarr ADL NeedsLichtenberg 2013205 (109minus491)PAuarr Functional ImpVandeweerd 2013113 (106minus119)EAdarr Phys Perform TstDong 2012271 (158minus464)EAdarr Phys Perform TstDong 2012228 (106minus493)PsyANeed ADL HelpArmstadter 2011150 (110minus120)EAPhys DisabilityWu 2011067 (038minus118)PsyAAny ADL NeedsBeach 2010106 (104minus109)SNdarr Phys Perform TstDong 20101353 (552minus3314)SNEAAny ADL NeedsChoi 2009096 (091minus099)EAdarr ADL NeedsOh 2006110 (100minus120)EAdarr Functional ImpCooper 2008111 (050minus246)HBSevere Physical ImpSasaki 2007154 (061minus385)PsyAuarr Functional ImpVandeWeerd2006112 (103minus122)HBuarr ADLIADLBeach2005140 (040minus460)EANew ADL ImpLachs1997

Psychological Wellminusbeing201 (123minus348)EAuarr Depressive SxDong 2014113 (091minus125)EAuarr Loneliness099 (093minus107)EAuarr Depressive SxDong 2013607 (154minus2309)EADepressionStrasser 2013053 (023minus122)PhyAdarr DepressionVandeweerd 2013109 (101minus118)FEuarr Depressive SxLichtenberg 2013115 (108minus122)EAuarr DepressionDong2012099 (090minus110)EAuarr Depressive SxDong2012451 (222minus914)EAMental health ltaverNaughton 2012550 (410minus730)EADepressionWu2011314 (056minus1762)PsyADepressionBeach 2010105 (101minus109)SNuarr DepressionDong2010326 (149minus710)EAuarr DepressionDong2008274 (119minus626)EAHighest LonelinessDong 2007057 (024minus073)PsyAdarr DepressionVandeWeerd 2006349 (170minus718)EAFeel lonelyShugrarman2003079 (037minus167)EADepressionanxiety238 (126minus448)SNDepression scale gt=16Abrams 2002

Social Wellminusbeing107 (091minus125)EAuarr Soc SupportDong 2014098 (095minus101)EAuarr Soc NetworkDong 2013096 (086minus107)EAuarr Soc Eng099 (096minus102)EAuarr Soc NetworkDong 2012086 (078minus096)EAuarr Soc Support098 (095minus102)EAuarr Soc NetworkDong 2012089 (078minus101)EAuarr Soc Engagement311 (129minus746)EAPoor Soc SupportNaughton 2012117 (077minus177)IPVuarr Soc SupportYan 2012351 (163minus753)PsyALow Soc SupportArmstadter 2011119 (102minus139)SNLowest Soc NetworkDong 2010218 (185minus258)SNLowest Soc Eng099 (098minus101)SNuarr Soc NetworkDong2010107 (104minus109)EAdarr Soc SupportChokkanathan 2005077 (066minus090)SNuarr OARS ScoresTierney 2004376 (158minus893)EABrittle SupportShugarman 2003

Odds Ratio and 95 Confidence Intervals

Figure 1 (Contd)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1227

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 15: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

3

ConsequencesofElder

Abuse

(EA)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Schofi

eld

2013

96

PS

126

6olderwom

enin

Australia

70ndash75

100

female

EADisability

mortality

Dem

ograph

icfactors

social

supp

orthealth

behaviors

health

cond

ition

Mortality

coercion

(HR=121

95

CI=106ndash1

40)dejection

(HR=112

95

CI=103ndash1

23)

Disabilityvulnerability

(HR=125

95

CI=106

ndash149)dejection

(HR=155

95

CI=138ndash1

73)

Don

g20

1260

PS

686

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

61

female

SN

Emergency

departmentuse

Sociodemog

raph

ic

medical

cond

ition

scogn

itive

and

physical

function

SN(RR=142

95

CI=129ndash

158

)greaterSNseverity

(mild

PE=027

SE=004

Plt001

mod

erate

PE=041

SE=003

Plt001

severePE=055

SE=009

Plt001

)Don

g20

1097

PS

784

1commun

ity-

olderadults

participatingin

CHAP

ge65

526

female

EAAll-causemortality

across

levels

ofdepression

social

network

social

participation

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

smoking

alcoho

lintake

CES

-Dtertilehigh

est(HR=217

95

CI=136

ndash436)middle

(HR=218

95

CI=119ndash3

99)

lowest(HR=161

95

CI=079

ndash327

)Socialnetworktertilelowest

(HR=242

95

CI=152ndash3

85)

middle(HR=265

95

CI=152ndash

460

)high

est(HR=097

95

CI=036ndash2

61)

Socialengagementtertilelowest

(HR=232

95

CI=147ndash3

68)

middle(HR=259

95

CI=141ndash

477

)high

est(HR=119

95

CI=052ndash2

72)

Mou

ton

2010

51

PS

93676

from

the

Wom

enrsquos

Health

Initiative(W

HI)

ObservationalStudy

50ndash79

100

female

Physicalverbal

abuse

Depressive

symptom

sMCS

score

Sociodemog

raph

ic

maritalstatus

smoking

alcoho

lreligioncomfort

livingalon

ebaseline

psycho

social

characteristics

Physicalabuse

3-year

change

indepressive

symptom

s(PE=020

95

CI=0

21ndash

060

)change

inMCSscore(PE=1

12

95

CI=2

45to

021)

Verbalabuse

3-year

change

indepressive

symptom

s(PE=018

95

CI=011

ndash024)change

inMCS

score(PE=055

95

CI=0

75to

034)

Physicalandverbalabuse

3-year

change

indepressive

symptom

s(PE=015

95

CI=0

05to

036

)change

inMCSscore

(PE=0

44

95

CI=1

11to

022)

(Continued)

1228 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 16: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Baker20

0953

PS

16067

6commun

itywom

enfrom

WHI

50ndash7

910

0female

Physicalverbal

abuse

All-cause

cause-

specificmortality

Sociodemog

raph

ic

BMIsm

oking

alcoho

lhealth

statusmedical

cond

ition

sfrailty

andpsycho

social

factors

Physicalabuse(HR=140

95

CI=093

ndash211)verbalabuse

(HR=102

95

CI=094

ndash110)

physical

andverbal

abuse

(HR=107

95

CI=086

ndash133)

Don

g20

095

PS

931

8commun

ity-

olderadults

participatingin

CHAP

ge65

61

female

EASN

All-causemortality

cause-specific

mortality

mortality

stratified

according

tocogn

itive

and

physical

function

Sociodemog

raph

ic

medical

cond

ition

sweigh

tlossmarital

statuscogn

itive

and

physical

function

BMICES

-D

cigarettesm

oking

alcoho

luse

social

well-being

SN1-year

mortality(HR=576

95

CI=511

ndash649)gt1-year

mortality

(HR=187

95

CI=164

ndash214)

SNseveritymild

(HR=471

95

CI=359

ndash617)mod

erate

(HR=587

95

CI=512

ndash673)

severe

HR=15

47

95

CI=11

18ndash

2141)

EAall-causemortality(HR=206

95

CI=148ndash2

88)cardiovascular

mortality(HR=386

95

CI=204

ndash729)

Schofi

eld20

0455

PS

10421

olderwom

enin

Australia

73ndash7

810

0female

EAPhysicalfunction

bodily

paingeneral

healthsocial

function

role

emotionaldifference

mentalhealth

differencePCST2

ndash1

MCST2ndash1

difference

BaselineMedical

Outcomes

Study

36-

item

Sho

rtForm

Surveyscoresfour

EAscoresage

sum

ofacuteillnesses

chroniccond

ition

slifeeventsstress

score

violent

relationship

BMI

smoking

marital

statuseducation

coun

tryof

birth

Dejectionpredictedph

ysical

function

(b=2

81

SE

=081

)bo

dily

pain

(b=1

99

SE

=097

)general

health

(b=1

61

SE

=070

)vitality(b

=3

54

SE

=071

)social

function(b

=ndash527

SE

=100

)role

emotionaldifference

(b=7

88

SE=160

)mental

health

difference

(b=4

63

SE

=060

)PCST2

ndash1difference

(b=0

75

SE

=036

)MCST2ndash1

difference

(b=0

41

SE

=074

)

Lachs

2002

57

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

Ecoho

rt

ge65

584

female

EASN

Long

-term

nursing

homeplacem

ent

Sociodemog

raph

ic

BMImedications

physical

and

cogn

itive

function

social

ties

incontinenceCES

-D

emotionalsupp

ort

chroniccond

ition

s

SN(HR=523

95

CI=407

ndash672

)EA

(HR=402

95

CI=250

ndash647)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1229

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 17: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

3(C

ontd)

Author

Year

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Lachs

1998

18

PS

281

2commun

ity-

livingolderadults

from

New

Haven

EPES

E

ge65

584

female

EASN

All-causemortality

Sociodemog

raph

ic

chroniccond

ition

sBMIcogn

ition

psycho

social

well-

being

SN(OR=170

95

CI=120

ndash250

)EA

(OR=310

95

CI=140

ndash670)

Don

g20

1361

CS

667

4commun

ity-

livingolderadults

participatingin

CHAP

ge65

584

female

563

black

EA

psycho

logical

financial

abuse

neglect

Hospitalization

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

logicalwell-

being

Elderabuse(RR=272

95

CI=184

ndash403)psycho

logicalabuse

(RR=222

95

CI=144

ndash343)

financial

exploitation(RR=175

95

CI=106ndash2

90)caregiver

neglect(RR=243

95

CI=

160ndash

369

)ge2

typesof

elderabuse

(RR=259

95

CI=182

ndash366)

Don

g20

1361

CS

10333

commun

ity-

olderadults

participatingin

CHAP

ge65

39

female

SN

EASociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(OR=175

95

CI=119

ndash259)

financial

exploitation(OR=173

95

CI=101ndash2

95)caregiver

neglect(OR=209

95

CI=124ndash

352

)multiple

form

sof

EA(OR=206

95

CI=122

ndash348)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARateof

emergency

departmentuse

Sociodemog

raph

ic

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=233

95

CI=160

ndash338)

psycho

logicalabuse(RR=198

95

CI=129

ndash300)fin

ancial

exploitation

(RR=159

95

CI=101

ndash252)

caregiverneglect(RR=204

95

CI=138

ndash299)

Don

g20

1361

CS

667

4commun

ity-

olderadults

participatingin

CHAP

ge65

584

female

EARates

ofadmission

toskilled

nursing

facilities

Sociodemog

raph

ic

medical

comorbidities

cogn

itive

and

physical

function

psycho

social

EA(RR=460

95

CI=285

ndash742)

psycho

logical(RR=231

95

CI=117

ndash456)ph

ysical

(RR=236

95

CI=119ndash4

66)fin

ancial

(RR=281

95

CI=153

ndash517)

neglect(RR=473

95

CI=303ndash

740

)

(Continued)

1230 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 18: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Olofsson

2012

52

CS

936

0olderadults

from

nationw

ide

public

health

survey

inSweden

65ndash8

453

1

female

Psycholog

ical

andph

ysical

abuse

Physicalandmental

healthuseof

healthcare

Agecivilstatus

workhistory

smoking

Psycholog

ical

abuse(wom

en)po

orgeneralhealth

(OR=380

95

CI=270ndash5

30)anxiety(OR=630

95

CI=370ndash1

100

)stress

(OR=630

95

CI=420

ndash930)

GHQ-12(OR=590

95

CI=440ndash

790

)suicidal

thou

ght(OR=350

95

CI=230ndash5

20)useof

healthcare

(OR=260

95

CI=190ndash3

50)

Physicalabuse(wom

en)anxiety

(OR=740

95

CI=360

ndash150)

sleeping

prob

lem

(OR=230

95

CI=140ndash4

50)stress

(OR=380

95

CI=190ndash7

60)GHQ-12

(OR=400

95

CI=240

ndash670)

pharmaceutical

(OR=210

95

CI=120ndash3

40)useof

healthcare

(OR=180

95

CI=100

ndash310)

Psycholog

ical

abuse(m

en)po

orgeneralhealth

(OR=220

95

CI=140ndash3

40)anxiety

(OR=10

00

95

CI=530ndash1

900

)sleeping

prob

lem

(OR=350

95

CI=210ndash5

90)stress

(OR=570

95

CI=350ndash9

50)GHQ-12

(OR=390

95

CI=270

ndash570)

suicidal

thou

ght(OR=730

95

CI=460ndash1

100

)suicideattempt

(OR=530

95

CI=230

ndash1200

)Physicalabuse(m

en)po

orgeneral

health

(OR=220

95

CI=120ndash

410

)anxiety(OR=71

95

CI=30ndash16

0)stress

(OR=590

95

CI=310ndash1

100

)GHQ-12

(OR=320

95

CI=190

ndash550)

suicidal

thou

ght(OR=470

95

CI=240ndash9

00)suicideattempt

(OR=540

95

CI=180

ndash1600

)

(Continued)

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1231

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 19: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Table

3(C

ontd)

AuthorYear

Type

StudyDescription

AgeSexRace

Predictor

Outcomes

Confounding

Factors

CriticalFindings

Begle20

1150

CS

902adults

aged

ge60

usingstratified

rand

omdigitdialing

compu

ter-assisted

teleph

oneinterview

ge60

599

female

Emotional

sexualph

ysical

abuse

Negativeem

otional

symptom

s(anxious

depressed

irritable)

Sociodemog

raph

ic

health

statussocial

supp

ortsocial

servicesph

ysical

function

Emotionalabuse(OR=213

95

CI=104

ndash436)ph

ysical

abuse

(OR=067

95

CI=022ndash2

03)

Cisler20

1098

CS

902adults

aged

ge60

inSou

thCarolina

ge60

60

female

EASelf-ratedph

ysical

health

Income

needing

help

with

ADLs

emotionalsymptom

s

Prior

expo

sure

topo

tentially

traumatic

events

(OR=189

95

CI=118ndash

303

)Fisher20

0699

CS

842commun

ity-

livingwom

enwho

completed

teleph

one

survey

ge60

100

female

EAHealth

status

medical

cond

ition

spsycho

logical

distressdigestive

prob

lems

Agesex

race

education

marital

statusincome

App

alachian

heritage

Greater

depression

oranxiety

(OR=224

95

CI=170ndash2

96)

greaterdigestiveprob

lems

(OR=160

95

CI=122ndash2

09)

greaterchronicpain

(OR=165

95

CI=128

ndash215)

Smith20

06100

CS

80APSreferrals

alon

gwith

matched

controlsubjects

from

clinical

popu

lation

Mean76

62

5

female

SN

Com

pletebloo

dcoun

tand

chem

istry

oxidative

damageand

antioxidants

fat-

solublevitamins

vitamin

B-12and

folatecalcium

and

bone

metabolism

NA

Serum

concentrationof

total

homocysteine13

6

45

lmolL

Plt05

redbloo

dcellfolate

concentration138

0

514nm

olL

Plt05

plasmab-carotene

028

02lm

olLPlt05

X-

tocoph

erol

232

93lmolL

Plt05

25-hydroxyvitamin-D

serum

concentration33

7

164

nmolL

Plt05

Franzini20

08101

CC

131APSclientsand

131matched

controls

toan

interdisciplinary

geriatricmedicine

clinic

ge65

695

female

SN

Health

utilization

clinic

visitsho

use

callsho

spitalstays

leng

thof

stay

healthcare

costs

Agesex

race

mentaldisorders

Totalcost$1

246

6forSNvs

$1951

0forcontrol(P

=36)

Physician

costs

PE0

29(040)

outpatient

paym

entsPE0

24

(045)inpatient

costs

PE0

20

(028)totalMedicarecosts

PE

036(033)clinic

visitsPE0

24

(010)ho

spitalstays

PE0

51

(005)

Mou

ton

1999

102

CS

257wom

enaged

50ndash7

9in

WHI

50ndash7

910

0female

Psych

Abu

seMentalhealth

Ageracemarital

statusfamily

income

and

education

Being

threatened

(PE3

32

P=01)

Parameter

estimate

(PE)is

acoefficientofchangein

theoutcomeforeveryunitincrease

inthepredictorvariable

ofinterest

PS=prospective

HR

=hazard

ratioCI=confidence

intervalCHAP=

ChicagoHealthAgingProjectSN

=self-neglectCES-D

=CenterforEpidem

iologic

StudyDepressionScaleRR

=risk

ratioSE=stan-

dard

error

WHI=

Womenrsquos

HealthInitiative

BMI=bodymass

indexMCS=MentalComponentSummaryEPESE=

Established

PopulationsforEpidem

iologic

StudiesoftheElderlyGHQ-12=General

HealthQuestionnaire

APS=AdultProtectiveServices

1232 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

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3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

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9 Government Accountability Office Elder Justice Stronger Federal Leader-

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able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

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office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

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[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 20: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

majority of studies of elder abuse were conducted in NorthAmerica Europe and Asia with only two studies identi-fied in Africa Almost all studies in North America wereconducted in the United States A lack of representativestudies in certain regions including Africa Canada Aus-tralia and South America has impeded the comparisonand understanding of prevalence of elder abuse across con-tinents and the number of studies in US minority popula-tions such as Asian American and Hispanic older adults isnot enough to perform a rigorous analysis of the differ-ences in elder abuse between cultural groups

In terms of the analysis of risk factors of elder abuseexisting studies have primarily focused on victim charac-teristics but perpetrator characteristics such as caregiverburden mental health substance abuse and premorbidrelationship may also affect the occurrence of elder abuseMoreover the majority of studies of risk factors of elderabuse have used a cross-sectional design which furtherhampers the ability to determine the causal relationshipbetween vulnerability risk factors and elder abuse

FUTURE RESEARCH DIRECTIONS

Longitudinal Studies on Elder Abuse

Longitudinal studies are needed to examine the incidence ofelder abuse subtypes in diverse settings and the associatedrisk and protective factors Longitudinal research may alsohelp to understand potential perpetratorsrsquo characteristicsrelationships settings and contexts with respect to elderabuse victims The fields of child abuse and domestic vio-lence have demonstrated the feasibility of conductingresearch on potential perpetrators Innovative approachesfor understanding perpetratorsrsquo perspectives are necessaryfor the design and implementation of future interventionsMoreover research is needed to understand pathway bywhich elder abuse leads to adverse outcomes especially therisk rate and intensity of health services use with respect toelder abuse Given the complexity of elder abuse research inolder adults with lower cognitive function more-rigorousstudies are needed to improve understanding of the issueCost-benefit and cost-effectiveness analyses are also neededto examine the costs associated with elder abuse and utilitiesof existing intervention programs Because many costndashbene-fit analyses are biased against older adults innovative strate-gies are needed to capture the range of personalcommunity financial and societal costs of elder abuse

Elder Abuse in Minority Populations

The prevalence of elder abuse in ethnic minority groups wasfound to be higher than in whites14ndash16 With the increas-ingly diverse aging population national priorities to betterunderstand the cultural factors related to elder abuse inracial and ethnic populations should be set62 The last dec-ade has seen a population growth rate of 57 for whites430 for Hispanics 433 for Asians 183 for NativeAmericans and 123 for African Americans63 Quantita-tive and qualitative studies are needed to better define theconceptual and cultural variations in the constructions anddefinitions of elder abuse subtypes Significant challengesexist in conducting aging research in minority communities

especially regarding culturally sensitive matters64 Commu-nity-based participatory research (CBPR) approaches couldbe frameworks for addressing elder abuse65 CBPR necessi-tates equal partnership between academic and communityorganizations and stakeholders to examine relevant issuesThis partnership requires reciprocal transfer of expertiseand sustainable infrastructure building Recent elder abuseresearch (Population Study of Chinese Elderly) in the Chi-cago Chinese community has demonstrated enhanced infra-structure and networks for community-engaged researchand communityndashacademic partnerships66

Prevention and Intervention Studies on Elder Abuse

Although elder abuse is common and universal few evi-dence-based prevention and intervention strategies havebeen developed to assist victims of elder abuse67 Commonforms of intervention programs may include advocacy ser-vice intervention support groups care coordination andpublic education Interventions on elder abuse could employCBPR and multidisciplinary team (M-Team) approaches

Through implementing the CBPR approach elderabuse intervention programs could build on strengths andresources in the community Using the CBPR approachthe Family Care Conference (FCC) was developed in anorthwestern Native American community The pilot studydemonstrated that the FCC approach helped to bring fam-ily membersrsquo attention to the problem of elder abuse andto incorporate their efforts into intervention68 In a quali-tative study of the perception of effectiveness challengesand cultural adaptations of elder abuse interventions olderadults participating in the study appraised the community-based intervention module and have positive attitudestoward interventions that community-based social servicesorganizations delivered69 Future research efforts shouldpromote and sustain the collaboration between communityorganizations and research institutions to better addressthe needs and concerns of older adults At the same timemore evidence-based studies should be conducted to exam-ine the efficacy and sustainability of intervention programsin diverse settings

M-Teams exist in the field of elder abuse despite adearth of data regarding the efficacy sustainability and costeffectiveness of the M-team approach An M-Team usuallycomprises a healthcare provider a social worker social ser-vices a legal professional an ethicist a mental health spe-cialist community leaders and residents Although manystate aging departments such as the Illinois Department onAging recommended M-teams systematic studies areneeded as well as rigorously designed intervention studieswith relevant outcome measures Given the different typesof elder abuse and variation in risk and protective factorsand perpetrator characteristics intervention and preventionstudies should begin to focus on specific high-risk dyadsPrevention and intervention studies must also consider costeffectiveness and scalability at the broad levels

IMPLICATIONS FOR HEALTH PROFESSIONALS

Health professionals are well situated to screen for elderabuse and detect vulnerabilities7071 How older adultsmanage their daily lives can suggest predisposing factors

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1233

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

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8 National Research Council Elder Mistreatment Abuse Neglect and

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and correlates of elder abuse using promotores Low-income immigrant

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2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 21: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

that may impair their ability to live independently andprotect themselves Assessing functional cognitive andpsychosocial well-being is important for understanding thepredisposing and precipitating risk factors associated withelder abuse A recent validation study of the elder abusevulnerability index suggests that older adults with three orfour vulnerability factors have almost 4 times the risk ofelder abuse whereas those with five or more factors havemore than 26 times the risk72

Because elder abuse victims often interact with healthsystems increased screening and treatment should be insti-tuted in healthcare settings Primary care outpatient prac-tices inpatient hospitalization episodes and dischargeplanning and home health could play pivotal roles in iden-tifying potentially unsafe situations that could jeopardizethe safety and well-being of older adults73 Early detectionand interventions such as incorporating effective treatmentof underlying problems providing community-based ser-vices and appropriately involving family may help delayor prevent elder abuse (Figure 2)

When health professionals suspect elder abusedetailed histories should be gathered especially psychoso-cial and cultural aspects In addition specific findings fromphysical examinations that may further indicate elderabuse should be documented Moreover health profession-als should document observations of patient behaviorreactions to questions and family dynamics and conflictsWhenever indicated health professionals should order lab-oratory tests and imaging tests These types of documenta-tion are critical for supporting the interdisciplinary teamand APS to ameliorate elder abuse and protect vulnerableolder adults Furthermore health professionals shoulddevise patient-centered plans to provide support educa-tion and follow-up and should monitor ongoing abuseand institute safety plans

Almost all states have mandatory reporting legislationrequiring health professionals to report reasonable suspi-cions of elder abuse Elder abuse reports can come fromvariety of sources and could be anonymous if within theauthorization of the statute but in most states reportingof elder abuse by health professionals is not anonymousbecause follow-up may be needed with the reporter to pro-vide further evidence and assessment When health profes-sionals suspect elder abuse they should contact the stateoffice on aging the ElderCare Locator (800ndash677ndash1116) orthe National Center on Elder Abuse

Health professionals may be reluctant to report elderabuse because of subtlety of signs victim denial and lackof knowledge about reporting procedures71 Other reasonsfor reluctance include concern about losing physicianndashpatient rapport concern over potential retaliation by per-petrators time limitation doubt regarding the effect ofAPS and perceived contradictions between mandatoryreporting and a providerrsquos ability to act in the patientrsquosbest interests74 A common misconception for reportingelder abuse is that convincing evidence is needed toreport In addition given the fear of liability the physi-cian may ask for proof rather than suspicion of abuse toreport elder abuse74 On the contrary elder abuse shouldbe reported to APS whenever a reasonable suspicionarises

Health professionals promote a patientrsquos rights toautonomy and self-determination maintain a family unitwhenever possible and provide recommendations for theleast-restrictive services and safety plan It must be pre-sumed that an older adult has decision-making capacity(DMC) and accept the personrsquos choices until a healthcareprovider or the legal system determines that the personlacks capacity One of the most difficult dilemmas is underwhat types of situations the medical community and soci-

Vulnerability Risk Direct Screening Self Family or Other Reports

Suspected Elder AbuseAssessment

History Physical Examination

Psychological Observation

Documentation SocialCultural Context

Willing to Accept Services

Yes

Education

Continued Support

Follow-Up

Monitory Safety

Alleviate Stressors

Safety Plan

Legal Services

Social Services

Continue Support

Education

Follow-Up

Monitor Severity

Examine State-Specific Statute on Elder Abuse and Reporting

No

YesNo

Neuropsychological Evaluation

Psychiatric Evaluation

Comprehensive Geriatric Assessment

Alleviate Reversible Factors

Conservatorship

Guardianship

Court Proceeding

Unsure

Decision-Making Capacity

Figure 2 Healthcare professional management strategies for elder abuse APS = Adult Protective Services

1234 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

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Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 22: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

ety at large have a responsibility to override personalwishes The presence or absence of capacity is often adetermining factor in what health professionals the com-munity and society need to do next75 but capacity is notpresent or absent rather it is a gradient relationshipbetween the problems in question and an older adultrsquosability to make these decisions Complex health problemsrequire higher levels of DMC For simpler problems evena cognitively impaired adult could have DMC but healthproviders are often forced to make gray areas black andwhite for purposes of guiding next steps such as guardian-ship or conservatorship Commonly used brief screeningtests such as the Mini-Mental State Examination are inade-quate for determining capacity except at the extremes ofthe score A more-useful test for assessing DMC is theHopkins Competency Assessment Test76

IMPLICATIONS FOR SOCIAL SERVICEPROVIDERS

Community Organizations

Community organizations play a critical role in reducingthe risk of elder abuse in community-dwelling older adultsEducation should be provided to increase awareness ofelder abuse in the community In particular given the cul-tural and linguistic barriers facing minority older adultscommunity organizations should improve minority olderadultsrsquo access to culturally sensitive services related toelder abuse Meanwhile community organizations shouldsustain and promote collaboration with academic organi-zations to explore and tackle elder abuse

Adult Protective Services

APS programs typically run by local or state healthdepartments provide protection for adults against abuseand investigate and substantiate reports After a report ofelder abuse an assigned APS worker would make an in-person home visit to investigate the nature and severity ofthe abuse From a comprehensive list of indicators andinput from older adults family members and otherinvolved parties elder abuse is substantiated partially sub-stantiated or not substantiated but even if it is not sub-stantiated it does not necessarily mean there was no elderabuse because there are often barriers to assessing olderadults and obtaining the information needed to substanti-ate a case

As the aging population continues to grow investiga-tions by APS have become increasingly complex77 Arecent systematic review of elder abuse and dementia sug-gested that insufficient financial resources insufficientaccess to information needed to resolve elder abuse casesinadequate administrative systems and lack of cross-train-ing with other disciplines in the aging field serving clientswith mental health disabilities may hinder the role of APSworkers in ameliorating abusive situations77 The M-Teamcould help confirm abuse document impaired capacityreview medications and medical conditions facilitate theconservatorship process persuade the client or family totake action and support the need for law enforcementinvolvement78

HEALTH POLICY IMPLICATIONS

Two important federal laws address elder abuse the OlderAmericans Act (OAA) and the Elder Justice Act (EJA) TheOAA authorizes funding for National OmbudsmanResource Center National Center on Elder Abuse Officeof State Long Term Care Ombudsman legal and justiceservices for victims funding of demonstration projectsoutreach activities and State Legal Assistance Developerto enhance coordinated care The EJA was passed in the110th Congress to unify federal systems and respond toelder abuse It required the Secretary of Health andHuman Services to promulgate guidelines for human sub-ject protections to assist researchers and establish elderabuse forensic centers across the United States The EJAauthorized funding and incentives for long-term care staff-ing builds electronic medical records technology collectsand disseminates annual APS data and sponsors and sup-ports training services reporting and the evaluation pro-gram for elder justice although the majority of programsand activities under the EJA have not received fundingand the EJA is in danger of being dissolved The authoriza-tion of appropriations for EJA provisions expired on Sep-tember 30 2014 and the likelihood of continuingCongressional resolution and reauthorization is uncer-tain79 The EJA plays an important role in elder abuseresearch and prevention The Government AccountabilityOffice described the EJA as providing ldquoa vehicle for settingnational priorities and establishing a comprehensive multi-disciplinary elder justice system in this countryrdquo9 Compre-hensive systematic coordinated multilevel advocacy andpolicy efforts are needed to address elder abuse in legisla-tion at the national level80

CONCLUSION

This review highlights the epidemiology of elder abuse andthe complexities of research and practice National longi-tudinal research is needed to better define the incidencerisk and protective factors and consequences of elderabuse in diverse racial and ethnic populations Health pro-fessionals should consider integrating routine screening ofelder abuse in clinical practice especially in high-risk pop-ulations Patient-centered and culturally appropriate treat-ment and prevention strategies should be instituted toprotect vulnerable populations Although vast gaps remainin the field of elder abuse unified and coordinated effortsat the national level must continue to preserve and protectthe human rights of vulnerable aging populations

ACKNOWLEDGMENTS

The author would like to thank the APS staff and otherfront-line aging professionals around the globe for theircontinued dedication and commitment to protecting vul-nerable victims of elder abuse in diverse populations

Conflict of Interest Dr Dong declares no conflict ofinterest Dr Dong was supported by National Institute onAging Grants R01 AG042318 R01 MD006173 R01 NR14846 R01 CA163830 R34MH100443 R34MH100393and RC4 AG039085 a Paul B Beeson Award in Agingthe Starr Foundation the American Federation for Aging

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1235

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 23: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Research the John A Hartford Foundation and theAtlantic Philanthropies

Author Contributions Dr Dong was responsible forthe conception and design as well as analysis and interpre-tation of data as well as the drafting of the manuscriptcritical revision of the manuscript

Sponsorrsquos Role None

REFERENCES

1 Institute of Medicine Confronting Chronic Neglect The Education and

Training of Health Professionals on Family Violence Washington DC

The National Academies Press 2002

2 National Center on Elder Abuse Types of Abuse 2014 [on-line] Available

at httpnceaaoagovFAQType_Abuse Accessed March 15 2014

3 Acierno R Hernandez MA Amstadter AB et al Prevalence and correlates

of emotional physical sexual and financial abuse and potential neglect in

the United States The National Elder Mistreatment Study Am J Public

Health 2010100292ndash2974 Beach SR Schulz R Castle NG et al Financial exploitation and psycho-

logical mistreatment among older adults Differences between African

Americans and non-African Americans in a population-based survey Ger-

ontologist 201050744ndash7575 Dong X Simon M de Leon CM et al Elder self-neglect and abuse and

mortality risk in a community-dwelling population JAMA 2009302517ndash526

6 OrsquoBrien JG A physicianrsquos perspective Elder abuse and neglect over

25 years J Elder Abuse Negl 20102294ndash1047 Burston GR Granny battering BMJ 1975iii592

8 National Research Council Elder Mistreatment Abuse Neglect and

Exploitation in an Aging America Washington DC The National Acade-

mies Press 2003

9 Government Accountability Office Elder Justice Stronger Federal Leader-

ship Could Enhance National Response To Elder Abuse [on-line] Avail-

able at httpaging senate goveventshr230kb2 pdf 2011 Accessed March

10 2014

10 Stoltzfus E The Child Abuse Prevention and Treatment Act (CAPTA)

Background Programs and Funding Congressional Research Service

20097ndash570011 White House Presidential Proclaimation World Elder Abuse Aware-

ness Day [on-line] Available at httpwww whitehouse govthe-press-

office20120614presidential-proclamation-world-elder-abuse-aware-

ness-day-2012 Accessed March 15 2014

12 Center for Medicare and Medicaid Services CMS Elder Mistreatment

Quality Measurement Initiative 2013 [on-line] Available at http

wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-

APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014

13 US Preventive Services Task Force Third Annual Report to Congress

on High-Priority Evidence Gaps for Clinical Preventive Services 2013

[on-line] Available at httpwwwuspreventiveservicestaskforceorg

PageNamethird-annual-report-to-congress-on-high-priority-evidence-

gaps-for-clinical-preventive-services Accessed March 18 2014

14 DeLiema M Gassoumis ZD Homeier DC et al Determining prevalence

and correlates of elder abuse using promotores Low-income immigrant

Latinos report high rates of abuse and neglect J Am Geriatr Soc

2012601333ndash133915 Dong X Chen R Simon MA Prevalence and correlates of elder mistreat-

ment in a community-dwelling population of US Chinese older adults J

Aging Health 2014261209ndash122416 Dong X Simon MA Evans DA Prevalence of self-neglect across gender

race and socioeconomic status Findings from the Chicago Health and

Aging Project Gerontology 201158258ndash26817 Laumann EO Leitsch SA Waite LJ et al Mistreatment in the United

States Prevalence estimates from a nationally representative study J Ger-

ontol B Psychol Sci Soc Sci 200863BS248ndashS25418 Lachs M Berman J Under the radar New York State elder abuse preva-

lence study Prepared by Lifespan of Greater Rochester Inc Weill Cor-

nell Medical Center of Cornell University and New York City

Department for the Aging 2011 [on-line] Available at httpwwwpre-

ventelderabuseorglibrarydocumentsUndertheRadar051211pdf Accessed

April 2 2014

19 Lindert J de Luna J Torres-Gonzales F et al Abuse and neglect of older

persons in seven cities in seven countries in Europe A cross-sectional

community study Int J Public Health 201358121ndash132

20 Cadmus EO Owoaje ET Prevalence and correlates of elder abuse among

older women in rural and urban communities in south western Nigeria

Health Care Women Int 201233973ndash98421 Wu L Chen H Hu Y et al Prevalence and associated factors of elder

mistreatment in a rural community in Peoplersquos Republic of China A

cross-sectional study PLoS ONE 20127e33857

22 Oh J Kim HS Martins D et al A study of elder abuse in Korea Int J

Nurs Stud 200643203ndash21423 Wiglesworth A Mosqueda L Mulnard R et al Screening for abuse and

neglect of people with dementia J Am Geriatr Soc 201058493ndash50024 Naughton C Drennan J Lyons I et al Elder abuse and neglect in Ireland

Results from a national prevalence survey Age Ageing 20124198ndash10325 Ajdukovic M Ogresta J Rusac S Family violence and health among

elderly in Croatia J Aggression Maltreatment Trauma 200918261ndash27926 Chokkanathan S Factors associated with elder mistreatment in rural

Tamil Nadu India A cross-sectional survey Int J Geriatr Psychiatry

201429863ndash86927 Lowenstein A Eisikovits Z Band-Winterstein T et al Is elder abuse and

neglect a social phenomenon Data from the First National Prevalence

Survey in Israel J Elder Abuse Negl 200921253ndash27728 Abdel Rahman TT El Gaafary MM Elder mistreatment in a rural area in

Egypt Geriatr Gerontol Int 201212532ndash53729 Dong X Simon MA Gorbien M Elder abuse and neglect in an urban

Chinese population J Elder Abuse Negl 20071979ndash9630 Straus MA Measuring intrafamily conflict and violence The Conflict Tac-

tics (ct) Scales J Marriage Fam 19794175ndash8831 Yan E Tang CS-K Prevalence and psychological impact of Chinese elder

abuse J Interpers Violence 2001161158ndash117432 Comijs HC Pot AM Smit JH et al Elder abuse in the community Preva-

lence and consequences J Am Geriatr Soc 199846885ndash88833 Dong X Do the definitions of elder mistreatment subtypes matter Find-

ings from the PINE Study J Gerontol A Biol Sci Med Sci 201469(Suppl

2)S68ndashS7534 Dong XQ Simon M Evans D Cross-sectional study of the characteristics

of reported elder self-neglect in a community-dwelling population Find-

ings from a population-based cohort Gerontology 201056325ndash33435 Abrams RC Lachs M McAvay G et al Predictors of self-neglect in com-

munity-dwelling elders Am J Psychiatry 20021591724ndash173036 Yan E Chan KL Prevalence and correlates of intimate partner violence

among older Chinese couples in Hong Kong Int Psychogeriatr

2012241437ndash144637 Beach SR Schulz R Williamson GM et al Risk factors for potentially

harmful informal caregiver behavior J Am Geriatr Soc 200553255ndash26138 Dong X Wilson RS Mendes de Leon CF et al Self-neglect and cognitive

function among community-dwelling older persons Int J Geriatr Psychia-

try 201025798ndash80639 Dong X Simon MA Wilson RS et al Decline in cognitive function and

risk of elder self neglect Finding from the Chicago Health Aging Project

J Am Geriatr Soc 2010582292ndash229940 Dong X Simon M Rajan K et al Association of cognitive function and

risk for elder abuse in a community-dwelling population Dement Geriatr

Cogn Disord 201132209ndash21541 Friedman LS Avila S Tanouye K et al A case control study of severe

physical abuse of older adults J Am Geriatr Soc 201159417ndash42242 Lachs MS Williams C OrsquoBrien S et al Risk factors for reported elder

abuse and neglect A nine-year observational cohort study Gerontologist

199737469ndash47443 Tierney MC Snow WG Charles J et al Neuropsychological predictors of

self-neglect in cognitively impaired older people who live alone Am J Ge-

riatr Psychiatry 200715140ndash14844 Dong X Simon MA Gorbien M et al Loneliness in older Chinese adults A

risk factor for elder mistreatment J Am Geriatr Soc 2007551831ndash183545 Dong X Chang E-S Wong E et al Association of depressive symptom-

atology and elder mistreatment in a US Chinese population Findings from

a community-based participatory research study J Aggression Maltreat-

ment Trauma 20142381ndash9846 Shugarman LR Fries BE Wolf RS et al Identifying older people at risk

of abuse during routine screening practices J Am Geriatr Soc

20035124ndash3147 Strasser SM Smith M Weaver S et al Screening for elder mistreatment

among older adults seeking legal assistance services West J Emerg Med

201314309ndash31548 VandeWeerd C Paveza GJ Walsh M et al Physical mistreatment in per-

sons with Alzheimerrsquos disease J Aging Res 20132013920324

49 Choi NG Kim J Asseff J Self-neglect and neglect of vulnerable older

adults Reexamination of etiology J Gerontol Soc Work 200952171ndash187

1236 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 24: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

50 Begle AM Strachan M Cisler JM et al Elder mistreatment and emotional

symptoms among older adults in a largely rural population The South Car-

olina Elder Mistreatment Study J Interpers Violence 2011262321ndash233251 Mouton CP Rodabough RJ Rovi SL et al Psychosocial effects of physi-

cal and verbal abuse in postmenopausal women Ann Fam Med

20108206ndash21352 Olofsson N Lindqvist K Danielsson I Fear of crime and psychological

and physical abuse associated with ill health in a Swedish population aged

65ndash84 years Public Health 2012126358ndash36453 Baker MW LaCroix AZ Wu C et al Mortality risk associated with phys-

ical and verbal abuse in women aged 50 to 79 J Am Geriatr Soc

2009571799ndash180954 Lachs MS Williams CS OrsquoBrien S et al The mortality of elder mistreat-

ment JAMA 1998280428ndash43255 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68556 Dong X Simon MA Fulmer T et al A prospective population-based

study of differences in elder self-neglect and mortality between black and

white older adults J Gerontol A Biol Sci Med Sci 201166A695ndash70457 Lachs MS Williams CS OrsquoBrien S et al Adult protective service use and

nursing home placement Gerontologist 200242734ndash73958 Dong X Simon MA Evans D Elder self neglect and hospitalization

Findings from the Chicago Health and Aging Project J Am Geriatr Soc

201260202ndash20959 Dong X Simon MA Elder abuse as a risk factor for hospitalization in

older persons JAMA Intern Med 2013173911ndash91760 Dong X Simon MA Evans D Prospective study of the elder self-neglect and

ED use in a community population Am J Emerg Med 201230553ndash56161 Dong X Simon MA Association between elder self-neglect and hospice

utilization in a community population Arch Gerontol Geriatr

201356192ndash19862 Dong X Chang E-S Wong E et al How do US Chinese older adults

view elder mistreatment Findings from a community-based participatory

research study J Aging Health 201123289ndash31263 US Census Bureau American Fact Finder 2010 [on-line] Available at

httpfactfinder2censusgovfacesnavjsfpagesindexxhtml Accessed

March 10 2014

64 Dong X Chang E-S Lost in translation To our Chinese patient Alzhei-

merrsquos meant lsquocrazy and catatonicrsquo Health Aff 201433712ndash71565 Leung MW Yen IH Minkler M Community based participatory

research A promising approach for increasing epidemiologyrsquos relevance in

the 21st century Int J Epidemiol 200433499ndash50666 Dong X Wong E Simon MA Study design and implementation of the

PINE study J Aging Health 2014261085ndash109967 Ploeg J Fear J Hutchison B et al A systematic review of interventions

for elder abuse J Elder Abuse Negl 200921187ndash21068 Holkup PA Salois EM Tripp-Reimer T et al Drawing on wisdom from

the past An elder abuse intervention with tribal communities Gerontolo-

gist 200747248ndash25469 Dong X Chang E Wong E et al Perceived effectiveness of elder abuse

interventions in psychological distress and the design of culturally adapted

interventions A qualitative study in the Chinese community in Chicago J

Aging Res 20132013845425

70 OrsquoBrien JG Riain AN Collins C et al Elder abuse and neglect A survey

of Irish general practitioners J Elder Abuse Negl 201426291ndash29971 OrsquoBrien JG Elder Abuse and the Physician Factors Impeding Recognition

and Intervention Stress Conflict and Abuse of the Elderly Jerusalem

Brookdale Institute 1989

72 Dong X Simon MA Vulnerability risk index profile for elder abuse in a

community-dwelling population J Am Geriatr Soc 20146210ndash1573 Dong X Simon MA Elder self-neglect Implications for health care pro-

fessionals Can Geriatr Soc J 2013325ndash2874 Rodriguez MA Wallace SP Woolf NH et al Mandatory reporting of

elder abuse Between a rock and a hard place Ann Fam Med

20064403ndash40975 Leo RJ Competency and the capacity to make treatment decisions A pri-

mer for primary care physicians Prim Care Companion J Clin Psychiatry

19991131ndash14176 Janofsky JS McCarthy RJ Folstein MF The Hopkins Competency

Assessment Test A brief method for evaluating patientsrsquo capacity to give

informed consent Hosp Community Psychiatry 199243132ndash13677 Dong X Chen R Simon MA Elder abuse and dementia A review of the

research and health policy Health Aff 201433642ndash64978 Mosqueda L Burnight K Liao S et al Advancing the field of elder mis-

treatment A new model for integration of social and medical services

Gerontologist 200444703ndash708

79 Colello KJ The Elder Justice Act Background and Issues for Congress

Congressional Research Service 2014 Available at httpfasorgsgpcrs

miscR43707pdf Accessed March 25 2014

80 Dong X Simon MA Enhancing National policy and programs to address

elder abuse JAMA 20113052460ndash246181 Buri H Daly JM Hartz AJ et al Factors associated with self-

reported elder mistreatment in Iowa frailest elders Res Aging

200628562ndash58182 Kissal A Beser Ae Elder abuse and neglect in a population offering care

by a primary health care center in Izmir Turkey Soc Work Health Care

201150158ndash17583 Biggs S Manthorpe J Tinker A et al Mistreatment of older people in the

United Kingdom Findings from the first National Prevalence Study J

Elder Abuse Negl 2009211ndash1484 Cooper C Selwood A Blanchard M et al Abuse of people with dementia

by family carers Representative cross sectional survey BMJ 2009338

b155

85 Garre-Olmo J Planas-Pujol X Lopez-Pousa S et al Prevalence and risk

factors of suspected elder abuse subtypes in people aged 75 and older J

Am Geriatr Soc 200957815ndash82286 Perez-Carceles MD Rubio L Pereniguez JE et al Suspicion of elder abuse

in south eastern Spain The extent and risk factors Arch Gerontol Geriatr

200849132ndash13787 Somjinda Chompunud ML Charoenyooth C Palmer MH et al Preva-

lence associated factors and predictors of elder abuse in Thailand Pac

Rim Int J Nurs Res Thail 201014283ndash29688 Lee M Caregiver stress and elder abuse among Korean family caregivers

of older adults with disabilities J Fam Violence 200823707ndash71289 Sasaki M Arai Y Kumamoto K et al Factors related to potentially harm-

ful behaviors towards disabled older people by family caregivers in Japan

Int J Geriatr Psychiatry 200722250ndash25790 Tierney MC Charles J Naglie G et al Risk factors for harm in cogni-

tively impaired seniors who live alone A prospective study J Am Geriatr

Soc 2004521435ndash144191 Lichtenberg PA Stickney L Paulson D Is psychological vulnerability

related to the experience of fraud in older adults Clin Gerontol

201336132ndash14692 Amstadter AB Zajac K Strachan M et al Prevalence and correlates of

elder mistreatment in South Carolina The South Carolina Elder Mistreat-

ment Study J Interpers Violence 2011262947ndash297293 Cooper C Manela M Katona C et al Screening for elder abuse in

dementia in the LASER-AD Study Prevalence correlates and validation

of instruments Int J Geriatr Psychiatry 200823283ndash28894 Dong X Simon MA Odwazny R et al Depression and elder abuse and

neglect among community-dwelling Chinese elderly population J Elder

Abuse Negl 20082025ndash4195 Ogioni L Liperoti R Landi F et al Cross-sectional association between

behavioral symptoms and potential elder abuse among subjects in home

care in Italy Results from the Silvernet Study Am J Geriatr Psychiatry

20071570ndash7896 Schofield MJ Powers JR Loxton D Mortality and disability outcomes of

self-reported elder abuse A 12-year prospective investigation J Am Geri-

atr Soc 201361679ndash68597 Dong XQ Simon MA Beck TT et al Elder abuse and mortality The role

of psychological and social wellbeing Gerontology 201057549ndash55898 Cisler JM Amstadter AB Begle AM et al Elder mistreatment and physi-

cal health among older adults The South Carolina Elder Mistreatment

Study J Trauma Stress 201023461ndash46799 Fisher BS Regan SL The extent and frequency of abuse in the lives of

older women and their relationship with health outcomes Gerontologist

200646200ndash209100 Smith SM Oliver SAM Zwart SR et al Nutritional status is altered in

the self-neglecting elderly J Nutr 20061362534ndash2541101 Franzini L Dyer CB Healthcare costs and utilization of vulnerable elderly

reported to Adult Protective Services for self-neglect J Am Geriatr Soc

200856667ndash676102 Mouton CP Rovi S Furniss K et al The associations between health and

domestic violence in older women Results of a pilot study J Womens

Health Gend Based Med 199981173ndash1179

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article

JAGS JUNE 2015ndashVOL 63 NO 6 ELDER ABUSE SYSTEMATIC REVIEW 1237

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS

Page 25: Elder Abuse: Systematic Review and Implications for Practiceeapon.ca/wp-content/uploads/2016/11/Dong-2015... · Epidemiology of Elder Abuse Elder abuse is a worldwide health problem.

Figure S1 Flowchart Describing Review Process forIdentification of Eligible Studies

Figure S2Range of Prevalence Across Five ContinentsTable S1 Prevalence Estimates of Elder Abuse by Popu-

lation SurveyMethods and Definitions

Please note Wiley-Blackwell is not responsible for thecontent accuracy errors or functionality of any support-ing materials supplied by the authors Any queries (otherthan missing material) should be directed to the corre-sponding author for the article

1238 DONG JUNE 2015ndashVOL 63 NO 6 JAGS


Recommended