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-
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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
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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
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
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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
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
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
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
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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
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
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
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
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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
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
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wwwiomedu~mediaFilesActivity20FilesGlobalViolenceForum2013-
APR-17Presentations02ndash07-McMullenpdf Accessed March 27 2014
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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
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
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
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
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
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
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
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
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
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
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
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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-
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-
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office20120614presidential-proclamation-world-elder-abuse-aware-
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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
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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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
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
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
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
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
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