Overview

According to the National Center on Elder Abuse, it is estimated that between 1 and 2 million Americans older than 65 years of age have been the victims of abuse. There are some studies that indicate that females are more likely to be victims of elder abuse. Other demographic factors that contribute to risk include unmarried status and non-white ethnic origin. Consequently, practitioners will need to become more culturally aware and sensitive to the cultural norms, belief systems, and needs of culturally diverse patients in order to provide culturally relevant services and interventions. In other words, it is inevitable that we talk about cultural competency. There has been a growing interest in the perceptions of elder abuse among ethnic minority populations. This reflects a recognition that culture, race, and ethnicity can influence what constitutes elder abuse, particularly because definitions of elder abuse reflect a white, middle-class perspective. This course will outline the impact of culture, race, and ethnicity on elder abuse and help seeking patters for abuse and provide tools for identifying and intervening in cases of elder abuse.

Education Category: Ethics - Human Rights
Release Date: 02/01/2014
Expiration Date: 01/31/2017

Audience

This course is targeted to physicians, nurses, social workers, and other allied health professionals who may identify and intervene in cases of elder abuse.

Accreditations & Approvals

NetCE is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE is approved by the California Nursing Home Administrator Program as a provider of continuing education. Provider number 1622. NetCE is approved to offer continuing education through the Florida Board of Nursing Home Administrators, Provider #50-2405. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is approved as a provider of online continuing education for certified nursing assistants through the California Department of Public Health Licensing and Certification Division. Nurse Aide Certification (NAC) Provider #7005. This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers. The course is approved for 5 CE contact hour(s). Activity code: H00021008. Approval Number: 160001800. To claim these CEs, log into your CE Center account at www.ccmcertification.org. NetCE SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this enduring material for a maximum of 5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. NetCE designates this continuing education activity for 4 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 5 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Social workers participating in this intermediate to advanced course will receive 5 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. This home study course is approved by the Florida Board of Nursing Home Administrators for 5 credit hour(s). This course is approved by the California Nursing Home Administrator Program for 5 hour(s) of continuing education credit - NHAP#1622005-5401/P. California NHAs may only obtain a maximum of 10 hours per course. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program. AACN Synergy CERP Category B.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.

Special Approvals

This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of this course is to increase the knowledge base of social workers, nurses, physicians and other allied health professionals about elder abuse, assessment, and intervention. This curriculum will focus on abuse against elders in domestic settings perpetrated by family members.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Summarize the historical context and scope of elder abuse.
  2. Define elder abuse and the different forms of elder abuse.
  3. Identify the general profile of the elder abuse victim.
  4. Analyze the different classifications of perpetrators of elder abuse.
  5. Discuss the various theoretical models to help explain the causes of elder abuse in domestic settings.
  6. Explain how culture, race, and ethnicity color views about family and aging and definitions of and attitudes toward elder abuse and help seeking.
  7. Discuss assessments for elder abuse victims.
  8. Describe general mandatory laws for and ethical issues associated with elder abuse.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Jane C. Norman, RN, MSN, CNE, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

Technical Requirements

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#97821: Elder Abuse: Cultural Contexts and Implications

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HISTORICAL OVERVIEW

EMERGENCE AND SOCIAL CONSTRUCTION OF FAMILY VIOLENCE

To understand the emergence of elder abuse as a social problem, it is helpful to first look at family violence in order to place elder abuse in an historical context. There has always been family violence, yet it is often assumed to be a recent phenomenon, perhaps because of the amount of media coverage to which we are exposed. Looking back in history, it becomes obvious that it is not a recent development. Violence against children or infanticide, for example, has been practiced since prehistoric times [28].

However, the process of a condition evolving into a social problem is a different story. Spector and Kitsuse assert that a condition becomes a social problem only when individuals and groups make claims and grievances about a condition being problematic and that such a condition should be eradicated or in need of intervention [74]. Child abuse, for example, came to the attention of the public in the 1870s when the abuse of a specific young girl was "discovered." The case was made by the Society for the Prevention of Cruelty to Animals that this young girl should not be abused because she was technically an animal [95]. Whether this is indeed true or fiction, it points to the fact that until parties make claims about the deleterious nature of a condition, it is not a social problem.

The focus on child abuse waned until the 1960s when Henry Kemp "rediscovered" child abuse, and his article "The Battered Child Syndrome" legitimized it as a social problem [40,94]. The characteristics of this medical syndrome included traumatic injuries to the heads of young children, typically younger than 3 years of age. It became a serious medical problem warranting medical as well as legislative intervention [40].

Similarly, we tend to associate domestic violence with the 1960s, when the feminist movement brought this issue onto the national agenda. However, assaults against women by husbands or intimate partners were not a new social issue. Dobash and Dobash argue that domestic violence has always existed [21]. In 1768, wife beating was legally sanctioned and codified in English common laws. Husbands were permitted to physically chastise their wives with sticks no larger than the circumference of their thumbs if they deemed that their wives were behaving inappropriately [21]. Out of this practice came the adage "rule of thumb." As recently as the 1970s, a Pennsylvania town had an ordinance that prohibited a husband from beating his wife after 10 p.m. on Sundays [33].

Until the feminist movement focused on the plight of battered women, minimal empirical attention was given to this condition. However, academic research flourished during this time [78]. In 1981, the first National Day of Unity was observed, and since 1984, Domestic Violence Awareness Week has been observed in October [33]. It is against this backdrop that elder abuse emerged as a recognized social problem in the 1980s.

EMERGENCE AND SOCIAL CONSTRUCTION OF ELDER ABUSE

As a form of family violence, elder abuse has existed for millennia, although it did not gain public attention until fairly recently. Anthropologists have described some cultures and societies that abandoned or killed the elderly during times of structural inequalities and tensions [35]. In cultures predominated by agriculture, the need for laborers and disputes over land inheritance fueled family conflict [67,75]. In general, throughout the ages and certainly in today's society, cultural norms dictate what is considered "productive" during the various cycles of the life span [35].

In Britain during the 1970s, the media coined the term "granny-bashing," which helped to reinforce the seriousness of the problem of elder abuse [91]. By the mid-1980s, the gerontology literature began including works on elder abuse, and in 1980, the House Select Committee on Aging heard testimony about the "social problem" of elder abuse in the United States [9]. Shocking testimony was given about elderly seniors who were beaten, neglected, left in filth, and financially exploited by children, grandchildren, or caregivers [51].

In the United States, the construction of elder abuse was closely linked with the concepts of child abuse. The picture of a frail elderly parent dependent upon their adult child caregiver was disseminated, and because there was no statute for elder abuse at that time, lawmakers and service providers turned to the child abuse model with its mandatory reporting laws [97]. In 1974, an amendment to the Social Security Act created the Adult Protective Services (APS). At that time, the purpose of APS was to protect adults with physical and/or mental limitations. However, the APS system became the solution when elder abuse became a public issue, allowing action on the matter without having to call on additional state funds [97]. Consequently, policies and programs were tailored to look like the child abuse and neglect model. For example, both child abuse and elder abuse models require the reporting of incidences of abuse through specific channels, the designation of certain professionals to report if incidences of abuse are learned, and penalties for violations. In both forms of family violence, a third party can intervene if there is suspected child or elder abuse [93].

In 1978, the Older Americans Act was amended to include the responsibility of each state to develop long-term care ombudsman programs to deal with elder abuse in nursing homes [174]. In 1987, with the increased public interest in elder abuse, the National Center on Elder Abuse was developed by the federal government to more clearly define elder abuse and neglect as well as to promote awareness and formulate educational programs for elder abuse [174].

In March 2010, the Elder Justice Act was passed. The goal of this act is to "provide federal resources to prevent, detect, treat, understand, intervene in, and, where appropriate, prosecute elder abuse, neglect, and exploitation" [175]. As a part of its activities, the Department of Health and Human Services will implement forensic centers to develop elder abuse services, enhance long-term care services by providing more staff training, provide funds to states' Adult Protective Services for more research, detection, and prosecution of cases of elder abuse, and provide funds to long-term care ombudsman programs to respond to elder abuse in care facilities [175].

The interest in elder abuse increased in the 1980s and continues today, partially due to the growth of the elderly population. According to the U.S. Census, in 2011, there were 41.4 million adults who were 65 years or older, which translates into 13.3% of the U.S. population [176]. By 2060, it is estimated that there will be 92 million adults 65 years of age and older, constituting 20% of the U.S. population. Persons 85 years of age and older are projected to number 18.2 million in 2060 [176]. This rapid growth is attributed to the aging of the baby-boomer generation, and the youngest baby boomer will be 96 years of age in 2060 [176]. In addition, life expectancy has continued to increase. It is projected that by 2050 the life expectancy will be 86 years for men and 92 years for women [173].

Similarly, the ethnic minority elderly population is growing rapidly. By 2050, individuals who identify as racial/ethnic minoities will represent 40% of the U.S. population [130]. Between 2010 and 2030, the white population is expected to increase by 59%, the African American population by 114%, the Asian and Pacific Islander population by 145%, the Hispanic population by 202%, and the Native American population by 145% [177]. These demographic trends have opened the eyes of policy makers and service providers to the needs of the elderly, and the specific needs of minority elderly populations.

Today, elder abuse remains a largely invisible problem. This partially stems from the fact that the elderly are isolated. Frail elders do not often leave the house, perhaps seen only by a caregiver. Therefore, the problem remains behind closed doors [67]. Also, our society has generally positive conceptions about this period of life and the notion of family. We generally view the elderly years as "golden." This is the period when children are grown up and married, with families of their own; when one retires; and when one travels and has leisurely time. In addition, our society believes that the family is a private domain, free from public scrutiny. However, as discussed in this course, elder abuse occurs in both domestic and institutional settings.

PREVALENCE AND SCOPE OF ELDER ABUSE

According to the National Center on Elder Abuse, it is estimated that between 1 and 2 million Americans older than 65 years of age have been the victims of abuse [127]. Epidemiological studies to detect the prevalence of elder abuse indicate a prevalence of between 2% and 10% [131]. According to a national telephone survey, 1.6% of elderly respondents reported experiencing physical abuse in the past year; 5.2% recounted financial abuse, 5.1% neglect, and 4.6% emotional abuse [132]. In another survey study with 3,005 adults between 57 and 85 years of age, Laumann, Leitsch, and Waite found that only 0.2% disclosed to physical abuse in the last year, 9% reported verbal abuse, and 3.5% indicated financial abuse [178]. In a national study conducted by the National Center on Elder Abuse in 2004, there were 565,747 reports of elder abuse to APS in the United States. This was an almost 15% increase from the 483,000 reports in 2000 [89].

The prevalence and scope of elder abuse in institutional settings, such as nursing homes, is not clear, in part due to lack of agreement about definitions. Elderly neglect is typically conveyed as poor care; however, this is a very simplistic definition and does not take into account clinical and legal ramifications [179]. For example, is patient neglect due to staff poor attitudes, medical negligence, human error, or some other factor?

In two studies on elder abuse in institutions, Buzgová and Ivanová reported that 54% of the staff from 12 different residential homes in the Czech Republic self-disclosed to having perpetrated some form of abuse on their elderly patients in the previous year; 65% of the staff witnessed another employee committing some form of elder abuse [180]. When patients were asked, only 11% reported having experienced some form of abuse by staff, and 5% witnessed another patient being abused by a staff member. In a study of 441 individuals living in nursing homes in Michigan, 21% of family members reported some type of elder neglect experienced by their relative in the last year [181]. The most significant predictor of neglect was the patient's ability to carry out activities of daily living, with more limitation correlating to greater likelihood for neglect.

In a study with 1,002 relatives of elderly residents of long-term-care facilities, 16.2% stated their family member had experienced neglect, 13% reported emotional abuse, and 12.7% reported caregiving abuse, which was defined as mistreatment that stemmed from caregiving activities such as withholding or delaying drugs, over administration of drugs, inappropriate uses of physical restraints and forced feeding [140]. The authors noted the limitations of using family relatives as proxies; however, family members are often keen observers of abuse and because the victim would not be identified in the study, the researchers felt that the relatives could be more truthful [140].

This was consistent with another telephone survey study of individuals who had an adult family member 65 years of age or older living in a long-term care facility [141]. Researchers found that 86% of participants reported that their elder family member experienced neglect, such as staff's failure to ensure personal safety and to provide food, water, and/or medications. Emotional or psychological mistreatment, defined as the elder family member being treated disrespectfully, not being allowed to talk or see family members, or being given the silent treatment, was reported by 79% of participants.

In a 2004 study conducted by Goergen in Germany, using a multi-data collection technique with surveys of residents, staff, and professional caregivers of nursing homes, interviews with staff revealed interesting findings [22]. A large majority (70%) of the staff disclosed to having acted abusively or neglectfully on at least one occasion; more than half witnessed another staff or caregiver verbally abuse nursing home residents, and 20% had observed inappropriate use of chemical restraints. Substance abuse on the part of staff, physically aggressive behavior by residents, caregiver burnout, and the ratio of residents to registered nurses were predictors of abuse and neglect [22].

Another study found that, in the last year, 36% of nurses and aides reported having witnessed physical abuse by other staff members; 10% admitted to perpetrating physical abuse against an elderly resident [126]. In another study, two-thirds of nursing aides reported that abuse against patients never or rarely happened [64]. However, of those surveyed, 14% disclosed witnessing daily abuse; slightly less indicated weekly abuse of patients. Abuse was most commonly psychological [64].

Sexual abuse experienced by elders in institutional care facilities has been minimally studied. The literature has documented that sexual offenders who sexually abuse elders in care facilities include employees, other residents, family members, and visitors to the facilities [142]. Perpetrators generally target victims who have mental or physical impairments. In one study, researchers found that the largest group of alleged sexual offenders consisted of employees of the facilities (43%) [142]. The majority of these employees provided direct care to the elder residents. The second largest group was other residents of the facility (41%).

Problems in obtaining prevalence rates stem from a lack of a definition of elder abuse [12]. For example, should the definition focus on acts of physical, psychological, verbal, sexual, and/or financial abuse? Some differentiate between different types of neglect: passive and active [12]. Passive neglect or benign neglect refers to when the caregiver is not aware they are injuring or causing harm to the elder, while active neglect is intentional harm [12]. Utilizing different definitions will affect the outcome of the scope of elder abuse.

Methodological issues, such as sampling and recruiting participants, are complicated because elder abuse is a private and sensitive topic matter. When race, culture, and ethnicity are added to the equation, it becomes even more complicated. Issues of translating and back-translating instruments, ensuring linguistic equivalence of constructs, and hiring linguistic and culturally proficient interviewers are some issues that arise with cross-cultural research. Consequently, to get a sense of the scope of elder abuse in ethnic minority communities, this course will focus on nonprobability sample studies.

SCOPE AND TRENDS OF ELDER ABUSE IN ETHNIC MINORITY COMMUNITIES

There are few empirical studies that look at the scope of elder abuse in ethnic minority communities. In a large-scale study with a representative sample of 5,777 older Americans obtained through random digit dialing, there were no racial or ethnic differences in rates of emotional and sexual elder abuse among whites and non-whites (self-classified as black, Pacific Islander, Native American or Alaska native, Asian, Hispanic, or other). There were slightly higher rates of physical elder abuse for non-whites compared to whites (3.0% vs. 1.4%, respectively) [182]. In another study with 200 Latino individuals 65 years of age and older, researchers found that 40.4% of the participants had experienced some form of abuse or neglect in the previous year; 25% disclosed experiencing psychological abuse, 10.7% physical abuse, 9% sexual abuse, and 16.7% financial abuse [183]. Finally, using a convenience sample of persons of Mexican origin who were 60 years of age or older, Sanchez recruited a total of 62 participants who obtained services from community centers in Michigan and Nevada [71]. Thirty-three percent of the Mexican elders reported awareness of at least one incident of elder abuse in the Mexican American community. When broken down into the types of abuse, 40% reported that they knew of someone who was denied shelter by family members; 22.6% neglect; 12.9% financial abuse; and 11.3% physical abuse. Again, these figures are not necessarily representative given the small sample size and the convenience sample employed. In addition, these are only indirect accounts of elder abuse; however, the study does indicate that elder abuse among Hispanics/Latinos deserves further examination.

There have been very few studies on Native American elders and victimization. A chart review of 550 urban American Indian and Alaskan Indian elders (defined as 50 years of age and older) living in Washington state was conducted to examine the effect of abuse on this population [101]. The researchers found that 10% of the cases indicated definite physical abuse, and another 7% were suggestive of abuse; that is, the alleged cause was not consistent with the location of the injury. Being female, depressed, or dependent on others for food were predictors of being physically abused [101].

In a telephone survey in Pennsylvania, 693 non-African American and 210 African American persons 60 years of age and older were asked about their experiences with financial and psychological abuse perpetrated by a spouse, child, family member, or another trusted individual [184]. Twenty-three percent of the African American respondents indicated they had experienced financial exploitation since turning 60 years of age compared to 8.4% of their non-African American counterparts. The figures were higher for African Americans regarding psychological abuse (24.4%) compared to the non-African American respondents (13.2%). In another study, Dimah and Dimah examined gender differences among African American elder abuse victims and perpetrators [102]. Forty-eight cases of substantiated elder abuse in a service agency were examined. They found that male elder abuse victims experienced more physical abuse (85%) than their female counterparts (42.9%). African American perpetrators of elder abuse were found to be more often related to their victims. Finally, financial exploitation was a common form of elder abuse, affecting 53% of the male victim cases and 54% of the female victim cases.

Chang and Moon conducted a study with 100 Korean immigrant elders and found that 34% had witnessed or heard about elder abuse that occurred among friends, family members, or acquaintances [17]. Financial abuse was the most common form. A common example of financial abuse cited from this study was a son stealing from his parents' Supplemental Security Income checks [55].

In Asia, the topic of elder abuse is receiving increased empirical attention. In a study of Korean caregivers and their elderly family members with various types of physical and cognitive abilities, the most common forms of elder abuses were psychological abuse and neglect [143]. Almost one-fifth of respondents (18%) disclosed to confining the elder family member in a room and 10% admitted to having hit the elder. In a large-scale study conducted in China, 2,039 individuals 60 years of age and older were interviewed, and 36% of the participants indicated they experienced elder mistreatment [185]. Specifically, the prevalence of physical elder abuse was 4.9%, psychological abuse was 27.3%, caregiver neglect was 15.8%, and financial mistreatment was 2% [185]. Risk factors for abuse included having depression, being alone (e.g., divorced, widowed), and having a labor intensive job. In another survey study of individuals 60 years of age and older living in an urban area in China, 35% of the sample (32% men and 42% women) reported elder abuse and neglect [144]. Caregiver neglect was the most common form (16.9%), followed by financial exploitation at 13.6%. In Hong Kong, Yan and Tang conducted a survey study on the risk factors of elder abuse with 276 elder Chinese individuals [105]. More than one-quarter (27.5%) admitted to having experienced at least one type of abusive behavior perpetrated by a caregiver during the past year. The findings of the study also found that verbal abuse was the most prevalent, at 26.8%, while violation of personal rights (5.1%) and physical abuse (2.5%) were less common. Participants who had visual or memory problems and who were dependent on their caregivers were more at risk of general abuse and verbal abuse [105].

It is crucial to remember that the lack of research in this area does not imply that elder abuse does not exist in ethnic minority communities. Unfortunately, cross-cultural research in this area requires considerable funding to obtain adequate sample sizes, the development of culturally sensitive instruments, and the hiring and training of interviewers who can meet the tremendous diversity within the many ethnic minority groups.

DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

In general, elder abuse literature has identified three basic categories of abuse and neglect: domestic elder abuse; institutional abuse; and self-neglect or self-abuse [50]. However, one of the biggest difficulties in the field of family violence revolves around the definition of the problem. Defining social problems is controversial because the definition determines the prevalence rate of who is counted as abused and who is not. It determines what the legislation does and does not cover, and it directs programs regarding the eligibility criteria of who receives services and who does not [50].

What constitutes elder abuse, mistreatment, and neglect? Often, the terms "abuse," "mistreatment," and "neglect" are used interchangeably. Yet, the definition is extremely important, as it sets the stage for measurement in empirical studies, reporting of incidences by practitioners, and development of policies and programs.

Abuse is generally perceived as more serious because it is viewed as a deliberate or intentional act to harm [67]. Conversely, neglect has generally been viewed as less serious because the intent of the perpetrator is not necessarily deliberate. That is, neglect is an act of omission—not doing something because of ignorance or some situational factor (such as stress) [67].

Other definitions have focused on the types and categories of abusive acts. The National Center on Elder Abuse has defined seven different types of elder abuse, which are based on state and federal definitions [81]:

  • Physical abuse: Use of physical force that results in injury, pain, and impairment. Examples include slapping, punching, kicking, and restraining.

  • Sexual abuse: Nonconsensual contact of any form.

  • Emotional abuse: Infliction of distress, anguish, and/or pain through verbal or nonverbal acts.

  • Financial/material exploitation: Illegal or improper use of the elder's resources, property, funds, and/or assets, without the consent of the elder.

  • Neglect: Refusal or failure to provide goods or services to the elder, such as denying food or medical-related services.

  • Abandonment: Desertion of an elderly person by the individual who has physical custody or who is the primary caretaker of the elderly person.

  • Self-neglect: Behaviors of the elderly person that jeopardize his/her own safety and/or physical health.

The types of elder abuse in nursing homes, categorized as institutional abuse, include physical abuse, psychological abuse, neglect, and financial abuse as identified above [106]. Other forms of nursing home abuse include use of inappropriate restraints, substandard care, overcrowding, authoritarian practices, denying residents' daily activity choices, and labeling troublesome individuals, which results in depersonalized treatment [106]. In a qualitative study of elderly nursing home residents and staff in the Czech Republic, one of the recurrent themes was the violation of rights to make decisions and free choice [145]. Due to the restrictive environment in institutional settings, freedom to make decisions regarding activities of daily living becomes important. The lack of respect for elderly residents' dignity and privacy were also noted as dimensions of abuse in institutional settings.

Another form of elder abuse in nursing homes that has been the subject of limited research is nursing home theft. In a study of 47 nursing homes, 6% of the nursing home staff members reported witnessing colleagues stealing from elderly patients [107]. Another 19% suspected coworkers of stealing.

It is important to remember that these forms of abuse are not mutually exclusive. An older individual who experiences one type of abuse will often be the victim of another form of abuse as well. A study of 842 women 60 years of age and older found they often experienced multiple abuses [146]. For example, 69% of the women who had been abused physically also experienced psychological abuse or controlling abuse.

Overall the definition and conceptualization of elder abuse has been fraught with challenges. Anetzberger offers an updated typology of elder abuse that may be when assessing the components of abuse [186]:

  • Perpetrator: Self, trusted other, or stranger or acquaintance

  • Setting: Domestic or institutional

  • Form: Neglect and/or abuse

  • Perpetrator motivation: Intentional or unintentional

  • Locus of harm: Physical, psychological, social, financial, and/or sexual

CASE STUDIES

Read each of the following case scenarios, and try to determine which what type of abuse was sustained.

Case Study I

For several weeks, church members noticed that Mr. L, 82 years of age, had bruises, cuts and scrapes on his face, hands, and arms. Mr. L always had some plausible explanation and, knowing that he was the sole caretaker for his very ill wife of 61 years, they did not press the issue. A hospital social worker finally contacted Adult Protective Services after Mr. L drove himself to the hospital emergency room, over 20 miles from his home, with multiple fractures to his left arm. The APS social worker eventually discovered that Mr. L was being attacked by his wife, who was suffering from undiagnosed Alzheimer's disease and had become combative. Mr. L did not know that his wife's behavior was a part of the illness and was protecting her.

Case Study II

Mrs. J, a long time insulin-dependent diabetic, was admitted to the hospital after being brought to her doctor's office by a neighbor who became concerned after not seeing Mrs. J for several days. Mrs. J finally told hospital staff members that she had run out of insulin several days ago and had given her grandson all the money she had to go and refill her prescription. He did not return, and Mrs. J did not call family members because she did not want to get him in trouble.

Case Study III

Mr. B, 74 years of age, complains with increasing frequency of pain. His physician is puzzled by the complaints because the methadone she has prescribed should be controlling the pain. She has already increased the dosage a couple of times and is reluctant to do so again. She finally asked a family member to bring all of Mr. B's medications to check for a problem in interaction or perhaps the wrong medication. Examination of the methadone tablets reveals that someone has switched most of the methadone with over-the-counter potassium tablets, which are nearly the same size and color. His failing eyesight prevents him from being able to tell the difference in the very similar tablets. Questioning revealed that Mr. B's niece, a former drug addict, has been living with him in exchange for his care, and she prepares his medications each day. The family has suspected that she is using drugs again, but was reluctant to probe too deeply because there is no one else to care for Mr. B.

GENERAL PROFILE OF ELDER ABUSE VICTIMS

There are some studies that indicate that women are more likely to be victims of elder abuse [108]. Other demographic factors that contribute to risk include unmarried status and non-white ethnic origin [110]. Elders who reside with a caregiver or family with a history of substance abuse, mental illness, and violence are more at risk of abuse [108]. Shugarman, Fries, Wolf, and Morris found that elders who have short-term memory problems, psychiatric diagnoses, and/or alcohol problems are more vulnerable to elder abuse [109]. Elders who have poor health and low income also appeared to be at risk of elder abuse [110,186].

TYPOLOGY OF ABUSERS

Ramsey-Klawsnik formulated a classification or typology of perpetrators of elder abuse [111]. This typology provides a description of overall characteristics of abusers. By understanding the different type of abusers, Ramsey-Klawsnik asserts that it has implications for interventions. There are five different types of abusers [111]:

The Overwhelmed Offender

This is an individual who is responsible for providing day-to-day care for the elder, and the amount of caregiving that is needed exceeds the caregiver's ability. This type of offender realizes that his/her behaviors are abusive but has difficulty asking and seeking help. Anetzberger notes that this type of abuser is the most often depicted [186]. However, the caregiver stress theory does not completely explain elder abuse.

The Impaired Offender

This is an individual who has a physical or mental impairment that makes caregiving difficult. This type of offender tends to be neglectful, administer medications inappropriately, and use restraints. Impaired offenders often do not realize that their behaviors are abusive. Research seems to indicate that perpetrators of elder abuse tend to have substance abuse and mental health issues [186].

The Narcissistic Offender

This type of offender does not want to provide caregiving and is only doing so to exploit the elder. Oftentimes, the abuse involves neglect and financial abuse.

The Bullying Offender

This offender has little empathy or compassion for elders. Bullying offenders want to exert power and control over their victims. Their victims are too frightened to disclose the abuse and will merely attempt to placate the abuser. These offenders employ a range of abusive behaviors from physical, sexual, verbal, emotional, to financial.

The Sadistic Offender

This type of perpetrator enjoys humiliating and inflicting terror to the elder and experiences no guilt or remorse for abusive actions.

CONTROVERSIES IN THEORETICAL CONCEPTUALIZATION

How a social problem is conceptualized or defined greatly influences the perceptions of the problem, its attributes, etiology, and the policies and interventions. Wolf identified six broad theoretical models to explain how practitioners and researchers have conceptualized why elder abuse occurs [98]. These models are:

  • Situational model (i.e., the overburdened caregiver)

  • The dependent victim and abuser

  • The impaired abuser

  • Social learning theory (i.e., childhood of abuse and neglect)

  • Feminist theory (i.e., imbalance of power in male/female relationships)

  • Political economic theory (i.e., macro structures and conditions that lead to violence and conflict)

The Overburdened Caregiver

This theoretical perspective argues that elder abuse is caused by a family member who assumes the caregiver role and who is exhausted, stressed, and burdened with the caregiver tasks revolving around the elderly individual who has functional and/or cognitive impairments [67,76]. In other words, there are external or situational stressors that precipitate the abuse. Because the locus of caring is shifting from institutions to the family, families are expected to provide care and support to impaired elders [67]. The caregiver stress theory is one of the most frequently cited to explain elder abuse. However, empirical findings suggest that stress and dependency do not explain or predict perpetrating elder abuse; they merely contribute to abuse [186]. To rely on the caregiver stress theory to predict elder abuse can inadvertently result in blaming the victim for "being difficult" or "recalcitrant" and minimize the perpetrator's accountability [187].

The pressures of caregiving are very real. Caregiver stress is caused when the demands of providing care for the elderly individual are perceived as exceeding available resources [48]. Caregiver burden comprises the range of physical, psychological, social, and financial strains or problems experienced by family members who have a family member with a chronic illness and who assume the primary caregiver role [13].

The literature has identified two types of caregiver burden or stress experienced: objective and subjective burden. Objective burden is characterized by tangible, external stressors. This includes providing physical care, financial stressors, employment, and overcrowding. Subjective burden is defined by the emotions that result from caregiver stresses [6]. In one study, for example, Aneshensel et al. found that the average length of caregiving was seven years [4]. Elders with dementia, for example, often require extensive assistance with bathing, feeding, and bladder and bowel incontinence [67].

Studies have shown that the severity of abuse often increases as elders' cognitive functioning level decreases [143]. Furthermore, family caregivers who have sufficient economic resources are less likely to report using some sort of abuse on the elder family member. Those who experiences higher levels of caregiver burden are more likely to abuse their elder family member.

Typically, overburdened caregivers are female, middle age and have families of their own. They provide much of the caregiving with minimal assistance from other family members. They have very little respite and are taxed with the responsibilities of caregiving and providing for their own families [77]. In in-depth interviews with 11 married and employed Japanese women who were caregiving for an elderly parent, researchers found that many of these women, despite their own career and professional aspirations, placed a higher priority of taking care of their elder family members due to deeply ingrained cultural beliefs about gender roles and filial piety [147]. The women initially took on the task of providing care to their elder parents or parents-in-law because this was the cultural norm. Over time, they felt oppressed as the caregiving duties became overwhelming. Their spouses often adhered to traditional beliefs that caregiving is a female responsibility. The multiple demands and strains these women experienced led to feelings of anger, loss of self-esteem, lack of self-worth, shame, and guilt.

Case Scenario

Mr. R, 54 years of age, and Mrs. R, 49 years of age, work full time in very demanding jobs. About one year ago, Mr. and Mrs. R built an apartment addition onto their home, depleting their savings, to accommodate Mrs. R's mother, Mrs. D. Mrs. R is the oldest of three siblings and care for her aging mother had become primarily her responsibility. The 90-minute drive to her mother's apartment in a nearby city each weekend had become increasingly taxing, and her mother's care had become more time consuming. When Mrs. D's long time physician announced his intent to leave private practice, it became reasonable to make the move. Mrs. D, while not enthusiastic, was agreeable. Mrs. R's brother and sister, who rarely visited or helped with her mother's growing needs, became angry about the move and stated that they had no intention of making such a trip. Now, in addition to working 9 to 10 hours per day, Mrs. R goes home to find numerous messages from her mother with various requests and demands. Additionally, because her mother can see her car drive up, the phone is usually ringing by the time she gets into the house to begin dinner for the three of them. There is an in-home aid who comes three days per week to help with bathing and light cleaning, but lately Mrs. R has questioned whether this is worth the added burden of mediating disputes between the aid and her mother. Each morning before work, Mrs. R prepares her mother's medications for the day and makes sure she has something available for breakfast. She longs for a vacation, but the routine continues 7 days per week. Besides, all her vacation and sick leave must be devoted to taking care of her mother's medical appointments and treatments. Lately, Mrs. R has been having difficulty sleeping with disturbing dreams of having forgotten some major task. She feels tired all of the time. She has also noticed that she snaps at her spouse and friends often and that her anxiety level is increasing. Her own household chores are piling up because she does not have the time or energy to do them. Last week she noticed a red rash on her thigh and wonders when she might find the time to see her own doctor.

As seen in the previous case scenario, elder abuse can be caused by stress, and the parties involved are elderly victims who have cognitive and functional impairments who rely on family caregivers. Research concludes that stress may be a contributing factor in elder abuse, but does not solely explain the phenomenon. Rather, the dependency of the perpetrator and the perpetrator's mental state are risk factors of elder abuse [97].

Dependency of the Victim and Abuser

This theoretical explanation is premised on exchange theory. One of the tenets of exchange theory is that the interaction between two or more persons will be positively evaluated if all persons involved benefit equally from the relationship [12]. However, an imbalance or unequal exchange in the relationship will be viewed negatively, and this imbalance will result in abuse. There are two strains of this theory as it relates to elder abuse: the victim is dependent, which causes elder abuse and the perpetrator is dependent on the victim.

The first strain assumes that elder abuse is the result of the increasing dependency of the elder on the caretaker, who is typically an adult child [12]. The caregiver stress perspective assumes that elderly individuals become weak and frail, thereby making it difficult for caregivers to provide care. The increasing cost in providing emotional, economic, and physical care to the elderly parent without the mutual exchange in the relationship may be viewed as unfair to the caretaker [12]. Thus, this imbalance may increase the risk of elder abuse.

Interestingly, Baumann argued that the picture of the frail, weak, and dependent elderly made it easy to call national attention to elder abuse and to justify allocating resources to this social problem [9]. However, Pillemer argues that there is no empirical evidence that elder dependency causes elder abuse [61]. In fact, elder abuse only occurs in a small percentage of the elderly population, and in a study with Alzheimer's patients, only 5% of the caregivers became abusive [65]. In addition, Pillemer and Wolf maintain that the problem with this perspective is that it rests on an ageist assumption that all people automatically become dependent and powerless as they age [66]. Thus, they assert that the dependency may lie elsewhere.

The second strain of this theory posits that the abuser (again, typically, an adult child) is dependent upon the elder for economic support [12]. Because of the sense of imbalance in the relationship and the violation of social expectations regarding independent adult behaviors, the perpetrator attempts to restore some sense of control by using violence [12]. However, some have a critical view of exchange theory, arguing that to use exchange theory for elder abuse "reproduces assumptions of market economics, independence, and value in the present that reproduce instrumental attitudes to relationships rather than focusing on altruism and life-course interdependence" [188]. However, Wolf and Pillemer found that in many instances of elder abuse, a large number of abusers were financially and emotionally dependent on the elder [96].

This dependency is illustrated in the following vignette.

Case Scenario

Mr. J had returned to live with his mother, Mrs. J, a widow of ten years, after his wife insisted he leave their house. During this time, he became depressed and started to drink. Mrs. J's neighbors became concerned that Mrs. J had lost a tremendous amount of weight and looked sad and disheveled lately. One day, Mrs. J confided to one of her neighbors that ever since her son returned to live with her, he had been pilfering her Social Security checks. Initially, she noticed that small amounts of money were missing from her pocketbook, but now, Mr. J threatens her both verbally and physically. He would smash and throw china at her until Mrs. J handed her signed Social Security check to him.

The Impaired Abuser

The focus of this theory is on the abuser's behavioral characteristics; however, there is minimal research evaluating this theory, as it is difficult to conduct research with elder abuse perpetrators [109]. Substance abuse and psychiatric illnesses are risk factors for elder abuse. In one study of the relationship between reported instances of elder abuse and regional levels of substance abuse, researchers found that elder abuse was related to higher rates of illicit drug use in the past month [189].

The Abuser was Abused/Neglected When Young

The social learning theory argues that individuals' learning patterns occur through observations of others [8]. When used to apply to the area of family violence, some researchers have coined the term "intergenerational transmission of violence," which maintains that abusive behaviors are learned. The intergenerational transmission theory argues that the dynamics of abusive behavior get perpetuated, and this is the reason why some abused children become abusers themselves [95]. A study conducted by Hotaling, Straus, and Lincoln found that abused children are more likely to exhibit aggressive behavior toward family members and to engage in crime outside the family [37]. The intergenerational theory is very popular and makes intuitive sense; however, empirical research does not indicate that abusers of the elderly are more likely to have been raised in families that were violent [12].

Feminist Theory

Feminist theorists argue that violence against women is broadly defined as male coercion of women [99]. In other words, patriarchy and male domination contribute to violence against women [44,72]. Patriarchy is perpetuated and reinforced by cultural ideologies, existing social institutions, gender socialization, and socioeconomic inequalities [44,72]. Thus, the root of violence against women stems from power imbalances in male and female relationships and male domination in the family, which is reinforced through current economic structures, social institutions, and the sexist division of labor [72].

Feminist theory has relevance to elder abuse because elderly abused women are often not thought of as battered women or domestic violence victims. In other words, we do not think of elderly women being abused by their spouses. Studies on domestic violence, for example, have typically excluded women older than 59 years of age [190]. Vinton argues that service providers and scholars have traditionally dichotomized the terms "battered women" and "elder abuse victims" [91]. Each of these terms conjures up images for us; for example, rarely do we associate a battered woman or domestic violence victim with an elderly woman. Instead, we might use the label "elder abuse" because we have inscribed in us a mental picture of an elder abuse victim as a frail elderly person being abused by a caretaker. However, domestic violence does occur throughout a woman's lifespan [70]. Band-Winterstein and Eisikovits argue that intimate partner or domestic violence does not necessarily "age out" and that this notion is a myth [148]. In a study of 620 middle-aged and older women recruited from emergency rooms in an urban setting, 5.5% had experienced intimate partner violence within the last 2 years [149]. Forms of abuse included sexual abuse and verbal threats or use of physical force to make them have sex. It may be that abuse among older couples can be better understood by the abuser-victim dynamics of the domestic violence model than the elder abuse model, which is based on the concept of caregiver stress [14,63]. For example, older women's inability to leave an abusive marital relationship is very similar to their younger female counterparts, such as fear of reprisal [190]. However, for older women, concerns of finances and economic resources stem from their ability to obtain a job, lack of pension, and health and physical limitations [148].

This type of dichotomous thinking has implications for interventions. On one hand, a battered woman will be referred to a shelter, and an elderly female victim of abuse will be referred to Adult Protective Services [92]. In part, this dichotomous conceptualization has been shaped by the historical legacy of the domestic violence and elder abuse movement. Domestic violence, or the battered women's movement, emerged in the late 1960s when feminist and social activism were active. Then, in the mid-1980s, elder abuse emerged as a separate, distinct social problem and was primarily depicted as a social problem where the perpetrators were caretakers.

Political Economic Theory

This theoretical perspective maintains that American societal norms and attitudes may contribute to elder abuse. First, negative attitudes about the elderly create an atmosphere that breeds elder abuse [67]. Ageism is defined as "any attitude, action, or institutional structure that subordinates a person or group because of age or any assignment of roles in society purely on the basis of age" [85]. Our stereotypical views of the elderly include images of elders losing their memory, being less flexible and resilient, and being grouchy and unproductive. Although there is no empirical research that directly links ageism to elder abuse, the argument is that these stereotypes and myths play a role in dehumanizing elders. The process of devaluing and dehumanizing a particular group lends to and perhaps even provides justification for certain discriminatory and/or abusive behaviors [150]. Ageism promotes apathy towards the treatment of elders, and consequently, social problems, including elder abuse and neglect, do not receive the same attention as other problems [67,150].

CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

Why is it necessary to put on a cultural lens when we talk about elder abuse? First, the United States is becoming increasingly diverse in terms of ethnic composition. According to U.S. Census data, there are 37.6 million foreign-born individuals in the United States. The majority (54.3%) are from Latin America (including the Caribbean, South America, and Central America) [191]. By 2050, it is expected that Hispanics will represent 24.4% of the U.S. population [192]. As a result, it is inevitable that race, culture, and ethnicity will have a profound effect on how we think, feel, and act. Race, culture, and ethnicity become the lens through which we view the world and touch on all aspects of human life [59]. Consequently, practitioners will need to become more culturally aware and sensitive to the cultural norms, belief systems, and needs of culturally diverse patients in order to provide culturally relevant services and interventions. In other words, it is inevitable that we talk about cultural competency. Cross-cultural competency is defined as a dynamic attribute that professionals develop in the areas of attitude, knowledge and skills to work with an increasingly multi-ethnic and diverse society [59]. Ultimately, the goal of cultural competence is to reduce the differences between the belief systems of clients and patients from diverse cultural groups and the institutional cultural norms of service delivery agents. This will then mitigate the disparities that exist in the current mental health and healthcare systems [152].

Second, cultural values and belief systems influence norms about family life and structure. It is vital to examine various ethnic groups' norms of family life, as every family system shapes and guides rules, obligations, roles, and labor divisions [19]. Because one's family of origin is the foundational building block to socialization, understanding general views about gender roles, beliefs about family authority, and views about elderly family members will assist us in understanding the intersection of culture, race, and ethnicity and family norms on elder abuse.

A third reason to take into account culture, race, and ethnicity in the study of elder abuse is that these factors influence the labeling or the perception of the social problem. Diller argues that human beings relate to their world through cognitive worldviews or paradigms [20]. These worldviews and paradigms provide individuals with rules and assumptions about how the world works. Culture and ethnicity provide the content of these worldviews [20]. Consequently, how a group labels or constructs abuse or maltreatment is influenced by their cultural beliefs and values, which ultimately affect how domestic violence is perceived, exhibited, and reported [5]. Furthermore, the social realities of the lives of older abused immigrant women may be uniquely different from their younger counterparts as a result of generation, acculturation, and gender role socialization differences. These factors may distinguish how elder abuse victims label their situations and what services they may seek [90].

Fourth, it has been postulated that certain ethnic minority groups may be more vulnerable to violence because of the existence of environmental risk factors such as poverty, racism, oppression, and discrimination. For example, the sociocultural backdrop of slavery, oppression, and economic deprivation may have contributed to any violent behavior seen in the African American community [32].

Finally, culture, race, and ethnicity influence help-seeking patterns. There are a host of factors that influence ethnic minority families and elders in seeking outside professional assistance. This might include financial limitations, suspiciousness or wariness of professionals, or inconvenience in locating and traveling to agencies [29]. However, help-seeking behavior is in part influenced by the individual's definition and understanding of the phenomenon, which is ultimately influenced by culture. For example, an ethnic minority elder who is being abused by another family caretaker may not seek help because he/she does not label the event as a problem. Instead, the victim believes that the event must be something that should be persevered. In other words, the victim shares a "cognitive map" or explanatory model about the explanations and expectations regarding illness, symptoms, or other events like violence [29].

CULTURAL NORMS AND VALUES REGARDING FAMILY AND THE ELDERLY

This section, will briefly review cultural values and norms about family structure and views about the elderly within each of the four ethnic groups: African Americans, Asian Americans, Hispanics/Latinos, and Native Americans. It is crucial that, as helping professionals, we understand cultural values because they are the driving forces guiding daily behavior [100]. Cultural norms about family life and the role of elderly family members will have an impact on how the elderly are treated within society and the family and, ultimately, how elder abuse is perceived.

It is important for readers to remember that there is tremendous diversity within groups. In other words, factors such as acculturation, age at immigration, education level, socioeconomic status, and religion all contribute to the heterogeneity within each subgroup. As a matter of fact, Falicov cautions against static descriptions of ethnic groups because they are merely social science simplifications rather than true portraits of the complexities of culture, race, and ethnicity [24]. Consequently, bear in mind that the following information is intended to present general themes to guide practice and not indicate hard and fast rules.

African Americans: Family and Elders

According to the U.S. Census, African Americans constitute 13.6% of the U.S. population as of 2009, numbering 41.8 million [193]. By 2050, it is projected they will comprise 15% of the U.S. population. They tend to be young; 30% of the African American population is younger than 18 years of age [193].

The family is very important in African American history, and values related to the family are rooted in African traditions. It has been said that the African American family structure is what enabled African Americans to survive during slavery and the challenging times of the Jim Crow era [194]. Willis observes that terms such as "my family," "my folks," and "my kin" refer to both blood relatives and those who are not related, such as special friends and cared for individuals [94]. This was confirmed in a qualitative study in which African American family therapists discussed the roles of African American families' strengths in therapy [154]. The therapists all identified the strong kinship bonds that existed in African American families and noted these bonds extended beyond nuclear family members into extended family members and into the community. Similarly, marriage is viewed among African Americans as a "sacred vow" and covenant [194]. During the slavery period, when family life was severely disrupted, kinship bonds were highly relied on for support. Young children of slaves, for example, were often cared for by older women or children [94]. Parents attempted to discipline and raise their children to the best of their ability given the constraints of life in slavery.

Extended family networks are common in African American families. Many African American family structures are multigenerational and interdependent. In a study conducted by Martin and Martin, it was found that an extended family network might consist of five or more households centered around a base unit, where the "family leader" resides [49]. This extended family network system pools resources to help during hard times. These strong kinship networks are the key element in helping African American families cope with economic stressors as well as structural issues such as racism, oppression and discrimination [49]. Similarly, Willis notes that the value of group effort for the common interest is highly valued [94]. There is an expectation that one shares with the larger African American community, and this value orientation is part of that strategy for survival. Simultaneously, the value of independence is emphasized, which focuses on the ability to stand on one's own feet and to have one's own focus [94]. It revolves around the ability to earn a living, care for one's family and provide for them, and have some left over to help others in the extended family [94]. Jackson observed that African American families have demonstrated an elastic quality, assuming flexible roles to adapt to change and stress [38]. Family therapists have noted the amazing resilience and creativity of African American family members in utilizing internal and external resources in handling the challenges that emerge [154]. Economic reasons are not the only reasons why African Americans share households. They also adhere to cultural beliefs about closeness and connectedness [26].

The elderly are highly valued in African American families. Dating back to Western African traditions, the provision of care of elders is embedded in the belief that it is the responsibility of the kin group and care is a collective process [155]. Even during slavery, slave communities provided care to elderly slaves who could no longer work. Although times and the structure of families have changed, many African American families still abide by these cultural norms. African Americans have the lowest utilization rates of nursing homes; tasks of caregiving in African American families are often spread out to different family members rather than having one identified primary caregiver assuming all responsibilities [155].

Elders are viewed as the repository of wisdom and hindsight, termed "elder educators" [94,195]. In traditional African religions, the oldest family members are believed to have special status and an ability to communicate with God [94]. Harper and Alexander note an interesting and unique trend about African American elders [34]. African American elders tend to live in multigenerational households; however, they do not go to live with their children. Rather, it is their children who move in with them. For example, daughters who are divorced, widowed, or separated commonly return with their children to live with their parents [34]. It is very common for grandmothers to help in rearing the children of single mothers [112].

Asian Americans: Family and Elders

In the 1990s, the number of Asian Americans in the United States increased tremendously due to high levels of immigration from Asian countries. When comparing 2006 and 2007, The Asian population increased by 2.9% between 2006 and 2007 [192]. It is projected that this number will reach 40 million by the year 2050, which would be 10% of the total population [16]. More than half (60%) are foreign-born, and many settled in the United States after 1980.

Approximately one-third (36%) reside in California; however, a greater dispersion of Asian Americans to other states has begun. This trend reflects the refugee groups that immigrated during the 1980s and the 1990s and more recent immigrants from India and Pakistan [88].

Generally, traditional Asian families can be characterized as hierarchical. In other words, family authority and structure is defined by family position, which is determined by age and gender [86]. Older family members have higher status than the young, and men hold higher positions than women [86]. Family harmony and equilibrium are valued, and one way to maintain this balance is to adhere to the hierarchical structure. In addition, traditional Asian American families are patriarchal in nature; the father maintains authority, and the sons are more desired and valued because they symbolically carry on the family line and care for their parents when they become old [86].

Mutual support, cooperation, and interdependence also characterize the family [30]. As a result of the close-knit nature of Asian American families, there is a strong sense of obligation and duty to others [46]. Problems are generally solved within the family, and a sense of family honor and pride limits outside information to be shared by counselors or other professionals [30].

The term "family" can be defined in multiple ways in the Asian American community and can include a wide network of kinship. In many Filipino families, for example, trusted friends serve as godparents to children and play a vital role in their socialization process [46].

Elders are generally venerated in Asia. China, for example, has been described as a gerontocracy because of the overall attitude of respect and veneration toward the elderly [18]. Filial piety refers to a series of obligations of the child to the parent for providing emotional and economic support and bringing honor to the parent by doing well educationally and occupationally. These obligations are dictated by Confucian values and have governed many generations of Asian families [47]. In India, children are socialized early to respect elders as an intricate part of the family system [156]. Unlike American society, which encourages independence to maintain self-esteem, Asian elders encourage their children to operate under a framework of mutual dependency [41]. Old age signifies wisdom, status, and power in the traditional Asian family system [45].

Due to westernization and modernization, many Asian countries are experiencing rapid shifts in cultural norms. It is speculated that in countries that have moved toward more capitalistic and market-driven economies, the values of family and collectivism have shifted to more to individualism. These changing social norms may have impacted the family structure and how families care for their elders [196]. For example, in Japan, more women have returned to the work force, perhaps due to the economic recession as well as shifts in gender role perceptions [196]. Some have noted that traditional and modern cultural beliefs are becoming more fused, including beliefs regarding filial piety [157]. In focus groups with Taiwanese university students, students' beliefs of filial obligation were found to be deeply rooted in their belief systems; they believed that it was their duty to care for their parents [157]. The participants acknowledged the deeply rooted traditions of filial piety that were passed down in their families. However, for some of the students, filial piety was not necessarily demonstrated by living with their parents. They argued by not living with their parents, they would have a greater chance of achieving intergenerational harmony. Furthermore, they stated it was not completely clear how they will actually practice the day-to-day dimensions of filial piety as circumstances are never constant. Therefore, filial piety is dependent on circumstances [157].

Loneliness and social isolation experienced by elders have been identified to be predictors of elder abuse. This might be more salient with ethnic minority elderly immigrants. In one study, the researchers found high rates of loneliness, ranging from 24% to 50%, among elder immigrants from China, Africa, the Caribbean, Bangladesh, and Pakistan [197]. Kao and Lam maintain that when Asian immigrants age in the United States, what they experience is very different from how they were socialized [41]. It is a more demanding task to age in a society where their contributions are devalued, compared to a society where elders are treated with deference. This is demonstrated by the fact that loneliness is a significant predictor to elder abuse. In a survey study of 410 elderly Chinese patients (60 years of age and older), elders with higher reported levels of loneliness were four times as likely to experience elder mistreatment compared to elders with lower scores [158]. It is possible the rapid industrial changes in China have created tension between the older and younger generations in their prescriptions of familial responsibilities and roles.

Hispanic/Latinos: Family and Elders

The Hispanic/Latino population is also a very diverse ethnic group. They hail from Mexico, Puerto Rico, Cuba, and Central and South America. Ramirez has observed that mestizaje contributes to these complex within-group differences [68]. Mestizo refers to the genetic mixture that evolved from amalgamation due to European colonization and the intermingling that occurred between the European population and the indigenous people of the Americas as well as within the various indigenous tribes [68]. The term "Latino" is the preferred term as one that is self-applied, and the term "Hispanic" is a category used by the U.S. Census [100]. Latino describes people whose ancestors come from the Spanish-speaking countries of Latin America as well as those of Spanish and Indian descent whose ancestors have always lived in areas of the Southwest United States, which was once part of Mexico [113]. The word Latino describes diverse ethnic cultural groups, not a singular religious or racial group. Latinos engage in a variety of religious and spiritual practices, and may be white, black, Indian, or Asian. Latinos most often identify themselves by their national origin, for instance, as Dominicans or Mexicans. According to the U.S. Census, 65.5% Hispanic Americans originate from Mexico [159].

Hispanics are the largest minority group in the United States, numbering 50.5 million in the 2010 U.S. Census [198]. This means they constitute 16.3% of the U.S. population. It is estimated that the Latino/Hispanic population will increase to 81 million by the year 2050 [87]. In the past, Latino/Hispanics have resided primarily in the Southwest and West and in a few urban areas, such as New York.

The family is of paramount value, which is influenced by both the Spaniards' Catholic religion as well as the values stemming from the indigenous people of the Americas [100]. In Hispanic culture, familismo, defined as putting the needs of the family before those if the individual, is a paramount cultural value [160]. The emphasis is on family reciprocity, including financial support, shared day-to-day activities and child rearing, and support related to the challenges of immigration [199].

It is both matrilineal and patrilineal, as there was a mixture of both matrilineal and patrilineal tribal governances among the indigenous people of the Americas [100]. However, in traditional Puerto Rican culture, there is a hierarchy of authority based on gender and age. Men and older family members are ascribed authority [53]. Similarly, patriarchal gender roles exist among many Mexican American families [24]. These differences reinforce the notion that there is tremendous heterogeneity within this ethnic group.

The family is an extended system that includes blood relations, those related by marriage, and fictive kin adopted through compadrazgo[27]. Compadres (i.e., godparents or co-parents) and extended family have very strong and close relationships with family members, providing financial and emotional support [200]. Padrinos is the relationship between godparents and godchildren [53]. It is not uncommon to transfer children from one family to another during times of hardship and crises, and mutual help, protection, and caregiving are provided [27].

Community is another value that is emphasized. Unlike individualism, which is the hallmark of many of the values in the United States, Hispanics/Latinos focus on the collective, which extends to valuing community life [100]. Consequently, fictive kinship is a part of the fabric of life. Stemming from this value of community is the emphasis of the value of cooperation versus competition. Latino families teach children the importance of sharing resources [100].

In the Hispanic/Latino culture, self-sufficiency is not expected for the elderly [25]. Because of the values of respect, cooperation, and family, elders expect to receive emotional assistance from their children. Elders are believed to be the storehouse of tradition, wisdom, and tradition [161]. They are viewed as advisors and it is not uncommon for family members to seek the advice of elders for parenting, childrearing, and other aspects of family life. Children are obligated to provide care and to respect their elderly parents [24]. They play important roles when they live with their adult children. Hispanic elders' attitudes about old age and well-being were contingent on their interactions and their sense of connectedness within the family unit [161]. Hispanic immigrant parents view these cultural values as important as they strive to teach their children the importance of respecting the elderly and addressing elders with the proper titles. Some lament the challenge of instilling these values to their children as they become Americanized [201].

Native Americans: Family and Elders

Native Americans, or American Indians, like other minority groups, encompass people with many different languages, religions, organizations, and relationships with the U.S. government [79]. They identify themselves as belonging to a specific tribe, each with unique customs and values. Again, readers are cautioned to regard the themes highlighted below merely as general cultural themes and to keep in mind the tremendous diversity within the Native American population.

The Native American/Alaska native population grew 18% between 2000 and 2010 [202]. As of 2009, this population numbered 5 million, or 1.6% of the U.S. population. It is projected that by 2050, this number will increase to 8.6 million, 2% of the total population [202]. There are more than 500 different tribes and 314 reservations, and for those who live on reservations, many may spend a majority of their time away from the reservation seeking employment, education, or other opportunities [79]. In 2004, this group was more likely to live in Arizona, California, or Oklahoma. The largest tribes are the Cherokee and Navajo. They are also a younger group, with a median age of 31.9 years compared to the median of 40.1 years for non-Hispanic whites [162].

The family is regarded as the cornerstone for emotional, social, and economic well-being for individuals [69]. The composition of the family is very different from the dominant Anglo culture in the United States. For some tribes, the term "family" goes beyond the nuclear family and includes everyone in the tribe or clan. The terms "brother" and "sister" are used to refer to cousins in Native American families [203]. Therefore, family members encompass both blood relatives and tribe members with no distinctions, which is consistent with cultural values that emphasize interconnectedness and harmony [163].

The primary relationship is not necessarily with the parents, but instead with the grandparents, who assume the caregiver and disciplinarian role [79]. For example, among the Native Americans from the Navajo tribe, it is common for grandchildren to be sent to live with their grandparents, which benefits both the child (by ensuring that care and traditional values are passed down to the younger generation) and the elder (by ensuring a means to provide assistance to older individuals) [164]. In addition, the term "grandparent" is not limited to the dominant culture's role of a grandparent, but instead grandparents for Native Americans can also include other relations such as aunts, great aunts, godparents, etc. Similarly, parental roles are assumed not only by the biological parents but also by siblings of the parents [79].

Elderly family members are highly regarded. The aged are believed to be the repository of wisdom, and their role is to teach the young the traditions, customs, legends, and myths of the tribe [7]. In addition, the view of reciprocity is woven in the interrelationships between elders and the young. Typically, elders help raise children, and caring for the elderly is considered "returning the favor" [204]. Consequently, in their old age they are taken care of by the tribe. This family orientation is reinforced by the cultural value of collectivism; that is, the value of being part of a group. Joe and Malach note that consensus is often the goal, and in decision-making processes, individuals often spend a lot of time trying to achieve consensus and harmony [39].

ROLE OF CULTURE, RACE, AND ETHNICITY IN ELDER ABUSE

Definitions and Perceptions of Elder Abuse

There has been a growing interest in the perceptions of elder abuse among ethnic minority populations. This reflects a recognition that culture, race, and ethnicity can influence what constitutes elder abuse, particularly because definitions of elder abuse reflect a white, middle-class perspective [54]. In addition, as noted previously, there is controversy about the definition of elder abuse and how to view the etiology of the problem.

Some studies employ cross comparisons among ethnic groups to identify similarities and differences regarding definitions of elder abuse. In a study that included African Americans, Korean Americans, and white elderly women, the participants were presented with scenarios of potentially abusive situations [56]. These scenarios included thirteen situations that covered various dimensions of elder abuse and mistreatment, such as physical, psychological, verbal, sexual, medical, and financial abuse and neglect [56]. They found that the Korean elderly women were more tolerant of potentially abusive situations compared to the other two groups. In other words, Korean elderly women perceived fewer of the situations (50%) to be elder abuse as compared to white elderly women (who perceived 67% to be abusive) and African American elderly women (73%). It is plausible that the Korean elderly women were more sensitive to hierarchy and traditional gender roles as espoused by traditional Korean culture. There are rigid role differentiations between husband, wife, and children in Korean culture; males are valued, and, therefore, hierarchy and patriarchy are emphasized in Korea [42]. These values affect the Korean elderly women's beliefs about what is acceptable behavior and what is not.

These findings were replicated in a study conducted by Moon and Benton [54]. The study consisted of 100 African Americans, 95 Korean Americans, and 90 white elderly individuals 60 years of age or older, all living in Southern California. All participants were interviewed face-to-face. In general, the majority of the participants, regardless of ethnicity, disapproved of obvious, blatant forms of physical abuse such as hitting an elder. Interestingly, some participants stated that it might be tolerated depending upon the circumstances. For example, 9.5% of the Koreans, 5.6% of the whites, and 2% of the African Americans indicated that it was acceptable to restrain an elderly parent in bed depending upon the circumstances. In addition, findings indicated that the Korean Americans and African Americans were more willing to tolerate medical mistreatment of elderly individuals. When asked about the causes of elder abuse, Korean Americans demonstrated a significantly different perception than either whites or African Americans. Korean Americans, for example, felt that elder abuse was primarily perpetrated by those with a mental illness or problems with substance abuse.

In a study comparing elders living in Korea and Korean immigrant elders in the United States, 90% of both groups agreed that scenarios that depicted physical and financial abuse were mistreatment. However, there was a lower percentage of agreement (37% to 40%) regarding the scenarios that portrayed neglect [205]. Both groups were more likely to seek help in cases of elder abuse, though the likelihood was lower for cases of neglect. However, Korean immigrants were 17 times more likely to seek help in cases of physical abuse compared to their Korean counterparts. Furthermore, women and more educated individuals were more willing to seek help [205].

In another similar study conducted by Anetzberger, Korbin and Tomita, four groups were recruited—whites, African Americans, Puerto Ricans, and Japanese Americans—for focus groups [5]. In general, the Puerto Rican respondents were more likely to label a situation as elder abuse without qualification, and the white and Japanese American focus group participants were least likely to label a situation as elder abuse. Meanwhile, African Americans tended to look at the context or circumstances to assist in understanding whether a situation was considered abusive or not. They were also asked what was "the worst thing that a family member can do to an elderly person." The white focus group participants stated psychological neglect was the worst thing, the Japanese Americans listed psychological abuse, and African Americans stated psychological abuse and exploitation. Although most studies report differences among ethnic groups about the definitions and perceptions of elder abuse, it is not always clear how cultural values and norms play a role in these differences. Therefore, the specific cultural context can influence definitions.

Modernization in India has negatively impacted the social status of the elderly. Along with modernization come shifts in power structures and dynamics in the family system [114]. Like many other Asian cultures, Asian Indian elders are highly respected, as age is a valued social status [114]. Using a series of research methodologies to collect data about elder abuse within an Asian Indian context, some interesting results emerged. First, the cultural context does influence perceptions and definitions of elder abuse. Psychological/emotional abuse goes beyond insults, criticisms, and pejorative statements. In the Indian context, elders perceive behaviors that go against their religious or philosophical beliefs as constituting psychological abuse. For example, many Hindus have day-to-day dietary restrictions, and when elders live with their children who do not observe the same dietary restrictions, the elders may change their lifestyle to the extent that they perceive it as abuse or neglect. In a study focusing on Tamil and Punjabi immigrants in Canada, daughters-in-law were often identified as perpetrators of elder abuse in multigenerational households [206]. Nagpaul describes an elderly Indian woman who has stopped eating in the family kitchen because her daughter-in-law uses the same utensils to cook meat as in her vegetarian dishes. She now survives on bananas. She feels she has no other residential living options than to live with her son and daughter-in-law [114].

Elder Abuse and Cultural and Social Contexts

While examining cross-cultural differences can be helpful in highlighting the differences and similarities between groups, some researchers have focused on studying one group in order to understand specifically how the qualitative details of their social realities might influence perceptions of elder abuse [31]. Again, because the sample sizes in such studies are frequently small, it is important to be cautious about generalizing findings to entire populations.

Using a review of the literature and the author's research with African Americans in North Carolina, Griffin noted that the generally accepted definition of elder abuse and the common profile of elder abuse victims and perpetrators may not necessarily apply for African Americans [31]. The general profile developed by Kosberg describes an elder abuse victim as older than 75 years of age, middle-class, widowed, white, and female, with mental or physical disabilities [43]. The perpetrator is described as a caregiver, typically a middle-aged adult female who resides in the home of the elder.

Griffin argues that elder maltreatment and abuse in African American communities takes place in a markedly different social context [31]. As previously noted, African American elderly individuals frequently live in multigenerational family households, and unlike white elders who leave their homes and live with their children, children come live with them [31]. This situation provides a unique set of stressors that may contribute to elder abuse and maltreatment in this community.

Much has been written and speculated about the culture of violence in African American communities and whether or not this plays a role in risk factors for elder abuse among this group. Some suggest that historical violence against African Americans, perpetrated by individuals as well as institutions, is partially responsible for violent behavior among African Americans [11]. In a qualitative study of 30 older African American women, some women mentioned the spill-over effect of violence in the streets into the home as a trigger to family violence [165]. However, these arguments are not conclusive. Some have noted that the family structure of African Americans (that is, multigenerational households) can place elders at risk in their homes [32]. As described previously, adult children, as well as grandchildren and other relatives, are more likely to move into an elder's home. The strength of such multigenerational households is that it has allowed generations of poor African American families to pool their resources during hardships [11]. It can be argued that support from multigenerational living arrangements as well as from the church can be protective factors to elder abuse. However, Benton argues that the circumstances that contribute to relatives moving into an elder's home are typically due to stressors such as divorce, unemployment, or drug problems, all of which are risk factors for elder abuse [11].

The social or economic contexts also play a role in elder abuse among Native Americans. Dependency has become a variable studied in the field of elder abuse. Interestingly, in the mainstream literature on elder abuse, the research focuses on the elder becoming dependent on family members, which is believed to play a role in elder abuse. Boudreau observed that the direction of financial dependency is opposite for Native Americans; many young Native Americans are dependent upon their elderly family relatives for financial support [12]. Many elderly receive monthly paychecks from pensions, Social Security, or welfare, and because of the high rates of unemployment, many younger Native American adults rely on their elderly family members' funds [15]. Consequently, many Native American elders are at risk of financial abuse. The economic stressors on many Indian reservations have also adversely impacted the family kinship system. Many have had to leave the reservations in order to find employment, leaving elders behind. Some service providers have asserted that this leaves elderly family members isolated, without family to provide for the care they might need [15]. Furthermore, years of social and historical forces that reinforce racism (e.g., failure to recognize tribal groups, relocations, forcible removal of children to boarding schools, and exploitation of Indian land) have negatively impacted the traditional Native American family system. Family ties and traditional values that emphasize the collective unit have both been disrupted [166].

Forces of social change impacting the traditional family structure have also affected Chinese elderly in Hong Kong. In recent years, the primary social support system for the elderly has been impacted by small public housing units, which have not encouraged multigenerational households [45]. Consequently, many young adult children move to new towns outside Hong Kong, leaving elderly parents behind. Elders who have been socialized to expect to be comfortable and cared for in their old age instead find themselves isolated. Consequently, principles of filial piety are challenged.

The theme of respecting elders and filial piety surfaced in a qualitative study with Asian American immigrants. They stated that adult children should support their elderly parents, especially if they have a successful life, and this value should be passed down [207]. Interestingly, Korean immigrants in Chang and Moon's study identified elder abuse in terms of "abrogation of filial piety" [17]. These acts included adult children not wanting to live with elderly parents, placing their elderly parents in a nursing home, or not showing adequate or proper respect. Many Korean adult children may have acculturated to new value systems that minimize familial responsibilities, particularly to parents. Pang found a similar theme surfacing among Korean elderly immigrants [60]. Many resented living with their adult children and having to watch children, cook, and clean the house. They felt they had become full-time childcare providers. Because many elders did not regard discussing and negotiating these matters appropriate, the situation merely worsened. They classified these scenarios as abuse.

Similarly, in a study with Vietnamese elders, Le found that some elders stated that their daughters-in-law did not want them to learn English or how to use the transportation systems [115]. Therefore, they were confined at home to do household chores as free laborers. They classified these behaviors as elder abuse. Interestingly, emotional abuse was pervasive, and it not only included threats of putting the elder in a nursing home, but the use of silent treatment and blatantly ignoring their presence.

In a study using focus groups with home care workers who worked with Chinese elderly, the theme of disrespect emerged prominently. Disrespect encompassed actions and attitudes that go against cultural norms of obedience, conformity, and filial piety. Such behaviors might include being bossy or rude, ordering an elderly person to leave the room for no reason, scolding, or being demeaning [167]. Disrespect led to social isolation among the elderly, and for some of these immigrant Chinese elderly, the social isolation was exacerbated by financial dependency or dependency on family members to help due to their low level of English proficiency. The dissonance experienced by the Chinese elders stemmed from their expectations of filial piety and being taken care of in their old age. When this did not happen, this led to loneliness and depression; in the elders' minds, this was a type of "abuse" [167].

This concept of disrespect is not specific to Asian culture. A qualitative study of African American, Hispanic, and white custodial grandfathers found that the men discussed their grandchildren and children being disrespectful. Not listening and not appreciating them, which ultimately made them feel devalued and in their eyes, fell into the category of emotional abuse [168].

Cultural values and norms of family and family obligations also color elder abuse and how victims perceive the abuse. Sanchez noted that in the Latino/Hispanic culture, particularly for Mexican Americans in the study, la familia may play a role in the sanctioning of family violence [71]. A majority of the Mexican American elderly participants justified the violence, stating they had instigated it and that it was best dealt with within the family. The needs of la familia are considered paramount and are more valued than the needs of the individual [71]. Therefore, incidences of elder abuse would not be disclosed to authorities; rather, they would be kept within the confines of the family. Related to this is the theme of verguenza, which emerged during the study. The word means shame or losing face. Disclosing that one's child has mistreated a parent brings shame to the family and violates norms about la familia[71]. Yet, one study found that length of residence in the United States predicted caregiver neglect among elders in Latino families [183]. This raises the question of whether immigrants' emphases on family and family obligation decay with acculturation. The role of family in the maintenance of elder abuse warrants more empirical attention.

Tomita discusses similar themes in the examination of elder abuse within a Japanese cultural context [84]. The Japanese have a strong sense of "we-self" or "familial self," which is markedly different from the Western/American "I" centered self. Again, the elder abuse victim may feel it is necessary to relegate his/her individual needs so as not to jeopardize group harmony. Cultural norms of perseverance, silent suffering, and quiet endurance are valued, but these are also associated with victimization; consequently, victims do not necessarily perceive and label themselves as victims of abuse. For many Japanese, it is more important to protect the family and the community by not discussing with outsiders anything that is shameful and dishonorable [83].

Although there are few research studies focusing on ethnic minority families and elder abuse, there is a growing recognition that more scholarly empirical work is needed to increase the knowledge base in this area. Practitioners and scholars realize that understanding and highlighting the cultural context of elder abuse will shed light on formulating culturally sensitive interventions for ethnic minority families and their elderly family members.

Role of Culture, Race, and Ethnicity in Help-Seeking Patterns

It has been said that ethnic minority elders experience multiple jeopardy. In other words, they are vulnerable to life stressors because of their age, being an ethnic and class minority, not being proficient in the English language, being unfamiliar with American institutions, and not having transportation or social support networks [23]. Furthermore, most ethnic minority elderly do not voluntarily seek out social, community, and mental health services. For example, in a study with elderly Korean immigrants from Los Angeles County, there was a disconnect with their views and their intention to seek help, even when they classified various scenarios as elder abuse [169]. For example, 91% of the elders stated the financial abuse scenario constituted elder abuse, but only 63.7% stated they would seek help. Consequently, it is important to step back and examine reasons for their reluctance because these factors are in part social and cultural, and lessons learned can be used to develop culturally sensitive interventions and programs for the ethnic minority elderly.

Language Barriers

Many ethnic minority elders may not be proficient in the English language. If the helping professional cannot communicate with the immigrant elder, the patient is less likely to disclose personal problems, particularly sensitive topics such as abuse [52]. However, many helping professionals in social services are not multilingual despite the efforts to recruit professionals who are both bilingual and bicultural. This becomes even more problematic in certain ethnic groups, such as the Chinese, who have numerous dialects.

Geographical and Operational Accessibility of Services

Often, social service and community agencies are located in areas that are not easily accessible to elderly individuals who may not be able to drive themselves. Thus, they find themselves relying on public transportation, which may not be reliable or convenient. In addition, many agencies operate traditional hours of service—weekdays, from 9 a.m. to 5 p.m. Again, because they must rely on their adult children who may be working, elderly individuals may find it difficult to gain assistance.

Financial Difficulties

Some elderly face increasing financial difficulties as they age. They are typically living on fixed incomes; some do not have Medicare, Social Security, or receive pensions [23]. Consequently, many elderly immigrants not only avoid seeking services but also put off seeking medical services and other necessities until the situation becomes extremely severe [41].

Stigma/Shame in Asking for Help

As mentioned earlier, the concept of shame in many ethnic minority cultures is very different from that of Western notions. In traditional Asian culture, for example, shame or loss of face extends to the collective unit such as the family and community. Therefore, not only is the individual embarrassed, but the shame is also experienced by the entire family system, including one's ancestors. This similar theme appeared in Sanchez's study with Mexican American elders [71]. They revealed that incurring shame to the family is to be avoided at all cost, and only on rare occasions, when someone's life is in jeopardy, should outside agencies be involved. In a study comparing Koreans and Korean immigrants in the United States, both groups indicated that physical and financial elder abuse was the most severe form of abuse compared to other forms of maltreatment [205].

Importance of Keeping Individual Problems from Outsiders

Tomita's qualitative interviews with Japanese adult immigrants revealed the importance of not discussing problems with outsiders [83]. They emphasized that it was unacceptable to make any disclosures about any unpleasantness to outsiders, but instead they must always maintain and present a happy and untroubled countenance to the public. Incidences of abuse would bring dishonor to the community and should be hidden at all costs.

Mistrust of Mainstream Services

Many ethnic minority immigrant elders are simply mistrustful of Western mainstream services. In a study of 124 Korean immigrant elders, one of the themes that emerged was mistrust of third-party interventions as a deterrent in seeking help [170]. Elders who adhered to traditional values were less likely to seek formal help. Coupled with unfamiliarity with Western notions of mental health and health and institutional procedures, many prefer to rely on traditional healers. For example, some Mexican American elders seek curanderos (folk healers) for healing and spiritual guidance [52]. African American elders are more likely to seek help from spiritual leaders, family, and the community than from mainstream services. Furthermore, many African Americans with strong ethnic affiliations are more likely to use prayer and forms of spirituality when they need help instead of seeking formal services [116].

Ambivalence Toward the Legal System

Another issue among many ethic/racial minority groups is ambivalence or fear of the established legal system. In one study, many of the participants (older African American, Hispanic, and white women) identified fear of police as a major barrier to seeking help through legal channels. Concerns that the police would not understand, demean the victim, and even trigger police brutality were expressed. There was also a perception that restraining orders or protective orders were ineffective and could exacerbate the abuse [139]. Since the 1980s, more tribes have developed legal codes for elder abuse [208]. However, these legal remedies mirror Euro-American legal standards, and they appear to go counter to tribal cultural values of collectivism, harmony, and healing. Legal punishment of the abuser may therefore be less effective, and some Native Americans may be reluctant to seek help through the legal system [208].

This list is not an exhaustive list of barriers experienced by ethnic minority elders. It does provide readers a glimpse into their social realities. Abuse and mistreatment take on a host of connotations, and then given the layers of barriers, many elders are reluctant to seek assistance from mental health professionals, physicians, and other authority figures.

ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

This section will provide readers an overview of various assessments and interventions for practitioners when working with elder abuse patients, particularly with those from ethnic minority groups. An emphasis will be placed upon gleaning cultural values and belief systems and incorporating them into assessments and interventions so that delivery of services can be both culturally sensitive and relevant.

ASSESSING FOR ELDER ABUSE

Assessing for elder abuse does not merely involve asking the possible victim questions. It also involves asking oneself difficult self-evaluative questions such as: Do I hold ageist attitudes? How are these attitudes translated when I conduct an assessment? Do I believe that elders can be abused, even sexually abused? Because of pervasive ageist attitudes, practitioners often fail to acknowledge that some forms of elder abuse occur [1]. This may impact whether certain assessment questions are asked.

Sengstock and Barrett recommend a two-step process in the identification of elder abuse [73]. The first step revolves around identifying elders who may be at-risk for elder abuse, and the second step involves verifying instances of abuse. Let us first review screening elders who may be at risk for abuse. According to Sengstock and Barrett, certain situations may make some elders more vulnerable to elder abuse [73]. Any elder, for example, who is incapable of taking care of his/her own daily needs and is dependent on another person is automatically in an at-risk situation.

For screening, Sengstock and Barrett recommend practitioners assess some of the following domains [73]:

  • Reason for visit to practitioner: Presence of acute or chronic psychological or physical disability, elder's inability to participate independently in activities of daily living, reluctance of caregiver to give information about the elder's condition, delay in elder's seeking professional or medical assistance, and inappropriate caregiver's reaction to practitioner's concern may indicate an at-risk situation or potential abuse.

  • Family history: Elders who grew up in violent homes, children who have antagonistic relationships with the elder, children's excessive dependence on the elder, use of substances such as alcohol or drugs by children, and children who were abused by the elder may indicate an at-risk situation or potential elder abuse.

  • Elder's personal/social circumstances: Caregivers who have unrealistic expectations of the elder, elders who are socially isolated, and conflict in the family system may also warrant further questioning by the practitioner.

  • History of accidents: Patterns of accidents that do not make sense should alert practitioners to potential abuse.

  • Healthcare utilization: Health care "shopping," in which the victim does not have a regular physician because of the perpetrator's fear of detecting abuse. Infrequent visits to physicians and caregivers overanxious to have elders hospitalized may also be signs of an at-risk situation.

Jayawardena and Liao also encourage practitioners to inquire about the domestic relationship between the elder and caregiver and underlying issues and dynamics of control [117]. For example, the practitioner should ask about the duration and nature of the relationship and how much responsibility the caregiver is assuming. In trying to gauge control and power dynamics, the practitioner may want to ask about financial resources, power of attorney, and how decisions are made [117].

The presence of any of the above does not necessarily mean that the elder is a victim of elder abuse. Rather, the presence of these factors warrants further questioning and observations on the part of practitioners. Assessment is a dynamic and holistic process, taking into account both individualistic and environmental factors. Given the legal nature of abuse, it is also important for practitioners to determine whether they are conducting an assessment or an investigation; an investigation implies an adversarial component, while assessment is a collaborative process [3].

Another screening device is the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). This is a 15-item tool that measures three aspects of abuse: violation of personal rights or direct abuse, characteristics of vulnerability, and potentially abusive situations. These 15 items were eventually reduced to six items, which were found to be as effective in identifying abuse as the original 15 items [58,98]. Practitioners can easily incorporate these six questions into their assessment, and positive responses should raise a "red flag" [58,98]:

  • Has anyone close to you tried to hurt or harm you recently?

  • Do you feel uncomfortable with anyone in your family?

  • Does anyone tell you that you give him or her too much trouble?

  • Has anyone forced you to do things that you did not want to do?

  • Do you feel that nobody wants you around?

  • Who makes decisions about your life, how you should live or where you should live?

The Elder Abuse Suspicion Index (EASI) is a five-item tool that provides practitioners with a very quick sense of whether there is potential presence of elder abuse [171]. It was originally developed for use by physicians, but it can be used by practitioners in diverse disciplines. The following items comprise the index [171]:

  • Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

  • Has anyone prevented you from food, clothes, medication, glasses, hearing aids, or medical care, or from being with people you wanted to be with?

  • Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

  • Has anyone tried to force you to sign papers or use your money against your will?

  • Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

The Brief Abuse Screen for the Elderly (BASE) consists of only five questions and takes less than one minute to complete [36]. It is not meant to be administered to the client, but is designed to determine the practitioner's level of suspicion. It is ideally suited to be used in conjunction with a tool that assesses for actual elder abuse [36].

Other guidelines for effective screening include [57]:

  • Ask open-ended questions.

  • Normalize the questions by stating to the patient that practitioners normally or routinely ask these types of questions.

  • Ask specific and behaviorally oriented questions. For example, if you ask a patient if he or she has been abused, you will likely receive a negative response. Instead, ask specific questions, such as:

    • Has anyone ever hurt you?

    • Has anyone ever touched you when you did not want to be touched?

    • Has anyone ever taken anything that was yours without your permission?

    • Does anyone ever talk or yell at you in a way that makes you feel lousy or bad about yourself?

    • Has anyone ever threatened you?

  • Explore any affirmatives to the above types of questions. Find out more about frequency, severity, what precipitates the violence, and the outcomes of the violence. Can the patient protect him/herself? What does the patient want to happen now?

Welfel, Danzinger, and Santoro encourage practitioners to interview family members separately [93]. This is more likely to elicit honest disclosures than interviewing elders and their family members together. An elder might feel embarrassed or intimidated and will refrain from disclosing abuse in the presence of family members. No family members should be discounted as possible perpetrators.

If the practitioner finds an elder is at-risk, the next step is to investigate, report and possibly verify the abuse [73]. A comprehensive assessment includes an examination of physical, psychological, and social characteristics of the elder and his/her family members and other significant others. It is important to note that physical abuse injuries are likely to be located in an upper extremity (e.g., arm, hand) or the maxillofacial, dental, and neck area [80].

CULTURALLY SENSITIVE ASSESSMENT: CONSIDERATIONS AND GUIDELINES

Many ethnic minority groups such as Hispanics/Latinos, Native Americans, and Asian Americans emphasize the collective unit. Tomita, in her work with Japanese elder abuse victims, discusses their strong sense of "we-self" and "familial self" which causes some elders to relegate their individual needs for the good of the group [84]. Consequently, they are less likely to discuss or complain about elder mistreatment. If they do complain, they will make certain that there are no negative ramifications on the family member or the perpetrator [82]. Tomita recommends the following tasks be incorporated into assessment when working with ethnic minority elders who subscribe to cultural norms emphasizing group collectivity [82]:

  • Explore the elder's level of collective self or commitment to the perpetrator. The practitioner, for example, can ask the elder if any of their finances, such as their pension, is shared with other family members and how they feel about this.

  • Examine the cultural context of abuse.

  • Assess the likelihood of employing outside interventions. Many ethnic minority families do not believe that family matters should be discussed with outsiders.

  • Assess for subtle signs of psychological abuse and neglect. The practitioner can ask the elder about their relationships with family members and then listen closely to the elder's choice of words. Chang and Moon, in their study with Korean elders, found that when asked if the elder gets enough to eat, the elder may not directly say "no" [17]. Rather, they might say in a roundabout way that the daughter-in-law often says: "You don't really need that second helping of rice, do you?"

The practitioner's choice of words is also vital during the assessment process. The term "abuse" is often unfamiliar or may be even a taboo word. In some ethnic minority groups, this term is difficult to translate. Therefore, it is more helpful to ask specific behaviorally oriented questions. Tomita suggests that practitioners find culturally acceptable terms for assessment [82]. When working with Asian immigrants, the terms "sacrifice," "suffering," and other related terms may be more meaningful because the cultures maintain that life has much suffering, and stresses the need to persevere.

It is important for practitioners to remember that the elderly population is not a homogenous group [36]. Racial and ethnic diversity contribute to their heterogeneity, but there are other dimensions that practitioners may not consider, including sexual orientation.

INTERVENTIONS FOR ELDER ABUSE

Mandatory Reporting Laws

All fifty states have enacted legislation dealing with elder abuse, and they share many features with child abuse statutes. Elder abuse laws are also called APS laws because many states combine the protection of elders and disabled adults under one law [120]. They provide legal definitions of elder abuse, establish administrative channels for the investigation of and intervention in elder abuse, define who is mandated to report, and designate penalties for violations [93]. However, the specifics of state laws vary, and elder abuse laws may be ambiguous. Individual states are responsible for their own interpretations of the laws [103].

What follows is a brief review of the administrative channels for the investigation of elder abuse cases. It is important to remember that each state has different elder abuse statutes and they differ along three major areas: mandatory versus voluntary reporting; the targeted elder population to be served (for example, some states focus on cognitively impaired or incapacitated elders); and the authority granted to elder abuse workers to investigate cases (for example, some states require that the worker seek consent from the elder) [120].

In all fifty states and the District of Columbia, an APS agency has been designated to investigate reports of elder abuse. This is the principal public agency that is responsible for both investigating reported cases of elder abuse and for providing victims and their families with treatment and protective services. Title XX of the Social Security Act makes it a federal requirement for states to implement APS in order to receive funds [104]. In most jurisdictions, the county departments of social services maintain an APS unit that serves the need of local communities [2]. In general, APS offers case management, emergency medical services, alternative housing arrangements, and help in obtaining Medicare, Medicaid, and aging services [104].

As noted, elder abuse laws differ from state to state. Tennessee, Virginia, and Texas uphold the principle of autonomy in that elders can refuse services. In other states, authorities can be called to intervene if elders refuse services [103].

Unlike child abuse statutes that mandate professionals in all states to report incidences of child abuse, there is less consistency among the states regarding mandatory reporting for elder abuse [93,108,172]. For example, practitioners may be mandated to report only in cases in which the elder is residing in institutional settings [93,108]. The definition of elderly may also differ [108].

Those people who are designated as mandated reporters vary from state to state. In Illinois, for example, licensed counselors are specifically named as mandated reporters [172]. Twenty-one states and protectorates required mental health professionals to report; 17 required psychologists to report; 5 required family and marriage counselors to report; and 30 required social workers to report elder abuse [172]. As with child abuse statutes, the practitioner does not have to prove that the abuse occurs before reporting; the practitioner must report even if he/she only suspects abuse. Only 75% of the state laws on elder abuse include a criminal penalty for failure to report [93]. To locate the number to call for specifics about your state's elder abuse laws or to report elder abuse, visit http://www.ncea.aoa.gov/Stop_Abuse/Get_Help/State.

Frequently, practitioners are reluctant to report elder abuse. It is estimated that less than 2% of suspected elder abuse cases are reported by physicians [129]. There are several barriers to reporting. First, many practitioners do not have a clear understanding of how APS operates. Many are not familiar with the elder abuse reporting laws, how they work, and/or who to contact if they were to report, and time constraints make it difficult to do additional research to locate the information. Second, practitioners fear they will make a bad situation worse or that nothing will change if they report the abuse [117,121,129]. Third, practitioners may also feel threatened for their own safety, and in some instances, it may be necessary to contact law enforcement as well [117,121]. Some are also concerned that they are breaking the confidentiality of the elderly individual [121,129]. Practitioners may be unsure due to lack of preparedness. There is a shortage of services for elders, particularly in rural areas, making it difficult to make proper referrals. In some rural areas, transportation barriers make it even more complex [128].

Education

Healthcare professionals can play a significant role in education and information dissemination. It is important to educate the victim by providing him/her with information about the nature of the problem, their options, and assuring the victim that he/she is not responsible for what has happened. Distribute literature about elder abuse when appropriate, and provide a list of emergency community resources (i.e., lock replacements, counseling, hotlines, shelters, meals-on-wheels, visiting nurse, adult day care, homemaker, etc.). Family members also require education.

Safety Planning

Practitioners should review safety planning with the elder. Components of safety planning involve encouraging the patient to have emergency numbers on hand; being able to identify warning signals that the violence might escalate; having bags packed in the event that the elder needs to leave immediately; and forming an escape plan by identifying all the exits. The elder should be encouraged to replace locks if necessary. Remember, older women and men do experience domestic violence or spousal abuse; and therefore, it is important to review safety planning. Again, safety planning should be done in such a way that it does not contradict the ethical principle of respect for persons; it should help keep elders safe but simultaneously empower them to change their situations [151].

Legal Assistance and Orders of Protection

Elders may require legal assistance to establish guardianships, revoke powers of attorney, and obtain orders of protection. Every state offers orders of protection for domestic violence. These orders are available for victims of provable violence perpetrated by a person to whom the victim is married or was formerly married, has a child in common, or is related by blood [122]. Some states extend the availability of orders of protection to include vulnerable adults [122]. Orders of protection essentially stipulate that the abuser must stay away from the victim and his/her home, vacate the home, and/or refrain from abuse or threats. Practitioners must be aware of the limitations of orders of protection and seek legal consultation for elder abuse victims. More states are expanding their definition of domestic violence to include other forms of family violence, including elder abuse [123].

Alternative Housing

Practitioners can discuss options for alternative living arrangements with elderly individuals. Depending on the situation, domestic violence shelters might be appropriate; in other cases, temporary stays in care facilities, senior housing, or shelters for victims of abuse may be preferred [133]. However, always begin with the least restrictive arrangements [57]. For example, does the elder have someone to stay with him/her? In addition, explore options such as home care arrangements and the issue of temporary or permanent alternative residences (i.e., a senior citizen residence, nursing home, shelters, etc.).

Providing services to elders at risk of abuse or who are victims of elder abuse is complicated. Practitioners must wrestle with issues of self-determination, mental competency, and, as discussed previously, inconsistency of elder abuse statutes from state to state. The concept of self-determination refers to the right of individuals to make their own decisions [10]. To truly self-determine, each person must have several alternatives that are feasible and appropriate to their situation. To complicate matters, in working with elder abuse victims, practitioners also must examine patients' levels of "learned helplessness," fear, and mental competency, all of which affect their ability to self-determine [10]. Consequently, working with elders requires a long-term casework approach—the building of a trusting relationship with the patient, referring, linking, and coordinating appropriate services, and providing counseling and support to the individual [10].

Prevention

Healthcare facilities often conduct background checks on their care providers. Families who hire care providers for their elder relatives should also conduct comprehensive background checks to reduce the risk of abuse. Family members may do some background checks themselves by calling references and verifying employment dates. With Internet technology, there are businesses that will conduct background reports for a nominal fee. Red flags that could indicate potential problems include [134]:

  • Unsigned applications

  • Gaps in employment that are not or are poorly reconciled

  • Unanswered questions regarding criminal background

  • References are friends or family members as opposed to previous employers/supervisors

  • Names of past supervisors cannot be recalled

  • Poor explanations for leaving other positions

  • Excessive cross-outs and changes made on the employment application

  • Background questions not answered

In some states, banks are mandated to report incidences of financial abuse of their elderly clients through APS [153]. However, many banks are concerned about legal liability despite the fact that there are immunity clauses for those who report in good faith.

ETHICAL ISSUES

There are unique ethical issues for practitioners when dealing with cases of elder abuse. Practitioners should consider the following ethical issues.

Autonomy and Self-Determination

Autonomy is defined as an ability to control one's own life and is based on independence and freedom [135]. On the other hand, self-determination is characterized by the ability to make informed decisions and plans to fulfill personal goals [124]. Both autonomy and self-determination are important aspects of care and should be protected. In some cases, the violation of clients' autonomy and self-determination is very subtle. For example, practitioners should consider whether the role of the practitioner's expert status inadvertently reinforces or mimics the power dynamic in an abusive relationship [136]. The abused elder should feel free to make decisions regarding his or her life or care.

The state may intercede when an individual cannot protect him/herself from harm. Referred to as parents patriae, the state's intervention allows agencies, such as APS, to provide voluntary and involuntary services for at-risk elders [125].

The balance between promoting self-determination and ensuring the welfare of the individual is a delicate issue. Practitioners should keep in mind that an elder's level of autonomy is not static. It will constantly change due to altering medical conditions and level of functioning. Therefore, is important to periodically evaluate the individual's level of autonomy to determine the balance between supporting self-determination and beneficence [151].

It is important that practitioners be supportive of patients' decisions regarding care [124]. To this end, the National Association of APS Administrators and others have identified best practice guidelines to promote principles of autonomy and self-determination [125,137]:

  • Seek informed consent from the elder.

  • Discuss values and preferences with the elder.

  • Avoid imposing one's own personal values on the elder, and support the client's values and preferences regardless of whether they conflict with one's own value system.

  • Recognize the elder's individual cultural and personal differences.

  • Involve the elder as much as possible with the intervention plan.

  • Evaluate care plans that take into account physical safety, independence, and the client's values and preferences.

  • Employ the least restrictive services first.

Informed Consent

The issues of self-determination and an individual's mental capacity are components of assuring informed consent. Although protecting a client's self-determination is important, there will be times when a person cannot give informed consent. If a client's capacity may be compromised, there are three courses of action that may be taken. A surrogate caregiver, ideally identified by the client via a durable health care power of attorney, could provide consent. Alternatively, the surrogate caregiver may give informed consent while the elder gives assent. Finally, the client may have created documents indicating consent for certain procedures or wishes (e.g., living wills, do not resuscitate orders) prior to incapacitation [138].

Confidentiality

The practitioner's duty to respect a patient's or client's privacy of information is referred to as confidentiality. If during any patient assessment abuse is suspected, the necessary steps of action will be dictated by the state laws regarding elder abuse. Effective collaboration involving sharing information across various agencies to coordinate services to protect the elder is vital, as is the protection of the client's right to confidentiality. Ultimately, the promotion of confidentiality should not breed inaction [139].

Capacity

It is unethical to assume that all elders do or do not have the capacity to make decisions. If an elder abuse victim does not take action against the perpetrator or to end the abusive relationship, this does not indicate lack of capacity [122].

It is often assumed that with old age comes diminished intellectual ability, which is an ageist attitude [122]. Normal aspects of aging, such as hearing loss, may make communication difficult, which may in turn be misinterpreted as diminished capacity. Therefore, each patient's physical limitations should be taken into account and communication modified as necessary. This allows important information to be accurately conveyed and ensures that all decisions are appropriately informed [122].

RESOURCES FOR PRACTITIONERS WORKING WITH THE ELDERLY AND ABUSE VICTIMS

The following resources are provided for practitioners to gain more information about various aspects of elder abuse as well as resources to get additional information about services to which to refer elders.

Administration on Aging
http://www.aoa.gov
Clearinghouse on Abuse and Neglect of the Elderly
http://www.cane.udel.edu
Eldercare Locator
http://www.eldercare.gov
Futures Without Violence
http://www.futureswithoutviolence.org
National Long Term Care Ombudsman Resource Center
http://www.ltcombudsman.org
Minnesota Center Against Violence and Abuse
http://www.mincava.umn.edu
National Academy of Elder Law Attorneys, Inc.
http://www.naela.org
National Adult Protective Services Association
http://www.napsa-now.org
National Center for Victims of Crime
http://www.victimsofcrime.org
National Clearinghouse on Abuse in Later Life
http://www.ncall.us
National Coalition Against Domestic Violence
http://www.ncadv.org
National Committee for the Prevention of Elder Abuse
http://preventelderabuse.org
National Institute of Justice
http://www.nij.gov
National Organization for Victim Assistance
http://www.trynova.org
National Online Resource Center on Violence Against Women
http://www.vawnet.org
The U.S. Government Senior Citizens' Resources
http://www.firstgov.gov/Topics/Seniors.shtml

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Evidence-Based Practice Recommendations Citations

1. Daly JM. Elder Abuse Prevention. Iowa City, IA: University of Iowa College of Nursing, John A. Hartford Foundation Center of Geriatric Nursing Excellence; 2010. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=34018. Last accessed January 24, 2014.

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