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Physical and Emotional Abuse of the Elderly

Guide No. 71

by Brian K. Payne

The Problem of Elder Physical and Emotional Abuse

What This Guide Does and Does Not Cover

This guide begins by describing the problem of elder physical and psychological abuse and reviewing factors that increase its risks. It then identifies a series of questions to help you analyze your local elder abuse problem. Finally, it reviews responses to the problem and what is known about these from evaluative research and police practice.

Elder physical and emotional abuse are but two components of the larger set of problems related to maltreatment of vulnerable persons. This guide is limited to addressing the particular harms created by elder physical and emotional abuse. Related problems not directly addressed in this guide, each of which requires separate analysis, include:

Some of these related problems are covered in other guides in this series, all of which are listed at the end of this guide. For the most up-to-date listing of current and future guides, see www.popcenter.org.

General Description of the Problem

Elder physical and emotional abuse are two types of elder maltreatment that frequently occur simultaneously. The National Center on Elder Abuse defines physical abuse as "the use of physical force that may result in bodily injury, physical pain, or impairment."1 Physically abusive acts include hitting, kicking, shaking, and a number of other acts. Emotional abuse (also known as psychological abuse) is defined as "the infliction of anguish, pain, or distress through verbal or nonverbal acts."2 Harassment, making threats, and intimidation are examples of emotional abuse. In some states emotional abuse of persons receiving formal health care is specified as illegal by statute. In Delaware, for example, a statute outlaws emotional abuse under this definition: "ridiculing or demeaning a patient or resident, making derogatory remarks to a patient or resident or cursing directed towards a patient or resident, or threatening to inflict physical or emotional harm to a patient."3

The first National Elder Abuse Incident Study found that approximately 450,000 older persons reported experiencing abuse or neglect in 1996.4 A later national study found that about 565,000 older persons reported experiencing abuse or neglect in 2003, with abuse substantiated in about one-third of those cases.5 Physical abuse made up about 11 percent of the substantiated cases and emotional abuse about 15 percent. Elder neglect, financial exploitation, and self-neglect made up the bulk of the remaining cases.
These figures underestimate the extent of elder physical and emotional abuse. Some older victims are unable to report their victimization because of cognitive impairments, and others are reluctant to report their mistreatment for one or more of the following reasons:

Less than a third of elder physical abuse victims contact the police about their victimization.7

Even though emotional abuse is the most frequent type of elder maltreatment-estimates suggest that approximately one in twenty older persons are emotionally/psychologically abused each year8-victims are especially unlikely to report emotionally abusive acts, primarily because there are no visible injuries and they may fear the consequences of reporting.9

It is commonly estimated that between one and two million individuals are victims of elder abuse in the United States each year.10 In domestic settings, estimates from the National Elder Mistreatment Study suggest that about one in 62 older persons, or about 575,000 in all, experience physical abuse each year.11 As the number of elderly persons living in the United States continues to grow, these numbers are likely to increase in the future. The percentage of people living in the United States who were elderly increased 15.1 percent between 2000 and 2010. A higher proportion of elderly persons now lives in the United States than at any time in its history.12

Regarding abuses occurring in institutional settings, a survey of nursing assistants from 10 nursing homes participating in an abuse prevention training program found that roughly one in six reported engaging in physically abusive behaviors and about half reported yelling at residents in the previous 30 days.13 There is some evidence that for-profit homes have more abuse complaints than nonprofit homes.14 Larger facilities also have a higher rate of complaints. While some have suggested that living in a nursing home is a risk factor for physical and emotional abuse, an estimated 90 percent of abuse cases reported to adult protective services (APS) occur in domestic settings.15


Image Name

Image: A survey of nursing assistants found that one in six reported engaging in physical abuse and about half reported yelling at residents.
Photo Credit: Shutterstock Photo No: 105457523


In both domestic and institutional settings, females are more likely than males to experience elder abuse.16 Males are more likely to abuse males and females are more likely to abuse females.17 Regardless of gender, among older crime victims, more than half have experienced both physical and emotional abuse.18 Among older women who experienced physical abuse, 95 percent also experienced psychological abuse.19 In addition, these acts do not occur just once; instead, they often re-occur among those victims who experience abuse.

In long-term-care settings, the majority of physical and emotional abuse is committed by nurse's assistants.20 Part of the reason that assistants have higher rates of abusive behavior is simply that they have more contact with residents than other staff. Another reason may be that the licensing and educational requirements for nurse's assistants are much lower than they are for nurses, physicians, directors, and other long-term-care staff.21

Laws Relating to Elder Physical and Emotional Abuse

Laws of various kinds define elder physical and emotional abuse or prescribe the legal interventions available in these cases. These laws include:

Forty-nine states and the District of Columbia define elder maltreatment laws in their protective services legislation.23 Emotional abuse is prohibited in the APS statutes of 42 states.24 Some states have laws requiring APS workers and the police to share information on certain types of cases.25

Harms Caused by Elder Physical and Emotional Abuse

Both elder physical and emotional abuse can have a devastating impact on victims, their family members, and communities. The consequences of these offenses include:

Researchers have only recently begun to explore the ties between mortality and elder abuse. One study found that elder abuse victims are about three times more likely to die prematurely than non-abuse victims.29 It is believed that many elder homicides are misclassified as deaths due to natural causes.

Factors Contributing to Elder Physical and Emotional Abuse

Understanding the factors that contribute to your problem will help you frame your own local analysis questions, determine appropriate effectiveness measures, recognize key intervention points, and select appropriate responses. This guide identifies the most common factors contributing to elder physical and emotional abuse. In some instances, additional factors may lead to abuse. After working with the various stakeholders involved in the collaborative response to elder abuse, law enforcement personnel will be able to identify risk factors that may not be addressed in this guide.

Elder abuse researchers and criminologists have cited various explanations for elder physical and emotional abuse. These explanations are easily understood through an examination of vulnerable targets, offender motivations, the absence of guardianship, and community and cultural factors.

Vulnerable Targets

Not all older persons experience victimization. Certain factors increase an older person's risk. Two commonly cited risk factors are the presence of Alzheimer's/dementia and dependency. Providing care to individuals with Alzheimer's and related forms of dementia is especially challenging and may increase the odds of committing abusive acts. In some situations, caregivers react to violent behaviors initiated by the individual with dementia, while in others the caregiver's aggression is tied to the strain that caregivers experience. Approximately one in ten caregivers of those with dementia reported physically abusing the individual in their care.30 Spouses are more likely to be violent toward care recipients who suffer from dementia, especially if they live in the same residence and if the care recipient sometimes hits the caregiver or is otherwise disruptive.31

Older individuals' dependence on their relatives has also been cited as a factor that makes them more vulnerable. Gerontologists use the phrase "generational inversion" to refer to the process by which older individuals lose their independence and become more dependent on relatives who once depended on them. The dependence can be emotional, logistical, or financial.32 Elders with cognitive impairments are especially dependent on others and this dependence increases the risk of victimization. About one-fourth of those dependent on others have experienced elder emotional abuse.33

The nature of the dependence may influence the victim's decision to contact the police. Being dependent on another person for care may cause victims to think about the consequences of not having the offender present to provide care. Dependence on a spouse for care inhibits older persons from reporting physical or emotional abuse by that person.34 Dependency varies across older persons. As a group, elderly persons are not nearly as dependent on younger persons as some may believe. Older people who report being mistreated are especially able to maintain independence in the criminal justice system and do things that make the system work for their interests.35

Offender Motivations

Offender motivations refer to factors that increase offenders' likelihood that they will be physically or emotionally abusive toward older persons. Offender motivations for committing elder abuse include the following:

Guardianship and Isolation

The more socially isolated older individuals are, the more at risk they are for physical abuse.45 Socially isolated individuals are less likely to be protected by loved ones, public safety professionals, or other potential guardians. Isolation is so problematic in elder abuse cases that some have argued that when individuals actively isolate older persons to gain power and control over their lives, this amounts to emotional abuse.46 It is also argued that the isolation found in long-term-care settings may place residents at a higher risk for maltreatment.47

Community and Cultural Factors

Community and cultural factors also contribute to elder physical and emotional abuse. In some cities, high poverty rates contribute to unemployment, which leads to adult offspring living at home with their aging parents. As noted, having unemployed adults live at home with aging relatives is a risk factor for elder maltreatment. In addition, residents providing care to Alzheimer's patients in disadvantaged areas are less likely to accept formal services, which may place them at a higher risk for maltreatment.48 Also, services available for older victims vary across rural and urban communities.49 Fewer services not only put individuals in some communities at higher risk for victimization, but the consequences of victimization are more difficult to address when certain services are not available.
Community factors also bear on institutional abuses. Urban areas, for example, have been found to have higher abuse rates in nursing homes.50 This difference potentially stems from the higher crime rates found in urban areas, and the difficulties of finding appropriate staff for these positions in these communities. In addition, nursing homes are distributed unequally across cities, making it more difficult for some loved ones to act as de facto guardians by visiting their aging relatives.

Cultural factors may also promote elder abuse. Cultures with high respect for the elderly have lower elder abuse rates.51 Cultures that devalue the elderly, in turn, promote values and behaviors that place older persons at risk. Ageism refers to attitudes or practices that systemically discriminate against the elderly population. Ageist attitudes foster abusive behaviors. In addition, a culture's level of altruism (willingness to help others) is tied to elder abuse. For example, institutional abuses have been tied to a culture's willingness to devote scarce financial resources to help those in need. The more charitable counties are, the lower their rate of institutional abuses.52 Similarly, putting profit (a cultural value) before high-quality health care places older individuals at risk for patient abuse.

Understanding Your Local Problem

The information provided above is only a generalized description of elder physical and emotional abuse. You must combine the basic facts with a more specific understanding of your local problem. Analyzing the local problem carefully will help you design a more effective response strategy.

Stakeholders

In addition to criminal justice agencies, the following groups have an interest in elder physical and emotional abuse and ought to be considered for the contribution they might make to gathering information about the problem and responding to it:

† AARP was formerly named the American Association of Retired Persons.

Asking the Right Questions

To respond effectively to elder physical and emotional abuse, you need to clearly define these terms for purposes of analysis. In addition, you will need to reach agreement with other key agencies on how to collect and maintain data about older victims. Appropriate data collection strategies will help you to better understand elder physical and emotional abuse in your community and will aid in your response to the problem.

The following are some critical questions you should ask in analyzing elder physical and emotional abuse, even if the answers are not always readily available. Your answers to these and other questions will help you choose the most appropriate set of responses later on. These questions may not apply in all situations, and some may call for answering over time to determine which responses to elder physical and emotional abuse are effective.

Incidents

Victims

Offenders

Locations/Times

Current Responses

 

Measuring Your Effectiveness

Measurement allows you to determine to what degree your efforts have succeeded and suggests how you might modify your responses, if they are not producing the intended results.
You should take measures of your problem before you implement responses to determine how serious the problem is, and after you implement them to determine whether they have been effective. You should take all measures in both the target area and the surrounding area. For more detailed guidance on measuring effectiveness, see Problem-Solving Tools Guide No. 1, Assessing Responses to Problems: An Introductory Guide for Police Problem-Solvers, and Problem-Solving Tools Guide No. 10, Analyzing Crime Displacement and Diffusion.
The following are potentially useful measures of the effectiveness of responses to elder physical and emotional abuse. Outcome measures relate to the impact that your responses have on the problem. Process measures relate to the implementation of responses to the problem.

Outcome Measures

Process Measures


Responses to the Problem of Elder Physical and Emotional Abuse

Your analysis of your local problem should give you a better understanding of the factors contributing to it. Once you have analyzed your local problem and established a baseline for measuring effectiveness, you should consider possible responses to address the problem.
The following response strategies provide a foundation of ideas for addressing your particular problem. These strategies are drawn from a variety of research studies and police reports. Several of these strategies may apply to your community's problem.
It is critical that you tailor responses to local circumstances and that you can justify each response based on reliable analysis. In most cases, an effective strategy will involve several different responses. Law enforcement responses alone are seldom effective in reducing or solving the problem.
Do not limit yourself to considering what police can do: carefully consider whether others in your community share responsibility for the problem and can help police better respond to it. The responsibility of responding, in some cases, may need to be shifted toward those who have the capacity to implement more effective responses. For more detailed information on shifting and sharing responsibility, see Response Guide No. 3, Shifting and Sharing Responsibility for Public Safety Problems.
For further information on managing the implementation of response strategies, see Problem-Solving Tools Guide No. 7, Implementing Responses to Problems.

General Considerations for an Effective Response Strategy

Responding to elder physical and emotional abuse cases can be complex and time consuming. The police role in elder abuse cases generally entails investigation, enforcement, and referral. 53

1. Improving police understanding of elder abuse. Police officers must learn to watch for signs of elder abuse. Compared to other crimes, however, most police practitioners receive little training about elder abuse. Improved awareness of elder abuse is key to improving service delivery to older victims. 54 In the early 1990s, some states began to train police officers about aging, elder abuse, and how to detect, investigate, and prevent the latter. 55, While researchers have not specifically examined whether gerontology training programs for police improve the response to elder abuse, studies have found that community training increases reports to APS, 56 support for formal responses to elder abuse, 57 and elder abuse substantiation rates. 58 Training in and of itself will not improve the response to elder physical and emotional abuse, and in some cases, may be ineffective, particularly if officers are trained about elder abuse best practices but are not provided the tools to apply the best practices.

† With funding from the U.S. Department of Justice Office of Violence Against Women, the National Sheriff's Association and the Federal Law Enforcement Training Center developed and delivers training for police officers about elder abuse as well as a train-the-trainers course so that communities can develop their own community-specific training courses (Brandl and Dawson 2011).

Elder abuse training should cover the following topics: 59

Recent studies have been especially effective in helping police understand bruises as a sign of physical abuse. One study concluded that if police officers see bruises somewhere other than on the older person's torso, arms, or legs, they should raise questions about elder physical abuse. 60 Other evidence suggests that bruises on both sides of the body and "wrap-around" bruises are rarely accidental.61 Bruises from elder physical abuse can be distinguished from accidental bruises: they tend to be larger and on the victim's face, torso or right arm (the right arm presumably because of the victim's efforts to defend him/herself).62

National City, California, police officers responded to numerous calls at one residence over a 10-year period. Within two years alone, they visited the residence on 67 separate occasions. Traditional efforts failed to eradicate the problems reported at the home. After examining the situation through a different lens, the neighborhood policing team recognized that the owner of the home-an elderly woman-was being taken advantage of by her daughter and grandson, who routinely brought gang members, drug users, and parolees to the home. Working with APS and other agencies, a public guardian was assigned to the woman and she was moved to an assisted-living facility. The daughter and grandson had to leave the residence and the calls for police to that home stopped. By recognizing that they were dealing with elder abuse, rather than traditional crimes, the neighborhood policing team was able to end the problem 63

2. Developing policies and protocol that communicate the importance of addressing elder abuse. Whereas most police departments have domestic violence policies, fewer have elder physical and emotional abuse policies. Police officers in agencies that do not clearly define police roles in elder abuse cases tend to understand less about elder abuse.64 The policies and protocol should define the roles and responsibilities of various agencies involved in responding to these cases. In addition, policies should convey that the abuses should be taken seriously. States with harsher penalties in elder abuse laws and policies have higher rates of investigation in elder abuse cases.65 Where laws and policies clearly define elder abuse as problematic, police and APS investigators tend to respond accordingly. After the West Columbia, South Carolina, Police Department developed the protocol and policies for its family violence unit, arrests for elder abuse increased 500 percent.66

3. Promoting collaborative efforts to respond to elder abuse. Victims of elder abuse require multiple interventions from criminal justice and social services professionals to be best served. A study of 83 elder abuse cases found that 473 intervention strategies had been employed to help the victims, an average of about six intervention strategies per case.67 In Rhode Island, eight different agencies with competing missions and goals respond to elder abuse.68 Because of the diverse agencies and the wide range of potential interventions, collaboration has been described as the "optimal method" for addressing elder abuse.69 By promoting awareness among team members, reducing duplication of effort, and minimizing turf battles, collaborative efforts benefit older persons, service recipients, and the community.70 Collaborative efforts are especially effective if they provide the victim with individual attention from a wide range of human services professionals.71

The police role in collaborative efforts can be quite broad. Officers may be called upon to determine if a crime was committed, make arrests, conduct well-being checks, assist with investigations, and file police reports and/or charges on behalf of the collaborative response team.72 In some cases, the police may take the lead in developing the efforts. The St. Petersburg, Florida, Police Department, for example, created an assisted living facility task force after receiving numerous calls for service from certain assisted-living facilities. One facility averaged 10 calls per month over a 6-month period. Working with other agencies serving vulnerable adults and elderly residents, the task force was able to shut down or force the sale of the problem facilities. Police calls to the facilities ended.73

The following factors can make it difficult for police to collaborate with other agencies in elder physical and emotional abuse cases:

Some of these problems may surface in the early stages of collaborative efforts. As representatives get to know one another and learn more about elder abuse, the obstacles can be overcome. Local laws that require police participation in collaborative efforts have been described as especially effective because they convey the importance of collaboration.75 The collaborating agencies should develop interagency protocols that describe their respective roles.

4. Customizing police responses to the special needs of elderly victims. Police referrals for some form of social services intervention are frequent in elder abuse cases. Some of the standard procedures for investigating conventional crimes and addressing victims' needs might not work well in elder abuse cases. For example, health and physical impairments of many older victims can make it difficult or impossible for them to take certain measures to protect themselves.76 In response, in 2005 in Jefferson County, Kentucky, steps were taken to allow homebound individuals over the age of 60 to seek emergency protective orders over the telephone.77

Older victims have different needs and risk factors than younger victims. Some older victims commonly require a broad range of social services and especially need help navigating the service network and criminal justice system. Offering general programs, services, and activities to older victims is likely to be ineffective.78 So is applying child abuse models and strategies to respond to elder abuse.79

In the early 1990s, the Rhode Island Senior Citizens Police Advocate Program placed an advocate for older persons in every police department in the state. The advocates received specialized training about older persons and served as an important bridge between the agencies and members of the community.80 Under this program, specialized officers rather than general patrol officers handled cases with older victims.81 The program reduced the workload of patrol officers and improved community relations.

The Community Police Partnership Unit in Glendale, California, created the First Responder Program by focusing on intervention and education for first responders to elder abuse. The unit formed a multidisciplinary partnership and developed a screening instrument that first responders were trained to use when they encountered older vulnerable adults. The program led to an increase in the number of older persons referred to police and a higher number of older adults receiving appropriate services. Officers believed that early intervention saved police time in the long term.82

The Milwaukee Police Department created the Senior Citizen Assault Prevention Unit in 1980. Subsequently called the Gray Squad, the unit was assigned primary responsibility for serving older victims. An evaluation found that victims served through this program were more satisfied with the police than were victims served through traditional responses.83

 

5. Reducing general community and cultural risk factors. Efforts to address community-level risk factors-such as high unemployment rates (important because unemployed adult offspring may target their aging parents or other relatives for abuse), lack of services for older mentally ill individuals and their families, and isolation of older persons-should reduce elder abuse rates. While police departments can do little to influence a community's unemployment rate, they can take an active role in providing services to older persons and reducing their isolation. Strategies to provide services can be specifically directed toward reducing the isolation of older persons through many of the measures described below. In addition, the police can take a lead role in combating ageism in a community. An initial step should be ensuring that police officers have an adequate level of understanding about the elderly population and that misunderstandings about the elderly do not foster ageist reactions to elder abuse. For example, the assumption that all elderly persons are as vulnerable as children must be countered. Holding such a belief might prompt some professionals to treat elder abuse victims the same way that they would treat child abuse victims. Such a response would not help older victims. Training in aging issues can give police officers the knowledge they need to serve this population.

Cultural issues also need attention. Professionals tend to view issues through their own cultural perspectives and may fail to recognize the role of specific cultural issues in elder abuse cases.84 In cases involving Asian victims, for instance, older persons may be more reluctant to participate in the justice process because their culture emphasizes the importance of family and avoiding actions that would embarrass the family.85 By contrast, traditional American values place a stronger emphasis on individualism. Older immigrants may be reluctant to participate in the criminal justice system out of a fear of being deported. It is imperative that officers recognize the cultural differences that surface, and administrators must ensure that officers are culturally competent. Cultural competence can avoid issues arising from language barriers, trust problems, and concerns about revictimization.

 

Specific Responses to Reduce Elder Physical and Emotional Abuse

 6. Checking on elderly people at home. Some police departments have found success in developing home visit programs. In general, home visit programs are either proactive or reactive. Proactive programs entail police officers identifying vulnerable older persons and visiting them at different times to reduce their isolation. In reactive programs specially trained officers visit older victims after their initial contact with police to check in on the individual. In Chicago, an officer from the Senior Citizen's Services Section visits elder abuse victims within 2 weeks of that person's first contact with the police.86 Visits from specialized officers increase the likelihood that victims will seek services, call the police for future help, and hold more favorable attitudes toward the police.87 Most home visits to elder abuse victims take only 5 to 20 minutes of officers' time.88

Some police departments have used telephone technology to add additional guardianship to older individuals. The Norfolk, Virginia, Sheriff's Department, for example, created the Check and Respond Everyday (CARE) program, using computer software to call and check in on isolated adults several times a day. If no one answers the call, an officer is sent to the home.89 The Kansas City, Missouri, Police Department created its own "Senior Watch" program, which allowed older residents to have information about themselves saved in a secure database should police be called to their residence. In this program, if residents do not come to the door when police are called to that residence, the police can check the database to see if neighbors or family members have keys to the residence and whether the resident has pressing medical issues.90 Other departments have developed programs where criminal justice officials personally call older vulnerable adults to talk to them about crime prevention and check on their welfare. The Glendale, California, Police Department developed the "Caring Caller Program," which used volunteers to call homebound older adults on a weekly basis.91

As a word of caution, second-response programs, which entail follow-up visits to victims from specially-trained law enforcement officers or social workers, do not always lower the likelihood of subsequent abuse, especially if the programs are implemented without other services or programs being provided to victims and offenders.92

7. Undertaking community outreach. Police can be involved in educating the public about elder physical and emotional abuse on topics such as how to recognize, report, and prevent abuse.93 Raising public awareness about elder abuse risk factors can reduce the isolation of older adults, both by informing elderly people how to protect themselves and by informing others how to protect elderly people. The World Health Organization has encouraged communities to formally recognize elder abuse through "calls to action" that emphasize the need for a community-wide response.94 Outreach efforts should target places frequented by elderly people (such as churches, health care offices, and senior centers).95 Abuse prevention tips like the following can be shared with older persons to reduce their vulnerability:

The media can be helpful in community outreach. Although newspapers tend to publish about 20 times as many articles on child abuse as on elder abuse, elder abuse receives more media coverage in regions of the country where criminal justice officials are active in responding to elder abuse. As an illustration, the San Diego Union-Tribune newspaper published ten times as many articles about elder abuse than did the Boston Herald over a 4-year period. The researchers posited that investigators in San Diego had developed better relationships with local reporters than had been formed in other parts of the country.97

8. Promoting the use of ombudsmen to watch for abuse in long-term elder care facilities. Ombudsmen can help monitor for elder abuse in nursing homes and other long-term-care facilities.98 Ombudsmen programs, developed as part of the 1965 Older Americans Act, receive and investigate complaints of all types about abuse occurring in nursing homes. While advocating on behalf of the residents, by law ombudsmen will not contact the police about suspected cases of mistreatment without the victim's consent.99 They are especially helpful in identifying minor problems and addressing them before they escalate to more serious offenses.100 Ombudsmen should be taught to recognize facility policies and building-security conditions that increase the risks of abuse and taught how to advocate for improvements.101 Nursing homes with volunteer resident-advocates as part of the ombudsmen program tend to have lower rates of abuse, which suggests that the volunteers also serve as effective abuse monitors.102 Some states permit nursing homes to install video surveillance cameras (sometimes referred to as "granny cams") in their residents' rooms to guard against physical and emotional abuse, although their use raises many privacy concerns.103

9. Checking the backgrounds of professional caregivers. Criminal background checks and abuser registries are ways to identify those with histories of abusing vulnerable adults. In most states, those hiring caregivers can purchase criminal background checks from the state police. Some states require criminal background checks for individuals working in licensed facilities, but individuals hiring their own caregivers might not do their own background checks unless they are encouraged to do so. Police administrators can also consider supporting abuse registry policies. Twenty-one states have registries that list individuals convicted of elder abuse offenses.104 Licensed facilities are expected to consult the registries before hiring employees who would have contact with vulnerable adults. Of course, background checks and registries do not protect residents from being abused by fellow residents.105

10. Participating in elder abuse centers. Demonstrating the need for a collaborative response, communities across the United States are developing elder abuse centers to respond to these cases. There are two primary types of centers: elder forensic centers and elder justice centers. Elder forensic centers bring together medical, social service, and criminal justice professionals to review possible elder abuse cases, educate one another about elder abuse, and identify appropriate interventions.106 Elder forensic centers differ from multidisciplinary teams: they meet more often, have more members, and are more focused on specific tasks related to investigations.107 The first elder abuse forensic center was developed in Orange County, California, in 2003 to provide abuse victims a one-stop shop through an initiative led by the University of California, Irvine's program in geriatrics.108 Since then, forensic centers have developed in several other locations, including New York City, Houston,109 San Diego,110 Los Angeles,111 and San Francisco. Elder abuse forensic centers have been shown to be efficient and effective.112

Elder justice centers are focused specifically on the criminal justice process. In the early 2000s, Palm Beach County, Florida, created an elder justice center to "enhance linkages between elder adults, the courts, and legal and social services systems within the community."113 Center employees assist victims in navigating the judicial system and identify older defendants with mental health issues to divert them from the criminal justice system and into mental health programs. Placing advocates, officers, prosecutors, and others in the same office makes it much easier for older victims to navigate the justice system.114

11. Developing elder abuse fatality review teams. Elder abuse fatality review teams are interdisciplinary, multi-professional groups that review fatalities to more accurately identify the cause of death in elderly persons. As of 2007, 11 states had these teams in place.115 Composed of coroners, police and prosecutors, medical examiners, social workers, health care workers, and others, the teams collect information about the victim, perpetrator, risk factors, and circumstances surrounding the death.116 The teams tend to serve one of two purposes: (1) identify suspicious deaths for subsequent prosecutions or (2) identify systemic problems in need of change.117 These review teams allow professionals to learn about elder physical abuse from one another and to improve the collaborative response system.118 The U.S. Department of Justice Office for Victims of Crime has developed a replication manual to assist jurisdictions in developing their own elder abuse fatality review teams. The manual provides an overview of why the teams are needed, how they evolved historically, issues that arise in forming teams, team activities, and strategies to maintain the team.119

Responses with Limited Effectiveness

12. Enacting elder abuse laws and policies in isolation from other effective practices and strategies. Laws that are passed and implemented without considering the victims' needs or available services have limited effectiveness in responding to elder physical and emotional abuse. Penalty enhancement statutes and mandatory reporting laws are illustrative. Penalty enhancement statutes provide for longer sentences for crimes that involve older victims. Ironically, research shows that penalties given to some elder abusers are actually shorter in states with these laws than are the penalties in states without the laws.120 One possible explanation is that the statutes are used to leverage plea bargains, which defeat the very purpose of the statutes.

A similar situation arises with regard to mandatory reporting laws. Based on child abuse reporting statutes, these laws were passed in the 1980s, even though no research supported the need for the laws. In addition, police officers were not trained in how to enforce the laws and no funding was provided to implement the laws.121 Thus, mandatory reporting laws, by themselves, should not be seen as an effective response to elder physical and emotional abuse.

13. Adopting mandatory arrest and prosecution policies. Although many police administrators are inclined to adopt aggressive responses to elder abuse, including mandatory arrest policies, such policies are potentially ineffective. Arrest and prosecution is not always the best option in elder abuse cases. For one thing, in contrast to child abuse cases, for example, older victims have more of a voice in self-determination.122 Whereas children may not have a choice about being removed from a violent home, older persons should be given such a choice.

Second, arresting and incarcerating the abuser may force the victim to move into an assisted living arrangement as they may not be able to manage living alone. They may be placed in a nursing home despite their lack of interest in nursing home care, and such a placement might not be in the victim's best physical, emotional, or financial interests. Sometimes criminal prosecutions jeopardize the victim's wellbeing. Advocates and elder abuse experts have long argued that the safety of the victim should take precedence over punishing the offender.123

To be sure, in some elder abuse cases arrests are necessary. When arrest is supported by the evidence and appears to be the appropriate course of action, police should initiate the arrest if local law permits, rather than leaving that responsibility to the victim. When family violence victims are expected to file the official complaint, they suffer a higher rate of further abuse than when the police make the arrest.124 When victims file the arrest complaint, the possibility that the offender will retaliate against the victim increases.

14. Punishing older offenders with Alzheimer's/dementia. Some cases of elder abuse may involve individuals with Alzheimer's/dementia being abusive toward those caring for them. In these situations, it is important to recognize that the aggressor usually lacks the capacity to form the intent to commit a crime. These individuals should not be treated as violent criminals; rather, the goals should be to protect the victim from further harm and to treat the offender medically. Cases of this sort should automatically be referred to adult protective services. APS officials can assist the caregiver and care recipient in understanding the services and resources available to them. In situations involving nursing home residents whose dementia results in repeated abuses of other residents, the emphasis should be on getting facility administrators and staff to better protect residents from abusive fellow residents, and holding them legally accountable if they fail to do so.125

Summary of Responses

The table below summarizes the responses to elder physical and emotional abuse, the mechanism by which they are intended to work, the conditions under which they ought to work best, and factors to consider before implementing a particular response. It is critical that you tailor responses to local circumstances and that you can justify each response based on reliable analysis. In most cases, an effective strategy will involve implementing several different responses. Law enforcement responses alone are seldom effective in reducing or solving the problem.

# Response How It Works Works Best If..... Considerations
 
General Considerations for an Effective Response Strategy
1

Improving police understanding of elder abuse

Improves response to elder physical and emotional abuse by better preparing professionals for these cases .....training covers a range of specific topics Limited evaluation of its overall impact on the problem; may be ineffective if not backed up by adequate resources to respond to elder abuse cases
2

Developing policies and protocol that communicate the importance of addressing elder abuse

Improves quality of investigations by providing specific directions and emphasizing seriousness of the problem .........policies and protocol are clear and specify nature of interagency relationships Policies must be reinforced through monitoring and enforcement
3 Promoting collaborative efforts to respond to elder abuse Ensures that victims will receive appropriate interventions from multiple professionals .....professionals are committed to working together and focused on the goal of protecting vulnerable older adults; backed by laws that require collaboration Requires attention to factors that commonly undermine interagency collaborations
4 Customizing police responses to the special needs of elderly victims Ensures that interventions are responsive to older persons' needs

.....tailored to local conditions

Requires extra time and effort to develop special responses for elderly victims
5 Reducing general community and cultural risk factors Reduces general risk factors that contribute to elder abuse .....special attention is given to risk factors affecting highest-risk victims (e.g., elderly persons with adult children as caregivers, mentally ill elderly persons) Difficult for police to affect general community-level factors such as poverty, unemployment, and isolation of elderly persons; impact on the problem may be difficult to measure
Specific Responses to Reduce Elder Physical and Emotional Abuse
6

Checking on elderly people at home

Provides a layer of guardianship to vulnerable adults .....targeted at highest-risk victims; personal and technological methods are integrated; intervention responses are available if needed Requires extra time and effort by police, but technology can improve efficiency
7

Undertaking community outreach

Reduces victimization risk by spreading abuse prevention tips and encouraging reporting of abuse .....the community has a "call to action" to demonstrate concern about the problem; targeted at places that seniors regularly visit Media can assist in outreach efforts if encouraged by criminal justice leaders
8 Promoting the use of ombudsmen to watch for abuse in long-term elder care facilities Improves guardianship and reporting .....ombudsmen are properly trained, including in police role in responding to elder abuse Advocates in nursing homes may not be permitted by law to report abuse without victim consent; ombudsmen primarily serve victims, not police; surveillance technology can be useful, but raises privacy issues
9 Checking the backgrounds of professional caregivers Limits offenders' access to vulnerable older persons .....policies and laws require abuser registries or criminal background checks Background checks will not always show criminal backgrounds from other states; will have no effect on abuse committed by fellow residents
10

Participating in elder abuse centers

Improves systemic response to problem .....dedicated space is made available where all professional responders can meet regularly Elder abuse forensic centers are distinct from multidisciplinary teams: they meet more regularly, are larger, and require greater effort to coordinate
11

Developing elder abuse fatality review teams

Helps detect and apprehend offenders, reducing future risk to other victims; improves systemic responses to elder abuse .....purpose of the team is clearly established and all relevant responders regularly participate Requires time and effort to establish and maintain; may require special information-sharing agreements
Responses with Limited Effectiveness
12 Enacting elder abuse laws and policies in isolation from other effective practices and strategies   .....criminal laws are used in conjunction with social service interventions If penalty enhancers are used merely for plea bargaining, net effect may be weaker sentences
13 Adopting mandatory arrest and prosecution policies   .........victim's individual needs and preferences are considered when deciding whether to arrest and prosecute offender Victims may lose their independence and experience more harm than good if offender is arrested; if arrest is to be made, police should initiate the action, rather than putting burden on victim to do so
14

Punishing older offenders with Alzheimer's/ dementia

  .....victims are protected and offender is treated medically; case is referred to APS; care facility is made to improve security to protect potential victims Offender usually cannot form intent to commit the crime

Endnotes

[1] Teaster et al. (2006).

[2] Teaster et al. (2006).

[3] Daly and Jogerst (2006, p. 25).

[4] Teaster et al. (2006).

[5] Teaster et al. (2006).

[6] Heisler (2000); Payne (2011); Reay and Browne (2001).

[7] Bulman (2010); Acierno et al. (2010).

[8] Acierno et al. (2010).

[9] Begle et al. (2011).

[10] Bonnie and Wallace (2003).

[11] Bulman (2010) provides estimate extrapolating from Acierno et al. (2010).

[12] Brandon (2012).

[13] Pillemer and Hudson (1993).

[14] Allen, Kellett, and Gruman (2003).

[15] Teaster et al. (2006).

[16] Brownell (1998); Klein et al. (2008).

[17] Payne (2011).

[18] Post et al. (2010).

[19] Fisher, Zink, and Regan (2011).

[20] Payne (2011).

[21] Payne (2011).

[22] Gittler (2008); Howze and White (2010).

[23] Daly and Jogerst (2006).

[24] Daly and Jogerst (2001).

[25] Brandl et al. (2007).

[26] Payne (2011).

[27] Fisher and Regan (2006).

[28] Fisher and Regan (2006).

[29] Lachs et al. (1998).

[30] Coyne, Reichman, and Berbig (1993).

[31] Pillemer and Suitor (1992).

[32] Kang and Lynch (2010).

[33] Cooper, Selwood, and Livingston (2008).

[34] Kang and Lynch (2010).

[35] Brownell (1998).

[36] Pillemer and Suitor (1992).

[37] Coyne, Reichman, and Berbig (1993).

[38] Paveza et al. (1992).

[39] Reay and Browne (2001).

[40] Korbin, Anetzberger, and Austin (1995).

[41] Payne (2011).

[42] Powell and Berman (2006).

[43] Pillemer and Moore (1990); Payne (2011).

[44] Tomita (1990).

[45] Bonnie and Wallace (2003).

[46] Leisey, Kupstas, and Cooper (2009).

[47] Hawes and Kimball (2009).

[48] Payne (2011).

[49] Nusbaum et al. (2006).

[50] Jogerst et al. (2006).

[51] Payne (2011).

[52] Payne (2011).

[53] Dolon and Hendricks (1989).

[54] Zevitz and Gurnack (1991).

[55] Rykert (1994).

[56] Wolf and Li (1999).

[57] Bell, Oyebode, and Olliver (2004).

[58] Jogerst et al. (2004).

[59] Hawes and Kimball (2009); Payne (2011); Shibley (1995).

[60] Connolly (2010).

[61] Illinois State Triad (1998).

[62] Bulman (2010).

[63] National City Police Department (2002).

[64] Plotkin (1996).

[65] Jogerst et al. (2005).

[66] West Columbia Police Department (2008).

[67] Nahmiash and Reis (2000).

[68] Klein et al. (2008).

[69] McNamee and Mulford (2007).

[70] Nerenberg (2003); Quinn and Heisler (2002).

[71] Groh and Linden (2011).

[72] Nerenberg (2003).

[73] St. Petersburg Police Department (1997).

[74] Dolon and Hendricks (1989); Nerenberg (2003); Plotkin (1988).

[75] U.S. Department of Justice (2000).

[76] Fisher and Regan (2006); Payne (2011).

[77] Stiegel and Teaster (2011).

[78] Nahmiash and Reis (2000).

[79] White and Lawry (2009).

[80] Shibley (1995, p. 24).

[81] Gilfillan (1994).

[82] Glendale Police Department (2001).

[83] Zevitz and Gurnack (1991).

[84] McGee (1997).

[85] Grayson (2001).

[86] Amendola et al. (2010).

[87] Stover et al. (2010).

[88] Davis, Medina, and Avitabile (2001, p. 21).

[89] Payne (2011).

[90] Kansas City Police Department (1999).

[91] Glendale Police Department (2001).

[92] Davis, Weisburd, and Hamilton (2007).

[93] Miller and Johnson (2003).

[94] World Health Organization (2002).

[95] Leisey, Kupstas, and Cooper (2009).

[96] Douglass (1992).

[97] Payne (2011).

[98] Cox (2008); Payne and Gainey (2006).

[99] Brandl et al. (2007).

[100] Allen, Kellett, and Gruman (2003).

[101] Payne (2011).

[102] Allen, Kellett, and Gruman (2003).

[103] Nerenberg (2008).

[104] Teaster et al. (2006).

[105] Connolly (2010).

[106] Connolly (2010).

[107] Schneider et al. (2010).

[108] McNamee and Mulford (2007).

[109] Navarro et al. (2010).

[110] San Diego Police Department (2003).

[111] Navarro et al. (2010).

[112] Wiglesworth et al. (2006, p. 27).

[113] Stiegel and Teaster (2011).

[114] San Diego Police Department (2003).

[115] Connolly (2010).

[116] Nerenberg (2008).

[117] Stiegel (2005).

[118] Stiegel (2005).

[119] Stiegel (2005).

[120] Payne and Gainey (2006).

[121] Payne (2011).

[122] Plotkin (1996).

[123] Wiglesworth et al. (2006).

[124] Klein (2008).

[125] Lachs et al. (2007).

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