Elderly Abuse and Neglect

The U.S. Department of Health and Human sservices (DHHS, 2004) estimates, between 1 and 2 million Americans age 65 or older are being injured, exploited, or other-wise mistreated by someone whom they depend on for care and protection. The increasing magnitude elderly abuse and neglect is a recognized social problem. A study conducted by the National Academy on Aging Society (NAOAS, 2000) predicted that over the next several decades as the population ages the frequency of occurrence of elderly mis- treatment will undoubtedly increase, the NOAS study was based on the life expectancy of people born in the United States. Although little is yet known about its, key elements, its causes, or consequences or about effective means of prevention or the management of elderly abuse and neglect, never the less it has attracted sustained efforts from practitioners and some interest from policy makers over the past two decades; but to date elderly abuse and neglect has received little, if any concomitant attention from researchers or from the agencies that provide research funding.

This current research on elderly abuse and neglect is intended to point the way toward better understanding of the nature and scope of the problem of elderly abuse and neglect and to find a necessary condition for the development of informed policies and programs. The aim of this study is to fill the knowledge gap and it aims to explore prevalence rate and risk factors for elder abuse in the United States. The present study specifically focuses on verbal abuse, physical abuse, and violation of personal rights of elder people in our society. Personal problems of the care giver and care taker that can lead to abusing a frail older person include care -giver care taker stress, mental or emotional illness, addiction to alcohol or other drugs, job loss or other personal crises, financial dependency on the older person, a tendency to use violence to solve problems. Care giver and care taker stress is a significant factor for abuse and neglect. When care givers and care takers are thrust into the demands of daily care for an elder without appropriate training and without information about how to balance the needs of the older person with their own needs, they frequently experience intense frustration and anger that can lead to a range of abusive behaviors.

Dependence is another contributing factor in elder abuse. When the caregiver is dependent financially on an impaired older person, there may be financial exploitation or abuse. When the reverse is true, and the impaired older person is completely dependent on the caregiver, the caregiver may experience resentment that leads to abusive behavior. Another factor that is attributed to elderly abuse and neglect is emotional and psychological problems of the caregiver/caretaker which can put the caregiver/caretaker at risk for abusing an older person in their care. The National Committee For the Prevention of Elder Abuse (NCPEA, 1998) study define Elder Abuse and Neglect as any form of mistreatment that results in harm or loss to an older person. Elderly Abuse and Neglect is generally divided into six categories by the NCEPA: (i) Physical Abuse (ii) Sexual Abuse (iii) Domestic Abuse (iv) Psychological Abuse (v) Financial Abuse and (vi) Neglect. A National Incidence Study on Elderly Abuse (NISEA, 1996) estimated that approximately over 450,000 elderly experienced abuse every year nationwide, if self neglect is included that number is even greater. Some studies on elder abuse (Bennet & Kingston, 1993; Chen et al., 1982; Eastman, 1984; Giordano & Giordano, 1984) have identified advanced age as one of the most salient risk factors of elderly abuse and neglect.

Other studies have mentioned gender as other frequent risk factors of elderly abuse and neglect, in that females are more likely to be abused compared to their male counterparts (Harris, 1996; Korbin et al., 1991; Lachs et al.,The early research on domestic violence had focused on the abuse of women and children; however, a growing number of researchers are beginning to focus their attention in elder abuse and neglect (Bennett & Kingston, 1993; Decalmer & Glendenning, 1993; Lau & Kosberg, 1979; Pillemer & Wolf, 1986). In recent years, the studies on prevalence of elder abuse have increased, and researchers across countries are now beginning to take note of the growing problem of elder abuse and neglect. Gailbraith (1989) argues that, although, the growing problem of elderly abuse is well known “because there is little consensus regarding the minimal standards of care necessary to maintain dignity and quality of life in old age as well as those responsibility to ensure those standards it has made it difficult for researchers to delineate the exact scope of elder abuse and neglect” (Gailbraith, 1989, p. 35-42).

Two gerontologists Pillemer & Finkelhor (1988, p. 51-57) who have studied the prevalence of elder abuse and neglect mentioned in their study that, “elderly abuse and neglect is known to affect nearly 4 percent of the population over the age of 65 in the United States.” In a large scale prevalence study conducted by Pillmer & Finkelhor, they found that about 3.2 % of their elder respondent reported being abused during the surveyed years. The Adult Protective Services (APS, 1996) documented a total of 293,000 reports of elder abuse and neglect cases. The National Center for Elderly Abuse (NCEA, 1998) report compared the APS 1996, agencies reports with figures from 1986 reports and indicated a 150% increase as compared to the figures in 1986.

The NCEA (1996) report further indicated that an estimated 449,924 elderly persons, aged 60 and over experienced abuse and neglect in domestic settings in the United States in 1996. The National Research Council (NRC, 2003) in a panel to review risk and prevalence of Elder Abuse and Neglect in an Aging America define elder abuse and mistreatment as “intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a care giver or other person who stands in a trusting relationship to the elder; or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (National Research Council, 2003, p. 40).

This current research on elderly abuse and neglect will use both qualitative and quantitative methodological approaches to addresses the interacting relationship between the context of care giving and abuse and neglect of older adults. The participants in this study were observed and examined through the thematic content analysis of risk factors that were identified in the thirty-six in-depth interviews of respondents who claimed they were abused and neglected victims. The interviews provide me with a portrait of the respondents past and present situations, their roles and relationships and the process through which they move into their described process of powerlessness. This exploratory study on elderly abuse and neglect will use both qualitative and quantitative research methodologies to understand the growing problem of elderly abuse and neglect in our American society. To accomplish the objective of this research on elderly abuse and neglect, this study will explore the use of both qualitative and quantitative methodological approaches. The qualitative method involves a series of qualitative in-depth interviews conducted with twenty elderly male aged between sixty and eighty years, and fifteen elderly female aged between sixty five and 85 years. The interviews lasted about one and a half to two hours for each (male and female) session. The interview guides were used to cover several content categories, including: effects of abuse on perceptions of life experiences over time.

The aim was to capture the depth and possible variation of the life experiences and the meanings relevant to the subject of the inquiry in this study. The qualitative methodological approach will be discussed further in the methodological section in this study. Elder abuse and neglect is a widespread and growing problem for a major segment of the American population that has resulted in a variety of negative societal and health outcomes. A national incidence study conducted in 1996 by the Department of Health and Human Services (DHHS, 1996) Administration on Aging found 551,011 persons aged 60 and over experienced abuse, neglect, and/or self-neglect in a one-year period. The DHHS report found that almost four times as many new incidents of abuse, neglect, and/or self-neglect were not reported as those that were reported to and substantiated by protective services agencies for adults. The DHHS report documented that persons, age 80 years and older, suffered abuse and neglect two to three times compared to their proportion of the older population; and among known perpetrators of abuse and neglect, the perpetrator was a family member in 90 percent of cases. The report also found that two-thirds of the perpetrators were adult children or spouses. After the widely held publicized hearings on the mistreatment of the elderly in the 1970s by Congressman Claude Pepper, policy makers and practitioners have sought ways to protect older Americans from physical, psychological, and financial abuse. Forty years later elderly abuse and neglect continues to be a social problem. Elderly abuse and neglect is a social problem that has continued to influence all members of the community so much that by 1993 each state had enacted laws addressing elder abuse in domestic/institutional settings.

However, the problem has been slow in federal legislative and depart- mental activity for addressing elderly abuse and neglect and lacks, coordination and comprehensiveness. In addition, funding to combat elder abuse by the federal government represents only a small percentage of that spent on such other abused populations as children and women. At the federal level, the barrier and challenges to addressing elder abuse and neglect are identified along with existing programs, but at the states and local levels on the other hand, initiatives show promise for effectively preventing or treating the problem of elderly abuse and neglect. Forty-four states and the District of Columbia have laws providing that individuals who assume the care or custody of the elderly mandated to report any abuse and neglect of the elderly under their care, these individuals are considered mandatory reporters by the states. Since 1992 the older population 65+ has increased by 3.3 million or 10.2% from 35.6 million in 2002 to 38.9 million. By the year 2030, older population will be more than double to about 71.5 million. Members of minority groups are projected to represent 26.4% of the older population in 2030, which is an increase from 16.4% in 2000. A report on the multicultural boomers cooping with family and aging issues compiled by the American Association of Retired Persons (AARP 2001) shows African Americans as comprising the largest group of ethnic and racial minority in the United States population aged 65 and older.

The National Academy on Aging Society (NAOAS, 2000) study predicted that based on age related health and disability rates, there will be a rise in the number of persons with debilitating conditions; the more disabled and chronically ill African American elders portend continuing need for dependent care. As a result of the changing demographics in aging and the increasing longevity of older African Americans research is needed to focus on persons most likely to assist elderly African Americans with daily living tasks, personal needs and long-term care. The personal losses associated with abuse can be devastating, and can include the loss of independence, homes, life savings, health, dignity and security. The occurrence and severity of elder mistreatment are likely to increase markedly over the coming decades as the population ages, care giving responsibilities and relationships change and increasing numbers of older persons require long-term care. Although the magnitude of elder mistreatment is unknown, its social and moral importance is self evident. However, there is no solid under- standing of the nature, causes and consequences of elder mistreatment, the effectiveness and cost of current interventions, or measure that could be successfully taken to prevent it or to ameliorate its effects. The purpose of this study is to help remedy this deficiency.

ASSUMPTIONS OF THE PROBLEM OF ELDERLY ABUSE AND NEGLECT

Traditionally, elderly abuse cases have been described in the literature mainly as “caregiver stress” rather than domestic abuse (Weiche, 1998). Interest in elderly abuse and neglect, and the recognition of it as a social problem in need of attention has developed recently not only in the United States, but in many other countries. This has however, been in the context of existing recognition of domestic violence and child abuse. This growth of interest in elder abuse shares a number of common features with these other areas of violence – slow recognition and acceptance; difficulties with definitions and concepts; an emphasis perhaps on stress and pathology as opposed to gender/power and male violence. The early research studies that considered elder abuse were not particularly concerned with gender and, following the classification developed by Hammer and Heam (1999), could be described as either ‘gender absent’ or ‘gender neutral’. Initially, studies were ‘gender absent’ in that there was a failure even to consider gender was considered, and included within research studies, but was viewed as a factor among several others that warranted attention. This type is what is referred to as ‘gender neutral’, as the potential effects of gender appear to be diluted within the research and theoretical considerations. One example of this is noted in Pillemer and Suitor (1992) who included the gender of the caregiver as an additional possible predictive variable in elder abuse. Pillemer and Suitor made no hypotheses regarding gender in their research, however, whilst spousal violence was found to be more likely than in other relationship, no comments concerning gender were made in their subsequent discussion. Whittaker (1995) view is that this gender, ungendered; gendered neutral approach held sway until relatively recently. He argues that research and theory construction occurs in occurs socio-political climate which privileges definitions and prevalence studies above the gender debate. The main ‘gender neutral’ approaches identified by Whittaker include situational stress which focuses on victims and is underpinned by stereotypical notions of ageing and dependency. When considering predisposing factors, she also identified the pathology of abusers, and family violence, which she views as reflecting the intention to safeguard what she referred to as ‘normal’ family relationships. Whittaker (1996) suggests that “there appears to be no attempt to include the victim’s subjective experience of abuse as part of the definitional debate and very little attention is paid to issues of inequality of power between victim and perpetrator other than to stress that old women are not children and that dependency exists as a two-way process within relationships and between them and their abusers.

OPERATIONAL DEFINITIONS OF ELDERLY ABUSE AND NEGLECT

A leading researcher in the field of elder abuse Wolf (1988) observed that “from the very beginning of the scientific investigation into the nature and causes of elder abuse definitions have been major issues” (Wolf, 1988, p. 758). Operational definitions for elderly abuse and neglect vary in terms, considerably from one state to another; never-the less, legislatures in all 5o states have passed some form of elder abuse prevention laws. It is suggested by (Bennett, 1999; Declaimer & Glendenning, 1993; Kozma & Stones, 1995) that lack of a generally acceptable definition of elderly abuse and neglect has spawned wide varieties of definitions, which to this day, still generates controversy and debate. The development of a widely accepted operational definition and validated standardized measurement methods for the elements of elderly abuse and neglect is urgently needed. The federal and state governmental agencies should develop widely accepted operational definitions of the elements of elder abuse and neglect, its different forms, and associated risk factors and outcomes. It is imperative that a series of measures for these elements be develop for each of the multiple contexts of research, including screening and case identification in clinical settings as well as studies of elder abuse and neglect in the population as a whole. Even without a generally acceptable definition for elderly abuse and neglect, most would agree on three basic categories of elderly abuse and neglect: (1) domestic elder abuse; (2) institutional abuse; and (3) self-neglect or self-abuse. Most would also agree on three major types of abuse. Researchers (Hudson, 1994; Wolf, 1992; Decalmer & Glendenning, 1993) suggest that most would also agree on the major types of abuse – physical, psychological, and financial abuse. For the purpose of this research paper, the definitions of abuse and neglect will be based on those set out by the National Council on Elder Abuse (NCEA), mainly because there is some consensus on their utility. “Domestic elder abuse” is conceptualize as any of several forms of maltreatment of an older person by someone who has a special relation-ship with the senior, such as a spouse, a sibling, child, a friend, or a caregiver, in the older person’s own home or in a care giver’s home (NCEA,1998). It is called “domestic abuse” because it occurs in a community rather than in an institution such as in a nursing home. In a study of elderly abuse researchers Hudson (1991) and McDonald (1996) suggests that the abusive behavior can cause psychological and material injury to the older person, resulting in distress and suffering. “Physical abuse” is operationalized as the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include, but not limited to, such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning (NCEA, 1998; Stones, 1995; Wolf & Pillemer, 1998). Maltreatment such as the inappropriate use of drugs, and physical restraints and force-feeding are also considered physical abuse (NCEA, 1998).

“Sexual abuse,” is operationalized as non-consensual sexual contact of any kind with an older adult. Sexual abuse is sometimes subsumed under physical abuse. It includes, but not limited to, unwanted touching and all types of sexual assault and battery, such as rape, sodomy, coerced nudity, and sexually explicit photography (NCEA, 1998). “Psychological or emotional abuse” is operationalized as the infliction of anguish, pain distress through verbal or non-verbal acts. This type of abuse includes, but not limited to, verbal assaults, insults, threats, intimidation, humiliation and harassment. Other examples of emotional abuse include treating an older person like an infant; isolating the person from his/her family, friends, or regular activities; giving the older person the silent treatment; and enforced social isolation. Emotion abuse is sometimes difficult to assess. “Material abuse” can be operationalized as the illegal or improper exploitation of an older person’s funds, property, or assets. This type of abuse is sometimes referred to as “financial abuse”. Scholars and researchers who have studied guardianship and trustees of older people (Gordon, 1992; McDonald, 1996) suggests that this type of abuse, includes but are not limited to, cashing an elderly person’s checks without authorization, forging an older person’s signature, misusing or stealing an older person’s money or possessions.

“Neglect” is operationalized as intentional or unintentional harmful behavior on the part of an informal or formal caregiver in whom the older person has placed his or her trust. Unintentional neglect is operationalized as failure to fulfill a care taking responsibility, but the caretaker does not intend to harm the older person. Intentional neglect in this study is operationalized as when the caregiver consciously and purposely fails to meet the needs of the older person, resulting in psychological, physical, or material injury to the older person. Typically (NCEA, 1998) refers to neglect as the refusal or failure of a care giver/care taker to provide an older person with the very necessities of life, such as water, food, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials. “Self neglect” is operationalized as the refusal or failure of older adults to provide his/her with the necessities of life. It is characterized as behavior by an older adult that threatens his/her own health and safety. Some of the symptoms of self neglect are mal-nutrition, dehydration, untreated bedsores, poor personal hygiene; unattended or untreated health problems; hazardous or unsafe living conditions; unsanitary or unclean living conditions, inappropriate and/or inadequate clothing, lack of medical aids (e.g., eye glasses, hearing aids), gross inadequate housing and homelessness.

VARIABLE OF INTEREST IN ELDERLY ABUSE AND NEGLECT

The variable of interest in this research is to examine what variables are the attributing factors responsible for perpetuating abuse and neglect on the elderly. Parker and Penhale (1998) suggests that social and health care practitioners both support and control, thus wield power in the private world of families from their position as agents of the State. Parker and Penhale argued that working to protect others, demands, in fact, the legitimate exercise of power in human situations. McCreadie’s (1992) perspective of the power relationships between the elderly and their social and health care practi- tioners will suggest that practitioners may also be likely to have personal power in the eyes of those with whom they work. McCreadie believes that more often it is the dispossed, disenfranchised and vulnerable, those who are most marginalized and excluded from and by society that become the victims. McCreadie also suggest that since the dual direction in old age is acknowledged, practitioners do not only exercise power, they too are bound by and subject to power of agency both the state, and legislation. Jack (1994) argued that since the function of caring has been professionalized in health and welfare settings, as a result it is generally conceptualized as women’s work. Illich (1997) in referring to the ways in which the organization of care practices could lead to ill health by increasing stress and bureau- cratizing care used the term ‘socialiautro-genesis’. The social organization of social and health care continues this process. Older people a perceived as receiving care rather than receive treatment. They are perceived and treated as passive recipients of care rather than active participants, centrally involved in an enterprise premised on partnership. This can be seen as potentially doubly stigmatizing because a positive outcome is generally denied such approaches. The emphasis is on the outcome and content rather than the process. Jack (1994) believes the powerlessness shared by old women and their female caregivers is as a result of the combination of ageism and sexism within the professionalization of welfare. Jack also believes that, this sense of powerlessness has lead to new perspectives on abuse and neglect by formal caregivers, who have perceived the abuser and abused as socially, organizationally and personally powerless, and as a result locked together in a relationship of mutual, enforced dependency.

Jack argues that the “exchange relationship of formal care is the medium through which this socially constructed powerlessness takes place and has resulted in the individual and collective abuse of elderly people” (Jack, 1994, p. 79). Using social exchange theory to determine the extent of power relationship between the care givers and caretakers (Dowd, 1975; Gelles, 1983) have also suggested that, a person who is less dependent on the social exchange relationship often uses his/her power advantage to effect further compliance and this may be in the form of abuse. Many scholars (Bennet & Kingston, 1993; Chen et al., 1982; Giordano & Giordano, 1984) who have studied the effect of dependence on elderly abuse and neglect have yielded mixed results. Most studies have portrayed an abused elder victim as one being dependent on the abuser. According to Frude (1990) Exchange theory suggests that individuals act according to real and perceived benefits and costs of continuing a relationship. The most dependent is the least powerful. However, the least powerless may also seek to maximize gains and minimize contributions to be made to a relationship. Aitken and Griffen (1996) have also suggested that, in this type of dependent relationship, the person cared for may be seen as an inconvenience and a subculture of abuse may arise in formal care-giving situations. Jack (1994) uses Seligman’s (1975) work on ‘learned helplessness’ to show that ageist stereo-types of dependence and increasing incompetence lead to the erosion of personal control in the context of formal care. Perceived powerlessness and dependency has been implicated in abusers in formal settings, since women care givers and care takers are the ones who predominate in the workforce, therefore, the work is subsequently devalued, and women who are cared for are also discriminated against. Jack’s argument in support of this perceived powerlessness is that “in order to ensure her dependency – needs are met, the old woman is compelled to surrender her claim to adult status to the female caregivers and caretaker, whose limited status within the organization depends on her complete possession of the care- giver and care taker role” (Jack, 1994, p. 89).

IMPORTANCE OF THE RESEARCH ON ELDERLY ABUSE AND NEGLECT

The importance of the research on elderly abuse and neglect is to help in the process of designing cases as incidents of mistreatment in order to improve criteria, investigation methods, decision making processes, and decision outcomes. Understanding abuse and neglect of older adults will help researchers and practitioners establish a sound foundation for a genuine long-term commitment of resources to this important, understudied area. Most of research on elderly abuses and neglect has been focused on abuse on nurse aides. The problems with researches on nursing home abuse include variations in definitions and methodologies, which have prevented researchers from comparing aggregating results and have created difficulties in distinguishing abuse from substandard care or bad practice. One other problem of the nursing home abuse and neglect research has been its contextual differences; this has limited the usefulness of cross-country or cross-cultural comparisons. The absence of a gold standard for case identification, and the momentous consequences of inaccurate decisions for example, highlight the need for studying and improving the process of case investigations. Researches are greatly needed that will examine the risk indicators and risk and protective factors for different types of elderly abuse and neglect. Research is needed for risk factors for neglect, psychological abuse, mistreatment, sexual abuse and financial abuse. A substantial commitment to research is needed to inform and guide a caring society as it hopes to cope with the challenges ahead. Most studies of the causes of elderly abuse that have been done on nursing homes have focused on characteristics of patients, workers or interactions between the two. This study on the other hand is focusing on the experiences of the elderly who have been abused and neglected at home by their care givers and care takers.

ETHICAL ISSUES RELATING TO ELDERLY ABUSE AND NEGLECT

Each year an estimated .1 million older Americans are victims of physical, psychological, or other forms of abuse and neglect. For every case of elder abuse and neglect that is reported to authorities, experts estimate that there may be as many as five cases that have not been reported. Like other forms of abuse, elder abuse is a complex problem, and it is easy for the general public to have misconceptions about it. When many people, hear of elder abuse and neglect, they always think about older people living in nursing homes or about elderly relatives who live all alone and never have visitors. This general misconception of elderly abuse and neglect is inaccurate, since most incidents don’t happen in a nursing home. It is true that such abuse does occur, but it is not the most common type of elder abuse. At any one time, only about 4 percent of older adults live in nursing homes, and the vast majority of nursing home residents have their physical needs met without experiencing abuse and neglect. On the contrary, most elder abuse and neglect takes place at home. The great majority of older people live on their own or with their spouses, children, siblings, or other relatives, not in institutional settings. The use of restraints for example, which are commonly used to prevent older adults from falls, stop wandering or aggressive behaviors, bed rails, cloth or leather straps, and geri-chairs (wheelchairs with fixtures to keep the person from rising) raises ethical questions.

Included in the discussion of the ethical dimensions involving the use of restraint are considerations for basic human rights, quality of life issues, the right to fall with the potential for injury in exchange for freedom, and issues of decision making. Dignity, independence, and a sense of control become even more important when an older individual is institutionalized and faced with increasing physical and emotional limitations and personal losses. The principle of autonomy speaks to the right of competent persons to make decisions about their own health care. It has been argued that older persons who are restrained are to begin with, confused and suffering from some degree of dementia. This poses the dilemma of making decision in the best interest of the older adult, whether to restrain or not to restrain. It has also been argued by ethicist in trying to protect the fundamental human rights of older adults that, every one has a right to life, liberty and security of person and the right not to be deprived except in accordance with the principles of fundamental justice. In order to follow the ethical guideline when taking care of older adults, care giver/care worker must have a justifiable reason to believe the older adult is not capable of making his/her own decisions; safe guard against violating the criminal ; or when the older adult poses a risk to self or to others. In most cases, intervention must be voluntarily agreed upon, therefore, for ethical as well as practical reasons; action plans should be the least intrusive and least restrictive, while best addressing individual situations. In essence, ethics as a form of reasoning is a reflective process that attempts to answer the basic question: “What should I Do in This situation, All things considered.

METHODOLOGY

A total of 36 elder people participated in the present study, 15 were approached individually in various recreational areas in the public housing estates, and the remaining 21 were elder people who participated in various senior activities organized by the local community at the senior center. There were significant differences in the gender ratio of the two samples, in that there were significantly more female participants than male. All the participants were informed that they were about to participate in a study relationships on family. Strict confidentiality was ensured and consent was obtained and the consent of the participants was obtained prior to administration of questionnaire that took approximately 45 minutes to complete. All participants completed the questionnaire voluntarily without monetary reward. All the participants were encouraged to share their opinion about the interview at the end of the session. A majority of them reported feeling happy to share their experience with the interviewer and were glad that someone was willing to listen to them No report of distress was recorded. Qualitative methodology (MacEachron & Gustavson, 1997) was used to collect and analyze the data. The aim of the qualitative research in this study is to capture the depth and the possible variation of life experiences and meanings relevant to elderly abuse and neglect. The research is based on in-depth interviews conducted with thirty-six elderly individuals (20 female and 16 males). The quantitative methodological approaches in this study are questionnaires and surveys, which were given to the participants to determine their perceived experiences of neglect from their caregivers/caretakers.This research wanted to find the emotional and psychological indicators from the respondents; their opinion about the quality of the care they received; and their subjective feelings related to their neglects.

The interviewees and respondents to the questionnaires and surveys were between the ages of sixty and eighty years. They were recruited for this study following their consent to participate in a group of elderly men and women in a senior center run by a non-profit social services organization of a large metropolitan area in southern California. Seven of the male participants in this study were widowed and living with relatives (adult children, grandchildren, nephews, nieces distant relatives); three were separated from their spouse (but not divorced) and living with male relatives; six were never married and are living with relatives. The sixteen male represented diverse ethnic origins and levels of education. Four of the male had once worked as professionals in various occupations; five once worked as a (farmer, salesperson, school custodian, school bus driver, and carpenter), and one once worked as construction workers, and two once worked as carpenters and the remaining four were still working as part-time janitors. The sixteen male who participated in this study had between five to twelve children. The twenty female also represented diverse ethnic origins and levels of education. Ten of the women were widowed; three of them were still living with spouse the remaining were divorced and living with relatives. Four of the women had once worked in various professional occupations (nurse, teacher, freelance decorator, secretary); five had once worked as part-time cleaning workers; seven had once worked as factory hands. Two of the female interviewees were religious; and about half of the women indicated partial traditional beliefs. The female have between twenty five to twenty seven children. Since my status of limited knowledge in working with elderly abuse and neglected persons, the 20 elderly female and 16 elderly male participants who claimed they have all experienced abuse and neglect during their life time, were conceived of as a practitioner, researcher-client collaboration in this study.

The aim was to help me in building and developing knowledge grounded in the participants’ experiences in dealing with abuse and neglect over time (Hess & Mullen, 1995; Karger, 1983). The goal of the collaboration was to understand and conceptualize the basic themes underlying elderly abuse and neglect from the experiences of the men and women in the study as guidelines for future intervention in the group and ensuring them that their voices are heard. The interviews, lasted about one and a half to two hours, and were taped-recorded and then transcribed verbatim. Several content categories were coved by the interview guide, including: effects of abuse on perceptions of their life experiences over time; their emotional and intimate relationship with their abusers; the effects of the abuse on their relationship with off-spring; differences in perception of abuse and neglect between male and female participants in the study. Rapport was easily established with all the participants in the study and thus resulted in participants being more willing to disclose their personal experience in this study. Furthermore, all the participants were interviewed in familiar and neutral settings, such as rooms in the senior community center or recreation areas in the senior housing estates they lived. Thus making them to feel more relaxed and were less fearful of repercussions from their caregivers/caretakers if they reported the latter abusive behaviors to the interviewer. Content analysis was performed by cross-case analysis and the constant-comparison method, in which core themes are identified and compared and analytical categories are derived (Denzin, 1989; Strauss & Corbin, 1990).

THE HISTORICAL CONTEXT OF ELDERLY ABUSE AND NEGLECT

Historically, elder abuse and domestic settings has been constructed as a problem between female abuser and older parents – often a mother – within a caring context. Aitkin and Griffin (1996) North Hampton shire study found, however, that male sons rather than husbands abused older women. Women were physically abused, men were psychologically abused. The literature is abounding with references to ‘dysfunctional families.’ Whittaker (1996) believes that this perspective creates the view that elder abuse represents a symptom within a poorly functioning family, which therefore avoids introducing gender issues into the debate. Harris (1996) speculates that although elderly abuse and neglect has only been recognized as a social problem, elderly spousal abuse is most likely as ancient as are both other forms of domestic violence, and family life itself. The British Medical Journal and Modern Geriatrics (Baker, 1975) and Burston (1975) first made references to elder abuse in the mid-1970s, marking the beginning of the medicalization of the problem. Mosqueda, Heath & Burnight (2001) were the first medical researchers to recognize physical abuse and neglect of the elderly in a skilled nursing facility. Mosqueda and colleagues suggests “Characteristics commonly observed in dementia patients, such as combativeness, aggressiveness and resistive behaviors have been linked to abuse insti- utional settings” (Mosqueda, Heath & Burnight, 2001, p. 183-186). As suggested earlier, elder abuse and neglect is the most recent form of interpersonal violence to have been recognized as a problem in need of attention.

It is also, however, an area that has been hidden from the public concern and has been regarded as a ‘taboo topic’. As Bennett et al, (1997) suggested in their discussion elsewhere, much of the abuse that occurs takes place behind close doors and is not open to public scrutiny. These scholars suggest that to make what happens in private a matter for public concern is not an easy, and this is in part due to the resistance experienced from proponents of familial rights to privacy and freedom from federal and state governmental intervention. Bennett and colleagues argue that, in addition, this is not a pleasant area to focus on, in particular as it challenges some of the myths and deeply held beliefs that have been constructed over time within and about society. Examples of such attitudes are the belief that families provide warm, nurturing environments for individuals or that institutions are safe places for older people to live in. It has not been easy to challenge this taboo and such beliefs, nor to encourage people to discuss situations, let alone to disclose them. The sexual abuse of older women is viewed for example, as an area that has proved extremely problematic to consider, largely due to difficulty that many people have in conceptualizing older people as sexual beings. For example, it was difficult enough to raise the issue of child sexual abuse in the 1980s, so to consider an older woman as the subject of sexual violence may have proven very difficult. Throughout the 1990s, issues concerning violence towards older people have been raised and the silence wrought by the taboo has been challenged and gradually eroded.

VALIDITY OF THE RESEARCH METHOD

The present study documents the life experiences of both male and female elderly individuals who have been psychologically, emotionally, financially and sexually abused by relatives, loved ones and care givers and caretakers in domestic settings; as well as identify risk factors associated with the phenomenon. However, there are a number of limitations in the present study, and this may call for caution in generalizing its findings. First of all, this study was based on retrospective reports by the elder participants and may be contaminated by their recall bias. Secondly, this study relied only on participants’ self reports and no attempt was made to verify the abused incidents. Also, this study focused only on the behavioral indicator of elder abuse and did not examine the contextual factors such as the antecedents and consequences of the abusive behavior, which might have important implication in the study of elder abuse. Moreover, most of the data from this study were collected from a relatively active and healthy elder sample, and may not generalize to the entire older population. For instance, studies have indicated that various types of abuse actually have higher prevalence rates in the communal settings than in the family context. The data generated from this research also indicates that there was a consistent trend that more females were represented than males in the sample population, and the results from the findings indicates that more females were abused compared to males for all types of abuse, though the differences were statistically insignificant. On the one hand, the findings in this study suggest that elder people of two genders might have been treated differently by their families and caregivers/caretakers. On the other hand, it might appear that females, who were assumed to be more expressive and willing to talk about their sufferings, might be more willing to admit to incidence of abuse.

INTERNAL AND EXTERNAL METHODS OF THE RESEARCH

The external data used in this research are the data analysis provided by the National Center For Elderly Abuse (NCEA, 2000) which addressed elder abuse in domestic settings administered by state protective service programs/agencies or state aging agencies. The NCEA data analysis is a compilation for domestic elder abuse reports for 17 states, investigations were compiled from reports for 47 states. Analysis were performed for the reports and investigations from those states. External data for this study included all types of abuse with categories delineated by each state. The internal data in this research emerges from interviews and discussions taken from elderly male and female individuals who participated in this study. All the content of the interviews and discussions from elderly abuse victims were collected and reduced pheno- menologically, followed by identification and coding of core themes. The core themes were identified at first through descriptive coding and then through more in-depth categorical and theoretical-substantive coding. The core themes were then recorded conceptually and placed back in the context derived from the larger interview. This made possible both the analysis and integration of large amounts of data, as well as generation of abstraction and interpretations. All the interviews were coded separately and from the subsequent coding, was able to identify emergent themes and to determine which themes needed further clarification and scrutiny.

The coding and analysis were finished when theme saturation occurred and new data could not add to an adequate explained category (Strauss & Corbin, 1990). For this research a theme was saturated if at least half of the interviewees supported the coder’s analysis. Themes saturation helps in addressing the internal validity of findings in this research. The qualitative methods employed in this research do not claim generalizability, and there is no expectation for replication of the results due to the idiosyncratic nature of the research. Concern was mainly focused on internal validity to ensure that the various aspects of the data collected complemented each other during the analysis and created consistent, rich and thick description (Schofield, 1993). Validity in qualitative research conflicts with the fundamental assumption of quantitative research whereby validity equals truth (Angen, 2000). In qualitative research, validity aims to achieve credibility (Lincoln & Guba, 1985) without arguing that a full version of truth has been achieved (Hammersley, 1995; Polkinghorne, 1991). In this sense, the emphasis is placed on validation rather than on validity, moving away from a definitive version of reality towards a process of inter-subjectivity and ongoing validation between researchers and readers (Angen, 2000).

DESCRIPTION AND SUMMARY OF THE SAMPLING METHOD AND HOW THE PROBLEM OF SAMPLING BIAS WAS HANDLED

This study used two urban community senior centers and three urban senior housing estates as the setting for screening. The older individuals who participate in this study were screened specifically for abuse and neglect. Since the objective of this study is to explore and to examine dyadic risk and vulnerability profiles of home-dwelling older adults and their caregivers/caretakers; thus, nursing home residents and self-neglect persons. All older adults in this study were approached and invited to participate in the study. All of the elderly male and female participants in this study were given written informed consent, the inclusion criteria of the subject matter to be studied were confirmed prior to the commencement of the research. All individuals 65 years and older were eligible for enrollment in this study. The mean age of the sample population was 79 years (± 6 years), with an upper age limit of 89. Fifty-six percent of the participants were females. Inclusion criteria required that participants have a sound cognition, be living at home as opposed to a nursing home, have a telephone and have a paid or unpaid caregiver providing 20 hours or more of care each week. A total of 75 older adults were approached but during the screening process only 36 of them who meet the criteria were enrolled in the study.

THE STRENGTH AND WEAKNESSES OF THE SAMPLING METHOD

Although the present study documents the occurrence and the prevalence of elderly abuse and neglect in the U. S. and was able to identify the risk factors associated with the phenomenon, however, a number of limitations in the sample population may call for special caution in generalizing its findings. First of all, one weakness of the sampling method is that all the participants in the sample population are from one region in the U.S (Southern California), and they all reside at home. Another weakness of the sampling method is that, the sample size was not large enough to be considered a representation of the older adult population in the Southern California, not to mention the population of older adults in the U. S. One other weakness of the sampling method is that, only older adults who were residing at home participated in the study, older adults residing in nursing homes was not included in the study. The contextual factors in this study, pose another weakness to the sampling method. This study’s main focus was on the behavioral indicator of elder abuse and neglect and did not examine the contextual factors as the antecedents and consequences of such abusive behaviors, which might have important implication in the study of elder abuse and neglect. The final weakness of the sampling method has to do with generalizability, since all the data in the study were collected from a relatively active and healthy elder sample, and may not generalize to the entire older population.

SUMMARY OF THE RESULTS AND FINDINGS

Those who participate in this study (interviewees) were structured along two dimensions. One concerned their awareness of suffering accumulated over many years of physical, psychological, and sexual abuse; the other concerned their awareness of their limitations of their chronological age, which were interpreted as “fragile glass-like” a perception which symbolizes a sense of urgency because of experience that they were running out of time. These two dimensions of the interviewees combine to produce a rising level of distress due to their experiencing themselves as elderly abused men and elderly battered women, two complementary “selves” delineated by their sufferings regardless of their gender variables. Four major themes emerged from the interviews: (1) Experiencing the self from two opposite poles: heroes/heroines and/or weaklings fools; (2) Giving up the self for the sake of family members; (3) Children as meaningful others: Friends or foes? (4) Lost in time between a painful past and a trap-like future. The women interviewees described domineering and aggressive tendencies of their spouses, older siblings and male caregivers as continuous life motifs. This was the context in which the interviewees (both men and women) needed to define their sense of self, which can be described as moving between two poles on a continuum. One was their self perception from a man’s point of view and the other from a woman’s perception as being defenseless in whatever the outcome. For the women, they viewed themselves as heroine having the ability to survive and to overcome suffering, whereas as the other was a negative, self-deprecating perception. While this study could not develop a clear-cut typology of either heroes/heroines or weaklings/fools, most of the interviewees tended to align themselves with one pole or the other. The following quote illustrates the heroic pole:. . . At home, he ate my heart out every day, ate my heart every day; there was a heart attack and afterwards a cerebral event. In spite of my education, I have become the caretaker of other people. To be a caretaker is like being a housemaid… There was violence along with suffering for many years; it was suffering, but I had a goal behind all this suffering, to have my children grow, get married and get an education…. I don’t know if the suffering was worthwhile for, I don’t know if it was worthwhile it was difficult. Today I look and say that I was a heroine, I was a heroine myself, with all the things I went through during the 50 years.

This interview reflects ambivalence over whether or not the suffering was worthwhile and concludes that it was. This woman establishes a split between her own self in relationships with meaningful others, namely the children. Such framing gives meaning to her suffering, facilitates her self presentation as a heroine, and it solves her dilemma of whether it was all worthwhile in light of the losses incurred.Another interviewee presented herself at the opposite pole: “I am not a heroine! Am I a heroine? For suffering and for becoming sick? You know what a paralysis, twice an open-heart operation; people look at me and cannot see that I have gone through these illnesses. This is no heroine! This is stupidity … for letting myself contract these illnesses. Had I left him, I would not have contracted all the illnesses I got ….I was an idiot woman. No woman lives like that, cooking and serving him after the beating . . . I say that I was an idiot. This interviewee, like the first one, has to cope with the framing of her psychological and physical condition, the feeling of non-existence in both body and soul. She perceives herself as fragile and weak outside her relation to her husband, and inside in her relations to her self. Unlike the first woman, she splits the self, with one part belonging to the past and the other part to the present, while connecting the two with the negative self-label of “idiot.” Perceiving herself as a heroine signifies power and understanding beyond understanding for those women, allowing them to define themselves as strong. Similarly, by choice of self-definition as foolish and weak, they see themselves becoming a prisoner of their own imperfectly grasped negative awareness, yet they remain empowered by the sense of acquiring meaning and disillusionment, based on a more realistic vision of their life and behavior. Giving Up the Self for the Sake of Family Members. The female interviewees who responded that they were abused described themselves as “good” women. While they may have abandoned hope in their relationships with their spouses at an early stage due to violence, these women developed increasing expectations from their children as a source of support and protection.

Their feelings towards their children in most cases were ambivalent, pride and satisfaction mixed with frustration, disappointment, betrayal, and desertion. One female interviewee described her forgiveness towards her husband, which ended working towards her: My forgiveness was actually for the house and for the kids, and all the time it ended up with the children and the house, without any consideration for myself. I actually did not see my self as worthy. I was just the maid and the servant of the entire house. My head was always full of the kids and house, their education. And in fact I had forgotten myself…… The existence of powerlessness and dependency on her husband is made visible in that interviewee’s description as she acknowledge that she had harmed herself by placing herself in an inferior position to that of her husband and children. She describes her acceptance of a role with a diminished self worth, while on the other hand it means yielding responsibility for her own destiny by expecting to receive something from an external source. This interviewee’s experience continues to be a central theme in the experiences of older women. The narrative of older abused women reveals their need to reconstruct meanings in the suffering arising from the continued accumulation of abuse, neglect, loss, anger, frustration, sorrow, loneliness, and shame. From the interviews of the twenty women in this study, this research concludes that elderly abuse and neglected women shape their self-perception along the dimensions of foolish victim or heroic survivor. Against this background of abuse and neglect that colors their life stories is a continuous tension with other themes that hinder their freedom, including existence for the sake of others and a sense of time running out.

Nonparametric correlation and Chi square analysis were the two quantitative methodological approaches employed in this research to help explore the relationship between major variables and occurrence of elder abuse. Using Chi square analysis, this study was able to analyze the responses of the participants who have responded positively to the survey and questionnaires for neglect. The outward appearance of some of the respondents in this elderly abuse and neglect study (poor clothing and skin integrity), suggests that their care givers/care takers may be paying less attention to their care recipients’ toileting and grooming needs. Those older participants in the study suspected to be neglected by their caregivers/caretakers were assessed to be more dependent on their care givers for help with daily living activities. In general, overall and verbal abuse were linked to participants’ advanced age, poor visual and memory abilities and dependence on caregivers/caretakers (p < .05). This study was able to correlate physical abuse of study participants’ with poor memory, dependence on caregivers/caretakers’ non dependence on them, and living with caregivers. Violations of the personal rights of older adults in the study were also related to their advanced age, poor memory, living with caregivers, and their dependence on the care givers/care takers. The gender of the participants in the study was not a significant correlate for elder abuse (p > .05). A series of stepwise logistic regression analysis were conducted to determine the best predictors for overall and various forms of elder abuse and neglect. Variables entered into the regression analysis included participants’ age, gender, living arrangement, visual ability, memory functioning, dependence on the caregivers and caretakers, and caregivers/caretakers dependence on the participant. Results showed that overall and violation of personal rights were best predicted by participants’ poor visual ability (β = -0.674, 0.658), dependence on caregivers/caretakers (β = 0.417, 0.461), care givers’ and care takers’ non-dependence on the participants (β = -2.093, 1.212). Advanced age of the participants was the only significant predictor for violation of personal rights (β = 0.106). Correlates of Elder Abuse and Neglect Table II. Summary of logistic Regression Analysis. The data in this study confirms the construct of dependency as being associated with the outcome of neglect. In terms of emotional/psychological indicators, those in the neglected category stated that they were left alone for long periods of time (p = .002), and did not have the companionship, news or information they felt they needed (p = .001).The data also tells us that older adults with cognitive capacity are willing and able to discuss their relationship with caregivers/caretakers, opinions about the quality of care they receive and their subjective feelings related to neglect.

GENERALIZABILITY OF FINDINGS

Even though, this research on elderly abuse and neglect was able to identify and document the risk factors that are associated with non standardized methods for defining elderly abuse and neglect, a number of limitations calls for special caution in gene- realizing its findings. This study cannot be generalize for the entire older adult population who have experience some kind of elderly abuse and neglect at some point in their life time for it was only able to explores and investigate a smaller population sample of only thirty-six elderly male and female elderly adults who voluntarily took part in the study. Another problem with generalizability in this study has to do with depicting of only risk factors, of the elderly participants while ignoring the characteristics of the abusers. As mentioned above, this study was based on retrospective reports by the elder participants, and there is no way of verifying those reports. This study also did not examine contextual factors such as the antecedents and consequence of the abusive behavior, which might have had important implication in the study, but instead, it focused only on the indicator of the behavioral aspect of elder abuse.

SUMMARY OF THE VARIOUS STUDY RELATING TO ELDERLY ABUSE AND NEGLECT

Briggs, Phillipson and Kingston (1995) promoted a domestic violence approach to elder abuse that emphasized power imbalances and highlighted the position of victimized groups in society. Using this power imbalance approach however, is not always possible to maintain a clear distinction between victim and perpetrator. This is seen in (Gelles and Straus, 1979; Gelles, 1993) Conflict Tactics Approach which views conflict as constructed and maintained by both parties. On the other hand, the domestic violence approach to elder abuse focuses on violence as the central theme. This in turn is viewed by Biggs, Phillipson and Kingston (1995) as leading to reduced recognition of other forms of abuse and neglect. Yillo’s (1993) domination model of domestic violence is view as the corrective approach, because of its focus on the power of male aggressors. Bennett, Kingston, and Penhale (1997) developed what they referred to as the family violence model. According to this model, family violence can be understood as violence which occurs in families and is perpetrated against powerless and vulnerable adults. This act of family violence is seen as an aggressive act by a more powerful individual, group or institution against someone with less power. Hughes (1995) suggests that the perception of power imbalance may not necessarily be at a conscious level, but can develop from the pattern of interaction between individuals from which relative positions in terms of power are secured. Thompson (1997, 1998) suggests that in these ways, the family violence approach fits with the personal, cultural and structural model of oppression. Hanmer and Hearn (1999) however, viewed neither model as wholly ‘gender present, and it is true as we can see, it is only comparatively recently that there had been a shift towards inclusion of analysis of gender considerations. Writing from a feminist perspective, Aitken and Griffin (1996) suggests that elder abuse should be included as a category in domestic violence, but should emphasize a gender – power analysis.

Aitken and Griffin suggests that “the relation-ship between elder abuse and care and between elder abuse and family violence needs to be revisited. Neither care nor family violence by itself offers a sufficient explanation for elder abuse; a more over-reaching way of thinking about elder abuse which would allow an appropriate integration of gender issues would be in terms of power and dependency” (Aitken & Griffin, 1996, p. 139). When view in a sociological perspective, we are likely, to find a combination of complex sociological and psychological factors operating at and between family, structural, organizational, and individual levels. On the one hand, the feminist perspectives only focus on the role of gender and power within domestic violence. Social, political and economic processes are seen to support patriarchy in the subjugation of women. Violence is seen, as representing the means men use to maintain positions of power at the societal, family and interpersonal levels. A range of causal factors must also be brought to bear and individual differences and diversity recognized. The additional variable of a person’s age must also be considered when discussing elder abuse and neglect.

A DISCUSSION ON HOW ELDERLY ABUSE HAS ENHANCED MY UNDERSTANDING OF ELDERLY ABUSE AND NEGLECT

Much of the literature on elder abuse and neglect does not make an essential distinction between theoretical explanations and the individual risk factors related to abuse. Typically, a theory will help provide us with a general systematic explanation of this urging social problem of elderly abuse and neglect. In most elder abuse literature, a particular risk factor, such as stress, is often treated as the theoretical explanation even though stress is only one factor, and as this study indicates, could be subsumed by a number of divergent theories. One major flaw of this stress perspective is that it fails to account for the fact that some care givers and care takers, who experience the same stresses as abuser, do not abuse their elderly. This perspective is almost tantamount to blaming the victim, because it identifies the older person as the source of the stress. Another major theory that is commonly used to explain elderly abuse and neglect is the social exchange theory, a theory founded on the assumptions that social interaction involves an exchange of rewards and punishments between at least two people, and that all people seeks to maximize rewards and minimize punishments. One of the difficulties with this perspective is its ageist assumption: people do not automatically become dependent and powerless as they age. As the male and female participants in this study reveals, it is the abuser’s sense of powerlessness that leads to maltreatment. The narrative of the older males and females in this study reveals society’s need to explore causes or predictors of abuse and to standardized its definition for the categories of the variables that constitutes elderly abuse and neglect. Elderly abuse and neglect should be recognized for what it is – a public health problem. There is need for a systematic response to elderly abuses, neglect and mistreatment that promotes it more thoroughly as a threat to the publics’ health. Further research is needed to help us understand the risk factors to help in detection of elderly abuse, mistreatment and neglect. Because older adults who became victims of abuse and neglect are seldom likely to seek help on their own, and by the time they are detected by the service agencies, the abuse and neglect may have progressed to a level of extreme seriousness. To help us to identify older adults who are victims of abuse and mistreatment there should be national guidelines for accurate detection and protocols to guide the publics’ response when elderly abuse and neglect is suspected. A national standardized guideline that defines what elderly abuse and neglects are will help us to develop the appropriate interventions and prevention programs that will help in reducing and eventually eliminate the risk factors or enhance protective factors that will reduce elderly abuse and neglect and its negative facts.

HOW THE RESEARCH METHODOLOGIES HAVE ENHANCED MY UNDERSTANDING OF THE ROLE OF RESEARCH IN UNDERSTANDING HUMAN BEHAVIOR.

The research methodologies in this study has given me a thorough insight to understand first hand the experience of what older people who have been abused and neglected are experiencing from a behavioral perspective rather than from a contextual frame of mind. The experiences of the older adults who in this study indicate that it is difficult to under-stand what they are experiencing, because it is a social problem that remains an extremely complex and notoriously difficult subject. From the qualitative methodological approach the in-depth interviewing and probing, of the participants in the study, it was a shocking though fascinating experience to hear the 20 females and 16 males’ participants tell me about their horrifying experiences with their spouses, siblings, adult sons, care givers and care takers. With the quantitative methodological approaches – the surveys and questionnaires this study was able to measure the prevalence rates of abuse of the older adults who participate in the study. Connecting gender and aging: Sociological approaches to gender relations in life, Buckingham: Open University Press.

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