Epidemiology of Elder Abuse

Epidemiology of Elder Abuse XinQi Dong, M.D., M.P.H. Director, Chinese Health, Aging and Policy Program Associate Director, Institute for Healthy Aging Associate Professor of Medicine, Nursing and Behavioral Sciences Rush University Medical Center, Chicago, IL & Senior Policy & Research Advisor, Administration on Aging Senior Policy Advisor, Centers for Medicare and Medicaid Services US Department of Health and Human Services

Aristotle:384-322: BC Old people are pessimistic, distrustful, malicious, suspicious, small minded, lacking in generosity, and cowardly.

Burston GR. BMJ 1975:iii

Types of Elder Abuse Psychological Abuse Physical Abuse Sexual Abuse Caregiver Neglect Self-Neglect Financial Abuse

Prevalence of Elder Abuse 5 Million Cases/yr in the US Prevalence : Incidence Depends on Age (60 or 65) Depends on Definition Depends on Population Sample Depends on Racial/Ethnic Subgroups Depends on Survey Methodology 1 /10 Cases are Elder Abuse Reported 1 /25 Cases of Financial Exploitation Reported Pillimer, Gerontologist 1995, NCEA, 2005, Podeniek, JEAN 2008, Dong, JEAN 2009, Acierno, AJPH 2010, Lauman, JGSS 2009, Lachs, NYC report 2011, MedLife Report 2011, Utah State Report 2010, Mosqueda & Dong, JAMA 2011, Beach, Gerontologist 2010

Variations in the Prevalence of Elder Abuse 7

Table 1: Variability in Prevalence Estimates of Elder Abuse by Population, Survey Methods and Definitions Author, Year Acierno 2010 Population 5,777 cognitively intact US community population Age, Sex & Race/Ethni city 60-97 years, 60% women, 88% white, 7% AA, 4% Latino, 2% Am Indian, 1% Asian Survey Methods Random digit dialing and computerassisted telephone interview Partici Definition pation rate 69% Emotional: verbal abuse, humiliation, harassment/coercion, or being ignored. Physical: Hit, restrained, injured. Sexual: Forced intercourse, molestation, forced to undress, photograph nude Potential Neglect: Unaddressed needs in transportation, obtaining food or medicine, cooking/eating/taking medicine, house cleaning/yard work, getting out of bed/dressed/showed, or making sure bills are paid. Financial: Family members spent money, did not make good decision, did not give copies, forged signature, forced to sign a document, stole money Point Specific Prevalence Any elder abuse 1-yr (exclude financial): 10% Emotional: 4.6% Physical: 1.6% Sexual: 0.6%, Neglect 5.1%, Financial: 5.2% Overall Prevalence Since age 60 Emotional: 13.5% Physical: 1.8% Sexual: 0.3%, Cooper, 2009 319 UK community caregivers of people referred to psychiatric services with dementia Caregiver: age, 24-92, 66% women, 83% white, Care recipient: age, 58-99, 72% women In person survey of caregivers 69% Psychological: screamed or yelled, used harm tone, insulted or swore, threaten to send to nursing home, afraid they might hit or hurt care recipient; threatened to stop taking care or abandon Physical: Hit or slap, shaken, handled roughly, threat of physical force, or withheld food. 3 Months physical or psychological : 34% Psychological : 33% Physical: 1% Any Physical or psychological: 52%.

Table 2: Variability in Prevalence Estimates of Elder Abuse by Population, Survey Methods and Definitions Author, Year Population Age, Sex & Race/Ethnic ity Survey Methods Partici pation rate Definition Point Specific Prevalence Overall Prevalence Lauman n, 2008 3,005 cognitively intact US community population 57-85 years, 52% women, 81% white, 10% AA, 7% Latino, 3% other 66% in person, 33% leave-behind selfadministered survey 75.5% Verbal: Insult or put you down Financial: Taken money or belonging without OK or prevented from getting them even when you ask Physical: Hit, kicks, slaps, or throw things 1-Yr: Verbal: 9% Financial: 3.5% Physical: 0.2% Wiglesw orth, 2010 129 US community caregivers of people with dementia Caregiver: age 67+12, 70% women, 88% white, 9% Hispanic. Carerecipient: age 77+8, 46% women, 94% white, 9% Hispanic In person survey of caregivers N/A Expert panel determination of based on assessment of physical assault and psychological aggression from Revised Conflict Tactic Scale (ie, insult, swore, pushed, kicked, etc), Elder Abuse Instrument (ie, bruising, pressure ulcer) and Safety of the Environment assessment (ie. Clutter or odor). N/A Any elder abuse: 47.3% Physical: 41.1% Psychological: 41.8% Neglect: 13.9% Multiple forms of elder abuse: 14.6%

Table 3: Variability in Prevalence Estimates of Elder Abuse by Population, Survey Methods and Definitions Author, Year Population Age, Sex & Race/Ethnic ity Survey Methods Partici pation rate Definition Point Specific Prevalence Overall Prevalence Beach, 2010 903 US community person with landline phone, Englishspeaking, no severe cognitive impairment 60 or older, 73% women, 23% African American, 73% white, 4% other Random digit dialing, and in-person, selfadministered by computer, and interactive voice response 37.7% (31.5% in person, 46.9% telepho ne) Financial: signed forms or document that you did not understand or explain to you, taken your checks without permission, tampering with saving or assets. Psychological: screamed, yelled, insulted, called names, swore, said something to deliberately hurt you, stomped out of room after argument, destroyed your belonging, threatened to hit you or throw things, or send you to nursing home, or abandon you or stop taking care of you. 6 Months: Financial: All, 3.5%, African American, 12.9%, white 2.4% Psychological: All, 8.2%, African American, 16.1%, white, 7.2% Since age 60: Financial: All, 9.7%, African American, 23%, white 8.4% Psychological: All, 14.3%, African American, 24.4%, white 13.2% Dong, 2007 412 cognitively intact community persons from general medical clinics in China 60 or older, 34% women, 100% Chinese Selfadministered survey 82.4% Physical: Hit, kick, slap, push, thrown at Neglect: Confine you in bed and tell you that you are sick when you are not Psychological: call names, put you down, made you feel bad recently Financial: Taken your money without ok, stopped you from getting your money or knowing about it Sexual: non-consenting sexual contact of any kind Abandonment: Left you in clinic, hospital, or any other public place N/A Any elder abuse: 35.2% Physical: 5.8% Neglect: 16.9% Psychological: 11.4% Financial: 13.6% Sexual: 1.2% Abandonment: 0.7% Multiple forms of elder abuse: 12.6%

Prevalence of Elder Abuse Any Form of Abuse 24% Psychological Financial 10% 10% Caregiver Neglect Physical Sexual 1% 0.2% 5%

Risk Factors: Age Sex Race/Ethnicity Socioeconomic Status Functional Impairment Cognitive Impairment Psychological Distress Social Isolation Medical Comorbidities Tatara, NCEA 1990; Cooper, Int J Geri Psych 2007; Mouton, AJPH 2004(94), Wolf, NCPEA 1997; Paveza, Gerontologist 1992(32), Lachs, JAGS 1994 (42); Dyer, JAGS 2000(48); Compton, Int J Geri Psych 1997 (12); Laumann, JGSC 2008(63); Bristowe, JEAN 1989(1), Homer, BMJ 1990(301), Fulmer, J Em Nursing 2000(26)

Health Implications of Elder Abuse: Dong et al, JAMA 2009 Mosqueda & Dong, JAMA 2011 Dong etal JAMA Int Med 2013 Halliday et al, Lancet 2000 Lach et al, JAMA 1998 Baker et al. Jr Geri Soc Work 2009 Dong & Simon JAMA 2011 Dong et al, JGMS 2011 Dong & Simon, AJEM 2013 Begal et al, Jr Interper Vio 2011 Lach et al, Gerontologist 2002 Mouton et al, Ann Fam Med 2010 Dong et al, AJEM, 2011 Dong, Cln Geriatric Med, 2005 Dong et al. Gerontology 2013 Schonfield Gerontologist 2006 Shield et al, Jr Forensic Sci 2004 Fisher et al, Gerontologist 2006 Dong et al, JAGS 2011 Dong et al Gerontology 2010 Fisher, Jr Int Per Vio 2011 Smith et al, Jr Nutrition 2006 Franzini et al, JAGS 2008

CHAP Study Chicago Health and Aging Project (CHAP) Prospective Longitudinal Study Since 1993 Stratified Random Sample with Detailed Clinical Evaluation Data From Social Services Agency CMS Data Matching: ED, Hospitalization, Hospice Data National Death Index Variables of Interest: age, sex, race, education, income, medical commorbidities, cognitive function, physical function, depression, social network, social engagement

Elder Abuse & Mortality 14 years of Follow-Up 5.9 Death / 100 Person Years VS. 18.3 Death /100 Person Years HR 95% CI Elder Abuse All Cause 2.06 1.48-2.88 Elder Abuse CV Specific 3.86 2.04-7.29 Elder Abuse MMSE <20 2.38 1.23-4.62 Elder Abuse: Chair Stand Ability= 0-1 2.35 1.45-3.81 Dong, 2009 JAMA

Cause Specific Mortality: 8 x Cardiovascular Related 9 x Pulmonary Related 15 x Cancer Related 13 x Endocrine or Nutritional Related 8 x Neurological or Psychiatric Related Dong, XQ: JAMA 2009

Association Between Self-Neglect and Elder Abuse Dong et al, Jr Aging Health 2012

Elder Abuse and ED Use Mean No Elder Abuse 0.74 Reported Elder Abuse 2.11 Confirmed Elder Abuse 2.22 Specific Elder Abuse Subtypes Caregiver Neglect 2.89 Psychological Abuse 2.01 Physical Abuse 2.27 Financial Exploitation 1.67 Number of Subtypes of Elder Abuse 1 type 2.04 2 or more types 2.19 Dong, 2013 Am Jr Emergency Medicine

Elder Abuse & Hospitalization RR 95% CI Elder Abuse 2.72 1.84-4.03 Psychological Abuse 2.22 1.44-3.43 Physical Abuse 1.57 0.83-2.98 Financial Exploitation 1.75 1.06-2.90 Caregiver Neglect 2.43 1.60-3.69 1 Type of Elder Abuse 1.41 0.75-2.65 2 or More Types of Elder Abuse 2.59 1.82-3.66 Dong, 2013 JAMA Internal Medicine

Elder Abuse & SNF RR 95% CI Elder Abuse 4.60 2.85-7.42 Psychological Abuse 2.31 1.17-4.56 Physical Abuse 2.36 1.19-4.66 Financial Exploitation 2.81 1.53-5.17 Caregiver Neglect 4.73 3.03-7.40 1 Type of Elder Abuse 2.75 1.60-4.74 2 or More Types of Elder Abuse 3.43 2.04-5.77 Dong, 2013 Gerontology

Elder Abuse Vulnerability Index Reported Elder Abuse OR (95% CI) Confirmed Elder Abuse OR (95% CI) Age > 80 3.01 (2.16-4.19) 3.34 (2.13-5.24) Female 1.76 (1.27-2.45) 1.76 (1.13-2.75) Black 5.76 (3.69-8.99) 10.10 (4.78-21.34) Income > $15,000 1.31 (0.91-1.89) 1.87 (1.10-3.18) Medical Condition > 3 2.26 (1.53-3.35) 2.67 (1.60-4.47) MMSE <23 1.88 (1.35-2.62) 1.94 (1.24-3.04) Difficulty w/ Stairs: 1 Flight 2.20 (1.56-3.11) 1.78 (1.10-2.89) CESD > 4 1.68 (1.22-2.29) 1.82 (1.19-2.79) Social Network < 2 1.61 (1.10-2.36) 1.84 (1.11-3.04)

Elder Abuse Vulnerability Index Number of Total Cohort No Abuse with Reported Abuse Confirmed Prevalence of Prevalence of Risk Factor Participants with Risk Factors with Risk Abuse with Risk Reported Elder Confirmed Elder Index Risk Factors Factors Factors Abuse (%) Abuse (%) 0 16 16 0 0 0% 0% 1 966 962 4 0 0.4% 0% 2 2727 2700 27 12 0.9% 0.4% 3 2660 2617 43 24 1.6% 0.9% 4 1127 1077 50 23 4.4% 2.1% 5 431 392 39 25 9.0% 6.0% 6 162 132 30 17 18.5% 11.4% 7 60 43 17 7 28.3% 14.0% 8 8 5 3 1 37.5% 16.7%

Elder Abuse Vulnerability Index Reported Elder Abuse OR (95% CI) Confirmed Elder Abuse OR (95% CI) All Variables Index Continuous Index (0-9) 2.19 (2.00-2.40) 2.27 (2.01-2.57) Categorical Index (0-9) 0-2 (Reference) 1.0 1.0 3-4 2.98 (1.98-4.49) 3.90 (2.07-7.36) 5 or more 18.46 (12.15-28.04) 26.79 (14.18-50.61) Dong et al. Jr of Am Ger Soc, 2013

Accuracy of the Elder Abuse Vulnerability Index Dong et al. Jr of Am Ger Soc, 2013

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