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PSYCHOGERIATRICS 2013; 13: 182–188

doi:10.1111/psyg.12009

REVIEW ARTICLE

Theories and measures of elder abuse Yadollah ABOLFATHI MOMTAZ,1 Tengku Aizan HAMID1,2 and Rahimah IBRAHIM1,2

1 Institute of Gerontology and 2Department of Human Development and Family Studies, Faculty of Human Ecology, Universiti Putra Malaysia, Serdang, Malaysia

Correspondence: Dr Yadollah Abolfathi Momtaz PhD, Institute of Gerontology, Universiti Putra Malaysia, 43400 UPM, Serdang, Selangor, Malaysia. Email: [email protected] Received 12 September 2012; revision received 5 March 2013; accepted 12 March 2013.

Key words: aged, elder abuse, measurement, theory.

Abstract Elder abuse is a pervasive phenomenon around the world with devastating effects on the victims. Although it is not a new phenomenon, interest in examining elder abuse is relatively new. This paper aims to provide an overview of the aetiological theories and measures of elder abuse. The paper briefly reviews theories to explain causes of elder abuse and then discusses the most commonly used measures of elder abuse. Based on the reviewed theories, it can be concluded that elder abuse is a multifactorial problem that may affect elderly people from different backgrounds and involve a wide variety of potential perpetrators, including caregivers, adult children, and partners. The review of existing measurement instruments notes that many different screening and assessment instruments have been developed to identify elders who are at risk for or are victims of abuse. However, there is a real need for more measurements of elder abuse, as the current instruments are limited in scope.

INTRODUCTION

THEORIES OF ELDER ABUSE

As the population ages, it is imperative to pay more attention to the issues affecting older adults’ quality of life and psychological well-being.1–4 A pervasive phenomenon across the world with devastating effects, elder abuse is associated with decreased quality of life and increased morbidity and mortality rates.5 Although it is not a new phenomenon, awareness of elder abuse and interest in examining the problem are relatively new. International studies estimate that 1–5% of community-dwelling elderly people aged 65 years and older suffer from abuse or at risk of being abused.6 According to the World Health Organization, elder abuse is defined as a ‘single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’.7 The goal of this review article is twofold: (i) to provide an overview of the theories might explain elder abuse; and (ii) to train healthand social-care providers and researchers about selecting and using existing elder abuse measurement instruments.

The first section of this article attempts to theorize the causes of elder abuse and why elderly people are vulnerable to abuse. Thus, theories from different disciplines, such as psychology, sociology, and biology, are presented to explain why elder abuse occurs. Table 1 presents a summary of the theories.

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Social exchange theory Social exchange theory supposes that two parties are both giving and receiving items of value from each other and that the interaction between two parties will be positively evaluated if both parties benefit equally from the relationship. According to this theory, elder abuse may occur because of the victim’s dependence on the abuser and vice versa. First, it is assumed that elder abuse is the result of the elder’s increasing dependence the caregiver. As people age, they become more powerless, vulnerable and, to some degree, dependent on family members for assistance, which may increase the risk of abuse. A caregiver may resent that the older person is completely dependent on the caregiver; the caregiver may experience anger © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society

Theories and measures of elder abuse Table 1 Summaries of elder abuse theories Name of theory

Key element 8–10

Social exchange theory

Dependency

Feminist theory11 Political economic theory12

Patriarchal family Dependency

Psychopathology of the caregiver theory13,19 Role accumulation theory14

Caregiver pathology

Situational theory15

Caregiver stress

Social learning theory16,17 Stratification theory18

Learnt abusive behaviour Caregiver stress

Symbolic interactionism theory20–22

Culture

Environmental stress

Descriptions Elder abuse is the result of the elderly’s increasing on the caregiver and vice versa. Elder abuse is the product of a patriarchal family. The changing role of the elderly removes them from the workforce and reduces their independence, which may lead to elder abuse. The abuser’s behavioural characteristics contribute to elder abuse. Family members with conflicting role obligations are not able to effectively manage stress in their lives. These strained family members may abuse an older adult as a way of coping with their stress. An overburdened caregiver who cannot cope with the demands of caring creates a situation for abuse. Violence is a learnt behaviour that may pass down from generation to generation. Caregivers’ low job satisfaction and low levels of education may contribute to elder abuse. Cultural values and expectations influence what behaviour is considered abusive.

that leads to abusive behavior.8 For example, if the caregiver perceives himself or herself as deserving of rewards for supporting that elderly person, abuse may occur if such rewards are denied. It has also been postulated that elder abuse is the result of a caregiver’s increasing financial dependency on the elderly person. Owing to a sense of imbalance in the relationship and the violation of social expectations concerning independent adult behaviours, the perpetrator tries to restore some sense of control with violence or threats of violence.9,10 Feminist theory Feminist theory focuses on spousal elder abuse as a significant dimension of elder abuse, wherein older women are more vulnerable to spousal abuse because older women tend to have less power than men. According to this theory, men have more social and financial resources and regard women as their property.11 Political economic theory This theory addresses that elderly people are gradually marginalized in their families and society. Therefore, they lose their role and depend on others. According to political economic perspective, the changing role of the elderly removes them from the workforce and reduces their independence, which may lead to elder abuse.12 © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society

Psychopathology of the caregiver theory This theory examines the role of the caregiver with a mental health problem and how that puts elders at risk for mistreatment.19 According to this theory, the abuser’s behavioural characteristics contribute to elder abuse. Caregivers who consumed alcohol and experienced depression and anxiety are more likely to use physical and verbal abuse against the elder.13 Role accumulation theory This theory argues that elderly people may be abused by family members including their spouse, adult child(ren), or son- or daughter-in-law. According to the role accumulation theory, family members with conflicting role obligations are not able to manage the stress of their own lives. These stressed family members may abuse an older adult as a way to cope with their stress.14 Situational theory Situational theory is one of the earliest and most widely accepted explanations of elder abuse. This theory focuses on the role of stress and the burden of caregiving in elder abuse. According to this theory, an overburdened caregiver who cannot cope with caring demands creates an environment for abuse. Overall, this theory supports the idea that stressed caregivers may become abusive towards their vulnerable seniors.15 183

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Social learning theory Social learning theory, also called the transgenerational theory, postulates that violence is a learnt behaviour that may be passed down from generation to generation. When children observe violence as a response to stress, they then internalize this behaviour as acceptable. In the case of elder abuse, an abused child may abuse her or his parents in the future. In addition, when an abusive spouse becomes ill or disabled, the previously abused partner may abuse him or her. Thus, the child or spouse who was abused by the parent or spouse continues the cycle of violence as a caregiver.16,17 Stratification theory Within this theory, elder abuse is particularly inflicted by caregivers. According to stratification theory, jobs at the bottom of the stratified system are not desirable because of their low status and pay, but they are needed in order to survive. Caregivers for the elderly receive low pay, and their job title has little prestige, regardless of where the job is done. It can be expected that elder abuse occurs when the caregiver tries to control the older person. When the caregiver must override the elder’s wishes, which could be influenced by dementia, the elderly person may resist the caregiver. With little status, the caregiver may feel the need to gain control over the elder. Within the stratification theory, it can be assumed that a caregiver’s low job satisfaction and low levels of education may contribute to elder abuse.18 Symbolic interactionism theory Symbolic interactionism is the way people react and view the world through their interactions with others.20 This theory can be used to explain why elder abuse takes place and how culture plays an important role in the perception of abuse. According to this theory, every object has different meaning to each person, and everyone has his or her own way to find meaning. Therefore, perception and interpretation of an object is not always same for all people. According to this perspective, cultural values and expectations influence what conduct is considered to be elder abuse.21 For example, in some cultures, sending elderly individuals to nursing homes is considered to be a form of abuse, whereas other cultures define it as a sign of caring.22 184

MEASURES OF ELDER ABUSE All relevant literature (released up to August 2012) was searched based on key words pertinent to the development and validation of instruments that measure elder abuse. Studies describing instrument development and validation were retrieved. After full-text articles were retrieved through electronic databases, the following information was drawn out: the instrument’s purpose and content; the instrument’s development and scoring; and the instrument’s reliability and validity. Table 2 presents a summary of the reviewed elder abuse instruments.

American Medical Association screen for various types of abuse and neglect (AMA-SVTAN) The AMA-SVTAN is a self-report questionnaire consisting of nine yes-or-no questions to determine various types of elder abuse: two questions for physical abuse, three questions for psychosocial abuse, two questions for financial abuse, and two questions for neglect. Elder respondents are interviewed by a health-care professional. A positive answer to each question is considered indicative of abuse. The AMA-SVTAN instrument demonstrated a test–retest reliability of 0.83 and a Cronbach’s a of 0.73. This assessment tool is usually used in clinical settings. Physicians interview and physically examine elderly patients to diagnose various types of abuse or neglect, including physical, psychological, financial, and material.23

Brief Abuse Screen for the Elderly The Brief Abuse Screen for the Elderly was developed by Reis and Nahmiash and contains five items. The scale has demonstrated good interrater reliability (86– 90%) and substantial predictive validity, ranging from 0.89 to 0.91. This instrument is not time-consuming to complete (it takes approximately 1 min) and may be useful in busy environments. However, there is no established scoring method. One disadvantage of this scale is that interviewers ideally should have some knowledge of and training on elder abuse before using the scale.24 The Brief Abuse Screen for the Elderly asks screeners to make an educated guess concerning the presence or absence of physical, psychosocial, and financial abuse or neglect by a caregiver. It also asks the screeners to estimate the needed intervention.25 © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society

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© 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society 41 items 6 questions

37 three-point

Straus (1979)27

Fulmer (1984)29

Yaffe et al. (2008)5

Ferguson et al. (1983)30

Conflict tactics scale (CTS)

Elder Assessment Instrument (EAI) Elder Abuse Suspicion Index (EASI)

31 items (long form) 18 items (short form) 25 items

12 items

Conrad et al. (2011)32

Conrad et al. (2011)32

Schofield and Mishra (2003)33 Carney et al. (2003)34

Older Adult Psychological Abuse Measure (OAPAM) The Older Adult Financial Exploitation Measure (OAFEM) Vulnerability to Abuse Screening Scale (VASS) Questions to Elicit Elder Abuse (QEEA) 15 closed-ended questions

22 items

Reis and Nahmiash (1998)31

15 questions

Likert-type items

Eight questions

Indicators of Abuse (IOA)

Neale et al. (1991)28

19 items

Bonnie and Wallace (2003)26

Comprehensive Geriatric Assessment (CGA)

Health, Attitudes Toward Aging, Living Arrangements, and Finances (HALF) Assessment Hwalek-Sengstock Elder Abuse Screening Test (HSEAST)

Three questions

Reis and Nahmiash (1995)24

Five items

Caregiver Abuse Screen (CASE)

Nine yes-or-no questions

Number of items

Reis and Nahmiash (1995)24

Aravanis et al. (1993)

Authors

American Medical Association Screen for Various Types of Abuse and Neglect (AMA-SVTAN) Brief Abuse Screen for the Elderly

Name of scale

Description Purpose

To identify older women at risk of abuse To determine if abuse is occurring

To identify potential financial abuse

To measure psychological abuse

To screen for abuse

To identify people at high risk

To screen for suspected elder abuse victims To raise a doctor’s suspicion about elder abuse To identify elders at risk

To determine elder abuse

To screen for elder neglect and abuse

To identify the risk for abuse

To assess the likelihood of abuse

To measure various types of abuse or neglect

Table 2 Descriptions of the reviewed elder abuse measurement instruments

Easy to use and can be mailed to subjects Easy to use and not time-consuming; evaluates physical, emotional, and financial abuse and neglect

Cronbach’s a = 0.74 to 0.31 Cronbach’s a = 0.83

Cronbach’s a = 0.93

Can be used by both clinicians and researchers The only validated financial abuse scale

Scores information

Cronbach’s a = 0.92

Cronbach’s a = 0.87 Cronbach’s a = 0.92

Easy to use by health and social service professionals

Assesses potential factors contributing to elder abuse

Used in all clinical settings Screens for all types of abuse

Ideal tool for evaluation of abused and neglected elderly people Measures psychological and physical abuse

Brief, quick and easy to use, but must be preceded by extensive training on elder abuse Not time-consuming

Screens for various types of elder abuse and neglect

Strengths

Cronbach’s a = 0.63

No psychometric properties

Specificity (0.72 to 0.99)

Sensitivity (0.03 to 0.28)

Cronbach’s a = 0.84.

Cronbach’s a = 0.79 to 0.95

Intrarater reliability = 0.95

Cronbach’s a = 0.77

Not documented

Cronbach’s a = 0.73

Psychometrics properties

Requires adequate cognitive capacity to complete Validated with older women No cross-cultural validation

Minimal ability to distinguish between cases of elder abuse and non-cases Time-intensive; not used in long-term care settings Does not assess all types of elder abuse

No established scoring procedure

No established scoring procedure; only the caregiver answers questions Should be conducted by a multidisciplinary team; time-consuming Not specifically developed for elderly people; does no address neglect No established scoring procedure Low sensitivity

No established scoring procedure; does not assess self-neglect

No ability to distinguish between cases of elder abuse and non-cases

Weaknesses

Theories and measures of elder abuse

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Caregiver Abuse Screen (CASE) The CASE is an eight-question screening tool with a dichotomous (yes/no) scoring method that is completed by caregivers. Answering ‘yes’ to any question counts as one point. The points are summed to create a total score with a possible score range 0–8. A score of 4 or more indicates ‘abuse likely’. However, depending on the question, a score of 1 can also be considered ‘abuse likely’. The scale has demonstrated acceptable to good internal consistency (Cronbach’s a = 0.77).24 According to the CASE, the caregivers are asked to answer screening questions for physical, psychological, and financial abuse or neglect.25 Comprehensive Geriatric Assessment (CGA) The CGA is an integrated and multidimensional approach that aims to assess the functional ability, health, and socio-environmental situation of older adults. It is also a well-validated procedure for assessment and intervention of abused and neglected elderly people. The CGA can be performed efficiently in both inpatient and outpatient settings such as hospitals, outpatient clinics, nursing homes, and private homes. The assessment is most successful when done by a multidisciplinary team consisting of a geriatrician, nurse, social worker, and pharmacist.26 The final diagnosis is made based on a combination of clinical acumen and test scores.19 The greatest limitations of the CGA are that it is time-intensive and only trained professionals can use it. Conflict tactics scale (CTS) The CTS is a 19-item self-report scale that measures the use of reasoning, verbal aggression, and physical violence for resolving family and interpersonal conflict. It has long been used to determine whether individuals have been threatened or assaulted. Although the CTS has demonstrated sound reliability (Cronbach’s a = 0.79–0.95),27 it is limited in the elder abuse context because it has not been specifically developed for measuring this type of abuse. The CTS asks respondents to indicate how many times they have been assaulted by or assaulted their partner in the past year. Elder Assessment Instrument (EAI) The EAI is a 41-item Likert assessment instrument designed specifically to assess signs, symptoms and 186

subjective complaints of elder abuse, neglect, abandonment and exploitation. It can be used in all clinical settings and is administered by trained nurses and clinicians. The results of psychometric studies of the EAI show a content validity index of 0.83, interrater agreement of 0.83, a specificity of 93%, and a sensitivity of 71%. The internal consistency reliability using Cronbach’s a has been reported to be 0.84. Although the instrument has good reliability and validity, there is no established method of scoring.28 The EAI is completed by a nurse using a one-to-one interview and physical assessment of the older person for possible mistreatment and can be used in all clinical settings.29 Elder Abuse Suspicion Index (EASI) The EASI, developed by Yaffe et al., is a six-item tool for physicians to assess suspected cases of elder abuse and neglect. A positive (yes) answer to one or more of the questions may establish the presence of abuse and requires follow-up. The goal of the EASI is not necessarily to measure elder abuse but to quantify a level of suspicion so that potentially vulnerable cases can be referred to a community expert in elder abuse for further assessment. Because this scale is easily and quickly administered, it may encourage doctors to refer possible elder abuse cases for further assessment. To our knowledge, no Cronbach’s a reliability coefficient has been reported for the EASI.5 Health, Attitudes Toward Aging, Living Arrangements, and Finances Assessment The Health, Attitudes Toward Aging, Living Arrangements, and Finances Assessment is an instrument used to identify elders who are at risk for abuse or actual victims of abuse. It is administered by healthcare professionals in a clinical setting. This 3-point Likert-type scale is administrated with both the caretaker and older adult.19 The instrument was presented by Ferguson and Beck with no psychometric data. The instrument assesses four potential factors contributing to elder abuse.30 Hwalek-Sengstock Elder Abuse Screening Test (HSEAST) The HSEAST is a 15-question instrument designed to identify elderly people at high risk of domestic violence. Respondents are asked to indicate whether they have experienced or are at risk of experiencing any of the listed conditions. A response of ‘no’ to © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society

Theories and measures of elder abuse

questions 1, 6, 12, and 14; a response of ‘someone else’ to question 4; and a response of ‘yes’ to the rest of the questions are scored in the ‘abused’ direction. Although the HSEAST has demonstrated good test– retest reliability with a = 0.86 and an acceptable internal consistency (Cronbach’s a = 0.63), it is limited because of its high false negative rate. 28

Indicators of abuse This is a 22-item home-based instrument for measuring abuse. This test is administered by an experienced and trained interviewer after a 2–3-h home assessment. A score of 16 and over suggests that the elderly subject is at significant risk for experiencing abuse. Internal consistency using Cronbach’s a was 0.92, demonstrating a high level of reliability for the indicators of abuse.31

Older Adult Psychological Abuse Measure (OAPAM) The OAPAM has been developed as a comprehensive measure of elder abuse. The OAPAM consists of either 31 items (long form) or 18 items (short form). It is a measure of psychological abuse that is completed by respondents. The unidimensional measure has sound reliability and validity in the assessment of psychological abuse of elderly people by both clinicians and researchers. The Rasch person reliability has been reported to be high for both the OAPAM long form (= 0.78, corresponding with Cronbach’s a = 0.87) and short form (= 0.86, corresponding with Cronbach’s a = 0.92).32

Older Adult Financial Exploitation Measure (OAFEM) The OAFEM is a 25-item screening tool that identifies potential financial abuse of older people. This instrument is the only validated financial abuse scale that assesses several forms of financial abuse, including theft and scams, financial victimization, coercion, financial entitlement, signs of possible financial exploitation, and money mismanagement. The completion of OAFEM requires adequate cognitive capacity (i.e. a score of 17 or above on the MiniMental Status Exam) is required. This self-report instrument is completed by older adults in an inter© 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society

view. The OAFEM has demonstrated high internal consistency reliability (Cronbach’s a = 0.93).32 Vulnerability to Abuse Screening Scale (VASS) The VASS is a 12-item screening instrument with yesor-no that is used to identify elderly people at risk of abuse. The instrument is completed by respondents and assesses four factors: vulnerability, dejection, dependence, and coercion. Cronbach’s a is reported from 0.74 for dependence to 0.31 for coercion, representing moderate to good reliability. Although the VASS has been validated with older women and is considered to be a gender-neutral instrument, it is not known whether the VASS is also valid for determining abuse in older men.33 Questions to Elicit Elder Abuse Questions to Elicit Elder Abuse evaluate the existence of 15 indicators of abuse based on a respondent’s questionnaire. This instrument has 15 closed-ended questions that assess the existence of physical abuse, emotional abuse, neglect, and exploitation. For each participant, a total and type of abuse score is generated by the sum of each ‘yes’ answer. Internal consistency measured by Cronbachs’ a was reported at 0.83 for the 15 items.34

CONCLUSIONS This review aimed to assess theories and measurements of elder abuse. Several theories that might explain possible causes for elder abuse were identified and discussed. Based on the reviewed theories, several factors including caregiver stress (situational theory; stratification theory), dependency (social exchange theory), negative attitude (political economic theory), environmental stress (role accumulation theory), learnt abusive behaviour (social learning theory), caregiver pathology (psychopathology of the caregiver theory), and spousal domestic abuse (feminist theory) cause elder abuse. Additionally, according to symbolic interactionism theory, cultural values and expectations influence what behaviour is considered abusive. Hence, it can be concluded that elder abuse is a multifactorial, complex problem that affects elderly people with different backgrounds at the hands of a wide variety of potential perpetrators including caregivers, adult children, and partners. Because our review reveals that no single theory can comprehen187

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sively explain all causes of elder abuse, developing an integrated theory with a comprehensive perspective is recommended. With regard to the second aim of the study, a review of existing instruments showed that many different screening and assessment tools have been developed to identify elders who are at risk for or are victims of abuse. Elder abuse instruments can be divided into two basic types depending on whether the abuse has already happened (to determine actual victims of abuse), such as AMA-SVTAN, or whether the abuse may happen in the future (to identify elderly people at risk of elder abuse) including HSEAST, VASS, and CASE. Therefore, in elder abuse studies it is important to be aware of the instrument’s purpose and reliability and validity for the population studied. These instruments may not be appropriate crossculturally. As such, there is a real need to develop measures for elder abuse that might have core indicators that are universal and sub-indicators that may be appropriate for certain situations.

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© 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society

Theories and measures of elder abuse.

Elder abuse is a pervasive phenomenon around the world with devastating effects on the victims. Although it is not a new phenomenon, interest in exami...
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