APPENDIX
A
Elder Mistreatment Measures and Studies



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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America APPENDIX A Elder Mistreatment Measures and Studies

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America TABLE A-1 Elder Mistreatment Measures Measure Summary Characteristics Properties Pathophysiological signs and symptoms Fulmer (1984) Lachs and Fulmer (1993) Dyer et al. (2000) Haviland and O’Brien (1989) O’Brien (1986) Uses items such as unexplained bruising, dehydration, urine burns, fractures. Subjective and objective clinical observations as documented by health care clinicians. Poor sensitivity and specificity. Conflict Tactic Scale Straus (1978) Perception of upsetting and injurious circumstances in a person’s life. 19-item self-report, e.g., “Has anyone threatened you with a knife or gun?” Chronbach’s alpha reliability: 0.88. Content validity 0.80. Available in Spanish. Elder Assessment Instrument Fulmer (1984) Provides information to clinicians to better inform judgments about risk of elder mistreatment. 40-item screening tool with both subjective and objective items to determine if an older person should be referred for suspected elder mistreatment. Content validity 0.83. Interrater agreement 0.84. Available in Spanish. The QUALCARE Scale Phillips et al. (1990a, 1990b) Assessment of six areas: physical, medical management, psychosocial, environmental, human rights, and financial. 53-item observational rating scale designed to quantify and qualify family caregiving. Extensive psychometrics reported: Interrater agreement range: 0.79-0.88. Chronbach’s alpha: 0.81-0.95 on 6 subscales. Hwalek-Sengstock Elder Abuse Screening Test Neale et al. (1991) Assessment of physical, financial, psychological, and neglectful situations. 15-item assessment screen for detecting suspected elder abuse and neglect. Discriminant function analysis: 9 items identified 94% of cases. Three conceptual domains: violation of personal rights, characteristics of vulnerability, and potentially abusive situations.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Measure Summary Characteristics Properties Fulmer Restriction Scale Fulmer and Gurland (1996) Assessment of physical, psychological, and financial restriction of older adults. 34-item scale designed to elicit information regarding unnecessary restriction of the older adult. Chronbach’s alpha: 0.78. Interrater agreement: 0.93. Available in Spanish. Indicators of Abuse Screen Reis and Nahmiash (1998) Developed specifically for use by social service agency practitioners likely to visit the older adult in the home. 29-item set of indicators for use by social service agency practitioners to identify elder mistreatment. Discriminant function analysis: 29 items identified 96.3% of cases. Factor analysis: no reliable pattern of variable clusters. Adult Protective Service Reports Intake forms used to document calls of suspected elder mistreatment from public hot lines and state agencies. No specific format. No psychometrics available.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America TABLE A-2 Elder Mistreatment Studies Study Methods Selected Findings Childs et al. (2000) Design: Descriptive Measure: (1) SVWS; (2) EAA BIS-R Sample: Nonrandom: 422 young and 201 middle-aged adults Theory: N/A Middle-aged respondents viewed psychological behavior more harshly than younger respondent.s Both middle-aged women and young men were less tolerant of middle-aged perpetrators. Data support relativistic nature of elder abuse. Coyne et al. (1993) Design: Descriptive survey Measure: Demographics; Zarit Burden interview; Zung Self-Rating Depression Scale Sample: 1,000 caregivers who called a telephone help line for dementia; 342 respondents Mean age of caregiver 56.1; 54.5% were adult children caring for parents; 37.1% caring for spouses; 8.4% cared for other relatives. 11.9% reported they had been physically abusive toward dementia patients. Abusers had been providing care for more years; patients functioned at a lower level; caregivers had higher burden and depression scores. Dyer et al. (2000) Design: Case-control study Intervention: Comprehensive geriatric assessment Measure: Standard geriatric assessment tools Sample: 47 older persons referred for neglect and 97 referred for other reasons 45 cases of abuse or neglect identified. 37 were self-neglect. Elder mistreatment cases were more likely to be white and male. Higher prevalence of depression and dementia. Ertem et al. (2000) Design: Descriptive Method: Meta-analysis Sample: 10 studies 10 studies: 4 cohort, 1 cross-sectional, and 5 case-control. The RR of maltreatment in children of abused parents were significantly increased in 4 studies (RR 4.75-37.8). In 3 other studies the RR was less than 2. Significant validity issues.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings Fulmer and Gurland (1996) Design: Descriptive Measure: CTS, FRS and NMAP Survey, Beck Depression Scale, BDBS Sample: 125 elder-caregiver dyads; 51 dyads with cognitive impairment and 74 dyads with no cognitive impairment; mean age of the elder 78 years Theory: Risk and vulnerability Cognitive impairment risk factor for elder mistreatment. CTS higher for CI patients. FRS higher for CI patients. CI patients more dependent. CI patients had higher BDBS. CI patients had higher Zarit Burden scores. Fulmer et al. (1999) Design: Descriptive Method: Analysis of a probability sample of ADHC clients in New York State. Social workers served as informants. Sample: 9 sites drawn through random sampling Prevalence of elder mistreatment 12.3%. Apprehensive behavior was highest reported behavior; with this item removed, prevalence 3.6%. Social workers noted concern regarding elders who appeared frightened in the presence of their home caregiver. Fulmer et al. (2000) Design: Descriptive Measure: EAI, MMSE Sample: 180 emergency department patients over the age of 70 with MMSE of 18 or greater 36 patients eligible for study. 7 patients screened positive for neglect. Nurses were able to screen for elder neglect with greater than 70% accuracy; true positive 71%, false positive 7%. Huber et al. (2001) Design: Descriptive Method: Analysis of cross-sectional 6-state ombudsman database Sample: 23,787 complaints 5 most frequent complaints were (1) loss of dignity and respect; (2) accidents; (3) physical abuse; (4) call lights unanswered; (5) poor personal hygiene. Race and gender differences noted. Hudson (1991) Design: Descriptive Measure: 3-round Delphi survey Sample: 63 elder mistreatment experts Agreement on a 5-level taxonomy. 11 theoretical definitions proposed by panel.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings Hwalek et al. (1996) Design: Descriptive Method: Database analysis Measure: Risk of Future Abuse instrument Sample: State of Illinois Abuse, Neglect and Exploitation Tracking System; 2,577 cases from October 1989 to December 1991. 552 substantiated reports used for this study 73% of victims were women. Mean age 77 (60-99). Caucasian 73%; widowed 54%; living at home 76%. Caregiver substance abuse more likely to involve physical or emotional abuse. Jogerst et al. (2000) Design: Descriptive Method: Analysis of county-level data between 1984 and 1993 to test association between county characteristics and rates of elder abuse Sample: 99 counties in Iowa Analysis: univariate correlational analysis and stagewise linear regression Community characteristics that had a positive association with rates of reported or substantiated elder mistreatment were: (1) population density; (2) children in poverty; (3) reported child abuse. Jones et al. (1997) Design: Descriptive Method: Random sample survey Sample: 3,000 members of the American College of Emergency Physicians; 705 completed surveys (response rate 24%) 52% of respondents described elder mistreatment as prevalent but less than spouse or child abuse. Respondents evaluated a mean of 4 ± 8 suspected cases of elder mistreatment in the last 12 months; 50% were reported. Lachs et al. (1994) Design: Prospective cohort study Method: Case matching with adult protective services database Sample: 329 elders investigated in 1985 and 1986 Analysis: Relative risk calculations 68 (2.4%) of database cohort members received ombudsman investigation. Risk factors for elder mistreatment investigation using logistic regression included requiring assistance with feeding OR 3.5, being a minority elder OR 2.3, over age 75 at cohort inception OR 1.9, and poor social networks OR 1.7.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings Lachs et al. (1997a) Design: Prospective cohort study Method: Case matching with adult protective services database Sample: 184 cohort members Analysis: Pooled logistic regression 47 cohort members were seen for elder mistreatment (prevalence 1.6%). Age, race, poverty, functional disability, and cognitive impairment were identified as risk factors for reported elder mistreatment, with ORs reported. The onset of new cognitive impairment was also associated with abuse and neglect. The influence of race and poverty is likely to be overestimated due to reporting bias. Lachs et al. (1997b) Design: Prospective cohort study Method: 7-year longitudinal database with identification of 182 victims of elder abuse Sample: 114 elders seen in 2 emergency departments 114 individuals accounted for 628 visits (median 3, range 1-46). 30.6% resulted in hospital admission. 66% had at least one visit that resulted in an injury-related chief complaint. Lachs et al. (1998) Design: Prospective cohort study Measure: mortality among elders for whom protective services were used to corroborate mistreatment and elderly persons for whom protective services were used for self-neglect Sample: 176 adult protective services elders Cohort members seen for elder mistreatment at any time during follow up had poorer survival (9%) than others. Reported and corroborated elder mistreatment and self-neglect are associated with shorter survival after adjusting for other factors associated with increased mortality in older adults.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings Moody et al. (2000) Design: Descriptive Measure: H-S/EAST Sample: 100 black, Hispanic, and white elders living in public housing Principal components FA of 15-item instrument supported the 3-factor structure for a total of 10 items explaining 38% of the variance. Discriminant function analysis showed that 6 items were as effective as the 9-item model in classifying cases as abused (71.4%). National Center on Elder Abuse at the American Public Human Services Association [formerly American Public Welfare Association] in collaboration with Westat, Inc. (1998) Design: Descriptive study Method: Incidence study using sentinel agency reports Sample: 20 counties in 15 states: nationally representative sample 551,000 elder mistreatment cases in 1996. Female elders are abused at higher rates than males. The oldest elders (80 years and older) are abused and neglected at 2-3 times their proportion in the elderly population. In almost 90% of elder mistreatment cases, the perpetrator is a family member and 2/3 are adult children or spouses. Victims of self-neglect are usually depressed, confused, or extremely frail. O’Malley et al. (1984) Design: Descriptive Measure: Case analysis using OARS Sample: 24 cases from primary care clinic Cases divided into three categories: (1) extremely impaired who receive care from individuals responsible for abuse and neglect (N = 4); (2) impaired elders who receive inadequate or intermittent care (N = 9); (3) involved independent elders whose only care needs resulted from threats or violence from relatives (N = 11).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America STudy Methods Selected Findings Paveza et al. (1992) Design: Descriptive Measure: CTS Sample: Purposive sample from Alzheimer’s disease registry: 184 patients Severe family violence as measured by the CTS was a significant problem: overall prevalence 17.4%. 15.8% of patients had been violent since diagnosis. 5.4% of caregivers reported being violent toward the patient. Violence by the Alzheimer’s disease patient against the caregiver was serious problem. Pavlik et al. (2001) Design: Descriptive Method: Analysis of Texas Department of Protective and Regulatory Services, Adult Protective Services Sample: 62,258 allegations of elder mistreatment in 1997 Neglect accounted for 80% of allegations. The incidence of being reported to adult protective services increased sharply after age 65. Prevalence was 1,310 over 100,000 = 65 years of age. Phillips and Rempusheski (1985) Design: Descriptive Method: Interviews with grounded theory analysis Sample: 29 health care providers (16 nurses and 13 social workers) 4-stage model describing decisions of health care providers about elder abuse. Model identifies 3 types of decisions: diagnostic, value, and intervention. Complexity of decision processes is revealed via 5 pathways. Phillips et al. (1990a) Design: Adaptation of the QUALPACS Method: Instrument development Sample: Piloted with 8 data collectors (4 in each of 2 sites) who interviewed 4 elder-caregiver dyads. A total of 29 elder-caregiver dyads were interviewed QUALCARE Scale contains six subscales and 53 items. Included in 6 subscales: environmental, physical, medical maintenance, psychological, human rights, and financial.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings Phillips et al. (1990b) Design: Descriptive correlational study Measure: QUALCARE Sample: Convenient sample of 249 elder-caregiver dyads Interrater reliability for 55 observations ranged from 79% to 88%. Internal consistency: alpha = .097. Conceptual structure: confirmatory factor analysis indicated 6 significant factors accounting for 64.4% of the variance. Criterion validity: all correlations between criteria variables and QUALCARE were in correct direction and p = 0.05 level. Construct validity: 8 of 9 correlations in the predicted direction. Pillemer and Finkelhor (1988) Design: Descriptive Method: Stratified random sample survey Sample: 2,020 community-dwelling elders in metropolitan Boston 63 elder persons were maltreated. Rate of 32 per 1,000. 95% confidence interval of 25-39 per 1,000. No minority differences or age differences. Those in poor health were 3 to 4 times likely to be abused. Males were more likely to be abused than females. Pillemer and Finkelhor (1989) Design: Descriptive Method: Case control Sample: 46 abuse or neglect victims and 215 random controls Factors associated with elder mistreatment included abuser factors of deviance, dependence on victim, and life stress. Victim factors included court help, disability, dependence on abuser, and conflictual relationship (spouse only).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings Pillemer and Moore (1989) Design: Descriptive Measure: CTS Sample: 577 nursing personnel from 31 nursing homes in New Hampshire 36% of the sample had seen at least one incident of physical abuse in the preceding year. Most frequent abuse observed was excessive restraint. Second most frequent type was physical abuse. 81% observed at least one psychologically abusive incident in the preceding year. 10% of respondents reported committing physical abuse. 40% of respondents reported committing psychological abuse. Pillemer and Suitor (1992) Design: Descriptive Method: Analysis of quantitative and qualitative data Sample: 236 family caregivers for dementia victims Characteristics predictive of violent feelings in caregivers included physical aggression by elder, disruptive behaviors, and a shared living situation. Structural relationship and caregiver age were related to actual violence: spouses were more likely to be violent than other relatives, as were older individuals. Violence by elder was positively related to caregiver violence. Rosenblatt et al. (1996) Design: Descriptive Method: Analysis of State of Michigan records of reported cases of suspected elder abuse 1989–1993 Sample: 27,371 cases of possible elder mistreatment 17,238 of cases were older than age 65. Physicians reported only 2% of cases. Physician reporting rates did not increase over a 5-year period.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings Shaw (1998) Design: Descriptive Method: Grounded theory Sample: 21 semistructured interviews conducted with six abuse investigators and 15 nursing home staff The two types of abusive nursing home staff were identified as reactive sadistic. Wolf (1986) Design: Descriptive Method: Analysis of cases from an elder mistreatment intervention project Sample: 59 elder mistreatment cases compared with 49 cases randomly selected from nonabuse caseload Victims and nonabuse clients were similar in age, sex, and health status. Caretakers for both groups were similar in age and health status. More perpetrators were males. A majority of elder mistreatment cases resided with family members versus nonabused persons living alone. Victims and perpetrators had more psychological and emotional health problems. Abused elders did not appear to be more dependent. Wolf and Pillemer (1997) Design: Descriptive Measure: ADLs, IADLs, CTS Sample: 73 older women: 22 victimized by husbands and 51 victimized by adult children Wives more likely to be dependent on husbands for IADLs. Adult children more likely to be dependent on mothers for housing and finances. Husbands more likely to use physical violence against wives than adult children

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Study Methods Selected Findings     against mothers. Wolf and Li (1999) Design: Descriptive Measure: DV was number of reports per 1,000 persons age 60 years and older during 1994 Sample: 27 geographical areas in Massachusetts Rate of reports varied from a low of 2.41 per 1,000 through 9.31 per 1,000. Higher rates of reporting were associated with lower socioeconomic status, more community training, higher agency service rating scores, lower community agency relationship score.   SOURCE: Adapted from Fulmer (2002).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America REFERENCES Childs, H.W., B. Hayslip, Jr, L.M. Radika, and J.A. Reinberg 2000 Young and middle-aged adults’ perceptions of elder abuse. The Gerontologist 40(1):75-85. Coyne, A.C., W.E. Reichman, and L.J. Berbig 1993 The Relationship Between Dementia and Abuse. American Journal of Psychiatry 150(4):643-646. Dyer, C.B., V.N. Pavlik, K.P. Murphy, and D.J. Hyman 2000 The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatrics Society 48(2):205-208. Ertem, I.O., J.M. Leventhal, and S. Dobbs 2000 Intergenerational continuity of child physical abuse: How good is the evidence? Lancet 356(9232):814-9. Fulmer, T. 1984 Elder abuse assessment tool. Dimensions of Critical Care Nursing 3(4):216-220. 2002 Elder mistreatment. In Annual Review of Nursing Research: Focus on Geriatric Nursing, vol. 20. P. Archbold and B. Stewart, eds. New York: Springer. Fulmer, T., and V.M. Cahill 1984 Assessing elder abuse: A study. Journal of Gerontological Nursing 10(12):16-20. Fulmer, T., and B. Gurland 1996 Restriction as elder mistreatment: Differences between caregiver and elder perceptions. Journal of Mental Health and Aging 2:89-98. Fulmer, T., G. Paveza, I. Abraham, and S. Fairchild 2000 Elder neglect assessment in the emergency department. Journal of Emergency Nursing 26(5):436-443. Fulmer, T., M. Ramirez, S. Fairchild, D. Holmes, M.J. Koren, and J. Teresi 1999 Prevalence of elder mistreatment as reported by social workers in a probability sample of adult day health care clients. Journal of Elder Abuse and Neglect 11(3):25-36. Haviland, S., and J. O’Brien 1989 Physical abuse and neglect of the elderly: Assessment and intervention. Orthopedic Nursing 8(4):11-19. Huber, R., K. Borders, F.E. Netting, and H.W. Nelson 2001 Data from long-term care ombudsman programs in six states: The implications of collecting resident demographics. The Gerontologist 41(1):61-68. Hudson, M.F. 1991 Elder mistreatment: A taxonomy with definitions by Delphi. Journal of Elder Abuse and Neglect 3(2):1-20. Hwalek, M., A. Neale, C. Goodrich, and K. Quinn 1996 The association of elder abuse and substance abuse in the Illinois Elder Abuse System. The Gerontologist 36(5):694-700. Jogerst, G.J., J.D. Dawson, A. J. Hartz, J.W. Ely, and L.A. Schweitzer 2000 Community characteristics associated with elder abuse. Journal of the American Geriatrics Society 48(5):513-518. Jones, J.S., T.R. Veenstra, J.P. Seamon, and J. Krohmer 1997 Elder mistreatment: National survey of emergency physicians. Annals of Emergency Medicine 30(4):473-479.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Lachs, M.S., L. Berkman, T. Fulmer, and R. Horwitz 1994 A prospective community-based pilot study of risk factors for the investigation of elder mistreatment. Journal of the American Geriatrics Society 42(2):169-73. Lachs, M.S., and T. Fulmer 1993 Recognizing elder abuse and neglect. Clinical Geriatric Medicine 9(3):665-81. Lachs, M.S., C. Williams, S. O’Brien, L. Hurst, and R.I. Horwitz 1997a Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. The Gerontologist 37(4):469-474. Lachs, M.S., C.S.Williams, S. O’Brien, L. Hurst, A. Kossack, A. A. Siegal, and M.E. Tinetti 1997b ED use by older victims of family violence. Annals of Emergency Medicine 30(4):448-454. Lachs, M. S., C.S. Williams, S. O’Brien, K.A. Pillemer, and M.E. Charlson 1998 The mortality of elder mistreatment. Journal of the American Medical Association 280(5):428-432. Moody, L. E., A. Voss, and C.A. Lengacher 2000 Assessing abuse among the elderly living in public housing. Journal of Nursing Measurement 8(1):61-70. The National Center on Elder Abuse 1998 The National Elder Abuse Incidence Study Final Report: Washington, DC: National Center on Elder Abuse. Neale, A., M. Hwalek, R. Scott, M. Sengstock, and C. Stahl 1991 Validation of the Hwalek-Sengstock Elder Abuse Screening Test. Journal of Applied Gerontology 10(4):406-418. O’Brien, J. G. 1986 Elder abuse and the physician. Michigan Medical Journal 85(11):618, 620. O’Malley, T.A., H.C. O’Malley, D.E. Everitt, and D. Sarson 1984 Categories of family-mediated abuse and neglect of elderly persons. Journal of the American Geriatrics Society 32(5):362-9. Paveza, G.J., D. Cohen, C. Eisdorfer S. Freels, T. Semla, J.W. Ashford, P. Gorelick, R. Hirschman, D.J. Luchins, and P. Levy 1992 Severe family violence and Alzheimer’s disease: Prevalence and risk factors. The Gerontologist 32(4):493-497. Pavlik, V.N., D.J.Hyman, N.A. Festa, and C. Bitondo Dyer 2001 Quantifying the problem of abuse and neglect in adults—analysis of a statewide database. Journal of the American Geriatrics Society 49(1):45-48. Phillips, L.R., E.F. Morrison, and Y.M. Chae 1990a The QUALCARE Scale: Developing an instrument to measure quality of home care. International Journal of Nursing Studies 27(1), 61-75. 1990b The QUALCARE Scale: Testing of a measurement instrument for clinical practice. International Journal of Nursing Studies 27(1):77-91. Phillips, L.R., and V.F. Rempusheski 1985 A decision-making model for diagnosing and intervening in elder abuse and neglect. Nursing Research 34(3):134-139. Pillemer, K.A., and D. Finkelhor 1988 The prevalence of elder abuse: A random sample survey. The Gerontologist, 28(1):51-57. Pillemer, K.A., and D. Finkelhor 1989 Causes of elder abuse: Caregiver stress versus problem relatives. American Journal of Orthopsychiatry 59(2):179-187.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Pillemer, K.A., and D.W. Moore 1989 Abuse of patients in nursing homes: Findings from a survey of staff. The Gerontologist 29(3):314-320. Pillemer, K. A., and J.J. Suitor 1992 Violence and violent feelings: What causes them among family caregivers? Journal of Gerontological Nursing 47(4):S165-S172. Reis, M., and D. Nahmiash 1998 Validation of the indicators of abuse (IOA) screen. The Gerontologist 38(4):471-480. Rosenblatt, D. E., K.H. Cho, and P.W. Durance 1996 Reporting mistreatment of older adults: The role of physicians. Journal of the American Geriatrics Society 44(1):65-70. Shaw, M.M.C. 1998 Nursing home resident abuse by staff: Exploring the dynamics. Journal of Elder Abuse and Neglect 9(4):1-21. Straus, M..A. 1978 The Conflict Tactic Scale. Reprinted in Handbook of Family Measurement Techniques, J. Touliatos, B. Perlmutter, and M. Straus, editors. Newbury Park, CA: Sage. Tatara, T 1993 Understanding the nature and scope of domestic elder abuse with the use of state aggregate data: Summaries of key findings of a national survey of state APS and aging agencies. Journal of Elder Abuse and Neglect 5:35-57. Wolf, R.S. 1986 Major findings from three model projects on elderly abuse. In Elder Abuse: Conflict in the Family, K.A. Pillemer and R.S. Wolf, eds. Dover MA: Auburn House Publishing. Wolf, R.S., and D. Li 1999 Factors affecting the rate of elder abuse reporting to a state protective services program. The Gerontologist 39(2):222-228. Wolf, R.S., and K.A. Pillemer 1997 The older battered woman: wives and mothers compared. Journal of Mental Health & Aging 3(3):325-336.