ELDER MISTREATMENT

Abuse, Neglect, and Exploitation in an Aging America

Panel to Review Risk and Prevalence of Elder Abuse and Neglect

Richard J. Bonnie and Robert B. Wallace, Editors

Committee on National Statistics and

Committee on Law and Justice

Division of Behavioral and Social Sciences and Education

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America ELDER MISTREATMENT Abuse, Neglect, and Exploitation in an Aging America Panel to Review Risk and Prevalence of Elder Abuse and Neglect Richard J. Bonnie and Robert B. Wallace, Editors Committee on National Statistics and Committee on Law and Justice Division of Behavioral and Social Sciences and Education NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract/Grant No. N01-0D-4-2139 between the National Academy of Sciences and DHHS/National Institutes of Health. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Bonnie, Richard J. Elder mistreatment : abuse, neglect, and exploitation in an aging America / Richard J. Bonnie and Robert B. Wallace, Editors. p. cm. Includes bibliographical references and index. ISBN 0-309-08434-2 (hardback) 1. Aged—Abuse of—United States I. Wallace, Robert B. II. Title. HV6626.3+ 362.6—dc21 2002012762 Additional copies of this report are available from The National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu Printed in the United States of America Copyright 2003 by the National Academy of Sciences. All rights reserved. Suggested citation: National Research Council. (2003). Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect. Richard J. Bonnie and Robert B. Wallace, Editors. Committee on National Statistics and Committee on Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America PANEL TO REVIEW RISK AND PREVALANCE OF ELDER ABUSE AND NEGLECT RICHARD J. BONNIE (Chair), Schools of Law and Medicine, University of Virginia TERRY FULMER, School of Nursing, New York University RICHARD A. KULKA, Research Triangle Institute, Research Triangle Park, NC EVA KUTAS, Mental Health and Development Disabilities Service Division, National Association of Adult Protective Administrators, Salem, OR EDWARD O. LAUMANN, Department of Sociology, University of Chicago CONSTANTINE G. LYKETSOS, Division of Geriatric Psychiatry and Neuropsychiatry, School of Medicine, The Johns Hopkins University, MD GARY B. MELTON, Institute on Family and Neighborhood Life, Clemson University, SC LAURA MOSQUEDA, Department of Family Medicine, University of California, Irvine GREGORY PAVEZA, School of Social Work, University of South Florida KARL PILLEMER, Department of Human Development, Cornell University, NY LORI A. STIEGEL, Commission on Legal Problems of the Elderly, American Bar Association, Washington, DC ROBERT B. WALLACE, Department of Epidemiology and Internal Medicine, University of Iowa Colleges of Public Health and Medicine EARL S. POLLACK, Study Director MARISA GERSTEIN, Research Assistant DANELLE DESSAINT, Senior Project Assistant TANYA M. LEE, Project Assistant LORA FLATTUM HAMP, Consultant

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America COMMITTEE ON NATIONAL STATISTICS 2001-2002 JOHN E. ROLPH (Chair), Marshall School of Business, University of Southern California JOSEPH G. ALTONJI, Department of Economics, Northwestern University, IL ROBERT BELL, AT&T Research Laboratories, Florham Park, NJ LAWRENCE D. BROWN, Department of Statistics, University of Pennsylvania ROBERT M. GROVES, Survey Research Center, University of Michigan HERMAN HABERMANN, United Nations Statistical Division, New York, NY JOEL L. HOROWITZ, Department of Economics, Northwestern University, IL WILLIAM KALSBEEK, Survey Research Unit, Department of Biostatistics, University of North Carolina ARLEEN LEIBOWITZ, School of Public Policy and Social Research, University of California, Los Angeles RODERICK J.A. LITTLE, School of Public Health, University of Michigan THOMAS A. LOUIS, The RAND Corporation, Arlington, VA DARYL PREGIBON, AT&T Laboratories-Research, Florham, NJ NORA CATE SCHAEFFER, Department of Sociology, University of Wisconsin-Madison MATTHEW D. SHAPIRO, Department of Economics, University of Michigan ANDREW A. WHITE, Director

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America COMMITTEE ON LAW AND JUSTICE 2001 CHARLES F. WELLFORD (Chair), Center for Applied Policy Studies and Department of Criminology and Criminal Justice, University of Maryland JOAN PETERSILIA (Vice Chair), School of Social Ecology, University of California, Irvine ALFRED BLUMSTEIN, H. John Heinz III School of Public Policy and Management, Carnegie Mellon University JEANETTE COVINGTON, Department of Sociology, Rutgers University RUTH DAVIS, The Pymatuning Group, Inc., Alexandria, VA JEFFREY FAGAN, Schools of Law and Public Health, Columbia University DARNELL HAWKINS, Department of African American Studies, University of Illinois at Chicago PHILIP HEYMANN, Center for Criminal Justice, Harvard Law School CANDACE KRUTTSCHNITT, Department of Sociology, University of Minnesota MARK LIPSEY, Department of Psychology and Human Development, Vanderbilt University COLIN LOFTIN, School of Criminal Justice, State University of New York at Albany JOHN MONAHAN, School of Law, University of Virginia DANIEL NAGIN, H. John Heinz III School of Public Policy and Management, Carnegie Mellon University PETER REUTER, Department of Criminology and Criminal Justice, University of Maryland WESLEY SKOGAN, Department of Political Science and Institute for Policy Research, Northwestern University KATE STITH, School of Law, Yale University MICHAEL TONRY, Institute of Criminology, Cambridge University CATHY SPATZ WIDOM, Department of Psychiatry, New Jersey Medical School CAROL PETRIE, Director RALPH PATTERSON, Senior Project Assistant

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Acknowledgments The Panel to Review Risk and Prevalence of Elder Abuse and Neglect wishes to thank the many individuals who contributed to the preparation to this report. The project was sponsored by the National Institute on Aging, National Institutes of Health, U.S. Department of Health and Human Services, with additional support from the Office of Behavioral and Social Science Research and the Office of Research on Women’s Health of the National Institutes of Health and the Agency for Health Care Research and Quality. Sidney Stahl served as project officer and was very helpful in orienting the panel to the major issues on elder abuse and neglect that needed to be considered. The panel also expresses its appreciation to Laurence Branch, Duke University; Larry Corder, Duke University; and Brian Kemp, University of California, Irvine, who prepared background papers in addition to those included in this volume. Thanks are also due to those who reviewed the papers commissioned by the panel and provided many helpful comments— Barbara Altman, National Center for Health Statistics; Jack Guralnik, National Institute on Aging; Jane Tilly, Urban Institute; Jordan Kosberg, University of Alabama; Kenneth Minaker, Massachusetts General Hospital; Carla VandeWeerd, University of South Florida; Richard Schulz, University of Pittsburgh; and George Annas, Boston University. The panel also wishes to thank Marie-Therese Connolly, U.S. Department of Justice; Patricia McFeeley, University of New Mexico; Joanne Otto, Colorado Department of Human Services; and Patsy Klaus, U.S.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Department of Justice, for their presentations of background information to the panel. The panel is also grateful to the staff of the National Research Council for its superb support throughout the course of the study. Study Director Earl Pollack, ably assisted by Marisa Gerstein, Danelle Dessaint, and Tanya Lee, helped the panel stay well-informed, on track, and on time. Constance Citro, senior project officer, provided many helpful suggestions. Lora Hamp, a third-year student at the University of Virginia Law School, provided valuable research assistance on elder mistreatment legislation and on legal and ethical issues in elder mistreatment research. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the Report Review Committee of the National Research Council. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their participation in the review of this report: Ira Ralph Katz, Institute on Aging, University of Pennsylvania; Jennifer M. Kinney, Department of Sociology, Gerontology, and Anthropology, Miami University; Jill E. Korbin, Office of the Dean, College of Arts and Sciences, Case Western Reserve University; Kenneth Minaker, Massachusetts General Hospital, Boston; Becky Morgan, Stetson College of Law; and Stephen Zarit, Gerontology Center, Pennsylvania State University. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations; nor did they see the final draft of the report before its release. The review of this report was overseen by Robert Butler, International Longevity Center-USA, Ltd., New York City. Appointed by the National Research Council, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Contents Preface   xiii Executive Summary   1 PART I: PANEL REPORT     1   Introduction   9 2   Concepts, Definitions, and Guidelines for Measurement   34 3   A Theoretical Model of Elder Mistreatment   60 4   The Occurrence of Elder Mistreatment   71 5   Risk Factors for Elder Mistreatment   88 6   Screening and Case Identification in Clinical Settings   104 7   Evaluating Interventions   121 8   Research Ethics   140 9   Moving Forward   150     References   153     Appendices     A   Elder Mistreatment Measures and Studies   165 B   Analysis of Elder Abuse and Neglect Definitions Under State Law Lora Flattum Hamp   181

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America C   Elder Abuse and Neglect: History and Concepts Rosalie Wolf   238 D   Biographical Sketches   249 PART II: BACKGROUND PAPERS     10   Elder Mistreatment: Epidemiological Assessment Methodology Ron Acierno   261 11   Ethical and Policy Issues in Research on Elder Abuse and Neglect Rebecca Dresser   303 12   The Clinical and Medical Forensics of Elder Abuse and Neglect Carmel Bitondo Dyer, Marie-Therese Connolly, and Patricia McFeeley   339 13   Financial Abuse of the Elderly in Domestic Settings Thomas L. Hafemeister   382 14   Elder Abuse in Residential Long-Term Care Settings: What Is Known and What Information Is Needed? Catherine Hawes   446 15   Elder Abuse Intervention: Lessons from Child Abuse and Domestic Violence Initiatives David A. Wolfe   501 Index   527

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Preface Reports of this kind typically begin by calling attention to the magnitude and social cost of the problem being explored. The fact that equivalent statements cannot be made with any confidence about elder mistreatment is a telling indication of the need for the report, as well as for an intensified program of research. No survey of the U.S. population has ever been undertaken to provide a national estimate for the occurrence of any form of elder mistreatment; the magnitude of the problem—among community-dwelling elders, as well as those residing in long-term care facilities—is basically unknown. The best estimates, based on figures extrapolated from local studies, suggest that the national prevalence of elder mistreatment (including physical abuse, psychological abuse, and neglect) is between 1 and 2 million. The occurrence and severity of elder mistreatment are likely to increase markedly over the coming decades, as the population ages, caregiving 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 understanding of the nature, causes, and consequences of elder mistreatment, the effectiveness and cost of current interventions, or measures that could successfully be taken to prevent it or to ameliorate its effects. The purpose of this report is to help the nation remedy this deficiency. In Understanding Child Abuse and Neglect (1993) and Violence in Families (1998), the National Research Council was able to map out a

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America comprehensive blueprint for research in the adjacent domains of child mistreatment and intimate partner violence. However, so little is now known about elder mistreatment that it would be premature to draw up a detailed research agenda for this nascent field. Instead, this report is best seen as laying the foundation for a much-needed scientific effort. The panel emphasizes the need to develop a better understanding of elder mistreatment in its different forms, to develop better measures for it, and to undertake a variety of population-based studies to ascertain prevalence and risk factors. Several priorities for research are identified in relation to the determinants of elder mistreatment, clinical screening and case identification, and preventive interventions. We are not the first to lament the poor state of knowledge about elder mistreatment. In 1986, a consensus conference of leading researchers (including two of our panel members) was convened at the University of New Hampshire to point the way toward advancing knowledge. The conclusions and recommendations reached at that conference are strikingly similar to those appearing in this report. One of the participants at the New Hampshire conference was Rosalie Wolf, by all accounts one of the founding leaders of the elder mistreatment field. The panel expressed its deep gratitude to Dr. Wolf for presenting her views at our initial meeting, despite her poor health, and was devastated when she passed away within weeks of her appearance at our meeting. We are publishing the remarks that she delivered at that meeting as an appendix to this report. Indeed, our report is in many ways a tribute to Dr. Wolf’s heroic efforts over three decades to nurture the field of elder mistreatment research. Abuse and neglect of older individuals in society breaches a widely embraced moral commitment to protect vulnerable people from harm and to ensure their well-being and security. To carry out this commitment, one cannot rely on good intentions alone. A substantial investment in scientific research along the lines outlined in this report is imperative to enable society to enhance its understanding of elder mistreatment and to mount an effective response to it in the 21st century. Richard J. Bonnie, Chair Panel to Review Risk and Prevalence of Elder Abuse and Neglect

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America ELDER MISTREATMENT

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