Research, Statistics, and Data

Research

The study of elder mistreatment is a fairly recent area of scholarship in the United States. First discussed in the 1970’s, abuse of older adults was for many years a largely hidden, private matter rather than an issue of social, health, or criminal concern. Research efforts began slowly as state laws recognizing the offense were enacted and public awareness rose. While a research base has been steadily growing, the subject matter is still largely understudied and there remains a critical deficit in the development of robust studies. Notably, elder abuse research and funding lag behind efforts in the comparable and related disciplines of child abuse and intimate partner violence. Further studies are vital to identify the scope of the problem, explore areas of need, and to validate evidence-informed, best practice strategies to address elder abuse prevention, detection, treatment, and remediation.
 
Theory-informed Research and Practice

Theories are essential to explain the complex causes, risk factors, inter-relational dynamics, and consequences of elder mistreatment. They frame the way research is conducted, collected, and analyzed and inform identification of patterns, themes, and tendencies that influence appropriate strategies for intervention. In addition to improving practice measures to prevent and detect abuse, theory is critical to the development of policies that advance the education of practitioners and knowledge in the field. Early theoretical models have been critiqued for several reasons, including their limited scope, discipline-specific focus, and failure to consider cultural implications. While there is no current theoretical consensus, a number of approaches have emerged that lend insight to the area, including the ecological model, the abuse intervention model, contextual framework, trauma-based theories, and stress process theory.

Research and Data
 
The statistics and data below provide information about the growing older adult population, definitions of abuse, the incidence and prevalence of mistreatment, and risk and protective factors for mistreatment, among other key topic areas. The research-based findings are sourced to peer-reviewed publications, articles, and relevant government agency data. Please note that the information referenced is based upon a variety of studies, each reflecting the author’s respective orientation, the type of research conducted, methods employed, measures evaluated, study-specific operational definitions, and contextually related data sets.
 
The Growing Older Population
 
As of 2018 there were 52.4 million adults 65 and over in the United States. By 2040, that number is expected to climb to 80 million, comprising nearly 21% of the total population. People aged 85 and older are predicted to almost triple from their current 6.7 million to 19 million by 2060. For the first time, in 2034, it is anticipated that older Americans will outnumber children. Declining rates of fertility and the aging of the baby boom generation are believed to contribute to the increasing ranks of older adults nationwide.
 Demographic Snapshot of Older Adults in the United States

• The aging population is becoming increasingly racially and ethnically diverse. In 2018, minority populations accounted for 23% of all older adults. Approximately 9% were non-Hispanic African Americans, 5% Asian, 0.5% American Indian and Alaska Native, 0.1% Native Hawaiian/Pacific Islander, and 0.8% of adults 65 and older identified as being of two or more races. Individuals of Hispanic origin constituted 8% of older Americans. The percentage of diverse Americans is projected to rise to 34% by 2040.
• Life expectancy has risen from 68 years in the mid-20^th century to the current average of about 81 years for women and 76 years for men.
• In 2018, there were 29.1 million older women in the United States, compared with 23.3 million older men.
• In 2018, almost one in 10 older adults lived below the poverty level. While this represents a decline from prior years, significant economic disparities exist within underserved diverse populations. In 2017, 19% of African American and 17% of Latino elders lived in poverty, more than double the 7% rate among older non-Hispanic whites.
• Overall, approximately 28% of older people live alone. More than 25% of those who live by themselves are older women aged 65-74. For women between the ages of 75-84, the proportionate share jumps to 39%, and for women over 85, 55% live by themselves.
• It is expected that by 2030, there will be a 50% increase in the number of elders over the age of 65 who require nursing home care.
• The number of older Americans living with Alzheimer’s disease will likely more than double from 5.8 million to 13.8 million in 2050.

Prevalence

To provide context, incidence and prevalence rates of mistreatment are informed by the core definitions, inclusion criteria, theoretical basis, and methodology utilized by respective researchers to guide the collection of data. As a result, prevalence estimates of abuse, as reflected in recent studies, are variable.
 

Definitions

Though there is increasing consensus on the core components of elder mistreatment, the field has not adopted a universally accepted definition of abuse. Several reasons have been suggested for the lack of uniformity. Different professional disciplines, each with their own objectives, interests, and perspectives may use distinct approaches to classify elder abuse.

Conceptual understandings may also vary based on differing cultural and social norms among communities. Socio-cultural orientations may derive from numerous factors including faith, family, circumstances, context, and community, resulting in diverse descriptions and perceptions of, and responses to, mistreatment. Notably, in the United States legal definitions of abuse vary by state statute. Internationally, definitional variability is observed both between and within countries. A lack of consistency in definitions and data elements on elder mistreatment across jurisdictions makes it challenging for researchers to measure elder mistreatment and identify trends.

Notwithstanding deficits in classification, the following definitions are commonly cited by researchers in their studies on elder mistreatment.
 

• According to the Centers for Disease Control and Prevention, “Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone age 60 or older. The abuse often occurs at the hands of a caregiver or a person the elder trusts.”
• The World Health Organization states that “Elder abuse can be 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." Elder abuse can take various forms such as financial, physical, psychological, and sexual. It can also be the result of intentional or unintentional neglect.”
• The National Research Council describes elder abuse as “(a) intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” 

Types of Elder Mistreatment

Elder mistreatment typically takes one of five forms: physical abuse, psychological or emotional abuse, sexual abuse, financial abuse, and neglect. As with the broader definition of elder mistreatment, understandings of specific types of maltreatment may vary. They are often impacted and informed by socio-cultural orientations and may be differently construed by diverse constituencies and individuals.

Physical Abuse: the intentional or reckless use of physical force or physical coercion that may result in bodily injury, physical pain, or impairment. Acts of physical violence include, but are not limited to, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. Physical abuse also embraces any unlawful, excessive, or unnecessary use of physical or chemical means to restrain or confine an elder, such as force-feeding and physical punishment.

Sexual Abuse: non-consensual sexual contact of any kind with an older adult, perpetrated through force, threats, or the exploitation of authority. Sexual abuse includes, but is not limited to, unwanted touching, sexual assault or battery, sexual harassment, and sexual interaction with elders who lack the capacity to give consent.

Emotional or Psychological Abuse: the infliction of anguish, pain, or distress through verbal or nonverbal acts including, but not limited to verbal assaults, insults, threats, intimidation, humiliation, isolation, and harassment.

Financial Abuse: the illegal or improper use of an elder's funds, property, or assets including, but not limited to misusing or stealing an older person's money or possessions, coercing or deceiving an older person into signing any document (e.g., contracts or will), and the improper use of conservatorship, guardianship, or power of attorney.

Neglect: the refusal or failure to fulfill any part of a person's obligations or duties of care to an elder which include, but are not limited to, life necessities such as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety.

Related Concepts

Self-neglect is a phenomenon related to but distinct from elder neglect. Self-neglect is a form of self-harm that may co-occur with, provoke, or be triggered by elder mistreatment. It is characterized as the behavior of an older person that threatens their own health or safety, including but not limited to the refusal or failure to provide themselves with life necessities.

Abandonment is oftentimes considered a subtype of neglect and other times believed to constitute a separate category of mistreatment. By definition, it is the desertion of an older adult by an individual who has physical custody of an elder, or who has assumed responsibility for providing care for that elder.

Signs of Mistreatment

The most frequently observed signs of mistreatment are referenced below. Please note that indicia of abuse may present differently based upon multiple factors, including the type, degree, duration, and context of abuse experienced. Manifestations of abuse may also be impacted by the older adult’s physical and cognitive condition, social connectedness, and emotional state.

Psychological Abuse
 

• Emotional distress or agitation
• Withdrawal from activities of daily life
• Uncommunicative or non-responsive
• Unusual behaviors commonly attributed to dementia (e.g., sucking, biting, rocking)
• Lack of self-care
• Lower self-esteem, feelings of despair, or a sense of worthlessness

Physical Abuse
 

• Bruises, abrasions, welts, lacerations, or rope marks
• Head trauma and/or bone fractures
• Open wounds, cuts, punctures, untreated injuries in various stages of healing
• Sprains, dislocations, and internal injuries/bleeding
• Bite, strangulation, burn marks, or patterns of injury
• Falls, including broken eyeglasses or frames
• Physical indicia of punishment, including evidence of physical restraints
• Medication overdose or chemical restraints
• Sudden behavioral changes

Financial Abuse
 

• Sudden changes in bank account or banking practices, including an unexplained withdrawal of large sums of money or the addition of signatories to an older person’s bank signature card
• Abrupt changes to a will or other financial documents
• The unexplained disappearance of funds or valuable possessions, or sudden transfer of assets
• Substandard care provision, unpaid bills, or eviction proceedings
• The provision of unnecessary services
• Depression or anxiety
• Evidence of poor financial decision making
• Malnutrition

Neglect
 

• Dehydration or malnutrition
• Untreated bed sores
• Poor personal hygiene
• Unattended or untreated health problems
• Unsafe living conditions
• Unsanitary living conditions

Sexual Abuse
 

• Bruises, abrasions, or lacerations around the breasts or genital area
• Unexplained sexually transmitted disease or genital infection
• Unexplained vaginal or anal bleeding or incontinence
• Increased anxiety or depressive symptoms
• Sleep disturbances, agitation, or restlessness

 
Abuse in Institutional Settings

Older residents of long-term care facilities who have disabilities or otherwise experience frailties may be at heightened risk of mistreatment and less able to safeguard themselves from environmental harm or extricate themselves from danger. Abuse within institutions may be observed in the forms outlined above but may also be discerned in other ways. For example, physical abuse may appear as hygiene neglect, which results in skin abrasions and breakdown such as pressure ulcers. Other means of institutional abuse are medication withholding, food deprivation, treatment neglect, and chemical restraints. Psychological mistreatment may be also employed and expressed as threats of death or harm.  

Impact of Mistreatment

Like the signs of abuse, the impact of elder mistreatment may be experienced differently by older adults. The effects of maltreatment are often related to the scope, nature, type, and degree of abuse. They are also influenced by the many multifactorial, intersecting medical, mental health, and socio-cultural components that comprise the elder’s life. Contextual factors, including a prior history of trauma, may also play a role in determining the impacts perceived and manifested by the individual who was abused. For elders who live with several types of abuse, the reactions may be overlapping and complex.

Among the devastating effects of abuse, older adults may sustain physical injuries, psychological harms, and financial losses. Traumas may lead to compromised health, hospitalization, and mortality. Elders may also experience deteriorated family relationships, diminished autonomy, and institutionalization, which may result in a diminished quality of life.

Below is a partial, representative list of abuse-related consequences by type of mistreatment experienced.

Psychological Abuse
 

• Feelings of shame and guilt
• Loss of self-esteem and compromised sense of self-worth
• Physical decline
• Loss of attachment to the perpetrator, who may be a family member caregiver
• Diminished psychological wellness
• Increased morbidity and mortality
• Emotional distress, loneliness, and isolation
• Depression, post-traumatic stress disorder, and other adverse psychological health outcomes

Physical Abuse
 

• Psychosocial consequences
• Physical trauma
• Increased hospitalization and mortality
• Depression and anxiety
• Cognitive decline

Neglect
 

• Malnutrition and dehydration
• Unmet basic physiological needs, including hygienic conditions and living quarters
• Functional impairment
• Lower quality of life
• Psychological distress and depression
• Poor physical health
• Increased disability and mortality

Financial Abuse
 

• Compromised physical wellness
• Diminished independence in later life
• Monetary loss, financial dependence
• Psychological decline
• Loneliness
• Depression, anxiety, and sleep disorders

Sexual Abuse
 

• Post-traumatic stress syndrome
• Sleep disturbances
• Depression and/or anxiety
• Dissociative symptoms
• Changes in self-image
• Increased hospitalization and poor health
• Feelings of shame and guilt

Risk Factors and Protective Factors of Mistreatment

Risk Factors

Recognizing the factors associated with the increased risk of elder mistreatment is critical to help us understand the sources and causes of abuse, neglect, and exploitation. It is important to note at the outset that elder abuse is a complicated phenomenon, often rooted in the qualities of the elder and the perpetrator within the context of their interconnected relationship. Each situation is unique and the particular risk factors may vary.

Research studies have discerned both victim and perpetrator characteristics that offer insight as to why certain older people may be susceptible to and targeted for mistreatment, and the reasons offenders may be more likely to commit acts of mistreatment. One study reported that offender traits may be a stronger predictor of abuse than victim features. Knowledge of the discrete and interrelated factors may inform efforts to mitigate the risk of elder abuse, manage environmental threats, and prevent recurrent abuse.

Risk factors can be characterized as “static” or “dynamic.” Static variables are those elements in an individual’s world that are fixed and unlikely to change, such as historical violence or criminality. Dynamic variables, on the other hand, are those factors which may be modified through risk management strategies and tailored interventions. This could include perpetrator substance abuse which may be controlled through treatment, medication, and/or court ordered protections.

Below are examples of risk factors commonly observed with victims and perpetrators. Because of the significance and interrelationship of abuse within the larger societal framework, the impact of socio-cultural risk factors will be addressed below as well.

Victim Risk Factors
 

• Chronic medical conditions and poor physical health
• Functional disability and dependence
• Mental health problems
• Cognitive deficits
• Financial dependence
• Lower socioeconomic status
• Substance misuse
• High levels of stress and poor coping mechanisms
• Prior exposure to trauma
• Limited social support
• Poor relationship between the victim and the perpetrator

Other victim-centric variables that have been correlated with a potential increased risk of abuse include the following:
 

• Gender (women)
• Race (one study cited support for the proposition that, compared with Caucasians, older African Americans may be at increased risk of financial abuse and psychological abuse)[81]
• Younger older age
• Health care insecurity

Perpetrator Risk Factors
 

• Chronic medical conditions and poor physical health
• Mental health problems
• Cognitive deficits
• Financial dependence
• Substance misuse
• High levels of stress and poor coping mechanisms
• Negative attitudes towards the older adult
• Early childhood abuse

Risk of Revictimization

Causal factors that forecast the initial onset of abuse are relevant to revictimization. Additional considerations have been identified that create or contribute to an increased risk of recurrence. These perpetuating factors include an older adult’s perception of the mistreatment, the degree to which they protect or defend the offender, the receptiveness to help, barriers to accessing supportive services, and the extent of influence imposed by the perpetrator to quash an older adult’s help-seeking behavior.

Potential Community and Socio-cultural Risk Factors

Community contexts and societal perceptions have been cited as possible predictors of elder abuse. Some studies have reported that living in urban centers may increase the likelihood of mistreatment. Others have noted that age bias and stereotypes about older people contribute to elder mistreatment. As public discourse and depictions portray elders as inept, fragile, or burdensome, audiences may begin to accept ageist misconceptions as fact and tolerate, even perpetuate, the adverse treatment of older adults.

Protective Factors

There is scant evidentiary support for protective factors which may safeguard older adults from mistreatment. Two factors, however, have been cited as effective means to shield elders from harm. High levels of social support and embedded community networks have been found to offer protection to ward off abuse. The other suggested supportive measure relates to the elder’s living environment. Empirical studies have found that shared living situations may accelerate the risk of abuse. Separation from conflict may serve to mitigate environmental stress which can foster mistreatment. For additional information on interventions, please see the section on Interventions, below.
 

Perpetrator Identity

Perpetrators of elder mistreatment share some common characteristics but are largely heterogeneous with significant variability across types of abuse. Greater insight into these differences in typology may serve to inform appropriate interventions and remediation. Below are general offender patterns extrapolated from research. An Abuser Risk Measure has been developed to measure the risk of abuse by perpetrators.

Offender Characteristics
 

• Age: The average age is 45.
• Gender: Much of the data indicates a lack of gender differences among offenders, but one study found that 62% of perpetrators were men.
• Race: 77% of perpetrators were found to be Caucasian.
• Education: 38% of perpetrators did not graduate from high school, although 44% received a high school diploma.
• Employment: Between one third and two thirds of offenders were unemployed at the time of the incident.
• Marital Status:  70% of elder abuse perpetrators were unmarried at the time of the offense.
• Health: Most perpetrators appeared to be relatively healthy.
• Family History: Almost half of the perpetrators reported a history of early childhood violence.
• Substance Abuse: 20% to 50% of perpetrators reported substance misuse.
• Mental Health: Approximately 25% to 35% of perpetrators reported having a serious mental illness.
• Criminal Record: Between 25% and 46% of perpetrators had a criminal record at the time of the offense.
• Relationship Problems: One study found that 68% of perpetrators experienced interpersonal relationship problems, while another reported only 21%.
• Living Arrangements: Between 53% and 64% of elder abuse victims and perpetrators cohabitated at the time of the offense.
• Financial Problems: 30% of financial exploitation perpetrators compared with less than 1% of interpersonal perpetrators had financial problems.
• Financial Dependence: Approximately one third of perpetrators were financially dependent upon the victim at the time of the offense.
• Social isolation: 35% of offenders reported lack of an individual they could contact to take them to the doctor or speak with if needed.

 
Offender Identity by Type of Mistreatment
 

• Psychological Abuse: The most frequent offender is a partner/spouse.
• Physical: The most frequent offender is a partner/spouse.
• Neglect: Adult children are the most frequent perpetrators.
• Financial: Family members (54%) and care workers (31%), compared with partners (13%), were the more frequent perpetrators.  
• Sexual abuse: There is little evidence to support a conclusion, but of the studies conducted it appears that sexual abuse was most often perpetrated by partner/spouses (40%) and acquaintances (40%).

 
Offender Classifications

One study differentiated perpetrators by personality and behavioral attributes. Four discrete profiles were identified: “Caregiver,” “Temperamental,” “Dependent Caregiver,” and “Dangerous.” Given the heterogeneity among offenders, researchers suggested that interventions be tailored by typology to effectively address the mistreatment and mitigate harm.  
 

Poly-victimization

Poly-victimization is the intersection of multiple co-occurring or sequential forms of abuse which result in cumulative and compounding harms for older adults. The concept of poly-victimization recognizes that past traumas over the life course can heighten the negative impact of mistreatment in older age. Early childhood adversity, both experiencing and witnessing mistreatment, can also exacerbate later life abuse. One study reported that approximately 1.7% of older people experienced prior year poly-victimization.
 

Ageism and Elder Mistreatment

Ageism is the systematic stereotyping and discrimination of people based upon their age. Often overlooked and significantly understudied, age prejudice is observed on a societal and personal level. With a biased lens, older people are perceived as an undifferentiated group with negative traits, among them forgetful, inept, ailing, and irritable. These blanket misperceptions tend to devalue individual aptitudes and disregard diversity within the older cohort. They also contribute to adverse physical and mental health correlates.One systematic review and meta-analysis of the literature found that interventions such as education and intergenerational contact may reduce stereotyping and the effects of age bias. Another study demonstrated that exposure to a brief framing intervention was able to reduce implicit bias against older adults.
 

Dementia and Elder Mistreatment

Older people with dementia are particularly susceptible to abuse. Nearly one in two older adults with cognitive impairment experiences abuse. In addition to being dependent upon others for assistance, elders with dementia are more likely to experience deficits in memory, communication, and judgment that make it harder for them to identify, prevent, and report mistreatment. Many may also be reluctant to report abuse by caregivers and others upon whom they rely. Older people with dementia are often at an increased risk of mistreatment because of pre-existing medical and mental health weaknesses.

Guardianship and Elder Mistreatment

Guardianship is a relationship created by state law in which a court gives one person or entity (the guardian) the duty and power to make personal and/or property decisions for another whom the court has found unable to make such decisions. Terms vary by state, but frequently a “guardian” makes personal and health care decisions, and a “conservator” makes financial decisions. In this summary, the generic term “guardianship” refers to both, unless otherwise indicated.

 Guardians are appointed by the court to protect an at-risk individual, and often to prevent or address abuse.  While many guardians act in the individual’s best interest, an unknown number take advantage of those they were named to protect -- making guardianship both a solution to and a source of elder abuse.

Despite tragic media exposes, the extent of guardianship abuse is unknown, as data is scant to nonexistent.  Courts need data to monitor guardianship practice, and policymakers need data to target necessary improvements.

Most states lack even basic information on the number of adults subject to guardianship.  Given insufficient state data, national figures have been estimates at best. In 1987, the Associated Press referenced “300,000 to 400,000 elderly people” under guardianship. In 2011, researcher from the National Center for State Courts (NCSC) calculated there may be 1.5 million adults subject to guardianship across the country, and in 2016, estimated 1.3 million open cases.

There are significant challenges in collecting consistent court data, for example:
 

• State and local courts have different technology, databases, and definitions;
• Many courts lack funding for technology to track guardianship cases;
• There may not be a distinct field for adult guardianship data, separate from probate data or from minors;
• Data may be collected going forward, but older open cases are not included;
• Data may be collected on the number of filings, but not on the number of open cases, demographics, the number of limited orders and restorations of rights, or key monitoring events; 
• There may be no data indicating abuse or exploitation, such as the number of removals of guardians for cause; and it is difficult to track use of less restrictive options used instead of guardianship.

Research on key guardianship data includes:
 

• A 2010 NCSC court survey finding that “quality data on adult guardianship filings and caseloads is generally lacking. The absence of accurate caseload measures is widespread.”
• A 2010 Government Accountability Office (GAO) report concluding that GAO “could not determine whether allegations of abuse by guardians are widespread,’ but identified hundreds of allegations in 45 states and DC between 1990 and 2010;

• A 2016 Government Accountability Office report concluding that “the extent of abuse by guardians nationally is unknown due to limited data on key factors related to elder abuse by a guardian.” The study profiled eight closed cases of guardianship abuse;
• A 2018 brief on conservatorship data quality by NCSC and research partners summarizing the status of guardianship data.; and
• A 2018 U.S. Senate Special Committee on Aging hearing and report that found “few states are able to report accurate or detailed guardianship data.”

Recent recommendations and resources have recognized and begun to address the compelling need for adult guardianship data:
 

• The 2013 National Probate Court Standards recommend that courts “collect and review meaningful caseload statistics including . . . the number of guardianships and conservatorships being monitored.”
•  In 2012, the Minnesota Judicial Branch launched a Conservator Account Auditing Program (CAAP) to improve statewide oversight of court-appointed conservators and protect assets. Conservators file electronically, and CAAP auditors review accounts and present the results to the parties and district judges. The Minnesota model has been refined and expanded, and other states have sought to adapt it.
• In 2020 NCSC released a report on Guardianship/Conservatorship Monitoring: Recommended Data Elements, to provide guidance on consistent collection of data.
• The U.S. Administration for Community Living developed a National Adult Maltreatment Reporting System (NAMRS) as a national reporting system for Adult Protective Services that includes elements on abuse by surrogate decision-makers including guardians.