Crime and Abuse of Older Adults

According to Professionals against Confidence Crimes (PACC), a nonprofit, nonpartisan organization of law enforcement professionals, national surveys reveal that the crimes older adults believe that they are most susceptible to are murder, aggravated assault and rape, armed robbery, theft from their person, burglary, and fraud. Their fears are not, however, entirely consistent with reality. Older adults are the least likely to become victims of violent crimes. The crimes more often committed against older adults are purse snatching and pocket picking (theft of their purses or wallets), fraud and confidence crimes, mail theft, vandalism, and burglary.

PACC attributes older adults' misplaced fears in part to sensational media reports that do not correctly convey the real crime risks for older adults. As a result, older adults do not have an accurate understanding about the crimes that affect them. PACC contends that unless older adults understand the real risks, they will not take the proper steps to protect themselves.

CRIME AGAINST OLDER ADULTS

The Bureau of Justice Statistics (BJS) reports that adults aged sixty-five or older experienced much less violence and victimization as well as fewer property crimes than younger people did between 1973 and 2005. Figure 11.1 reveals that adults aged sixty-five and older had the lowest rates of violent victimization of any age group. As Table 11.1 shows, violent crimes against older adults have steadily declined since 1995 and have remained relatively unchanged in recent years, from 2002–03 to 2004–05. (See Table 11.2.)

Figure 11.2 shows that even though violent victimizations were unchanged from 2004 to 2005, property crimes continued to decline. However, older adults were disproportionately victimized by personal crimes. About 20% of personal crimes against adults aged sixty-five and older were thefts (e.g., purse snatching and pocket picking), compared to 6% for those aged fifty to sixty-four. (See Figure 11.3.)

Violent Crimes

Like property crimes, older adults also experienced the lowest rates of violent crimes in 2005. For example, there was a dramatic drop in the rate of robberies among people aged fifty to sixty-four (9.3 per 1,000 people), compared to those aged sixty-five and older (1.9 per 1,000 people). (See Table 11.3.)

Older adults also have lower rates of murder than other age groups, and the number of homicides of older adults decreased between 1976 and 2004. The BJS (July 11, 2007, http://www.ojp.usdoj.gov/bjs/homicide/elders.htm) notes that in 2004 just 5% of all homicides were adults aged sixty-five or older. More older men were homicide victims than women of the same age. (See Figure 11.4.)

There has not only been a decline in the murder rate of older adults but also in the rate of older offenders. In 2004 the homicide victimization rate was 2 per 100,000 population and the offending rate was just 0.7 per 100,000 population for people aged sixty-five and older. (See Figure 11.5.)

Older adults are more likely to be killed during a felony than younger victims. In 2004 more than half of all murders of people aged seventy-two and older occurred in this circumstance. (See Figure 11.6.)

Women of all ages are more likely than male victims to be killed by an intimate—a spouse, family member, or friend. Table 11.4 shows that from 1976 to 2004 three times as many women over age sixty (21%) were murdered by an intimate as were men (7%).

The Physical and Emotional Impact of Crime

According to the BJS, most older Americans who are the victims of violent crime are not physically injured. However, physical injuries do not tell the whole story. Victimization and fear of victimization can have far more serious effects on the quality of older adults' lives than they might for younger people.

Older adults are often less resilient than younger people. Even so-called nonviolent crimes, such as purse snatching, vandalism, or burglary, can be devastating. Stolen or damaged articles and property are often irreplaceable because of their sentimental or monetary value. Furthermore, nonviolent crimes leave victims with a sense of violation and heightened vulnerability.

Older People Are Considered Easy Prey

Because of their physical limitations, older adults are often considered easy prey. They are less likely than younger victims to resist criminal attacks. Their reluctance to resist may be based on awareness that they lack the strength to repel a younger aggressor and the understanding that they are physically frail and at risk of injuries that could permanently disable them. The U.S. Bureau of Justice reports that crime victims over age sixty-five who try to protect themselves most often use nonphysical actions, such as arguing, reasoning, or screaming. Younger victims are more likely to use physical action, such as attacking, resisting, or running from or chasing offenders.

FRAUD

Older adults are also considered easy prey for fraud, deception, and exploitation. They are more readily accessible to con artists than other age groups because they are likely to be at home to receive visits from door-to-door salespeople, e-mails, or calls from telemarketers. Older adults who are homebound or otherwise isolated may not have regular contact with others who might help them to identify possible schemes or frauds. Law enforcement officials and consumer advocates assert that older people are targeted because:

• They are more likely than younger people to have substantial financial savings, home equity, or credit, all of which are tempting to fraud perpetrators.
• They are often reluctant to be rude to others, so they may be more likely to hear out a con's story. They may also be overly trusting.
• Older adults are less likely to report fraud because they are embarrassed, do not know how or to whom to report the crime, or they fear appearing incapable of handling their personal finances.
• Older adults who do report fraud may not make good witnesses. Their memories may fade over the often protracted span of time between the crime and the trial, and on the witness stand they may be unable to provide detailed enough information to lead to a conviction.

According to the National Fraud Information Center, in "2006 Top 10 Telemarketing Scam Trends from NCL's Fraud Center" (2006, http://fraud.org/stats/2006/telemarketing.pdf), older consumers—people aged sixty and over—reported a higher percentage of complaints for telemarketing frauds in 2006. Older victims made one-third of all complaints that year. Older consumers were especially vulnerable to certain kinds of telemarketing fraud: magazine sales scams (71%), prizes/sweepstakes (53%), and phishing—tricking someone into giving confidential information that might be used for identity theft—by phone (40%).

The Federal Trade Commission (FTC) is the federal government's lead consumer protection agency. FTC authority extends over practically the entire economy, including business and consumer transactions via telephone and the Internet. The FTC's consumer mission includes prohibiting unfair or deceptive acts or practices.

The U.S. Food and Drug Administration (FDA) and the FTC actively work to prevent health fraud and scams. These agencies identify products with substandard or entirely useless ingredients as well as those with fraudulent or misleading advertising to prevent the dissemination of unsubstantiated or deceptive claims about the health benefits of particular products or services.

The FTC monitors practices and industries such as dietary supplements, arthritis remedies, and memory aids that especially appeal to older consumers. In Activities Affecting

Older Americans, September 2001–August 2003 (2003, http://www.ftc.gov/os/2003/11/aging20012003.pdf), the FTC describes law enforcement initiatives within its consumer protection purview that are important to older consumers, including health-care initiatives, financial practices initiatives, sales and promotional practices initiatives, and enforcement initiatives against fraud.

Health Fraud

Older adults may be particularly susceptible to false or misleading claims about the safety and efficacy of over-the-counter (nonprescription) drugs, devices, foods, dietary supplements, and health-careservices, because the marketing of such products and services often relates to conditions associated with aging. Also, many of these unproven treatments promise false hope and offer immediate cures for chronic (long-term) diseases or complete relief from pain. It is easy to understand how older adults who are frightened or in pain might be seduced by false promises of quick cures.

Working together, the FTC and the FDA combat deceptive advertising for health services such as false and unsubstantiated claims for dietary supplements. Examples of such claims include Coral Calcium, a supplement marketed to cure diseases such as multiple sclerosis and cancer, and the Q-Ray Bracelet, a device advertised as a pain cure.

COUNTERFEIT PRESCRIPTION DRUGS.

Skyrocketing Internet sales of prescription drugs have created another form of health fraud: counterfeit drugs. Because older adults often take multiple prescription medications, they are an ideal target market for this type of health fraud. According to the National Consumers League (NCL), in "Consumer Group Says Americans Vulnerable to, Unaware of Counterfeit Drugs" (NCL News,June21, 2004), which reports on an NCL survey of over one thousand adults, 26% of adults aged fifty-five and older said they had purchased medications online, and most consumers purchasing prescription drugs online said they did not know how to tell whether the drugs they received were legitimate. The survey revealed that more than half of those who purchased drugs online felt there was no way to tell if the drugs they obtained were real or counterfeit, and nearly one-third of purchasers said they were not required to have a prescription to make their purchases.

Financial Fraud and Exploitation

Financial crimes against older adults are on the rise. Along with telemarketing, mail fraud, Internet scams, and health-care and insurance fraud, there have been pension and trust fund fraud, mail theft, reverse mortgage fraud, and many others. In "They Can't Hang Up: Help for Elderly People" (March 24, 2006, http://www.fraud.org/elderfraud/elderbroch.htm), the National Fraud Information Center estimates

that there are fourteen thousand illegal telemarketing operations in the United States and that the older population is swindled out of more than $40 billion each year.

In 2006 IC3 Annual Report (2006, http://www.ic3.gov/media/annualreports.aspx), the Internet Fraud Complaint Center, a partnership between the Federal Bureau of Investigation and the National White Collar Crime Center, reports that in 2006, 24% of complainants were aged fifty and older and that this group reported higher losses than other age groups. Complainants over age sixty reported average losses of $866, compared to the $500 average suffered by complainants less than twenty years old.

Common financial schemes frequently used by fraudulent direct-mail marketers are sweepstakes and free giveaways. Consumers receive postcards announcing that they are entitled to claim a prize. The postcards bear a toll-free telephone number that the consumers need to call to claim their prize. Once the toll-free number is accessed, a recording instructs the consumer to touch numbers on the telephone key pad that correspond with a "claim number" that appears on the postcard.

Ultimately, the consumer receives no prize. Instead, the unsuspecting victim receives a telephone bill that reflects a substantial charge for the call, just as if a 900 number had been called. The entry of the sequence of numbers that matched the claim number engages an automated information service for which the consumer is charged.

Medicare Fraud>

Every year Medicare loses millions of dollars because of fraud and abuse. The most common forms of Medicare fraud are:

• Billing for services not furnished
• Misrepresenting a diagnosis to justify a higher payment
• Soliciting, offering, or receiving a kickback
• Charging Medicare higher fees than normal for certain procedures
• Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment
• Billing for a service not furnished as billed

The Health Insurance Portability and Accountability Act of 1996 allocated funds to protect Medicare's integrity and prevent fraud. In one of the largest efforts in the history of Medicare, the program has undertaken a major campaign to help eliminate Medicare fraud, waste, and abuse.

To combat Medicare fraud at the level of the beneficiary, the U.S. Administration on Aging (AoA) provides grants to local organizations to help older Americans become more vigilant health-care consumers so that they can identify and prevent fraudulent health-care practices. The Senior Medicare Patrol, now known as the SMP program, trains community volunteers, many of whom are retired professionals, such as doctors, nurses, accountants, investigators, law enforcement personnel, attorneys, and teachers, to help Medicare and Medicaid beneficiaries become better health-care consumers. Since 1997 the SMP program (2007, http://www.smpresource.org/eSeries/AM/Template.cfm?Section=Volunteers_Make_a_Difference) has established an "army" of more than 41,000 trained volunteers and recouped more than $22 million in 2006 alone.

The "Who Pays? You Pay" campaign is an example of a successful outreach effort to combat Medicare fraud. It is a partnership between the AARP, the U.S. Department of Health and Human Services, and the U.S. Department of Justice. It establishes a line of defense against a problem that costs the Medicare program billions of dollars each year.

The campaign asks beneficiaries to regularly review their Medicare statements and ask questions such as: "Did I receive the services or products for which Medicare is being billed? Did my doctor order the service or product for me? And, to the best of my judgment, is the service or product necessary given my health condition?" If the answer to any of these questions is no, the partners emphasize working first with the health-care provider or Medicare insurance company. If there is still doubt, beneficiaries are advised to call a hotline (1-800-HHS-TIPS). Medicare beneficiaries receive cash rewards for successfully identifying fraud and abuse.

ABUSE AND MISTREATMENT
OF OLDER ADULTS

Domestic violence against older adults is a phenomenon that first gained publicity during the late 1970s, when the congressman Claude Pepper (1900–1989) held widely publicized hearings about the mistreatment of older adults. In the three decades since those hearings, policy makers, health professionals, social service personnel, and advocates for older Americans have sought ways to protect the older population from physical, psychological, and financial abuse.

Magnitude of the Problem

It is difficult to determine exactly how many older adults are the victims of abuse or mistreatment. As with child abuse and domestic violence among younger adults, the number of actual cases is larger than the number of reported cases. There is consensus among professionals and agencies that deal with issues of elder abuse that it is far less likely to be reported than child or spousal abuse. The challenge of estimating the incidence and prevalence of this problem is further compounded by the varying definitions of abuse and reporting practices used by the voluntary, state, and federal agencies, as well as the fact that comprehensive national data are not collected. Furthermore, research suggests that abuse often occurs over long periods of time and that only when it reaches a critical juncture, such as instances of severe injury, will the neglect or abuse become evident to health, social service, or legal professionals.

Even though the magnitude of the problem of abuse and mistreatment of older adults is unknown, its social and moral importance is obvious. Abuse and neglect of older individuals in society violates a sacred trust and moral commitment to protect vulnerable individuals and groups from harm and to ensure their well-being and security.

The National Center on Elder Abuse (NCEA), in the 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years of Age and Older (February 2006, http://www.elderabusecenter.org/pdf/2-14-06%20FINAL%2060+REPORT.pdf), a follow-up to a 2000 report prepared by the National Committee for the Prevention of Elder Abuse and the National Adult Protective Services Association, finds a 19.7% increase in the number of reports of elder and vulnerable adult abuse. With just thirty-two states reporting, Adult Protective Services received over 253,000 reports on people aged sixty and older.

In the fact sheet "Elder Abuse Prevalence and Incidence" (March 2005, http://elderabusecenter.org/pdf/publication/FinalStatistics050331.pdf), the NCEA observes that in 2005 between one and two million Americans aged sixty-five and older had been injured, exploited, neglected, or otherwise mistreated by someone they depended on for care. According to the article "Chair of Senate Aging Committee Backs New Bill to Stop Elder Abuse" (SeniorJournal.com, March 30, 2007), the U.S. Senate Special Committee on Aging estimates that there may be as many as five million victims every year.

Types of Mistreatment

Federal definitions of elder abuse, neglect, and exploitation appeared for the first time in the Older Americans Act Amendments of 1987. Broadly defined, there are three basic categories of abuse: domestic elder abuse, institutional elder abuse, and self-neglect or self-abuse.

Most documented instances of elder abuse refer to a form of maltreatment of an older person by someone who has a special relationship with the older adult, such as a spouse, sibling, child, friend, or caregiver. Until recently, most data indicated that adult children were the most common abusers of older family members, but Pamela B. Teaster of the University of Kentucky, in A Response to the Abuse of Vulnerable Adults: The 2000 Survey of State Adult Protective Services (March 7, 2003, http://www.elderabusecenter.org/pdf/research/apsreport030703.pdf), summarizes the 2000 NCEA survey and finds that spouses are the most common perpetrators of abuse and mistreatment. The major types of elder abuse and mistreatment include:

• Physical abuse—inflicting physical pain or bodily injury
• Sexual abuse—nonconsensual sexual contact of any kind with an older person
• Emotional or psychological abuse—inflicting mental anguish by, for example, name calling, humiliation, threats, or isolation
• Neglect—willful or unintentional failure to provide basic necessities, such as food and medical care, as a result of caregiver indifference, inability, or ignorance
• Material or financial abuse—exploiting or misusing an older person's funds or assets
• Abandonment—the desertion of an older adult by an individual who has physical custody of the elder or who has assumed responsibility for providing care for the older person
• Self-neglect—behaviors of an older person that threaten his or her own health or safety

Theft by Family and Friends

The criminal justice system documents the fact that money and property are stolen from older adults at an alarming rate. John Wasik writes in "The Fleecing of America's Elderly" (Consumers Digest, March–April 2000) that just one out of twenty-five cases of financial abuse of older adults is reported, which suggests that there may be five million financial abuse victims each year. Because financial abuse is difficult to define, the identification, investigation, and prosecution of perpetrators is made even more difficult. One challenge that even stymies law enforcement agents is to distinguish an unwise but legitimate financial transaction from an exploitative one resulting from undue influence, duress, or fraud. The crimes are even more complicated to resolve because a large portion are committed not by professional criminals but by relatives, friends, home health aides, household workers, and neighbors. In-home care for older adults frequently offers hired caregivers ready access to the financial and property assets of the older adults in their care.

Financial abuse also differs from physical and emotional mistreatment in that it is more likely to occur with the unspoken permission of the older adult and, as a result, may be more difficult to detect and confirm. In some instances the older adult may feel that the perpetrator is entitled to the older person's assets. Older adults may want to compensate their relatives and caregivers. These complex family and caregiver dynamics may make it difficult to distinguish between a transfer of assets made with consent from one performed in response to coercion. Like other forms of mistreatment, financial abuse in a family is generally not a single identifiable event. Instead, it reflects actions that may have started out as legitimate efforts to help but over time became abusive. As a result, determining when financial abuse began can be difficult.

Who Are the Abuse Victims?

According to the NCEA, most of the reported cases of mistreatment are older women; this may simply be the result of the disproportionate number of older female adults, or it may mean that older women are at greater risk for mistreatment than are older men.

The2004 Survey of State Adult Protective Services finds that 65.7% of elder abuse victims were female, 77.1% were white, 42.8% were aged eighty or older, and 89.3% of instances of elder abuse occurred in domestic settings.

Reporting Abuse

Like child abuse and sexual assault crimes, many crimes against older adults are not reported because the victims are physically or mentally unable to summon help or because they are reluctant or afraid to publicly accuse relatives or caregivers. Loneliness or dependency prevents many victims from reporting the crimes, even when they are aware of them, simply because they are afraid to lose the companionship and care of the perpetrator. When financial abuse is reported, the source of the information is likely to be someone other than the victim: a police officer, an ambulance attendant, a bank teller, a neighbor, or other family member.

Since 1983 most states have required physicians and other social service professionals to report evidence of abuse, neglect, and exploitation. Teaster finds that reporting requirements vary widely. Thirty-four states stipulated time frames for reports ranging from immediately (twenty-three states) to more than four days in one state. The most common penalty for failing to report abuse was a misdemeanor with possible fines ranging from $100 to $10,000 and/or jail sentences. Nine states had prosecuted individuals for failing to report abuse.

Causes of Elder Abuse

According to the NCEA, no single theory can explain why older people are abused. The causes of abuse are diverse and complicated. Some relate to the personality of the abuser, some reflect the relationship between the abuser and the abused, and some are reactions to stressful situations. Even though some children truly dislike their parents and the role of caregiver, many others want to care for their parents or feel it is the right thing to do but may be emotionally or financially unable to meet the challenges of caregiving.

STRESS.

Meeting the daily needs of a frail and dependent older adult is demanding and may be overwhelming for some family members who serve as caregivers. When the older person lives in the same household as the caregiver, crowding, differences of opinion, and constant demands often add to the strain of providing physical care. When the older person lives in a different house, the pressure of commuting and managing two households may be unduly stressful.

Stress may be a reality in the life of caregivers, but research does not support its role as a contributing factor in abuse of older adults. The findings of thirteen research studies published between 1988 and 2000 were reviewed by Bonnie Brandl and Loree Cook-Daniels in "Domestic Abuse in Later Life, Causation Theories" (August 2002, http://www.elderabusecenter.org/pdf/research/risks.pdf). Brandl and Cook-Daniels strive to explain why perpetrators abuse older adults and serve to dispel the popular belief that the stress of care-giving prompts abuse. Just two studies suggested a possible link between the stress of caregiving and abuse.

FINANCIAL BURDEN.

Caring for an older adult often places a financial strain on a family. Older parents may need financial assistance at the same time that their children are raising their own family. Instead of an occasional night out, a long-awaited vacation, or a badly needed newer car, families may find themselves paying for ever-increasing medical care, prescription drugs, special dietary supplements, extra food and clothing, or therapy. Saving for their children's college education, for a daughter's wedding, or for retirement may be difficult or impossible. Even though it seems intuitively correct that resentment might provoke emotional or physical abuse of older adults by their caregivers, there are no data to support the hypothesis that financial strain is a major contributor to mistreatment of older adults.

CYCLE OF ABUSE.

One theory of the causation of abuse of older adults posits that people who abuse an older parent or relative were themselves abused as children. Suzanne K. Steinmetz, the director of Resources for Older Americans at the University of Delaware and a recognized expert on domestic violence, finds support for this hypothesis in her study of abusers,Duty Bound: Elder Abuse and Family Care (1988). She finds only one out of four hundred children who were treated nonviolently when they were raised attacked their older parents; by contrast, one out of two children who were violently mistreated as children abused their older parents.

INVASION OF PRIVACY.

Richard J. Bonnie and Robert B. Wallace indicate in Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (2002) that research suggests that a shared living arrangement is a major risk factor for mistreatment of older adults, with older people living alone at the lowest risk for abuse. A shared residence increases the opportunities for contact, conflict, and mistreatment. When the home must be shared, there is an inevitable loss of a certain amount of control and privacy. Movement may be restricted, habits may need to change, and rivalries between generations may follow. Frustration and anxiety may result as both older parent and supporting child try to suppress anger, with varying degrees of success.

SOCIAL ISOLATION.

Bonnie and Wallace note that social isolation is linked to abuse and the mistreatment of older adults. Several studies find that low levels of social support are associated with verbal and physical abuse by caregivers. To a certain extent, socially isolated families are better able to hide unacceptable behaviors from friends, kin, and neighbors who might report the abusers. Even though there are no data that support the corollary to this finding, it is hypothesized that mistreatment is less likely in families rooted in strong social networks.

ALZHEIMER'S DISEASE OR OTHER DEMENTIA.

According to Bonnie and Wallace, the diagnosis of Alzheimer's disease or other dementia is a risk factor for the physical abuse of older adults. Several studies estimate prevalence rates of mistreatment in samples of dementia patient caregivers and compare them to rates in general population surveys. Because the prevalence findings of rates of physical abuse fall in the 1% to 3% range in the general population, and between 5% and 12% among dementia patient caregivers, it would appear that people suffering from dementia are at a greater risk for mistreatment. Research has not pinpointed the relationship between dementia and the risk for abuse; however, it may be that dementia itself is not the risk factor but the disruptive behaviors that result from dementia. This hypothesis is consistent with research that shows that the disruptive behavior of Alzheimer's disease patients is an especially strong predictor and cause of caregiver stress.

REVERSE DEPENDENCY.

Some sources believe that abusers may be quite dependent, emotionally and financially, on their victims. Research reveals that abused older adults are no more likely to have had a recent decline in health or be seriously ill or previously hospitalized than nonabused older adults. In fact, as a group, the abused older people are more self-sufficient in preparing meals, doing ordinary housework, and climbing stairs than are the nonabused older adults.

By contrast, Bonnie and Wallace note that abusing caregivers often seem more dependent on their victims for housing, financial assistance, and transportation than are nonabusing caregivers. They appear to have fewer resources and are frequently unable to meet their own basic needs. Rather than having power in the relationship, they are relatively powerless. From these observations, some researchers speculate that abusing caregivers may not always be driven to violence by the physical and emotional burden of caring for a seriously disabled older person but may have mental health problems of their own that can lead to violent behavior. Several studies specifically point to depression as a characteristic of perpetrators of elder mistreatment.

The Abusive Spouse

The high rate of spousal abuse among the older population is possibly because many older adults live with their spouses, so the opportunity for spousal violence is great. Violence against an older spouse may be the continuation of an abusive relationship that began years earlier—abuse does not end simply because a couple ages. Sometimes, however, the abuse may not begin until later years, in which case it is often associated with mental illness, alcohol abuse, unemployment, postretirement depression, and/or loss of self-esteem.

Intervention and Prevention

All fifty states and the District of Columbia have laws addressing abuse of older adults, but like laws aiming to prevent and reduce child abuse and domestic violence among younger people, they are often ineffective. The effectiveness of laws and the enforcing agencies vary from state to state and even from county to county within a given state. No standard definition of abuse exists among enforcement agencies. In many cases authorities cannot legally intervene and terminate an abusive condition unless a report is filed, the abuse is verified, and the victim files a formal complaint. An older adult could understandably be reluctant, physically unable, or too fearful to accuse or prosecute an abuser.

In a telephone conversation with the author on August 10, 2007, Laurie Spiegel of the American Bar Association indicated that as of mid-2007 forty-five states and the District of Columbia operated mandatory reporting systems, which require selected professionals to report suspected abuse. In eight states reporting is voluntary. In eight of the mandatory reporting states—Delaware, Indiana, Kentucky, New Mexico, North Carolina, Rhode Island, Texas, and Wyoming—any person who suspects mistreatment is required to report it. Even though it is thought to reduce instances of abuse, mandatory reporting has never been evaluated to determine whether it is an effective measure for preventing or reducing mistreatment of older people.

Clearly, the best way to stop elder abuse is to prevent its occurrence. Older people who know that they will eventually need outside help should carefully analyze the potential challenges of living with their families and, if necessary and possible, make alternate arrangements. All older adults should take action to protect their money and assets to ensure that their valuables cannot be easily taken from them.

Families or individuals who must serve as caregivers for older adults, voluntarily or otherwise, must be helped to realize that their frustration and despair do not have to result in abuse. Health and social service agencies offer myriad interventions including group support programs and counseling to help caregivers and their families. Many communities allocate resources to assist families to offset the financial burden of elder care, for example, through tax deductions or subsidies for respite care.

INSTITUTIONAL ABUSE—A FORGOTTEN
POPULATION?

Abuse of the older population can and does occur in the institutions—nursing homes, board-and-care facilities, and retirement homes—charged with, and compensated for, caring for the nation's older population. The term institutional abuse generally refers to the same forms of abuse as domestic abuse crimes but is perpetrated by people who have legal or contractual obligations to provide older adults with care and protection. Even though the Omnibus Budget Reconciliation Act of 1987 states that nursing homes must take steps to attain or maintain the "highest practicable physical, mental, and psychosocial well-being of each resident," too many residents are the victims of neglect or abuse by these facilities or their employees.

Older adult residents of long-term care facilities or supportive housing are thought to be at higher risk for abuse and neglect than community-dwelling older adults. They are particularly vulnerable because most suffer from one or more chronic diseases that impair their physical and cognitive functioning, rendering them dependent on others. Furthermore, many are either unable to report abuse or neglect, or they are fearful that reporting may generate reprisals from the facility staff or otherwise adversely affect their life. Others are unaware of the availability of help.

Even though there are federal laws and regulations that govern nursing homes, there are no federal standards that oversee or regulate residential care facilities, such as personal care homes, adult congregate living facilities, residential care homes, homes for the aged, domiciliary care homes, board-and-care homes, and assisted living facilities. As a result, it is much more difficult than with nursing homes to estimate the prevalence or nature of abuse or neglect in these facilities. Despite reports in recent years that have raised the specter of widespread and serious abuse of institutionalized older people, as of 2007 there had never been a systematic study of the prevalence of abuse in nursing homes or other residential facilities.

Types of Abuse and Neglect

Nursing home neglect and abuse can take many forms, including:

• Failure to provide proper diet and hydration
• Failure to assist with personal hygiene
• Over- or undermedication
• Failure to answer call lights promptly
• Failure to turn residents in their beds to promote circulation and prevent decubitus ulcers (bedsores)
• Slapping or other physical abuse
• Leaving residents in soiled garments or beds or failure to take them to the toilet
• Use of unwarranted restraints
• Emotional or verbal abuse
• Retaliation for making a complaint
• Failure to provide appropriate medical care
• Sexual assault, unwanted touching, indecent exposure, or rape
• Theft of the resident's property or money

Surveys conducted with certified nursing assistants (CNAs) who work in long-term care facilities are summarized in "Preventing Abuse and Neglect in Nursing Homes: The Role of Staffing and Training" (November 23, 2003, http://sp.srph.tamhsc.edu/centers/moved_SRHRC/PPT/nh2_gsa03.ppt) by Catherine Hawes, the director of the Southwest Rural Health Research Center at Texas A&M University. Hawes reveals that more than one-third of CNAs have witnessed abuses including incidents of physical and verbal or psychological abuse, such as:

• Aggressiveness with a resident and rough handling
• Pulling too hard on a resident
• Yelling in anger
• Threatening behavior
• Punching, slapping, kicking, or hitting
• Speaking in a harsh tone, cursing at a resident, or saying harsh or mean things to a resident

The CNAs also offered examples of neglect, which is often more difficult to detect and measure, including:

• Neglecting oral/dental care
• Failing to perform prescribed range of motion exercises
• Failing to change residents after an episode of incontinence
• Ignoring residents who are bedfast, particularly not offering activities to them
• Not performing prescribed wound care
• Failing to bathe residents regularly
• Performing a one-person transfer (move from bed to chair or wheelchair) when the resident required a two-person transfer
• Not providing cuing or task segmentation to residents who need that kind of assistance to maximize their independence
• Failing to perform scheduled toileting or helping residents when they ask
• Not keeping residents hydrated
• Turning off a call light and taking no action on the resident's request

Resident Risk Factors

Even though there has been scant research describing the factors that contribute to risk for abuse of institutionalized older adults, some studies indicate that the risk for abuse increases in direct relationship to the older resident's dependence on the facility's staff for safety, protection, and care. One study suggests that a patient with a diagnosis of Alzheimer's disease, another dementia, or some type of memory loss or confusion was also higher among nursing home residents who had been abused than in the average nursing home population. Another study suggests that residents with behavioral symptoms, such as physical aggressiveness, appeared to be at higher risk for abuse by staff; this finding was supported by interviews with CNAs. These studies are summarized by Catherine Hawes, Denise Blevins, and Leticia Shanley in "Preventing Abuse and Neglect in Nursing Homes: The Role of the Nurse Aide Registries" (Report to the Centers for Medicare and Medicaid Services, 2001).

Social isolation may also increase the risk for abuse. Residents who have no visitors are especially vulnerable, because they lack family or friends who could oversee their care, bear witness to and report any abuses, and advocate on their behalf.

Efforts to Identify and Reduce Abuse

In an effort to improve the quality of care and eliminate abuse in nursing homes, government regulations and laws have been enacted that require greater supervision and scrutiny of nursing homes. In 1987 President Ronald Reagan (1911–2004) signed the Omnibus Budget Reconciliation Act, which included protections for patient rights and treatment. The law went into effect October 1990, but compliance with the law varies from state to state and from one nursing facility to another.

Many states have adopted additional legislation to help stem instances of institutional abuse and neglect. For example, in 1998 the state of New York enacted Kathy's Law, which created the new felony-level crime of "abuse of a vulnerable elderly person." At the state level there are many agencies involved in identifying and investigating cases of abuse and neglect. These agencies differ across states but may include ombudsmen (offices that assist patients who have complaints), adult protective services, the state survey agency responsible for licensing nursing homes, the state agency responsible for the operation of the nurse aide registry, Medicaid fraud units in the attorney general's office, and professional licensing boards.

The U.S. Government Accountability Office, in Nursing Homes: Despite Increased Oversight, ChallengesRemain in Ensuring High-Quality Care and Resident Safety (December 2005, http://www.gao.gov/new.items/d06117.pdf), a report that assesses the progress the Centers for Medicare and Medicaid Services has made since 1998, notes that despite intensified efforts to improve quality:

• A small but still unacceptable proportion of nursing homes actually caused harm to residents, or through neglect or mistreatment placed them at risk for serious injury or death. Table 11.5 shows the percentage of nursing homes cited for harming or jeopardizing residents and changes in these percentages from 1999 through 2005.
• Complaints from residents, family members, or staff about possible mistreatment or harm may not be investigated for weeks or months and delays in reporting alleged abuse hampers investigations and prolongs the potential risk of harm to residents.
• In general, federal oversight mechanisms to monitor safety and quality were limited in their scope and effectiveness.

ADEQUATE STAFFING AND TRAINING CAN AMELIORATE ABUSE.

Testifying before the U.S. Senate Committee on Finance, Catherine Hawes (July 17, 2003, http://finance.senate.gov/hearings/testimony/2003test/071703chtest.pdf) asserted that quality improved immediately after the implementation of the nursing home reform provisions of the Omnibus Budget Reconciliation Act, but that there is evidence that quality has deteriorated in recent years. Hawes attributed this decline in part to inadequate regulatory processes but states the major cause of poor nursing home quality is inadequate staffing, compounded by insufficient staff training.

To illustrate her concerns about training, Hawes compared the Texas requirements of manicurists, who must complete six hundred hours of approved training and pass an examination, with the relatively lax requirement—just seventy-five hours of training—for CNAs who provide daily hands-on care in settings where residents suffer from multiple and/or chronic diseases, may be incontinent, have some form of significant cognitive impairment, and need help with more than four basic activities of daily living, including bathing, dressing, locomotion, and using the toilet. Based on research she and her colleagues conducted, Hawes contended that 85% of abuse and neglect resulted from inadequate staffing—too few staff, bad staff-to-resident ratios, difficulty hiring qualified staff, poor training, poor supervision and management, staff turnover, and low wages.

Hawes acknowledged that the total cost of increasing staffing levels, providing adequate training, and paying CNAs a living wage would be high, but she observed that without these actions and the funding to support them, conditions will not improve. She concluded her testimony with a plea for expanding funding, explaining that the nation's "1.6 million nursing home residents don't have that much time to wait."

LONG-TERM CARE OMBUDSMAN PROGRAM.

Long-term care ombudsmen are advocates for residents of nursing homes, board-and-care homes, assisted living facilities, and other adult care facilities. The Long-Term Care Ombudsman Program was established under the Older Americans Act, which is administered by the AoA. The Long-Term Care Ombudsman Resource Center (2001, http://www.ltcombudsman.org/ombpublic/49_151_855.CFM) reports that ninety-four hundred paid and volunteer ombudsmen advocate on behalf of individuals and groups of residents, provide information to residents and their families about the long-term care system, investigate more than 264,000 complaints each year, and work to effect systems changes at the local, state, and national levels. They serve as an ongoing presence in long-term care facilities by monitoring care and conditions.

According to the AoA, in 2005 state long-term care ombudsman programs investigated 241,684 complaints. Table 11.6 shows the increasing number of nursing facility complaints from the late 1990s through 2005 and lists the top complaint categories. Table 11.7 lists the complaint categories and the number of board-and-care facility complaints investigated by ombudsman programs for the same time period.

ADULT PROTECTIVE SERVICES LEGISLATION.

According to the Analysis of 2006 State Legislation Amending Adult Protective Services Laws (2007, http://www.elderabusecenter.org/), an analysis of adult protective services legislation performed for the NCEA by the American Bar Association Commission on Law and Aging, ten states—Arizona, Florida, Iowa, Illinois, Massachusetts, South Carolina, Utah, Washington, Wisconsin, and West Virginia—amended their adult protective services laws in 2006. The recently enacted legislation acted to:

• Amend definitions of elder abuse
• Enhance the ability of adult protective services laws to access victims
• Strengthen collaboration between agencies
• Create civil liability for perpetrators
• Add or change provisions related to disclosure of records
• Add or change provisions related to elder abuse fatality teams
• Strengthen government oversight
• Create a registry of perpetrators
• Clarify and standardize definitions of elder abuse
• Enhance outreach to victims and increase public awareness about the problem.