Abolfathi Et Al., (2013)
Abolfathi Et Al., (2013)
REVIEW ARTICLE
1
Institute of Gerontology and 2Department of Abstract
Human Development and Family Studies, Faculty
of Human Ecology, Universiti Putra Malaysia, Elder abuse is a pervasive phenomenon around the world with devastating
Serdang, Malaysia effects on the victims. Although it is not a new phenomenon, interest in
Correspondence: Dr Yadollah Abolfathi Momtaz PhD, examining elder abuse is relatively new. This paper aims to provide an
Institute of Gerontology, Universiti Putra Malaysia, overview of the aetiological theories and measures of elder abuse. The paper
43400 UPM, Serdang, Selangor, Malaysia. Email: briefly reviews theories to explain causes of elder abuse and then discusses
[email protected]
the most commonly used measures of elder abuse. Based on the reviewed
Received 12 September 2012; revision received 5 March
theories, it can be concluded that elder abuse is a multifactorial problem that
2013; accepted 12 March 2013.
may affect elderly people from different backgrounds and involve a wide
variety of potential perpetrators, including caregivers, adult children, and
partners. The review of existing measurement instruments notes that many
different screening and assessment instruments have been developed to
identify elders who are at risk for or are victims of abuse. However, there is
Key words: aged, elder abuse, measurement, a real need for more measurements of elder abuse, as the current instru-
theory. ments are limited in scope.
that leads to abusive behavior.8 For example, if the Psychopathology of the caregiver theory
caregiver perceives himself or herself as deserving of This theory examines the role of the caregiver with a
rewards for supporting that elderly person, abuse may mental health problem and how that puts elders at risk
occur if such rewards are denied. It has also been for mistreatment.19 According to this theory, the
postulated that elder abuse is the result of a care- abuser’s behavioural characteristics contribute to
giver’s increasing financial dependency on the elderly elder abuse. Caregivers who consumed alcohol and
person. Owing to a sense of imbalance in the relation- experienced depression and anxiety are more likely to
ship and the violation of social expectations concern- use physical and verbal abuse against the elder.13
ing independent adult behaviours, the perpetrator
tries to restore some sense of control with violence or
Role accumulation theory
threats of violence.9,10
This theory argues that elderly people may be abused
by family members including their spouse, adult chil-
Feminist theory d(ren), or son- or daughter-in-law. According to the
Feminist theory focuses on spousal elder abuse as a role accumulation theory, family members with con-
significant dimension of elder abuse, wherein older flicting role obligations are not able to manage the
women are more vulnerable to spousal abuse stress of their own lives. These stressed family
because older women tend to have less power than members may abuse an older adult as a way to cope
men. According to this theory, men have more social with their stress.14
and financial resources and regard women as their
property.11
Situational theory
Situational theory is one of the earliest and most widely
Political economic theory accepted explanations of elder abuse. This theory
This theory addresses that elderly people are gradu- focuses on the role of stress and the burden of caregiv-
ally marginalized in their families and society. There- ing in elder abuse. According to this theory, an over-
fore, they lose their role and depend on others. burdened caregiver who cannot cope with caring
According to political economic perspective, the demands creates an environment for abuse. Overall,
changing role of the elderly removes them from the this theory supports the idea that stressed caregivers
workforce and reduces their independence, which may become abusive towards their vulnerable
may lead to elder abuse.12 seniors.15
185
Theories and measures of elder abuse
Y. Abolfathi Momtaz et al.
Caregiver Abuse Screen (CASE) subjective complaints of elder abuse, neglect, aban-
The CASE is an eight-question screening tool with a donment and exploitation. It can be used in all clinical
dichotomous (yes/no) scoring method that is com- settings and is administered by trained nurses and
pleted by caregivers. Answering ‘yes’ to any question clinicians. The results of psychometric studies of the
counts as one point. The points are summed to create EAI show a content validity index of 0.83, interrater
a total score with a possible score range 0–8. A score agreement of 0.83, a specificity of 93%, and a sensi-
of 4 or more indicates ‘abuse likely’. However, depend- tivity of 71%. The internal consistency reliability using
ing on the question, a score of 1 can also be considered Cronbach’s a has been reported to be 0.84. Although
‘abuse likely’. The scale has demonstrated acceptable the instrument has good reliability and validity, there is
to good internal consistency (Cronbach’s a = 0.77).24 no established method of scoring.28 The EAI is com-
According to the CASE, the caregivers are asked to pleted by a nurse using a one-to-one interview and
answer screening questions for physical, psychologi- physical assessment of the older person for possible
cal, and financial abuse or neglect.25 mistreatment and can be used in all clinical settings.29
questions 1, 6, 12, and 14; a response of ‘someone view. The OAFEM has demonstrated high internal
else’ to question 4; and a response of ‘yes’ to the rest consistency reliability (Cronbach’s a = 0.93).32
of the questions are scored in the ‘abused’ direction.
Although the HSEAST has demonstrated good test– Vulnerability to Abuse Screening Scale (VASS)
retest reliability with a = 0.86 and an acceptable inter- The VASS is a 12-item screening instrument with yes-
nal consistency (Cronbach’s a = 0.63), it is limited or-no that is used to identify elderly people at risk of
because of its high false negative rate. 28 abuse. The instrument is completed by respondents
and assesses four factors: vulnerability, dejection,
dependence, and coercion. Cronbach’s a is reported
Indicators of abuse
from 0.74 for dependence to 0.31 for coercion, repre-
This is a 22-item home-based instrument for measur- senting moderate to good reliability. Although the
ing abuse. This test is administered by an experienced VASS has been validated with older women and is
and trained interviewer after a 2–3-h home assess- considered to be a gender-neutral instrument, it is not
ment. A score of 16 and over suggests that the elderly known whether the VASS is also valid for determining
subject is at significant risk for experiencing abuse. abuse in older men.33
Internal consistency using Cronbach’s a was 0.92,
demonstrating a high level of reliability for the indica-
Questions to Elicit Elder Abuse
tors of abuse.31
Questions to Elicit Elder Abuse evaluate the existence
of 15 indicators of abuse based on a respondent’s
Older Adult Psychological Abuse questionnaire. This instrument has 15 closed-ended
Measure (OAPAM) questions that assess the existence of physical
The OAPAM has been developed as a comprehensive abuse, emotional abuse, neglect, and exploitation.
measure of elder abuse. The OAPAM consists of For each participant, a total and type of abuse score
either 31 items (long form) or 18 items (short form). It is generated by the sum of each ‘yes’ answer. Internal
is a measure of psychological abuse that is completed consistency measured by Cronbachs’ a was reported
by respondents. The unidimensional measure has at 0.83 for the 15 items.34
sound reliability and validity in the assessment of psy-
chological abuse of elderly people by both clinicians CONCLUSIONS
and researchers. The Rasch person reliability has This review aimed to assess theories and measure-
been reported to be high for both the OAPAM long ments of elder abuse. Several theories that might
form (= 0.78, corresponding with Cronbach’s a = 0.87) explain possible causes for elder abuse were identified
and short form (= 0.86, corresponding with Cron- and discussed. Based on the reviewed theories,
bach’s a = 0.92).32 several factors including caregiver stress (situational
theory; stratification theory), dependency (social
exchange theory), negative attitude (political econo-
Older Adult Financial Exploitation mic theory), environmental stress (role accumulation
Measure (OAFEM) theory), learnt abusive behaviour (social learning
The OAFEM is a 25-item screening tool that identifies theory), caregiver pathology (psychopathology of the
potential financial abuse of older people. This instru- caregiver theory), and spousal domestic abuse (femi-
ment is the only validated financial abuse scale that nist theory) cause elder abuse. Additionally, according
assesses several forms of financial abuse, including to symbolic interactionism theory, cultural values and
theft and scams, financial victimization, coercion, expectations influence what behaviour is considered
financial entitlement, signs of possible financial abusive. Hence, it can be concluded that elder abuse is
exploitation, and money mismanagement. The a multifactorial, complex problem that affects elderly
completion of OAFEM requires adequate cognitive people with different backgrounds at the hands of
capacity (i.e. a score of 17 or above on the Mini- a wide variety of potential perpetrators including
Mental Status Exam) is required. This self-report caregivers, adult children, and partners. Because our
instrument is completed by older adults in an inter- review reveals that no single theory can comprehen-
sively explain all causes of elder abuse, developing an 12 Strasser SM, Kerr J, King PS et al. A survey of Georgia adult
protective service staff: implications for older adult injury pre-
integrated theory with a comprehensive perspective is
vention and policy. West J Emerg Med 2011; 12: 357–364.
recommended. 13 Homer AC, Gilleard C. Abuse of elderly people by their carers.
With regard to the second aim of the study, a Br Med J 1990; 301: 1359–1362.
review of existing instruments showed that many dif- 14 Sieber SD. Toward a theory of role accumulation. Am Sociol Rev
1974; 39: 567–578.
ferent screening and assessment tools have been 15 McClennen J, McClennen JC. Social Work and Family Violence:
developed to identify elders who are at risk for or are Theories, Assessment, and Intervention. New York: Springer,
victims of abuse. Elder abuse instruments can be 2010.
16 Snyder DR, Christmas C. Geriatric Education for Emergency
divided into two basic types depending on whether Medical Services. Burlington, MA: Jones & Bartlett Learning,
the abuse has already happened (to determine actual 2003.
victims of abuse), such as AMA-SVTAN, or whether 17 Juma L, Juma B. Elder abuse. Interdiscip Soc Work J 2006; 1:
12–18.
the abuse may happen in the future (to identify elderly
18 Ritzer G. Sociological Theory, 8th edn. Boston, MA: McGraw,
people at risk of elder abuse) including HSEAST, 2010.
VASS, and CASE. Therefore, in elder abuse studies it 19 Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress
is important to be aware of the instrument’s purpose in elder abuse screening and assessment instruments. J Am
Geriatr Soc 2004; 52: 297–304.
and reliability and validity for the population studied. 20 LaRossa R, Reitzes DC. Symbolic interactionism and family
These instruments may not be appropriate cross- studies. In: Boss PG, Doherty WJ, LaRossa R, Schumm WR,
culturally. As such, there is a real need to develop Steinmetz SK, eds. Sourcebook of Family Theories and
Methods: A Contextual Approach. New York: Plenum Press,
measures for elder abuse that might have core indi- 1993; 135–163.
cators that are universal and sub-indicators that may 21 Flanagan AY. Elder abuse: cultural contexts and implications.
be appropriate for certain situations. 2005. [Cited 12 Mar 2012.] Available from URL: http://
www.netcegroups.com/380/Course_8781.pdf
22 Krysik JL, Finn J. Research for Effective Social Work Practice.
REFERENCES New York: McGraw Hill, 2010.
1 Hamid TA, Momtaz YA, Ibrahim R. Predictors and prevalence of 23 Aravanis SC, Adelman RD, Breckman R et al. Diagnostic and
successful aging among older Malaysians. Gerontology 2012; treatment guidelines on elder abuse and neglect. Arch Fam Med
58: 366–370. 1993; 2: 371–388.
2 Momtaz YA, Hamid TA, Ibrahim R, Yahaya N, Abdullah SS. 24 Reis M, Nahmiash D. Validation of the Caregiver Abuse Screen
Moderating effect of Islamic religiosity on the relationship (CASE). Can J Aging 1995; 14 (Suppl 2): 45–60.
between chronic medical conditions and psychological well- 25 Reis M, Nahmiash D. When Seniors Are Abused: A Guide to
being among elderly Malays. Psychogeriatrics 2012; 12: 43–53. Intervention. North York, ON: Captus Press Inc, 1995.
3 Momtaz YA, Hamid TA, Yahaya N. The role of religiosity on 26 Bonnie RJ, Wallace RB. Elder Mistreatment: Abuse, Neglect,
relationship between chronic health problems and psychologi- and Exploitation in an Aging America. Washington, DC: The
cal well-being among Malay Muslim older persons. Res J Med National Academic Press, 2003.
Sci 2009; 3: 188–193. 27 Straus MA. Measuring intrafamily conflict and violence: the con-
4 Momtaz YA, Hamid TA, Ibrahim R. Unmet needs among dis- flict tactics (CT) scales. J Marriage Fam 1979; 41: 75–88.
abled elderly Malaysians. Soc Sci Med 2012; 75: 859–863. 28 Neale AV, Hwalek MA, Scott RO, Sengstock MC, Stahl C. Vali-
5 Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and dation of the Hwalek-Sengstock elder abuse screening test. J
validation of a tool to improve physician identification of elder Appl Gerontol 1991; 10: 406–418.
abuse: the Elder Abuse Suspicion Index (EASI). J Elder Abuse 29 Fulmer T. Screening for mistreatment of older adults. Am J Nurs
Negl 2008; 20: 276–300. 2008; 108: 52–59.
6 Gorbien MJ, Eisenstein AR. Elder abuse and neglect: an over- 30 Ferguson D, Beck C. H.A.L.F.—A tool to assess elder abuse
view. Clin Geriatr Med 2005; 21: 279–292. within the family. Geriatr Nurs 1983; 4: 301–304.
7 World Health Organization. Toronto Declaration on the Global 31 Reis M, Nahmiash D. Validation of the indicators of abuse (IOA)
Prevention of Elder Abuse. Geneva: WHO, 2002; 3. screen. Gerontologist 1998; 38: 471–480.
8 Gordon RM, Brill D. The abuse and neglect of the elderly. Int J 32 Conrad KJ, Iris M, Ridings JW, Langley K, Anetzberger GJ.
Law Psychiatry 2001; 24: 183–197. Self-report measure of psychological abuse of older adults.
9 Boudreau FA. Elder abuse. In: Hampton RL, Gullotta TP, Adams Gerontologist 2011; 51: 354–366.
GR, eds. Family Violence: Prevention and Treatment. Newbury 33 Schofield MJ, Mishra GD. Validity of self-report screening scale
Park, CA: Sage Publications, 1993; 142–158. for elder abuse: women’s health Australia study. Gerontologist
10 Ritter LA, Lampkin SM. Community Mental Health. Burlington, 2003; 43: 110–120.
MA: Jones & Bartlett, 2011; 386. 34 Carney MT, Kahan FS, Paris B. Elder abuse: is every bruise a
11 Whittaker T. Violence, gender and elder abuse: towards a femi- sign of abuse? Mt Sinai J Med 2003; 70: 69–74.
nist analysis and practice. J Gend Stud 1995; 4: 35–45.