Elder Abuse: Systematic Review and Implications for Practice

Xin Qi Dong, MD, MPH

J Am Geriatr Soc. 2015;63(6):1214-1238.

Health Policy Implications

Two important federal laws address elder abuse: the Older Americans Act (OAA) and the Elder Justice Act (EJA). The OAA authorizes funding for National Ombudsman Resource Center, National Center on Elder Abuse, Office of State Long Term Care Ombudsman, legal and justice services for victims, funding of demonstration projects, outreach activities, and State Legal Assistance Developer to enhance coordinated care. The EJA was passed in the 110th Congress to unify federal systems and respond to elder abuse. It required the Secretary of Health and Human Services to promulgate guidelines for human subject protections to assist researchers and establish elder abuse forensic centers across the United States. The EJA authorized funding and incentives for long-term care staffing; builds electronic medical records technology; collects and disseminates annual APS data; and sponsors and supports training, services, reporting, and the evaluation program for elder justice, although the majority of programs and activities under the EJA have not received funding, and the EJA is in danger of being dissolved. The authorization of appropriations for EJA provisions expired on September 30, 2014, and the likelihood of continuing Congressional resolution and reauthorization is uncertain.^[79] The EJA plays an important role in elder abuse research and prevention. The Government Accountability Office described the EJA as providing "a vehicle for setting national priorities and establishing a comprehensive multidisciplinary elder justice system in this country."^[9] Comprehensive, systematic, coordinated, multilevel advocacy and policy efforts are needed to address elder abuse in legislation at the national level.^[80]

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Abstract and Introduction
Methods
Discussion
Future Research Directions
Implications for Health Professionals
Implications for Social Service Providers
Health Policy Implications
Conclusion
References

Table 1. Prevalence Estimates of Elder Abuse According to Population, Survey Method, and Definition
Author, Year	Population	Age; Sex; Race and Ethnicity	Survey Method	Participation rate, %	Measure	No. item	Cutoff Points	Prevalence
North/South America
Dong, 2014³³	3,159 elderly Chinese in Chicago	≥60; 58.9% female	In person	91.9	H-S/EAST, VASS	10	≥1 items	15.0% since age 60
Dong, 2014³³	3,159 elderly Chinese in Chicago	≥60; 58.9% female	In person	91.9	CTS; caregiver neglect assessment; financial exploitation assessment	56	^a	13.9–25.8% since age 60
Deliema, 2012¹⁴	198 Hispanics in Los Angeles	≥66; 56% female	In person	65	University of Southern California Older Adult Conflict Scale	54	≥1 items	1-year, 40.4%; multiple, 21%
Dong, 2012⁵⁸	4,627 adults in Chicago	≥65; 64.4% female	In person	N/A	Chicago Elder Self-Neglect Scale	21	≥1 items	Black: men, 13.2%; women, 10.9% White: men, 2.4%; women, 2.6%
Lachs, 2011⁵⁴	4, 156 English- or Spanish-speaking community; cognitively intact older New Yorkers	60–101; 35.5% female; 19.0% black, 75.5% white, 6.0% Hispanic, 0.8% American Indian, 1.2% Asian	Telephone	N/A	CTS	31	^a	14.1% since age 60
Acierno, 2010³	5,777 cognitively intact U.S. community population	60–97, 60% female; 88% white, 7% black, 4% Hispanic, 2% American Indian, 1% Asian	Random-digit dialing and computer-assisted interview	69	Interpersonal Violence Measure and Acierno EM Measure	22	≥1 items	Any elder abuse (exclude financial): 10%
Wiglesworth, 2010²³	129 older adults with dementia and their caregivers	77.1 ± 8.0; 45.7% female;93.8 white, 8.5% Hispanic	In-person survey of caregivers	N/A	CTS, Elder Abuse Instrument, Self-Neglect Assessment Scale	NA	^a	1-year 47.3%; multiple, 14.6%.
Beach, 2010³⁷	903 U.S. community-dwelling older adults with landline, English-speaking, no severe cognitive impairment	≥60; 73.3% female; 23.3% black, 72.8% white, 3.9% other	Random-digit dialing, in-person, self-administered	37.7	Modified CTS	12	^a	6-month financial exploitation, 3.5%; 6-month psychological mistreatment, 8.2%
Laumann, 2008¹⁷	3,005 older adults in the National, Social Life, Health and Aging project	57–85; 51.2% female; 80.7% white, 10.0% black; 6.8% Hispanic; 2.5% other	In-person and mail survey	75.5	H-S/EAST, VASS	3	≥1 items	1-year: verbal, 9%; financial, 3.5%; physical, 0.2%
Buri, 2006⁸¹	498 older adults in the Iowa Medicaid Waiver Program	65–101; 70.9% female; 96% white, 3% black	Mail survey	49	Elder Abuse Screen	5	≥1 items	20.9%: 1 type, 15.8%; 2 types, 4.0%; 3 types, 1.0%
Europe
Lindert, 2013¹⁹	4,467 older adults from seven countries in Europe	60–84; 57.3% female	In-person and mail survey	45.2	Modified CTS	52	≥1 items	1-year, 12.7–30.8%
Naughton, 2011²⁴	2,021 community-dwelling older people in Ireland	≥65; 55% female	In person	83	CTS, UK and NY prevalence studies	NA	^a	1-year, 2.2%
Kissal, 2011⁸²	331 older adults in Izmir, Turkey	≥65; 56.8% female	In person	N/A	Investigator-determined	5	^a	6-month, 13.3%
Biggs, 2009⁸³	2,111 older adults in the community in United Kingdom	≥66	In person	65	Built on literature	34	^a	2.6% with neglect; 1.6% without neglect
Ajdukovic, 2009²⁵	303 older adults in Croatia	65–97; 76.6% female	In person	NA	Elder Abuse in the Family questionnaire	20	NA	1-year, 61.1%
Cooper, 2009⁸⁴	220 UK caregivers of people with dementia	58–99, 72% female	In person	69	Modified CTS	10	Score ≥2	3-month, 52%
Garre-Olmo, 2009⁸⁵	676 community-dwelling older adults in Girona, Spain	≥75; 58.2% female.	In person	82	AMA Screen	9	≥1 items	1-year, 29.3%; 2 types, 3.6%; 3 types, 0.1%
Perez Carceles, 2008⁸⁶	460 older adults in health center in Spain	≥65; 53.3% female	In person	N/A	Canadian Task Force, AMA Screen	19	≥1 items	44.6%
Comijs, 1998^31,32	1,797 older people living independently in Amsterdam, the Netherlands	69–89; 62.8% female	Interview	44.4	CTS, Measure of Wife Abuse, Violence Against Man Scale	NA	^a	1-year, 5.6%; ≥2 types, 0.4%
Asia/Austria
Wu, 2012²¹	2,039 Chinese older adults in rural China	≥60; 59.9% female	In person	90.8	H-S/EAST, VASS	NA	≥1 items	1-year, 36.2%; ≥2 types, 10.5%
Somjinda Chompunud, 2010⁸⁷	233 cognitively functioning older adults in Thailand	60–90; 73.4% female	In person	73.3	Interview guideline for screening for elder abuse	6	≥1 items	1-year, 14.6%; 1 time, 9.9%; ≥2 times, 4.7%
Lowenstein, 2009²⁷	1,045 community-living older adults from the first national survey in Israel	≥65; 62.5% female	In person	75	CTS2, short situational descriptions, Respondents' Reactions to Aggression	NA	^a	1-year, 35.0%
Oh, 2009²²	15,230 older adults in Seoul, Korea	≥65; 65.3% female	In person	N/A	Compiled through literature	25	≥2 times	1-month, 6.3%
Lee, 2008⁸⁸	1,000 primary caregivers of family members with disabilities in Seoul, Korea	65–102; 69.5% female	In person	N/A	N/A	6	^a	Not answered question, 10.5%; yelled, 10.9%; confined, 18%; hit, 9.7%; neglected, 13.6%
Dong, 2007⁴⁴	412 cognitively intact community-living persons from medical clinics in China	≥60, 34% female	Self-administered survey	82.4	H-S/EAST, VASS	13	≥1 items	35.2% since age 60; 1 type, 64%; 2 types, 16%; ≥3 types, 20%
Sasaki, 2007⁸⁹	412 pairs of disabled older adults and family caregivers in Japan	Mean 80.5, 60.1% female	Self-administrated survey	70.0	Checklist developed by literature	9	≥1 items	6-month, 34.9%
Chokkanathan, 2006²⁶	400 community-living cognitively intact older adults in India	≥65; 49.5% female	In person	80	CTS	18	^a	1-year, 14%
Yan, 2001³¹	355 community-living older adults in Hong Kong, China	≥60; 62% female	Self-administered	N/A	Revised CTS	25	≥1 items	1-year, 21.4%; multiple types, 17.1%
Africa
Cadmus, 2012²⁰	404 elderly women in Oyo state, southwestern Nigeria	≥60; 100% female; 100% Yoruba	Semistructured questionnaires	N/A	Standardized questionnaire developed by World Health Organization	18	Score ≥1	1-year, 30%
Rahman, 2012²⁸	1,106 older adults living at home in rural area of Mansoura city, Dakahilia Governate, Egypt	≥60; 53.2% female	In-person interview	95.3	Questionnaire to elicit abuse	15	≥1 items	1-year, 43.7%; 1 type, 35.4%; 2 types, 3.8%; 3 types, 3.8%; 4 types, 0.6%

For detailed table on the definitional criteria for specific subtypes of elder abuse and its prevalence, see online Table S1.
^aCutoff varies according to subtype of abuse and more detailed information regarding the cut-off point of each type of abuse please see the appendix.
H-S/EAST = Hwalek-Sengstok Elder Abuse Screening Test; VASS = Vulnerability to Abuse Screening Scale; CTS = Conflict Tactics Scale; AMA = American Medical Association, N/A = not applicable.

Table 2. Risk Factors Associated with Elder Abuse (EA)
Author, Year	Type	Study Description	Age; Sex; Race	Independent Variables	Outcome	Confounding Factors	Key Findings of Risk for EA
Dong, 2012⁵⁸	PS	6,159 elderly adults from CHAP	≥65; 61% female	Physical function	EA	Sociodemographic, medical conditions, depressive symptoms, social network and social participation	Physical performance testing (OR = 1.13, 95% CI = 1.06–1.19), lowest tertile of physical performance testing (OR = 4.92, 95% CI = 1.39–17.46)
Dong, 2010³⁴	PS	5,519 elderly adults from CHAP	≥65; 61% female; 64% black	Cognitive function	SN	Sociodemographic, medical condition, physical function, depression, social networks	Executive function (OR = 1.01, 95% CI = 1.00–1.02)
Dong, 2010³⁴	PS	5,570 elderly adults from CHAP	≥65; 66.9% female	Physical function	SN	Sociodemographic, medical condition, depression, cognition, social networks	Decline in physical performance (OR = 1.06, 95% CI = 1.04–1.09), increase in Katz impairment (OR = 1.08, 95% CI = 1.03–1.13), Rosow-Breslau impairment (OR = 1.23, 95% CI = 1.14–1.32), Nagi impairment (OR = 1.07, 95% CI = 1.02–1.13)
Tierney, 2007⁴³	PS	130 community-living participants who scored <131 on DRS	≥65; 70.8% female	Executive function, judgment, attention and concentration, verbal fluency	SN	Age, sex, education, Charlson Comorbidity Index, MMSE	Rey Auditory Verbal Learning Test recognition (OR = 0.94, 95% CI = 0.89–0.98), Trail-Making Test Part B (OR = 1.01, 95% CI = 1.00–1.02), Wechsler Adult Intelligence Scale-Revised similarities (OR = 0.88, 95% CI = 0.81–0.98)
Tierney, 2004⁹⁰	PS	139 community-living adults who scored <131 on DRS	≥65; 70.8% female	MMSE, medical conditions, medications, OARS	SN	Age, sex, education, international classification of disease, Charlson index, OARS, MMSE	Higher MMSE score (OR = 0.87, 95% CI = 0.78–0.97), chronic obstructive pulmonary disorder (OR = 7.72, 95% CI = 2.44–24.43), higher OARS score (OR = 0.70, 95% CI = 0.66–0.89), stroke (OR = 3.09, 95% CI = 1.20–7.96)
Abrams, 2002³⁵	PS	2,812 elderly adults from New Haven EPESE cohort	≥65; 65.4% female	Depressive symptoms, cognitive impairment	SN	Age, sex, race, education, income, marital status, living situation, medical morbidity	Depressive symptoms (CES-D score ≥16) (OR = 2.38, 95% CI = 1.26–4.48), cognitive impairment (≥4 errors on the Pfeiffer Short Portable Mental Status Questionnaire, OR = 4.63, 95% CI = 2.32–9.23)
Lachs, 1997⁴²	PS	6,222 elderly adults in EPESE cohort	≥65; 64.8% female	ADL impairment, cognitive disability	EA	Age, sexual, race, and income	New ADL impairment (OR = 1.4, 95% CI = 0.4–4.6), new cognitive impairment (OR = 5.1, 95% CI = 2.0–12.7)
Dong, 2014³³	CS	78 older Chinese in United States	≥60; 52% female	Depressive symptomatology	EA	Sociodemographic, marital status, health status, quality of life, physical function, loneliness and social support	Depressive symptomatology (OR = 2.01, 95% CI = 1.23–3.48)
Chokkanathan, 2014²⁶	CS	902 older adults in Nadu, India	≥61; 54.3% female	Older adults: physically abuse family members Family members: age, education, alcohol consumption, mistreatment of other family members Environment: family cohesion, stress	EA	Older adults (age, sex, employment, dependency, physically abused) Family member (age, education, alcohol use, mistreat others) Environment (family cohesion, family stress, wealth index)	Older adults: physically abusing family members (OR = 9.06, 95% CI = 2.82–29.04) Family members: middle age (OR = 2.06, 95% CI = 1.01–4.23), tertiary education (OR = 0.32, 95% CI = 0.11–0.97), alcohol (OR = 3.08, 95% CI = 1.68–5.70), mistreatment of other family (OR = 6.24, 95% CI = 2.11–18.41), reported more conflicts with their family members (OR = 14.14, 95% CI = 6.63–30.14), low family cohesion (OR = 1.75, 95% CI = 1.43–2.15)
Dong, 2013⁶¹	CS	10,333 older adults in Chicago	≥65; 39% female	Elder self-neglect	EA	Sociodemographic, medical comorbidities, cognitive and physical function and psychosocial well-being	Elder abuse (OR = 1.75, 95% CI = 1.18, 2.59), financial exploitation (OR = 1.73, 95% CI = 1.01, 2.95), caregiver neglect (OR = 2.09, 95% CI = 1.24, 3.52), multiple forms of elder abuse (OR = 2.06, 95% CI = 1.22, 3.48)
Lichtenberg, 2013⁹¹	CS	4,440 older adults from Health and Retirement Study	Mean 65.8; 61.9% female; 85.4% white	Education, depressive symptoms, financial satisfaction, social needs	Financial abuse	Sociodemographic, marital status, CES-D, physical function, self-rated health, financial status, psychological factors	More education (OR = 1.09, 95% CI = 1.03–1.16), more depressive symptoms (OR = 1.09, 95% CI = 1.01–1.18), less financial satisfaction (OR = 0.76, 95% CI = 0.63–0.90), greater ADL needs (OR = 1.01, 95% CI = 0.78–1.30), greater disease burden (OR = 1.03, 95% CI = 0.88–1.21)
Strasser, 2013⁴⁷	CS	112 older adults who participated in legal program	≥60; 68.2% female	Sex, ethnicity, depression	EA	Sex, ethnicity, cohabitation, depression, visits to a mental health provider	Male (OR = 5.54, 95% CI = 1.85–16.57), Hispanic (OR = 11.73, 95% CI = 1.06–130.06), depression (OR = 6.07, 95% CI = 1.54–23.09)
Vandeweerd, 2013⁴⁸	CS	254 caregivers and 76 older adults with dementia	≥60; 59% female, 85% white, 10.3% Hispanic, 4.5% black	Sex, functional impairment, dementia symptoms, violence by older adult, self-esteem, caregiver alcoholism	Phy A	Sex, number of dementia symptoms, level of functional impairment, violence by older adult, caregiver self-esteem, caregiver alcoholism	Sex (OR = 0.82, 95% CI = 0.42–0.95), functional impairment (OR = 2.05, 95% CI = 1.09–4.91), dementia symptoms (OR = 4.82, 95% CI = 3.51–12.52), older adults used violence OR = 4.167 (2.18–8.40), depression (OR = 0.53, 95% CI = 0.23–1.22), caregiver with high self-esteem (OR = 0.66, 95% CI = 0.59–8.40)
Dong, 2012⁶⁰	CS	8,932 elderly adults from CHAP	≥65; 76% female	Physical function	EA	Sociodemographic, hypertension, heart disease, diabetes mellitus, stroke, cancer, hip fracture, depression symptoms	Lowest level of physical performance testing: EA (OR = 2.71, 95% CI = 1.58–4.64) psychological abuse (OR = 2.69, 95% CI = 1.27–5.71), caregiver neglect (OR = 2.66, 95% CI = 1.22–5.79), financial abuse (OR = 2.35, 95% CI = 1.21–4.55)
Naughton, 2012²⁴	CS	2,021 older people in Ireland	≥65; 55% female	Mental health, social support	EA	Age, sex, income, physical health, mental health, social support	Mental health below average (OR = 4.51, 95% CI = 2.22–9.14), lower social support (OR = 3.11, 95% CI = 1.29–7.46)
Wu, 2012²¹	CS	2,039 adults in three rural communities in Hubei, China	≥60; 59.9% female	Marital status, physical disability, living arrangement, depression	EA	Education, living status, living source, chronic disease, physical disability, labor intensity, depression	Not being married (OR = 1.80, 95% CI = 1.40–2.40), physical disability (OR = 1.50, 95% CI = 1.10–2.20), living with spouse and children (OR = 0.70, 95% CI = 0.50–0.90), depression (OR = 5.50, 95% CI = 4.10–7.30)
Yan, 2012³¹	CS	937 married or cohabiting older adults in Hong Kong	≥60; 42.4% female	Age, sex, education, income, living arrangement, chronic illness, social support	Intimate partner violence	Sociodemographic, living arrangement, immigrants or not, employment, receiving social security, indebtedness, chronic illness, social support	Age (OR = 0.97, 95% CI = 0.95–0.99), female (OR = 0.80, 95% CI = 0.59–1.08), education levels ≤3 years (OR = 1.83, 95% CI = 0.96–3.47), no income (OR = 0.73, 95% CI = 0.40–1.35), living with children (OR = 0.88, 95% CI = 0.64–1.19), chronic illness (OR = 1.09, 95% CI = 0.81–1.47), lower social support (OR = 1.17, 95% CI = 0.77–1.77)
Amstadter, 2011⁹²	CS	902 community-dwelling older adults	60–97; 59.9% female; 77% white, 17.3% black, 1.9% Native American, 0.1% Asian	Functional status, race, social support, and health status	Psychological, financial abuse	Age, income, having experienced prior traumatic event	Emotional mistreatment: low social support (OR = 3.51, 95% CI = 1.63–7.53), needing assistance with ADLs (OR = 2.28, 95% CI = 1.06–4.93) Neglect: nonwhite (OR = 3.49, 95% CI = 1.37–8.89), low social support (OR = 6.74, 95% CI = 1.54–29.62), poor health (OR = 3.79, 95% CI = 1.46–9.81) Financial exploitation: needing assistance with ADLs (OR = 2.75, 95% CI = 1.17–6.48)
Dong, 2011¹⁶	CS	8,932 elderly adults from CHAP	≥65; 76% female	Cognitive function	EA	Sociodemographic, medical conditions, depressive symptoms, social network, social participation	Lowest turtles of cognition (OR = 4.18, 95% CI = 2.44–7.15), lowest levels of global cognitive function and physical abuse (OR = 3.56, 95% CI = 1.08–11.67), emotional abuse (OR = 3.02, 95% CI = 1.41–6.44), caregiver neglect (OR = 6.24, 95% CI = 2.68–14.54), financial exploitation (OR = 3.71, 95% CI = 1.88–7.32)
Friedman, 2011⁴¹	CS	41 elderly adults from trauma unit in Chicago and 123 controls from trauma registry	≥60; 58.5% female	Having a neurological or mental disorder	Physical abuse	Age, injury severity, hospital, length of stay	Eurological or mental disorder (OR = 9.10, 95% CI = 2.50–33.60)
Beach, 2010⁴	CS	Population-based survey of 903 adults in Allegheny County, Pennsylvania	≥60, 73% female, 23% black, 73% white, 4% other	Race	Psychological abuse	Sociodemographic, marital status, household composition, cognitive function, physical disability, and depression symptoms	Black race (OR = 2.30, 95% CI = 0.55–9.62)
Choi, 2009⁴⁹	CS	Assessment of 2,005 samples reported to APS for self-neglect	>60; 64.4% female; 44.2% white, 15.9% black, 27.5% Hispanic	Economic resources, healthcare and social service programs	SN	Age, sex, race, marital status, language, living arrangement	Economic resource deficit (OR = 4.60, 95% CI = 2.33–9.08), any ADL impairment (OR = 13.53, 95% CI = 5.52–33.14), cognitive impairment (OR = 11.39, 95% CI = 4.20–30.90)
Dong, 2009⁵	CS	9,056 elderly adults from CHAP cohort	≥65; 62.2% female	Social networks, social engagement	SN	Age, sex, race, education, medical morbidity, physical function, depression, body mass index	Lower social network (OR = 1.02, 95% CI = 1.01–1.04), lower social participation (OR = 1.15, 95% CI = 1.09–1.22)
Oh, 2009²²	CS	15,230 older adults in Seoul, Korea	≥65; 65.3% female	Sex, age, support, physical function, health, living arrangement, economic level, family relationships	EA	Elderly: sex, age, education, economic capacity, ADLs, IADLs, sick days Family: household type, economic level, family relations	Older men (OR = 1.34, 95% CI = 1.21- 1.61), aged 65–69 (OR = 1.33, 95% CI = 1.05–1.68), partially supported (OR = 0.74, 95% CI = 0.57–0.96), ADLs (OR = 0.96, 95% CI = 0.91–0.99), IADLs (OR = 1.03, 95% CI = 1.00–1.06), living with family of married children (OR = 1.96, 95% CI = 1.16–3.32), lowest economic level (OR = 4.84, 95% CI = 3.03–7.75), good family relations (OR = 0.02, 95% CI = 0.01–0.04)
Cooper, 2008⁹³	CS	86 community-living adults with Alzheimer's disease and their caregivers	Mean 82.4; 69.8% female	Caregiver: sex, burden Care recipient: behavioral, cognitive, physical function	EA	Caregiver: burden, anxiety Care recipient: receiving 24-hour care, ADLs, irritability	Caregiver: male (OR = 6.80, 95% CI = 1.70–27.80), reporting greater burden (OR = 1.10, 95% CI = 1.00–1.10) Care recipient: clinically significant irritability (OR = 38.30, 95%CI = 4.60–326.00), less functional impairment (OR = 1.10, 95% CI = 1.00–1.20), greater cognitive impairment (OR = 1.20, 95% CI = 1.00–1.40)
Dong, 2008⁹⁴	CS	412 individuals in n urban medical center in Nanjing, China	≥60; 34% female	Depression	EA	Age, income, number of children, level of education	Dissatisfaction with life (OR = 2.92, 95% CI = 1.51–5.68), being bored (OR = 2.91, 95% CI = 1.53–5.55), feeling helpless (OR = 2.79, 95% CI = 1.35–5.76), feeling worthless OR = 2.16, (1.10–4.22), depression (OR = 3.26, 95% CI = 1.49–7.10)
Dong, 2007⁴⁴	CS	412 adults in a medical clinic in Nanjing, China	≥60; 34% female	Loneliness	EA	Age, sex, education, income, marital status, depressive symptoms	Loneliness (OR = 2.74, 95% CI = 1.19–6.26), lacking companionship (OR = 4.06, 95% CI = 1.49–11.10), left out of life (OR = 1.69, 95% CI = 1.01–2.84)
Dong, 2007⁴⁴	CS	412 adults in a medical clinic in Nanjing, China	≥60; 34% female	Age, sex, education, income, marital status	EA	Age, sex	Aged 65–69 (OR = 0.79, 95% CI = 0.45–1.37), female (OR = 1.55, 95% CI = 1.01–2.38), illiterate (OR = 3.03, 95% CI = 1.43–6.45), no income (OR = 2.86, 95% CI = 1.33–6.16), widowed (OR = 1.56, 95% CI = 0.92–2.66)
Ogioni, 2007⁹⁵	CS	4,630 adults receiving home care in Italy	≥65; 59.6% female	Behavioral symptoms	EA	Age, sex, marital status, ADLs, cognition, delirium, depression, medical condition, loneliness, distress, social support, pain	Behavioral symptoms (OR = 1.56, 95% CI = 1.21–2.00)
Sasaki, 2007⁸⁹	CS	412 pairs of disabled older adults and caregivers in Japan	Mean 80.5; 60.1% female	Behavioral disturbance, adult child as caregiver	Potentially harmful behaviors	Severity of physical impairment, hearing problems, caregiver burden	Greater behavioral disturbance (OR = 3.61, 95% CI = 1.65–7.90), adult child as caregiver (OR = 2.69, 95% CI = 1.23–5.89)
VandeWeerd, 2006⁴⁸	CS	254 caregivers and 76 elderly adults	Mean 78.6, 59% female	Age, sex, cognitive impairment, physical function, depression	Psychological abuse	Age, sex, race, dementia symptoms, functional impairment, depression, medication, verbal aggression, violence	Age (OR = 0.43, 95% CI = 0.31- 0.64), sex (OR = 0.48, 95% CI = 0.04–5.34), number of dementia symptoms (OR = 0.34, 95% CI = 0.15–0.88), level of functional impairment (OR = 1.54, 95% CI = 0.61–3.85), depression (OR = 0.57, 95% CI = 0.24–0.73)
Beach, 2005³⁷	CS	265 caregiver–care recipient dyads for impaired, community-dwelling family members	≥60; 58% female	ADL and IADL needs, caregiver cognitive impairment, caregiver physical symptoms, caregiver depression	Potentially harmful behaviors	Care recipient age, sex, education, cognitive status self-rated health Caregiver age, sex, education, self-rated health	Greater care recipient ADL and IADL needs (OR = 1.12, 95% CI = 1.03–1.22), spouse caregiver vs other (OR = 8.00, 95% CI = 1.71–37.47), greater caregiver cognitive impairment (OR = 1.20, 95% CI = 1.04–1.38), more caregiver physical symptoms (OR = 1.07, 95% CI = 1.01–1.13), caregiver at risk for clinical depression (OR = 3.47, 95% CI = 1.58–7.62)
Chokkanathan, 2005²⁶	CS	400 community-living cognitively intact older adults in Chennai, India	60–90; 73.4% female	Sex, social support, subjective physical health	EA	Sex, marital status, education, living status, subjective health, income, social support	Female (OR = 2.55, 95% CI = 1.03–6.28), less social support (OR = 1.07, 95% CI = 1.04–1.09), poorer subjective health status (OR = 3.26, 95% CI = 1.43–7.42)
Shugarman, 2003⁴⁶	CS	701 adults seeking home- and community-based services in Michigan	≥60; 71.3% female	Memory problems, disease, abuses alcohol, not at ease interacting with others, expresses conflict with family or friends, indicates feels lonely, brittle support system	EA	Sex, cognitive symptoms, disease diagnoses, physical functioning, behavioral problems, social functioning, support	Memory problems (OR = 2.66, 95% CI = 1.28–5.34), psychiatric disease (OR = 2.48, 95% CI = 1.18–5.23), alcohol (OR = 10.26, 95% VI=2.73–38.5), not at ease interacting with others (OR = 2.75, 95% CI = 1.21–6.21), conflict with family or friends (OR = 2.13, 95% CI = 1.08–4.23), lonely (OR = 3.49, 95% CI = 1.70–7.18), brittle support (OR = 3.76, 95% CI = 1.58–8.93)
Comijs, 1999³²	CS	147 elderly adults reporting chronic verbal aggression, physical aggression, and financial abuse in Amsterdam	≥65	Hostility and coping capacity	EA	Age, sex, other matching variables (Buss-Durkee Hostility Inventory, Utrechtse Copinglijst)	Verbal aggression: direct aggression (OR = 1.31, 95% CI = 1.05–1.62), locus of control (OR = 1.19, 95% CI = 1.01–1.41) Physical aggression: coping (OR = 1.24, 95% CI = 1.01–1.51), avoidance (OR = 1.26, 95% CI = 1.08–1.47) Financial mistreatment: indirect aggression (OR = 1.23, 95% CI = 1.07–1.42), perceived self-efficacy (OR = 1.11, 95% CI = 1.02–1.20)

PS = prospective; CS = cross-sectional; CHAP = Chicago Health Aging Project; OR = odds ratio; CI = confidence interval; SN = self-neglect; DRS = Dementia Rating Scale; MMSE = Mini-Mental State Examination; OARS = Older American Resources and Services; EPESE = Established Populations for Epidemiologic Studies of the Elderly; CES-D = Center for Epidemiologic Studies Depression Scale; ADL = activity of daily living; IADL = instrumental activity of daily living; GDS = Geriatric Depression Scale.

Table 3. Consequences of Elder Abuse (EA)
Author, Year	Type	Study Description	Age; Sex; Race	Predictor	Outcomes	Confounding Factors	Critical Findings
Schofield, 2013⁹⁶	PS	1,266 older women in Australia	70–75; 100% female	EA	Disability mortality	Demographic factors, social support, health behaviors, health condition	Mortality: coercion (HR = 1.21, 95% CI = 1.06–1.40), dejection (HR = 1.12, 95% CI = 1.03–1.23) Disability: vulnerability (HR = 1.25, 95% CI = 1.06–1.49), dejection (HR = 1.55, 95% CI = 1.38–1.73)
Dong, 2012⁶⁰	PS	6,864 community-living older adults participating in CHAP	≥65; 61% female	SN	Emergency department use	Sociodemographic, medical conditions, cognitive and physical function	SN (RR = 1.42, 95% CI = 1.29–1.58), greater SN severity (mild: PE = 0.27, SE = 0.04, P < .001; moderate: PE = 0.41, SE = 0.03, P < .001; severe: PE = 0.55, SE = 0.09, P < .001)
Dong, 2010⁹⁷	PS	7,841 community- older adults participating in CHAP	≥65, 52.6% female	EA	All-cause mortality across levels of depression, social network, social participation	Sociodemographic, medical conditions, weight loss, marital status, cognitive and physical function, smoking, alcohol intake	CES-D tertile: highest (HR = 2.17, 95% CI = 1.36–4.36), middle (HR = 2.18, 95% CI = 1.19–3.99), lowest (HR = 1.61, 95% CI = 0.79–3.27) Social network tertile: lowest: (HR = 2.42, 95% CI = 1.52–3.85), middle (HR = 2.65, 95% CI = 1.52–4.60), highest (HR = 0.97, 95% CI = 0.36–2.61) Social engagement tertile: lowest:(HR = 2.32, 95% CI = 1.47–3.68), middle (HR = 2.59, 95% CI = 1.41–4.77), highest (HR = 1.19, 95% CI = 0.52–2.72)
Mouton, 2010⁵¹	PS	93,676 from the Women's Health Initiative (WHI) Observational Study	50–79; 100% female	Physical, verbal abuse	Depressive symptoms, MCS score	Sociodemographic, marital status, smoking, alcohol, religion comfort, living alone, baseline psychosocial characteristics	Physical abuse: 3-year change in depressive symptoms (PE = 0.20, 95% CI = −0.21–0.60), change in MCS score (PE = −1.12, 95% CI = −2.45 to −0.21) Verbal abuse: 3-year change in depressive symptoms (PE = 0.18, 95% CI = 0.11–0.24), change in MCS score (PE = 0.55, 95% CI = −0.75 to −0.34) Physical and verbal abuse: 3-year change in depressive symptoms (PE = 0.15, 95% CI = −0.05 to 0.36), change in MCS score (PE = −0.44, 95% CI = −1.11 to −0.22)
Baker, 2009⁵³	PS	160,676 community women from WHI	50–79; 100% female	Physical, verbal abuse	All-cause, cause-specific mortality	Sociodemographic, BMI, smoking, alcohol, health status, medical conditions, frailty, and psychosocial factors	Physical abuse (HR = 1.40, 95% CI = 0.93–2.11), verbal abuse (HR = 1.02, 95% CI = 0.94–1.10), physical and verbal abuse (HR = 1.07, 95% CI = 0.86–1.33)
Dong, 2009⁵	PS	9,318 community- older adults participating in CHAP	≥65; 61% female	EA, SN	All-cause mortality, cause-specific mortality, mortality stratified according to cognitive and physical function	Sociodemographic, medical conditions, weight loss, marital status, cognitive and physical function, BMI, CES-D, cigarette smoking, alcohol use, social well-being	SN: 1-year mortality (HR = 5.76, 95% CI = 5.11–6.49), >1-year mortality (HR = 1.87, 95% CI = 1.64–2.14) SN severity: mild (HR = 4.71, 95% CI = 3.59–6.17), moderate (HR = 5.87, 95% CI = 5.12–6.73), severe HR = 15.47, 95% CI = 11.18–21.41). EA: all-cause mortality (HR = 2.06, 95% CI = 1.48–2.88), cardiovascular mortality (HR = 3.86, 95% CI = 2.04–7.29)
Schofield, 2004⁵⁵	PS	10,421 older women in Australia	73–78; 100% female	EA	Physical function, bodily pain, general health, social function, role emotional difference, mental health difference, PCS T2–1, MCS T2–1 difference	Baseline Medical Outcomes Study 36-item Short Form Survey scores, four EA scores, age, sum of acute illnesses, chronic conditions, life events, stress score, violent relationship, BMI, smoking, marital status, education, country of birth	Dejection predicted physical function (β = −2.81, SE = 0.81), bodily pain (β = −1.99, SE = 0.97), general health (β = −1.61, SE = 0.70), vitality (β = −3.54, SE = 0.71), social function (β = –5.27, SE = 1.00), role emotional difference (β = −7.88, SE = 1.60), mental health difference (β = −4.63, SE = 0.60), PCS T2–1 difference (β = −0.75, SE = 0.36), MCS T2–1 difference (β = −0.41, SE = 0.74),
Lachs, 2002⁵⁷	PS	2,812 community-living older adults from New Haven EPESE cohort	≥65; 58.4% female	EA, SN	Long-term nursing home placement	Sociodemographic, BMI, medications, physical and cognitive function, social ties, incontinence, CES-D, emotional support, chronic conditions	SN (HR = 5.23, 95% CI = 4.07–6.72), EA (HR = 4.02, 95% CI = 2.50–6.47)
Lachs, 1998¹⁸	PS	2,812 community-living older adults from New Haven EPESE	≥65; 58.4% female	EA, SN	All-cause mortality	Sociodemographic, chronic conditions, BMI, cognition, psychosocial well-being	SN (OR = 1.70, 95% CI = 1.20–2.50), EA (OR = 3.10, 95% CI = 1.40–6.70)
Dong, 2013⁶¹	CS	6,674 community-living older adults participating in CHAP	≥65; 58.4% female; 56.3% black	EA; psychological, financial abuse; neglect	Hospitalization	Sociodemographic, medical comorbidities, cognitive and physical function, psychological well-being	Elder abuse (RR = 2.72, 95% CI = 1.84–4.03), psychological abuse (RR = 2.22, 95% CI = 1.44–3.43), financial exploitation (RR = 1.75, 95% CI = 1.06–2.90), caregiver neglect (RR = 2.43, 95% CI = 1.60–3.69), ≥2 types of elder abuse (RR = 2.59, 95% CI = 1.82–3.66)
Dong, 2013⁶¹	CS	10,333 community- older adults participating in CHAP	≥65; 39% female	SN	EA	Sociodemographic, medical comorbidities, cognitive and physical function, psychosocial	EA (OR = 1.75, 95% CI = 1.19–2.59), financial exploitation (OR = 1.73, 95% CI = 1.01–2.95), caregiver neglect (OR = 2.09, 95% CI = 1.24–3.52), multiple forms of EA (OR = 2.06, 95% CI = 1.22–3.48)
Dong, 2013⁶¹	CS	6,674 community- older adults participating in CHAP	≥65; 58.4% female	EA	Rate of emergency department use	Sociodemographic, comorbidities, cognitive and physical function, psychosocial	EA (RR = 2.33, 95% CI = 1.60–3.38), psychological abuse (RR=1.98, 95% CI = 1.29–3.00), financial exploitation (RR = 1.59, 95% CI = 1.01–2.52), caregiver neglect (RR = 2.04, 95% CI = 1.38–2.99)
Dong, 2013⁶¹	CS	6,674 community- older adults participating in CHAP	≥65; 58.4% female	EA	Rates of admission to skilled nursing facilities	Sociodemographic, medical comorbidities, cognitive and physical function, psychosocial	EA (RR = 4.60, 95% CI = 2.85–7.42), psychological (RR = 2.31, 95% CI = 1.17–4.56), physical (RR = 2.36, 95% CI = 1.19–4.66), financial (RR = 2.81, 95% CI = 1.53–5.17), neglect (RR = 4.73, 95% CI = 3.03–7.40)
Olofsson, 2012⁵²	CS	9,360 older adults from nationwide public health survey in Sweden	65–84; 53.1% female	Psychological and physical abuse	Physical and mental health, use of healthcare	Age, civil status, work history, smoking	Psychological abuse (women): poor general health (OR = 3.80, 95% CI = 2.70–5.30), anxiety (OR = 6.30, 95% CI = 3.70–11.00), stress (OR = 6.30, 95% CI = 4.20–9.30), GHQ-12 (OR = 5.90, 95% CI = 4.40–7.90), suicidal thought (OR = 3.50, 95% CI = 2.30–5.20), use of healthcare (OR = 2.60, 95% CI = 1.90–3.50) Physical abuse (women): anxiety (OR = 7.40, 95% CI = 3.60–15.0), sleeping problem (OR = 2.30, 95% CI = 1.40–4.50), stress (OR = 3.80, 95% CI = 1.90–7.60), GHQ-12 (OR = 4.00, 95% CI = 2.40–6.70), pharmaceutical (OR = 2.10, 95% CI = 1.20–3.40), use of healthcare (OR = 1.80, 95% CI = 1.00–3.10). Psychological abuse (men): poor general health (OR = 2.20, 95% CI = 1.40–3.40), anxiety (OR = 10.00, 95% CI = 5.30–19.00), sleeping problem (OR = 3.50, 95% CI = 2.10–5.90), stress (OR = 5.70, 95% CI = 3.50–9.50), GHQ-12 (OR = 3.90, 95% CI = 2.70–5.70), suicidal thought (OR = 7.30, 95% CI = 4.60–11.00), suicide attempt (OR = 5.30, 95% CI = 2.30–12.00) Physical abuse (men): poor general health (OR = 2.20, 95% CI = 1.20–4.10), anxiety (OR = 7.1, 95% CI = 3.0–16.0), stress (OR = 5.90, 95% CI = 3.10–11.00), GHQ-12 (OR = 3.20, 95% CI = 1.90–5.50), suicidal thought (OR = 4.70, 95% CI = 2.40–9.00), suicide attempt (OR = 5.40, 95% CI = 1.80–16.00)
Begle, 2011⁵⁰	CS	902 adults aged ≥60 using stratified random digit dialing, computer-assisted telephone interview	≥60; 59.9% female	Emotional, sexual, physical abuse	Negative emotional symptoms (anxious, depressed, irritable)	Sociodemographic, health status, social support, social services, physical function	Emotional abuse (OR = 2.13, 95% CI = 1.04–4.36), physical abuse (OR = 0.67, 95% CI = 0.22–2.03)
Cisler, 2010⁹⁸	CS	902 adults aged ≥60 in South Carolina	≥60; 60% female	EA	Self-rated physical health	Income, needing help with ADLs, emotional symptoms	Prior exposure to potentially traumatic events (OR = 1.89, 95% CI = 1.18–3.03)
Fisher, 2006⁹⁹	CS	842 community-living women who completed telephone survey	≥60; 100% female	EA	Health status, medical conditions, psychological distress, digestive problems	Age, sex, race, education, marital status, income, Appalachian heritage	Greater depression or anxiety (OR = 2.24, 95% CI = 1.70–2.96), greater digestive problems (OR = 1.60, 95% CI = 1.22–2.09), greater chronic pain (OR = 1.65, 95% CI = 1.28–2.15)
Smith, 2006¹⁰⁰	CS	80 APS referrals along with matched control subjects from clinical population	Mean 76; 62.5% female	SN	Complete blood count and chemistry, oxidative damage and antioxidants, fat-soluble vitamins, vitamin B-12 and folate, calcium and bone metabolism	N/A	Serum concentration of total homocysteine 13.6 ± 4.5, μmol/L, P < .05; red blood cell folate concentration 1,380 ± 514 nmol/L, P < .05; plasma b-carotene 0.28 ± 0.2 μmol/L, P < .05; X-tocopherol 23.2 ± 9.3 μmol/L, P < .05; 25-hydroxyvitamin-D serum concentration 33.7 ± 16.4 nmol/L, P < .05
Franzini, 2008¹⁰¹	CC	131 APS clients and 131 matched controls to an interdisciplinary geriatric medicine clinic	≥65; 69.5% female	SN	Health utilization, clinic visits, house calls, hospital stays, length of stay healthcare costs	Age, sex, race, mental disorders	Total cost: $12,466 for SN vs $19,510 for control (P = .36) Physician costs, PE −0.29 (0.40); outpatient payments, PE −0.24 (0.45); inpatient costs, PE −0.20 (0.28); total Medicare costs, PE −0.36 (0.33); clinic visits, PE −0.24 (0.10); hospital stays, PE −0.51 (0.05)
Mouton, 1999¹⁰²	CS	257 women aged 50–79 in WHI	50–79; 100% female	Psych Abuse	Mental health	Age, race, marital status, family income, and education	Being threatened (PE −3.32, P = .01)

Parameter estimate (PE) is a coefficient of change in the outcome for every unit increase in the predictor variable of interest.
PS = prospective; HR = hazard ratio; CI = confidence interval; CHAP = Chicago Health Aging Project; SN = self-neglect; CES-D = Center for Epidemiologic Study Depression Scale; RR = risk ratio; SE = standard error; WHI = Women's Health Initiative; BMI = body mass index; MCS = Mental Component Summary; EPESE = Established Populations for Epidemiologic Studies of the Elderly; GHQ-12 = General Health Questionnaire; APS = Adult Protective Services.

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