#77824: Elder Abuse: Cultural Contexts and Implications

For several weeks, church members noticed that Mr. L, 82 years of age, had bruises, cuts, and scrapes on his face, hands, and arms. Mr. L always had some plausible explanation and, knowing that he was the sole caretaker for his very ill wife of 61 years, they did not press the issue. A hospital social worker finally contacted APS after Mr. L drove himself to the hospital emergency room, over 20 miles from his home, with multiple fractures to his left arm. The APS social worker eventually discovered that Mr. L was being attacked by his wife, who was suffering from undiagnosed Alzheimer disease and had become combative. Mr. L did not know that his wife's behavior was a part of her illness and was protecting her.

Mrs. J, a long time insulin-dependent diabetic, was admitted to the hospital after being brought to her physician's office by a neighbor who became concerned after not seeing Mrs. J for several days. Mrs. J finally told hospital staff members that she had run out of insulin several days ago and had given her grandson all the money she had to go and refill her prescription. He did not return, and Mrs. J did not call family members because she did not want to get him in trouble.

Mr. B, 74 years of age, complains with increasing frequency of pain. His physician is puzzled by the complaints because the methadone she has prescribed should be controlling the pain. She has already increased the dosage a couple of times and is reluctant to do so again. She finally asked a family member to bring in all of Mr. B's medications so that she could check for drug/drug interactions or perhaps prescribe another medication. Examination of the methadone tablets revealed that someone had switched most of the methadone with over-the-counter potassium tablets, which are nearly the same size and color. Mr. B's failing eyesight prevented him from being able to tell the difference between the very similar tablets. Questioning revealed that Mr. B's niece, a former drug addict, had been living with him in exchange for his care, and that she prepared his medications each day. The family suspected that she was using drugs again, but was reluctant to probe too deeply because there was no one else to care for Mr. B.

This is an individual who is responsible for providing day-to-day care for the elder, and the amount of caregiving that is needed exceeds the caregiver's ability. This type of offender realizes that his/her behaviors are abusive but has difficulty asking for or seeking help. This type of abuser is the most often depicted [55]. However, the caregiver stress theory does not completely explain elder abuse.

This is an individual who has a physical or mental impairment that makes caregiving difficult. This type of offender tends to be neglectful, administer medications inappropriately, and use restraints. Impaired offenders often do not realize that their behaviors are abusive. Research seems to indicate that perpetrators of elder abuse tend to have substance abuse and mental health issues [55].

This type of offender does not want to provide caregiving and is only doing so to exploit the elder. Oftentimes, the abuse involves neglect and financial abuse.

This offender has little empathy or compassion for elders. Bullying offenders want to exert power and control over their victims. Their victims are too frightened to disclose the abuse and will merely attempt to placate the abuser. These offenders employ a range of abusive behaviors that includes physical, sexual, verbal, emotional, and financial.

This type of perpetrator enjoys humiliating and inflicting terror on the elder and experiences no guilt or remorse for abusive actions.

These different typologies do not necessarily contradict each other. Rather, they can be used supplementally to assist in developing targeted interventions for elder abuse perpetrators [226].

This overburdened caregiver perspective is perhaps the only theory specific to elder abuse [218]. It argues that elder abuse is caused by a family member who assumes the caregiver role and who is exhausted, stressed, and burdened with the caregiver tasks revolving around the elderly individual who has functional and/or cognitive impairments [10,62]. In other words, there are external or situational stressors that precipitate the abuse. Because the locus of caring is shifting from institutions to the family, families are expected to provide care and support to impaired elders [10]. The caregiver stress theory is one of the most frequently cited to explain elder abuse. However, empirical findings suggest that stress and dependency do not explain or predict perpetrating elder abuse; they merely contribute to abuse [55]. To rely on the caregiver stress theory to predict elder abuse can inadvertently result in blaming the victim for "being difficult" or "recalcitrant" and minimize the perpetrator's accountability [63].

The pressures of caregiving are very real. Caregiver stress is caused when the demands of providing care for the elderly individual are perceived as exceeding available resources [64]. Caregiver burden comprises the range of physical, psychological, social, and financial strains or problems experienced by family members who have a family member with a chronic illness and who assume the primary caregiver role [65].

The literature has identified two types of caregiver burden or stress experienced: objective and subjective burden. Objective burden is characterized by tangible, external stressors. This includes providing physical care, financial stressors, employment, and overcrowding. Subjective burden is defined by the emotions that result from caregiver stresses [66]. In one study, the average length of caregiving was seven years [67]. Elders with dementia, for example, often require extensive assistance with bathing, feeding, and bladder and bowel incontinence [10].

Studies have shown that the severity of abuse often increases as elders' cognitive functioning level decreases [45]. Furthermore, family caregivers who have sufficient economic resources are less likely to report using some sort of abuse on the elder family member. Those who experience higher levels of caregiver burden are more likely to abuse their elder family member.

Typically, overburdened caregivers are female, middle age, and have families of their own. They provide much of the caregiving with minimal assistance from other family members. They have very little respite and are taxed with the responsibilities of caregiving and providing for their own families [68]. In in-depth interviews with 11 married and employed Japanese women who were caregiving for an elderly parent, researchers found that many of these women, despite their own career and professional aspirations, placed a higher priority of taking care of their elder family members due to deeply ingrained cultural beliefs about gender roles and filial piety [69]. The women initially took on the task of providing care to their elder parents or parents-in-law because this was the cultural norm. Over time, they felt oppressed as the caregiving duties became overwhelming. Their spouses often adhered to traditional beliefs that caregiving is a female responsibility. The multiple demands and strains these women experienced led to feelings of anger, loss of self-esteem, lack of self-worth, shame, and guilt. The majority of modern elder abuse prevention interventions (e.g., reducing caregiver stress) stem from this theory [218].

Case Scenario

Mr. R, 54 years of age, and Mrs. R, 49 years of age, work full time in very demanding jobs. About one year ago, Mr. and Mrs. R built an apartment addition onto their home, depleting their savings, to accommodate Mrs. R's mother, Mrs. D. Mrs. R is the oldest of three siblings and care for her aging mother had become primarily her responsibility. The 90-minute drive to her mother's apartment in a nearby city each weekend had become increasingly taxing, and her mother's care had become more time consuming. When Mrs. D's long-time physician announced his intent to leave private practice, it became reasonable to make the move. Mrs. D, while not enthusiastic, was agreeable. Mrs. R's brother and sister, who rarely visited or helped with her mother's growing needs, became angry about the move and stated that they had no intention of making such a trip. Now, in addition to working 9 to 10 hours per day, Mrs. R goes home to find numerous messages from her mother with various requests and demands. Additionally, because her mother can see her car drive up, the phone is usually ringing by the time she gets into the house to begin dinner for the three of them. There is an in-home aide who comes three days per week to help with bathing and light cleaning, but lately Mrs. R has questioned whether this is worth the added burden of mediating disputes between the aide and her mother. Each morning before work, Mrs. R prepares her mother's medications for the day and makes sure she has something available for breakfast. She longs for a vacation, but the routine continues seven days per week. Besides, all her vacation and sick leave must be devoted to taking care of her mother's medical appointments and treatments. Lately, Mrs. R has been having difficulty sleeping with disturbing dreams of having forgotten some major task. She feels tired all of the time. She has also noticed that she snaps at her spouse and friends often and that her anxiety level is increasing. Her own household chores are piling up because she does not have the time or energy to do them. Last week she noticed a red rash on her thigh and wonders when she might find the time to see her own doctor.

Early theoretical models proposed that caregiver stress was a contributing factor to elder abuse; however, stress alone does not explain the phenomenon. Researchers tend now to look at stress in the wider context of the overall quality of the relationship between abused and abuser. The nature of the pre-abuse relationship between the caregiver and the care recipient may be an important predictor of future abuse [15,70].

Early theories on elder abuse sought to associate dependency with increased risk of abuse [70]. This is based on Family Power-Dependent Relationship Model and social exchange theory. In the Family Power-Dependent Relationship Model, the child caregiver perceives that there is a reduction of power because the elder has become more frail and dependent. By using aggression, The caregiver uses aggression to claim more power [218]. Similarly, social exchange theory posits that the interaction between two or more persons will be positively evaluated if all persons involved benefit equally from the relationship [36; 218; 256]. An imbalance or unequal exchange in the relationship will be viewed negatively, and this imbalance will result in abuse. Initially, the focus of research was on the increasing dependency of the elder victim on the caregiver or abuser, often an adult child [36,70]. The increasing cost to the caregiver of providing emotional, economic, and physical care to the elderly parent without the positive mutual exchange in the relationship might be viewed as unfair to the caretaker, leading to relationship imbalance and increased risk of elder abuse [36]. Interestingly, Baumann argued that the picture of the frail, weak, and dependent elderly made it easy to call national attention to elder abuse and to justify allocating resources to this social problem [13]. However, Pillemer argues that there is no empirical evidence that elder dependency causes elder abuse [71]. In fact, elder abuse only occurs in a small percentage of the elderly population, and in a study of patients with Alzheimer disease, only 5% of the caregivers became abusive [72]. In addition, Pillemer and Wolf maintain that the problem with this perspective is that it rests on an ageist assumption that all people automatically become dependent and powerless as they age [73]. Thus, they assert that the dependency may lie elsewhere.

Later case work identified abusers who were dependent on the older person (e.g., an adult child dependent on an elderly parent for housing or financial assistance) [70,254]. Because of the sense of imbalance in the relationship and the violation of social expectations regarding independent adult behaviors, the perpetrator attempts to restore some sense of control by using violence [36]. However, some have a critical view of exchange theory, arguing that to use exchange theory for elder abuse "reproduces assumptions of market economics, independence, and value in the present that reproduce instrumental attitudes to relationships rather than focusing on altruism and life-course interdependence" [74]. However, Wolf and Pillemer found that in many instances of elder abuse, a large number of abusers were financially and emotionally dependent on the elder [75]. In some instances, a "web of interdependency"—a strong emotional attachment between the abused and the abuser—made intervention efforts difficult [70]. Some experts have reported on a "tacit exchange," whereby the elderly individually tacitly accepts the abuse in order to obtain care and companionship. Furthermore, victims may be fearful of being removed from their current living situation to a nursing home [257]. To date, no interventions have been developed based on this theory [218].

This dependency is illustrated in the following vignette.

Case Scenario

Mr. J had returned to live with his mother, Mrs. J, a widow of ten years, after his wife insisted he leave their house. During this time, he became depressed and started to drink. Mrs. J's neighbors became concerned that Mrs. J had lost a tremendous amount of weight and looked sad and disheveled lately. One day, Mrs. J confided to one of her neighbors that ever since her son returned to live with her, he had been pilfering her Social Security checks. Initially, she noticed that small amounts of money were missing from her pocketbook, but now, Mr. J threatens her both verbally and physically. He would smash and throw china at her until Mrs. J handed her signed Social Security check to him.

The focus of this theory is on the abuser's behavioral characteristics; however, there is minimal research evaluating this theory, as it is difficult to conduct research with elder abuse perpetrators [58]. Substance abuse and psychiatric illnesses are risk factors for elder abuse. In one study of the relationship between reported instances of elder abuse and regional levels of substance abuse, researchers found that elder abuse was related to higher rates of illicit drug use in the past month by either the victim or the perpetrator [76].

The social learning theory argues that individuals' learning patterns occur through observations of others [77]. When applied to the area of family violence, some researchers have coined the term "intergenerational transmission of violence," which maintains that abusive behaviors are learned. The intergenerational transmission theory argues that the dynamics of abusive behavior get perpetuated, and this is the reason why some abused children become abusers themselves [3,218]. A study conducted by Hotaling et al. found that abused children are more likely to exhibit aggressive behavior toward family members and to engage in crime outside the family [78]. The intergenerational theory is very popular and makes intuitive sense; however, empirical research does not indicate that abusers of the elderly are more likely to have been raised in families that were violent [36].

Feminist theorists argue that violence against women is broadly defined as male coercion of women [79]. In other words, patriarchy and male domination contribute to violence against women [80,81]. Patriarchy is perpetuated and reinforced by cultural ideologies, existing social institutions, gender socialization, and socioeconomic inequalities [80,81]. Thus, the root of violence against women stems from power imbalances in male/female relationships and male domination in the family, which is reinforced through current economic structures, social institutions, and the sexist division of labor [81].

Some argue that feminist theory is not useful to addressing elder abuse, because it does not necessarily explain the different types of elder abuse or the typologies of abusers [218]. However, feminist theory has relevance to elder abuse because elderly abused women are often not thought of as battered women or domestic violence victims. In other words, we do not think of elderly women being abused by their spouses. Studies on domestic violence, for example, have typically excluded women older than 59 years of age [82]. Vinton argues that service providers and scholars have traditionally dichotomized the terms "battered women" and "elder abuse victims" [12]. Each of these terms conjures up images for us; for example, rarely do we associate a battered woman or domestic violence victim with an elderly woman. Instead, we might use the label "elder abuse" because we have inscribed in us a mental picture of an elder abuse victim as a frail elderly person being abused by a caretaker. However, domestic violence does occur throughout a woman's lifespan [83]. Band-Winterstein and Eisikovits argue that intimate partner or domestic violence does not necessarily "age out" and that this notion is a myth [84]. In a study of 620 middle-aged and older women recruited from emergency rooms in an urban setting, 5.5% had experienced intimate partner violence within the last 2 years [85]. Forms of abuse included sexual abuse and verbal threats or use of physical force to make them have sex. It may be that abuse among older couples can be better understood by the abuser-victim dynamics of the domestic violence model than the elder abuse model, which is based on the concept of caregiver stress [86,87]. For example, older women's inability to leave an abusive marital relationship is very similar to their younger female counterparts, such as fear of reprisal [82]. However, for older women, concerns of finances and economic resources stem from their ability to obtain a job, lack of pension, and health and physical limitations [84].

This type of dichotomous thinking has implications for interventions. On one hand, a battered woman will be referred to a shelter, and an elderly female victim of abuse will be referred to Adult Protective Services [88]. In part, this dichotomous conceptualization has been shaped by the historical legacy of the domestic violence and elder abuse movements. Domestic violence, or the battered women's movement, emerged in the late 1960s when second-wave feminism and social activism were active. Then, in the mid-1980s, elder abuse emerged as a separate, distinct social problem and was primarily depicted as a social problem where the perpetrators were caretakers.

This theoretical perspective maintains that American societal norms and attitudes may contribute to elder abuse. First, negative attitudes about the elderly create an atmosphere that breeds elder abuse [10,258]. Ageism is defined as "any attitude, action, or institutional structure that subordinates a person or group because of age or any assignment of roles in society purely on the basis of age" [89]. Our stereotypical views of the elderly include images of elders losing their memory, being less flexible and resilient, and being grouchy and unproductive. Although there is no empirical research that directly links ageism to elder abuse, the argument is that these stereotypes and myths play a role in dehumanizing elders. The process of devaluing and dehumanizing a particular group lends to and perhaps even provides justification for certain discriminatory and/or abusive behaviors [90]. Ageism promotes apathy towards the treatment of elders, and consequently, social problems, including elder abuse and neglect, do not receive the same attention as other problems [10,90].

Disengagement theory was proposed by social scientists in 1961 and was the first social science theory of aging. It describes a process of disengagement from social life that people experience as they age. The theory states that, over time, elderly people withdraw from the social roles and relationships that were central to their life in adulthood. This process is deemed necessary and beneficial to maintaining societal stability and order [91]. The theory caused controversy as soon as it was published. Opponents argued that it ignored many aspects of aging and that it failed to capture the complex and rich social lives of the elderly and the many forms of engagement that follow retirement. The authors of one paper developed a profile of the social integration of older adults that included nine dimensions of connectedness [92]. Using data from the National Social Life, Health, and Aging Project (NSHAP), they conducted a population-based study in 2005–2006 of noninstitutionalized Americans 57 to 85 years of age. Their findings suggested that age was negatively related to network size and closeness to network members but positively related to frequency of socializing, religious participation, and volunteering. The authors concluded that late life transitions (e.g., retirement, bereavement) may prompt greater connectedness.

According to the U.S. Census, African Americans constitute 14.7% of the U.S. population as of 2019, numbering 48.2 million [263]. By 2060, it is projected they will comprise 17.9% of the U.S. population.

The family is very important in African American history, and values related to the family are rooted in African traditions. It has been said that the African American family structure is what enabled African Americans to survive during slavery and the challenging times of the Jim Crow era [106,229]. Terms such as "my family," "my folks," and "my kin" refer to both blood relatives and those who are not related, such as special friends and cared for individuals [5]. This was confirmed in a qualitative study in which African American family therapists discussed the roles of African American families' strengths in therapy [107]. The therapists all identified the strong kinship bonds that existed in African American families and noted these bonds extended beyond nuclear family members into extended family members and into the community. Similarly, marriage is viewed among African Americans as a "sacred vow" and covenant [106]. During the slavery period, when family life was severely disrupted, kinship bonds were highly relied on for support. Young children of slaves, for example, were often cared for by older women or children [5]. Parents attempted to discipline and raise their children to the best of their ability given the constraints of life in slavery.

Extended family networks are common in African American families. Many African American family structures are multigenerational and interdependent. In a study conducted by Martin and Martin, it was found that an extended family network might consist of five or more households centered around a base unit, where the "family leader" resides [108]. This extended family network system pools resources to help during hard times. These strong kinship networks are the key element in helping African American families cope with economic stressors as well as structural issues such as racism, oppression, and discrimination [108]. Similarly, Goode notes that the value of group effort for the common interest is highly valued [5]. There is an expectation that one shares with the larger African American community, and this value orientation is part of that strategy for survival. Simultaneously, the value of independence is emphasized, which focuses on the ability to stand on one's own feet and to have one's own focus [5]. It revolves around the ability to earn a living, care for one's family and provide for them, and have some left over to help others in the extended family [5]. Jackson observed that African American families have demonstrated an elastic quality, assuming flexible roles to adapt to change and stress [109]. Family therapists have noted the amazing resilience and creativity of African American family members in utilizing internal and external resources in handling the challenges that emerge [107]. Economic reasons are not the only reasons why African Americans share households. They also adhere to cultural beliefs about closeness and connectedness [110].

The elderly are highly valued in African American families [229]. Dating back to Western African traditions, the provision of care of elders is embedded in the belief that it is the responsibility of the kin group and care is a collective process [111]. Even during slavery, slave communities provided care to elderly slaves who could no longer work. Although times and the structure of families have changed, many African American families still abide by these cultural norms. African Americans have the lowest utilization rates of nursing homes; tasks of caregiving in African American families are often spread out to different family members rather than having one identified primary caregiver assuming all responsibilities [111].

Elders are viewed as the repository of wisdom and hindsight, termed "elder educators" [5,112]. In traditional African religions, the oldest family members are believed to have special status and an ability to communicate with God [5]. Harper and Alexander note an interesting and unique trend about African American elders [113]. African American elders tend to live in multigenerational households; however, they do not go to live with their children. Rather, it is their children who move in with them. For example, daughters who are divorced, widowed, or separated commonly return with their children to live with their parents [113]. It is very common for grandmothers to help in rearing the children of single mothers [114].

In the 1990s, the number of Asian Americans in the United States increased tremendously due to high levels of immigration from Asian countries. In 2019, 22.9 million Americans identified solely as Asian [264]. It is projected that this number will reach 41 million by the year 2050, which would be 9% of the total population [94]. More than half (58%) were foreign-born in 2005, but by 2050, fewer than half (47%) will be foreign-born [94].

Approximately one-third (31%) reside in California; however, a greater dispersion of Asian Americans to other states has begun. This trend reflects the refugee groups that immigrated during the 1980s and the 1990s and more recent immigrants from India and Pakistan [116].

Generally, traditional Asian families can be characterized as hierarchical. In other words, family authority and structure is defined by family position, which is determined by age and gender [117]. Older family members have higher status than the young, and men hold higher positions than women [117]. Family harmony and equilibrium are valued, and one way to maintain this balance is to adhere to the hierarchical structure. In addition, traditional Asian American families are patriarchal in nature; the father maintains authority, and the sons are more desired and valued because they symbolically carry on the family line and care for their parents when they become old [117].

Mutual support, cooperation, and interdependence also characterize the family [118]. As a result of the close-knit nature of Asian American families, there is a strong sense of obligation and duty to others [119]. Problems are generally solved within the family, and a sense of family honor and pride limits outside information to be shared by counselors or other professionals [118].

The term "family" can be defined in multiple ways in the Asian American community and can include a wide network of kinship. In many Filipino families, for example, trusted friends serve as godparents to children and play a vital role in their socialization process [119].

Elders are generally venerated in Asia. China, for example, has been described as a gerontocracy because of the overall attitude of respect and veneration toward the elderly [120]. Filial piety refers to a series of obligations of the child to the parent for providing emotional and economic support and bringing honor to the parent by doing well educationally and occupationally. These obligations are dictated by Confucian values and have governed many generations of Asian families [121]. In India, children are socialized early to respect elders as an intricate part of the family system [122]. Unlike American society, which encourages independence to maintain self-esteem, Asian elders encourage their children to operate under a framework of mutual dependency [123]. Old age signifies wisdom, status, and power in the traditional Asian family system [124].

Due to westernization and modernization, many Asian countries are experiencing rapid shifts in cultural norms. It is speculated that in countries that have moved toward more capitalistic and market-driven economies, the values of family and collectivism have shifted more to individualism. These changing social norms may have impacted the family structure and how families care for their elders [125]. For example, in Japan, more women have returned to the work force, perhaps due to the economic recession as well as shifts in gender role perceptions [125]. Some have noted that traditional and modern cultural beliefs are becoming more fused, including beliefs regarding filial piety [126]. In focus groups with Taiwanese university students, students' beliefs of filial obligation were found to be deeply rooted in their belief systems; they believed that it was their duty to care for their parents [126]. The participants acknowledged the deeply rooted traditions of filial piety that were passed down in their families. However, for some of the students, filial piety was not necessarily demonstrated by living with their parents. They argued by not living with their parents, they would have a greater chance of achieving intergenerational harmony. Furthermore, they stated it was not completely clear how they will actually practice the day-to-day dimensions of filial piety as circumstances are never constant. Therefore, filial piety is dependent on circumstances [126,231].

Loneliness and social isolation experienced by elders have been identified to be predictors of elder abuse. This might be more salient with ethnic minority elderly immigrants. In one study, the researchers found high rates of loneliness, ranging from 24% to 50%, among elder immigrants from China, Africa, the Caribbean, Bangladesh, and Pakistan [127]. Kao and Lam maintain that when Asian immigrants age in the United States, what they experience is very different from how they were socialized [123]. It is a more demanding task to age in a society where their contributions are devalued, compared to a society where elders are treated with deference. This is demonstrated by the fact that loneliness is a significant predictor to elder abuse. In a survey study of 410 elderly Chinese patients (60 years of age and older), elders with higher reported levels of loneliness were four times as likely to experience elder mistreatment compared to elders with lower scores [128]. It is possible the rapid industrial changes in China have created tension between the older and younger generations in their prescriptions of familial responsibilities and roles.

The Hispanic/Latino population is also a very diverse ethnic group. They hail from Mexico, Puerto Rico, Cuba, and Central and South America. Ramirez has observed that mestizaje contributes to these complex within-group differences [129]. Mestizo refers to the genetic mixture that evolved from amalgamation due to European colonization and the intermingling that occurred between the European population and the indigenous people of the Americas as well as within the various indigenous tribes [129]. The term "Latino" is the preferred term as one that is self-applied, and the term "Hispanic" is a category used by the U.S. Census [103]. Latino describes people whose ancestors come from the Spanish-speaking countries of Latin America as well as those of Spanish and Indian descent whose ancestors have always lived in areas of the Southwest United States, which was once part of Mexico [130]. The word Latino describes diverse ethnic cultural groups, not a singular religious or racial group. Latinos engage in a variety of religious and spiritual practices, and may be White, Black, Indian, or Asian. Latinos most often identify themselves by their national origin, for instance, as Dominicans or Mexicans. According to the U.S. Census, 63.4% Hispanic Americans originated from Mexico in 2015 [131].

Hispanics are the largest minority group in the United States, numbering 60.6 million in 2019 [265]. It is estimated that the Latino/Hispanic population will increase to 128 million by the year 2050 [94]. In 2019, the three states with the largest Hispanic population (California, Texas, and Florida) also had the most growth [266].

The family is of paramount value, which is influenced by both the Spaniards' Catholic religion as well as the values stemming from the indigenous people of the Americas [103]. In Hispanic culture, familismo, defined as putting the needs of the family before those of the individual, is a paramount cultural value [133,234]. The emphasis is on family reciprocity, including financial support, shared day-to-day activities and child rearing, and support related to the challenges of immigration [134].

It is both matrilineal and patrilineal, as there was a mixture of both matrilineal and patrilineal tribal governances among the indigenous people of the Americas [103]. However, in traditional Puerto Rican culture, there is a hierarchy of authority based on gender and age. Men and older family members are ascribed authority [135]. Similarly, patriarchal gender roles exist among many Mexican American families [104]. These differences reinforce the notion that there is tremendous heterogeneity within this ethnic group.

The family is an extended system that includes blood relations, those related by marriage, and fictive kin adopted through compadrazgo[136]. Compadres (i.e., godparents or co-parents) and extended family have very strong and close relationships with family members, providing financial and emotional support [137]. Padrinos is the relationship between godparents and godchildren [135]. It is not uncommon to transfer children from one family to another during times of hardship and crises, and mutual help, protection, and caregiving are provided [136].

Community is another value that is emphasized. Unlike individualism, which is the hallmark of many of the values in the United States, Hispanics/Latinos focus on the collective, which extends to valuing community life [103]. Consequently, fictive kinship is a part of the fabric of life. Stemming from this value of community is the emphasis of the value of cooperation versus competition. Latino families teach children the importance of sharing resources [103].

In the Hispanic/Latino culture, self-sufficiency is not expected for the elderly [138]. Because of the values of respect, cooperation, and family, elders expect to receive emotional assistance from their children. Elders are believed to be the storehouse of tradition, wisdom, and tradition [139]. They are viewed as advisors and it is not uncommon for family members to seek the advice of elders for parenting, childrearing, and other aspects of family life. Children are obligated to provide care and to respect their elderly parents [104]. They play important roles when they live with their adult children. Hispanic elders' attitudes about old age and well-being were contingent on their interactions and their sense of connectedness within the family unit [139]. This is one reason threatening to send elderly parents to a nursing home is perceived as a form of abuse in some Hispanic families [234]. Hispanic immigrant parents view these cultural values as important as they strive to teach their children the importance of respecting the elderly and addressing elders with the proper titles. Some lament the challenge of instilling these values to their children as they become Americanized [140].

Native Americans, or American Indians, like other minority groups, encompass people with many different languages, religions, organizations, and relationships with the U.S. government [141]. They identify themselves as belonging to a specific tribe, each with unique customs and values. Again, readers are cautioned to regard the themes highlighted below merely as general cultural themes and to keep in mind the tremendous diversity within the Native American population.

As of 2019, the Native American population numbered 6.9 million, or approximately 2.0% of the U.S. population [267]. It is projected that by 2060, this number will increase to 10.2 million, 2.4% of the total population [143]. As of 2022, in the United States, there are 574 federally recognized tribes and 324 federally recognized reservations [267].

In 2019, this group was more likely to live in Arizona, California, Texas, or Oklahoma [143]. The largest tribes are the Cherokee and Navajo. They are also a younger group, with a median age of 30.2 years compared to the median of 37.8 years for non-Hispanic White persons [143]. In 2019, this group had a poverty rate of 20.3%, compared with 9% among non-Hispanic White individuals [268].

The family is regarded as the cornerstone for emotional, social, and economic well-being for individuals [144]. The composition of the family is very different from the dominant Anglo culture in the United States. For some tribes, the term "family" goes beyond the nuclear family and includes everyone in the tribe or clan. The terms "brother" and "sister" are used to refer to cousins in Native American families [145]. Therefore, family members encompass both blood relatives and tribe members with no distinctions, which is consistent with cultural values that emphasize interconnectedness and harmony [146].

The primary relationship is not necessarily with the parents, but instead with the grandparents, who assume the caregiver and disciplinarian role [141]. For example, among the Native Americans from the Navajo tribe, it is common for grandchildren to be sent to live with their grandparents, which benefits both the child (by ensuring that care and traditional values are passed down to the younger generation) and the elder (by ensuring a means to provide assistance to older individuals) [147]. In addition, the term "grandparent" is not limited to the dominant culture's role of a grandparent, but instead grandparents for Native Americans can also include other relations, such as aunts, great aunts, and godparents. Similarly, parental roles are assumed not only by the biologic parents but also by siblings of the parents [141].

Elderly family members are highly regarded. The aged are believed to be the repository of wisdom, and their role is to teach the young the traditions, customs, legends, and myths of the tribe [148,236]. In addition, the view of reciprocity is woven into the inter-relationships between elders and the young. Typically, elders help raise children, and caring for the elderly is considered "returning the favor" [149]. Consequently, in their old age they are taken care of by the tribe. This family orientation is reinforced by the cultural value of collectivism; that is, the value of being part of a group. Joe and Malach note that consensus is often the goal, and in decision-making processes, individuals often spend a lot of time trying to achieve consensus and harmony [150].

There has been a growing interest in the perceptions of elder abuse among ethnic minority populations. This reflects a recognition that culture, race, and ethnicity can influence what constitutes elder abuse, particularly because definitions of elder abuse reflect a White, middle-class perspective [151]. In addition, as noted previously, there is controversy about the definition of elder abuse and how to view the etiology of the problem.

Some studies employ cross comparisons among ethnic groups to identify similarities and differences regarding definitions of elder abuse. In a study that included African Americans, Korean Americans, and White elderly women, the participants were presented with scenarios of potentially abusive situations [152]. These scenarios included thirteen situations that covered various dimensions of elder abuse and mistreatment, such as physical, psychological, verbal, sexual, medical, and financial abuse and neglect [152]. They found that the Korean elderly women were more tolerant of potentially abusive situations compared to the other two groups. In other words, Korean elderly women perceived fewer of the situations (50%) to be elder abuse as compared to White elderly women (who perceived 67% to be abusive) and African American elderly women (73%). It is plausible that the Korean elderly women were more sensitive to hierarchy and traditional gender roles as espoused by traditional Korean culture. There are rigid role differentiations between husband, wife, and children in Korean culture; males are valued, and, therefore, hierarchy and patriarchy are emphasized in Korea [153]. These values affect the Korean elderly women's beliefs about what is acceptable behavior and what is not.

These findings were replicated in a study conducted by Moon and Benton [151]. The study consisted of 100 African Americans, 95 Korean Americans, and 90 White elderly individuals 60 years of age or older, all living in Southern California. All participants were interviewed face-to-face. In general, the majority of the participants, regardless of ethnicity, disapproved of obvious, blatant forms of physical abuse, such as hitting an elder. Interestingly, some participants stated that it might be tolerated depending upon the circumstances. For example, 9.5% of the Koreans, 5.6% of the White Americans, and 2% of the African Americans indicated that it was acceptable to restrain an elderly parent in bed depending upon the circumstances. In addition, findings indicated that the Korean Americans and African Americans were more willing to tolerate medical mistreatment of elderly individuals. When asked about the causes of elder abuse, Korean Americans demonstrated a significantly different perception than either White or African Americans. Korean Americans, for example, felt that elder abuse was primarily perpetrated by those with a mental illness or problems with substance abuse.

In a study comparing elders living in Korea and Korean immigrant elders in the United States, 90% of both groups agreed that scenarios that depicted physical and financial abuse were mistreatment. However, there was a lower percentage of agreement (37% to 40%) regarding the scenarios that portrayed neglect [154]. Both groups were more likely to seek help in cases of elder abuse, though the likelihood was lower for cases of neglect. However, Korean immigrants were 17 times more likely to seek help in cases of physical abuse compared to their Korean counterparts. Furthermore, women and more educated individuals were more willing to seek help [154]. In one study, older Korean immigrants were less likely to perceive psychological or emotional abuse as elder abuse [221]. For example, silent treatment and name calling were not perceived as elder abuse.

In a Chinese study, elders were recruited for focus groups to discuss their perceptions of elder abuse [269]. Most of the debate about what constituted abuse was centered around intentionality. Some felt that if an unintentional behavior caused distress to a parent, it should be considered abuse. Because of Chinese tension between traditional cultural norms of filial piety and children's more Western acculturated views of independence and family, parents may view their children not spending time with them or not being attentive to their well-being as being neglectful [269]. In another similar study, four groups were recruited—Whites, African Americans, Puerto Ricans, and Japanese Americans—for focus groups [99]. In general, the Puerto Rican respondents were more likely to label a situation as elder abuse without qualification, and the White and Japanese American focus group participants were least likely to label a situation as elder abuse. Meanwhile, African Americans tended to look at the context or circumstances to assist in understanding whether a situation was considered abusive or not. They were also asked what was "the worst thing that a family member can do to an elderly person." The White focus group participants stated psychological neglect was the worst thing, the Japanese Americans listed psychological abuse, and African Americans stated psychological abuse and exploitation. Although most studies report differences among ethnic groups about the definitions and perceptions of elder abuse, it is not always clear how cultural values and norms play a role in these differences. Therefore, the specific cultural context can influence definitions.

Modernization in India has negatively impacted the social status of the elderly. Along with modernization come shifts in power structures and dynamics in the family system [155]. Like many other Asian cultures, Asian Indian elders are highly respected, as age is a valued social status [155]. Cultural norms about the treatment of elders can influence definitions. A quantitative study with older adults in India found that 52% stated they experienced disrespect as a form of elder abuse; this is not generally accepted as a form of abuse in U.S. laws and research [270]. Using a series of research methodologies to collect data about elder abuse within an Asian Indian context, some interesting results emerged. First, the cultural context does influence perceptions and definitions of elder abuse. Psychological/emotional abuse goes beyond insults, criticisms, and pejorative statements. In the Indian context, elders perceive behaviors that go against their religious or philosophical beliefs as constituting psychological abuse. For example, many Hindus have day-to-day dietary restrictions, and when elders live with their children who do not observe the same dietary restrictions, the elders may change their lifestyle to the extent that they perceive it as abuse or neglect. In a study focusing on Tamil and Punjabi immigrants in Canada, daughters-in-law were often identified as perpetrators of elder abuse in multigenerational households [156]. Nagpaul describes an elderly Indian woman who has stopped eating in the family kitchen because her daughter-in-law uses the same utensils to cook meat as in her vegetarian dishes. She now survives on bananas. She feels she has no other residential living options than to live with her son and daughter-in-law [155].

Financial exploitation may also fail to be viewed as abusive. In many cases, cultural norms may influence definitions and perceptions of financial elder abuse [237]. Behaviors such as family members taking small amounts of money from an elder, taking advantage of an elder for housing, or pressuring an older family member to provide excessive or inappropriate childcare may be common but not necessarily viewed as abusive. Financial abuse was further categorized by Chinese American elders in focus groups [271]. The first type of financial exploitation involved the perpetrator taking the elders' money, property, and/or resources without their permission or against their will. The second type was financial neglect, whereby the elder is experiencing financial hardship in getting their basic needs met but their adult children do not help [271]. All of the focus group participants saw these behaviors as breaking the values of filial piety.

While examining cross-cultural differences can be helpful in highlighting the differences and similarities between groups, some researchers have focused on studying one group in order to understand specifically how the qualitative details of their social realities might influence perceptions of elder abuse [157]. Again, because the sample sizes in such studies are frequently small, it is important to be cautious about generalizing findings to entire populations.

Using a review of the literature and the author's research with African Americans in North Carolina, Griffin noted that the generally accepted definition of elder abuse and the common profile of elder abuse victims and perpetrators may not necessarily apply for African Americans [157]. The general profile developed by Kosberg describes an elder abuse victim as older than 75 years of age, middle-class, widowed, White, and female, with mental or physical disabilities [158]. The perpetrator is described as a caregiver, typically a middle-aged adult woman who resides in the home of the elder.

Griffin argues that elder maltreatment and abuse in African American communities takes place in a markedly different social context [157]. As previously noted, African American elderly individuals frequently live in multigenerational family households, and unlike White elders who leave their homes and live with their children, children come live with them [157]. This situation provides a unique set of stressors that may contribute to elder abuse and maltreatment in this community.

Much has been written and speculated about the culture of violence in African American communities and whether this plays a role in risk factors for elder abuse among this group. Some suggest that historical violence against African Americans, perpetrated by individuals as well as institutions, is partially responsible for violent behavior among African Americans [159]. In a qualitative study of 30 older African American women, some women mentioned the spill-over effect of violence in the streets into the home as a trigger to family violence [160]. However, these arguments are not conclusive. Some have noted that the family structure of African Americans (that is, multigenerational households) can place elders at risk in their homes [101]. As described previously, adult children, as well as grandchildren and other relatives, are more likely to move into an elder's home. The strength of such multigenerational households is that it has allowed generations of poor African American families to pool their resources during hardships [159]. It can be argued that support from multigenerational living arrangements as well as from the church can be protective factors to elder abuse. However, Benton argues that the circumstances that contribute to relatives moving into an elder's home are typically due to stressors such as divorce, unemployment, or drug problems, all of which are risk factors for elder abuse [159].

The social or economic contexts also play a role in elder abuse among Native Americans. Dependency has become a variable studied in the field of elder abuse. Interestingly, in the mainstream literature on elder abuse, the research focuses on the elder becoming dependent on family members, which is believed to play a role in elder abuse. Boudreau observed that the direction of financial dependency is opposite for Native Americans; many young Native Americans are dependent upon their elderly family relatives for financial support [36]. Many elderly receive monthly paychecks from pensions, Social Security, or welfare, and because of the high rates of unemployment, many younger Native American adults rely on their elderly family members' funds [161]. Consequently, many Native American elders are at risk of financial abuse [238]. The economic stressors on many Indian reservations have also adversely impacted the family kinship system. Many have had to leave the reservations in order to find employment, leaving elders behind. Some service providers have asserted that this leaves elderly family members isolated, without family to provide for the care they might need [161]. Furthermore, years of social and historical forces that reinforce racism (e.g., failure to recognize tribal groups, relocations, forcible removal of children to boarding schools, and exploitation of Indian land) have negatively impacted the traditional Native American family system. Family ties and traditional values that emphasize the collective unit have both been disrupted [162].

Forces of social change impacting the traditional family structure have also affected Chinese elderly in Hong Kong. In recent years, the primary social support system for the elderly has been impacted by small public housing units, which have not encouraged multigenerational households [124]. Consequently, many young adult children move to new towns outside Hong Kong, leaving elderly parents behind. Elders who have been socialized to expect to be comfortable and cared for in their old age instead find themselves isolated. Some in the younger generations have also redefined what filial piety is to them. For example, paying nursing care fees for an elderly family member may be considered a demonstration of filial piety in some families or communities [231]. Consequently, principles of filial piety are challenged.

The theme of respecting elders and filial piety surfaced in a qualitative study with Asian American immigrants. Participants in the study stated that adult children should support their elderly parents, especially if they have a successful life, and this value should be passed down [163]. Interestingly, Korean immigrants in Chang and Moon's study identified elder abuse in terms of "abrogation of filial piety" [43]. These acts included adult children not wanting to live with elderly parents, placing their elderly parents in a nursing home, or not showing adequate or proper respect. In Korea, the low birth rate and increase in one-child families have led to an expansion of the role of daughters. Traditionally, sons (and their wives) were expected to care for their elderly parents. In 1991, an equal inheritance ratio was legislated in Korea, and many have linked greater gender equity to the weakening of other cultural values, such as filial piety demonstrated by sons [272]. Many Korean adult children may have acculturated to new value systems that minimize familial responsibilities, particularly to parents.

Pang found a similar theme surfacing among Korean elderly immigrants [164]. Many resented living with their adult children and having to watch children, cook, and clean the house. They felt they had become full-time childcare providers. Because many elders did not regard discussing and negotiating these matters appropriate, the situation merely worsened. They classified these scenarios as abuse. Similarly, in a study with Vietnamese elders, Le found that some elders stated that their daughters-in-law did not want them to learn English or how to use the transportation systems [165]. Therefore, they were confined at home to do household chores as free laborers. They classified these behaviors as elder abuse. Interestingly, emotional abuse was pervasive, and it not only included threats of putting the elder in a nursing home, but the use of silent treatment and blatantly ignoring their presence.

In a study using focus groups with home care workers who worked with Chinese elderly, the theme of disrespect emerged prominently. Disrespect encompassed actions and attitudes that go against cultural norms of obedience, conformity, and filial piety. Such behaviors might include being bossy or rude, ordering an elderly person to leave the room for no reason, scolding, or being demeaning [166]. Disrespect led to social isolation among the elderly, and for some of these immigrant Chinese elderly, the social isolation was exacerbated by financial dependency or dependency on family members due to their low level of English proficiency. The dissonance experienced by the Chinese elders stemmed from their expectations of filial piety and being taken care of in their old age. When this did not happen, this led to loneliness and depression; in the elders' minds, this was a type of "abuse" [166]. Ultimately, what is considered disrespect is heavily influenced by culture; Asian culture-specific behaviors that may be considered disrespectful to elders include addressing them by name or not giving a seat of honor at the dinner table [269]. However, the boundaries are not clear as to when disrespect crosses over to abuse.

This concept of disrespect is not specific to Asian culture. A qualitative study of African American, Hispanic, and White custodial grandfathers found that the men discussed their grandchildren and children being disrespectful. Not listening and not appreciating them, which ultimately made them feel devalued and in their eyes, fell into the category of emotional abuse [167].

Cultural values and norms of family and family obligations also color elder abuse and how victims perceive the abuse. Sanchez noted that in the Latino/Hispanic culture, particularly for Mexican Americans in the study, la familia may play a role in the sanctioning of family violence [39]. A majority of the Mexican American elderly participants justified the violence, stating they had instigated it and that it was best dealt with within the family. The needs of la familia are considered paramount and are more valued than the needs of the individual [39]. Therefore, incidences of elder abuse would not be disclosed to authorities; rather, they would be kept within the confines of the family. Related to this is the theme of verguenza, which emerged during the study. The word means shame or losing face. Disclosing that one's child has mistreated a parent brings shame to the family and violates norms about la familia[39]. Yet, one study found that length of residence in the United States predicted caregiver neglect among elders in Latino families [38]. This raises the question of whether immigrants' emphases on family and family obligation decay with acculturation. The role of family in the maintenance of elder abuse warrants more empirical attention.

Tomita discusses similar themes in the examination of elder abuse within a Japanese cultural context [168]. The Japanese have a strong sense of "we-self" or "familial self," which is markedly different from the Western/American "I" centered self. Again, the elder abuse victim may feel it is necessary to relegate his/her individual needs so as not to jeopardize group harmony. Cultural norms of perseverance, silent suffering, and quiet endurance are valued, but these are also associated with victimization; consequently, victims do not necessarily perceive and label themselves as victims of abuse. For many Japanese, it is more important to protect the family and the community by not discussing with outsiders anything that is shameful and dishonorable [169].

For Native American Indians, the context of historical trauma considered in understanding elder abuse. Experiences with forced tribal relocations, forced removal of children, and the adverse outcomes of American colonization have created a backdrop of violation of human rights [230]. Some have speculated that these violations have eroded social infrastructures, contributing to abuse and violence [230].

Although there are few research studies focusing on ethnic minority families and elder abuse, there is a growing recognition that more scholarly empirical work is needed to increase the knowledge base in this area. Practitioners and scholars realize that understanding and highlighting the cultural context of elder abuse will shed light on formulating culturally sensitive interventions for ethnic minority families and their elderly family members.

It has been said that ethnic minority elders experience multiple jeopardy. In other words, they are vulnerable to life stressors because of their age, being an ethnic and class minority, not being proficient in the English language, being unfamiliar with American institutions, and not having transportation or social support networks [170]. Furthermore, most ethnic minority elderly do not voluntarily seek out social, community, and mental health services. For example, in a study with elderly Korean immigrants from Los Angeles County, there was a disconnect with their views and their intention to seek help, even when they classified various scenarios as elder abuse [171]. For example, 91% of the elders stated the financial abuse scenario constituted elder abuse, but only 63.7% stated they would seek help. Consequently, it is important to step back and examine reasons for their reluctance because these factors are in part social and cultural, and lessons learned can be used to develop culturally sensitive interventions and programs for the ethnic minority elderly.

Language Barriers

Many ethnic minority elders may not be proficient in the English language. If the helping professional cannot communicate with the immigrant elder, the patient is less likely to disclose personal problems, particularly sensitive topics such as abuse [28,172]. Not only is lack of English proficiency a barrier to help-seeking but it exacerbates social isolation, which can increase the risk for abuse [28]. However, many helping professionals in social services are not multilingual despite the efforts to recruit professionals who are both bilingual and bicultural. This becomes even more problematic in certain ethnic groups, such as the Chinese, who have numerous dialects.

Geographic and Operational Accessibility of Services

Often, social service and community agencies are located in areas that are not easily accessible to elderly individuals who may not be able to drive themselves. Thus, they find themselves relying on public transportation, which may not be reliable or convenient. In addition, many agencies operate traditional hours of service—weekdays, from 9 a.m. to 5 p.m. Again, because they must rely on their adult children who may be working, elderly individuals may find it difficult to gain assistance.

Financial Difficulties

Some elderly face increasing financial difficulties as they age. They are typically living on fixed incomes; some do not have Medicare, Social Security, or receive pensions [170]. Lack of health insurance and high costs of medical services can be a challenge for many immigrant elders, further exacerbated by not knowing how to navigate the health and social service systems [273]. Consequently, many elderly immigrants not only avoid seeking services but also put off seeking medical services and other necessities until the situation becomes extremely severe [123].

Stigma/Shame in Asking for Help

Fear and shame of disclosing abuse emerged as a dominant barrier to help-seeking among elder abuse victims in a 2022 systematic review [274]. As mentioned, the concept of shame in many ethnic minority cultures is very different from that of Western notions. In traditional Asian culture, for example, shame or loss of face extends to the collective unit, such as the family and community. Therefore, not only is the individual embarrassed, but the shame is also experienced by the entire family system, including one's ancestors [239,240]. This similar theme appeared in Sanchez's study with Mexican American elders [39]. They revealed that incurring shame to the family is to be avoided at all cost, and only on rare occasions, when someone's life is in jeopardy, should outside agencies be involved. Often, preserving family honor takes priority [274]. In a study comparing Koreans and Korean immigrants in the United States, both groups indicated that physical and financial elder abuse was the most severe form of abuse compared to other forms of maltreatment [154].

Attitudes and Definitions of Abuse

Some victims may view a behavior some identify as abusive as a normal part of life [239]. In a 2019 study, some participants perceived problematic behaviors as family conflict rather than abusive, and thus did not see a need for formal support [241]. A quantitative study found that Chinese elders who experienced psychological abuse had the lowest intentions of seeking formal or informal help [275]. In another study of African American elders, the participants tended to accept abuse as an implicit agreement or exchange for caregiving or for being allowed to remain at home (versus a nursing home) [242].

Importance of Keeping Individual Problems from Outsiders

Tomita's qualitative interviews with Japanese adult immigrants revealed the importance of not discussing problems with outsiders [169]. They emphasized that it was unacceptable to make any disclosures about any unpleasantness to outsiders, but instead they must always maintain and present a happy and untroubled countenance to the public. Incidences of abuse would bring dishonor to the community and should be hidden at all costs. Along with the belief that it is shameful to discuss family matters, some consider abuse to be a part of one's fate [243].

Mistrust of Mainstream Services

Many ethnic minority immigrant elders are simply mistrustful of Western mainstream services. In a study of 124 Korean immigrant elders, one of the themes that emerged was mistrust of third-party interventions as a deterrent in seeking help [173]. Elders who adhered to traditional values were less likely to seek formal help. Coupled with unfamiliarity with Western notions of mental health and health and institutional procedures, many prefer to rely on traditional healers. For example, some Mexican American elders seek curanderos (folk healers) for healing and spiritual guidance [172]. African Americans are often wary of government and legal entities, and African American elders tend to be more likely to seek help from spiritual leaders, family, and the community than from mainstream services [244]. Furthermore, many African Americans with strong ethnic affiliations are more likely to use prayer and forms of spirituality when they need help instead of seeking formal services [174].

Ambivalence Toward the Legal System

Another issue among many ethic/racial minority groups is ambivalence or fear of the established legal system. In one study, many of the participants (older African American, Hispanic, and White women) identified fear of police as a major barrier to seeking help through legal channels. Concerns that the police would not understand, demean the victim, and even trigger police brutality were expressed. There was also a perception that restraining orders or protective orders were ineffective and could exacerbate the abuse [175]. Since the 1980s, more tribes have developed legal codes for elder abuse [176]. However, these legal remedies mirror Euro-American legal standards, and they appear to go counter to tribal cultural values of collectivism, harmony, and healing. Legal punishment of the abuser may therefore be less effective, and some Native Americans may be reluctant to seek help through the legal system [176,230].

This is not an exhaustive list of barriers experienced by ethnic minority elders. It does provide readers a glimpse into their social realities. Abuse and mistreatment take on a host of connotations, and then given the layers of barriers, many elders are reluctant to seek assistance from mental health professionals, physicians, and other authority figures.

APS is situated in civil law, meaning that they are civil rather than criminal laws [218]. All 50 states have enacted legislation dealing with elder abuse, and they share many features with child abuse statutes. Elder abuse laws are also called APS laws because many states combine the protection of elders and disabled adults under one law [189]. They provide legal definitions of elder abuse, establish administrative channels for the investigation of and intervention in elder abuse, define who is mandated to report, and designate penalties for violations [16]. However, the specifics of state laws vary, and elder abuse laws may be ambiguous. Individual states are responsible for their own interpretations of the laws [190].

What follows is a brief review of the administrative channels for the investigation of elder abuse cases. It is important to remember that each state has different elder abuse statutes and they differ along three major areas: mandatory versus voluntary reporting; the targeted elder population to be served (e.g., some states focus on cognitively impaired or incapacitated elders); and the authority granted to elder abuse workers to investigate cases (e.g., some states require that the worker seek consent from the elder) [189].

In all 50 states and the District of Columbia, an APS agency has been designated to investigate reports of elder abuse [246]. This is the principal public agency that is responsible for both investigating reported cases of elder abuse and for providing victims and their families with treatment and protective services. Title XX of the Social Security Act makes it a federal requirement for states to implement APS in order to receive funds [191]. In most jurisdictions, the county departments of social services maintain an APS unit that serves the need of local communities [192]. In general, APS offers case management, emergency medical services, alternative housing arrangements, and help in obtaining Medicare, Medicaid, and aging services [191]. It is important to remember that, unlike the child abuse, older adults can refuse services or accept only partial services, even if APS substantiates an incident of abuse [246,247]. In some cases, APS can petition the court for assistance after it has demonstrated probable cause [247].

As noted, elder abuse laws differ from state to state, and definitions, procedures, and training can likewise vary [248]. Tennessee, Virginia, and Texas uphold the principle of autonomy in that elders can refuse services. In other states, authorities can be called to intervene if elders refuse services [190]. Unlike child abuse statutes that mandate professionals in all states to report incidences of child abuse, there is less consistency among the states regarding mandatory reporting for elder abuse [16,56,192]. For example, practitioners may be mandated to report only in cases in which the elder is residing in institutional settings [16,56]. The definition of elderly may also differ [56].

Those people who are designated as mandated reporters vary from state to state. In Illinois, for example, licensed counselors are specifically named as mandated reporters [192]. Twenty-one states and protectorates required mental health professionals to report; 17 required psychologists to report; 5 required family and marriage counselors to report; and 30 required social workers to report elder abuse [192]. All states except New York, the District of Columbia, and Puerto Rico require healthcare professionals to report, and failing to do so can result in penalties [249]. As with child abuse statutes, the practitioner does not have to prove that the abuse occurs before reporting; the practitioner must report even if he/she only suspects abuse. Only 75% of the state laws on elder abuse include a criminal penalty for failure to report [16]. To locate the number to call for specifics about your state's elder abuse laws or to report elder abuse, visit the NCEA's website at https://ncea.acl.gov/Resources/State.aspx [193]. The Elder Abuse Guide for Law Enforcement (EAGLE) site allows users to access specific state codes and mandatory reporting requirements. It is available at https://eagle.usc.edu/state-specific-laws.

Frequently, practitioners are reluctant to report elder abuse. It is estimated that less than 2% of suspected elder abuse cases are reported by physicians [194]. In one study with 358 primary care physicians, recognition of physical abuse was the lowest (70%); the highest rate was of sexual abuse (91%) [278]. Intention to report was low for physical abuse, emotional abuse, and neglect among physicians in the study. There are several barriers to reporting. First, many practitioners do not have a clear understanding of how APS operates. Many are not familiar with the elder abuse reporting laws, how they work, and/or who to contact if they were to report, and time constraints make it difficult to do additional research to locate the information given there are often competing responsibilities and priorities [279]. Second, practitioners fear they will make a bad situation worse or that nothing will change if they report the abuse [179,194,195]. Third, practitioners may also feel threatened for their own safety, and in some instances, it may be necessary to contact law enforcement as well [179,195]. Some are also concerned that they are breaking the confidentiality of the elderly individual [194,195]. If the potential perpetrator is a staff person, a sense of loyalty can impede the reporting of elder abuse [279]. Practitioners may be unsure due to lack of preparedness. There is a shortage of services for elders, particularly in rural areas, making it difficult to make proper referrals. In some rural areas, transportation barriers make it even more complex [196].

Ultimately, the effectiveness of mandatory reporting laws remains unclear. There does not appear to be a difference in the number of reports in states with and without mandatory reporting laws [226].

Healthcare professionals can play a significant role in education and information dissemination. It is important to educate the victim by providing him/her with information about the nature of the problem, their options, and assuring the victim that he/she is not responsible for what has happened. Distribute literature about elder abuse when appropriate, and provide a list of emergency community resources (e.g., lock replacements, counseling, hotlines, shelters, meals-on-wheels, visiting nurse, adult day care). Family members also require education. The key is coordination of various professionals and organizations in order to provide education, technical assistance, and services [247]. Educating practitioners about elder abuse is also crucial. Interactive trainings, utilizing case studies, simulations, and role plays, are more effective [278].

Practitioners should review safety planning with the elder. Components of safety planning involve encouraging the patient to have emergency numbers on hand; being able to identify warning signals that the violence might escalate; having bags packed in the event that the elder needs to leave immediately; and forming an escape plan by identifying all the exits. The elder should be encouraged to replace locks if necessary. Remember, older women and men do experience domestic violence or spousal abuse; and therefore, it is important to review safety planning. Again, safety planning should be done in such a way that it does not contradict the ethical principle of respect for persons; it should help keep elders safe but simultaneously empower them to change their situations [197].

Elders may require legal assistance to establish guardianships, revoke powers of attorney, and obtain orders of protection. Every state offers orders of protection for domestic violence. These orders are available for victims of provable violence perpetrated by a person to whom the victim is married or was formerly married, has a child in common, or is related by blood [198]. Some states extend the availability of orders of protection to include vulnerable adults [198]. Orders of protection essentially stipulate that the abuser must stay away from the victim and his/her home, vacate the home, and/or refrain from abuse or threats. In a quantitative study, researchers found that older men were less likely to receive a protective order, and older women were less likely to have a second hearing [280]. Generally, requested protective orders tended to be for the petitioner's residence. Practitioners must be aware of the limitations of orders of protection and seek legal consultation for elder abuse victims. More states are expanding their definition of domestic violence to include other forms of family violence, including elder abuse [199].

Practitioners can discuss options for alternative living arrangements with elderly individuals. Depending on the situation, domestic violence shelters might be appropriate; in other cases, temporary stays in care facilities, senior housing, or shelters for victims of abuse may be preferred [200]. However, domestic shelters are not always suitable for elders, especially if they have limited mobility or require assistance with activities of daily living [218]. Always begin with the least restrictive arrangements. For example, does the elder have someone to stay with him/her? In addition, explore options such as home care arrangements and the issue of temporary or permanent alternative residences (e.g., a senior citizen residence, nursing home, shelters).

Providing services to elders at risk of abuse or who are victims of elder abuse is complicated. Practitioners must wrestle with issues of self-determination, mental competency, and, as discussed previously, inconsistency of elder abuse statutes from state to state. The concept of self-determination refers to the right of individuals to make their own decisions [201]. To truly self-determine, each person must have several alternatives that are feasible and appropriate to their situation. To complicate matters, in working with elder abuse victims, practitioners also must examine patients' levels of "learned helplessness," fear, and mental competency, all of which affect their ability to self-determine [201]. Consequently, working with elders requires a long-term casework approach—the building of a trusting relationship with the patient, referring, linking, and coordinating appropriate services, and providing counseling and support to the individual [201].

Healthcare facilities often conduct background checks on their care providers. Families who hire care providers for their elder relatives should also conduct comprehensive background checks to reduce the risk of abuse. Family members may do some background checks themselves by calling references and verifying employment dates. With Internet technology, there are businesses that will conduct background reports for a nominal fee. Red flags that could indicate potential problems include [202]:

In some states, banks are mandated to report incidences of financial abuse of their elderly clients through APS [203]. However, many banks are concerned about legal liability despite the fact that there are immunity clauses for those who report in good faith.

In terms of general prevention, social services and other outreach programs can help with early detection and overcoming the barrier of isolation [231].

Although elder abuse has been the subject of intense research and debate for several decades, there remains little consensus about the effectiveness of any one particular intervention [250]. Studies that evaluate elder abuse interventions often have small sample sizes, lack methodologic rigor, and tend to rely on poor-quality evidence, making it challenging to definitively identify effective intervention and prevention services [250,251,252].

Autonomy is defined as an ability to control one's own life and is based on independence and freedom [204]. On the other hand, self-determination is characterized by the ability to make informed decisions and plans to fulfill personal goals [205]. Both autonomy and self-determination are important aspects of care and should be protected. In a systematic review, the ethical principle of autonomy emerged the most often in geriatric literature [289]. Autonomy issues involved human dignity and integrity, respect for the elders' wishes, the value of family members' views, and information given to the elders and family about diagnosis, treatment, and end-of-life interventions [289]. In some cases, the violation of clients' autonomy and self-determination is very subtle. For example, practitioners should consider whether the role of the practitioner's expert status inadvertently reinforces or mimics the power dynamic in an abusive relationship [206]. The abused elder should feel free to make decisions regarding his or her life or care.

The state may intercede when an individual cannot protect him/herself from harm. Referred to as parens patriae, the state's intervention allows agencies, such as APS, to provide voluntary and involuntary services for at-risk elders [207].

The balance between promoting self-determination and ensuring the welfare of the individual is a delicate issue. Practitioners should keep in mind that an elder's level of autonomy is not static. It will constantly change due to altering medical conditions and level of functioning. Therefore, is important to periodically evaluate the individual's level of autonomy to determine the balance between supporting self-determination and beneficence [197,253].

It is important that practitioners be supportive of patients' decisions regarding care [205]. To this end, the National Association of APS Administrators and others have identified best practice guidelines to promote principles of autonomy and self-determination [207,208,253]:

The issues of self-determination and an individual's mental capacity are components of assuring informed consent. Although protecting a client's self-determination is important, there will be times when a person cannot give informed consent or there are questions regarding the patient's degree of capacity [290]. If a client's capacity may be compromised, there are three courses of action that may be taken. A surrogate caregiver, ideally identified by the client via a durable health care power of attorney, could provide consent. Alternatively, the surrogate caregiver may give informed consent while the elder gives assent. Finally, the client may have created documents indicating consent for certain procedures or wishes (e.g., living wills, do not resuscitate orders) prior to incapacitation [209].

The practitioner's duty to respect a patient's or client's privacy of information is referred to as confidentiality. Because a victim's trust has been violated, he/she may have difficulty trusting practitioners and may be reluctant to accept help [253]. If during any patient assessment abuse is suspected, the necessary steps of action will be dictated by the state laws regarding elder abuse [253]. Effective collaboration involving sharing information across various agencies to coordinate services to protect the elder is vital, as is the protection of the client's right to confidentiality. Ultimately, the promotion of confidentiality should not breed inaction [175].

It is unethical to assume that all elders do or do not have the capacity to make decisions. If an elder abuse victim does not take action against the perpetrator or to end the abusive relationship, this does not indicate lack of capacity [198].

It is often assumed that with old age comes diminished intellectual ability, which is an ageist attitude [198]. Normal aspects of aging, such as hearing loss, may make communication difficult, which may in turn be misinterpreted as diminished capacity. Therefore, each patient's physical limitations should be taken into account and communication modified as necessary. This allows important information to be accurately conveyed and ensures that all decisions are appropriately informed [198]. It may be necessary to take more breaks or otherwise accommodate the elder's needs during appointments [218].

Beneficence refers to doing good and promoting the well-being of others, while maleficence is avoiding doing harm to others [291]. Because Western society views elders as vulnerable, practitioners may be inclined to engage in an intervention on behalf of the elder, believing it is in their best interest [290]. There is a continual ethical balance of promoting client autonomy and beneficence [290].