In the United States, the conception of elder abuse was closely linked with the concept of child abuse [20]. The picture of a frail elderly parent dependent upon their adult child caregiver was disseminated, and because there was no statute for elder abuse at that time, lawmakers and service providers turned to the child abuse model with its mandatory reporting laws [15,20]. In 1974, an amendment to the Social Security Act created the Adult Protective Services (APS) [22]. At that time, the purpose of APS was to protect adults with physical and/or mental limitations [25]. However, the APS system became the solution when elder abuse became a public issue, allowing action on the matter without having to call on additional state funds [15]. Consequently, policies and programs were tailored to look like the child abuse and neglect model. For example, both child abuse and elder abuse models require the reporting of incidences of abuse through specific channels, the designation of certain professionals to report if incidences of abuse are learned, and penalties for violations. In both forms of family violence, a third party can intervene if there is suspected child or elder abuse [16].

In the late 1970s, there was a shift in attention to elder abuse in nursing homes. The Administration on Aging advocated including elder abuse prevention in the Older Americans Act [25]. In 1978, the Older Americans Act was amended to include the responsibility of each state to develop long-term care ombudsman programs to deal with elder abuse in nursing homes [17]. A public health perspective was also introduced in the 1980s, as the Centers on Disease Control and Prevention implemented more policies and resources in this area [25]. By the 1980s, research tended to focus on elder abuse rather than adult protective services, likely because elder abuse sounded like a more dramatic social problem [105]. In 1987, with the increased public interest in elder abuse, the National Center on Elder Abuse was developed by the federal government to more clearly define elder abuse and neglect as well as to promote awareness and formulate educational programs for elder abuse [17]. By 1991, there were mandatory reporting laws in 42 states; however, a study by the Government Accounting Office found that these laws were not effective in reducing elder abuse [105].

Elder abuse remains a largely invisible problem, which is due in part to the fact that the elderly are frequently isolated. Frail elders often do not leave the house, perhaps seen only by a caregiver, allowing their abuse to remain behind closed doors [10]. Also, our society has some misconceptions about this period of life. We generally view the elderly years as "golden," as a period when one retires, travels, and spends time pursuing leisurely activities. Additionally, we believe that the family is a private domain, free from public scrutiny. These factors allow elder abuse to continue to occur in both domestic and institutional settings.

In a systematic review that represented 28 different countries, the overall prevalence rates of elder abuse was assessed at 15.7%; 11.6% had experienced psychological abuse [213]. It is estimated that approximately 1 in 10 Americans older than 60 years of age has been the victim of abuse, including physical abuse, psychological or verbal abuse, sexual abuse, financial exploitation, and neglect [23,24,214]. According to data from the National Intimate Partner and Sexual Violence Survey (NISVS), 14% of adults 70 years of age and older had experienced some form of abuse in the past year [215]. In a national study of older Americans (mean age: 75.5 years), 40% of women and 22% of men reported at least one form of mistreatment (i.e., emotional, physical, or financial) [40].

In Asia, the topic of elder abuse is receiving increased empirical attention. In a study of Korean caregivers and their elderly family members with various types of physical and cognitive abilities, the most common forms of elder abuses were psychological abuse and neglect [45]. Almost one-fifth of respondents (18%) disclosed to confining the elder family member in a room and 10% admitted to having hit the elder. In a large-scale study conducted in China, 2,039 individuals 60 years of age and older were interviewed, and 36% of the participants indicated they experienced elder mistreatment [46]. Specifically, the prevalence of physical elder abuse was 4.9%, psychological abuse was 27.3%, caregiver neglect was 15.8%, and financial mistreatment was 2% [46]. In another study in China, psychological abuse in the past year was reported by 11% of children of elderly parents [233]. Risk factors for abuse included having depression, being alone (e.g., divorced, widowed), and having a labor intensive job. In another survey study of individuals 60 years of age and older living in an urban area in China, 35% of the sample (32% men and 42% women) reported elder abuse and neglect [47]. Caregiver neglect was the most common form (16.9%), followed by financial exploitation at 13.6%. In Hong Kong, Yan and Tang conducted a survey study on the risk factors of elder abuse with 276 elder Chinese individuals, 27.5% of whom admitted to having experienced at least one type of abusive behavior perpetrated by a caregiver during the past year [48]. The findings of the study also found that verbal abuse was the most prevalent, at 26.8%, while violation of personal rights (5.1%) and physical abuse (2.5%) were less common. Participants who had visual or memory problems and who were dependent on their caregivers were more at risk of general abuse and verbal abuse [48]. In a study of 3,157 older Chinese immigrants, 15% reported experiencing mistreatment by a family member [222]. In a separate study of 2,713 older Chinese Americans, the overall abuse rate was 8.8% [223]. In a study of Chinese women older than 60 years of age, 15.8% experienced mistreatment [224]. In each of these studies, poorer health status and/or deteriorating health were associated with mistreatment.

In general, elder abuse literature has identified three basic categories of abuse and neglect: domestic elder abuse; institutional abuse; and self-neglect or self-abuse. The World Health Organization (WHO) defines elder abuse as "a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust that causes harm or distress to an older person" [225]. However, one of the biggest difficulties in the field of family violence revolves around the definition of the problem. Defining social problems is controversial because the definition determines the prevalence rate of who is counted as abused and who is not. It determines what legislation does and does not cover, and it directs programs regarding the eligibility criteria of who does and does not receive services.

Abuse is generally perceived as more serious because it is viewed as a deliberate or intentional act to harm [10]. Conversely, neglect has generally been viewed as less serious because the intent of the perpetrator is not necessarily deliberate. That is, neglect is an act of omission—not doing something because of ignorance or some situational factor (such as stress) [10]. The Centers for Disease Control and Prevention, the NCEA, and other organizations include both an intentional act and a failure to act in their definitions of elder abuse [23,49].

Other definitions have focused on the types and categories of abusive acts. The NCEA and the Administration on Aging have defined seven different types of elder abuse, which are based on state and federal definitions [49,50,218]:

There are some studies that indicate that women are more likely than men to be victims of elder abuse [56]. Other demographic factors that contribute to risk include unmarried status and non-White ethnic origin [57]. Elders who reside with a caregiver or family with a history of substance abuse, mental illness, and violence are more at risk of abuse [56]. One study found that elders who have short-term memory problems, psychiatric diagnoses, and/or alcohol problems are more vulnerable to elder abuse [58]. Elders who have poor health and low income also appeared to be at risk of elder abuse [55,57]. Many studies that have found a relationship between elder abuse and existing health problems, functional physical deficits, and frailty. Whether health status is measured with objective evaluations or via self-reports, an elderly individual with poor health is at an increased risk of elder abuse [254]. Certain personality traits are also associated with elder abuse. Those who score higher on measures of neuroticism have been found more likely to report elder abuse [255]. Neuroticism is a personality trait whereby one tends to experience negative emotions and greater emotional instability. These persons may be more reactive to conflicts and tend to focus on negative rather than positive events [255].

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 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.

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.

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.

A third reason to take into account culture, race, and ethnicity in the study of elder abuse is that these factors influence the labeling or the perception of the social problem. Diller argues that human beings relate to their world through cognitive worldviews or paradigms [98]. These worldviews and paradigms provide individuals with rules and assumptions about how the world works. Culture and ethnicity provide the content of these worldviews [98]. Consequently, how a group labels or constructs abuse or maltreatment is influenced by their cultural beliefs and values, which ultimately affect how domestic violence is perceived, exhibited, and reported [99]. Furthermore, the social realities of the lives of older abused immigrant women may be uniquely different from their younger counterparts as a result of generation, acculturation, and gender role socialization differences. These factors may distinguish how elder abuse victims label their situations and what services they may seek [100].

It is important to remember that there is tremendous diversity within groups. In other words, factors such as acculturation, age at immigration, education level, socioeconomic status, and religion all contribute to the heterogeneity within each subgroup. Falicov cautions against static descriptions of ethnic groups because they are merely social science simplifications rather than true portraits of the complexities of culture, race, and ethnicity [104]. Consequently, bear in mind that the following information is intended to present general themes to guide practice and not indicate hard and fast rules.

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].

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].

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].

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 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.

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].

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.

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].

Assessing for elder abuse does not merely involve asking the victim questions. It also involves asking oneself difficult self-evaluative questions such as: Do I hold ageist attitudes? How are these attitudes translated when I conduct an assessment? Do I believe that elders can be abused, even sexually abused? Because of pervasive ageist attitudes, practitioners often fail to acknowledge that some forms of elder abuse occur [177]. This may impact whether certain assessment questions are asked.

To screen elders who may be at risk, Sengstock and Barrett recommend that practitioners assess the following domains [178]:

The Elder Abuse Suspicion Index (EASI) is a five-item tool that provides practitioners with a very quick sense of whether there is potential presence of elder abuse [182]. It was originally developed for use by physicians and has been recommended by the U.S. Preventive Services Task Force, but it can be used by practitioners in diverse disciplines [245]. The following items comprise the index [182]:

Other guidelines for effective screening include [186]:

Welfel, Danzinger, and Santoro encourage practitioners to interview family members separately [16]. The environment should be quiet and calm, as possible; it may take some time for the patient's story to emerge, and the practitioner should not rush this process [277]. This is more likely to elicit honest disclosures than interviewing elders and their family members together. An elder might feel embarrassed or intimidated and will refrain from disclosing abuse in the presence of family members. No family members should be discounted as possible perpetrators.

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].

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.

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].

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]:

ICP teams for elder abuse include attorneys, law enforcement personnel, and geriatric specialists from the medical, nursing, and social work [286]. Forensic accountants might be necessary to identify and document financial abuse [292]. ICP teams might also include paraprofessionals, who can bridge the health, social, legal, and mental health care systems with members from different racial and ethnic minority communities. These paraprofessionals include religious leaders, cultural experts, translators, interpreters, and other frontline community workers [287].

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].