Phenomenon Correlating Relationship to Mortality

Elder Abuse Phenomenon Correlating Relationship to Elder Mortality

Elder abuse has received increased scrutiny from the law enforcement and healthcare community in recent years. This increased attention is due in part to the increasing number of elderly in the United States and the passage of various laws designed to improve the reporting of such episodes of abuse as well as the prosecution of those who abuse the elderly. Unfortunately, elder abuse is particularly difficult to detect in some cases and studies have shown time and again that many elderly people are highly reluctant to admit to such abuse for fear of reprisals from the abuser or the possibility of being institutionalized if existing domestic living arrangements are disrupted. The purpose of this study was to critically review the relevant peer-reviewed and scholarly literature concerning elder abuse in general and its contribution to premature death among this population in particular in order to identify opportunities for improving the delivery of support services and describing best practices as they exist today. To this end, a summary of the research, salient findings and recommendations are presented in the concluding chapter.

Chapter 1: Introduction

Statement of the Problem

Purpose of Study

Importance of Study

Scope of Study

Rationale of Study

Overview of Study

Chapter 2: Review of Related Literature

Chapter 3: Methodology

Description of the Study Approach

Data-gathering Method and Database of Study

Chapter 4: Data Analysis

Chapter 5: Summary, Conclusions and Recommendations

Elder Abuse Phenomenon Correlating Relationship to Elder Mortality

Chapter 1:

Introduction

Statement of the Problem

Elder abuse is a growing phenomenon across a wide range of societies and populations today. The research on this social problem has tended to focus on estimates of its prevalence and on characterizations of its perpetrators and victims; however, there remains a paucity of research that have offered explanations for emergence of the phenomenon itself (Litwin & Zoabi, 2004). Estimates of elder abuse in the Western world vary widely, making it difficult to confirm the extent of the problem. In many cases, the phenomenon is underreported due in large part because physical and psychological symptoms of abuse may be denied by victims or misinterpreted by services personnel as simply being the normal consequences of the aging process (Litwin & Zoabi, 2004). In addition, elder abuse is more difficult to detect than others forms of abuse because elders tend to be reluctant to disclose such behaviors, especially when they involve close family members, out of fear of future retribution or their institutionalization if they are removed from the abusive environment.

Moreover, the lack of satisfying treatment alternatives on behalf of abused older people is a disincentive to reporting of risk status (Litwin & Zoabi, 2004). This point is made by Bergeron (2000) who reports that “Elder abuse has been documented to be a social problem of national and international concern” (p. 40). Indeed, the Select Committee on Aging of the U.S. House of Representatives reported that, “Some 5% of the Nation’s elderly may be the victims of abuse from moderate to severe… Or more than 1.5 million elderly may be victims of such abuse each year” (Select Committee, 1990, p. xi). A consistent theme that quickly emerges from the research is just how underreported the problem of elder abuse may be in many parts of the country. While all states have laws and services in place to detect domestic elder abuse, only about one in five actual cases is reported and substantiated; therefore, how cases are identified and resolved varies significantly across the nation because laws and regulations vary greatly (Jogerst, 2004).

According to Gellert (1997), there are three settings in which elder abuse generally takes place (a) domestically; institutionally (in nursing homes, hospitals, and long-term care facilities); and through self-neglect and self-abuse. In this regard, Gellert notes that, “Elder abuse tends to occur in a situation in which an elderly person’s needs are exceeding, or will soon exceed, the ability of a caregiver to address them adequately. The caregiver experiences increasing frustration and stress as his or her ability to give care diminishes. Elder abuse tends to increase in frequency and severity over time” (Gellert, p. 190). In his book, Handbook of Domestic Violence Intervention Strategies: Policies, Programs, and Legal Remedies, Roberts (2002) reports that:

Elder abuse as a form of institutional abuse involves a care-dependent victim and an abusive formal caregiver (e.g., nurse’s aide, nurse, home health aide). Institutional abuse can occur in a nursing home, hospital, or the victim’s home, with the abuser part of a formal care system. Depending on the severity of the neglect or mistreatment of a care-dependent older adult by a formal caregiver, the abuse or neglect may constitute a criminal offense. Most state laws mandate reporting of any suspected or actual abuse or neglect of a formal caregiver against a care-dependent older adult to the state department of health. Perpetrators may be subject to criminal investigation, prosecution, fines, and loss of license to practice. (p. 488)

While institutional elder abuse has received a great deal of attention, elder abuse by family members has been identified as a growing problem in American society in recent years as well. In fact, since the beginning of the first congressional investigation of elder abuse in 1978 (Olinger, 1991), every state has implemented some form of elder abuse reporting law with an agency designated to accept reports of suspected elder abuse, investigate such allegations, and provide intervention for the elderly victim (Bergeron & Gray, 2003). The American Medical Association (AMA) also issued its first guidelines on elder abuse in 1992, urging physicians and other healthcare providers to be more alert to signs of mistreatment or neglect of older patients by their families or caregivers (Aguilera, 1998). According to this author, “The 42-page guidelines, part of a new AMA campaign against family violence, come amid growing national concern about a long-hidden problem in which as many as 2 million elderly Americans are believed to be victims of abuse or neglect” (Aguilera, p. 112).

According to the National Elder Abuse Incidence Study (National Center on Elder Abuse, 1998) “the best national estimate is that a total of 449,924 elderly people, aged 60 and over, experienced abuse and/or neglect in domestic settings in 1996” (p. 4), and of that number approximately 16% were reported to elder protection agencies. Experts in the field say that elder abuse is grossly underreported for several reasons: the isolation of elderly people, lack of uniform reporting laws, and the general resistance of people, including professionals, to report suspected cases of elder abuse and neglect (Tatara, 1993). The majority of perpetrators of domestic elder abuse are family members (Bergeron & Gray).

According to Baker (2007), the mistreatment of the elderly – even unto death — represents a widespread and increasingly serious problem in the United States today. “Elders who are mistreated face negative consequences, including higher mortality risk when compared to nonmistreated peers,” Baker advises, and adds, “Factors such as childhood physical abuse or neglect, depression, and dependence on others for activity of daily living assistance make elders vulnerable to mistreatment. Geriatric syndromes, such as frailty, may also contribute to elder mistreatment vulnerability, whereas chronic stress may be a mediator in early mortality” (p. 313). Finally, as Ebersole and Hess (1998) emphasize, “In a society becoming increasingly more violent, it is reasonable to assume that abuse of elders and other vulnerable persons will continue to increase” (p. 562).

Purpose of Study

Complex problems require complex solutions and such is the case with elder abuse. According to Thursz, Nusberg and Prather (1995), “The causes of elder abuse are complex, arising from any one of the following: the abuser’s personality, the older person’s behavior, family dynamics, or environmental pressures” (p. 42). Within this broad range of contributors factors is a constellation of social, cultural and gender issues that make developing effective interventions problematic, and the problem is only going to get worse in the years to come. As Gellert (1997) advises, “A number of factors contribute to elder abuse, including psychological, social, medical, and economic influences. These influences affect an elderly person’s interpersonal and family relationships” (p. 191). Therefore, the purpose of this study was to critically review the relevant peer-reviewed and scholarly literature concerning elder abuse in general and its contribution to premature death among this population in particular in order to identify opportunities for improving the delivery of support services and describing best practices as they exist today.

Importance of Study

Since the beginning of the 20th century, average life expectancy in the United States has increased from 47 years to over 75 years (Gardner & Hudson, 1996). According to Johnson (1999), “In 1900, over half of all deaths involved persons 14 years of age or younger. Today only 2% of all deaths occur within this age group. As a corollary, an increase in the relative size of the older population (persons 65 years of age or over) is clearly evident. Elderly persons comprised 4% of the total population in 1900, 12.6% in 1990, and will be as much as 23% by the year 2050” (p. 126). Although there are an increasing number of elderly in the United States today with many more expected in the future, the study of elder abuse is of fairly recent origin. During the last three decades of the 20th century, following the “discovery” of child abuse and domestic violence, scholars and professionals started taking an active interest in the subject of elder abuse. This increased attention from the academic community, together with a clear indication from the respective state and federal governments that they were willing to intervene in family matters and the growing aging population of elders at risk for violence in the home, makes it understandable what elder abuse has gained public and scholarly attention in recent years. In this regard, Nadien (1995) notes that, “Violence against the elderly, often referred to as elder abuse, emerged as a serious concern only in the late 1970s and early 1980s. At that time, the first set of published research and governmental findings revealed that maltreatment, while only 4% among the well elderly, reached 10% among the frail or impaired elderly. Today elder maltreatment is thought to be six times greater than these figures suggest” (p. 177).

Despite this growing attention, though, some observers suggest that elder mistreatment research is lagging 20 years behind (Kurst-Swanger & Petcosky, 2003). Indeed, although the abuse of elders has generated considerable interest over the past two decades as the prevalence of the problem has become more discernible, the problem has not received the attention it needs (Ebersole & Hess, 1998). According to these authors, “States on average spend $22 per child for youth protective services but only $2.90 per elder for protective services, though 40% of reported abuse involves elders” (Ebersole & Hess, p. 562). The results of an 11-year longtitudinal study of community elders showed that almost 10% of them were referred for adult protective services at some point in time (Lachs et al., 1996). Moreover, recent increases in the incidence of elder abuse has introduced some difficult questions concerning the advantages of separating family members when abuse or neglect has been reported, especially when the abused person is dependent on the relationship for important benefits (Chalk & King, 1998). Finally, as Proctor (2004) emphasizes, “Nearly half a million cases of elder abuse are reported each year. Yet, we know very little about it. The little that is known comes from small studies or anecdotal information. Thus, research on the correlates and causes of elder abuse are badly needed” (p. 131).

Scope of Study

Although the study examined the issues surrounding elder abuse across various cultural settings, there was a specific focus on the United States.

Rationale of Study

Because there are going to be more elderly people in the United States in the years to come, it is reasonable to posit that the incidence of elder abuse will also continue to increase as well. According to Adler and Denmark (1995), “The need to identify and remedy elder abuse takes on urgency in the light of a burgeoning of the aged population, who currently make up almost 13% of the U.S. population and who are projected to account for over 20% of the population by the year 2020, with 21% of all males and 24% of all females expected to be 65 years or older” (p. 177). Indeed, it goes without saying that elders who are emotionally, physically, or sexually abused are at increased risk for the entire constellation of comorbidities that can accompany such abuse, including death.

Furthermore, besides being the fastest-growing age segment, the elderly segment of the American population today is living much longer. As Adler and Denmark point out, “Among U.S. residents who reached age 65 during the 1980s, males can expect to live until age 80, and females to age 84. Thus, it is important to find ways of detecting and checking the maltreatment of impaired old-agers” (p. 177). Much has been written about improving the quality of life for senior citizens over the years, but the bottom line outcome for the purposes of this investigation is the relationship of such abuse to premature deaths. As one authority notes, “The ultimate measure of the quality of life is mortality” (Kosberg, 2005, p. 9).

There are some profound constraints involved in investigating instances of abuse among the elderly, though, because it requires a long-term casework approach. In this regard, Bergeron (2000) emphasizes that, “The building of trust with older clients, particularly abused older clients, is paramount in creating a working relationship. Elderly people traditionally are skeptical of the helping profession. They are slow to disclose, and they fear being removed from their homes and placed in nursing homes” (p. 40). In fact, at least one study has shown that elder victims of abuse would choose to remain in their own homes and continue to suffer from the abuse than be uprooted to a nursing home setting (Bergeron). Indeed, this fear is not without basis. As Kohl (2003) reports, “Despite the stringent federal regulation of long-term care facilities, nursing home abuse remains rampant throughout the United States” (p. 2083).

Overview of Study

This study used a five-chapter format to achieve the above-stated research purpose. The first chapter introduced the topics under consideration, the purpose of the study and its importance, scope and rationale. The second chapter presents a critical review of the relevant peer-reviewed and scholarly literature concerning elder abuse, including its incidence, causes and current intervention approaches. Chapter three describes more fully the research methodology used to develop the research findings, and chapter four provides a recapitulation and summary of key findings from the research. Finally, chapter five provides a summary of the research, salient conclusions and recommendations for policymakers and those providing caregiving services for the elderly, as well as directions for future directions in research.

Chapter 2:

Review of Related Literature

Background and Overview.

Although no specific legal definition is provided for elder abuse by Black’s Law Dictionary (1990), Gellert (1997) provides a useful working definition of the topic under consideration: “Elder abuse is any action that, either by commission or omission, harms an elderly person. Elder abuse and neglect are complex problems that have evaded clear definition” (p. 183). Likewise, Adler and Denmark (1995) note that, “Violence against the elderly assumes different forms. Although all forms entail suffering for the victim, the source of that pain may derive either from something inflicted or something withheld” (p. 178). Researchers concerned with elder abuse differ significantly, though, on precisely what constitutes elder abuse. According to Gellert, “While child and spouse abuse have been clearly recognized for a number of years, elder abuse has received substantial attention only quite recently. Abuse of the elderly involves physical injury by care givers, psychological abuse, financial exploitation, violation of human rights, and neglect. The varying aspects have not been shaped into a single definition” (p. 183). It remains nebulous, for instance, as to whether the definition of physical abuse should include the failure to provide medical care to an elderly person. Should it include lack of supervision or lack of personal care, or should it be restricted to include only physical injuries? Does elder abuse occur when the victim is fifty-five years and older or sixty-five and older? Widely differing viewpoints have been expressed on these and other issues (Gellert).

It is possible to identify several aspects of elder abuse. Physical or sexual abuse involves direct physical assault. This would include intentionally striking an elderly person, rough handling, sexual assault, and threats with a weapon. Force-feeding and improper use of restraints or medications also constitute physical abuse of the elderly. Psychological elder abuse would include verbal assault, social isolation, or threats that create fear, anguish, and anxiety. Psychological abuse occurs when an elderly person is humiliated or intimidated. It may also include denying older persons participation in decisions that affect their lives (Gellert). In their study of elder abuse patterns, Oktay and Tompkins (2004) report that, “Verbal abuse, (sometimes called psychological abuse) is usually the most frequent type of mistreatment, followed by physical abuse and neglect; sexual abuse is usually the least prevalent type of abuse” (p. 177).

Victimization of the elderly can take place in a number of other ways as well. For example, the elderly are frequently easy marks for entrapment in financial schemes in which they are coerced or otherwise manipulated to give others their money, rewrite their wills, give up control over their finances, assign durable power of attorney, or sign away ownership of their homes and property (Gellert). According to this author, “Financial elder abuse involves fraud, theft, or unauthorized use of an elderly person’s money or property for the gain of an advisor or caretaker. Neglect is failure to meet the needs of an elderly person and withholding or failing to provide that person with the essentials of life, such as food, shelter, clothing, the means for personal hygiene, medical care, and social stimulations. Neglect often overlaps with other kinds of elder abuse” (p. 183). The financial exploitation of elders has resulted in many trust officers paying careful attention to signs of abuse by caregivers. In this regard, Lunt (1995) reports that, “Trust officers watch out for signs of elder abuse. We’re very conscious of conflicts of interest, where we suspect that a client may be being taken advantage of by one person or another,” he says. “When an officer suspects something, he usually tells a family member or the client’s attorney about it and then works with that person to step in and stop it” (Lunt, p. 20).

By sharp contrast, physical abuse involves inflicted pain which can occur when frail or ill elderly are pushed, shoved, grabbed, hit, or assaulted with a gun, knife, or other weapon (Pillemer & Finkelhor, 1988). Such inflicted injuries or concomitant pain may also result from psychological abuse, as occurs in (a) verbal aggression (e.g., insults, blame, ridicule), (b) threats where no weapon is involved, or – some form of coercion, abandonment, or confinement (Adler & Denmark). In addition, inflicted pain may derive from legal or material abuse, the misuse or misappropriation of an elder’s real property (e.g., cash or other resources) as described above (Adler & Denmark).

The growing body of research into elder abuse has provided some useful insights and starting points for further investigation. The early attention given to elder abuse was largely focused on elderly residents of nursing homes in which there were incidents of abuse by employees; since the majority of care provided for elderly Americans occurs in the home, though, it is not surprising that the majority of elder abuse happens in these settings. As a result, some of the underlying causes of elder abuse include the vulnerability of older individuals, the high level of violence in society generally, stress, substance abuse, and poverty among both victims and abusers (Gellert).

Elder abuse has been generally regarded as a public health issue, and like the allocation of educational resources for domestic violence, much of the literature specifically on teaching about elder abuse is largely found in nursing and medicine (Wilke & Vinton, 2003). According to these authors, “The medicalization of elder abuse results from elders being viewed as a group whose impairments are exacerbated by abuse or neglect and therefore requires health care services. Because elder abuse is now covered by both civil law and criminal law, proposals have been suggested for its inclusion in legal education” (p. 225). As the baby boomers continue to reach retirement age and begin experiencing the physical ravages that go hand-in-hand with the aging process, though, an increasing number of adult children are going to be tasked with caregiving responsibilities to some extent. These caregivers will likely not enjoy the same level of preparedness – or indeed the fundamental wherewithal — as healthcare professionals and other members of the helping professions, and the problems associated with the increased levels of stress that are natural concomitants of this caregiving are well documented. Moreover, there are also issues of spousal abuse and self-abuse among the elderly, and these issues are discussed further below as to their respective incidence and the perpetrators involved and the typical causes of elder abuse today.

Causes of Elder Abuse.

Recent innovations in medical technology have provided the ability for people to live longer lives, but this does not necessarily equate to healthier and fulfilled lives. Although some people in the United States may not realize it, many frail or sick elderly people continue to live in their homes and are cared for by various family members who are mostly women and who are frequently the spouse of the elder (Bergeron & Gray, 2003). Despite these findings, Kosberg points out that, “Although males are popularly depicted as abusers (of children and females), there is reason to believe that males are at least as likely as females to be victims of abuse — including elder abuse” (p. 9).

Domestic caregivers of the elderly of whatever gender, though, are frequently beset by a wide range of financial, emotional, and physical stresses associated with their caregiving responsibilities, and some common feelings reported by such caregivers are isolation and loneliness; in many cases, a dearth of community resources contributes to the sense of hopelessness and fatigue they experience during their provision of care (Bergeron & Gray). According to Jensen (2001), “Elder abuse is found to be associated with the stresses of caring for elders. These include psychological exhaustion, subsuming individual needs to the needs of the elderly family member, devaluing the caregiving, and financial strains involved in caregiving. The less others are available to assist, the greater the dependency of the elder on a single caregiver, and the greater the degree of dependence, the more likely it is that abuse will take place” (p. 54). As Thursz and his colleagues (1995) point out, “Under the burden of care, the caregiver lashes out. In other cases, the caregiver may be settling old scores, after the ‘fall of the tyrant,’ taking revenge on a once-powerful parent for real or imagined slights and hurts sustained in childhood” (p. 42).

Some of traits typically found in elderly abusers include: (a) low self-esteem, (b) poor coping mechanisms and communication skills, – drug or alcohol abuse, and (d) mental illness (Thursz et al.). Those who abuse the elderly may feel trapped and resent loss of career, friends, and leisure time; disappointment at inadequate recognition or rewards for caregiving; and outrage at the injustice of an unshared caregiving burden within the family (Thursz et al.). According to Gellert, “Elderly people with severe mental and/or physical disabilities are more likely to be abused than those without disabilities. The amount and complexity of care required for a disabled elderly person promotes stress in the caretaker and contributes to abuse as described above. Some experts believe that violent behavior is learned by younger generations from parents and transmitted in a cycle of violence” (p. 191).

The traits found most irritating and provocative in the dependent elderly have been identified as including selfishness, self-pity, masochism, sadism, complaining, feigned illnesses, indulging in amateur dramatics, begging for overdoses, or to be smothered or killed (Thursz et al.). The various family dynamics that have been shown to contribute to elder abuse include poor family integration, cycles of violence inherited by each generation, sibling feuds, and social isolation removing the family from the controlling factor of neighborhood disapproval (Thursz et al.). Finally, environmental factors contributing to elder abuse may include unemployment, inadequate housing, migration, and man-made and natural disasters (Thursz et al.). Consequently, elder homicide, as an extension of these types of elder abuse, can reasonably be posited to be influenced by these factors (Bergeron & Gray).

Moreover, women’s relationships with children and elders have some significant commonalities including the following:

The social demand, in more traditional social systems, for women to care exclusively for both the very young and the elderly;

The frequent deviantizing of women caregivers seeking outside help such as child care or nursing home care; and,

The economic strain such caregiving often causes and the negative impact of women’s disadvantage in the workforce on the economic costs of caring for elders or children (Jensen).

From these general background themes, it can be readily discerned that although every situation is unique, there are some commonalities involved in the dynamics of elder abuse.

For instance, emotional stress has been identified as a major trigger in elder abuse, but it is unlikely that stress alone will result in a homicidal event. In this regard, Coney and his colleagues report, “Stress, when combined with a lack of social and economic support and extreme isolation, can lead to a state in which options are seen as limited. Isolation and feelings of entrapment were also reported in elder abusers [and] these problems are compounded by the dependency of the elder on the caregiver (Jensen).

The effects of isolation and limitations of social options can be intensified by a lack of economic resources to obtain necessary assistance. In both child abuse studies (Milner and Crouch, 1993; Gelles, 1993) and elder abuse studies (Boudreau, 1993; Gelles, 1993; Hooyman and Ryan, 1987), limited economic resources interacted with subjective experiences of stress to make abuse more likely. If these familial homicides are viewed as a lethal extension of abuse, a picture emerges of women as more likely to kill when they are expected to be the sole caregivers and to sacrifice their own needs, when they are experiencing stress from caregiving demands, when they are isolated, and when they receive little financial assistance. Low levels of gender equality increase the likelihood that women will experience these conditions (Jensen).

The homicidal event will likely be a final effort to escape from a seemingly inescapable situation. Like her intimate partner homicide counterpart, the female familial homicide offender will kill the perceived object of her oppression. As Unnithan and colleagues (1994) discuss, in lethal violence the choice of homicide occurs when the source of one’s stress and anger becomes externalized and located outside the self. At this point aggression will be turned toward that perceived source. It is at this point that the killing of children and family members is most likely to happen, particularly if no other alternatives are seen for alleviating the stress. There is also a sense that abuse (and, by extension, killing) of the powerless is fed by a woman’s own powerlessness and represents a desperate attempt to gain power for herself (Jensen). The basis for this sense of powerlessness can be regarded as resulting – at least in some part — from a society that does not provide the full range of equal opportunities that are typically afforded men, and the general features of gender equality may operate in these specific types of family killing scenarios (Jensen).

Finally, Johnson (1999) reports that, “No form of elder abuse receives more public and professional involvement than self-neglect (including self-abuse)” (p. 197). This author suggests that this fact is evident in at least three ways:

The higher reporting of self-neglect over other abuse forms;

The breadth of agencies encountering self-neglect situations; and,

The importance placed on handling self-neglect cases in protective practice (Johnson, p. 197).

One of the natural outcomes of long-term self-neglect, of course, is premature death, but this problem in particular remains understudied; nevertheless, it is well established that psychological well-being plays a significant role in the preservation of physical health and functional capacity (Grant, 1996). According to Lachs (2007), “Although self-neglect in community-dwelling elders is suspected to have psychiatric antecedents, depression has not been formally investigated as a predictor of this syndrome” (p. 37).

When older people are removed from the comfortable surroundings that they have been familiar with for years and thrust into such alternative living arrangements, it is not surprising that many of them will experience some degree of depression. To the extent that such depression is allowed to continue unresolved, though, is likely the extent to which self-neglect and its adverse outcomes will occur. To explore this relationship further, Lachs and his colleagues (2007) sought to determine the contribution of depressive symptoms to a multivariate model predicting self-neglect in community elders. According to Lachs, “The New Haven Established Population for Epidemiologic Studies in the Elderly (EPESE) cohort, which included 2,812 community residents older than 65 years in 1982 was linked to adult protective service records within the catchment area of the cohort. The principal outcome measure was referral to adult protective service for self-neglect occurring over a nine-year follow-up from cohort inception” (p. 2). The variables assessed at the beginning of the study were used to develop a predictive multi-variable model of self-neglect for this cohort. From the original 1982 cohort of 2,812 subjects, the researchers ended up with complete data for analysis on 2,161 of them (Lachs et al., 2007).

The incidence of clinically significant depressive symptomatology at baseline (score >16 on the Center for Epidemiologic Studies for Depression Scale (CESD)) was found to be 15.4% (Lachs et al.). During the period 1982 to 1991, these researchers identified 92 corroborated cases of self-neglect among the 2,161 subjects in the analysis, resulting in a weighted crude incidence of 0.007 self-neglect cases per person year (Lachs et al.). The study subjects who had CESD >16 were 2.6 times more likely than subjects with lower scores to experience self-neglect over the course of the study; in addition, after adjusting for age, gender, race and income, depression at the CESD >16 level continued to be a significant predictor of self-neglect, with an incidence rate ratio of 2.4 (95% confidence interval, 1.3-4.5, p<.007) (Lachs et al., 2007).

A final model for self-neglect was developed by Lachs and his colleagues using a stepwise selection procedure for risk factors requiring a significance level of 0.25 for entry and 0.15 for staying in the model; depression contributed significantly to this model (incidence rate ratio, 2.04; 95% confidence interval, 1.12-3.69, p<.05), as did male gender, age, income less than $5,000 per year, living alone, cognitive impairment, history of hip fracture and history of stroke (Lachs et al., 2007). In addition, after controlling for socio-demographic and medical factors, depression remained among the significant predictive factors for self-neglect in an established sample of community-dwelling elders (Lachs et al.). These authors conclude that, “Whether aggressive identification and treatment of depression in isolated older adults would decrease the subsequent onset of self-neglect is an area worthy of future study” (Lachs et al., p. 37). These findings are congruent with other studies of self-abuse and self-neglect among elders. According to Byers and Zeller (1995), “Self-neglect may be the most common form of neglect among older adult protective services clients according to several abuse and neglect studies of older people. Some data suggest that nearly one-half of all elder-abuse cases and possibly two thirds of all neglect cases involve self-neglect” (p. 331).

Likewise, no type of elder abuse has been examined from an ethical perspective than self-neglect, but unlike other aspects of elder abuse, this is not a recent trend; in fact, self-neglect has been the subject of debate for decades. According to Johnson, “Some of this controversy emerges from inquiry into the evolution of protective services. Protective practice defined itself in the 1960s to be a range of services with potential use of legal authority aimed at preventing or remedying neglect or exploitation experienced by adults whose reduced mental or physical capabilities meant that they could not protect themselves. The target population of early protective practice was not unlike the self-neglecting elder of today, although the population was not so labeled” (Johnson, p. 197). The causes of self-abuse among elders, like the other types described above, depends on who is doing the defining and in many cases, a highly subjective assessment of older peoples’ cognitive abilities and capacity to care for themselves.

Furthermore, it is important to note that elder abuse can be either intentional or unintentional. In this regard, Gellert notes that, “If unintentional, it usually results from ignorance or inexperience in a caregiver or a lack of desire to provide care. Some organizations recognize self-neglect and self-abuse among the elderly, which is neglectful or abusive behavior by an older person that threatens his or her own health and safety. It usually results from physical and/or mental impairment in an elderly person, particularly when he or she is socially isolated” (p. 184).

Constraints to Identifying and Prosecuting Instances of Elder Abuse.

Identifying instances of elder abuse and distinguishing them from physical injuries that are a natural consequence of the aging process (bruises resulting from stumbles and so forth) can be problematic. Some of the general indicators of elder abuse and neglect include the following:

Delay in obtaining necessary treatment

Malnutrition, dehydration

Contractures

Pressure ulcers

Evidence of inappropriate medication use, oversedation, and lack of administration of antihypertensives or insulin

Pattern of “doctor shopping” or physician hopping

Previous unexplained injuries/injuries inconsistent with medical findings

Lack of appropriate clothing or assistive devices, such as glasses, hearing aid, or dentures

Certain nonverbal victim behaviors, such as apprehension, fear, withdrawal, or passivity

Reluctance to provide information

Depression or severe helplessness/hopelessness

Anorexia

Tearfulness (Aguilera, p. 112).

In conducting a preliminary assessment of whether an older adult may be the victim of elder abuse, Roberts (2002) recommends that practitioners should be alert to the signs and symptoms described in Table 1 below.

Table 1.

Categories of elder abuse and their indicators.

Category of abuse

Indicators

Physical

Bruises, welts, scratches, burns, fractures, lacerations, or punctures;

Bleeding under the scalp or missing patches of hair;

Signs of excessive or insufficient medication (agitation or decreased alertness);

Missing eyeglasses, dentures, hearing aids;

Dehydration;

Decubitus ulcers (pressure sores); signs of restraints like rope burns;

Soiled clothing or poor hygiene;

Unexplained genital infections or venereal disease (sexual abuse).

Psychological

Sleep disturbances

Change in eating patterns

Unexplained weight changes

Depression and crying

Paranoid references

Low self-esteem

Extreme fearfulness

Confusion and disorientation

Apathy or agitation

Financial

Complaints of hunger or lack of food;

Unexplained inability to pay bills;

Overinvolvement of family member in client’s financial affairs;

Refusal of client or caregiver to pay for needed assistance, even though finances appear to be adequate;

Unexplained withdrawals from bank account.

Source: Roberts, p. 489.

This author and the others reviewed herein emphasize the need for caution in interpreting any of these signs and symptoms of abuse, especially in older patients who suffer from Alzheimer’s disease, dementia, or clinical depression (Roberts). In this regard, Roberts reports that:

Many of these indicators of abuse or neglect resemble symptoms of other problems. A thorough psychosocial assessment is necessary to determine whether abuse or neglect is involved and, if so, whether it is intentional or unintentional on the part of the abuser or caregiver. Even if the client is not experiencing active abuse or neglect, the presence of any of these signs and symptoms of abuse can suggest a vulnerability to abuse or exploitation, and preventive services should be considered. (p. 489)

Likewise, Gellert (1997) provides a list of signs of potential elder abuse that should alert others to the possibility of such abuse taking place; however, the signs of physical elder abuse depend upon the kind of assault made on the victim. According to this author, “Bruises and lacerations around the eyes, mouth, and other parts of the face may indicate abuse. Similar injuries on the body, particularly in the shape of common household items or in the shape of a handslap may be observed. Bald spots from hair-pulling, burns, and skin discoloration or rope burns from being tied up or restrained are all possible signs” (Gellert, p. 189). Depending on the severity and prolonged nature of such abuse, it is reasonable to conclude that any or all of the above could readily contribute to the premature death of the elder victim.

Other signs of elder abuse might not be as straightforward to identify. For example, psychological and emotional disturbances such as depression, fearfulness, and anxiety may be exhibited, and inconsistent histories provided by the elderly person and the caregiver may be indications of possible abuse (Gellert). Certainly, some of these reactions and conditions are simply natural concomitants of the aging process, but as this author and many of the others reviewed herein emphasize, making a judgment call on such suspected incidents of elder abuse require a careful assessment and interpretation; however, the stakes are high for the elders involved and the need for the timeliness of interventions is consistently stressed. In addition, Gellert notes that, “Unexplained injuries or a history of injury that is not consistent with the type or degree of injury observed may indicate abuse. Unexplained delays in seeking care, vague or bizarre explanations, or the denial of obvious injuries are indications of maltreatment. Histories of being ‘accident prone’ or ‘doctor shopping’ and missed medical appointments may indicate an attempt to conceal abuse” (p. 189). Other indications of elder abuse might be more readily discerned. For example, “Obvious fear of the caregiver or a caregiver who demonstrates stress or low tolerance in interacting with the elder are signs of a potentially abusive relationship. Suspicion should increase when the elderly person is not allowed to speak for him- or herself in the presence (or the absence) of the caregiver and is reluctant to respond when questioned” (Gellert, p. 189).

According to Aguilera, “Assessment protocols have been developed that concentrate on physical and behavioral symptoms of elder abuse. These protocols are focused on identifying abuse but were developed with the assumption that problems can be identified after abuse has occurred” (p. 112). In some cases, though, these approaches may result in too little intervention too late with the death of the elder being the result. However it is identified, though, prosecuting elder abuse is a complicated and challenging enterprise as well. Based on the concept that caregivers who experience such levels of stress are more likely to abuse the elderly, a number of caregiver support groups have emerged in recent years with a view to reducing, eliminating, or preventing that level of stress; unfortunately, though, caregiver support group facilitators are confronted with some profound ethical and legal issues concerning elder abuse reporting laws (Bergeron & Gray). In this regard, Wolf (1996) reports that healthcare providers tasked with conducting investigations and intervening in founded cases of elder abuse practice within a framework of laws in which.”.. establishing procedures for reporting, investigating, and treating elder abuse cases” (Wolf, 1996, p. 90) remains complicated and convoluted (Bergeron, 2000). According to this author, “These practitioners must understand the dilemmas inherit to practicing with abused adults under the sometimes conflicting principles of ‘duty to protect’ and ‘preservation of autonomy.’ They must also be skilled in areas of gerontology, family systems, assessment, family violence, and community resources — all while negotiating within the confines of their state’s elder protection laws” (Bergeron, p. 40). Despite the growing need and the increasingly complex nature of their work, these members of the helping professions typically receive little attention in the professional literature and frequently work with far less support than do child abuse protection workers (Bergeron).

In her book, Handbook on Ethical Issues in Aging, Johnson (1999) reports that in some ways, the ethical dilemmas surrounding elder abuse are much the same as those surrounding other forms of family violence, but there are some important differences that must be taken into account as well, including the following:

Should health and social service professionals be required to report family violence when reporting is seen as an abridgment of patient confidentiality or may erode hard-won rapport established with the patient?

Is family violence a private matter, or by its very nature is it subject to public scrutiny?

Should family violence be reframed when an ethnic or religious group defines particular behavior otherwise?

Should perpetrators be treated as criminals or persons with problems?

Do individuals have the right to elect to remain in violent relationships? Does this right of self-determination change when society is asked to bear related health care and other costs?

Do victims have a right to expect quick and consistent response to calls for help, even when they refuse to follow through with recommended protective measures? (Johnson, p. 189).

In this regard, Thursz and his colleagues point out that, “Gathering information on domestic elder abuse is usually difficult. Anxiety or withdrawal symptoms can easily be misinterpreted as age-related feebleness. Family loyalty and dependency keep older persons from reporting abuse. In some cases, reporting abuse could further strain family relationships and result in institutionalization of the older person (a course of action to be avoided except when necessary for medical care)” (p. 42). Neighbors, neighborhood groups, and service professionals, especially primary health care staff and general medical practitioners, are probably in the best position to objectively observe and report the incidence of abuse in these situations (Thursz et al.).

Cases of elder abuse are unlike those for other forms of family violence because they differ from those surrounding violence against younger adults, including spouses, because age is more likely to bring with it chronic illness and disabilities. The results are dependency, need for care, and diminished opportunities for self-sufficiency or escape from the current situation based more upon physical than psychological incapacity; it is important not to overgeneralize the diseases and disabilities associated with old age, though, because most older people are not functionally incapacitated, and few suffer from Alzheimer’s disease or other forms of cognitive impairment (Johnson). As this author concludes, “The tendency of American society to infantilize older people can result in the acceptance of this negative image by elders themselves and their consequent adoption of childlike behavior as a kind of self-fulfilling prophecy. Moreover, the distinctions between victim and perpetrator as well as independent and dependent are often blurred in elder abuse. There are many documented instances of violence going in both directions in these situations” (Johnson, p. 190).

Ethical dilemmas in elder abuse can be analyzed by intervention role. Ten roles are particularly important to understanding and addressing this problem:

Victim: experiences elder abuse

Perpetrator: inflicts elder abuse

Family, friend, or neighbor: witnesses elder abuse or its effects

Reporter: detects elder abuse and describes it to authorities

Investigator: assesses reported elder abuse and determines the need for services

Service provider: offers assistance in correcting or discontinuing elder abuse

Program administrator: manages services aimed at preventing or treating elder abuse

Community planner: develops program and community education initiatives to address elder abuse

Legislator: enacts public policy related to elder abuse

Researcher: conducts studies to better understand elder abuse and effective strategies to impact it (Johnson).

The first three intervention roles are used by practitioners who are closely associated to particular abuse situations, with the remainder by individuals with professional responsibility for addressing or studying elder abuse (Johnson). Each discrete role has inherent ethical dilemmas that reflect its unique perspective on elder abuse and illustrations of these ethical dilemmas by intervention role as provided in Table 2 below:

Table 2.

Illustrative vignettes concerning ethical dilemmas in identifying and reporting elder abuse.

Role

Dilemma

Victim:

If authorities find out about my situation, what will happen to me? Will they blame me for causing the problem? Find me mentally ill or incompetent? Remove me from my home? What will the authorities do to the perpetrator, who also represents family to me? What are my responsibilities to that person?

Perpetrator:

Doesn’t the elder have an obligation to help me out with housing and spending money, since I’m unemployed and likely to inherit her estate anyway? Isn’t it better to tie the elder in a chair than to have her wander out of the house and maybe get hurt?

Family, friend, or neighbor:

Does the abusing family’s right to privacy take precedence over my responsibility as a neighbor to help? When should I act to protect others from the possibility of the perpetrator exploiting elders whom he befriends?

Reporter:

Should I report an elder-abuse situation when I don’t believe that reporting will make any positive difference in it? Should I report if this places the elder at greater risk or labels someone as an elder-abuse perpetrator?

Investigator:

How honest am I with the victim as to the purpose of my visit? How much contact do I initiate with family and neighbors of the victim in an attempt to gain information?

Service provider:

What separates establishing rapport with the victim in an effort to offer service from cajoling her into compliance with my service plan? Is it appropriate for me to abandon a victim who refuses protective intervention?

Program administrator:

What are the implications of offering elder-abuse programming when scarce funding limits it to short-term crisis intervention without provision for follow-up services? How much emphasis should be placed on use of the criminal code in elder-abuse situations?

Community planner:

Should community education on elder abuse be initiated when insufficient resources exist locally for addressing the problem? What is the relative importance of case finding and crisis intervention to case prevention?

Legislator:

Should elder-abuse laws be enacted without adequate accompanying appropriations? Should protective-services laws cover all adults or only elderly ones? Does this decision in any way reinforce ageism in American society?

What should I do if a respondent acknowledges elder abuse? Will reporting the situation to authorities compromise my role and integrity as a researcher?

Source: Johnson, p. 190.

Theoretical Model.

Several theories have been advanced to help understand and respond to the growing problem of elder abuse in the United States as described further in Table 3 below.

Table 3.

Theoretical models for elder abuse.

Theory

Description/Relationship to Elder Abuse

Intergenerational theory

This theory states that violent and abusive adults learned this behavior as a result of witnessing or directly experiencing abuse within the family of origin. This theory views abusive parents as disciplining their children by physical means based on how they were disciplined as children; as a result, their own children will grow up to do the same, and the “cycle of abuse” will continue.

Social learning theory

Research on domestic violence using this theory has focused extensively on marital violence. In particular, social learning theory researchers have studied whether or not witnessing or experiencing violence as a child leads to perpetrating violence or being the victim of violence in adult intimate relationships. The research has attempted to confirm the idea that children who experience abuse are more likely to abuse or to be victims of abuse as adults. Straus, Gelles, and Steinmetz (1980) found that sons who had witnessed their fathers’ violence had a 1000% greater battering rate than those who had not. Similarly, Gelles and Straus (1988) found that husbands who batter their wives are more likely to come from homes in which they themselves were abused or homes in which they witnessed their fathers abusing their mothers. A number of variables affect the outcome in these cases, though and it remains unclear which is more predictive of later experience with abuse — “being abused or witnessing abuse. The research, therefore, has yet to account for these problems and to determine exact intervening variables and pathways.

The patriarchal theory

This feminist theory holds that domestic violence is the result of the social structure of our society. Our society, as these theorists see it, is socially structured by gender — “specifically, a long history of male dominance. Therefore, these theorists focus on wife abuse. The theory states that, because males have historically had greater access to resources, including property, employment opportunities, education, material possessions, community groups and services, and status, they have maintained power over women. Male social power and the complementary legal system enable men to use abusive tactics to maintain the status quo and resolve conflicts without consequence.

Culture of violence theory looks at violence based on the larger societal norms and structure. It views violence under this social structure in two perspectives: (a) the cultural approval of violence and (b) the subculture of violence. The cultural approval of violence perspective attributes violence in the home to the level of acceptance of violence in the larger society; therefore, if violence is an accepted means of conflict resolution, goal attainment, or status quo maintenance, it will more likely play into family interactions. Furthermore, if society provides reinforcements (e.g., lack of social sanctions, media images) and if weapons are readily available, violence will become an accepted means of conflict resolution on both institutional/structural and personal levels.

Political economy theory

This theory is a gerontological perspective that expands on the interactionist theory described previously. The political economy theory, as a macro level theory, looks at how society and societal structures affect the elderly. This theory asks questions about how we view and treat the elderly population and why. Specifically, the political economy theory sees aging as not only a biological but also a socially constructed phenomenon. As such a distinct division of labor and a structure of inequality exist for this population. The political economy theory argues that the elderly are not treated equally. They are isolated from the rest of society not only by their age and health status but also by their perceived dependency, unemployability, and lack of productivity. Socially created dependency has a political and economic function in society. This societal structure supports a strong and productive economy, keeping important work and positions open for the younger members. Because the aged may be physically challenged and thus considered a devalued group, the political economy theory views them as predisposed to abuse. Not only is it a difficult time in their lives, but it is also stressful for those who care for them. In addition, the theory sees their stigmatization in society as fostering a lack of viable services and opportunities for them, thus compounding the problem.

Environmental stress/strain theory

This theory looks at elder abuse from the perspective of the structural inequalities involved (i.e., poverty, socioeconomic status, and racial inequalities) in society. The groups that have fewer opportunities due to these inequalities are said to be predisposed to an increased incidence of family violence.

General systems theory

This theory asserts that role expectations, labels, or behavioral scripts develop as to how one should act. In this instance, family members learn to be tough or to be victims. At this point, the system functions to promote negative self-concepts and advance what has been termed a self-fulfilling prophecy. From this perspective, family members are encouraged to be violent or victims of violence, and, subsequently, each develops a negative self-image as a result of receiving negative messages. They therefore produce behaviors that parallel the labels and self-concepts, such as “perpetrator” or “victim.” general systems theory maintains that incoming stimulus or input is mediated within the family and that a response or output is returned to the environment. If the output is less than some maximum, the feedback is positive, and if the output has reached a maximum level, the feedback will be negative. If the feedback is positive, the system violence is reinforced through social interaction, the mass media, or both. Thus positive feedback regarding the violence produces an upward spiral or escalation of violence because the initial violence serves to create further conflicts and violence. For example, if the violence serves to create a stable environment, produces desired results, and is a culturally accepted means of dealing with conflict, the feedback will be positive and the violence will be reinforced. Eventually, the violence will escalate until the point at which change is sought.

Ecological theory

James Garbarino (1977) and Jay Belsky (1980) developed the ecological theory of family violence in order to explain child abuse. They asserted that abuse must be viewed under three levels of analysis:

1. The relationship between the organism and the environment

2. The interacting and overlapping systems in which human development occurs

3. The quality of the environment

In addition, these researchers maintain that a mismatch between any of the organisms can create abusive situations. Mismatches can occur between a parent and a child or between a family and a neighborhood. Abuse is more likely to occur when the functioning — “whether mental, emotional, physical, or social — “of the parent, the child, or both is impaired. For example, children with developmental disabilities are at greater risk of abuse. Likewise, mentally ill parents are at an increased risk of abusing. Besides these mismatches, ecological theory holds that the abuse is heightened when the family faces other stressors (e.g., poor or stressful relations between parents, lack of financial resources or community support systems, etc.). The ecological theory provides a clearer view of how family violence can occur and while it was originally intended to explain child abuse, it could easily be applied to other forms of abuse, as well.

Source: Kurst-Swanger & Petcosky, pp. 44-51.

Taken together, the foregoing theoretical models provide some useful techniques for identifying, understanding and responding to cases of elder abuse, but even the best theory will be unable to account for misleading or inaccurate data. In fact, notwithstanding the foregoing theoretical frameworks for understanding and responding to elder abuse, there remains some profound misconceptions concerning who commits the most abuse against the elderly and which interventions are most appropriate. To date, studies have shown that men are in reality not far more likely to commit domestic violence toward women but rather than the reverse is true and women’s tendency toward being a perpetrator of domestic violence is not considered minimal or trivial (Coney et al.). Epidemiological studies on randomized, if not random, samples of elder abuse, though, portray a much different picture. For example, in a survey of spousal homicides, in the U.S. from 1976 to 1985, Daly & Wilson (1992) found that women were responsible for 42.8% of 18,417 homicides, but in some cities, these rates were substantially higher. These authors report, “For example, in Chicago, from 1965-1989, 50.5% of the spousal homicides were committed by women, while in Detroit, for 1972, women committed 54.4% of the spousal homicides. In a study in St. Louis of ‘intimate partner homicides,’ the Homicide Research Working Group (Lattimore & Nahabedian, 1996) reported that 56.4% of the victims were men” (Coney et al.).

Other researchers have investigated the relationship between marital violence across the life course using one or the other of the theories described above, and while the rate reported by men and women across all age groups has been shown to decline over time, a significant number of older women continue to be victims of domestic violence. For instance, the results of a large-scale random-sample survey of elder abuse by Pillemer and Finkelhor (1988) determined that the rate of abuse for persons aged 65 and over who were living with only a spouse was 41 per 1,000 couples; the perpetrators of this elder abuse were most likely to be spouses (58%) rather than adult children (24%). According to Wilke and Vinton (2003), the National Elder Abuse Incidence Study also identified evidence of abuse in old age, although it was reported that proportionately fewer of the perpetrators of this violence (23%) were spouses.

Interventions for Elder Abuse.

The fundamental goal of any intervention will be to first stop the abuse of the elder (Ebersole & Hess). Depending on the setting, a number of interventions have been shown to be effective in reducing or otherwise mitigating the incidence of elder abuse, but almost all of these approaches have some profound constraints involved. If the abuse is taking place in the home, for example, interventions designed to eliminate the source of the abuse, such as elevated stress levels by the caregiver, may be appropriate (Ebersole & Hess). According to these authors, “Most frequent are the stress-related situations. These are responsive to almost anything that eases the burden: removal of the stressor, often this is the elder; support groups for ventilation of frustrations and peer support; respite; crisis hot lines; professional consultation; victim support groups; victim volunteer companions and, above all, thoughtful and compassionate care for the victim and the perpetrator” (Ebersole & Hess, p. 565).

The psychoeducational model provides a useful approach to intervening in cases of elder abuse by providing caregivers with the tools and training they will need to survive the rigors on caring for an elder, particularly those suffering from dementia or other cognitive problems. According to Corcoran (2003), these techniques have been shown to be effective in effecting change in elder abuse situations, but certain steps need to be taken to ensure a therapeutic relationship is established with the caregiver and elder alike, as well as the need to provide planned respite breaks for the caregiver and ensure that caregivers receive recognition for their hard work and sacrifice. In this regard, the author reports, “Collaboration exists between the practitioner and the caregiver with a focus on the strengths of the caregiver. In order for the intervention to be effective, the practitioner needs to develop a rapport with the client and establish an atmosphere of support and trust. The practitioner seeks to find out the caregiver’s knowledge about the dementia process and what the caregiver perceives as relevant to her situation, and then places this information into a framework that the caregiver can understand without feeling blame” (Corcoran, p. 301).

Irrespective of whether this type of intervention is provided in an individual or group format, and regardless of the length of time involved, the psychoeducational approach with caregivers of older adults includes the following components at a minimum:

Joining with the family, developing rapport and empathy;

Providing an explanation of the psychoeducational approach;

Education on dementia and management of behavioral symptoms;

Information on caregiver stress and coping strategies;

Education on depression and cognitive-behavioral strategies; and,

Information on community resources for in-home and long-term care including nursing home placement (Corcoran, p. 303).

Finally, some preventive interventions that have been offered for elder abuse include the following:

Make professionals aware of potentially abusive situations.

Educate the public about normal aging processes.

Help families develop and nurture informal support systems.

Link families with support groups.

Teach families stress-management techniques.

Arrange comprehensive care resources.

Provide counseling for troubled families.

Encourage the use of respite care and day care.

Obtain necessary home health care services.

Inform families of resources for meals and transportation.

Encourage caregivers to pursue their individual interests (Ebersole & Hess).

Chapter Summary.

This chapter presented an overview and the background of the problem under consideration, a discussion of the various causes of elder abuse, an analysis of the constraints to identifying and prosecuting cases of elder abuse, a description of the various theoretical perspectives that have been offered to help understand and react to the problem of elder abuse, followed by a description of some interventions that have been shown to be effective in addressing instances of elder abuse. Chapter three below describes more fully the research methodology used in this study.

Chapter 3:

Methodology

Description of the Study Approach

This study used a mixed methodology to achieve the above-stated research purpose. The first part of the mixed methodology consisted of a review of the relevant peer-reviewed and scholarly literature. This approach is highly congruent with a number of social researchers who emphasize that a well conducted literature review is essential in almost any research project. For example, Fraekel and Wallen (2001) report that, “Researchers usually dig into the literature to find out what has already been written about the topic they are interested in investigating. Both the opinions of experts in the field and other research studies are of interest. Such reading is referred to as a review of the literature” (p. 48). In addition, Gratton and Jones (2003) point out that a review of the relevant literature is an essential task in all types of research endeavors. “No matter how original you think the research question may be,” they advise, “it is almost certain that your work will be building on the work of others. It is here that the review of such existing work is important” (Gratton & Jones, p. 51). Reseachers using a literature review component to their research should also seek to identify gaps in the existing research: “A literature review is the background to the research, where it is important to demonstrate a clear understanding of the relevant theories and concepts, the results of past research into the area, the types of methodologies and research designs employed in such research, and areas where the literature is deficient” (p. 51). To help guide the direction of the literature review, the guidance provided by Wood and Ellis (2003) was followed concerning important outcomes of a well conducted literature review:

It helps describe a topic of interest and refine either research questions or directions in which to look;

It presents a clear description and evaluation of the theories and concepts that have informed research into the topic of interest;

It clarifies the relationship to previous research and highlights where new research may contribute by identifying research possibilities which have been overlooked so far in the literature;

It provides insights into the topic of interest that are both methodological and substantive;

It demonstrates powers of critical analysis by, for instance, exposing taken for granted assumptions underpinning previous research and identifying the possibilities of replacing them with alternative assumptions;

It justifies any new research through a coherent critique of what has gone before and demonstrates why new research is both timely and important.

Likewise, Silverman (2005, p. 300) suggests that a well conducted literature review should aim to answer the following questions:

What do we know about the topic?

What do we have to say critically about what is already known?

Has anyone else ever done anything exactly the same?

Has anyone else done anything that is related?

Where does your work fit in with what has gone before?

Why is your research worth doing in the light of what has already been done?

The second part of the mixed methodology consisted of a recapitulation of the peer-reviewed studies and scholarly sources reviewed in the first part of the methodology in tabular form. This approach is also congruent with the American Psychological Association’s Publication Manual (5th ed.), which states, “Word tables present qualitative comparisons or descriptive information. For example, a word table can enable the reader to compare characteristics of studies in an article that reviews many studies, or it can present questions and responses from a survey or shown an outline of the elements of a theory. Word tables illustrate the discussion in the text” (p. 161). The organization of the studies was accomplished using Noblit and Hare’s approach to synthesizing various type of studies.

According to York (1994), the meta-synthesis technique is a type of research that “systematically compares studies in order to interpret meaning, to clarify research foci, and to resolve existing substantive, methodological, or interpretive problems” (p. xiii). This approach allows the researcher to “compare and analyze text, creating new interpretations in the process” (Noblit & Hare, 1988, p. 9).

The seven-step process developed by these researchers for such synthesis is described further in Table 4 below.

Table 4.

Noblit and Hare’s comparative method.

Research Phase

Description

Phase 1:

Getting started. This step involves finding an area of interest in need of synthesis.

Phase 2:

Deciding what is relevant to the initial interest. This phase involves conducting a literature search based on sample criteria.

Phase 3:

Reading the studies. This involves reading and re-reading the studies and identifying common themes in each.

Phase 4:

Determine how the studies are related. In this step, the studies are “put together” and relationships between the studies are forged. It is suggested that a list of key metaphors, phrases, ideas and concepts are made for each study. The metaphors are then compared and juxtaposed. Three different relationships are possible: a direct comparison using reciprocal translations; a refutational comparison where studies oppose each other; and a grouping of studies that represent a line of argument.

Phase 5:

Translating the studies into one another. Simply stated, the themes are compared with each other.

Phase 6:

Synthesizing translations. This step requires the researcher to make the parts of each study into a whole through synthesis of the information.

Phase 7:

Expressing the synthesis. The final step requires the researcher to write up and report the results.

Source: Noblit & Hare, 1988, pp. 26-29.

Data-gathering Method and Database of Study

Both public and university libraries were consulted for resources for the study, as well as reliable online research databases such as Questia, EBSCO and Medline.

Chapter 4:

Data Analysis

Table 5.

Incidence of elder abuse in the United States.

Author/Date/Title/Publication

Key Findings

Comments

Tatara, T. (1993). Understanding the nature and scope of domestic elder abuse with the use of state aggregate data: Summaries of the key findings of a national survey of state APS and aging agencies. Journal of Elder Abuse and Neglect, 5(4), p. 3557.

In 1986, the National Aging Resource Center on Elder Abuse documented 117,000 elder-abuse reports nationwide. By 1991, reporting had reached 227,000, a 94% increase. During the same period, the percentage of state budgets for adult protective services declined from 6.6% in 1980 to 4.7% in 1985 to 3.9% in 1989, a 41% decrease.

Funding for adult protective services have decreased as the incidence of elder abuse reports has increased.

Jogherst, G. (2004, April). Abuse underreported in many states. USA Today (Society for the Advancement of Education), 132, p. 3.

Different definitions and reporting requirements confound research and the establishment of benchmarks for future research. Authors note that domestic eider abuse is the victimization of adults or dependent / vulnerable adults age 60 and older — age 65 and older in California, Maryland, and Nebraska; age 55 and older in Alabama — who live in private residences, not care facilities. Domestic elder abuse reports varied from 4.5 per 1,000 elders in New Hampshire to 14.6 in California. Investigation rates ranged from.5 per 1,000 in Wyoming to 12.1 in Texas. Substantiations ranged from.1 per 1,000 in Wyoming to 8.6 in Minnesota. Forty-five percent of cases investigated were classified as actual abuse according to state laws. States where investigators handle only elder abuse cases had a nearly 50% substantiation ratio compared to 34% where investigators handle both child and elder abuse cases.

Dependent adults are defined as those who are unable to care for themselves as a result of a physical or mental condition and depend on others to help them with tasks of daily living.

Emery, R.E., & Laumann-Billings, L. (1998). Overview of the nature, causes, and consequences of abusive family relationships: Toward differentiating maltreatment and violence. American Psychologist, 53(2), p. 125.

Since elder abuse was first publicly recognized about a decade ago, the number of reports has more than doubled, from 117,000 in 1986 to 241,000 in 1994.

The increased reporting of elder abuse likely is at least partially due to increased awareness.

Lau, E. E, & Kosberg, J.I.: (1979, September/October). Abuse of the elderly by informal care providers, Age & Ageing, p. 43.

The incidence of elder abuse is probably underreported because the elderly are reluctant to report abuse by relatives. These researchers found that one-third of the elderly who were judged to have been abused denied any problem existed.

Elders may believe that the problem is a family affair, fear reprisals by the abuser or may be embarrassed or ashamed of the behavior of the abuser. The elderly may be reluctant to initiate legal or criminal action against a relative for fear that the solution will be worse than the problem itself — “institutionalization. They may believe that they are being paid back for their earlier abusive behavior toward others, such as a child or spouse.

Gellert, G.A. (1997). Confronting violence: Answers to questions about the epidemic destroying America’s homes and communities. Boulder, CO: Westview Press, p. 190.

The typical setting for elder abuse is within families that have poor communication and emotional dynamics; in fact, elderly individuals who are physically abused live with the abuser in the same home in 75% of instances of abuse. Individual members of the family, or the family as a whole, may be facing serious external stresses, such as low income or unemployment. Abuse tends to occur when the abuser is dependent on the victim for financial support or housing or when the victim, usually physically and/or psychologically impaired, is very dependent on the rest of the family for care.

While many studies have shown that abuse of the elderly tends to occur more frequently in white and middleclass families, it is not yet clear whether this is an actual trend or whether it reflects the fact that more studies are conducted on this group.

Kurst-Swanger, K., & Petcosky, J.L. (2003). Violence in the home: Multidisciplinary perspectives. New York: Oxford University Press, p. 107.

Although intimate partner violence appears to occur with less frequency in those over the age of 50 years, abuse remains an issue for concern. The rate of violence by an intimate partner for those over age 50 was less than 3 victimizations per 1,000 persons. The National Elder Abuse Incidence Study, conducted in 1996, revealed that spouses were responsible for approximately 19% of all substantiated cases of elder abuse.

Intimate partner abuse among elderly couples involves a complex set of dynamics, some of which mirror the abusive patterns found in younger couples. Although many of the risk factors for abuse are similar to those found in younger couples, the unique features of aging must be taken into account. For example, an inability to cope with caregiving responsibilities, acting-out behavior associated with cognitive impairments, barriers to independent living, disability, and so forth may all have distinctive roles to play in this form of elder abuse.

Jamner, M.S., & Stokols, D. (2000). Promoting human wellness: New frontiers for research, practice, and policy. Berkeley, CA: University of California Press, p. 476.

The prevalence of elder abuse is estimated to be between 4% and 10%, which translates to 1.5 to 3.2 million Americans.

Ebersole, P., & Hess, P. (1998). Toward healthy aging: Human needs and nursing response. St. Louis, MO: Mosby, p. 562.

Estimates are that from 1.5 to 2 million adults experience abuse or neglect each year in the United States (Aravanis et al., 1993). The National Center on Elder Abuse (1996) estimated the number from 820,000 to 1,860,000.

It is impossible to get an accurate estimate because there is no place where elders are routinely exposed to scrutiny as in the case of children in school

Table 6.

Identifying effective interventions for elderly abuse in the United States.

Author/Date/Title/Publication

Key Findings

Comments

Ebersole, P., & Hess, P. (1998). Toward healthy aging: Human needs and nursing response. St. Louis, MO: Mosby, p. 565.

The goals of intervention are to stop exploitation of elders, protect the victim and society from inappropriate and illegal acts, hold perpetrators of mistreatment accountable, rehabilitate the offender, and order restitution of property and payment for expenses incurred as a result of the perpetrator’s conduct.

The rules of the court dictate the procedures to accomplish these goals. Both civil and criminal laws require that the accused perpetrator of elder abuse is provided with notice of what they have allegedly done. This may create additional problems for the victim unless immediate removal from the abusive setting can be accomplished. Few states have legal alternatives that can quickly be brought to play to immediately remove the elder to a protected situation; those states that do provide legal avenues frequently involve delays or placement in nursing homes, but neither of those may be effective actions.

Thursz, D., Nusberg, C., & Prather, J. (1995). Empowering older people: An international approach. Westport, CT: Auburn House, p. 43.

A multidisciplinary team approach is often recommended for assessment and treatment of domestic elder abuse, with well-identified tasks for all team members and a designated key worker to keep in regular contact with the client.

Prevention of abuse is an important focus for public policy requiring an empowering environment from birth to enable individuals to achieve their full potential and support for the family to remain or become a democratic institution where problems are discussed and the burden of care is shared.

Chalk, R., & King, P.A. (1998, Winter). Facing up to family violence. Issues in Science and Technology, 15(2), pp. 39-41.

Service providers consistently search for solutions that can meet the needs of the vulnerable adult, preserve the older person’s autonomy and decision-making authority, and retain family support systems where appropriate.

Elder abuse has never received the level of national attention given to child maltreatment and domestic violence, but it has been a topic of recurring concern among social service and health care agencies. Local agencies responsible for services for the aging have long been troubled by the cases of elder neglect that come to their attention.

Corcoran, J. (2003). Clinical applications of evidence-based family interventions. New York: Oxford University Press, p. 301.

Psychoeducational interventions have been found to be very effective for affecting the stress of caregivers and improving their coping skills. Individual interventions produce more positive effects on caregivers’ psychological functioning and well-being than group intervention.

Psychoeducation is used with groups of families, with individual families, with the patient present, or even in the patient’s absence.

Kaye, L.W., & Crittenden, J.A. (2005). Principles of clinical practice with older men. Journal of Sociology & Social Welfare, 32(1), p. 99.

Authors note that elder abuse and victimization is becoming a topic of increased attention among researchers; however, most of the research is focused on the victimization of older women. While women are more likely to experience a majority of the types of abuse, older men are disproportionately represented among those older adults experiencing abandonment. Despite the growing need, older men are much less likely to be aware of community services available to them and they are less likely to utilize services generally due in large part to the manner in which these services are organized and how practitioners function within them.

The uniqueness of men’s experiences with such issues as loss of a spouse, retirement, caregiving, and victimization warrant particular attention by gerontological practitioners. Male-friendly interventions that take into account traditional male values will foster greater participation and better quality care for older men.

Kingston, P., & Penhale, B. (1995). Elder abuse and neglect: issues in the accident and emergency department, Accident and Emergency Nursing 3(3), p. 122.

Elder abuse tends to be episodic and recurrent rather than an isolated event. Therefore, it is important to review past records of accidents and emergency room visits that may create a “high index of suspicion” when taken in total.

Table 7.

General causes of elder abuse.

Author/Date/Title/Publication

Key Findings

Comments

Gillespie, M.A. (2001). Mainstream legal responses to domestic violence vs. real needs of diverse communities. Fordham Urban Law Journal, 29(1), 13.

While a popular misconception exists that one of the leading causes of elder abuse is caregiver stress, research has proven caregiver stress does not necessarily cause elder abuse. “The pathology of the abuser causes elder abuse” (p. 13).

Hawkins, D.F. (2003). Violent crime: Assessing race and ethnic differences. Cambridge, England: Cambridge University Press, p. 198.

Among the varied forms of interpersonal aggression, intimate violence, particularly violence against women, has now clearly been shown to be a significant and persistent social problem that may result in death and has serious consequences for individuals, their families, and society as a whole

Youth has not been found to be a risk factor for elder abuse perpetration, although the rate of elder abuse is lower than the rate of other forms of family.

McCuan, E.R., & Jenkins, M.B. (1992). A general framework for elder self-neglect. In E.R. McCuan & D.R. Fabian (Eds.), Self-neglecting elders: A clinical dilemma (pp. 4-8). Westport, CT: Auborn House, p. 21.

Although the desire to remain independent may be a potentially powerful force associated with self-neglect, the importance of environmental, or situational, factors, maintaining that the.”.. impact of environmental factors can often be greater than individual conditions influencing self-neglect.” singular, important environmental factor is thus the inaccessibility of formal support networks or community protective service resources. These researchers stress the importance of both situational and dispositional factors but seem to place more emphasis on environmental influences.

Lachs, M.S., Berkman, L., Fulmer, T., & Horwitz, R.I. (1994). A prospective community-based pilot study of risk factors for the investigation of elder mistreatment. Journal of the American Geriatric Society, 42(2), p. 169.

Risk factors for elder abuse include a history of mental illness, alcohol / drug abuse, a family history of violence, isolation of the victim, limited social network, minority status, stressful lifestyle of the victim and/or abuser, presence of dementia, behavioral problems, incontinence, and the need to be fed. To make an adequate assessment it is necessary to observe the living arrangements, evaluate the financial status, social supports, interactions of family members, and emotional stressors in the present situation.

Emery, R.E., & Laumann-Billings, L. (1998). Overview of the nature, causes, and consequences of abusive family relationships: Toward differentiating maltreatment and violence. American Psychologist, 53(2), p. 126.

Many factors contribute to the development of family violence, including individual personality factors, family interaction patterns, poverty and social disorganization, acute stressors, and the cultural context in which the family lives. Consistent with their comorbidity, a number of the same factors increase the risk for spousal abuse among the elderly. Personality factors such as low self-esteem, poor impulse control, external locus of control, negative affectivity, and heightened response to stress all increase the likelihood that an individual will perpetrate family violence. Likewise, alcohol or drug dependence also plays a role both as a background risk factor and as an immediate precipitant of family violence.

Although the evidence is less consistent, some research has also suggested that the victims of family violence share some common characteristics, including poor physical or mental health, behavioral deviancies, and difficult temperament or personality features. Where research indicates differences in the etiology of different forms of abuse; too little evidence is available on elder abuse to consider these topics adequately.

Table 8.

Effects of elder abuse facilitating victim’s resultant premature death.

Author/Date/Title/Publication

Key Findings

Comments

Vinton, L. (1993). Educating case managers about elder abuse and neglect. Journal of Case Management, 2(3), p. 101.

Many types of elder abuse can contribute to premature death. This researcher studied clients referred to an intensive case management program and found numbers of elders had been subjected to physical and sexual abuse that had gone undetected because they had not been asked about such experiences. The dimensions of maltreatment identified in this study included deprivation; verbal, physical, psychologic, material, and sexual abuse; violation of rights; passive and active neglect; and financial exploitation.

Until a standardized method of identification and reporting is adopted, each case must be subject to the clinical judgment of experts in the field.

Jenkins, R., Mcculloch, a., Friedli, L., & Parker, C. (2002). Developing a national mental health policy. New York: Psychology Press, p. 147.

A number of studies in have shown that the needs of the elderly who cannot fend for themselves tend not to be adequately met by the state, causing neglect, including starvation, abuse, hypothermia, and neglect of physical illness.

Oktay, J.S., & Tompkins, C.J. (2004). Personal assistance providers’ mistreatment of disabled adults. Health and Social Work, 29(3), pp. 177-178.

Increased incidences of premature death in nursing homes was largely due to male caregivers. In studies of elder abuse in nursing homes, male employees were responsible for the majority of the incidents (65%), and studies of mistreatment of community-based elderly people showed that 71% of the perpetrators were men.

Longman, P.J. (2003, April). The health of nations: Instead of forcing seniors into HMOs, how about forcing them to exercise? Washington Monthly, 35(4), p. 16.

Overmedication in hospitals and nursing homes is a leading form of elder abuse that contributes to premature deaths.

An estimated 17% of all hospital admissions among persons over 70 result from harmful combinations of prescriptions drugs.

Gellert, G.A. (1997). Confronting violence: Answers to questions about the epidemic destroying America’s homes and communities. Boulder, CO: Westview Press, p. 191.

Some types of elder abuse will naturally result in premature death because such behaviors tend to be a chronic or long-term victimizations. Over one-half of abused elderly people have been the victims of prior abuse. Abuse is recurrent in up to 70% of cases and elder abuse does not typically end or resolve spontaneously. The abuse usually escalates in much the same way as occurs in domestic battering, until a major change occurs in the care setting or the home. Change is not easily achieved, since between one- and three-fourths of all victims or families refuse to seek help for the abuse.

Elder abuse tends to occur more commonly in institutions in which there is a shortage of beds, a surplus of patients, and low staff-to-patient ratios. Poorly paid and undereducated staff are other characteristics of higher risk institutions

Table 8.

Comparative analysis: bruising as a result of abuse vs. age related changes, abrasions and lacerations, etc.

Author/Date/Title/Publication

Key Findings

Comments

Aguilera, D.C. (1998). Crisis intervention: Theory and methodology. St. Louis, MO: Mosby, p. 111.

Physical findings indicative of possible elder abuse and neglect include patterns of bruising or of injuries that are morphologically similar to an object (e.g., belt marks, hand marks, lesions at the corners of the mouth indicating use of a gag, and marks left by restraints, ropes, or cords), burns, immersion injuries of extremities in a stocking/glove distribution, and unexplained fractures and falls.

Accurate documentation in cases of suspected abuse and neglect is crucial. Information obtained from interviews of the alleged victim, perpetrator, and witnesses should be recorded verbatim, if possible, and a detailed description of the physical examination, including injuries, functional status, and cognitive status, should be documented. Injuries must be described in detail, including size and location and, if possible, photographs of the injuries obtained. These may be invaluable in proving cases of abuse or neglect.

Gellert, G.A. (1997). Confronting violence: Answers to questions about the epidemic destroying America’s homes and communities. Boulder, CO: Westview Press, p. 189.

Some signs that elder abuse might be taking place include weight loss, poor nutritional status and dehydration, bad hygiene, bed sores, and a general appearance of physical neglect are other signs. There may be also be signs of over- or under-medication involved in cases of elder abuse. Unexplained sexually transmitted diseases or genital infections may suggest sexual abuse.

Many of these signs require medical assessment to determine the likely origin. If someone believes that a loved one is a victim of elder abuse, medical attention should be sought from a personal doctor, a local clinic, or a hospital emergency room.

Roberts, a.R. (2002). Handbook of domestic violence intervention strategies: Policies, programs, and legal remedies. New York: Oxford University Press, p. 489.

The signs of elder abuse depends on what type of abuse is involved, whether physical, psychological or emotional, financial abuse, and intentional or unintentional, and each category has its own set of indicators.

Table 9.

Proposed preventative measures possibly including legislative collaboration,

Author/Date/Title/Publication

Key Findings

Comments

Baker, M.W., & Heitkemper, M.M. (2001). Nursing Outlook, 53(5), pp. 253-9.

Elder mistreatment (EM) is a growing and hidden problem. Nurses have a responsibility to identify potential and actual EM victims. The authors describe the roles of nurses on interprofessional elder mistreatment teams. Current nursing roles in the recognition and management of EM include assessment and screening, mandatory reporting, direct care, and complaint investigation. While the efforts of individual nurses in the detection and management of cases is important, EM is a complex problem that is best approached through interprofessional collaboration. In the greater Seattle area, such collaboration is accomplished through membership on the King County Elder Abuse Project teams. Nurses give expert opinion, educate team members, and provide case consultation. University faculty experience on the teams inspired the start of a Master’s pathway in Forensic Nursing, focused nursing research, and increased public policy activity and community service.

Study concerns the roles of nurses on interprofessional teams to combat elder mistreatment. Authors conclude that nurses on interprofessional teams gain networking opportunities as well as experience with the system that is in place to protect and serve vulnerable adults.

Gillespie, M.A. (2001). Mainstream legal responses to domestic violence vs. real needs of diverse communities. Fordham Urban Law Journal, 29(1), p. 13.

Forty-two states have enacted mandatory reporting requirements of elder abuse by certain professionals.

New York is not one of them.

Tilden, V.P., Schmidt, T.A., Limandri, B.J., Chiodo, G.T., Garland, M.J., & Loveless, P.A. (1994). Factors that influence clinicans’ assessment and management of family violence. American Journal of Public Health, 84(4), p. 628.

The findings of this study clearly showed that the helping professions need more education concerning elder abuse. This was a large (1,521 subjects) interdisciplinary study designed to determine factors that influenced clinicians’ decision making regarding identification, reporting, and intervention with victims of family violence. Over 33% of the respondents indicated they had no education regarding abuse in their professional training programs and felt incapable of making such judgments.

Most states now have mandatory laws requiring the reporting of elder mistreatment.

Chapter 5:

Summary, Conclusions and Recommendations

Summary

The causes of elder abuse were found to include the vulnerability of older individuals, the high level of violence in society generally, stress, substance abuse, and low socioeconomic status among both victims and abusers. Given the well-documented relationship between increased levels of stress and the incidence of elder abuse, caregivers should ensure they coordinate respite care to provide time for themselves, obtain timely information concerning dementia, and what services and benefits are available for the elder in their charge. The research also showed that it is important for caregivers to receive some recognition for their hard work. Furthermore, caregivers must learn to recognize and deal with the warning signs of caregiver stress, including denial, anger, social withdrawal, anxiety, depression, exhaustion, sleeplessness, irritability, and lack of concentration.

The research showed that in cases of elder mortality resulted from abuse, the traits that were determined to be the most irritating and provocative were selfishness, self-pity, masochism, sadism, complaining, malingering, indulging in amateur dramatics, pleading for overdoses, or to be smothered or even killed. The research also showed that the various family dynamics that contribute to the incidence of elder abuse include poor family integration, cycles of violence inherited by each generation, sibling feuds, and social isolation removing the family from the controlling factor of neighborhood disapproval. Environmental factors contributing to elder abuse were shown to include unemployment, inadequate housing, migration, and man-made and natural disasters. As a result, elder homicide, as a direct extension of these types of elder abuse and neglect, can reasonably be posited to be influenced by these factors.

Practitioners working in adult protective services who are confronted with elder abuse tend to experience some profound challenges and constraints in resolving them today, including the following:

lack of funding to assist in investigations, intervention, and services;

Disproportionately low funding, which appears to be decreasing over the years instead of increasing with the aging population;

Inconsistency regarding who is protected (vulnerable or well elders), who is required to report, and what the penalties are for non-reporting individuals;

An inconsistency of language within the laws from state to state; and,

Adult protective services practitioners work within the very complex, yet often oversimplified, principle of self-determination of the elder abuse victim contained in every reporting law (Bergeron).

Conclusions

Taken together, the bad news was that the research was clear in showing that there are going to be more older people in the United States in the years to come, and it is reasonable to conclude that the incidence of elder abuse will continue to increase. The good news, though, was that the problem has been receiving an increasing amount of attention in recent years and most states have enacted laws designed to strengthen reporting requirements for suspected elder abuse. Even here, though, discerning legitimate cases of elder abuse can be extremely difficult because of the reluctance of many elders to disclose such behaviors by family members for various reasons, as well as the sprains, bruises and other physical injury symptoms that frequently go hand-in-hand with the natural aging process.

Practitioner bias was shown to affect not only whether services are delivered to those suspected of elder abuse but also how effective and helpful those services may be to some segments of American society based on gender, minority or socioeconomic status. Healthcare providers and other members of the helping professions must remember that many elderly citizens are reluctant to seek out intervention services and depending on their particular circumstances and inclinations, this may have kept them from taking advantage of needed services in the past.

Recommendations for Future Research.

It is suspected that not all professionals in states with mandatory reporting legislation are aware of their responsibility (Aguilera); therefore, future research concerning the level of specific level of awareness of professional responsibilities for elder abuse reporting requirements and its signs in the several states represents a timely area of investigation.

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You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment  Help Service Works

1.      Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2.      Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3.      Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4.      Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!

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