2-1- Introduction
In the upcoming chapter, the title will be review of research literature. This chapter considered as the heart of research supervises al the time research stages and is theoretical and performance guidance of research. This chapter consists of three main topics. The first topic titled “review of research theoretical literature” deals with theoretical approaches of the elderly abuse including definition, forms and associated theories. Outlines and former subject researches about the elderly abuse which have been done by different domestic and international researchers in forms of bachelor, master, doctoral theses or research projects were labeled as “review of experimental research literature” and forms the second topic of this chapter. And finally, the last topic which will be discussed in this chapter is “elective theoretical research frame” that we will try to review the former two topics (theoretical and experimental literature) and discuss theories and approaches which will be used regarding the influential factors on elderly abuse in Malaysia and based on them other stages of research will be followed up in future chapters.
Now in this part, firstly theoretical fundamentals of research will be discussed and then the assessment of experimental research literature inside and outside of the country will be covered:
2-2- Review of theoretical literature
The following sentences relates to theoretical dimensions and conceptive environment of research topic. In another word, explanations and theoretical approaches about the elderly abuse including definition and effective factors are issues that will be covered and it will be tried that by exploring these topics, thought and mind environments of research will be clarified and we would be able to provide a background for future chapters, particularly results, conclusion, and suggestions.
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2-2-1- The Definition of the Abuse of the Elderly
Although there is an absence of agreed or standard definitions of abuse, commented on by McCreadie (1996) and others, a number of definitions of elder abuse have emerged. Early attempts at defining mistreatment in the UK context were relatively specific as seen, for example, in the following: “A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person” (Action on Elder Abuse, 1995)
However, later definitions tend to have been more widely drawn, as in the recent government document, No Secrets, in which the definition is given as: “Abuse is a violation of an individual’s civil or human rights by any other person or persons” (DoH, 2000).
Given the lack of consensus concerning definition, which ultimately may not result in any major difficulty (Penhale, 1993), it is at least reassuring to find that most people concerned with the issue agree on the different types of mistreatment that can happen. The usual types of mistreatment included within most definitions are physical abuse, sexual abuse, neglect, financial abuse (also referring to exploitation and misappropriation of an individual’s property and possessions), psychological and emotional abuse. When considering neglect, separate, stand-alone definitions do not usually appear, with neglect often appearing as a sub-type of abuse. Thus in the Social Services Inspectorate (1993) definition, elder abuse is described as: “. . . physical, sexual, psychological or financial. It may be intentional or unintentional or the result of neglect” (DoH, 1993, para 2.1).
More recently, draft guidance issued by the Social Services Inspectorate indicates that abuse may occur: “. . . as a result of a failure to undertake action or appropriate care tasks. It may be physical, psychological, or an act of neglect . . .” (DoH, 1999, para 2.7).
Neglect and acts of omission are then further delineated as: “. . . including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating” (DoH, 1999, para 2.8).
To these may be added such categories as enforced isolation and deprivation of necessary items for daily living (warmth, food or other aspects, such as teeth). In general, however, situations of self-neglect by an older person would not be considered within the UK perspective of mistreatment. Although many practitioners work with older individuals who self-neglect, usually this is not considered within an elder mistreatment or indeed an adult protection framework.
Abuse within institutions also encompasses situations that arise because of the regime or system that may operate in the unit in addition to individual acts of abuse that occur. There also may be abusive situations that arise between a resident and a member of care staff, initiated by the older person as protagonist, so there may be dual directionality of abuse, or unidirectional abuse from resident towards staff member (McCreadie, 1996). Neglect within institutions may arguably be more pervasive and insidious, affecting the daily lives of many residents in a myriad of ways, from overt to covert.
According to the American Medical Association Council on Scientific Affairs (1987), with elderly abuse has several forms and definition is as follows: any act of commission or omission that results in harm or threatened harm to the health and benefit of an old people. The Select Committee on Aging defined the following categories of abuse: physical abuse, Neglect, emotional abuse, financial abuse, and self-neglect. In its most common usage, elder abuse is an all-inclusive term representing all types of mistreatment or abusive behavior toward older adults. Abusive acts include the following: striking, burning, threatening, abandoning, starving older adults, or taking their property without consent. If an act of violence, such as a slap, occurs only once, by most standards it is probably not considered to be elder abuse. If it happens fairly often or results in the hospitalization of the victim, the action is deemed abuse; likewise, threatening with a gun, sexual assault, or other markedly violent acts need only occur once (Wolf, 2000).A shocking way for elderly people to spend their final days is in a state of maltreatment known as elder abuse. Although it can occur in institutions, it is most often suffered by frail elderly people living with their spouses or their children (Papalia & aIds, 1995).
2-2-2- Forms of Older Adult Abuse
There are many types of abuse that affect older adults. According to Gray-Vickrey (2001), the five most common types of abuses are as follows:
1. Neglect, whether intentional or unintentional, accounts for 49% of substantiated elder abuse cases. Neglect generally to happen when a care provider to not do what is excepted for an old people with adequate food, clothing, shelter, medical care, or assistance with activities of daily living.
2. Emotional abuse, the willful infliction of anguish through threats, intimidation, humiliation, and isolation, is involved in 35% of cases.
3. Financial abuse is the misuse of someone’s property and resources by another person. Financial or material exploitation occurs in 30% of cases.
4. Physical abuse, the use of physical forces that results in pain, impairment or bodily injury, accounts for 25% of substantiated elder abuse cases. Hitting, slapping, restraining, molesting, biting, burning, pushing, or pulling all qualify as physical abuse.
5. Sexual abuse is another extremely devastating form of the abuse of older adults.
Sexual abuse can be seen as a type of physical abuse (Arbetter, 1995). However, it is often discussed separately due to the different types of harm inflicted upon older adults.
In one study, researchers found that the urogenital injury due to sexual abuse was …. Prevalent among elderly people (Muram, Miller, & Culter, 1992). There main sexual abuse behaviors are mentioned frequently in relevant literatures. First activity or activities which are done without any physical contacts. They something are called “Hand – off “behaviors. A common form of hand-off abuse is to make the victim to watch pornographic sceneries, exhibition and voyeuristic activities. The second form of sexual abused is called ” Hand-on ” behaviors involving some physical contact with the victim. The third and most dramatic form of sexual abuse is a kind of painful action on victims sexual or rectal region.(Ramsey, Klawsnick, 1999).
On the other hand, Pritchard (1999) introduced another category of abuse among older people which are commonly seen by health professionals:
History of incest between mother and son.
Husband wife sexual abuse.
Older gay man abused in the community.
Research is mixed concerning the victim-offender relationship in elder sexual abuse cases. Muram et al. (1992) compared the medical record of older sexual assault victims (n=53) to younger sexual assault victims (n=55) and found that older adults were more likely to be assaulted by strangers and to have the assault occur in their home. Johnson (1995) seems to agree, stating, “Most sexual assaults of elderly women occur in the victim’s home by an assailant who is unknown to the victim” (p.221).
Research by Ramsey-Klawsnick (1991) and Holt (1993) suggested slightly different patterns. Ramsey-Klawsnick (1991) asked twenty adult protective service workers to identify and describe cases of sexual abuse among older adults they have seen in the past. The case workers identified twenty-eight cases of sexual abuse, with eighty one percent of the cases reportedly committed by caregivers. Seventy-eight percent of the abusers were relatives, with sons representing the majority of offenders. Research by Holt (1993), studied seventy-seven elder sexual abuse cases in Great Britain and found that fifty percent of the cases were committed by sons of the victims. None of the sexual assaults in Holt’s study were committed by strangers. According to NCEA (1998), sexual assault is a problem that is usually not associated with older adults, often accounting for approximately less than 1% of reported elder maltreatment cases.
There is other dramatic type of psychological abuse. This kind of abuse can be demonstrated in different forms such as threats, bargaining, seduction, stalking or manipulation ( Marshal, Benton, & Brazier, 2000). The most common characteristics of this kinds of abuse is their difficulty to be assessed. Johnson (1995) stated that they psychological abuse are not concrete, so they are hard to be assessed.
According to Quirm and Tomita (1997), psychological abuse is an integral part of other types of abuse. Victims often report being threatened with nursing home placement if they protest physical abuse or if they threaten to tell someone outside of the family, or if they refuse to hand over money. According to NCEA (1998), psychological abuse accounted for approximately 35% of the cases of maltreatment reported in 1996.
A well known form of abuse can be financial abuse which extremely traumatic in nature. In order to recognize financial abuse, it is suggested to have the following items in mind:
Unusual transaction in bank activities.
Older person’s inability to sign other documents such as power of attorney, will or other bank drafts.
Care givers disappear suddenly.
D) There is a lack of amenities, when the estate can afford it (Quinn & Tomita, 1997). Larue (1992) suggests that financial abuse might have been even more common than reports indicate because it is so difficult to detect. Research that relies on interviews with people in their communities instead of abuse complaints filed with governmental agencies tends to support this view. For example, Canadian researchers who randomly sampled citizens at home showed financial exploitation to be more common than neglect (Podnieks, Pillemer, Nicholson, Shillington, & Frizzell, 1990). According to Welfel, Danzinger, and Santoro (2000), the financial exploitation of older adults ometimes experienced through fraudulent telemarketing schemes or through unscrupulous contractors who are strangers are not the primary domains of elder mistreatment laws.
Criminal statutes relating to fraud and extortion are probably better suited to deal with such schemes. However, if a person befriends an older person and begins caring for that older adult in order to take money or material goods from him or her, that person would likely be subject to the elder abuse statutes. The most common form of the abuse of older adults is neglect, which involves failure to provide essential physical or mental care for an older person. Physical neglect includes withholding food or water, failing to provide proper hygiene, or neglecting to offer physical aid or safety precautions. Neglect needs not to be intentional; it sometimes occurs when the caregiver is unable to provide the older person with proper care (Lachs & Pillemer, 1995). Overall, 49% of the reports of elder maltreatment involve neglect and maltreatment, either intentional or unintentional (NCEA, 1998). Abandonment is a particular form of neglect. The state of Connecticut defines abandonment as “the desertion or willful forsaking of an elder by a caretaker or foregoing, withdrawal, or neglect of duties and obligations owned an elder by a caretaker or others” (Fulmer, Mc Mahon, Baer-Hines, & Forget, 1992, p. 506). According to the American College of Emergency Physicians (1999), scenarios of abandonment include family members dropping off elderly persons, boarding homes or nursing homes dropping off elderly persons, and, in some cases, elderly persons seeking out care in emergency rooms on their own because they are unable to care for themselves.
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There are times when the neglect older adults suffer results from their own actions or inactions. This problem is referred to as self-neglect. Older adults may self-neglect when they fail to take medications, repeatedly skip meals, use alcohol or other drugs to excess, or fail to attend to personal hygiene. Often, such self-neglect is associated with untreated physical or mental health problems, especially depression (Quinn & Tomita, 1997). Tatara (1996) suggested that as many as one third of elder abuse cases involve self-neglect or self-abuse. The NCEA (1997) gathered data about self-neglect and found that self-neglect cases are those that are most often dealt with by protective service employees. Estimates of the extent of self-neglect are likely low because most elderly persons who are neglecting themselves would be unlikely to report their self-neglect to authorities (Hall, 1987). Byers and Lamanna (1993) further note that protective service workers often find these cases the most difficult to handle because efforts to stop the self neglect are resisted by the victim.
2-2-3 Factors that Contribute to the elder abuse
Everitt, O’Malley, and Campion, (1983). (a) Those focusing on the victim’s dependency: That is, there are a variety of factors that may contribute to older adult abuse and neglect. According to Bennett and Kingston (1993) and Biegel and Blum (1990), several factors predisposing elderly abuse by caresr include
: (1) mental and physical dependence to one family, (2) poor communication or a failure of relationship, (3) considerable change in a caregiver’s lifestyle,(4) perceptions of caregivers towards dependence of older persons, (5) frequent visits to general practitioners by the informal caregivers to talk about their problems, (6) role reversal, and (7) isolation of the household. Preliminary hypotheses regarding the cause of elder mistreatment that was based on case reports and early studies were reviewed by O’Malley on physical and mental impairment of an older adult, (b) Those emphasizing the effect of stress on the caregiver, (c) Those concerned with the influence of families who have learned to solve problems by being violent with one another, (d) Those that focus on the individual problems of the abuser, and (e) Effects of a society, which casts older adults in the role of non-persons through ageism, sexism, and destructive attitudes toward the disabled and toward those who are perceived to be unattractive. Several researchers have identified various risk factors that can potentially lead to mistreatment or abuse of older adults. According to Anastasio (1981), risk factors that characterize precipitators are inability to provide care, financial needs and inability to maintain one’s home. For victims, the risk factors include functional impairment and adverse physiological change. There are a variety of probable causes of the abuse of older adults. Most causes of abuse are committed in residential rather than institutional settings, and the most likely culprits are spouses, children, siblings, relatives, or paid caregivers. In older persons, the most common types of maltreatment are neglect, emotional/psychological abuse, and physical abuse (Marshall, Benton, & Brazier, 2000). Other risk factors in abuse are (1) shared living arrangements between the elder person and the abuser, (2) dependence of the abuser on the victim, and (3) social isolation of the elder person.
The typical victim is an elderly person in poor health that lives with someone. Elderly people living alone, whether widowed, divorced, or never married are at low risk. The abuser is more likely to be a spouse than a child, reflecting the fact that more elderly people live with their spouses than with children; and the risk factor is greater when the caregiver is depressed (Pillemer & Finkelhor, 1988: Paveza, et al. 1992). Although many older men are abused, abuse against women inflicts more injuries.
Rates of violence are high in families with an elder person suffering from dementia; in these families punching, kicking, and other violent behaviors are high in both directions (Paveza, et. al., 1992). In the United States, the number of reported cases of domestic elder abuse nationwide, calculated by combining state reports and adjusting for differences in definitions and eligibility criteria, has increased steadily from 117,000 in 1986 to 296,000 in 1996 (Tatara, 1995; Tatara, Kuzmeskas, and Duckhom, 1997).
2-2-4Competing theoretical explanations of elder abuse
Five major theories have been set forth in an effort to understand the causes of elder mistreatment. These theories include (a) the impairment theory, which advances the idea that elderly persons who have a severe mental impairment are most likely to be abused; (b) the theory of psychopathology of the abuser, contending that personality traits or character disorders cause persons to be abusive; (c) the transgenerational violence theory, which holds that violence is a learned normative behavior in some families; (d) the stressed caregiver theory, which examines the burdens a dependent elder places on the family; and (e) the exchange theory, which evaluates the effect of external influences upon the relationship between victim and abuser (Fulmer, 1998).
Lachs & fulmer (1993) reported seven leading theories or conceptual frameworks are used to examine the etiology of elder abuse. Of course, in addition to these seven theories, exchange theory has paid attention to the elderly abuse subject from the view of expenses and rewards that will be pointed out in the following of the seven theories.
2-2-4-1- Psychology of the abuser
The first is psychology of the abuser, which refers to caregivers who have pre- existing condition that impair their capacity to give appropriate care. For example, a caregiver who has mental retardation or alcohol dependency may not be able to exercise appropriate judgment in care giving of older adults. This can ultimately lead to abuser neglect (Lachs & fulmer, 1993).
2-2-4-2 Transgenerational violence
The next Theory is related to transgenerational violence. According to this theory, elderly abuse can be a part of the continuing domestic violence that started with child abuse and elderly abuse will end. Little research has been done to obtain empirical evidence to support this theory, but the same number also emphasized on its importance. Another aspect of transgenerational violence relates to adult children that long time lived with their parents and children were abused then grow up and the elderly parents living with them are being abused. (Lachs & fulmer, 1993).
2-2-4-3- Learning theory
Finally, transgenerational violence has been explained in terms of a learning theory in that a child who observes violence as a coping mechanism may learn it and bring to adult life (Lachs & fulmer, 1993).
2-2-4-4- Isolation theory
National center on elder abuse and the American public human services association (1998) has reported isolation theory espouses that mistreatment is prompted by a dwindling social network. According to the National Elder Abuse incidence study about 25% of all elderly person live alone and even more interact only with family members and have little social interaction with the outside word. Isolated older adults are at the particular risk because there are no outsiders watching out for them, and they may not be identified by the healthcare system or reporting agencies until it is too late (Lachs & fulmer, 1993).
According to Godkin, Wolf, and Pillemer (1989), it is difficult to determine whether isolation is the result of mistreatment (family members or caregivers may be trying to hide the abuse from the outside word) or precipitating factor of abuse.
2-2-4-5- Identity Theory
Other theories are role and identity theories. A synthesis of role theory and identity theory has provides an explanation of the effects of socially constructed roles and identities for the elderly. It assists in understanding how these socially constructed roles and identities may increase the elder’s vulnerability to abuse.
2-2-4-6- Role Theory
In their classic text on role theory, Biddle and Thomas (1986) noted that one of the key characteristics of social behavior is “the fact that human beings behave in ways that are different and predictable depending on their respective social identities and the situation”. Key concepts of role theory includes: the identities that actors assume, the expectations for behavior of the actor that is mutually understood and adhered to by the individuals, and the social behaviors that are characteristic of the particular behavior.
2-2-4-7- Social exchange theory
Another conceptual model that has been used to explain elder abuse has been derived from social exchange theory. Social exchange theory is based on the idea that social interaction involves the exchange of reward and punishments between at least two people and that all individuals seek to maximize reward and perform instrumental services. In fact, with increasing physical infirmities, the individual begins to require more and more in the form of instrumental services. Therefore, when one is old and infirm, violating the law of distributive justice is relatively easy. In addition, because of the losses associated with aging, the individual’s potential to supplement social ties and to extend a personal power base is reduced. As a result, the individual becomes less able to reciprocate rewarding behaviors and less likely to have a choice about continuing unrewarding or punishing social exchanges with those who perform an instrumental service. Figuratively speaking, the elderly individual must begin to live on the credit accumulated over the years because there are few ways to replenish the bank. One outcome of the aging condition that Dowed predicts is that as the imbalance in power increases, the older person is likely to display more passivity and compliance and more withdrawing behaviors in an effort not to alienate the remaining few people who can provide rewards and services.
2-2-4-8- Situational theory
Steinmets (1990) have explained situational theory, which is also referred to as caregiver stress. As care burdens multiply, they outweigh the caregiver’s capacity to meet the needs of the older adult; therefore, caregiver stress can overwhelm the situation. Elder abuse can be outcome.
The situational model is the explanatory base that was the earliest devised to explain elder abuse. It also appears to be the most widely accepted at this time. Derived from the theoretical base associated predominately with child abuse and less strongly with other forms of intrafamily violence, this model has considerable intuitive appeal. In addition, among clinicians, this model has popular support, since its basic premise fit easily within an intervention framework.
Very simply, the basic premise of the situational model is that as the stress associated with certain situational and/or structural factors increases for the abuser, the likelihood increases of abusive acts directed at a vulnerable individual who is seen as being associated with the stress. The situational variables that have been linked with abuse of the elderly have included 1) elder related factors such as physical and emotional dependency, poor health, impaired mental status, and a difficult personality. 2) Structural factors such as economic strains, social isolation, and environmental problems, and 3) caregiver related factors such as life crisis, burn out or exhaustion with care giving, substance abuse problems, and previous socialization experiences with violence.
There is a lot of support to approve the situational model. It is obviofied us that the …… burden of stress to caregivers makes more than overwhelmed and older abuse family members. Moreover, psychological model of child abuse and interfamily violence model which are highly related to structural and situational stress. Bring up the problem of older abuse. If gives a strong approval to use situational model for abuse among older people. Finklhor and Pillemer stated that there are some similarity between child abuse and elder abuse. They found this similarity in vulnerability of abuse victim and frustration in caregivers. Moreover, both child and elder abuse share the social context and are identified by healthcare professionals. They believe that the story is true for spouse abuse, too.
Whatever the reason of abuse, it can be prevented. This …….that shows that situational model is an applicable model for elder abuse.
2-2-4-9 Physical/Mental Dependence (Impairment)
This theory is based on the belief that elderly persons who have a severe mental or physical impairment are most vulnerable to becoming abused. In relationships where one person is dependent and another person is the helper or caregiver, there is always potential for misuse of power by the caregiver.
Summary of theoretical explanations
To explain the causes of elder abuse, some researchers in developed countries have viewed it as a problem of an overburdened caregiver (situational model), a mentally disturbed abuser (intra-individual dynamics), or a dependent perpetrator and dependent victim (exchange theory). Others have used learned behavior (social learning theory), the imbalance of power within relationships (feminist theory), and the marginalization of elders (political economy theory), or a lack of fit between the organism and the environment (ecological theory).
2-3- Review of experimental literature
Phenomenon of the elderly abuse and its forms and causes are subjects that have been explored by sociologists, social psychologists and hygiene experts to find its visible and invisible dimensions. This part of the draft, as is clear from its topic, is discussing subject experimental literature about characteristics of victims. This literature involves all performed studies and researches in the form of governmental reports, organizational researches, bachelor, master, and doctoral theses that are cited according to the year they have been performed.
No one explanation for the cause of elder abuse exists. Abuse is a complex problem which is rooted in multiple factors (Wolf, 2000). Caregiver stress and burden was once regarded as a major causative factor of elder abuse. However, Anetzberger (2000) discusses the complexity of elder abuse and the results of prior studies, which suggest that the etiology of elder abuse is multifaceted, and that caregiver stress and burden is not the only dominant risk factor. She stresses that the reality of elder abuse demands the development of new explanatory and intervention models (Anetzberger, 2000). A number of socio-demographic factors have been identified as possible contributors to elder abuse. Levine (2003) lists the following factors: intra-family stressors including separation, divorce and financial strain, ageism, increased life expectancy and medical advances that have prolonged years lived with chronic disease (Levine, 2003).
Elders are abused in homes, hospitals, nursing homes and in other institutions (Nelson, 2002). Prevalence or incidence data on elder abuse in institutional settings are lacking despite the vast existing literature on issues of quality of care (Wolf, 2000). Most elder abuse and neglect takes place in the home and is inflicted by family, household members and paid caregivers (Smith, 2002). A survey conducted in one US state reported that 36% of nursing and support staff reported having witnessed at least one incident of physical abuse by another staff member during the prior year and 10% admitted to having committed at least one act of physical abuse themselves (Wolf, 2000). A cross-sectional retrospective chart review of new in- and outpatients
conducted by a Montreal General Hospital Division of Geriatric Psychiatry in one calendar year, studied the prevalence and correlates of four types of elder abuse and neglect in a geriatric psychiatry service (Vida, Monks, & Des Rosiers, 2002) Although this study was limited by a clinically derived and a relatively small sample size of 126 patients, it was reported that elder abuse and neglect was suspected or confirmed in 16% of patients studied. Living with non-spouse family, friends, or other persons in a non-supervised setting, along with a history of family disruptions by widowhood, divorce, or separation were significantly correlated with abuse, while statistically non-significant yet potentially important identifiers included female gender, alcohol abuse, and low functional status.
Elders are most at risk from family members (Nelson, 2002). The perpetrator is a family member in two-thirds of known cases of abuse and neglect and was identified as adult children or spouses (National Center on Elder Abuse, 1998). Despite the popular image of elder abuse occurring in a setting of a dependent victim and an overstressed caregiver, there is accumulating evidence that it is neither ca regiver stress levels nor the dependence level of the victim that are the core factors leading to elder abuse (Wolf, 2000). It is now felt that stress may be a contributing factor in abuse cases but it does not explain the phenomenon (Wolf, 2000). Recent studies on the relationships between caregiver stress, Alzheimer’s disease, and elder abuse suggest that it is the long-term or pre-abuse nature of the relationships which is the important factor in predicting instances of maltreatment (Wolf, 2000). The mental status of the perpetrator which includes emotional, psychiatric, and substance abuse problems, the dependency of the perpetrator on the victim, and the lack of outside the home external support for the victim continue to emerge as elder abuse risk factors (Wolf, 2000).
A cohort of 2,812 community-dwelling adults over the age of 65 from the
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