Context Although elder mistreatment is suspected to be life threatening in some
instances, little is known about the survival of elderly persons who have
been mistreated.
Objective To estimate the independent contribution of reported elder abuse and
neglect to all-cause mortality in an observational cohort of community-dwelling
older adults.
Design Prospective cohort study with at least 9 years of follow-up.
Setting and Patients The New Haven Established Population for Epidemiologic Studies in the
Elderly cohort, which included 2812 community-dwelling adults who were older
than 65 years in 1982, a subset of whom were referred to protective services
for the elderly.
Main Outcome Measures All-cause mortality among (1) elderly persons for whom protective services
were used for corroborated elder mistreatment (elder abuse, neglect, and/or
exploitation), or (2) elderly persons for whom protective services were used
for self-neglect.
Results In the first 9 years after cohort inception, 176 cohort members were
seen by elderly protective services for verified allegations; 10 (5.7%) of
these were for abuse, 30 (17.0%) for neglect, 8 (4.5%) for exploitation, and
128 (72.7%) for self-neglect. At the end of a 13-year follow-up period from
cohort inception, cohort members seen for elder mistreatment at any time during
the follow-up had poorer survival (9%) than either those seen for self-neglect
(17%) or other noninvestigated cohort members (40%) (P<.001).
In a pooled logistic regression that adjusted for demographic characteristics,
chronic diseases, functional status, social networks, cognitive status, and
depressive symptomatology, the risk of death remained elevated for cohort
members experiencing either elder mistreatment (odds ratio, 3.1; 95% confidence
interval, 1.4-6.7) or self-neglect (odds ratio, 1.7; 95% confidence interval,
1.2-2.5), when compared with other members of the cohort.
Conclusions Reported and corroborated elder mistreatment and self-neglect are associated
with shorter survival after adjusting for other factors associated with increased
mortality in older adults.
ELDER MISTREATMENT is suspected to be a morbid and mortal entity, but
little is known about the ultimate fate of older victims of family violence.
Studies have examined risk factors for mistreatment1-3
and prevalence surveys have been performed (32 cases per 1000 adults in the
most commonly cited study),4 but no longitudinal
studies of survival of mistreated elderly persons have been conducted.
We previously completed a study that identified risk factors for adult
protective service use and reported elder mistreatment in a large group of
older adults followed up for more than a decade.2,3,5
In that research, we linked the records of a well-characterized cohort of
community-dwelling older adults interviewed annually (The New Haven Established
Population for Epidemiologic Studies in the Elderly [EPESE]) with records
from protective services for the elderly from Connecticut, which was the official
entity charged with the investigation of suspected elder mistreatment. The
goal was to identify features of older adults that would predict subsequent
elder mistreatment. After completing that research, it occurred to us that
elder mistreatment could be viewed not only as an adverse outcome for these
subjects, but also as a risk factor itself for other adverse outcomes, such
as mortality. Thus, we were able to longitudinally examine the mortality associated
with elder mistreatment in a well-characterized cohort of community-dwelling
older adults.
Description of the Cohort
The New Haven EPESE study is 1 of 4 cohorts funded by the National Institute
on Aging.6 In its inception year, 1982, the
study sample consisted of 2812 community-dwelling adults older than 65 years
derived from a stratified sample of residence types: public housing for elderly
persons (ie, age and income restricted), private housing for elderly persons
(ie, age but not income restricted), and community (ie, no restrictions).
The sample at baseline consisted of 1643 women and 1169 men; 593 subjects
were nonwhite. At cohort inception the average age of subjects was 74 years;
13.1% of subjects had 1 or more impairments in activities of daily living
and 61.3% rated their health as excellent or good. A detailed description
of the sampling strategy as well as the demographic, clinical, and other characteristics
have been reported elsewhere.7
At baseline, subjects had a detailed interview covering broad medical,
functional, demographic, and psychosocial domains. Standardized instruments
were used to assess cognition, depressive symptomatology, social networks,
sources of emotional and other support, and chronic conditions. Subjects were
interviewed every third year in person and annually by telephone. Interrater
reliability substudies were conducted to ensure data quality and mortality
follow-up is assumed to be complete. A description of the scales and interview
methods has also been published.6
Protective Services for the Elderly in Connecticut
Connecticut has the oldest mandatory elder abuse reporting law in the
United States, enacted in 1978 (4 years before inception of the New Haven
EPESE cohort). The law defines a group of mandatory reporters who are likely
to have frequent contact with older adults by virtue of their occupation (such
as physicians, nurses, and social service providers), and might therefore
be in a position to identify cases of suspected elder abuse. Reports are made
to a regional ombudsman in the elderly protective services division who makes
an on-site visit to the elderly person to interview the client and any other
involved party. Based on the information obtained, the ombudsman verifies
or refutes a suspicion of mistreatment and assigns 1 or more of 3 designations
to a case: abuse, neglect (including self-neglect), or exploitation. Elder abuse is defined as the willful infliction of physical
pain, injury, or mental anguish, or the willful deprivation by a caretaker
of services necessary to maintain physical and mental health. Neglect is defined as an elderly person alone who is not able to provide
himself/herself the services necessary to maintain physical and mental health,
or who is not receiving those services from a responsible caretaker. Thus,
under Connecticut definitions it is possible to be self-neglected. Exploitation is defined as taking advantage of an older adult for monetary
gain or profit.
The ombudsman then develops a client-specific care plan that is typically
multidisciplinary in nature and is intended to ensure safety while maximizing
the autonomy of the older adult. Interventions vary and might include home
care, physician or other health care clinician referral, pursuit of guardianship,
or nursing home placement.
Identification of Cohort Members Seen by the Ombudsman
We performed a manual record matching of EPESE and Connecticut Ombudsman/Elderly
Protective Service records to determine if any cohort members had been seen
by the ombudsman during an 11-year follow-up period from cohort inception
(1982-1992 inclusive). This manual matching was performed in such a way as
to protect the confidentiality of all subjects involved (ie, so that elderly
protective services had no knowledge of who EPESE cohort members were and
EPESE investigators had no knowledge of which cohort members might have been
seen by elderly protective services). The protocol was approved by the institutional
review board, and the final merged data set (which contained the standardized
EPESE data merged with elderly protective services–derived information
about the nature of the problems noted by the ombudsman in the home investigation)
had no information that would permit the identification of any party.
After cohort members who were seen by protective services for the elderly
were identified, weighted 13-year survival curves from cohort inception were
constructed for 3 subgroups of subjects: (1) those found to have sustained
verified elder mistreatment (abuse, neglect, and/or exploitation) by another
person, (2) those seen by protective services for corroborated self-neglect,
or (3) other members of the cohort who had no contact with elderly protective
services. Cohort members who were seen by the ombudsman, but who had no verified
complaints were excluded. All analyses were weighted and adjusted for the
sampling design of the cohort.8
Multivariate analysis was conducted with all-cause mortality as the
dependent variable. The goal of multivariate analysis was to estimate the
independent contribution of reported and corroborated elder mistreatment or
self-neglect to all-cause mortality after adjusting for other factors known
to predict mortality. The group of cohort members not seen by protective services
for any reason served as the referent group. The categories of covariate characteristics
were demographic (age, sex, race, education, and income); health related (self-reported
chronic conditions including myocardial infarction, stroke, cancer, diabetes,
hypertension, and hip fracture, as well as body mass index in tertiles [a
measure of weight in kilograms divided by the square of height in meters];
physical functioning (number of activities of daily living impairments [0
to 7] and number of Rosow-Breslau or Nagi impairments [0 to 8])9,10;
social networks and support (number of social ties, including marital status,
frequent contact with friends and relatives, regular attendance at religious
services, and participation in social or community groups, and number of sources
of emotional support; cognitive performance (Pfeiffer Short Portable Mental
Status Questionnaire [SPMSQ]11); and psychosocial
domains (Center for Epidemiological Studies Depression Scale12).
For body mass index and household income, which had more than 5% missing data,
dummy variables were created for the missing data so that the 2 measures could
be retained in the model.
Pooled logistic regression13 was used
to allow for updating the independent variables, including referral to elderly
protective services as well as characteristics ascertained in the EPESE interviews
(such as depression scores and chronic conditions). Proportional hazards regression
could not be used because the data did not meet the assumptions. Many of the
potential confounders of the association between elder mistreatment and mortality
were assessed at only the triennial face-to-face interviews, so we used 9
years of follow-up divided into three 3-year intervals. According to this
strategy, each of 3 observation periods (1982-1985, 1985-1988, and 1988-1991)
was included as a separate record for each subject in the pooled sample. For
each record, the covariates were updated using the subject's status at the
beginning of the interval. Likewise, the 3-level protective services variable
(no contact with protective services for the elderly, corroborated self-neglect,
and corroborated mistreatment by another party) was updated for each interval
by using the dates of ombudsman investigation. The outcome for each interval
was whether the subject died during that interval. Subjects who died were
dropped from subsequent intervals. Subjects who were seen by the ombudsman
but had no verified complaints during follow-up (n=38) were excluded from
intervals subsequent to their first investigation, although we examined their
survival separately.
A series of 7 hierarchical models was constructed to sequentially adjust
for domains of potential confounders of the association between elder mistreatment
or self-neglect and mortality. The first model included only an indicator
for the 3-year interval and dummy variables for self-neglect and elder mistreatment
while the seventh model included the covariates from all 6 domains. The pooled
method assumes that the odds ratio (OR) is consistent across intervals; therefore,
we tested this assumption by running models including interaction terms between
protective services status and interval.
We also sought to determine which cohort members might have been placed
in nursing homes over the follow-up period. Connecticut has a long-term care
registry to which, since 1977, all skilled nursing facilities have been required
to report admissions. We submitted identifying data on all members of the
study cohort (Social Security number, name, date of birth, sex, and race)
to the registry, which identified matches with residents listed. Cohort members
(or their proxies) were also asked during each annual interview if the respondent
had been admitted to a nursing home at any time in the past year. These reports
were confirmed by telephone calls to the nursing homes. Data are currently
available for this cohort from cohort inception in 1982 through December 1990.
As ascertainment of mortality is virtually complete for the New Haven
EPESE cohort, we also examined the distribution of the cause of death for
the 3 groups of cohort members previously described. Cause of death was determined
from death certificate data.
The number of verified and nonverified mistreatment and self-neglect
events over the follow-up period are shown in Figure 1. By year 8 of follow-up, 90% of the total mistreatment
events that had occurred within the cohort over the entire 13-year follow-up
had accrued. The 13-year survival curves for the 3 groups are shown in Figure 2. While at the beginning of the follow-up
period (years 1-5) survival rates were similar, at the end of follow-up, cohort
members seen for abuse and/or neglect had poorer survival (9%) than either
those seen for self-neglect (17%) or those cohort members who had no contact
with protective services for the elderly (40%) (P<.001
for differences, weighted χ2). Survival of subjects who had
nonverified allegations (39%) was not significantly different than the cohort
numbers who were not seen by protective services.
Table 1 shows the 3-year
pooled bivariate risk of death for several covariates that appear in the final
multivariable models; most are associated with increased mortality (older
age, male, lower educational attainment, more than 1 chronic medical condition,
low body mass index, any activities of daily living or higher impairment,
poor social network, cognitive impairment, and depressive symptomatology).
In bivariate analysis, elder mistreatment also was significantly associated
with many of these covariates.
Table 2 shows all-cause
mortality over the three 3-year intervals by risk group. In each interval
and for the total pooled results, elder mistreatment (abuse and/or neglect)
and self-neglect conferred a significantly increased risk of death. In all
but the first interval, elder mistreatment was associated with a significantly
higher risk of death than self-neglect.
The results of hierarchical pooled logistic regression are shown in Table 3. The risk of death adjusted only
for the interval of follow-up was substantial for both subjects who were mistreated
(OR, 5.1; 95% confidence interval [CI], 2.8-9.5) as well as those who were
self-neglected (OR, 3.1; 95% CI, 2.3-4.2). Subsequent models show the influence
of adjusting for demographic characteristics, functional status, social networks,
cognitive status, and depressive symptomatology. In general these models decreased
the magnitude of the association between elder mistreatment and all-cause
mortality, with demographic characteristics and functional status having the
greatest influence on the ORs. However, after adjusting for all these covariates,
the risk of death remained elevated for both cohort members experiencing elder
mistreatment (OR, 3.1; 95% CI, 1.4-6.7) and those seen for self-neglect (OR,
1.7; 95% CI, 1.2-2.5), when compared with other members of the cohort.
The most common causes of death for these 3 groups are shown in Table 4. In general, the major causes of
death were similarly distributed among the 3 groups. Notably, no death in
either the mistreated group or the self-neglected group was deemed to be due
to injury.
Elder mistreatment and self-neglect may be risk factors for entering
a nursing home. For the elderly person who has been mistreated, the nursing
home may reflect a safe haven from mistreatment. For the self-neglecting elder,
a long-term care facility might afford access to food, medicines, or care
that would otherwise be inaccessible in the community. Alternatively, nursing
home residents generally are at a higher risk of death than their community-dwelling
counterparts, and nursing home placement might alter the cause of death for
a previously mistreated subject. Accordingly, we assessed the proportion of
deaths occurring in long-term care facilities for all 3 groups (Table 5). While those subjects experiencing self-neglect were more
likely to die in a nursing home compared with uninvestigated subjects, those
experiencing mistreatment were not.
This longitudinal study is the first to examine mortality in a well-characterized
cohort of community-dwelling older adults, a subset of whom both have been
referred to protective services and have experienced elder mistreatment. The
results demonstrated a mortality gradient in which older adults who have been
mistreated were more likely to be dead at the end of a 13-year follow-up period
than either their self-neglected counterparts or those cohort members who
had no interaction with adult protective services. Survival was similar at
the beginning of the study, but midway through follow-up, the survival curves
diverged. Notably, the majority of mistreatment events had occurred in the
cohort by this time, which may reflect a saturation effect in the pool of
persons susceptible. Additionally, a multivariable analysis that controlled
for other factors known to be predictive of mortality in older adults revealed
that both the need for protective service use generally and elder mistreatment
specifically were independent predictors of early death.
Notably, no deaths in the mistreated group were immediately ascribed
to injury. How then might elder mistreatment confer additional risk for mortality?
One possibility is that we did not adequately adjust for the confounders (eg,
comorbidity) or did not identify all confounders that might be associated
with mortality, such as noncompliance with medical treatment or poor access
to medical care. For example, malnutrition might be associated with many of
the covariates in these models, but was only indirectly assessed through body
mass index. Comorbidity adjustment in this study was through self-report of
7 medical conditions, which is less accurate than medical record–based
abstraction. Another possibility is that protective service use and elder
mistreatment represent comprehensive markers of frailty not captured by traditional
constructs of the older adult at risk. It may do this by amalgamating, individually,
high-risk features known to be associated with adverse outcomes such as poor
functional status, cognitive impairment, and poverty into an identifiable
composite characteristic that is easily measured.
An intriguing, but somewhat speculative, hypothesis derives from the
growing body of literature on the relationship between various forms of interpersonal
stress (sometimes termed negative social support)
and individual well-being. Research has consistently shown that negative interpersonal
interactions with network members strongly predict a variety of negative psychological
outcomes and are strongly related to distress.14-18
The caregiver burden associated with caring for a frail or demented loved
one may lead to mistreatment in some situations.19
Although research using mortality as an outcome is lacking, it seems plausible
that experiencing elder abuse is an extreme form of negative social support.
In the same manner that social integration reduces mortality, it may conversely
be the case that the extreme interpersonal stress resulting from elder abuse
situations may confer additional death risk. Future research that examines
this hypothesis is greatly needed.
Nursing home placement is an intervention that is frequently implemented
for egregious adult protective services cases involving both mistreatment
and/or self-neglect. This study had limited follow-up of deaths occurring
in long-term care facilities, but in general, self-neglecting older adults
were more likely to die in long-term care facilities than either mistreated
subjects or those who had no contact with adult protective services. Unfortunately,
the numbers in this study were small, and we believe that defining the outcomes
of long-term care placement for adult protective service clients of all types
is a crucial area of study, since nursing home placement is a radical, restrictive,
and expensive intervention. It is also one of the most difficult decisions
that adult protective services workers and elder abuse field workers face
in their jobs. More objective data on when it is appropriate and efficacious
are greatly needed.
Another limitation of this study is that it examines the survival of
individuals sustaining reported elder mistreatment and there are likely mistreatment
cases among the nonprotective services group. Similarly, physicians probably
underreport elder abuse as a contributing cause of death on death certificates,
either unaware that it existed or unaware that it might contribute to death.
This study argues that it may. Additionally, we have no way of adjusting for
length of abuse because protective service referral does not indicate when
mistreatment began, only when it became known to an official agency.
In summary, reported elder mistreatment confers additional death risk.
Whether multidisciplinary interventions directed at stopping elder mistreatment
would avert the associated increased mortality is an area worthy of further
investigation.
1.Johnson T. Elder Mistreatment: Deciding Who Is at Risk . Westport, Conn: Greenwood Press; 1991.
2.Lachs MS, Williams C, O'Brien S, Hurst L, Horwitz R. Older adults: an 11-year longitudinal study of adult protective service
use.
Arch Intern Med.1996;156:449-453.Google Scholar 3.Lachs MS, Williams C, O'Brien S, Hurst L, Horowitz R. Risk factors for reported elder abuse and neglect: a nine year observational
cohort study.
Gerontologist.1997;37:469-474.Google Scholar 4.Pillemer KA, Finkelhor D. The prevalence of elder abuse: a random sample survey.
Gerontologist.1988;28:51-57.Google Scholar 5.Lachs MS, Berkman L, Fulmer T, Horowitz RI. A prospective community-based pilot study of risk factors for the investigation
of elder mistreatment.
J Am Geriatr Soc.1994;42:169-173.Google Scholar 6.National Institute on Aging. Established Populations for Epidemiologic Studies of the Elderly:
Resource Data Book . Washington, DC: US Dept of Health and Human Services; 1986. NIA publication
86-2443.
7.Cornoni-Huntley J, Ostfeld AM, Taylor JO.
et al. Established populations for epidemiologic studies of the elderly: study
design and methodology.
Aging (Milano).1993;5:27-37.Google Scholar 8.Shah BV, Barnwell BG, Bieler GS. SUDAAN User's Manual, Release 7.0 . Research Triangle Park, NC: Research Triangle Institute; 1996.
9.Rosow I, Breslau N. A Guttman health scale for the aged.
J Gerontol.1966;21:556-559.Google Scholar 10.Nagi SZ. An epidemiology of disability among adults in the United States.
Milbank Mem Fund Q Health Soc.1976;54:439-468.Google Scholar 11.Pfeiffer E. A short portable mental status questionnaire for the assessment of
organic brain deficit in elderly patients.
J Am Geriatr Soc.1975;23:433-441.Google Scholar 12.Radloff LS. The CES-D scale: a self-report depression scale for research in the
general population.
Appl Psychol Meas.1977;1:385-401.Google Scholar 13.Cupples LA, D'Agostio RB, Anderson K, Kannel WB. Comparison of baseline and repeated measure covariate techniques in
the Framingham Heart Study.
Stat Med.1988;7:205-218.Google Scholar 14.Fiore J, Becker J, Coppel DB. Social network interactions: a buffer or a stress?
Am J Community Psychol.1983;11:423-439.Google Scholar 15.Okun MA, Melichar JF, Hill MD. Negative daily events, positive and negative social ties, and psychological
distress among older adults.
Gerontologist.1990;30:193-199.Google Scholar 16.Pillemer K, Suitor JJ. Family stress and social support among caregivers to persons with Alzheimer's
disease. In: Pierce GR, Sarason BR, Sarason IG, eds. Handbook of Social
Support and Family . New York, NY: Plenum; 1996:467-494.
17.Rook K. The negative side of social interactions: impact on psychological well-being.
J Pers Soc Psychol.1984;46:1097-1108.Google Scholar 18.Vinocur AD, van Ryn M. Social support and undermining in close relationships: their independent
effects on the mental health of unemployed persons.
J Pers Soc Psychol.1993;65:350-359.Google Scholar 19.Pillemer KA, Suitor JJ. Violence and violent feelings: what causes them among family caregivers?
J Gerontol.1992;47:S165-S172.Google Scholar