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Invited Commentary
Geriatrics
August 12, 2021

Identifying the Incidence and Factors Associated With the Risk of Elder Mistreatment

Author Affiliations
  • 1Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick
  • 2School of Nursing, Rutgers, The State University of New Jersey, Newark
JAMA Netw Open. 2021;4(8):e2119593. doi:10.1001/jamanetworkopen.2021.19593

Burnes and colleagues1 provide data on the 10-year incidence of elder mistreatment (EM), using the wave 1 (2009) and wave 2 (2019) data from the New York State Elder Mistreatment Prevalence Study. Among 4156 older adults living in New York State who completed the wave 1 interview, 628 participants completed the wave 2 interview and reported an overall 10-year EM incidence of 11.4%.1 Poor health status, change in living arrangement, and Black race were identified as factors associated with increased risk of both overall EM and subtypes of EM.1 These findings set an agenda for future research aimed at understanding the factors associated with risk of EM and factors associated with protection against EM.

Factors associated with the risk of EM identified in the cohort study by Burnes et al1 and previous cross-sectional research include individual characteristics of adults experiencing EM (eg, sex, race/ethnicity, dementia, and functional dependency), individual characteristics of perpetrators (eg, mental illness, abuse history, substance abuse, and caregiver stress), characteristics of the relationship between the perpetrator and the elderly individual, and environmental factors.2 Factors associated with risk of EM differ not only among different EM subtypes, but also by definitions of EM and across sociodemographic and socioeconomic groups. An increasing number of EM studies have started to examine a composite risk factor index,3 as well as the typology of those experiencing abuse and the perpetrators.4 Compared with studies of risk factors, there is limited empirical evidence regarding factors associated with protection against EM.

Examining the incidence of EM and the factors associated with its risk and factors that may protect against it in longitudinal studies has both theoretical and practical implications. Improved understanding of factors associated with risk of EM and factors associated with protection against EM could help to inform best strategies for screening, treatment, and prevention efforts. A prior study by Dong and Wang5 reported that the 2-year incidence rate of EM was 8.8% among older Chinese American individuals in the greater Chicago area. Leveraging community-based participatory research methods, the Population-Based Study of Chinese Elderly is a longitudinal population-based of 3157 Chinese older adults.5 In that study, older age, female sex, longer duration of residence in the US, preference of speaking Mandarin or English, and perceived worsened health status were factors associated with increased risk for incidence of overall EM and EM subtypes.5 More prospective studies are needed to understand the incidence of EM.

To advance our understanding of the incidence of EM, there are major areas of research that can be pursued. First, collecting prospective data on EM incidence is difficult. EM takes longer to occur in some situations, whereas in other situations, EM occurs in a short time, and evidence shows that older adults might die within a few years after exposure to EM.6 Thus, a 2-wave prospective study with a short interval could exclude the former case, whereas a long interval could exclude the latter case and have a potential risk for recall bias, especially over the 10-year period as in the present study by Burnes et al.1 Both situations are likely to confound the estimation for EM incidence. Whenever feasible, researchers should leverage technology to conduct frequent EM assessments, such as the Ecological Momentary Assessment,7 which has been thoughtfully used in many psychosocial studies to measure process and outcomes.

Second, prior EM incidence studies have largely not paid attention to the key issues of EM severity. EM, as with many geriatric syndromes, occurs along a continuum of severity. Incidence studies have not considered how to categorize changes in severity of EM with respect to factors associated with increased risk of EM and those associated with protection against EM. In addition, the field should consider the dynamic circumstances of EM, where an individual can transition in and out of EM, depending on circumstances, caregiving, living situations, and so forth. Considering how to address these issues in categorizing EM incidence and progression of EM severity is complex and deserves further exploration.

Third, almost all prior EM cross-sectional and longitudinal research considers factors associated with risk of EM and those associated with protection against EM as either categorical or linear in terms of their effect. However, very few things in research and in life operate in this way. For example, multiple prior studies postulate that social isolation is associated with increased risk of EM and that social support is associated with protection against EM. However, evidence also suggests that although social isolation may be associated with increased risk for older adults who neglect themselves, it is associated with protection against physical, psychological, and financial mistreatment. Moreover, although social support may be associated with protection against EM, evidence also suggests that too much social support may compromise independence, reinforce feelings of vulnerability, and create family conflicts, which are also deleterious toward health.8

Fourth, the EM incidence rate likely varies across different racial and ethnic populations. With the rapid growth of diverse populations in the US, multiple prior studies suggest that EM prevalence is higher in historically marginalized populations.9,10 Differing cultural norms, definitions, perceptions, and burdens associated with EM across racial and ethnic groups can pose substantial challenges in estimating EM incidence.2 Future population-based EM studies are needed to examine EM incidence across racial and ethnic groups.

Fifth, several conceptual frameworks and perspectives (eg, life course perspective, caregiver stress model, and the Bronfenbrenner ecological model) guide the investigation of the factors underlying EM.2 For example, the life course theoretical framework indicates that socioeconomic disadvantages in prior life stages may be associated with increased risk of EM in later life. The caregiver stress model posits that EM is created by the dependence of an older person on a caregiver. The ecological theory emphasizes the broader context in which EM occurs. Empirical prospective studies on the factors associated with the risk of EM have primarily examined individual characteristics of those experiencing EM, leaving the factors associated with the perpetrators or caregivers, the relationship between the abuser and the individual experiencing abuse, and environment understudied. In addition, most studies have examined the direct effects of these factors on EM. Although some factors do not show a significant direct effect, there might be significant mediating or moderating effects. Future studies could examine multilevel factors associated with risk of EM, including individual-level factors (those experiencing EM and the perpetrators), relationship factors, and environmental factors, as well as mediating and moderating mechanisms to understand incident EM.

Finally, cross-sectional studies cannot distinguish between factors that might cause EM vs factors that are caused by EM. Cross-lagged panel correlations are unable to uncover whether one variable is the cause of another variable. Instead, they demonstrate whether A is associated with higher risk of B than B is of A. Future prospective studies could further examine the direction of association between the incidence of EM and the factors associated with its risk and those associated with protection against it.

In conclusion, EM incidence is an important but understudied area, especially in diverse populations. Representative national EM incidence and the factors associated with its risk and those associated with protection against EM are critically needed for improved research understanding, clinical management, and policy formulation. Such studies are needed in both community settings and health care settings. Older adults are more likely than young adults to visit a health care professional, which creates a unique opportunity to screen and detect EM in health care settings. Evidence-based and culturally appropriate screening, treatment, and prevention strategies should be developed to protect these at-risk populations.

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Article Information

Published: August 12, 2021. doi:10.1001/jamanetworkopen.2021.19593

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Li M et al. JAMA Network Open.

Corresponding Author: XinQi Dong, MD, MPH, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 112 Paterson St, 2nd Floor, New Brunswick, NJ 08901 (xdong@ifh.rutgers.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Burnes  D, Hancock  DW, Eckenrode  J, Lachs  MS, Pillemer  K.  Estimated incidence and factors associated with risk of elder mistreatment in New York State.   JAMA Netw Open. 2021;4(8):e2117758. doi:10.1001/jamanetworkopen.2021.17758Google Scholar
2.
Dong  X, ed.  Elder Abuse: Research, Practice and Policy. Springer International Publishing; 2017.
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Dong  X, Simon  MA.  Vulnerability risk index profile for elder abuse in a community-dwelling population.   J Am Geriatr Soc. 2014;62(1):10-15. doi:10.1111/jgs.12621PubMedGoogle ScholarCrossref
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Dong  X, Wang  B.  Incidence of elder abuse in a US Chinese population: findings from the longitudinal cohort PINE study.   J Gerontol A Biol Sci Med Sci. 2017;72(1)(suppl):S95-S101. doi:10.1093/gerona/glx005PubMedGoogle Scholar
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Li  M, Liang  Y, Dong  X.  Different definitions of elder mistreatment and mortality: a prospective cohort study from 2011 to 2017.   J Am Geriatr Soc. 2019;67(S3):S506-S512. doi:10.1111/jgs.15641PubMedGoogle Scholar
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Shiffman  S, Stone  AA, Hufford  MR.  Ecological momentary assessment.   Annu Rev Clin Psychol. 2008;4:1-32. doi:10.1146/annurev.clinpsy.3.022806.091415PubMedGoogle ScholarCrossref
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Silverstein  M, Chen  X, Heller  K.  Too much of a good thing? intergenerational social support and the psychological well-being of older parents.   J Marriage Fam. 1996;58(4):970-982. doi:10.2307/353984Google ScholarCrossref
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DeLiema  M, Gassoumis  ZD, Homeier  DC, Wilber  KH.  Determining prevalence and correlates of elder abuse using promotores: low-income immigrant Latinos report high rates of abuse and neglect.   J Am Geriatr Soc. 2012;60(7):1333-1339. doi:10.1111/j.1532-5415.2012.04025.xPubMedGoogle ScholarCrossref
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Beach  SR, Schulz  R, Castle  NG, Rosen  J.  Financial exploitation and psychological mistreatment among older adults: differences between African Americans and non-African Americans in a population-based survey.   Gerontologist. 2010;50(6):744-757. doi:10.1093/geront/gnq053PubMedGoogle ScholarCrossref
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