A Silent Enemy: Elder abuse in Miami-Dade County, Florida.

Elder abuse in the United States, as in many other countries, traditionally has not been a high-priority policy issue. Typically, it has been overshadowed by more visible cases of domestic violence and child abuse. Except for an occasional high-profile case in a nursing home or other institutional

setting, elder abuse, particularly when it involves family members in the home, does not receive much public discussion or analysis. Unfortunately, as caseloads continue to rise, many important issues remain in addressing the dynamics of treatment and prevention. Better understanding of these issues in the United States may help countries throughout the Americas identify concerns in their own societies and design policies and programs to confront them.

Patterns of Abuse

Elder abuse can be an act of commission whereby either physical or psychological injury is inflicted on another person. It also can be manifested as neglect, the failure to fulfill an obligation or duty to another person, or as exploitation, the illegal use of another's property. A national US study of 1996 data estimated that of approximately 44 million older adults 60 and above, 450,000 had experienced abuse, neglect or exploitation. This figure constitutes an incident rate of around 10 per 1,000 older adults.

A study the authors conducted of 1997 data for Miami-Dade County, Florida identified an incident rate of 5.36 per 1,000, or only 54% of the national rate. The discrepancy most likely involves the underreporting of actual cases, but additional issues were identified that may be of importance to other jurisdictions. These include understanding the profiles of abuse victims and perpetrators; the level of recidivism; race, ethnicity and cultural influences; risk factors; the use of available data to assist policymakers and those responsible for investigations; the availability of appropriate treatment models; professional training; and community awareness.

The reason for the apparent underreporting of cases of elder abuse in Miami-Dade County is unclear. Hispanics represent nearly 60% of all older adults in the county. We speculate that this group is significantly less likely to report elder abuse, especially when it occurs in the family. Unfortunately, the state of Florida agency responsible for investigating and providing services for victims does not collect data on ethnicity. Therefore, we could not analyze the profiles of victims and perpetrators based on this critical variable.

A crucial factor that emerged from the data, however, is the age of both the victims and the perpetrators of abuse. Nearly one-half of substantiated cases involved victims 80 years of age or older. People in this age group were victims of maltreatment at a rate more than 2.5 times their proportion in the total population of older adults. Approximately three-quarters of victims were white and one-quarter were black. Women were victims in nearly two-thirds of substantiated cases.

More than 86% of perpetrators were under 60 years of age compared to 66% nationwide, strongly suggesting that perpetrators are significantly younger in Miami-Dade County. More children or younger family members seem to be committing elder abuse in this area, but again, the reasons are unclear. Three-fifths of perpetrators were white and a little more than one-quarter were black (the rest were categorized as "other" or "unknown"). Approximately 53.5% of cases involved female perpetrators, climbing to 56.2% in cases involving a male victim.

Tracking the Warning Signs

Some of the patterns that emerged from the Miami-Dade data have significant implications for the way authorities address elder abuse. For example, a third of the South Florida cases involved at least one previous incident within the last year. This statistic leads us to conclude that the system of intervention and assistance to victims is not working effectively.

One major reason for this failure may be a lack of important information at the state agency responsible for this system. Knowledge of risk factors or indicators that can be used to predict future abuse is critical to the state's ability to respond effectively in terms of identification, intervention and prevention. If case data that address the issue of risk are not collected and made easily retrievable for those engaged in the system, the state's ability to carry out its responsibilities is dramatically reduced.

Many different factors may contribute to elder abuse. Researchers have been able to describe the elements typically identified in family abuse situations, including victim characteristics, perpetrator characteristics, and the history and dynamics of their interaction. The literature strongly suggests that the primary risk factors are: 1) past abuse; 2) physical or mental dysfunction of the older person; 3) financial dependency of an adult child; 4) emotional ill health of a dependent adult child; and 5) social isolation of the family. Such patterns could be discerned if information were available to track health status measurements, such as household structure (including the ages and relationships of each household member), and mental or personality disorders of victims and alleged perpetrators. Recording and computerizing the data that could help track these factors would assist key staff in achieving the state's goals.

Another major factor that limits the state's ability to respond more effectively to abusive situations is the low level of funding and the scope of services provided. The only source of funding in Florida is for long-term care services for the victim; e.g., in-home services designed for frail elders. These services are limited to addressing the victim's physical situation, not the underlying issues of intra-family violence and prevention of future episodes of abuse. The state has no responsibility to address issues related to the perpetrator.

Keeping the Problem in the Public Eye

Elder abuse is a complex issue that requires a more comprehensive model of explanation and treatment. Experience in responding to the broader category of domestic violence in the United States offers insight into the elements required to design a more comprehensive approach.

Models for addressing elder abuse should emphasize crisis intervention. In addition to the hotlines that already exist to report abuse, they should provide for special shelters, support groups, safety planning for the victims, imposition of legal sanctions, and anger management services for the perpetrators. All of these approaches are intended to underscore the importance of providing opportunities for victims to become more independent.

One of the most valuable lessons learned from the domestic violence experience is the importance of insuring that the issue of elder abuse has high visibility among both professionals and the public. Designers and implementers of treatment and prevention models have an ongoing responsibility to ensure that professionals working in the system--investigators, police, fire-rescue personnel and others--receive both pre- and in-service training in the issues addressed here. Training in investigative skills, understanding the importance and usefulness of case information and other related topics, such as substance abuse and sexual abuse, is vital to the success of state efforts. Those most likely to report elder abuse--doctors, nurses, social workers and others who come into regular contact with older adults--should be educated about risk factors and how to identify them. All professionals need to understand the cultural dimensions of abuse and should be part of the continuing effort to expand community awareness about elder abuse prevention, reporting and intervention.

Public awareness is perhaps the most important factor in a community's effort to prevent the occurrence of elder abuse. Public education campaigns related to each of the issues discussed here should be launched in collaboration with clergy and religious institutions as well as the local media, which can be effective in targeting geographic areas with high rates of abuse. The more information the public has about what constitutes abuse, how to recognize it, how and where to report it, what happens when a report is made, and what resources are available to assist victims, the more effectively a community can generate resources to combat it.

Max B. Rothman, J.D., LL.M. is executive director of Florida International University's Center on Aging. Burton D. Dunlop, Ph.D. is the center's director of research.