HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fulmer, T. Articles by Norman, R. Search for Related Content PubMed PubMed Citation Articles by Fulmer, T. Articles by Norman, R.

Dyadic Vulnerability and Risk Profiling for Elder Neglect

Correspondence: Address correspondence to Terry Fulmer, Division of Nursing, New York University, 246 Greene Street, New York, NY 10003-6677. E-mail: terryfulmer.don{at}nyu.edu

	Abstract

TOP Abstract Conceptual Model Methods Results Discussion and Future Research References

 
Purpose: Neglect of older adults accounts for 60% to 70% of all elder-mistreatment reports made to adult protective services. The purpose of this article is to report data from research, using a risk-and-vulnerability model, that captures the independent contributions of both the elder and the caregiver as they relate to the outcome of neglect. Methods: Between February 2001 and September 2003, older adults were screened and recruited through four emergency departments in New York and Tampa. The diagnosis of neglect was made by an expert neglect-assessment team. Elders and their caregivers were then scheduled for separate face-to-face interviews after discharge. Results: Constructs within the risk-and-vulnerability model were examined for scale-score significance based on the outcome diagnosis of neglect. In the risk domain, caregivers' functional status, childhood trauma, and personality were statistically significant. In the vulnerability domain, the elders' cognitive status, functional status, depression, social support, childhood trauma, and personality were significant. Implications: Findings from this study underscore the value of interdisciplinary assessment teams in emergency departments for screening elder neglect, with attention given to risk factors related to the caregiver and elder vulnerability factors, including reports of childhood trauma. The risk-and-vulnerability model may provide a link between the caregiving and neglect research. Data should be collected independently from both members of the elder–caregiver dyad in order for clinicians to understand factors related to elders who receive the diagnosis of neglect from interdisciplinary teams.

Key Words: Elder mistreatment • Assessment • Caregiver burden • Childhood trauma

Elder Mistreatment
The National Research Council (2003) has defined elder mistreatment as "(a) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trusting relationship to the elder or (b) failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm." Elder mistreatment results in serious and often debilitating consequences for older adults, both physically and emotionally. The enormous number of hours that go into a protective-service evaluation and the subsequent time spent in counseling with the older adult add to the burden of this problem. The untoward outcomes caused by abuse, neglect, exploitation, and abandonment of elderly individuals (Hudson, Johnson, & O'Brien, 1986) have to be systematically explored in order for us to begin to understand the elder-mistreatment syndrome. Elder mistreatment was largely unrecognized as a problem until mandated reporting laws became common in the early 1980s (Capezuti, Brush, & Lawson, 1997), and prevalence from a classic random sample survey estimated elder mistreatment at 32/1,000, for an annual prevalence figure of 700,000 to 1.2 million cases in the United States (Pillemer & Finkelhor, 1988). Similar figures have been reported in Britain and Canada with the use of the same measures (Ogg & Bennett, 1992; Podnieks, 1987). The National Center for Elder Abuse, which reports data from state mandatory reporting law agencies, has put the figure at more than 1 million annually (Tatara, 1993; T. Tatara, personal communication, March 18, 1996). It should be noted that there are few data for the incidence and prevalence of elder mistreatment. There has never been a national prevalence study, and available data are becoming dated.

Elder Neglect
Neglect of older adults accounts for 60% to 70% of all elder-mistreatment reports made to Adult Protective Services (APS; Tatara, 1993) and usurps over 50% of all APS resources (T. Tatara, personal communication, March 18, 1996). The National Elder Abuse Incidence Study documented that, of the 70,942 incident cases of neglect substantiated in that study by APS, 34,525 (48.7%) were categorized as neglect (The National Center on Elder Abuse at The American Public Human Services Association in Collaboration with Westat, Inc., 1998). In addition, the report documented that neglect is the most common form of elder mistreatment; it increased dramatically over the 4-year reporting period, from 47% in 1990 to 58.5% in 1994, although reports of abuse as a percentage of all reported elder mistreatment declined from 20.2% to 15.7%. The report described neglect as the refusal or failure to fulfill any part of a caregiving person's obligations or duties to an elder.

Neglect is defined more broadly by the National Research Council (2003) as "an omission by responsible caregivers that constitutes ‘neglect’ under applicable federal or state law," and may include refusal or failure by a person who has fiduciary responsibilities to provide care for an elder (e.g., failure to pay for necessary home care service, or the failure on the part of an in-home service provider to provide necessary care). Physical neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included as a responsibility or an agreement. Psychological or emotional neglect is the "failure to provide dependent elderly individuals with social stimulation," which might involve leaving elders alone for long periods of time, ignoring them or giving them the silent treatment, or failing to provide any kind of companionship, change in routine, news, or information (American Medical Association, 1992; Aravanis et al., 1993; National Research Council). Neglect cases can be just as serious, if not more serious, than physical abuse cases (Fulmer & Ashley, 1989; Fulmer, Ashley, & Reilly, 1986; Fulmer et al., 2004).

Rationale for This Study
Specific literature on elder neglect has been modest, and models from the child abuse and spouse abuse literature do not apply. Investigators in the field of child abuse and neglect have more predictable sets of norms in terms of growth and development for children, in contrast with the multiple health presentations in later life. Unlike signs and symptoms that might occur in children or younger adults, older adults often have several chronic diseases or disorders such as diabetes, hypertension, and congestive heart failure, which can mask or mimic elder mistreatment (Fulmer & Ashley, 1989; Lachs & Pillemer, 1995; Lachs, Williams, O'Brien, Hurst, & Horwitz, 1996). Cognitive impairment in elders also may compromise the ability of health professionals to obtain an accurate history of elder mistreatment. Battered women research is another paradigm that does not adequately help explain caregiver mistreatment of older adults. Generic factors in models of risk for elder mistreatment include status inequality, power-and-exchange dynamics, relationship types, social embeddedness of the elder and trusted other, and individual level factors (National Research Council, 2003). The complexity of the interactions across and among these factors is particularly challenging.

Fulmer and Ashley (1989) conducted an exploratory factor analysis to test the construct validity of items related specifically to neglect in an Elder Abuse Assessment Instrument (EAI). Results suggested that three constructs might be related to neglect: (a) nutritional deficits, (b) altered skin integrity, and (c) alterations in elimination. Interestingly, these constructs closely reflect eating and feeding, bathing, transfer, and toileting on the Activities of Daily Living Scale (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963).Clinicians must understand the older person's context to interpret sign and symptoms, which may or may not be the result of caregiver neglect.

Why a Dyadic Approach
Dyadic-interview approaches have been used in other studies to examine characteristics and perceptions of each member of the dyad independently and how these characteristics might result in elder mistreatment. In a study of unnecessary restriction, Fulmer and Gurland (1996, 1997), found that the caregivers of elders in that study differed significantly in their profiles on the basis of whether they were paid or unpaid caregivers. This approach has great utility in helping clinicians to better understand all types of elder mistreatment, because of the complex nature of caregiving relationships and the reciprocity that takes place. Matthias and Benjamin (2003) reported that limited research has been conducted regarding paid home care workers and elder mistreatment. In an effort to better understand this relationship, they analyzed data from California's In-Home Supportive Services program. Findings suggest that clients of the professional agency model were twice as likely to report neglect as the clients of the consumer-directed model (a model that allows the client to hire anyone, even a relative, as a provider). Clients who hired relatives as paid home care workers reported less abuse and neglect than clients who hired nonfamily home care workers.

Caregiver researchers have long sought to understand the features of humans that make them better or lesser caregivers (Dellasega, 1991; George & Gwyther, 1986; Lawton, Moss, Kleban, Glicksman, & Rovine, 1991; Lawton, Rajagopal, Brody, & Kleban, 1992). Caregiver role strain has been examined, with discussion of self-perceived caregiver skills, and constructs such as self-efficacy, caregiver mastery, competence, preparedness, and quality have been examined (Schumacher, Stewart, & Archbold, 1998). There is a need to link the literature between the caregiving and neglect research, because caregiving research is extremely important to the understanding of elder mistreatment. To date, the caregiver research has focused on the nature of caregiving and caregiver attributes, with respect to perceived burden and quality of care. In this study, we seek to link caregiving and neglect research by using a risk-and-vulnerability model.

	Conceptual Model

TOP Abstract Conceptual Model Methods Results Discussion and Future Research References

 
The risk-and-vulnerability model was based on the Rose and Killien (1983) model as applied to elder abuse by Frost and Willette (1994; see Figure 1).

View larger version (19K): [in this window] [in a new window]   Figure 1. The conceptual model for risk and vulnerability

Several theoretical explanations have been advanced as to why elder mistreatment occurs, but few of these theories have been empirically tested (Gelles & Pedrick-Cornell, 1990; National Research Council, 2003; Pillemer & Finkelhor, 1988). One theory that has widespread support in the elder-abuse literature is the situational model (Phillips, 1986). This model proposes that, as the stress associated with certain situational or structural factors increases for the caregiver, the likelihood for elder mistreatment increases (Gelles & Pedrick-Cornell; Phillips & Rempusheski, 1986). We believe this model does not sufficiently separate the contributions of the elder from those of the caregiver toward neglect. Data from a few studies seem to indicate a relationship between elder mistreatment and the presence of mental or physical impairments of the elder (Wolf, Godkin, & Pillemer, 1984).

Four studies (Coyne, Reichman, & Berbig, 1993; Fulmer, McMahon, Baer-Hines, & Forget, 1992; Pillemer & Finkelhor, 1988; Rose & Killien, 1983) reported a relationship between cognitive impairment and abuse. The first study (Coyne et al.) concluded that caregivers who were victims of physical abuse by the cognitively impaired elder were more likely to be abusive back. Unfortunately, this study had several limitations, including a singular focus on physical events; a cross-sectional study design that did not allow for an analysis of the relationship between the progression of cognitive impairment and elder mistreatment; and potential sample bias caused by the use of an anonymous questionnaire. The second study reported a significant positive association between cognitive impairment (both delirium and dementia) and the outcome of abuse (Fulmer et al.). In another report (Pillemer & Finkelhor), causal theories for elder abuse include caregiver stress, dependency of the abuser, the elder's degree of physical or mental impairment, learned violence, societal attitudes, and characteristics in institutions related to the staff, facility, and elder resident. That report recommended programs of research that look at the characteristics of victims and abusers, causes of abuse, and analysis of the APS system. The risk-and-vulnerability model encompasses both the environmental and elder sources and provides an integrative framework to address the aforementioned debate.

On the basis of the model, we hypothesized that older adults, diagnosed as neglected, would have different risk-and-vulnerability profiles from those who were not neglected (American Medical Association, 1994; Aravanis et al., 1993). The vulnerability of the elder to the risk posed by the caregiver (Frost & Willette, 1994) posits the interaction of both within the elder–caregiver dyadic relationship (Fulmer & Paveza, 1998). In this study, in an effort to better understand the likelihood and determinants of neglect within the dyadic context of elder and caregiver, we looked at differences between neglect and no-neglect cases in terms of elder vulnerability as well as environmental risk posed by the caregiver. The research questions were as follows: Are there differences between neglected elders and those not neglected in terms of demographics, functional status, depression, health status, cognitive status, elder behavior, social support, childhood trauma, and personality? Further, are there differences between the caregivers of neglected elders and those not neglected, in terms of demographics, caregiver burden, functional status, depression, health status, cognitive status, social support, childhood trauma, and personality?

	Methods

TOP Abstract Conceptual Model Methods Results Discussion and Future Research References

 
Between February 2001 and September 2003, older adults were screened and recruited through four urban emergency departments in New York and Tampa (Fulmer et al., 2004). Following the dissemination of written material about the study and after obtaining verbal consent from the older adult, the research assistants proceeded with the screen to determine study eligibility. Inclusion criteria for the study included the following: being 70 years of age or older; speaking English or Spanish; having a Mini-Mental State Examination (MMSE) score of 18 or greater; using a paid or unpaid caregiver 20 hr a week or more; and having a telephone in the home. Once the research assistants determined eligibility, they obtained written consent; they collected information regarding demographics, an MMSE, and an initial elder-assessment screen using the EAI (Fulmer, 1984; Fulmer, Street, & Carr, 1984). The research assistants forwarded all completed assessment data to an expert neglect-assessment team. The neglect-assessment team made the diagnosis of neglect or no neglect, and we used this diagnosis for case designation (Fulmer et al., 2004).

Elders and their caregivers who agreed to participate in the study were then scheduled for separate face-to-face interviews once the elders were discharged from the hospital, and they were compensated $20 on completion of the interview. We used the elder face-to-face interview that captured vulnerability factors to collect demographic information and information regarding the older adult's cognitive status, functional status, depression, health status, social support, childhood trauma, and personality. We used the caregiver face-to-face interview that captured risk factors to collect demographic information and assessment of risk factors for neglect in the elder. Specifically, we gathered data regarding the caregiver's cognitive status, functional status, depression, health status, social support, childhood trauma, personality, and burden, all of which would contribute to elder risk. The average time to conduct the interviews ranged from 60 to 90 min; caregivers and older adults were interviewed in isolation of one another.

Measures
The demographic data we collected on the elder and the caregiver consisted of age, gender, ethnic or racial background, religious preference, education, (former) occupation, marital status, and current living arrangement. We also collected information regarding financial status (i.e., income, financial support), health resources utilization, specific relationship to caregiver, all sources of care by amount provided, morbidity, place of birth, house ownership, and insurance status.

We assessed elder and caregiver cognitive status by using the MMSE (Folstein, Folstein, & McHugh, 1975), a 30-item instrument measuring orientation, memory, attention, ability to name, ability to follow verbal and written commands, ability to write a sentence spontaneously, and ability to copy a geometric figure. We used a cutoff score of 18 to determine if the elder was still eligible to participate in the face-to-face interview.

We measured elder and caregiver functional status by using the Determination of Need Scale (DON-R; Hagopian, Paveza, Prohaska, & Cohen, 1990; Paveza, Prohaska, Hagopian, & Cohen, 1989; Prohaska, Hagopian, Cohen, & Paveza, 1989). The DON-R assesses level of impairment on six ADLs and nine IADLs, using specific definitions for each of the functional abilities and specific definitions for each of the levels of impairment. Functional ability is rated on two Likert subscales; one measures impairment in functioning, and the second measures need for care. Combining the levels of impairment and need for care subscales results in a total score that measures the demand for care.

We assessed depression in both elders and caregivers by using the Center for Epidemiological Studies–Depression Scale (CES-D; National Institute of Mental Health, 1977; Radloff, 1977). The CES-D is a 20-item, Likert scale in which higher scores indicate a higher level of clinical symptomology of depression.

We assessed elder and caregiver health status by using the Medical Outcomes Study 36-Item Short Form (MOS SF-36; Ware & Sherbourne, 1992). The MOS SF-36 is a self-report health status instrument with eight scales that measure both physical and mental dimensions of health status. These include physical functioning, role limitations secondary to physical functioning, bodily pain, general health perception, vitality, social functioning, role limitations that are due to emotional problems, and mental health. Each scale is scored separately, resulting in a profile of eight scores for each dyad member.

We measured perceived social support for the elder and the caregiver by using the Personal Resource Questionnaire (PRQ-85), Part 2 (Weinert, 1988; Weinert & Brandt, 1987). The instrument has five subscales: intimacy; social integration; reassurance and worth as an individual and in role accomplishments; the availability of informational, emotional, and material help; and nurturance (Weinert & Brandt). The instrument includes 25 items, each scored on a 7-point Likert scale (strongly agree to strongly disagree), and we used the summated score, with higher scores indicating higher levels of perceived social support.

We assessed elder and caregiver childhood trauma by using the Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998). The CTQ is a brief 28-item, Likert, self-report inventory that assesses five types of maltreatment: emotional, physical, and sexual abuse, and emotional and physical neglect. Cut scores have been set for each type of trauma at four levels of maltreatment: none (or minimal), low (to moderate), moderate (to severe), and severe (to extreme). Higher scores suggest more severe maltreatment experiences.

We assessed elder and caregiver personality by using the NEO Five Factor Inventory (NEO-FFI; Costa & McCrae, 1989). The NEO-FFI, a shortened version of the NEO Personality Inventory (NEO-PI; Costa & McCrae, 1985), is a 60-item instrument designed to assess the five major domains of personality (i.e., neuroticism, extraversion, openness, agreeableness, and conscientiousness). Each subscale is composed of 12 summated items, and answer choices fall on a 5-point scale ranging from strongly agree to strongly disagree.

We measured caregiver burden by using the Caregiver Hassles Scale (CHS; Kinney & Stephens, 1989). The CHS is a 42-item, Likert instrument comprising five subscales that assess hassles related to care with basic ADLs, IADLs, cognitive status, the care recipient's behavior, and the caregiver's support network. We computed subscale scores by summing ratings across the items, with higher scores indicating greater perceived burden.

Data Analysis
We entered data into SPSS v12.0 and analyzed the relationship between the measured variables and the neglect-assessment team's diagnosis of neglect by using one of several techniques, depending on the scale of measurement of the variable. The scoring instructions for each instrument were followed for treating missing data. For variables measured on interval or ratio scales, we assessed association by using an independent samples t test when parametric assumptions were met or by Mann–Whitney–Wilcox on test when they were not. We set statistical significance for all tests at p .05, and no multiple comparison adjustments have been performed.

	Results

TOP Abstract Conceptual Model Methods Results Discussion and Future Research References

 
Sample Demographics
Of the 405 older adults and caregivers who were eligible to participate in the study, 165 (41%) completed the face-to-face in-home interview. Of the 240 who did not complete the face-to-face in-home interview, 29 (12%) were deceased, 49 (20%) were ineligible at the time of the in-home interview, 26 (11%) were unreachable (wrong number), 6 (3%) were not diagnosed by the neglect-assessment team, and 130 (54%) refused to participate.

Overall, the demographics of the neglect and no-neglect groups were the same except in the following areas (Tables 1 and 2). Elders in the neglect group had fewer people living in the home (p <.04) and were more likely to be Hispanic or Latino by self-report (p <.02), to have health problems that limited activities (p <.05), and to be Medicaid recipients (p <.03). Caregivers of the neglect group were more likely to be Hispanic or Latino by self-report (p <.04), were less likely to have health problems that required a doctor's attention (p <.02), and were less likely to be on Medicare (p <.01). Interestingly, the mean age of the two caregiver groups was not significantly different, although the no-neglect group was significantly more likely to report "yes" to Medicare benefits (p <.01).

Risk Constructs
In the risk domain, caregiver functional status, caregiver childhood trauma, and caregiver personality were statistically significant (Table 3). In terms of functional status, caregivers in the neglect group were more likely to report unmet need for assistance with ADLs (p <.04) and unmet need for assistance with IADLs (p <.03). This would indicate a caregiver group in poorer health with less capacity to provide care. Caregivers of elders in the neglect group were also more likely to have experienced childhood physical neglect (p <.02). This may mean that these caregivers had a lower standard for caregiving quality, based on norms of care provided to them in their own lives. To explore this further, follow-up interviews with this group are being planned. Finally, caregivers in the neglect group were more likely to have openness as a personality trait (p <.05) than caregivers of elders in the no-neglect group. Openness on the NEO-FFI reflects frankness in responding to questions. It may be that the caregiver is therefore more likely to admit, in an open way, that he or she had problems with caregiving. Further, the openness trait might predispose the caregiver to discuss any neglect in his or her own childhood (see Table 3).

Limitations
Although results from this study indicate some statistically significant differences between caregivers and elders in the neglect group versus caregivers and elders from the no-neglect group, there are several limitations that have to be addressed. Even though we used four emergency departments in four urban settings as the point of entry into this study, the sample comes primarily from New York State. Of the 29 cases in the neglect category, only 2 came from the Florida sites. The New York hospitals were more effective at integrating the study protocol into their emergency departments. Another important limitation may be selection bias. Participants were recruited into this study from emergency departments, and therefore, the sample may be overrepresentative of elders who do not have a primary care provider, or health insurance. The high proportion of Hispanic participants is likely due to the demography of the neighborhood at one of the New York City sites. Further, the fact that the interviews were conducted in only English or Spanish precludes any knowledge of elders from groups that speak languages other than these. Older adults enrolled in the study had health problems that needed medical attention, and this suggests that the caregivers acknowledged the older adult's need for medical care. Thus, it is possible that the more severely neglected individuals were never brought to the emergency department and are excluded from the study. Selection bias also could result from excluding those older adults in the emergency department who may have met the eligibility criteria but were never approached because they were too ill to be seen by the research staff. In the community sample, sample bias also could occur given the high attrition rate described in this article. Those people who elect to participate may be different from those who refuse, and this warrants further exploration in future studies.

	Discussion and Future Research

TOP Abstract Conceptual Model Methods Results Discussion and Future Research References

 
This study provides preliminary findings, given study limitations, that older adults who are diagnosed as neglected are sicker, have fewer financial resources, and have less help in the home. Although findings are consistent with previous studies (Lachs et al., 1996; Lachs, Williams, O'Brien, Hurst, & Horwitz, 1997), this study provides some insight into elder and caregiver characteristics that may have mutual influences on elder neglect. They indicate that when older adults are frail, cognitively limited, and report childhood trauma, they are more likely to be diagnosed as neglected by a clinical care team. Cognitive decline, depression, poorer social support, and neuroticism are associated with the outcome diagnosis of neglect. The relationship between self-reported childhood trauma experience and later-life neglect suggests that older adults who suffered from physical neglect and abuse in childhood may be more likely to tolerate poor care in later life. This type of care may be perceived as normative, or there may be a sense of despair and belief that things cannot be better. Regardless, further examination of the childhood trauma status of older adults is warranted when one is screening for neglect. Personality profiles also should be taken into consideration when one is screening for elder neglect. This study's data suggest that the trait of openness may contribute to a willingness to self-report, and the converse, that those less-open individuals maybe be less likely to report neglect or neglectful situations. Neuroticism, as determined by the measure used here, is more difficult to interpret. Older adults who scored as neurotic may be more paranoid and more suspect of caregivers, or more likely to complain of poor care. Conversely, they may be more likely to score as neurotic from years of bad care. Longitudinal studies have been suggested that follow children through older age to understand how patterns of personality and care affect later life. This study underscores the need for such longitudinal studies to further our understanding of the prevention of elder neglect, as well as other types of mistreatment.

Conclusions
Previously, elder neglect by caregivers was poorly understood from the context of the elder–caregiver relationship. This study provides new data that can begin to inform intervention studies designed to look at educational interventions that may reduce the risk of elder neglect. Health care providers, especially those responsible for rapid assessment and triage, can create or improve interdisciplinary assessment tools and procedures that screen for risk and vulnerability in elders at risk for neglect. Future research should continue to employ a dyadic approach when feasible, and focus on elder health problems that limit function, assess for depression, and screen for childhood trauma and poor social support.

	Footnotes

 
This study was supported by the National Institute on Aging and the National Institute for Nursing Research under Grant RO1-AG17588.

¹ Steinhardt School of Education, New York University, New York.

² College of Arts and Science, School of Social Work, University of South Florida–Tampa.

³ The James and Jennifer Harrell Center, College of Public Health, University of South Florida–Tampa.

⁴ Pulmonary Lab, New York University School of Medicine, New York.

Decision Editor: Linda S. Noelker, PhD

Received for publication September 13, 2004. Accepted for publication February 21, 2005.

	References

TOP Abstract Conceptual Model Methods Results Discussion and Future Research References

 

• American Medical Association. (1992). Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: Author.
• American Medical Association. (1994). National conference on family violence. Washington, DC: Health and Justice Conference Proceedings.
• Aravanis, S. C., Adelman, R. D., Breckman, R., Fulmer, T., Holder, E., & Lachs, M. S., et al (1993). Diagnostic and treatment guidelines on elder abuse and neglect. Archives of Family Medicine, 2, 371-388.[Abstract/Free Full Text]
• Bernstein, D., & Fink, L., (1998). Childhood Trauma Questionnaire: A retrospective of self-report. San Antonio, TX: Psychological Corporation.
• Capezuti, E., Brush, B. L., & Lawson, W. T., (1997). Reporting elder mistreatment. Journal of Gerontological Nursing, 23, (7), 24-32.
• Costa, P. T., Jr., & McCrae, R. R., (1985). NEO Personality Inventory. Odessa, FL: Psychological Assessment Resources.
• Costa, P. T., & McCrae, R. R., (1989). NEO Five-Factor Inventory (NEO-FFI). Odessa, FL: Psychological Assessment Resources.
• Coyne, A. C., Reichman, W. E., & Berbig, L. J., (1993). The relationship between dementia and elder abuse. American Journal of Psychiatry, 150, 643-646.[Abstract/Free Full Text]
• Dellasega, C., (1991). Caregiving stress among community caregivers for the elderly: Does institutionalization make a difference? Journal of Community Health Nursing, 8, (4), 197-205.[Medline]
• Folstein, M. F., Folstein, S. E., & McHugh, P. R., (1975). Mini-mental state: A practical method for grading the cognitive state of patients for clinicians. Journal of Psychiatric Research, 12, 189-198.[Medline]
• Frost, M. H., & Willette, K., (1994). Risk for abuse/neglect: Documentation of assessment data and diagnoses. Journal of Gerontological Nursing, 20, (8), 37-45.
• Fulmer, T., (1984). Elder abuse assessment tool. Dimensions of Critical Care Nursing, 3, 216-220.[Medline]
• Fulmer, T., & Ashley, J., (1989). Clinical indicators of elderly neglect. Applied Nursing Research, 2, (4), 161-167.
• Fulmer, T., Ashley, J., & Reilly, C., (1986). Geriatric nursing in acute settings. Annual Review of Gerontology and Geriatrics, 6, 27-80.
• Fulmer, T., & Gurland, B., (1996). Restriction as elder mistreatment: Differences between caregiver and elder perceptions. Journal of Mental Health and Aging, 2, 89-98.
• Fulmer, T., & Gurland, B., (1997). Evaluating the caregiver's intervention in the elder's task performance: Capacity versus actual behavior. International Journal of Geriatric Psychiatry, 12, 920-925.[Medline]
• Fulmer, T., McMahon, D. J., Baer-Hines, M., & Forget, B., (1992). Abuse, neglect, abandonment, violence, and exploitation: An analysis of all elderly patients seen in one emergency department during a six-month period. Journal of Emergency Nursing, 18, 505-510.
• Fulmer, T., & Paveza, G., (1998). Neglect in the elderly patient. Nursing Clinics of North America, 33, 457-466.
• Fulmer, T., Paveza, G., VandeWeerd, C., Guadagno, L., Fairchild, S., & Norman, R. G., et al in press. Neglect assessment in urban emergency departments and confirmation by an expert clinical team. Journal of Gerontology: Medical Sciences..
• Fulmer, T., Street, S., & Carr, K., (1984). Abuse of the elderly: Screening and detection. Journal of Emergency Nursing, 10, (3), 131-140.
• Gelles, R., & Pedrick-Cornell, C., (1990). Intimate violence in families (2nd ed.). Newbury Park, CA: Sage.
• George, L. K., & Gwyther, L., (1986). Caregiver well-being: A multidimensional examination of family caregivers of demented adults. The Gerontologist, 26, 253-259.[Medline]
• Hagopian, M., Paveza, G. J., Prohaska, T., & Cohen, D., (1990). Determination of need—Revision: Final report, Volume III. Chicago: University of Illinois at Chicago.
• Hudson, M. F., Johnson, T. F., & O'Brien, J. G., (1986). Report of the Health Care Provider Survey on elder abuse: The experiences of primary care physicians and nurse practitioners in Michigan and North Carolina. Unpublished manuscript.
• Katz, S., Ford, A., Moskowitz, R., Jackson, B., & Jaffe, M., (1963). Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914-919.
• Kinney, J. M., & Stephens, M. A., (1989). Caregiving Hassles Scale: Assessing the daily hassles of caring for a family member with dementia. The Gerontologist, 29, 328-332.
• Lachs, M. S., & Pillemer, K. A., (1995). Abuse and neglect of elderly persons. New England Journal of Medicine, 332, 437-443.[Free Full Text]
• Lachs, M. S., Williams, C., O'Brien, S., Hurst, L., & Horwitz, R., (1996). Older adults. An 11-year longitudinal study of adult protective service use. Archives of Internal Medicine, 156, 449-453.[Medline]
• Lachs, M. S., Williams, C., O'Brien, S., Hurst, L., & Horwitz, R. I., (1997). Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. The Gerontologist, 37, 469-474.[Abstract]
• Lawton, M. P., Moss, M., Kleban, M., Glicksman, A., & Rovine, M., (1991). A two-factor model of caregiving appraisal and psychological well-being. Journal of Gerontology: Psychological Sciences, 46, P181-P189.
• Lawton, M. P., Rajagopal, D., Brody, E. M., & Kleban, M., (1992). The dynamics of caregiving for a demented elder among Black and White families. Journal of Gerontology, 47, S156-S164.[Medline]
• Matthias, R. E., & Benjamin, A. E., (2003). Abuse and neglect of clients in agency-based and consumer-directed home care. Health and Social Work, 28, (3), 174-184.
• The National Center on Elder Abuse at The American Public Human Services Association in Collaboration with Westat, Inc. (1998). The National Elder Abuse Incidence Study: Final report. Washington, DC: National Aging Information Center.
• National Institute of Mental Health. (1977). Center for Epidemiologic Studies Depression Scale (CES-D). Bethesda, MD: Author.
• National Research Council. (2003). Elder mistreatment: Abuse, neglect, and exploitation in an aging America. Panel to review risk and prevalence of elder abuse and neglect. R. J. Bonnie & R. B. Wallace (Eds.). Committee on National Statistics and Committee on Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press.
• Ogg, J., & Bennett, G., (1992). Elder abuse in Britain. British Medical Journal, 305, 998-999.
• Paveza, G. J., Prohaska, T., Hagopian, M., & Cohen, D., (1989). Determination of need—Revision: Final report, Volume I. Chicago: University of Illinois at Chicago.
• Phillips, L. R., (1986). Theoretical explanations of elder abuse: Competing hypotheses and unresolved issues. In K. A. Pillemer & R. S. Wolf (Eds.), Elder abuse: Conflict in the family (pp. 197–217). Dover, MA: Auburn House.
• Phillips, L. R., & Rempusheski, V. F., (1986). Making decisions about elder abuse. The Journal of Contemporary Social Work, 67, (3), 131-140.
• Pillemer, K. A., & Finkelhor, D., (1988). The prevalence of elder abuse: A random sample survey. The Gerontologist, 28, 51-57.[Medline]
• Podnieks, E., (1987). The victimization of older persons. Canadian Journal of Psychiatric Nursing, 28, (1), 6-11.
• Prohaska, T., Hagopian, M., Cohen, D., & Paveza, G. J., (1989). Determination of need—Revision: Final report, Volume II. Chicago: University of Illinois at Chicago.
• Radloff, L. S., (1977). The CES-D scale: A new self-report depression scale for research in the general population. Applied Psychological Measures, 1, 385-401.
• Rose, M. H., & Killien, M., (1983). Risk and vulnerability: A case for differentiation. Advances in Nursing Science, 5, (3), 60-73.[Medline]
• Schumacher, K. L., Stewart, B. J., & Archbold, P. G., (1998). Conceptualization and measurement of doing family caregiving well. Image: Journal of Nursing Scholarship, 30, (1), 63-69.
• Tatara, T., (1993). Understanding the nature and scope of domestic elder abuse with the use of state aggregate data: Summaries of key findings of a national survey of state APS and aging agencies. Journal of Elder Abuse and Neglect, 5, 35-57.
• Ware, J. E., & Sherbourne, C. D., (1992). The MOS 36-item Short-Form Health Survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30, 473-481.[Medline]
• Weinert, C., (1988). Measuring social support: Revision and further development of the Personal Resources Questionnaire. In C. Waltz & O. Strickland (Eds.), Measuring of nursing outcomes. Measuring client outcomes (pp. 309–327). New York: Springer.
• Weinert, C., & Brandt, P., (1987). Measuring social support with the Personal Resources Questionnaire. Western Journal of Nursing Research, 9, 589-602.[Free Full Text]
• Wolf, R. S., Godkin, M., & Pillemer, K. A., (1984). Elder abuse and neglect: Findings from three model projects. Worcester: University of Massachusetts Medical Center, University Center on Aging.

This article has been cited by other articles:

				M. W. Baker Elder Mistreatment: Risk, Vulnerability, and Early Mortality Journal of the American Psychiatric Nurses Association, January 1, 2007; 12(6): 313 - 321. [Abstract] [PDF]

				S. M. Strasser and T. Fulmer The Clinical Presentation of Elder Neglect: What We Know and What We Can Do Journal of the American Psychiatric Nurses Association, January 1, 2007; 12(6): 340 - 349. [Abstract] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fulmer, T. Articles by Norman, R. Search for Related Content PubMed PubMed Citation Articles by Fulmer, T. Articles by Norman, R.