The findings, which appear in the December issue of the American Journal of Public Health, indicate that how domestic elder abuse cases are detected and handled differs significantly across states because the relevant state laws and regulations vary greatly. In particular, the study found that states that require mandatory reporting and tracking of domestic elder abuse reports have much higher investigation rates than states without these mandatory requirements. The study is believed to be the first to comprehensively relate domestic elder abuse rates to laws and regulations in all 50 states and the District of Columbia.
Domestic elder abuse is abuse of adults or dependent/vulnerable adults age 60 and older (age 65 and older in California, Maryland and Nebraska; age 55 and older in Alabama) who live in private residences, not care facilities. Dependent adults are unable to care for themselves as a result of a physical or mental condition and depend on others to help them with tasks of daily living.
The UI study also suggests that particular professions need not be singled out in statutes as mandatory reporters and that types of abuse need to be better defined within many state regulations. In addition, the findings indicate that it may be more effective to have caseworkers handle only adult abuse cases rather than both child and adult cases.
"Laws do have an impact on public health, and this study demonstrates that different aspects of laws related to domestic elder abuse impact the amount of abuse reported, investigated and found to be actual abuse," said Gerald Jogerst, M.D., associate professor and interim head of family medicine in the UI Roy J. and Lucille A. Carver College of Medicine and lead investigator of the study. "Our findings suggest that improvements and standardization are needed nationwide in how information on elder abuse is collected and how state laws are created."
The UI study was based on data for 1999 that included all available domestic elder abuse reports, investigations and substantiations. Specifically, there were 190,005 reports from 17 states (not all states keep track of reports); 242,530 investigations from 46 states and the District of Columbia; and 102,879 substantiations from 35 states. A total of four states were not included in the investigation totals because they either reported no data (Georgia, North Dakota, Ohio) or were not sure of its accuracy (Colorado). In addition, not all states were able to provide substantiation of investigation data.
A "report" is an allegation or suspicion of abuse received by a state's adult protective service; an "investigation" involves actually going to a potential victim's home to see whether abuse is taking place; and "substantiation" is the finding of abuse as defined by that state's law. The UI team analyzed each state's statute and regulation regarding adult protective services. The team found that domestic elder abuse reports ranged from 4.5 per 1,000 elders in New Hampshire to 14.6 in California. "The range of reporting rates is very high, and is one of the indicators that there is high variability in how states document elder abuse," Jogerst said.
Elder abuse investigations rates ranged from .5 per 1,000 elders in Wyoming to 12.1 in Texas. Substantiations ranged from .1 per 1,000 elders in Wyoming to 8.6 in Minnesota. Forty-five percent of cases investigated were substantiated as actual abuse according to state laws.
The terminology used to describe elder abuse varies greatly. As a result, the UI team first had to review and re-codify terms used so that appropriate comparisons could be made across states, said Jeanette Daly, Ph.D., UI geriatric nurse researcher in family medicine and the study's co-principal investigator.
"The team members drew on the disciplines of nursing, medicine, law, biostatistics and social work. We worked together to code more than 80 aspects of the different statutes and come to consensus about categorizing these definitions," Daly said.
In addition, variations are widespread in how states document cases. For example, some states, including Iowa, used the term "report" in summaries when referring to what, by standard definition, is considered an "investigation." "The National Association of Adult Protective Services has a model reporting system for states to mimic. However, some states are hindered in implementing the model because their adult and child protection services share a computerized system," Daly said.
The team found that mandatory reporting, which was part of the law in 44 states during the year studied, is linked to higher investigation rates. While mandatory reporting apparently affects how many elder abuse cases are investigated, the researchers found that it is not necessary for states to spend time and resources defining who should be a mandatory reporter.
"Some states list 'any person' as a mandatory reporter and other states list professionals such as physicians, nurses and bankers," Jogerst said. "However, when you compare these two groups of states, there is no overall difference in the number of reports, investigations or substantiations. The law simply should say 'any person.'"
States that tracked reports had more investigations and nearly three times as many substantiated cases as did states that did not track reports. This was true even when considering how much funding a state has to track such cases.
"We think an aspect of this requirement to track reports puts administrators and workers on alert that they are being monitored in their performance," Jogerst said. "It also sends a message that the state government feels that tracking reports is important."
The team also found that states where investigators handle only elder abuse cases had a nearly 50 percent substantiation ratio compared to a 34 percent substantiation ratio in states where investigators handle both child and elder abuse cases. The substantiation ratio was determined by dividing the number of substantiations by the number of investigations.
"This substantiation difference may exist because investigators devoted to one type of abuse probably acquire more expertise by doing more elder abuse investigations," Jogerst said.
Iowa is one of 11 states that currently have protective services caseworkers handling both elder and child abuse cases.
The team also determined that it is "worth the time to spell out abuse definitions within regulations." Abuse definitions are broken down into eight categories: abandonment, emotional/psychological, exploitation (usually financial), sexual, self-neglect, neglect (by another person), physical and abuse not otherwise specified. Self-neglect is the failure, either by the adult's action or inaction, to provide the proper or necessary support or medical or any other care necessary for his own well-being.
"We saw that state regulations that included most or all of the abuse definitions have increased substantiation rates and ratios," Jogerst said. "This suggests investigators can do a better job of documenting abuse when they have more to go on and the definitions are clear and precise."
In addition to Jogerst and Daly, the study team included Margaret Brinig, Ph.D., professor in the UI College of Law; Jeffrey Dawson, Sc.D., associate professor of biostatistics in the UI College of Public Health; Gretchen Schmuch, social worker in the UI Department of Family Medicine; and Jerry Ingram, a doctoral student and research assistant in the UI School of Social Work.
The study was supported by a grant from two entities within the Centers for Disease Control and Prevention (CDC) – the CDC Division of Violence Prevention and the CDC Public Health Law Program.
University of Iowa Health Care describes the partnership between the UI Roy J. and Lucille A. Carver College of Medicine and UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide. Visit UI Health Care online at www.uihealthcare.com.
STORY SOURCE: University of Iowa Health Science Relations, 5137 Westlawn, Iowa City, Iowa 52242-1178. Becky Soglin (writer)
Journal
American Journal of Public Health