Older adults affected by polyvictimization: A review of early research

Trauma and Incarceration: A Latent Class Analysis of Lifetime Trauma Exposures for Individuals in Prison

This paper aims to contribute to the knowledge base about the lives of individuals who experience incarceration in the U.S. in order to advance post-release intervention services. Research has shown that among the millions of Americans who cycle through prisons and jails each year, the majority are poor, in poor health, living in contexts of chronic violence, often with mental illness, and more than half are people of color. Of particular concern for this population are high rates of trauma exposure and PTSD, though the research in this area is underdeveloped, particularly for men. Using survey data gathered during a large (n = 1,516, 90% male) multi-state randomized control trial of a reentry intervention, this study used latent class analysis (LCA) to explore types and timing of trauma exposures across the life course. LCA has been found to be an effective statistical tool in intervention research for identifying high-risk groups and for informing the tailoring of interventions. This study found three latent classes: 1) Lifetime Interpersonal Polyvictimization, 2) Lifetime Environmental Exposures, and 3) Low Exposure. About one third of the sample fell within each class. Study findings indicate that not only should trauma-informed and trauma-specific interventions be the norm in reentry services, including for men, but that these interventions should target both individual and environmental factors.

Childhood Polyvictimization and Associated Health Outcomes: A Systematic Scoping Review

Background: Polyvictimization, the experience of multiple types of victimization, is associated with detrimental health outcomes. Despite extensive research on the health consequences of polyvictimization, one challenge in understanding this literature lies in the varied operationalized definitions of polyvictimization and health outcomes. This scoping review provides the volume of the current literature on this topic, documents the varied constructs of polyvictimization and associated health outcomes, identifies knowledge gaps, and guides future research directions. Method: A systematic search of English-language original articles that presented quantitative associations of childhood polyvictimization and health outcomes was performed through six-database searches, a gray literature search, and citation mining from June 2020 to January 2021. The varied constructs of polyvictimization, health outcomes, and other study characteristics were extracted. Results: A total of 96 studies were included. Two ways of creating continuous variables (30.21%) and four ways of constructing categorical variables (72.92%) were identified for operationalizing polyvictimization. The majority of health outcomes were mental, behavioral, or social (96.88%), while slightly more than 10% of studies examined physical health (11.46%) or general health conditions (10.42%), respectively. More than half of studies used U.S. samples (56.25%). Conclusions: The varied constructs of polyvictimization suggests that there is a need to establish a valid polyvictimization construct that is consistently agreed upon in the research community. Findings summarize the specific health outcomes that can be targeted for further investigation and prevention efforts. Findings also suggest that the study of resilience and coping education for childhood polyvictims is sorely needed.

The Context of Elder Maltreatment: an Opportunity for Prevention Science

Elder maltreatment (EM) has been understood as a worldwide major public health threat for decades, yet it remains a form of victimization receiving limited attention, resources, and research. EM, which includes caregiver neglect and self-neglect, has far-reaching and long-lasting impacts on older adults, their families, and communities. Rigorous prevention and intervention research has significantly lagged in proportion to the magnitude of this problem. With rapidly growing population aging, the coming decade will be transformative: by 2030, one in six people worldwide will be aged 60 or older, and approximately 16% will experience at least one form of maltreatment (World Health Organization, 2021). The goal of this paper is to raise awareness of the context and complexities of EM, provide an overview of current intervention strategies based on a scoping review, and discuss opportunities for further prevention research, practice, and policy within an ecological model applicable to EM.

Elder abuse and life-course victimization in hospitalized older adults in Sweden: prevalence and associations with mental ill-health

BACKGROUND

The prevalence of elder abuse has only rarely been investigated in Sweden and never in a hospital setting. Therefore, the aims of this study were to: 1) Estimate the prevalence of elder abuse and life-course victimization among hospitalized older adults in Sweden, 2) Explore factors associated with elder abuse in the same sample, and 3) Explore the associations between life-course victimization and mental ill-health.

METHODS

The study was conducted at a university hospital in Sweden. Adults over the age of 65 years admitted to a medical or geriatric acute care ward during spring 2018 were consecutively recruited. The participant rate was 44% (n = 135/306). Participants were assessed via a face-to-face interview about their experiences of elder abuse and abuse earlier in life. Mental ill-health was measured using a self-administered depression assessment (Patient Health Questionnaire-9), along with information about medications and diagnoses retrieved from medical records.

RESULTS

Altogether, 40.7% (n = 55) of the participants reported some form of abusive experience during their life course. The prevalence of elder abuse was 17.8% (n = 24), and 58% (n = 14) of elder abuse victims also reported victimization earlier in life. Being abused before the age of 65 was the only background factor associated with elder abuse (OR = 5.4; 95% CI 1.9-15.7). Reporting abusive experiences both before and after the age of 65 was associated with current anti-depressant medication (OR = 6.6; 95% CI 1.1-39.2), a PHQ-9 result of 10 or more (OR = 10.4; 95% CI 2.1-51.0), and nine or more symptom diagnoses (OR = 4.0, 95% CI 1.0-16.1). Being abused only before or after the age of 65 was not significantly associated with any mental ill-health outcome measure.

CONCLUSIONS

Elder abuse and victimization earlier in life are highly prevalent among hospitalized older patients, and our findings underline the importance of a life-course perspective both in research on elder abuse and in clinical practice. Identifying and caring for older adults who have been subjected to abuse should be a priority in health care.

Elder Mistreatment as a Risk Factor for Depression and Suicidal Ideation in Korean Older Adults

Older adults suffering from mistreatment are especially vulnerable to adverse health outcomes. The current study examined the associations of elder mistreatment (single- and multi-type mistreatment) with depression or suicidal ideation in a Korean representative sample. The data were derived from the 2017 National Survey of Living Conditions and Welfare Needs of Korean Older Persons (unweighted n = 10,059 and weighted n = 10,055). Descriptive statistics and multivariate logistic regression analyses were performed. In the weighted population, 9.8% of older adults had mistreatment experiences. Results indicated that single- and multi-type mistreatment experiences were associated with increased risks of depression (OR = 1.93, 95% CI = [1.61, 2.32] and OR = 3.51, 95% CI = [2.52, 4.87], respectively), after adjusting for the confounding factors (socio-demographic, health-related, and social relation characteristics). Experiences of single- and multi-type mistreatment were also associated with suicidal ideation (OR = 2.48, 95% CI = [1.97, 3.12] and OR = 3.19, 95% CI = [2.25, 4.51], respectively), even after adjusting for the above confounding factors and depression. Similar results were found in sensitivity analyses using unweighted data. The current findings expanded our knowledge of the associations of mistreatment with depression and suicidal ideation in later life.

Characterizing Elder Abuse in the UK: A Description of Cases Reported to a National Helpline

The abuse of older adults by someone in a position of trust-also known as elder abuse (EA)-has a severe impact on victims and society. However, knowledge about EA in the UK is limited in comparison to other types of interpersonal violence and international knowledge. The present study utilized secondary data from a UK national EA helpline to investigate the characteristics of reported cases. Over a one-year period between 2017 and 2018, 1,623 records met inclusion criteria. Descriptive statistics are provided to describe this sample. Most cases reported to the helpline pertained to female victims, suffering from financial or psychological abuse. Co-occurrence of different abuse types was common. Findings provide updated knowledge about the phenomenology of EA cases in the UK. Recommendations are provided for advancing research in this area, including the need for examining cases across longer periods of time with a view to informing practice and policy.

Managing abusive experiences: a qualitative study among older adults in Sweden

Background

Elder abuse is prevalent, and is associated with poor health outcomes. How an older adult is affected by abusive experiences is dependent on myriad factors, including aspects of the abuse itself, other life circumstances, coping strategies, and what kind of help the older adults receive to manage the experience. In this study, we sought to investigate how older adults themselves describe how they manage abusive experiences. An increased understanding of this could help to tailor society’s response to older adults suffering from abuse.

Method

Participants (n = 30) were recruited from patients admitted to one acute geriatric and one acute internal medicine ward at a university hospital in Sweden. Patients over the age of 65 who reported experiences of elder abuse or who reported that they were still suffering from abuse that had occurred earlier in life were included. In-depth qualitative interviews were conducted, transcribed verbatim, and analyzed using qualitative content analysis.

Results

The analysis resulted in five themes, three pertaining to strategies used to manage abusive experiences (self-reliant coping, restoring dignity in relation to others, and needing formal and informal help) and two pertaining to the disclosure process (inner resistance to disclosure, and external barriers and facilitators for disclosure).

Conclusion

Older adults were found to use a combination of different strategies to manage abusive experiences. Some were self-reliant, but older adults often managed their experiences with the help of others. Health care professionals were generally in a position to facilitate disclosure, but some participants reported poor encounters with health care. The findings indicate a need to facilitate disclosure by, for example, training professionals on issues related to elder abuse and developing more easily navigated response systems that can respond to the complex needs of older adults trying to manage abusive experiences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03143-y.

"Who Would Sexually Assault an 80-Year-Old Woman?": Barriers to Exploring and Exposing Sexual Assault Against Women in Late Life

The phenomenon of Sexual Assault against Women in Late Life (SAWLL) has received increasing research attention in recent years. Yet, there is still only scant knowledge on it, compared with research on the sexual assault of younger women. Sexual assault is considered a sensitive topic, generally characterized by a conspiracy of silence. The aim of this article is to explore the barriers that hinder the identification and exposure of SAWLL, as reported by professionals. The research question was as follows: How do welfare and health care professionals present the motives and processes that obstruct exploring, exposing, and intervening in cases of SAWLL? A qualitative research design was used. Participants were 18 experienced welfare and health care professionals engaged in intervention with sexual assault in late life victims as well as offenders. Data were collected through in-depth, semi-structured interviews, which were later transcribed and thematically analyzed. Four themes emerged from the data analysis: (a) Leading Negative Emotions, (b) Lack of Language, (c) Implications of Cumulative and Complex Trauma, and (d) Social Exclusion. Women and professionals alike undergo complementary processes involving silence and silencing. These processes construct a "wall" of barriers, requiring professionals' sensitivity and awareness to deconstruct these barriers. Professional intervention through open discourse with the abused women can break this conspiracy of silence. We recommend that training programs for professionals intervening in cases of elder abuse and neglect will be directed along two paths: The first path should focus on professionals' competence and skills, and the second path should address the women's specific needs. These programs will include a particular module that will specifically address SAWLL. This module should comprise knowledge on typical emotional reactions to SAWLL, the use of language in creating reality, cumulative and complex trauma, and the social construction of ageism and sexism, which lead to social exclusion.

The Interplay Between Poly-Victimization and Sexual Assault in Late Life in the Context of Life Course Perspective

The aim of this article is to explore the interplay between poly-victimization and sexual assault against women in late life (SAWLL) according to the life-course perspective. Two themes emerged from qualitative interviews with 18 experienced welfare and health care professionals who intervened in cases of SAWLL: sexual assault by a spouse co-occurring with other types of abuse within marital relationships, and sexual assault and other types of abuse by two or more perpetrators along the life course. In many cases, SAWLL is an expression of a broader experience of poly-victimization, which relates to vulnerability in old age.

Factors associated with staff-to-resident abuse in Norwegian nursing homes: a cross-sectional exploratory study

BACKGROUND

Elder abuse is a public health problem that is gaining attention due to its serious impacts on people's health and well-being, and it is predicted to increase along with the world's rapidly ageing population. Staff-to-resident abuse in nursing homes is a complex and multifaceted phenomenon associated with multiple factors on different levels of the ecological model. This study aimed to explore individual, relational, and institutional characteristics associated with perpetrated staff-to-resident abuse in nursing homes, using a multilevel hierarchical approach.

METHODS

This was a cross-sectional exploratory study of 3693 nursing staff (response rate 60.1%) in 100 randomly selected nursing homes in Norway. We explored the characteristics of nursing staff, their relationship with residents, and institutional features associated with three types of abuse: psychological abuse, physical abuse, and neglect. These were modelled using multilevel mixed-effects logistic regression analyses.

RESULTS

Individual staff factors found to be associated with all three types of abuse were 1) being a registered nurse/social educator (OR 1.77-2.49) or licensed practical nurse (OR 1.64-1.92), 2) reporting symptoms of psychological distress (OR 1.44-1.46), 3) intention to leave the job (OR 1.35-1.40), and 4) reporting poor attitudes towards people with dementia (OR 1.02-1.15). Also, staff who reported poorer quality of childhood were more likely to perpetrate neglect (OR 1.14). Relational factors such as care-related conflicts (OR 1.97-2.33) and resident aggression (OR 1.36-2.09) were associated with all three types of abuse. Of institutional factors, lack of support from a manager was associated with perpetrating psychological abuse (OR 1.56).

CONCLUSIONS

We found several predictors of staff-to-resident abuse on different levels of the ecological model, which underlines the importance of using a multifaceted approach to identify risk factors of elder abuse in nursing homes. However, future studies should explore the underlying mechanism and causes with a prospective or qualitative design and target the multifaceted nature of risk factors when designing preventive interventions.

Lifetime prevalence of polyvictimization among older adults in Sweden, associations with ill-heath, and the mediating effect of sense of coherence

Background

Experiences of violence and abuse is a prominent part of the life history of many older adults and is known to have negative health effects. However, the importance of multiple victimization over the life course, e.g., lifetime polyvictimization, is not well investigated in this age group. The objective of this study was to investigate the prevalence of lifetime physical, emotional, and sexual victimization as well as polyvictimization among older adults in Sweden. We explored background characteristics associated with polyvictimization and hypothesized that violence victimization and especially polyvictimization would be associated with lower health status. To better understand factors that promote health in the aftermath of victimization, we also explored the effect of two resilience factors, sense of coherence (SOC) and social support, on the association between victimization and ill-health.

Method

Cross-sectional data from a random population sample in Sweden (women n = 270, men n = 337) aged 60–85 was used. Respondents answered questions about exposure to violence, health status, social support, and SOC. Conditional process analysis was used to test if SOC mediates the association between victimization and health outcome, and if social support moderates the association.

Results

Overall, 24.8% of the women and 27.6% of the men reported some form of lifetime victimization and 82.1% of the female and 62.4% of the male victims were classified as polyvictims, i.e., reported experiences of more than one episode of violence. As hypothesized, we found a negative association between victimization and health status and the association was most prominent for polyvictims. We found moderated mediation for the association between polyvictimization and health status, i.e., polyvictimization was associated with lower SOC and SOC had a positive correlation with health status. Social support moderated the association, i.e., victims without social support had lower health scores.

Conclusions

Lifetime polyvictimization was common among older adults and associated with lower health status. To help victims of violence recover, or preferably never develop ill-health, a better understanding of what fosters resilience is warranted. This study implies that social support, and especially SOC may be factors to consider in future interventions concerning older adults subjected to violence.

Breaking the Taboo: Sexual Assault in Late Life as a Multifaceted Phenomenon-Toward an Integrative Theoretical Framework

Sexual assault (SA) in late life has been receiving growing attention over the past two decades. It is directed primarily against older women and has been the least frequently reported form of abuse. Despite the growing awareness and body of knowledge on this phenomenon, the theoretical framework is still limited. Therefore, the aim of the present article is to suggest a theoretical conceptualization of the multifaceted phenomenon of sexual assault against women in late life (SAWLL). This conceptualization has been developed through several stages: (a) identification of three grounded fields of inquiry that are relevant to SAWLL: SA, elder mistreatment, and intimate partner violence; (b) classification of SAWLL along four paths: (1) ongoing SA in the context of lifelong IPV; (2) SA beginning in old age in the family within the community, involving spouses, family members, caregivers, dating mates, and so on; (3) ongoing SA, continuing in institutions, perpetrated by family members; and (4) SA in institutions, beginning in old age, relating to staff, residents, and family members; (c) We suggest three additional theoretical perspectives: trauma, a life-course perspective, and social constructionism, which provide further in-depth knowledge for understanding SAWLL. The combination of the three abovementioned stages composes an integrative theoretical framework, addressing SAWLL as a multifaceted phenomenon.

Who is in the revolving door? Policy and practice implications of recurrent reports to adult protective services

Repeat referral to adult protective services APS (recurrence) is a much-discussed topic among APS agencies as it may indicate ongoing harm, yet there is limited research examining prevalence or causes. This paper provides a foundational investigation of recurrence within a California APS county program. Drawing from thirty-three months of de-identified reports, we used logistic regression to examine the impact of intake report characteristics on repeat referral within one year after baseline case closure. One-fifth of the sample was recurrent (19.9%, n=987/4,958), with self-neglect being the most common type of report to recur (14.3%, n=307/2,141). Overall recurrence was predicted by female gender, older age, living alone, and multiple elder abuse, neglect, and exploitation (ANE) types reported at baseline, and report placed by social service provider, friends, family, landlords, and victim self-reports. Reporters personally related to the victim and social service providers are potential partners in identifying ANE, and alternate intervention approaches may be necessary.

Pent-up demand for care among dual-eligible victims of elder financial exploitation in Maine

Elder financial exploitation (EFE), the misuse of a vulnerable adult's property or resources for personal gain, is a form of elder abuse. This study addresses whether dual-eligible EFE victims were experiencing pent-up demand for health services alleviated through investigation by Adult Protective Services (APS). A quasi-experimental design addressed health service utilization and costs for 131 dual-eligible Maine APS clients over age 60 with substantiated allegations of EFE relative to comparable non-APS controls. APS case files spanning 2007-2012 were linked to 2006-2014 Medicare and Medicaid claims data. Service utilization and costs were analyzed 1 year prior, during, and 2 years after the initial APS investigation. Difference in differences logistic regression and generalized linear models addressed the likelihood of incurring costs and expenditure levels relative to matched controls, respectively. Victims of EFE had higher overall odds of using inpatient and long-term services and supports (LTSS) and higher odds of using LTSS post-investigation than controls. Higher overall levels of outpatient and prescriptions expenditures and higher inpatient expenditures during the APS event year contributed toward APS clients incurring $1,142 higher PMPM total costs than controls. Victims of EFE were experiencing significant pent-up demand for health services post-APS involvement.

Polyvictimization and Recurrent Falling in Older Ecuadorian Adults: The Mediation Role of Depressive Symptoms

Objective: To assess depressive symptoms as a mediator in the association between polyvictimization and recurrent falling. Methods: Using data from the Salud, Bienestar y Envejecimiento (Health, Well-being, and Aging) Ecuador Study, we analyzed community-dwelling adults 60 years and older (n = 5227). Recurrent falling was determined as ≥2 falls during the prior 12 months. Polyvictimization was determined as a history of ≥2 types of abuse. The mediator was depressive symptoms. Mediation analyses were based on the VanderWeele method. Results: Polyvictimization was significantly associated with higher odds of recurrent falling, and odds ratio (OR) = 1.45 (95% confidence intervals [CI] 1.20-1.76). Higher depressive symptoms increase the odds for recurrent falling (OR = 1.09 and 95% CI 1.07-1.11). Moreover, depressive symptoms were a significant mediator between polyvictimization and recurrent falling. The mediating effect was 28.4%. Discussion: Polyvictimization was associated with higher odds of recurrent falling, and this association was mediated by depressive symptoms.

Utilization of social workers in home care: An analysis of service use

Social workers are well positioned to address mental health complications impacting home care populations, yet social work has one of the lowest utilization rates of offered home care supports in Ontario. This study analyzed care plan data of frontline in-home social work services. Results identified adjustment to illness as the most common category and that seniors required significantly fewer visits and days on service than non-seniors. Most patients were able to accomplish their social work-based goals. Results highlight a need for further research and for capitalizing on the untapped potential value of social work home care services for patients.

Validation of REAGERA-S: a new self-administered instrument to identify elder abuse and lifetime experiences of abuse in hospitalized older adults

This study aimed to develop and validate REAGERA-S, a self-administered instrument to identify elder abuse as well as lifetime experiences of abuse in older adults. REAGERA-S consists of nine questions concerning physical, emotional, sexual, financial abuse and neglect. Participants were recruited among patients (≥ 65 years) admitted to acute in-hospital care (n = 179). Exclusion criteria were insufficient physical, cognitive, or language capacity to complete the instrument. A semi-structured interview conducted by a physician was used as a gold standard against which to assess the REAGERA-S. The final version was answered by 95 older adults, of whom 71 were interviewed. Sensitivity for lifetime experiences of abuse was 71.9% and specificity 92.3%. For elder abuse, sensitivity was 87.5% and specificity was 92.3%. REAGERA-S performed well in validation and can be recommended for use in hospitals to identify elder abuse as well as life-time experience of abuse among older adults.

Polyvictimization in later life: Trauma-informed best practices

This article provides a summary of salient trauma findings and conveys the dearth of research pertaining specifically to the trauma of elder abuse. This material, in conjunction with information contained in other articles composing this special issue, lays the foundation for advancing a trauma-informed approach to assisting older adults who have experienced polyvictimization. Informed by the findings presented and their extensive clinical experience with victims of violence, the authors suggest steps for providing a trauma-informed and victim-centered response to older adults who have suffered polyvictimization. These steps are then illustrated with an in-depth late-life polyvictimization case analysis.